Socioeconomic Deprivation and Invasive Breast Cancer Incidence by Stage at Diagnosis: A Possible Explanation to the Breast Cancer Social Paradox

In this study, we assessed the influence of area-based socioeconomic deprivation on the incidence of invasive breast cancer (BC) in France, according to stage at diagnosis. All women from six mainland French departments, aged 15+ years, and diagnosed with a primary invasive breast carcinoma between 2008 and 2015 were included (n = 33,298). Area-based socioeconomic deprivation was determined using the French version of the European Deprivation Index. Age-standardized incidence rates (ASIR) by socioeconomic deprivation and stage at diagnosis were compared estimating incidence rate ratios (IRRs) adjusted for age at diagnosis and rurality of residence. Compared to the most affluent areas, significantly lower IRRs were found in the most deprived areas for all-stages (0.85, 95% CI 0.81-0.89), stage I (0.77, 95% CI 0.72-0.82), and stage II (0.84, 95% CI 0.78-0.90). On the contrary, for stages III-IV, significantly higher IRRs (1.18, 95% CI 1.08-1.29) were found in the most deprived areas. These findings provide a possible explanation to similar or higher mortality rates, despite overall lower incidence rates, observed in women living in more deprived areas when compared to their affluent counterparts. Socioeconomic inequalities in access to healthcare services, including screening, could be plausible explanations for this phenomenon, underlying the need for further research.

Multidimensional penalized splines for survival models: illustration for net survival trend analyses

BACKGROUND

In descriptive epidemiology, there are strong similarities between incidence and survival analyses. Because of the success of multidimensional penalized splines (MPSs) in incidence analysis, we propose in this pedagogical paper to show that MPSs are also very suitable for survival or net survival studies.

METHODS

The use of MPSs is illustrated in cancer epidemiology in the context of survival trends studies that require specific statistical modelling. We focus on two examples (cervical and colon cancers) using survival data from the French cancer registries (cases 1990-2015). The dynamic of the excess mortality hazard according to time since diagnosis was modelled using an MPS of time since diagnosis, age at diagnosis and year of diagnosis. Multidimensional splines bring the flexibility necessary to capture any trend patterns while penalization ensures selecting only the complexities necessary to describe the data.

RESULTS

For cervical cancer, the dynamic of the excess mortality hazard changed with the year of diagnosis in opposite ways according to age: this led to a net survival that improved in young women and worsened in older women. For colon cancer, regardless of age, excess mortality decreases with the year of diagnosis but this only concerns mortality at the start of follow-up.

CONCLUSIONS

MPSs make it possible to describe the dynamic of the mortality hazard and how this dynamic changes with the year of diagnosis, or more generally with any covariates of interest: this gives essential epidemiological insights for interpreting results. We use the R package survPen to do this type of analysis.

Socioeconomic and geographic disparities of breast cancer incidence according to stage at diagnosis in France

PURPOSE

Low socioeconomic background (SB) has been associated with lower breast cancer (BC) incidence and higher BC mortality. One explanation of this paradox is the higher frequency of advanced BC observed in deprived women. However, it is still unclear if SB affects similarly BC incidence. This study investigated the link between SB and early/advanced BC incidence from Loire-Atlantique/Vendee Cancer registry data (France).

MATERIALS AND METHODS

Fourteen thousand three hundred fifty three women living in the geographic area covered by the registry and diagnosed with a primary BC in 2008-2015 were included. SB was approached by a combination of two ecological indexes (French European Deprivation Index and urban/rural residence place). Mixed effects logistic and Poisson regressions were used, respectively, to estimate the odds of advanced (stage ≥ II) BC and the ratio of incidence rates of early (stage 0-I) and advanced BC according to SB, overall and by age group (< 50, 50-74, ≥ 75).

RESULTS

Compared to women living in affluent-urban areas, women living in deprived-urban and deprived-rural areas had a higher proportion of advanced BC [respectively, OR = 1.11 (1.01-1.22), OR = 1.60 (1.25-2.06)] and lower overall (from - 6 to - 15%) and early (from - 9 to - 31%) BC incidences rates Advanced BC incidence rates were not influenced by SB. These patterns were similar in women under 75 years, especially in women living in deprived-rural areas. In the elderly, no association between SB and BC frequency/incidence rates by stage was found.

CONCLUSION

Although advanced BC was more frequent in women living in deprived and rural areas, SB did not influence advanced BC incidence. Therefore, differences observed in overall BC incidence according to SB were only due to higher incidence of early BC in affluent and urban areas. Future research should confirm these results in other French areas.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Trends in incidence of invasive vaginal cancer in France from 1990 to 2018 and survival of recently diagnosed women - A population-based study

OBJECTIVE

The aim of this study was to analyze trends in the incidence of vaginal cancer in France over a 28-year period and to present survival for recently-diagnosed women.

METHODS

French cancer registries provided data on invasive vaginal cancers diagnosed from 1990 to 2015 and followed up through June 2018. Trends in incidence were analyzed using a Poisson model with a bidimensional penalized spline of age and year at diagnosis. Net survival analysis was restricted to recently-diagnosed cases (2010-2015) and used a novel approach based on a bidimensional penalized spline of age and time-since-diagnosis to model excess mortality hazard.

RESULTS

With 162 new cases estimated in France in 2018, vaginal cancer represented 0.9 % of genital cancers in French women. In 2018, the world population age-standardized incidence rate was 0.2 per 100,000 person-years, median age at diagnosis was 75 years. The standardized incidence rate decreased significantly by 3 % per year (95 % CI, -3.8; -2.2) between 1990 and 2018 (0.4 cases per 100,000 person-year in 1990, vs 0.2 in 2018). Age-standardized net survival at 1 and 5 years after diagnosis was respectively 74 % and 45 %.

CONCLUSIONS

This study confirms that vaginal cancer is still a rare malignancy in France with 5-year net survival that remains low. We observed a consistent decrease in the incidence rate between 1990 and 2018. It may be too early to attribute these trends to a positive impact of vaccination campaigns against hrHPV infection, since vaginal cancer mainly affects older women and HPV vaccination has only been available since the early 2000s, and only targets young girls.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Survival after breast cancer according to participation in organised or opportunistic screening and deprivation

BACKGROUND

Many studies have investigated the survival of women by comparing those who participated in organised screening with those who did not. However, among those who do not participate in organised screening, some women undergo opportunistic screening, but these women remain difficult to identify, particularly in France. Therefore, the aim of this study was to identify opportunistic screening, and then to study survival after breast cancer separately according to participation in organised, opportunistic or no screening, and taking into account sociodemographic inequalities.

METHODS

The study population was identified from 3 French cancer registries, whose data was crossed with the screening coordination centers and the National Health Data System to identify the different type of screening. The European Deprivation Index was used to define the level of deprivation. We estimated net survival using the Pohar-Perme method.

RESULTS

The 5-year net survival probabilities were higher for women who attended organised screening (97.0 %) than for women with opportunistic screening (94.1 %) or non-attenders (78.1 %). According to the level of deprivation, a significant difference was observed between the groups of women screened by organised and opportunistic screening, compared to the non-attenders.

CONCLUSION

The identification of opportunistic screening is an important element in identifying women who do not screening. It enables to us to see that women who do not attend any screening have a much higher loss-of-opportunity in terms of survival than those who participate in organised or opportunistic screening, and even more so in the most deprived areas.

Is survival rate lower after breast cancer in deprived women according to disease stage?

BACKGROUND

Socioeconomic deprivation has been associated with lower breast cancer (BC) survival, but the influence of stage at diagnosis on this association merits further study. Our aim was to investigate this association using the Loire-Atlantique/Vendee Cancer Registry (France).

METHODS

Twelve-thousand seven-hundred thirty-eight women living in the area covered by the registry and diagnosed with invasive breast carcinoma between 2008 and 2015 were included in the study. They were censored at maximal 6 years. Deprivation was measured by the French European Deprivation Index. Excess hazard and net survival were estimated for deprivation level, stage and age at diagnosis using a flexible excess mortality hazard model.

RESULTS

After adjustment by stage, women living in the most deprived areas had a borderline non-significant higher excess mortality hazard (+25% (95% CI: -3%; +62%)) compared to those living in the least deprived areas. Stage-adjusted 5-year net survival differed significantly between these two subgroups (respectively, 88.2% (95% CI:85.2%-90.5%) and 92.5% (95% CI:90.6%-93.9%)).

CONCLUSION

BC survival remained lower in deprived areas in France, despite universal access to cancer care. Intensification of prevention measures could help to reduce advanced BC, responsible for the majority of deaths from BC. A better understanding of remaining social disparities is crucial to implement specific interventions.

Is the Social Gradient in Net Survival Observed in France the Result of Inequalities in Cancer-Specific Mortality or Inequalities in General Mortality?

BACKGROUND

In cancer net survival analyses, if life tables (LT) are not stratified based on socio-demographic characteristics, then the social gradient in mortality in the general population is ignored. Consequently, the social gradient estimated on cancer-related excess mortality might be inaccurate. We aimed to evaluate whether the social gradient in cancer net survival observed in France could be attributable to inaccurate LT.

METHODS

Deprivation-specific LT were simulated, applying the social gradient in the background mortality due to external sources to the original French LT. Cancer registries' data from a previous French study were re-analyzed using the simulated LT. Deprivation was assessed according to the European Deprivation Index (EDI). Net survival was estimated by the Pohar-Perme method and flexible excess mortality hazard models by using multidimensional penalized splines.

RESULTS

A reduction in net survival among patients living in the most-deprived areas was attenuated with simulated LT, but trends in the social gradient remained, except for prostate cancer, for which the social gradient reversed. Flexible modelling additionally showed a loss of effect of EDI upon the excess mortality hazard of esophagus, bladder and kidney cancers in men and bladder cancer in women using simulated LT.

CONCLUSIONS

For most cancers the results were similar using simulated LT. However, inconsistent results, particularly for prostate cancer, highlight the need for deprivation-specific LT in order to produce accurate results.

Socioeconomic Environment and Survival in Patients with Digestive Cancers: A French Population-Based Study

Social inequalities are an important prognostic factor in cancer survival, but little is known regarding digestive cancers specifically. We aimed to provide in-depth analysis of the contextual social disparities in net survival of patients with digestive cancer in France, using population-based data and relevant modeling. Digestive cancers (n = 54,507) diagnosed between 2006-2009, collected through the French network of cancer registries, were included (end of follow-up 30 June 2013). Social environment was assessed by the European Deprivation Index. Multidimensional penalized splines were used to model excess mortality hazard. We found that net survival was significantly worse for individuals living in a more deprived environment as compared to those living in a less deprived one for esophageal, liver, pancreatic, colon and rectal cancers, and for stomach and bile duct cancers among females. Excess mortality hazard was up to 57% higher among females living in the most deprived areas (vs. least deprived) at 1 year of follow-up for bile duct cancer, and up to 21% higher among males living in the most deprived areas (vs. least deprived) regarding colon cancer. To conclude, we provide a better understanding of how the (contextual) social gradient in survival is constructed, offering new perspectives for tackling social inequalities in digestive cancer survival.

How do age and social environment affect the dynamics of death hazard and survival in patients with breast or gynecological cancer in France?

Several studies have investigated the association between net survival (NS) and social inequalities in people with cancer, highlighting a varying influence of deprivation depending on the type of cancer studied. However, few of these studies have accounted for the effect of social inequalities over the follow-up period, and/or according to the age of the patients. Thus, using recent and more relevant statistical models, we investigated the effect of social environment on NS in women with breast or gynecological cancer in France. The data were derived from population-based cancer registries, and women diagnosed with breast or gynecological cancer between 2006 and 2009 were included. We used the European deprivation index (EDI), an aggregated index, to define the social environment of the women included. Multidimensional penalized splines were used to model excess mortality hazard. We observed a significant effect of the EDI on NS in women with breast cancer throughout the follow-up period, and especially at 1.5 years of follow-up in women with cervical cancer. Regarding corpus uteri and ovarian cancer patients, the effect of deprivation on NS was less pronounced. These results highlight the impact of social environment on NS in women with breast or gynecological cancer in France thanks to a relevant statistical approach, and identify the follow-up periods during which the social environment may have a particular influence. These findings could help investigate targeted actions for each cancer type, particularly in the most deprived areas, at the time of diagnosis and during follow-up.

Association of Mammography Screening With a Reduction in Breast Cancer Mortality: A Modeling Study Using Population-Based Data From 2 French Departments

Meta-analyses of randomized controlled trials that started from 1963 to 1991 reported a decrease of breast cancer mortality, associated with mammography screening. However, the effectiveness of population-based screening programs conducted currently might have changed due to the higher effectiveness of treatments for late-stage cancers and the better diagnostic performance of mammography. The main objective of this study was to predict the reduction of breast cancer mortality associated with mammography screening in the current French setting. We compared breast cancer mortality in 2 simulated cohorts of women, which differed from each other solely in a 70% biennial participation in screening from 50 to 74 years old. The microsimulation model used for predictions was calibrated with incidence rates of breast cancer according to stage that were observed in Isère and Loire-Atlantique departments, France, in 2007-2013. The model predicted a decrease of breast cancer mortality associated with mammography screening of 18% (95% CI: 5, 31) and 17% (95% CI: 3, 29) for models calibrated with data from Isère and Loire-Atlantique departments, respectively. Our results highlight the interest in biennial mammography screening from ages 50 to 74 years old to decrease breast cancer mortality in the current setting, despite improvements in treatment effectiveness.

What is the most appropriate period to define synchronous cancers?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Implementation of National Cervical Cancer Screening Program in France]

In 2017 in France, cervical cancer (CC) was diagnosed in 2850 women and 1100 women died. The decline in incidence and mortality rates observed for several decades has slowed since the early 2000s. CC is due to the persistence of a sexually transmitted infection by human papillomaviruses (HPV). Currently CC prevention depends on HPV vaccination and Pap smear tests (PST) and up until 2018 diagnosis has been carried out an individual basis in France. The 2014-2019 French Cancer Plan has planned to implement a nationally organized screening program of CC which proposes in the short term to continue screening by PST, according to the recommendations set by HAS in 2010, while creating the conditions for the transition to HPV-testing in primary screening. The objective of this program is to reduce the incidence and number of CC deaths by 30% within the next 10 years, by achieving an 80% coverage rate in the target population and making screening more accessible to vulnerable populations and/or those who have poor access to the healthcare system. CC is one of the rare cancers that could become exceptional. The combination of the two primary and secondary prevention methods, with high rates of vaccination and screening coverage, should make it possible to eliminate this cancer in countries with sufficient economic resources for the effective implementation of these prevention programs.

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

Background

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

Methods

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

Results

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

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

Conclusion

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

Adolescent and young adult oncology patients in France: Heterogeneity in pathways of care

BACKGROUND

In order to evaluate at the population level the impact of the actions developed in France since 2004 to organize the care of adolescents and young adults (AYAs) with cancer, we conducted the present study to provide an unbiased view of the pathway of care of these patients.

METHODS

Using a population-based registry, we conducted a review of all cases of cancer diagnosed during 2012 and 2013 in 15- to 24-year-old patients living in nineteen French administrative areas.

RESULTS

The median times for diagnosis and treatment of the 993 included AYAs were 9 weeks (3-22) and 1 day (0-20), respectively. Delays in diagnosis were significantly longer in young adults than in adolescents, especially for soft-tissue sarcomas (48.7 weeks vs. 15.4 weeks, P = 0.04) and bone tumors (21.4 weeks vs. 10.1 weeks, P = 0.04). The first physicians seen by patients were mostly general practitioners (67.4%). Most patients (77.5%) were treated in adult units. Management decisions were taken within the context of a multidisciplinary team (MDT) in 85.3% of cases. MDT meetings that involved both pediatric and adult oncologists were uncommon (15.7% of patients). Twenty-six percent of patients were included in randomized or nonrandomized clinical studies. The proportion of inclusion was significantly higher in adolescents (39.5%) than in young adults (16.8%).

CONCLUSION

In France, pathways of care for AYAs are heterogeneous. It is necessary to organize a national network of expert centers with adequate medical skills and specific psychosocial support and facilities to provide the best possible care for these patients.

Trends in molecular subtypes of breast cancer: description of incidence rates between 2007 and 2012 from three French registries

Background

The incidence and incidence trends of breast cancer according to molecular subtype are unknown at a population level in France. The registry data enables this study and may give this information, that is crucial to describe and understand breast cancer epidemiology.

Methods

We estimated the incidence rates of breast cancer for each molecular subtype using data from three cancer registries in France for the period from 2007 to 2012. Molecular subtypes were defined with immunohistochemical data. Poisson models were estimated to modelize the course of breast cancer incidence and to test the trends.

Results

The study included 12,040 patients diagnosed between 2007 and 2012 in the three administrative areas covered by the registries. There was no significant trends in the proportion of each molecular subtype year by year. The age distribution of incident cases was different depending on the molecular subtypes (p < 0.001). The course of incidence between 2007 and 2012 was also different depending on molecular subtype according to the multivariate Poisson model (p < 0.001).

Conclusion

The description of incident cases of breast cancer according to molecular subtype at a population level showed differences in trends. The trends in incidence differed according to molecular subtype, and this should improve our understanding of overall changes in incidence. This analysis is important to plan screening and treatment resources at a population level.

Long-term trends in incidence and survival of penile cancer in France

BACKGROUND

Penile cancer is rare, and few population-based studies have described changes in time trend. This study aims to determine whether there has been an evolution in incidence and survival of penile cancer over time in France.

METHODS

Rates of age world-standardized incidence (ASRW) and net survival (NS) between 1989 and 2011 were calculated using data from 16 French cancer registries. Time trend incidence and survival analysis were confined to the eight registries operating throughout the full period. Log-linear Poisson regression analysis was used to estimate the average annual percentage change (AAPC) in incidence rates. The incidence rate for the most recent period was also calculated from all 16 cancer registries operating during 2009-2011. Human papillomavirus (HPV) exposure was deduced from the morphological code. NS was estimated using the Pohar-Perme estimator of the net cumulative rate.

RESULTS

No significant change in incidence was observed between 1989 and 2011 (AAPC: 0.08%; 95%CI: -1.01%; +1.17%). The incidence increased with age. The ASRW in 16 registries operating in 2009-2011 was 0.59 per 100,000 (95%CI: 0.50-0.68). The proportion of cases potentially linked to HPV was nearly 11% and did not change significantly over time. NS decreased with age but did not change over time (around 65% at 5 years).

CONCLUSION

Penile cancer remains rare in France, but survival is still low - probably because of delays in diagnosis and limited improvements in care. International clinical trials are needed to develop care recommendations based on an adequate level of evidence.

Occupational exposure to endotoxins and lung cancer risk: results of the ICARE Study

Objectives

To investigate the role of occupational exposure to endotoxins in lung cancer in a French population-based case–control study (ICARE (Investigation of occupational and environmental causes of respiratory cancers)).

Methods

Detailed information was collected on the occupational history and smoking habits from 2926 patients with histologically confirmed lung cancer and 3555 matched controls. We evaluated each subject’s endotoxin exposure after cross referencing International Standard Classification of Occupations (ISCO) codes (for job tasks) and Nomenclature d'Activités Françaises (NAF) codes (for activity sectors). Endotoxin exposure levels were attributed to each work environment based on literature reports. ORs and 95% CIs were estimated using unconditional logistic regression models and controlled for main confounding factors.

Results

An inverse association between exposure to endotoxins and lung cancer was found (OR=0.80, 95% CI 0.66 to 0.95). Negative trends were shown with duration and cumulative exposure, and the risk was decreased decades after exposure cessation (all statistically significant). Lung cancer risk was particularly reduced among workers highly exposed (eg, in dairy, cattle, poultry, pig farms), but also in those weakly exposed (eg, in waste treatment). Statistically significant interactions were shown with smoking, and never/light smokers were more sensitive to an endotoxin effect than heavy smokers (eg, OR=0.14, 95% CI 0.06 to 0.32 and OR=0.80, 95% CI 0.45 to 1.40, respectively, for the quartiles with the highest cumulative exposure, compared with those never exposed). Pronounced inverse associations were shown with adenocarcinoma histological subtype (OR=0.37, 95% CI 0.25 to 0.55 in the highly exposed).

Conclusions

Our findings suggest that exposure to endotoxins, even at a low level, reduces the risk of lung cancer.

Breast cancer incidence: Decreasing trend in large tumours in women aged 50-74

Objective A decrease in advanced breast cancer incidence is considered an early indicator of breast cancer mortality reduction in a screening programme. We describe trends in breast cancer incidence according to tumour size and age in three French administrative areas, where an organized screening programme was implemented during the 1990s. Methods Our study included all 28,092 invasive breast cancers diagnosed from 2000 to 2010 in women living in three areas (Hérault, Isère, Loire-Atlantique). Age, year of diagnosis, and size of tumour at diagnosis was provided by the three area cancer registries. Poisson regression models were fitted to estimate changes in incidence over time, after adjustment for age and administrative area. Results From 2000 to 2010, the incidence rate of large (tumour size >20 mm) breast cancer linearly decreased in women aged 50-74 (target age of the screening programme) from 108.4 to 84.1/100,000 (annual percent change = -1.9%, p < 0.001). No change in large breast cancer incidence rate was found in women aged 20-49, or older than 74. Conclusions A decreasing trend in incidence of large tumour size breast cancer in the target age of the screening programme is demonstrated for the first time in France. The overall 20.9% linear decrease over 11 years in these three areas is encouraging and should be closely monitored and extended to other areas of France, where the screening programme was generally implemented only in 2004.

Are disparities of waiting times for breast cancer care related to socio-economic factors? A regional population-based study (France)

The increasing number of breast cancer cases may induce longer waiting times (WT), which can be a source of anxiety for patients and may play a role in survival. The aim of this study was to examine the factors, in particular socio-economic factors, related to treatment delays. Using French Cancer Registry databases and self-administered questionnaires, we included 1,152 women with invasive non-metastatic breast cancer diagnosed in 2007. Poisson regression analysis was used to identify WTs' influencing factors. For 973 women who had a malignant tissue sampling, the median of overall WT between the first imaging procedure and the first treatment was 44 days (9 days for pathological diagnostic WT and 31 days for treatment WT). The medical factors mostly explained inequalities in WTs. Socio-economic and behavioral factors had a limited impact on WTs except for social support which appeared to be a key point. Better identifying the factors associated with increase in WTs will make it possible to develop further interventional or prospective studies to confirm their causal role in delay and at last reduce disparities in breast cancer management.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Occupation and head and neck cancer in women-Results of the ICARE study

BACKGROUND

Few occupational studies have addressed head and neck cancer, and these studies have been predominantly conducted in men. Accordingly, our objective was to investigate the association between head and neck cancer and occupation in women.

METHODS

ICARE, a French population-based case-control study, included 296 squamous cell carcinomas of the head and neck in women and 775 controls. Lifelong occupational history was collected. Odds ratios (ORs) and 95% confidence intervals (CI), adjusted for smoking, alcohol drinking and education level, were estimated for occupations and industries.

RESULTS

An elevated OR was observed for working proprietors working for 10 years or more (OR = 3.83, 95% CI: 1.12-13.0) with a significant trend with duration of employment (P = 0.047). Elevated but non-significant ORs were observed for street vendors (OR = 3.76, 95% CI: 0.99-14.3, P for trend = 0.13), bakers (OR = 4.19, 95% CI: 0.63-27.9, P for trend = 0.06), and welders and flame cutters (OR = 2.18, 95% CI: 0.33-14.4, P for trend = 0.05).

CONCLUSIONS

This exploratory study suggests a role of occupational exposures in the development of HN cancer in women. Further investigations of exposures to specific agents are needed.

Are prognostic factors more favorable for breast cancer detected by organized screening than by opportunistic screening or clinical diagnosis? A study in Loire-Atlantique (France)

PURPOSE

Comparisons of breast cancer characteristics between organized and opportunistic screening have been limited. This study was designed to compare characteristics of cancers detected by either organized or opportunistic screening as well as clinically diagnosed cancers in Loire-Atlantique (a French administrative entity), from 2003 to 2007.

METHODS

This study is based on data from the population-based Loire-Atlantique Cancer Registry. Stage at diagnosis and prognostic characteristics of carcinomas detected by organized screening were compared, by age-adjusted logistic regressions, to those of cancers detected by opportunistic screening and diagnosed clinically. Analyses were restricted to women aged 50-74 years (the age group targeted by the organized screening program) for the 2003-2007 period.

RESULTS

Between 2003 and 2007, 2864 invasive and 400 in situ breast cancer cases were diagnosed in women aged 50-74 years in Loire-Atlantique. Compared to cancers diagnosed clinically, cancers detected by organized screening were more likely to be in situ (13.7% vs. 3.8%), diagnosed at an early stage (74.4% vs. 51.3%), have a low SBR grade (grade 1: 35.4% vs. 18.5%), and be positive for estrogen-progesterone receptors (68.3% vs. 59.0%). The distribution of stage at diagnosis and prognostic characteristics between organized and opportunistic screening were similar.

CONCLUSION

These findings are consistent with the hypothesis that breast cancers are detected early by organized screening. Cancer characteristics were similar between the two screening modes. Estimating the impact of mammography screening on mortality in Loire-Atlantique should be the object of further investigations.

Trends in incidence of breast cancer among women under 40 in seven European countries: a GRELL cooperative study

Young women are not usually screened for breast cancer (BC). The trends in incidence in this population may better reflect changes in risk factors. However, studies on this subject are scarce and heterogeneous. The aim of this study was to describe the trends in incidence of BC in women under 40 from 1990 to 2008, using pooled European data. Thirty-seven European population-based cancer registries from Belgium, Bulgaria, France, Italy, Portugal, Spain and Switzerland participated in this study. World age-standardized incidence rates were first analyzed graphically and then using a Poisson regression model, in order to estimate average annual percent changes (AAPCs). The overall incidence rate of BC in the area covered increased linearly during the study period by 1.19% (0.93; 1.46) on average per year. This increase varied between countries from 0.20% (-0.53; 0.64) in Bulgaria to 2.68% (1.97; 3.40) in Portugal. In Italy, after a significant rise of 2.33% (1.14; 3.54) per year, BC incidence began decreasing in 2002 by -2.30% (-4.07; -0.50) yearly. The rise in incidence was greater for women under 35 and for ductal carcinomas. This increase can be due to a rise in risk factors and/or changes in diagnosis and surveillance practices, but we could not clearly distinguish between these two non-exclusive explanations.

Consistency and inconsistency in testing biomarkers in breast cancer. A GRELL study in cut-off variability in the Romance language countries

PURPOSE

Biological markers are crucial factors in order to differentiate female breast cancers and to determine the right therapy. This study aims at evaluating whether testing for biomarkers for female breast cancer has similar frequency and characteristics across and within countries.

METHODS

Population-based cancer registries of the Association for cancer registration and epidemiology in Romance language countries (GRELL) were asked to complete a questionnaire on biomarkers testing. The data collected referred to invasive female breast cancer cases diagnosed between 2004 and 2009. The investigation focused on 1) the overexpression and amplification of the human epidermal growth factor receptor 2 oncogene (HER2); 2) the expression of oestrogen (ER) and progesterone (PgR) receptors; and 3) the proliferation index (PI). Weighted percentages, the heterogeneity among and within countries, and the correlation between responses and calendar years were evaluated. The study was based on 19,644 breast cancers.

RESULTS

Overall, 85.9% of the cases were tested for HER2, 91.8% for both ER and PgR, and 74.1% for proliferative markers. For HER2 and ER-PgR, the frequency of testing increased from 2004 to 2009. Testing varied among countries (HER2 from 82.0% to 95.9%, ER-PgR from 89.3% to 98.9%, PI from 10% to 92%) and also within the same country (e.g. HER2 in Italy from 51% to 99%) as well as within single cancer registries. The most relevant differences were in the scores for positive/negative/not clearly defined HER2 (e.g. HER2 was defined positive if IHC 3+ in 21/33 registries), and in the cut-off of positive cells for ER/PgR (from >0% to >30%) and PI positivity (from >0% to >20%).

CONCLUSIONS

Biological markers are widely tested in the Romance language countries; however, the parameters defining their positivity may vary, raising concerns about homogeneity in breast cancer classification and treatment.

Waiting time disparities in breast cancer diagnosis and treatment: a population-based study in France

Waiting times are key indicators of a health's system performance, but are not routinely available in France. We studied waiting times for diagnosis and treatment according to patients' characteristics, tumours' characteristics and medical management options in a sample of 1494 breast cancers recorded in population-based registries. The median waiting time from the first imaging detection to the treatment initiation was 34 days. Older age, co-morbidity, smaller size of tumour, detection by organised screening, biopsy, increasing number of specimens removed, multidisciplinary consulting meetings and surgery as initial treatment were related to increased waiting times in multivariate models. Many of these factors were related to good practices guidelines. However, the strong influence of organised screening programme and the disparity of waiting times according to geographical areas were of concern. Better scheduling of diagnostic tests and treatment propositions should improve waiting times in the management of breast cancer in France.

Unbiased estimates of long-term net survival of solid cancers in France

In cancer studies, net survival (observed if cancer was the only cause of death) is a useful indicator but survival estimation at 5 years is insufficient for planning healthcare needs. We estimated the net survivals at 5 and 10 years in a cohort of 387,961 patients who had solid tumors between 1989 and 2004 and were followed-up until January 1, 2008. The cases were actively followed-up. Net survival was estimated with the unbiased Pohar-Perme method. The standardized net survival used the international cancer survival standard weights. In men, the standardized net survivals ranged from 92% at 5 years and 89% at 10 years (testis) to 6% at 5 years and 5% at 10 years (pancreas). In women, it ranged from 91% at 5 years and 88% at 10 years (thyroid) to 10% at 5 years and 7% at 10 years (pancreas). The most frequent cancers had the highest net survivals: 84% at 5 years and 71% at 10 years for prostate and 84% at 5 years and 74% at 10 years for breast cancer. Advanced age was associated with poorer prognosis. In most cancers, the net survivals at 5 and 10 years increased over periods of diagnosis. Net cancer survival is unaffected by mortalities due to other causes. It is the only indicator suitable for comparisons between countries or periods of diagnosis within a given country. The 10-year net survival confirmed the persistent unfavorable role of age in prognosis and the general improvement of cancer management over the last decade.