Distribution of the workforce involved in cancer care: a systematic review of the literature

Background

A skilled health workforce is instrumental for the delivery of multidisciplinary cancer care and in turn a critical component of the health systems. There is, however, a paucity of data on the vast inequalities in cancer workforce distribution, globally. The aim of this study is to describe the global distribution and density of the health care workforce involved in multidisciplinary cancer management.

Methods

We carried out a systematic review of the literature to determine ratios of health workers in each occupation involved in cancer care per 100 000 population and per 100 cancer patients (PROSPERO: protocol CRD42018095414).

Results

We identified 33 eligible papers; a majority were cross-sectional surveys (n = 16). The analysis of the ratios of health providers per population and per patients revealed deep gaps across the income areas, with gradients of workforce density, highest in high-income countries versus low-income areas. Benchmark estimates of optimal workforce availability were provided in a secondary research analysis: mainly high-income countries reported workforce capacities closer to benchmark estimates. A paucity of literature was defined for critical health providers, including for pediatric oncology, surgical oncology, and cancer nurses.

Conclusion

The availability and distribution of the cancer workforce is heterogeneous, and wide gaps are described worldwide. This is the first systematic review on this topic. These results can inform policy formulation and modelling for capacity building and scaleup.

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Workforce is an essential component of the health systems.

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Stark inequalities are reported for the distribution of health workforce worldwide, but data are limited.

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We aimed at portraying the first global figure of the comprehensive cancer workforce for cancer management.

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Inequalities in density and distribution of the workforce regard all the key health personnel involved in cancer management.

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These data will inform the development of evidence-informed policies for the workforce in low- and middle-income countries.

Epidemiological evidence of carcinogenicity of sunbed use and of efficacy of preventive measures

The International Agency for Research on Cancer classified, in July 2009, exposure to artificial tanning devices (sunbeds) as carcinogenic to humans. This classification was based on evidence from epidemiological and experimental animal studies. The present chapter will review these epidemiological evidences. The summary risk estimates from 27 epidemiological studies obtained through a meta-analysis showed an increased risk of melanoma: summary relative risk (SRR) = 1.20 [95% confidence interval (CI) 1.08-1.34]. The risk was higher when exposure took place at younger age (SRR = 1.59; 95% CI 1.36-1.85). The risk was independent of skin sensitivity or population and a dose response was evident. A meta-analysis of 12 studies was conducted for non-melanoma skin cancers and showed a significantly increased risk for basal cell carcinoma (SRR = 1.29; 95% CI 1.08-1.53) and for squamous cell carcinoma (SRR = 1.67; 95% CI 1.29-2.17). As for melanoma, the risk for other skin cancers increased for first exposures at young age. Epidemiological studies have gradually strengthened the evidence for a causal relationship between indoor tanning and skin cancer and they fit with prior knowledge on relationship between UV exposure and skin cancer. Additionally, several case-control studies provided consistent evidence of a positive association between use of sunbed and ocular melanoma, also with greater risk for first exposures at younger age. Preventive measures based on information on risk or by requiring parental authorization for young users proved to be inefficient in several studies. The significant impact of strong actions or total ban, such as performed in Iceland, or a total ban of sunbed use, as in Brazil or Australian states, needs to be further assessed.

Abstract P5-08-04: Overview of breast cancer mortality trends in the world

Background: Since the 1990s, important changes in the detection and management of breast cancer have taken place. We analysed breast cancer mortality trends from 1989 to 2012 in 47 countries with data available for most years since 1987.

Methods: Breast cancer deaths and populations were extracted from the WHO mortality database. Age-standardised mortality rates were computed using the World standard population over the period 1987-2012 for women of all ages and for women aged <50 years, 50-69 years and ≥70 years. Percent changes in mortality trends were assessed over the period 1989-2012. Mortality rates are reported per 100,000 women. We constituted groups of comparable countries that are located in same region, have similar economic status and same mortality rates in 1987-89.

Results: Annual breast cancer mortality rates in 1987-89 ranged from 2.6 in South Korea to 29.3 in England and Wales (median rate of 18.5). In 2010-12, mortality rates ranged from 5.1 in South Korea to 18.4 in Denmark (median rate of 14.8). From 1989 to 2012 (23 years), declines in breast cancer mortality were observed in 39 out of 47 countries. Mortality changes ranged from a -45% reduction in England and Wales to a 79% increase in South Korea (median change of -28%). Mortality declines were more pronounced in countries with high mortality in 1987-89. In groups of comparable countries, sharp contrasts in mortality changes were observed, for instance -21% reduction in France against -37% reduction in Spain, or 5% increase in Latvia against -17% reduction in Slovakia. Although the mortality rates in 1987-89 were 20.9 in Australia and 27.4 in New Zealand, a mortality reduction of -38% was observed in both countries. Of note, in these groups of comparable countries, reductions in mortality were the same in countries that introduced mass breast screening around 1990 than in countries where breast screening was introduced in 2005 or after. Regarding age groups, the largest declines in mortality were observed in women less than 50 in all the countries except New Zealand and Hong Kong, and only three countries had an increased mortality in this age group (Brazil, Colombia, South Korea). Mortality changes in young women ranged from -59% reduction in Slovenia to 32% increase in South Korea (median change of -45%). Mortality changes in young women were not different in countries where breast screening before age 50 has always been uncommon (e.g., Norway, England and Wales) or is widespread since the late 1980's (e.g., the USA, Sweden). In women aged 50-69 years, mortality changes ranged from -49% reduction in England and Wales to 111% increase in South Korea (median change of -27%). In women aged 70 years or more, mortality changes ranged from a -33% reduction in the Netherlands to a 151% increase in South Korea (median of -11%).

Conclusions: Huge disparities in changes in breast cancer mortality rates are observed around the World, and across age groups. Downward trends in breast cancer mortality prevail in most of Europe, North America, Oceania, and in few countries of Latin America and Asia. The situation in high income Asian countries is not easy to interpret because access to efficient therapies is commonplace. There seems to be no discernible influence of screening on mortality trends.

Citation Format: Pizot C, Boniol M, Boyle P, Autier P. Overview of breast cancer mortality trends in the world [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-04.

Cancer mortality in cohorts of workers in the European rubber manufacturing industry first employed since 1975

BACKGROUND

Increased cancer risk has been reported among workers in the rubber manufacturing industry employed before the 1960s. It is unclear whether risk remains increased among workers hired subsequently. The present study focused on risk of cancer mortality for rubber workers first employed since 1975 in 64 factories.

PATIENTS AND METHODS

Anonymized data from cohorts of rubber workers employed for at least 1 year from Germany, Italy, Poland, Sweden, and the UK were pooled. Standardized mortality ratios (SMRs), based on country-specific death rates, were reported for bladder and lung cancer (primary outcomes of interest), for other selected cancer sites, and for cancer sites with a minimum of 10 deaths in men or women. Analyses stratified by type of industry, period, and duration of employment were carried out.

RESULTS

A total of 38 457 individuals (29 768 men; 8689 women) contributed to 949 370 person-years. No increased risk of bladder cancer was observed [SMR = 0.80, 95% confidence interval (CI) 0.46; 1.38]. The risk of lung cancer death was reduced (SMR = 0.81, 95% CI 0.70; 0.94). No statistically significant increased risk was observed for any other cause of death. A reduced risk was evident for total cancer mortality (SMR = 0.81, 95% CI 0.76; 0.87). Risks were lower for workers in the tyre industry compared with workers in the general rubber goods sector. Analysis by employment duration showed a negative trend with SMRs decreasing with increasing duration of employment. In an analysis of secondary end points, when stratified by type of industry and period of first employment, excess risks of myeloma and gastric cancer were observed each due, essentially, to results from one centre.

CONCLUSION

No consistent increased risk of cancer death was observed among rubber workers first employed since 1975, no overall analysis of the pooled cohort produced significantly increased risk. Continued surveillance of the present cohorts is required to confirm the absence of long-term risk.

Abstract P4-13-08: Diabetes, Related Factors and Breast Cancer Risk

Diabetes and breast cancer are both extremely common conditions in women and may share common risk factors. It is natural to investigate any potential common risk factors and to seek biological clarification and improve prospects for prevention.

Therefore, in order to help clarify the potential association between diabetes, related factors and breast cancer risk, a comprehensive literature review and formal meta-analysis was carried out, planned, conducted and reported following PRISMA guidelines regarding meta-analysis of observational studies. Variables studies in relation to breast cancer risk were adiposity, physical activity, glycaemic load, glycaemic index, diabetes, IGF-1, fasting glucose, fasting insulin and C-peptide, adiponectin and metformin and glargine use among patients with diabetes. For all variables except diabetes and breast cancer, only prospective studies were included in meta-analyses. Summary Relative Risks (SRR) and corresponding 95% Confidence Intervals (CI) were calculated from random effect models.

For breast cancer at all ages, the calculated risks were as follows: diabetes (SRR = 1.27 95% CI (1.16, 1.39); physical activity (SRR = 0.88, 95% CI (0.85, 0.92)); glycaemic load (SRR = 1.06, 95% CI (1.00, 1.12)); glycaemic index (SRR = 1.04, 95% CI (0.99, 1.10)); fasting glucose (SRR = 1.12, 95% CI (1.01, 1.24)); serum insulin (SRR = 1.18, 95% CI (0.75, 1.85)); c-peptide (SRR = 1.29, 95% CI (0.91, 1.82)); adiponectin (SRR = 1.16, 95% CI (0.93, 1.46)); metformin (SRR = 1.00, 95% CI (0.69, 1.46)); and glargine (SRR = 1.11, 95% CI (1.00, 1.24)). An increase of 5 units in Body Mass Index (a weight increase if 14.5 kg in a person 1.70 metres tall) was associated in post-menopausal breast cancer (SRR = 1.12, 95% CI (1.08, 1.16)) but not at pre-menopausal ages (SRR = 0.83, 95% CI (0.72, 0.95)). Serum insulin was associated with breast cancer at post-menopausal ages but not at pre-menopausal ages whereas with c-peptide there was a significant association at pre-menopausal ages but not post-menopausal. For IGF-1, Hodge's Standardised Mean Difference (HSMD) was calculated in cohort studies and there was no significant association with breast cancer at all ages (HSMD = 0.003, 95% CI (−0.059, 0.065)), at post-menopausal ages (HSMD = −0.014, 95% CI (−0.106, 0.077)) or at pre-menopausal ages (HSMD = 0.039, 95% CI (−0.038, 0.117)).

The risk of breast cancer is increased among post-menopausal women who have diabetes. Among those factors related to diabetes, key risk factors for breast cancer appear to be adiposity and lack of physical activity which are both related to the risk of developing diabetes. Action on these lifestyle factors should form the basis of a common prevention strategy. There is a need to re-evaluate potential biological mechanisms to explain the increased risk in post-menopausal women with diabetes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-08.

Abstract P4-13-07: Meta-analysis of epidemiological studies of Insulin Glargine and Breast Cancer Risk

After having lain dormant for a while, the association between diabetes, its risk factors and treatments, and cancer risk and death is now high on the clinical and research agenda. The microscope is currently focused on the relationships between Pioglitazone and Bladder Cancer, Exenatide and Pancreas Cancer, Liraglutide and pancreas cancer and insulin use and lung cancer. The potential association between use of insulin glargine and breast cancer risk has been the subject of recent major studies.

All data regarding cancer risk and use of insulin glargine has been assembled and meta-analyses performed using state-of-the-art statistical methodology. A random effects model was employed with tests for heterogeneity (I2) and publication bias. These meta-analyses are based on reports from 21 epidemiological studies involving over one million patients and 3 million person-years of observation.

Based on independent estimates from these studies, the Summary Relative Risk (SRR) for all forms of cancer was (SRR = 0.91, 95% CI (0.84, 0.99)), and for breast cancer SRR = 1.11 (95% CI (1.00, 1.48)). For new users of glargine, the SRR for breast cancer was SRR = 1.22 (95% CI (1.00, 1.48)). For colorectal cancer the SRR = 0.83 (95% CI (0.74, 0.94)) and for prostate cancer SRR = 1.14 (95% CI (0.93, 1.39)). Overall, the risk of developing cancer among users of insulin glargine is reduced compared to the risk of users of other insulins. Similarly, the risk of colorectal cancer is reduced among users of glargine.

While the lower bound of the 95% confidence interval is 1.00, the risk of breast cancer does not increase with increasing duration of use of glargine. In some studies the trend in risk with increasing duration of use goes in opposite directions. The development of a detectable breast cancer from the initial carcinogenic event depends on the tumour doubling time. The time for a de novo breast cancer to become detectable ranges from 12.3 years for a doubling time of 150 days; 16.4 years for a doubling time of 200 days; and 20.5 years for a doubling time of 250 days. Most published studies have a maximum of 3–4 years of glargine use.

The databases employed in these analyses were not designed for such epidemiological investigation. A major limitation is the absence of knowledge as to why a potential treatment was prescribed for an individual and why a change in therapy was indicated. Further potential limitations to this meta-analysis include that the comparison group was not the same in all studies but this could also be seen as a strength. The meta-analysis of the randomized trials had several insulin comparators and the retinopathy study had NPH as the comparator. This is not likely to invalidate the findings of this analysis nor would the fact that different adjustments were made in the individual studies.

The current evidence gives no support to the hypothesis that insulin glargine is associated with an increased risk of cancer as compared to other insulins and should give reassurance to physicians and their patients. In respect to breast cancer, there is no indication of a causal association between use of insulin glargine and increased risk of breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-07.

Securing the data economy: translating privacy and enacting security in the development of DataSHIELD

Contemporary bioscience is seeing the emergence of a new data economy: with data as its fundamental unit of exchange. While sharing data within this new 'economy' provides many potential advantages, the sharing of individual data raises important social and ethical concerns. We examine ongoing development of one technology, DataSHIELD, which appears to elide privacy concerns about sharing data by enabling shared analysis while not actually sharing any individual-level data. We combine presentation of the development of DataSHIELD with presentation of an ethnographic study of a workshop to test the technology. DataSHIELD produced an application of the norm of privacy that was practical, flexible and operationalizable in researchers' everyday activities, and one which fulfilled the requirements of ethics committees. We demonstrated that an analysis run via DataSHIELD could precisely replicate results produced by a standard analysis where all data are physically pooled and analyzed together. In developing DataSHIELD, the ethical concept of privacy was transformed into an issue of security. Development of DataSHIELD was based on social practices as well as scientific and ethical motivations. Therefore, the 'success' of DataSHIELD would, likewise, be dependent on more than just the mathematics and the security of the technology.

Advanced breast cancer incidence following population-based mammographic screening

BACKGROUND

Breast cancer mortality is declining in many Western countries. If mammography screening contributed to decreases in mortality, then decreases in advanced breast cancer incidence should also be noticeable.

PATIENTS AND METHODS

We assessed incidence trends of advanced breast cancer in areas where mammography screening is practiced for at least 7 years with 60% minimum participation and where population-based registration of advanced breast cancer existed. Through a systematic Medline search, we identified relevant published data for Australia, Italy, Norway, Switzerland, The Netherlands, U.K. and the U.S.A. Data from cancer registries in Northern Ireland, Scotland, the U.S.A. (Surveillance, Epidemiology and End Results (SEER), and Connecticut), and Tasmania (Australia) were available for the study. Criterion for advanced cancer was the tumour size, and if not available, spread to regional/distant sites.

RESULTS

Age-adjusted annual percent changes (APCs) were stable or increasing in ten areas (APCs of -0.5% to 1.7%). In four areas (Firenze, the Netherlands, SEER and Connecticut) there were transient downward trends followed by increases back to pre-screening rates.

CONCLUSIONS

In areas with widespread sustained mammographic screening, trends in advanced breast cancer incidence do not support a substantial role for screening in the decrease in mortality.

Impact of PSA testing and prostatic biopsy on cancer incidence and mortality: comparative study between the Republic of Ireland and Northern Ireland

OBJECTIVES

To investigate the impact of different PSA testing policies and health-care systems on prostate cancer incidence and mortality in two countries with similar populations, the Republic of Ireland (RoI) and Northern Ireland (NI).

METHODS

Population-level data on PSA tests, prostate biopsies and prostate cancer cases 1993-2005 and prostate cancer deaths 1979-2006 were compiled. Annual percentage change (APC) was estimated by joinpoint regression.

RESULTS

Prostate cancer rates were similar in both areas in 1994 but increased rapidly in RoI compared to NI. The PSA testing rate increased sharply in RoI (APC = +23.3%), and to a lesser degree in NI (APC = +9.7%) to reach 412 and 177 tests per 1,000 men in 2004, respectively. Prostatic biopsy rates rose in both countries, but were twofold higher in RoI. Cancer incidence rates rose significantly, mirroring biopsy trends, in both countries reaching 440 per 100,000 men in RoI in 2004 compared to 294 in NI. Median age at diagnosis was lower in RoI (71 years) compared to NI (73 years) (p < 0.01) and decreased significantly over time in both countries. Mortality rates declined from 1995 in both countries (APC = -1.5% in RoI, -1.3% in NI) at a time when PSA testing was not widespread.

CONCLUSIONS

Prostatic biopsy rates, rather than PSA testing per se, were the main driver of prostate cancer incidence. Because mortality decreases started before screening became widespread in RoI, and mortality remained low in NI, PSA testing is unlikely to be the explanation for declining mortality.

Decline in breast cancer incidence in the Flemish region of Belgium after a decline in hormonal replacement therapy

BACKGROUND

Breast cancer incidence rate in Belgian women was as high as 152.7 for 100 000 in 2003 (adjusted on European population). We made an estimation of the contribution of hormone replacement therapy (HRT) on breast cancer incidence from 1999 to 2005 in women aged 50-69 years in Flanders.

METHODS

Breast cancer data were extracted from the Belgium Cancer Registry. Drug consumption was computed from drug sales data. The fraction of breast cancers attributable to HRT was calculated by year, using the relative risks of the Million Women Study in the UK.

RESULTS

The proportion of women aged 50-69 years using HRT in Flanders increased since 1992, peaked at 20% in 2001, then decreased to 8% in 2008. The incidence of breast cancer in 100 000 women aged 50-69 years in Flanders increased from 332.8 in 1999 to 407.9 in 2003, then decreased to 366.1 in 2005; the variations were mostly noticeable for tumors <20 mm in size. The fraction of breast cancers attributed to HRT peaked at 11% in 2001 and decreased afterward.

CONCLUSION

The high level of breast cancer observed in the years 2001-2003 in Flanders can be partly attributed to the use of HRT. Since participation to mammography screening of Flemish women aged 50-69 years was still on the rise in 2003 and never exceeds 62%, the decrease in breast cancer incidence was likely to be due to the decrease in HRT use and not to screening saturation.

Second primary cancers in patients with skin cancer: a population-based study in Northern Ireland

Among all 14,500 incident cases of basal cell carcinoma (BCC), 6405 squamous cell carcinomas (SCC) and 1839 melanomas reported to the Northern Ireland Cancer Registry between 1993 and 2002, compared with the general population, risk of new primaries after BCC or SCC was increased by 9 and 57%, respectively. The subsequent risk of cancer, overall, was more than double after melanoma.

Changes in breast cancer incidence and mortality in middle-aged and elderly women in 28 countries with Caucasian majority populations

BACKGROUND

Mammography screening and menopause hormone therapy is essentially offered to women 50-69 years old.

METHODS

In 28 European ancestry countries, we quantified changes in breast cancer incidence and mortality using a joinpoint regression analysis from 1960 until last year of available data.

RESULTS

Since 1960, increases in incidence often in the order of 2%-3% per year occurred in all countries, mainly in women 50-69 years old whose incidence in eight countries surpassed the incidence in women 70 years old and more. In 10 countries, a decrease in incidence in women >or=70 years was noticeable in the last years of observation, but the magnitude of this decrease was far from matching the magnitude of the increases observed in the 50-69 age-group. In the beginning of years 2000s, a persistent decrease in mortality of approximately 2% per year was observed in women 50-69 years old in most countries and parallel declines in mortality were observed in women 70 years or more.

CONCLUSIONS

In years 2000s, in a number of countries, the incidence of breast cancer has become greater in middle-aged women than in older women. If trends remain unchanged, the same phenomenon is likely to happen in other countries.

Estimates of the cancer incidence and mortality in Europe in 2006

BACKGROUND

Monitoring the evolution of the cancer burden in Europe is of great value. Estimates of the cancer burden in Europe have been published for 2004 and estimates are now being presented for cancer incidence and mortality in Europe for 2006.

METHODS

The most recent sources of cancer incidence and mortality data have been collected and projections have been carried out using short-term prediction methods to produce estimated rates for 2006. Additional estimation was required where national incidence data were not available, and the method involved the projection of the aggregations of cancer incidence and mortality data from representative cancer registries. The estimated 2006 rates were applied to the corresponding estimated country population to obtain the best estimates of the cancer incidence and mortality in Europe in 2006.

RESULTS

In 2006 in Europe, there were an estimated 3,191,600 cancer cases diagnosed (excluding nonmelanoma skin cancers) and 1,703,000 deaths from cancer. The most common form of cancers was breast cancer (429,900 cases, 13.5% of all cancer cases), followed by colorectal cancers (412,900, 12.9%) and lung cancer (386,300, 12.1%). Lung cancer, with an estimated 334,800 deaths (19.7% of total), was the most common cause of death from cancer, followed by colorectal (207,400 deaths), breast (131,900) and stomach (118,200) cancers.

CONCLUSIONS

The total number of new cases of cancer in Europe appears to have increased by 300,000 since 2004. With an estimated 3.2 million new cases (53% occurring in men, 47% in women) and 1.7 million deaths (56% in men, 44% in women) each year, cancer remains an important public health problem in Europe and the ageing of the European population will cause these numbers to continue to increase even if age-specific rates remain constant. Evidence-based public health measures exist to reduce the mortality of breast and colorectal cancer while the incidence of lung cancer, and several other forms of cancer, could be diminished by improved tobacco control.

Sortie précoce dans le post-partum : état des lieux en France

BACKGROUND

Early postpartum discharge is a recent practice in France and for which there are few national data.

METHODS

The Sentinel AUDIPOG network was used to describe the practice of postpartum early discharge (< 3 days in case of vaginal delivery and < 5 days in case of caesarean section) from 1994 till 2002, after standardization on the distribution according to the type of hospital and the region (n = 128232). Secondarily, the prognostic medical factors of an early postpartum hospital discharge were researched, in univariate analysis and logistic regression analysis, of the births of 2001-2002.

RESULTS

Early postpartum discharges concerned 3% of the deliveries in 1997 and 7% in 2002. Eearly postpartum discharge was more frequent in the level II and III obstetric facilities, in non- university hospitals, in facilities with more than 1 500 deliveries a year, in urban hospitals and in Paris and the surrounding area. The women leaving early in the postpartum were more often multiparas, with no pregnancy pathology, with a single pregnancy, without postpartum hemorrhage, and a child > 2500 g without risk of infection. At present, 40% of vaginal delivery and 25% of caesarean section primiparas and 55% of vaginal delivery and 30% of caesarean section multiparas could be discharged early.

CONCLUSION

The reduction of the postpartum hospital stay is inevitable but it is advisable to take care that the women who are discharged are medically fit for discharge.

Public awareness about risk factors could pose problems for case-control studies: The example of sunbed use and cutaneous melanoma

In a large case-control study we found no association between sunbed use and melanoma risk, but indications for potential recall and recruitment biases made the interpretation of the results difficult. Associations with skin phototype (adj OR for skin type I vs. IV: (2.6, 95% CI 1.5-4.8)), hair colour (adj OR red/blond vs. brown/black 2.0 (95% CI 1.4-2.8)) and number of naevi on both arms (OR>10 vs. 10 3.13 (95% CI: 2.47; 3.97)) were comparable to previous studies, but negative associations were found between sun exposure and melanoma risk (adj. OR 0.87 (95% CI: 0.65-1.18)) and in cases between sun exposure and naevus count. These observations led us to speculate that cases may have underreported their sun exposure and, most likely, their sunbed exposure. High percentages of sunbed use among controls indicated possible recruitment bias: eligible controls who were sunbed users were probably more likely to accept the invitation to participate than non-users, possibly due to a feeling of 'guilt' or 'worry' about their habits. Such selective participation may have strongly influenced the risk estimates of sunbed use in our study.

Lower incidence rates but thicker melanomas in Eastern Europe before 1992

The objective of this study was to investigate the epidemiology of melanoma across Europe with regard to Breslow thickness and body-site distribution. Incidence data from Cancer Incidence in 5 Continents and the EUROCARE-melanoma database were used: 28?117 melanoma cases from 20 cancer registries in 12 European countries, diagnosed between 1978 and 1992. Regression analysis and general linear modelling were used to analyse the data. Melanomas in Eastern Europe were on average 1.4 mm thicker (P<0.05) than in Western Europe and appeared more often on the trunk. From 1978 to 1992, their Breslow thickness had decreased in Western but not Eastern Europe. There was a latitude gradient in incidence, with highest rates in southern regions in Eastern Europe and an inverse gradient in Western Europe, with highest rates in the North. Mortality:incidence ratios were less favourable in southern parts across Europe, especially in Eastern Europe. If Eastern European populations copy the sunbathing behaviour of the West it is likely that in the near future a higher melanoma incidence can be expected there.

Response to a phase II study of concomitant-to-sequential use of etoposide and radiation therapy in newly diagnosed malignant gliomas

We evaluated the antitumor efficacy of and patient tolerance to a phase II study of concomitant-to-sequential use of etoposide and radiotherapy for newly diagnosed malignant gliomas. Fifty-two supratentorial malignant glioma patients were enrolled in this phase II study between May 1995 and May 1998. Standard cranial irradiation and six courses of etoposide (100 mg/m2 - xdays 1-3) were administered. The first course of etoposide was given on days 1 to 3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks. Fifty-one patients were assessable for toxicity, response, and survival. A complete surgical resection was only noted for 17 patients. Six patients had a confirmed complete response, and eight patients displayed a partial response. Six patients progressed within the first 3 months of starting treatment. The rate of objective response for assessable patients with residual tumor was 41.1%. Hematologic toxicity was mild; grade 3 or 4 neutropenia was noted in five patients, without sepsis. The overall median survival time (MST) was 12.5 months, and the mean survival of this population was 14.9 months. These results suggest a certain efficacy of this regimen testing a concomitant-to-sequential use of etoposide and radiotherapy for newly diagnosed malignant gliomas, and that continued evaluation of this combination is warranted, especially because this treatment is also well tolerated.

Sun exposure and sun protection in young European children: an EORTC multicentric study

Most European children experience exposure to the sun during the summer holidays. The aim of this study was to examine the behaviour of European children when in the sun during their holidays. In 1995-1997, a total of 631 young children were recruited during a multicentric study in Belgium, Germany, France and Italy. For each holiday period from birth, parents gave detailed information on sun exposure and child behaviour. Predictors and trends over time of sun protection were investigated. Forty percent of children were exposed to sunlight in the first and 86% in the sixth year of life. At the same time, the number of children who experienced sunburns rose from 1 to 23%. In the whole period of 6 years, only 8% of children always wore trousers and shirt when in the sun, while 25% children always used a sunscreen. The proportion of sun-exposed children who used sunscreen was stable with age (approximately 50%), while those who always wore trousers and shirts dropped from 46% (1st year) to 19% (6th year). Multinomial logistic regression showed that sunscreen use, but not the wearing of clothes was associated with sun-sensitivity. In summary, sun exposure increases steadily, while sun protection decreases in the first 6 years of life in our cohort of children. In this cohort, use of a sunscreen was much more frequent than the wearing of clothes and a reduction in sun exposure.

Intermediate-effect biomarkers in prevention of skin cancer

Skin cancers, both non-melanoma and melanoma, usually progress through sequential steps towards malignant transformation, leading to mutant clones and precancerous lesions. Prevention of skin cancers relies on reduction of exposure to solar radiation and may be evaluated by measuring induction of intermediate-effect biomarkers such as sunburn cells or p53 mutations in the epidermis, actinic (solar) keratoses, UV-induced immunosuppression or naevi. Sunburn cells (apoptotic keratinocytes) and p53 mutations are indicators of UV-induced DNA lesions as early steps of malignant transformation of epidermal keratinocytes. Actinic keratoses are premalignant sun-induced skin lesions, characterized as keratinized patches with aberrant cell differentiation and proliferation; they represent risk factors for basal-cell carcinoma and melanoma and are precursors of squamous-cell carcinoma. Studies in humans have investigated UV-induced immunosuppression and its modulation by topical sunscreen application, focusing on contact hypersensitivity as measured by immunization or response to haptens, or on modulation of stimulation of allogeneic lymphocytes by epidermal cells, or local release of immunomodulatory molecules such as cis-urocanic acid or interleukin-10. Naevi are focal collections of melanocytes, usually found at the junction of the epidermis and dermis or at various depths in the dermis. Common acquired naevi arise after birth both spontaneously and in response to sun exposure. Most acquired naevi are clonal, while most melanocytes in non-naeval areas are not. Although it is not yet certain whether naevi represent premalignant lesions or risk factors, many melanomas arise in acquired naevi, and the number of naevi constitutes the best predictor of individual risk of melanoma. The presence of large (i.e., >5 mm) or atypical naevi (i.e., large naevi with non-uniform colour and irregular borders) is associated with elevated melanoma risk, independently of the number of smaller naevi. Children seem particularly vulnerable to sun-induced biological events involved in the genesis of melanoma, and the greatest increase in naevus numbers per unit of skin surface occurs before adolescence. Therefore, the distribution of naevi and their development in children are relevant to understanding melanoma occurrence in adults.

The body site distribution of melanocytic naevi in 6-7 year old European children

The number and size of melanocytic naevi are the main predictors of cutaneous melanoma. Naevus development per unit of skin surface is greatest during childhood. We assessed the body distribution of naevi 2-4.9 mm and > or = 5 mm in 649 European children aged 6-7 years old from Brussels (Belgium), Bochum (Germany), Lyon (France) and Rome (Italy). The numbers of naevi 2-4.9 mm and naevi > or = 5 mm were strongly correlated, especially on the trunk. For naevi 2-4.9 mm, the highest relative densities were found on the face, back, shoulders and the external surface of the arms. The lowest relative densities were found on the hands, legs, feet and abdomen. The relative density of naevi > or = 5 mm was higher on the trunk than on any other body site. Similar body distributions were observed in both sexes and at each centre. The body site distribution of naevi 2-4.9 mm seemed to parallel the usual sun exposure patterns of young European children. It is suggested that the development of naevi > or = 5 mm might be a marker of the vulnerability of melanocytes to the harmful effects of solar radiation. Vulnerability would be maximal on the back, and would decrease from proximal to distal skin areas, with melanocytes of the hands and feet having the lowest vulnerability. The number of naevi acquired on a specific area of skin would result from the combined effects of local vulnerability to solar radiation and local sun exposure history. The origin of acquired body site differences in the susceptibility of melanocytes to ultraviolet radiation is unknown, although it seems to parallel the body site density of sensory innervation.