Differences in Treatment and Outcome of Pancreatic Adenocarcinoma Stage I and II in the EURECCA Pancreas Consortium

BACKGROUND

The EUropean REgistration of Cancer CAre (EURECCA) consortium aims to investigate differences in treatment and to improve cancer care through Europe. The purpose of this study was to compare neo- and adjuvant chemotherapy (ACT) and outcome after tumor resection for pancreatic adenocarcinoma stage I and II in the EURECCA Pancreas consortium.

METHODS

The eight, collaborating national, regional, and single-center partners shared their anonymized dataset. Patients diagnosed in 2012-2013 who underwent tumor resection for pancreatic adenocarcinoma stage I and II were investigated with respect to treatment and survival and compared using uni- and multivariable logistic and Cox regression analyses. All comparisons were performed separately per registry type: national, regional, and single-center registries.

RESULTS

In total, 2052 patients were included. Stage II was present in the majority of patients. The use of neo-ACT was limited in most registries (range 2.8-15.5%) and was only different between Belgium and The Netherlands after adjustment for potential confounders. The use of ACT was different between the registries (range 40.5-70.0%), even after adjustment for potential confounders. Ninety-day mortality was also different between the registries (range 0.9-13.6%). In multivariable analyses for overall survival, differences were observed between the national and regional registries. Furthermore, patients in ascending age groups and patients with stage II showed a significant worse overall survival.

CONCLUSIONS

This study provides a clear insight in clinical practice in the EURECCA Pancreas consortium. The differences observed in (neo-)ACT and outcome give us the chance to further investigate the best practices and improve outcome of pancreatic adenocarcinoma.

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.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Performance of opportunistic breast cancer screening in Slovenia

The purpose of the study was to assess performance indicators of opportunistic breast screening carried out in one of the Primary Breast Diseases Centers (PBDC) and to find out if these indicators meet the standards set in "European guidelines for quality assurance in mammographic screening". The records of 1,896 asymptomatic women, aged between 50 and 69 years who attended PBDC for the first time in the period from October 15 1998 to October 15 2002, were reviewed. In all of them, clinical examination and mammography was done. If necessary, non-invasive additional imaging was also performed in the PBDC. If malignancy could not be excluded, the women were referred to the Institute of Oncology (IO) for additional invasive diagnostic procedures. The data on these findings were collected from the records of the IO. We compared our results with the recommended values of performance indicators valid for organized screening programs as determined by "European guidelines". Of 1,896 women, 415 (22%) were recalled for additional imaging. In 335/415 women the suspicion for malignancy was excluded with noninvasive diagnostic methods. Invasive diagnostic procedures were applied in 80/415 women. Carcinomas were detected in 23 women, the majority of them (96%) were non palpable. All carcinomas were ductal; 9 (39%), 7 (30.5%), 7 (30.5%) were grade 1, 2 and 3, respectively. One carcinoma was preinvasive; 20 had the tumor size T1, 1 had T2, while in one the size was not specified. The axillary lymph nodes were negative in 14/23 (61%) women with invasive carcinoma and positive in 5/23 (22%). Surgery of the axilla was considered unnecessary in 4/23 (17%). Diagnostic sensitivity in presented cohort was 96%, specificity 79%. After a negative mammogram 1 interval cancer was detected. Compared to the "European guidelines" we achieved satisfactory results in the number and size of detected and interval cancers, but the analysis showed a higher recall rate with too many false-positive results. Efforts should target lowering the recall rate without reducing the cancer detection rate. Compared to Slovenian average, a large percentage of localized breast cancers in our study claim for organized breast cancer screening program in Slovenia at earliest convenience.

The association between induced and spontaneous abortion and risk of breast cancer in Slovenian women aged 25-54

The risk of breast cancer may be increased by induced or spontaneous abortion. The evidence for this association was evaluated in a population based case-control study in Slovenia, where 624 women aged 25-54 years with breast cancer diagnosed during 1988-1990 were matched for age and site of residence with controls randomly selected from the Slovenian Population Registry. Odds ratios (OR) and 95% confidence intervals (CI) were obtained by conditional logistic regression analyses. Spontaneous abortion was not associated with a significantly increased risk of breast cancer (nulliparous women: OR=1.41, 95% CI 0.22-9.01; uniparous women: OR=0.98, 95% CI 0.50-1.91; women with parity 2 or more: OR=1.40, 95% CI 0.91-2.15). Induced abortion was not associated with a statistically significant elevated risk. The risk of breast cancer was higher in nulliparous women (OR=2.49, 95% Cl 0.68-9.09), and was less among women who had more deliveries. In uniparous women, the risk of breast cancer appeared higher when the induced abortion took place before a first full-term pregnancy (OR=1.94, 95% CI 0.70-5.39) rather than after a first full-term pregnancy (OR=1.22, 95% CI 0.71-2.10) but neither of these odds ratios reached significance. We found no significant association between spontaneous abortion or induced abortion and breast cancer risk. This study found an elevated, but not statistically significant, risk associated with induced abortion among nulliparous women and among parous women when the induced abortion was before the first full-term pregnancy.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Breast cancer incidence rates in Slovenia 1971-1993

BACKGROUND

Analyses of time trends in breast cancer incidence and mortality have generally revealed cohort-based changes in the rates. These have been linked to cohort-based changes in lifestyle factors. The effect of the changes in the reproductive risk factors on the changes in the rates, and the relative importance of the reproductive characteristics in Slovenia, a country which has not had much breast cancer screening, are investigated.

METHODS

Data on breast cancer incidence for 1971-1993 were obtained from the Cancer Registry of Slovenia (Registry). The Registry covers the whole population of the Republic of Slovenia (1.99 million on 30 June 1993). The statistical analysis uses parametric age-period-cohort models.

RESULTS

Breast cancer incidence has increased by 70% in Slovenia from 1971 to 1993, These changes are dominated by cohort effects and the cohorts born in 1907-1922 have the greatest increase in incidence. Period effects on changes in incidence were modest. The percentage of nulliparous women in the cohort and the average family size in the cohort explained 38% of the variation in the cohort effects.

CONCLUSIONS

The percentage of nulliparous women in the cohort is the most important reproductive variable associated with the trends in the rates, with breast cancer risk predicted to be higher in cohorts with a larger percentage of nulliparous women. As the cohorts born 1932-1946 have a more favourable reproductive pattern as regards breast cancer risk, compared to the 1907-1922 cohorts, age-specific incidence rates in Slovenia would be predicted to decline in the future in the absence of changes in the other risk factors.

Future trends in breast, cervical, lung, mouth and pharyngeal cancer incidence in Slovenia

OBJECTIVES

Breast, cervical, lung, mouth and pharyngeal cancers are important public health problems in Slovenia, and in many other Central and South European countries. The aim of this study was to predict the incidence of these cancers in Slovenia up to the year 2009, based on the data of the Cancer Registry of Slovenia for the period 1965-1994 and on the official national population projections for the Republic of Slovenia.

METHODS

Age-period-cohort models were applied. In the case of data heterogeneity in lung as well as in mouth and oropharyngeal cancer in males, an additional parameter indicating differences in lifestyle was introduced in the model.

RESULTS

After accounting for major site-specific risk factors, we predict in females a steady increase in breast and lung cancer, but no major changes in cervical cancer case-load. In males a steady decrease in the lung cancer case-load is expected throughout the predicted period, while for mouth and pharyngeal cancer a moderate decrease is expected only after the year 2000.

CONCLUSION

Despite some uncertainties inherent in cancer incidence predictions, the obtained results are important in setting priorities for national cancer control strategies in Slovenia, especially in further efforts towards primary prevention of lung, mouth and pharyngeal cancer, and in more efficient early detection of breast, cervical, mouth and pharyngeal cancer.

Screening mammography for early detection of breast cancer

From numerous studies on breast cancer it can be concluded that no single measure can lessen the burden of this frequent cancer in women in all developed countries. Complex strategies including primary prevention by identification of risk factors and their modification, secondary prevention by earlier detection and tertiary prevention by improving treatment outcome are needed to control the disease. Besides age, the established breast cancer risk factors include certain benign breast diseases, family history, ionising radiation, some reproductive factors and obesity. Primary prevention includes general recommendation for healthy lifestyle, e.g., avoidance of obesity, proper diet, physical activity and moderate alcohol consumption. Randomised controlled trials conducted in the USA, Canada, Scotland and Sweden have shown that regular mammography, alone or in combination with clinical examination, is effective in reducing mortality for about 30% in women over the age of 50, and much less in younger population. However, mammography screening has several drawbacks, the major being its tendency towards false positive and false negative results with all their potential psychosocial consequences. High quality assurance and control, as well as effective and readily available treatment, all of which demand high investments, are indispensable for good results. Even in the absence of organised screening, the availability of effective treatment may contribute to reduction in breast cancer mortality.

Effect of parity and age at delivery on breast cancer risk in Slovenian women aged 25-54 years

In 1988, a case-control study on breast cancer and oral contraceptives with 624 cases and 624 matched controls in the age range 25-54 years was undertaken in Slovenia. This analysis assesses the relationship between parity and breast cancer risk: the relative importance of age at first birth, age at subsequent births and total parity. We also evaluate whether a dual effect of an increased risk immediately after childbirth followed by a long-term benefit exists. Three logistic regression models were used. Age at first delivery is an important breast cancer risk factor: among parous women it was associated with a 5.3% increase/year in the odds of breast cancer. Multiparity was not shown to be an independent risk factor. Age at subsequent deliveries was associated with a 1% increase in risk for every 1 year increase of age at any birth, but this contribution to the risk was not significant. In the analysis stratified by parity the most important influence is with the age at first birth. We find no evidence of an effect on the odds of breast cancer associated with the age at the second, or later, births. We do find that there is an increased risk associated with the birth of the first child followed by a longer term protective effect. A post-menopausal woman has a reduced breast cancer risk compared with a pre-menopausal woman of the same age, adjusting for the same number of deliveries and ages at these deliveries.

Breast cancer and hormonal contraceptives: further results. Collaborative Group on Hormonal Factors in Breast Cancer

The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on breast cancer risk and use of hormonal contraceptives. Original data from 54 studies, representing about 90% of the information available on the topic, were collected, checked and analysed centrally. The 54 studies were performed in 26 countries and include a total of 53,297 women with breast cancer and 100,239 women without breast cancer. The studies were varied in their design, setting and timing. Most information came from case-control studies with controls chosen from the general population; most women resided in Europe or North America and most cancers were diagnosed during the 1980s. Overall 41% of the women with breast cancer and 40% of the women without breast cancer had used oral contraceptives at some time; the median age at first use was 26 years, the median duration of use was 3 years, the median year of first use was 1968, the median time since first use was 16 years, and the median time since last use was 9 years. The main findings, summarised elsewhere, are that there is a small increase in the risk of having breast cancer diagnosed in current users of combined oral contraceptives and in women who had stopped use in the past 10 years but that there is no evidence of an increase in the risk more than 10 years after stopping use. In addition, the cancers diagnosed in women who had used oral contraceptives tended to be less advanced clinically than the cancers diagnosed in women who had not used them. Despite the large number of possibilities investigated, few factors appeared to modify the main findings either in recent or in past users. For recent users who began use before age 20 the relative risks are higher than for recent users who began at older ages. For women whose use of oral contraceptives ceased more than 10 years before there was some suggestion of a reduction in breast cancer risk in certain subgroups, with a deficit of tumors that had spread beyond the breast, especially among women who had used preparations containing the highest doses of oestrogen and progestogen. These findings are unexpected and need to be confirmed. Although these data represent most of the epidemiological evidence on the topic to date, there is still insufficient information to comment reliably about the effects of specific types of oestrogen or of progestogen. What evidence there is suggests, however, no major differences in the effects for specific types of oestrogen or of progestogen and that the pattern of risk associated with use of hormonal contraceptives containing progestogens alone may be similar to that observed for preparations containing both oestrogens and progestogens. On the basis of these results, there is little difference between women who have and have not used combined oral contraceptives in terms of the estimated cumulative number of breast cancers diagnosed during the period from starting use up to 20 years after stopping. The cancers diagnosed in women who have used oral contraceptives are, however, less advanced clinically than the cancers diagnosed in never users. Further research is needed to establish whether the associations described here are due to earlier diagnosis of breast cancer in women who have used oral contraceptives, to the biological effects of the hormonal contraceptives or to a combination of both. Little information is as yet available about the effects on breast cancer risk of oral contraceptive use that ceased more than 20 years before and as such data accumulate it will be necessary to re-examine the worldwide evidence.

Breast-cancer risk and oral contraceptive use in Slovenian women aged 25 to 54

Results of a previous case-control study in Slovenia showed a significantly elevated risk of breast cancer for ever-OC users aged 25 to 54 years. A further study was conducted in 1988-1990 in the whole of Slovenia, employing more rigorous epidemiological methodology. Cases were 624 women with breast cancer, aged 25 to 54 years, diagnosed at the Institute of Oncology in Ljubljana and other Slovenian hospitals. Controls were 624 women identified through the Population Registry, randomly selected and matched with cases by date of birth and commune of residence. Data were collected by personal interview, using coloured photographs of packages of all OC on the Slovenian market since 1964. A calendar of reproductive life events was constructed with participants to improve estimation of exposure. The adjusted odds ratio (OR) for ever-users was 1.09. There was no increase in risk with total duration of use, interval since first use, age at starting OC, according to use before or after first delivery and time between menarche and age at first use. Increased risk (OR = 2.92) was found for OC users at the time of diagnosis and for those stopping them less than 6 months before (current users). The risk was not increased for those who stopped OC more than 6 months before diagnosis. The results of this study are consistent with most studies showing no overall effect of OC in women aged till 55 years ever using them. Increased risk of breast cancer in current OC users suggests a possible promoting effect of the pill in susceptible women, and indicates the need for careful breast surveillance of these women while they are using OC and in the period immediately following cessation.

Leukaemia and residence near electricity transmission equipment: a case-control study

A population-based case-control study of leukaemia and residential proximity to electricity supply equipment has been carried out in south-east England. A total of 771 leukaemias was studied, matched for age, sex, year of diagnosis and district of residence to 1,432 controls registered with a solid tumour excluding lymphoma; 231 general population controls aged 18 and over from one part of the study area were also used. The potential for residential exposure to power frequency magnetic fields from power-lines and transformer substations was assessed indirectly from the distance, type and loading of the equipment near each subject's residence. Only 0.6% of subjects lived within 100 m of an overhead power-line, and the risk of leukaemia relative to cancer controls for residence within 100 m was 1.45 (95% confidence interval (CI) 0.54-3.88); within 50 m the relative risk was 2.0 but with a wider confidence interval (95% CI 0.4-9.0). Over 40% of subjects lived within 100 m of a substation, for which the relative risk of leukaemia was 0.99. Residence within 25 m carried a risk of 1.3 (95% CI 0.8-2.0). Weighted exposure indices incorporating measures of the current load carried by the substations did not materially alter these risks estimates. For persons aged less than 18 the relative risk of leukaemia from residence within 50 m of a substation was higher than in adults (PR = 1.5, 95% CI 0.7-3.4).