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.

Morphometric analysis of the distal femur in total knee arthroplasty and native knees

AIMS

Analysis of the morphology of the distal femur, and by extension of the femoral components in total knee arthroplasty (TKA), has largely been related to the aspect ratio, which represents the width of the femur. Little is known about variations in trapezoidicity (i.e. whether the femur is more rectangular or more trapezoidal). This study aimed to quantify additional morphological characteristics of the distal femur and identify anatomical features associated with higher risks of over- or under-sizing of components in TKA.

METHODS

We analysed the shape of 114 arthritic knees at the time of primary TKA using the pre-operative CT scans. The aspect ratio and trapezoidicity ratio were quantified, and the post-operative prosthetic overhang was calculated. We compared the morphological characteristics with those of 12 TKA models.

RESULTS

There was significant variation in both the aspect ratio and trapezoidicity ratio between individuals. Femoral trapezoidicity was mostly due to an inward curve of the medial cortex. Overhang was correlated with the aspect ratio (with a greater chance of overhang in narrow femurs), trapezoidicity ratio (with a greater chance in trapezoidal femurs), and the tibio-femoral angle (with a greater chance in valgus knees).

DISCUSSION

This study shows that rectangular/trapezoidal variability of the distal femur cannot be ignored. Most of the femoral components which were tested appeared to be excessively rectangular when compared with the bony contours of the distal femur. These findings suggest that the design of TKA should be more concerned with matching the trapezoidal/rectangular shape of the native femur.

TAKE HOME MESSAGE

The distal femur is considerably more trapezoidal than most femoral components, and therefore, care must be taken to avoid anterior prosthetic overhang in TKA

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.

Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty - why?

The aim of this study was to investigate the relationship between the geometry of the proximal femur and the incidence of intra-operative fracture during uncemented total hip arthroplasty (THA). We studied the pre-operative CT scans of 100 patients undergoing THA with an uncemented femoral component. We measured the anteroposterior and mediolateral dimensions at the level of division of the femoral neck to calculate the aspect ratio of the femur. Wide variations in the shape of the femur were observed, from round, to very narrow elliptic. The femurs of women were narrower than those of men (p < 0.0001) and small femurs were also narrower than large ones. Patients with an intra-operative fracture of the calcar had smaller and narrower femurs than those without a fracture (p < 0.05) and the implanted Corail stems were smaller in those with a fracture (mean size 9 vs 12, p < 0.0001). The variability of the shape of the femoral neck at the level of division contributes to the understanding of the causation of intra-operative fractures in uncemented THA.

National cancer incidence is estimated using the incidence/mortality ratio in countries with local incidence data: is this estimation correct?

BACKGROUND

In countries with local cancer registration, the national cancer incidence is usually estimated by multiplying the national mortality by the incidence/mortality (I/M) ratio from pooled registries. This study aims at validating this I/M estimation in France, by a comparison with estimation obtained using the ratio of incidence over hospital discharge (I/HD) or the ratio of incidence over health insurance data (long-duration diseases, I/LDD).

METHODS

This comparison was performed for 22 cancer sites over the period 2004-2006. In France, a longitudinal I/M approach was developed relying on incidence and mortality trend analyses; here, the corresponding estimations of national incidence were extracted for 2004-2006. The I/HD and I/LDD estimations were performed using a common cross-sectional methodology.

RESULTS

The three estimations were found similar for most cancers. The relative differences in incidence rates (vs. I/M) were below 5% for numerous cancers and below 10% for all cancers but three. The highest differences were observed for thyroid cancer (up to +21% in women and +8% in men), skin melanoma (up to +13% in women and +8% in men), and Hodgkin disease in men (up to +15%). Differences were also observed in women aged over 60 for cervical cancer. Except for thyroid cancer, differences were mainly due to the smoothing performed in the I/M approach.

CONCLUSION

Our results support the validity of I/M approaches for national estimations, except for thyroid cancer. The longitudinal version of this approach has, furthermore, the advantage of providing smoothed estimations and trend analyses, including useful birth-cohort indicators, and should thus be preferred.

[Diversity of incidence trend patterns: implications for carcinogenesis?]

OBJECTIVE

Cancers of the ENT, oesophagus and lungs are caused mainly by alcohol and/or tobacco consumption but have potentially heterogeneous latencies and dose-incidence relationships. The incidence of cancers having the same risk factors may vary in a similar way over time and space. The aim of the study was to identify groups of cancers with similar spatio-temporal incidence trends.

METHODS

Fifty thousand nine hundred and eighty cases of ten cancer types were collected between 1982 and 2002 in six French departments. The incidence levels and trends were assessed using an age-cohort random-effect model that took into account heterogeneity of incidence levels and trends between departments.

RESULTS

Three groups of cancer sites/types with similar spatio-temporal incidence trends were identified: (1) oral cavity, oropharynx, hypopharynx, larynx, oesophagus, and lung squamous cell carcinomas in which the incidence decreased similarly in time and space; (2) other types of lung cancer and lung adenocarcinomas whose incidence increased similarly; and (3) lung large- and small-cell carcinomas whose incidence trends were heterogeneous.

CONCLUSION

Using the tools of descriptive epidemiology different cancer groups with different temporal and spatial incidence trends were identified. This diversity suggests different latencies and different sensitivities of those groups to the main risk factors, alcohol and tobacco.

Identifying prevalent cases of breast cancer in the French case-mix databases

OBJECTIVES

Little is known about cancer prevalence due to a lack of systematic recording of cancer patient follow-up data. To estimate the annual hospital prevalence of breast cancer in the general population of the Isère department (1.1 million inhabitants) in the Rhône-Alpes region, the second largest region in France (6 million inhabitants), we used the inpatient case-mix data, available in most European countries, to develop a method of cancer case identification.

METHODS

A selection process was applied to the acute care hospital datasets among women aged 18 years or older, living in the Isère department and treated for breast cancer between 2004 and 2007. The first step in case selection was based on the national anonymous unique patient identifier. The second step consisted of retrieving all hospital stays for each case. The third step was designed to detect inconsistencies in the coding of the primary localization. An algorithm based on ICD-10 code for the hospital admission diagnosis was used to rule out hospitalizations unrelated to breast cancer. Five possible models for estimating prevalence were created combining selection steps with the admission diagnosis algorithm.

RESULTS

Hospital prevalence over the four-year period varied from 6073 breast cancer cases for the simplest model (first selection step without the admission diagnosis algorithm) to 4951 when the first selection step was associated with the breast cancer code as admission diagnosis. The model combining the third selection step with a breast cancer-specific admission reason provided 5275 prevalent cases.

CONCLUSION

The last model seems more appropriate for case-mix-data coding. Selecting admission diagnosis improved specificity. Combining all hospital stays for each patient has improved diagnostic sensitivity.

[Some interpretation of regional estimates of the incidence of cancer in France over the period 1980--2005]

Francim Network has already provided French national estimations of cancer incidence then regional estimations for Metropolitan France. The present technical note summarizes the underlying hypotheses and the limits of the method and suggests some aspects of interpretation of those regional results in terms of absolute numbers and of standardized rates. Results on "all cancers" illustrate those comments.

An overall strategy based on regression models to estimate relative survival and model the effects of prognostic factors in cancer survival studies

Relative survival provides a measure of the proportion of patients dying from the disease under study without requiring the knowledge of the cause of death. We propose an overall strategy based on regression models to estimate the relative survival and model the effects of potential prognostic factors. The baseline hazard was modelled until 10 years follow-up using parametric continuous functions. Six models including cubic regression splines were considered and the Akaike Information Criterion was used to select the final model. This approach yielded smooth and reliable estimates of mortality hazard and allowed us to deal with sparse data taking into account all the available information. Splines were also used to model simultaneously non-linear effects of continuous covariates and time-dependent hazard ratios. This led to a graphical representation of the hazard ratio that can be useful for clinical interpretation. Estimates of these models were obtained by likelihood maximization. We showed that these estimates could be also obtained using standard algorithms for Poisson regression.

Survival of cancer patients in France: a population-based study from The Association of the French Cancer Registries (FRANCIM)

We present the main results of the first population-based cancers survival study gathering all French registry data. Survival data on 205,562 cancer cases diagnosed between 01/01/1989 and 31/12/1997 were analysed. Relative survival was estimated using an excess rate model. The evolution of the excess mortality rate over the follow-up period was graphed. The analysis emphasised the effect of age at diagnosis and its variation with time after diagnosis. For breast and prostate cancers, the age-standardised five-year relative survivals were 84% and 77%, respectively. The corresponding results in men and women were 56% versus 58% for colorectal cancer and 12% versus 16% for lung cancer. For some cancer sites, the excess mortality rate decreased to low values by five years after diagnosis. For most cancer sites, age at diagnosis was a negative prognostic factor but this effect was often limited to the first year after diagnosis.

Keeping Data Continuous when Analyzing the Prognostic Impact of a Tumor Marker: An Example with Cathepsin D in Breast Cancer

The prognostic value of cathepsin D has been recently recognized, but as many quantitative tumor markers, its clinical use remains unclear partly because of methodological issues in defining cut-off values. Guidelines have been proposed for analyzing quantitative prognostic factors, underlining the need for keeping data continuous, instead of categorizing them. Flexible approaches, parametric and non-parametric, have been proposed in order to improve the knowledge of the functional form relating a continuous factor to the risk. We studied the prognostic value of cathepsin D in a retrospective hospital cohort of 771 patients with breast cancer, and focused our overall survival analysis, based on the Cox regression, on two flexible approaches: smoothing splines and fractional polynomials. We also determined a cut-off value from the maximum likelihood estimate of a threshold model. These different approaches complemented each other for (1) identifying the functional form relating cathepsin D to the risk, and obtaining a cut-off value and (2) optimizing the adjustment for complex covariate like age at diagnosis in the final multivariate Cox model. We found a significant increase in the death rate, reaching 70% with a doubling of the level of cathepsin D, after the threshold of 37.5 pmol mg(-1). The proper prognostic impact of this marker could be confirmed and a methodology providing appropriate ways to use markers in clinical practice was proposed.

Addition of oxaliplatin to continuous fluorouracil, l-folinic acid, and concomitant radiotherapy in rectal cancer: the Lyon R 97-03 phase I trial

PURPOSE

Oxaliplatin could increase the efficacy of fluorouracil (5-FU)/folinic acid chemoradiotherapy in rectal cancer. We tested three dose levels to identify a feasible oxaliplatin dose for combination therapy.

PATIENTS AND METHODS

Between February 1998 and April 2000, we included 17 rectal adenocarcinoma patients in a single-center phase I study. Patients had T4 rectal carcinoma, T1-T3 disease with colostomy refusal, or potentially operable T2/T3 M1 requiring local treatment. Pelvic radiotherapy was 45 Gy over 5 weeks, 1.8 Gy/fraction, with concomitant chemotherapy weeks 1 and 5. Chemotherapy was oxaliplatin 80, 100, or 130 mg/m2 2-hour infusion on day 1 followed by L-folinic acid 100 mg/m2/d intravenous bolus, and 5-FU 350 mg/m2/d continuous infusion on days 1 to 5 (FolfoR1). Six patients refusing surgery received additional contact radiotherapy +/- brachytherapy. Dose escalation proceeded if less than two of six patients had dose-limiting toxicity (DLT) at a given dose-level.

RESULTS

All except two patients completed treatment; patients at level 1 (prolonged grade 1 thrombocytopenia) and level 3 (prolonged cold-related dysesthesia) had no second chemotherapy course. Median follow-up is 14 months (range, 2 to 28 months). One elderly patient at dose level 1 had DLT asthenia, severe diarrhea and vomiting, and more than 10% weight loss. There were no other DLTs and no severe rectitis or gastrointestinal toxicity. There were objective responses at all doses and no progressions. Eight patients underwent radical surgery after chemoradiotherapy. Two had complete pathologic responses.

CONCLUSION

FolfoR1 seems feasible and effective. Dose escalation did not increase toxicity. Although the MTD was not reached in this study, we recommend oxaliplatin 130 mg/m2 for phase II studies because it is the dose determined from studies in metastatic patients with no toxicity when given concurrently with radiation.

Breastfeeding and risk of breast cancer: a metaanalysis of published studies

Evidence in favour of an association of breastfeeding with a breast cancer risk reduction remains limited and inconsistent. To evaluate the relation between breastfeeding and breast cancer, a meta-analysis based on a review of the literature was carried out, using as variables ever/never breastfeeding and duration of breastfeeding. Menopausal status at the time of diagnosis of breast cancer was considered to be a potential effect modifier. Only case-control studies could be included in the final analysis. A slight but significant decreased risk of breast cancer was observed in ever breastfeeding, compared with never breastfeeding parous women, using both the fixed and random-effect models. This decrease was more pronounced in non-menopausal women at the time of diagnosis of breast cancer and in long-term breastfeeding women. Hence, breastfeeding appeared to be a protective factor but was of small magnitude compared with other known risk factors for breast cancer. Whether this result should imply a modification in the attitude of both health care providers and women towards breastfeeding, which represents one of the few identified protective factors which is under the control of the mother, and is thus (theoretically) modifiable, remains questionable.

[Oral contraception and genetic factors in breast cancer: characteristics and limits of case-only studies]

The analysis of the interaction between environmental and genetic factors is a matter of increasing interest in cancerology. More particularly the discovery of the BRCAx family and the high cumulated incidence of familial breast cancers related to mutations of these proteins raised the issue of the differential effect of long term and/or early exposure to oral contraceptives in the presence of these mutations. The classical case-control design assumes the presence of a control group, which can be sometimes difficult to obtain from both the technical and ethical points of view. Case-only or case-case studies, which are based only on series of cases, making them apparently attractive, have been proposed to analyze more specifically the interaction term. The aim of the present paper is to review and discuss the methodological basis and main assumptions of the case-only design, and their applicability to breast cancer studies. The measure of the interaction between an environmental factor and a susceptibility genetic factor differs in an important aspect from the measure of the association between an environmental factor and a acquired tumoral genetic factor; this aspect is reminded.

The effect of nonhomogeneous clone length distribution on the progress of an STS mapping project

We provide both theoretical and simulation results on the progress of an STS mapping project in the presence of clone length inhomogeneity. For an example in which the genome comprises alternating regions of clones with short and long average length, the main conclusion is that the efficiency of the project is clearly decreased in the presence of such inhomogeneity. The case of deterministic clone length gives the worst progress. The general simulation algorithm we propose shows that strategies that space the anchors as regularly as possible do best: fewer contigs of larger average length are expected. The simulation algorithm can be used to study many statistical properties of the progress of any anchoring project.

[Prognostic importance of ambulatory arterial pressure monitoring in France. Initial results of the OCTAVE II study. OCTAVE II Research Group]

RATIONALE

Ambulatory blood pressure measurement (ABPM) is commonly used in clinical practice, whereas its added value to the management of hypertension is not definitely documented.

OBJECTIVE

The OCTAVE II study was launched in 1991 to explore the prognostic value of ABPM, compared to that of the gold standard, the clinical blood pressure measurement.

METHODS

Two hundred and six French cardiologists recruited 3569 participants over 18 years of age, provided they deemed ABPM was useful (mean age of 56 years, 52% of men, 65% already treated by antihypertensive drugs). The prognostic value of various blood pressure measurements, systolic or diastolic, clinical or ambulatory (diurnal, nocturnal or during 24 hours), has been assessed in multivariate models adjusted on the baseline characteristics associated with risk. The outcome was the occurrence of a major cardiovascular event, including stroke, myocardial infarction and cardiovascular death.

RESULTS

After an average follow-up of five years, cardiovascular morbidity was known for 85% of the participants, and their vital status for 91%. On the whole population, the best prognostic indicators were systolic blood pressure compared with diastolic, ABPM compared with clinical blood pressure measurements, and nocturnal ABPM compared with diurnal ABPM. In the untreated participants at baseline, cardiovascular risk regularly increased among the four groups: normotensives, white-coat hypertensives, dippers, non-dippers. Between the extreme categories, the cardiovascular event rate was multiplied by 6.5.

CONCLUSION

In this French population, ABPM and most of all its nocturnal component, was better correlated with cardiovascular prognosis. It remains to assess: 1) the general value of our findings, 2) the respective values of self blood pressure measurement versus ABPM, and 3) whether ABPM allows a better risk prevention.

[Hierarchies according to the level of evidence of source data, before their integration in the synthesis, in the matter of therapeutic efficacy]

The discipline therapeutic information uses the concept of the level of evidence for source data concerning therapeutic efficacy, and its ordering before integration in syntheses. In this paper we will start by considering the problems raised by the definition of the level of evidence in terms of the dimensions it covers. We have differentiated three components: clinical pertinance of the question asked, the methods used to reply and the quality of the data collected. Second, we will examine the different criteria important for each of these three dimensions. There are many criteria possible which do not all have the same weight, and thus for any non-arbitrary tool developed to enable the level of evidence to be ordered, it is necessary to know the weight of the different criteria. Thirdly, we will present the techniques used for working with multicriteria situations in econometrics which represent a methodology we propose using to apply in our context. To do so we need to build a 'reference' base for the level of evidence using 'experts' opinions which will help us to examine the weights of the different criteria. This approach, in conjunction with some epistemological and sociological considerations, may contribute to a better understanding of the different dimensions of this concept.

Risk of infectious diseases in children attending different types of day-care setting. Epicrèche Research Group

This population-based prospective cohort study compared the risk of recurrent infections in children attending family day care (< or = 3 children per family), small (10-20 children) day-care centers (DCCs), and large (> or = 40 children) DCCs. The parents of a total of 1,242 children participated in the study (97% of the families initially contacted). An infectious episode was defined as the acute occurrence of a new symptom lasting for at least 48 h and resulting in specific treatment. Two episodes were counted as such only if they were separated by a symptom-free week. Surveillance was under the responsibility of a nursing director and was similar for all three types of DCCs. During the 8.5-month follow-up period, 3,639 infectious episodes were recorded. Compared to those in family day-care, children attending small DCCs presented a higher risk for > or = 6 total infectious episodes [odds ratio (OR) = 2.4; 95% confidence interval (CI) = 1.6-3.7]; > or = 5 upper respiratory tract infections (OR = 2.2; 95% CI = 1.4-3.4); > or = 2 episodes of otitis media (OR = 2.6; 95% CI = 1.0-2.6); > or = 2 episodes of conjunctivitis (OR = 4.1; 95% CI = 2.1-8.2); and > or = 2 episodes of croup (OR = 4.1; 95% CI = 1.6-10.9). The risk for children attending large DCCs was intermediate between those in family day care and those in small DCCs.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug prescription in young children: results of a survey in France. Epicrèche Research Group

A 8.5-month prospective study was performed in the Rhône area of France to study the incidence of infectious diseases in children in day care, and the qualitative and quantitative aspects of drug prescriptions for young children. The families of 1.359 children agreed to participate (98.5% of those selected). During the follow-up period 3.605 infections episodes were reported and 10.706 medications were used, an average of 3.0 medications per episode. Antibiotics were used in the treatment of 2.333 infectious episodes (65%) amoxycillin (36%), cephalosporin (23%), macrolide (17%) and trimethoprim-sulphamethoxazole (9%). Acetylsalicylic acid and paracetamol were used 865- and 1.568-times, respectively. Drugs with multi-active components represented 11.3% of the total number of systemic medicines reported. Paracetamol was prescribed in 59% of cases in a multi-active component drug, whereas this type of product accounted for 83.5% of the antihistamines (used 932-times). The rationale behind the paediatric prescribing habits of French medical doctors is discussed in relation to results previously obtained in other European countries.