Gender and immunosuppression impact on Merkel cell carcinoma diagnosis and prognosis. A population based cohort study

Background

Merkel cell carcinoma (MCC), a rare cutaneous neuroendocrine endocrine tumour is increasing in incidence, and continues to carry a poor prognosis.

Objectives

The objectives of this study were to examine all Irish cases of MCC from 1 January 1994 over 2 decades, focusing on gender and organ transplantation recipients (OTRs). Cases were identified from the National Cancer Registry of Ireland. Covariates of interest included age, body site, period of diagnosis, deprivation‐status and history of non‐melanoma skin cancer (NMSC).

Results

In total 314 MCC cases were identified. A female predominance was noted (53.8%). Comparison between age‐standardised rates between the earliest period (1994–1996) with the latest period (2012–2014) showed an increase of 105% in total. The trend in age‐standardised incidence rates were noted to be increasing significantly (p = 0.0004). Average age at diagnosis was 77.6 years (male 75.1 years, female 79.7 years). Overall, the majority of MCC cases presented on the head and neck (n = 170, 54.1%). Differences in anatomical location of MCCs were noted between genders. Males were found to be more likely to have a history of previous NMSCs (males n = 73 [57.9%], females n = 53 [42.1%]). Thirty‐one percentage of patients died from MCC, average survival was 3.5 years in those who died of this malignancy. Ten organ transplant recipients developed MCC. OTR who developed MCC were diagnosed at a younger average age of 65.1 years. Standardized incidence ratio for MCC in OTR was 59.96. A higher proportion of OTR died from MCC (70%), with a shorter median survival of 0.14 years. In competing risks regression, gender was not significantly associated with risk of dying, females having a non‐significantly higher hazard of dying. Organ transplant recipients and patients from less deprived areas were at greater risk of dying from MCC.

Conclusions

This population based study provides epidemiological, clinical and outcome data for MCC over a 20‐year period.

Penile cancer in Ireland - A national review

OBJECTIVE

Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival.

SUBJECTS AND METHODS

All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival.

RESULTS

360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis.

CONCLUSION

This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland.

LEVEL OF EVIDENCE

2b.

An 18 year population-based study on site of origin and outcome of patients with peritoneal malignancy in Ireland

Peritoneal malignancy (PM) is predominantly metastatic spread from advanced gastrointestinal or gynaecological cancer. PM is generally considered incurable and therefore has rarely been the focus of novel therapeutic strategies. This study assessed patterns and survival outcomes for patients with PM in Ireland. The National Cancer Registry Ireland database was interrogated to identify patients diagnosed with PM during the period 1994-2012. Patient and tumour characteristics were retrieved and survival outcomes calculated. 5791 patients were diagnosed during the study period. Median age at diagnosis was 68 years; females accounted for 62%. The incidence increased annually from 228 in 1994 to 401 in 2012. Primary PM accounted for 3% of cases. Colorectal (22%), ovarian (16%) and gastric (13%) cancers accounted for the majority of cases of secondary PM. Almost 75% of patients had PM at initial presentation. Almost 40% of patients (n = 2274) underwent surgical intervention, while 44% (n = 2560) had tumour directed chemotherapy. The median survival (MS) in patients with secondary PM was 6.6 months, and did not improve significantly during the study period. Outcomes were best in patients with ovarian cancer (MS 15.9 months) and colorectal cancer (MS 14.3 months) and worst in patients with lung (MS 2.4 months) and pancreas (MS 1.9 months) cancers. This is the first population-based study from Ireland to report the incidence and outcomes for PM. PM is more common than previously reported and survival remains poor. These findings highlight the need for greater clinician awareness and the need to focus on new therapeutic approaches to improve patient outcomes.

Have developments in palliative care services impacted on place of death of colorectal cancer patients in Ireland? A population-based study

BACKGROUND

Whether developments in palliative care have impacted on where cancer patients die is unknown. We investigated time trends in place of death for colorectal cancer.

METHODS

Details were abstracted on 10,175 colorectal cancer deaths during 1994-2004. Time trends were analysed by joinpoint regression.

RESULTS

Nearly half (49%) of deaths occurred in acute hospitals, 29% at home, 13% in hospices and 7% in nursing homes. Hospital deaths were unchanged over time. Hospice deaths rose from 6% in 1994 to 17% in 2003. Home deaths decreased significantly, but only in health boards with hospices [estimated annual percentage change (EAPC) = -3.6%, 95%CI -4.19 to -2.97%, p < 0.001]. Nursing home deaths rose significantly in areas without hospices (EAPC = 8.0%, 95%CI 2.27 to -13.94%, p = 0.011).

CONCLUSIONS

Most colorectal cancer deaths occur in hospital. Availability of hospice facilities is a key determinant of where the burden of death falls. The results suggest unmet demand for hospice care in Ireland.

Where do people with lung cancer die and how is this changing? A population-based study

Investigating trends in where cancer patients die may help inform decisions about how healthcare should be organised to support those in need of end-of-life care. We analysed time trends in place of death for lung cancer during 1994-2005, based on 18,078 death certificates. Time trends were analysed by joinpoint regression. 9,485 (53%) deaths occurred in an acute hospital, 5,239 (29%) at home, 2,178 (12%) in hospices and 728 (4%) in nursing homes. Hospice deaths rose from 7% (108/1539) in 1994 to 15% (234/1560) in 2003, falling slightly in 2004-05. Hospital deaths were unchanged over time, but were more common in areas without hospices. Home deaths decreased significantly (annual percentage change (APC)=-2.2%, 95%CI -3.0% to -1.3%). Nursing home deaths rose significantly (APC=5.7%, 95%CI 2.5% to 8.9%). These trends were not explained by temporal changes in the age-sex distribution of deaths. Despite evidence suggesting most cancer patients would prefer to die at home, and developments in palliative care services, home deaths are declining and most lung cancer deaths occur in hospital.

Improved malignant melanoma prognosis at a consultant-delivered multidisciplinary pigmented lesion clinic in Cork

Early detection and excision is the only effective treatment for malignant melanoma. To assess the effect of a consultant-delivered, rapid-access pigmented lesion clinic (PLC) established at the South Infirmary-Victoria University Hospital (SIVUH), we analyzed melanoma tumour-stage prior to (1998-2002) and after (2003-2007) the advent of the PLC. Patients attending SIVUH had a greater proportion of early-stage tumours (65.3%) compared to the rest of Cork (51.2%), County Cork as a whole (56.7%) and all of Ireland (57.4%). The proportion of SIVUH males with early-stage tumours was statistically significantly higher than the rest of County Cork (chi2 = 11.23, P < 0.05). The proportion of patients > 50y with early-stage tumours was also statistically significantly higher than the rest of County Cork (chi2 = 18.88, P < 0.05), the whole of County Cork (chi2 = 7.84, P < 0.05) and all of Ireland (chi2 = 9.67, P < 0.05). We believe that the early detection and improved prognosis of Cork melanoma patients is at least partly due to the PLC.

Mortality predictions for esophageal, stomach, and pancreatic cancer, Ireland, up to 2015

BACKGROUND AND AIM OF THE STUDY

An analysis was undertaken to predict numbers of esophageal, stomach, and pancreatic cancer deaths and their World age standardized mortality rates (WASMRs) per 100,000 person years (100,000 PY-1) in Ireland for the years 2005, 2010 and 2015.

METHODS

Linear and log-linear Poisson regression models were applied to 1950-2002 Irish cancer mortality data.

RESULTS

By 2015, esophageal cancer WASMR for males is expected to rise to 9.1 100,000 PY-1, but for females to fall to 2.3 100,000 PY-1. In women under 65 yr, the WASMR is expected to decline to 0.8 100,000 PY-1 but to increase to 3.6 100,000 PY-1 in men. The stomach cancer WASMR for males is predicted to decrease to 5.3 100,000 PY-1 and for females to 2.9 100,000 PY-1. In males under 65 yr, the WASMR is predicted to fall to 1.7 100,000 PY-1 and to 1.0 100,000 PY-1 in women. The male WASMR for pancreatic cancer is predicted to decrease to 5.9 100,000 PY-1 and to 4.7 100,000 PY-1 in women. In men under 65 yr, the WASMR is predicted to drop to 1.7 100,000 PY-1 and to fall in women to 1.2 100,000 PY-1.

CONCLUSIONS

Apart from male esophageal cancer, the findings would indicate that declines in Irish WASMRs for these three cancer types are expected to occur by 2015.

Mortality predictions for colon and anorectal cancer for Ireland, 2003-17

OBJECTIVE

Colorectal cancer mortality predictions for Ireland are presented for all ages and for the age group 0-64 years.

METHODS

Log and log-linear Poisson regression modelling was fitted to colorectal cancer mortality data for each year between 1950 and 2002 to predict average European age standardized mortality rates (EASMRs) per 100,000 person years (100,000 PY(-1)) and average numbers of deaths.

RESULTS

EASMRs for colon cancer are predicted to fall to 17.3 100,000 PY(-1) (95%PI 14.4, 20.2) in men and to 8.4 100,000 PY(-1) (95%PI 6.9, 10.2) in women by 2013-17. EASMRs for anorectal cancer are also predicted to fall to 8.0 100,000 PY(-1) (95%PI 6.6, 9.5) in men and to 3.0 100,000 PY(-1) (95%PI 2.3, 3.8) in women by this time. Truncated EASMRs for colon cancer for those aged between 0 and 64 years are predicted over the next 15 years to fall from their current levels to 4.4 100,000 PY(-1) (95%PI 3.0, 5.8) in men and to 2.3 100,000 PY(-1) (95%PI 1.5, 3.2) in women. For anorectal cancer, truncated EASMRs for those aged between 0 and 64 years are also predicted over the next 15 years to fall from their current levels to 2.9 100,000 PY(-1) (95%PI 2.0, 3.8) in men and to 0.9 100,000 PY(-1) (95%PI 0.4, 1.3) in women.

CONCLUSIONS

Ireland currently has one of the highest colorectal mortality rates in the developed world but recent downward trends, the advent of new screening tests and well targeted public health promotion programmes may lead to further reductions.

Delays in treatment in the cancer services: impact on cancer stage and survival

This study describes waiting times for cancer treatment in Ireland, tests for differences between health board areas and investigates if delay affected cancer stage or prognosis. We measured the times between referral, outpatient attendance and treatment for all patients diagnosed with five common cancers in Ireland in 1999. There was a four-fold spread of waiting time between the 25th and 75th centile. The time from referral to treatment was shortest for breast cancer (median 4 weeks), twice this for colorectal cancer, lung cancer and lymphoma, and 15 weeks for prostate cancer. Delays varied significantly, but not consistently, between health boards. Patients with longer waiting times generally had less advanced disease and better survival, suggesting that typical delays are not of clinical significance, but that patients with advanced disease are probably being "fast-tracked" by GPs and hospitals.