[Clinical and epidemiological cancer registries: two complementary sources of information on cancer incidence]

The law for the development of early cancer detection and quality assurance by clinical cancer registries regulates the duties, the funding, and the functions of the clinical cancer registries and thereby the cooperation between epidemiological and clinical registries. The necessary regulations and interfaces are described here. The progress in new concepts of cancer registration is triggered by fundamental changes in oncological care such as the increasing use of high-quality guidelines and the certification of oncological health-care units.

Population level survival of patients with chronic myelocytic leukemia in Germany compared to the US in the early 21st century

INTRODUCTION

The advent of tyrosine kinase inhibitors has produced 5-year survival of 90 + % for chronic myelocytic leukemia (CML) patients in clinical trials. However, population level survival has been lower, especially in older patients. Here, we examine survival of patients with CML in Germany and compare it to survival of patients in the United States (US).

METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results database in the US and 11 cancer registries in Germany. Patients 15-69 years old diagnosed with CML were included in the analysis. Period analysis for 2002-2006 was used to provide the most up-to-date possible estimates of five-year relative survival.

RESULTS

Five-year relative survival was 68.7% overall in Germany and 72.7% in the US. Survival was higher in the US for all age groups except for ages 15-39 years, but the difference was only statistically significant for ages 50-59 years (at 67.5% vs 77.7% in Germany and the US, respectively). Survival decreased with age, ranging from 83.1% and 81.9%, respectively, in Germany and the US for patients 15-39 years old to 54.2% and 54.5%, respectively, in patients 65-69 years old. Survival increased between 2002 and 2006 by 12.0% points in Germany and 17.1% points in the US.

CONCLUSIONS

Five-year survival estimates were higher in the US than in Germany overall, but the difference was only significant for ages 50-59 years. Survival did not equal that seen in clinical trials for either country, but strong improvement in survival was seen between 2002 and 2006.

Adjuvant therapy reduces the benefit of palliative treatment in disseminated breast cancer - own findings and review of the literature

BACKGROUND

Adjuvant treatment concepts have improved the 10-year cure rate of breast and colon cancer, but new treatments for metastatic disease have yielded only incremental benefit. If treatments for disseminated cancer were actually prolonging life rather than only increasing remission rates, this effect should have been documented over the last 30+ years. However, published data concerning advances in treatment for disseminated cancer have been contradictory.

PATIENTS AND METHODS

To add data-based information, we analyzed 2 sources: a regional population-based cancer registry (Hamburgisches Krebsregister, HKR), and a research cancer registry (Projektgruppe Internistische Onkologie, PIO). We compared the survival of several thousand patients with metastatic disease who received treatment only after dissemination with that of patients who received initial adjuvant therapy.

RESULTS

After adjuvant treatment, survival in patients with disseminated breast cancer is up to a third shorter than that of patients without adjuvant therapy.

CONCLUSIONS

In accordance with published evidence, we conclude that ineffective adjuvant treatment shortens survival after documentation of metastatic disease. This is probably due to the elimination of chemo-sensitive tumor cells or to the induction of resistance in remaining micrometatases. This negative effect on survival after dissemination has been shown clearly for breast cancer and is also probable for cancer of the colon and other sites.

Characterization of cyclic CSF flow in the foramen magnum and upper cervical spinal canal with MR flow imaging and computational fluid dynamics

CSF flow has been shown to exhibit complex patterns in MR images in both healthy subjects and in patients with Chiari I. Abnormal CSF flow oscillations, according to prevailing opinion, cause syringomyelia and other clinical manifestations that affect some patients with the Chiari I malformation. For this article, we reviewed the literature on PC MR of CSF flow, collected the published CFD studies relevant to CSF flow, and performed flow simulations. PC MR creates cine and still images of CSF flow and measurements of flow velocities. CFD, a technique used to compute flow and pressure in liquid systems, simulates the CSF flow patterns that occur in a specific geometry or anatomy of the SAS and a specific volume of flow. Published PC MR studies show greater peak CSF velocities and more complex flow patterns in patients with Chiari I than in healthy subjects, with synchronous bidirectional flow one of the characteristic markers of pathologic flow. In mathematic models of the SAS created from high-resolution MR images, CFD displays complex CSF flow patterns similar to those shown in PC MR in patients. CFD shows that the pressure and flow patterns vary from level to level in the upper spinal canal and differ between patients with Chiari and healthy volunteers. In models in which elasticity and motion are incorporated, CFD displays CSF pressure waves in the SAS. PC MR and CFD studies to date demonstrate significant alterations of CSF flow and pressure patterns in patients with Chiari I. CSF flow has nonlaminar complex spatial and temporal variations and associated pressure waves and pressure gradients. Additional simulations of CSF flow supplemented by PC MR will lead to better measures for distinguishing pathologic flow abnormalities that cause syringomyelia, headaches, and other clinical manifestations in Chiari I malformations.

Cancer survival analysis in Hamburg 1995-2003: assessing the data quality within a population-based registry

INTRODUCTION

Population-based cancer survival analysis constitutes valuable reference material for the clinical field of oncology. The objectives of this study were to assess the quality of the Hamburg Cancer Registry's (HCR) database in this respect, to perform survival analyses by means of selected sites, and to evaluate the results in relation to prevalent opinions and external estimates.

METHODS

Data quality was assessed by the proportion of cases documented as diagnosed at death, external estimates of completeness, reliability of follow-up, histological verification and information on stage. Included were first primary malignancies of the colon (ICD10 C18, n=4,544), female breast (C50, n=9,259), prostate (C61, n=5,707) and urinary bladder (C67, D09.0, n=3,148), diagnosed in Hamburg residents 1995-2003. Observed and relative survival (OS, RS) were estimated by site, sex, time, age and stage.

RESULTS

Regarding female breast cancer in Hamburg, high levels of data quality and completeness exist while the explanatory power concerning malignancies of the colon, prostate and urinary bladder is limited. Age-standardised 5-year relative cancer survival estimates amounted for female breast to 81%, for colon to 49% (male) and 52% (female), for prostate to 81% and for urinary bladder to 71% (male) and 62% (female).

CONCLUSION

The study demonstrates the capacities and limitations of an epidemiological cancer registry to produce convincing survival estimates for clinical use, under the terms of a voluntary case reporting system.

Menopausal hormone therapy and risk of clinical breast cancer subtypes

BACKGROUND

Breast cancer is a heterogeneous disease with subtypes that may vary in their etiologies. Menopausal hormone therapy has been associated more strongly with lobular and tubular than ductal histologic types and with tumors that are smaller, hormone receptor-positive, and of lower grade. At the same time, correlations have been observed between histology and clinical characteristics. To identify those tumor subtypes most strongly associated with hormone therapy use, it is necessary to disentangle these interrelationships.

METHODS

Based on 3,464 postmenopausal breast cancer cases and 6,657 controls from the population-based Mammary carcinoma Risk factor Investigation study, we used polytomous logistic regression to evaluate associations between hormone therapy use and risk of invasive breast cancer subtypes. We assessed variations in risk for selected tumor characteristics among histologic and hormone receptor subtypes, both overall and for specific hormone therapy regimens.

RESULTS

Lobular and mixed types showed less variation by prognostic factors than did ductal tumors. Current hormone therapy use had the strongest associations with prognostic variables in estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive ductal tumors and in lobular tumors regardless of ER/PR status, with little effect on ER/PR-negative ductal tumors. The observed associations varied minimally by hormone therapy type or regimen.

CONCLUSION

Current hormone therapy use was associated with more favorable breast cancer characteristics for ductal tumors but had less effect on prognostic characteristics in women with lobular tumors. Both histologic type and estrogen receptor/progesterone receptor status seem to be important in explaining the role of hormone therapy in the etiology of breast cancer subtypes.

Das maligne Melanom der Haut in epidemiologischen Krebsregistern in Deutschland - Inzidenz, klinische Parameter, Variationen in der Erhebung

PURPOSE

To exclude bias of registration evidenced by relevant differences among German cancer registries in the incidence of malignant melanoma (melanocarcinoma).

METHODS

Cancer registries in the Federal German states of Hamburg, Schleswig-Holstein, Bremen, Rhineland-Palatinate, Saarland, the Munich District and the County of Münster featured registration data of malignant melanoma diagnosed in 2000 A. D. Figures and incidence rates, distribution of T-stage of the primary tumour were analysed as well as the distribution of sources reporting melanoma to the registries. Details of outpatient treatment of cutaneous melanoma by dermatologists in private practice were investigated.

RESULTS

Data of 2,471 malignant melanoma cases were analysed. The highest age standardised incidence rates were 15.7 per 100,000 women and 19 per 100,000 men while the lowest rates were reported as 7.8 and 6.6 per 100,000, respectively (European standard). The proportion of stage T1 tumours varied between 21.5 and 59.2 %. We observed remarkable variations in the structure of reporting sources among the registries. The proportion of reports from dermatologists in private practice varied between 2.2 and 62 %, with higher proportions associated with more T1-T2 tumours but also lower completeness of stage reports. No clear association was identified between incidence of melanoma and reporting sources.

CONCLUSION

Malignant melanomas of smaller size (T1-T2) are reported more frequently in an outpatient setting but very often without data. Hospital departments of dermatology contribute high-quality data with better completeness especially for later stage melanomas. Desirable inclusion of notifications from nationwide operating dermatopathology laboratories is complicated by the Federal German structure of cancer registration. Especially in case of malignant melanoma of the skin notification reports from all sectors of the health care system are imperative for valid epidemiological results.

Lead exposure by drinking water: an epidemiologial study in Hamburg, Germany

Study objective was to investigate the extent of lead exposure via tap water in Hamburg and the relevance of preventive strategies. Two hundred and forty-eight non-smoking young women participated in the cross-sectional study program and 52 women completed the intervention program. In the cross-sectional study program most women (N = 178) didn't know anything about the material of the plumbing system at their homes. Participants with lead in the tap water above the detection limit of 5 microg/l (N = 142) showed significantly higher blood lead levels (median 31 microg/l) compared to those with no detectable lead in the tap water (N = 106; median blood lead 24 microg/l, p < = 0.001). There is a close correlation between the average lead concentration in the tap water and blood lead concentrations (N = 142 value pairs, Spearman's rho 0.43, p < = 0.0001). In the intervention program, the women were asked to minimize exposure by flushing water or to exclude it by consuming bottled water. Intervention lowered blood lead-level significantly (median decrease of 11 microg/l, p < = 0.001). "Minimizers" could lower their blood lead levels by about 21% of the initial value, "excluders" by about 37% (ns, p < = 0.17). The majority judged neither minimizing nor excluding tap water as practicable health preventive behaviour pattern in the long run. Lead in tap water stands for an avoidable surplus exposure. These results underline the relevance of health care preventive measures for the most sensitive groups.

Activation of A(3) receptors by endogenous adenosine inhibits synaptic transmission during hypoxia in rat cortical neurons

PURPOSE

The aim of our study was to characterize the influence of A(3) receptors on synaptic potentials (PSPs) in pyramidal cells from the rat cingulate cortex during hypoxia.

METHODS

Intracellular recordings (n=49) were taken from slice preparations. PSPs were evoked by electrical stimulation.

RESULTS

Hypoxia (95%N(2)-5%CO(2), 5 min) reduced the amplitude of the PSPs significantly. The effect was more pronounced in the presence of adenosine re-uptake inhibitor S-(p-nitrobenzyl)-6-thioguanosine (NBTG) and deaminase inhibitor erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA); the effect was completely reversed by bovine adenosine deaminase. Hypoxic inhibition induced after A(1) receptor blockade with 1,3-dipropyl-8-cyclopentylxanthine (DPCPX) in the presence of NBTG was completely reversed by the A(3) antagonist 9-chloro-2-(2-furanyl)-5-[(phenylacetyl)amino]-1,2,4-triazolo[1,5-c]quinazoline (MRS 1220), indicating the involvement of A(3) receptors in hypoxic PSP inhibition. This was confirmed by A(3) agonist N(6)-(3-iodobenzyl)-adenosine-5'-N-methylcarboxamide (IB-MECA) inhibiting PSPs. The effect of IB-MECA was blocked by the rat A(3) receptor-selective antagonist 3-propyl-6-ethyl-5-[(ethylthio)carbonyl]-2-phenyl-4-propyl-3-pyridinecarboxylate (MRS 1523) and was not observed in the presence of G-protein inhibitor guanosine-5'-O-2-thiodiphosphate (GDP-beta-S).

CONCLUSION

We conclude that a high level of endogenous adenosine, which occurs during hypoxia, activates A(3) receptors. Their activation contributes to PSP inhibition by adenosine during hypoxia.

Head injuries in skiers and snowboarders in British Columbia

BACKGROUND

At the Vancouver General Hospital Neurosurgical Service there have been a significant number of seriously brain injured snowboarders, seemingly out of proportion to the number of skiers. The purpose of this study was to determine whether snowboarders suffered more serious head injuries than skiers in the Vancouver catchment area.

METHODS

The British Columbia Trauma Registry was searched for patients incurring head injuries while skiing or snowboarding on British Columbia mountains during the period from January 1992 to December 1997. Patients were included if they were admitted to hospital and underwent neurosurgical consultation.

RESULTS

A total of 40 skiers and 14 snowboarders met the above criteria. Of the skiers, 15% sustained a severe head injury by Glasgow Coma Score, another 30% sustaining moderate head injuries, while 29% of snowboarders had a severe injury and 36% a moderate injury. A concussion was present in 60% of the skiers and 21% of the snowboarders. Snowboarders suffered an intracranial hemorrhage in 71% of the cases compared to 28% of the skiers. A craniotomy was performed acutely in 10% of skiers and in 29% of snowboarders. Three deaths occurred as a direct result of head injury, one while snowboarding. All but one of the surviving skiers were able to return home, whereas four of 13 surviving snowboarders required additional inpatient rehabilitation or transfer to another acute hospital for ongoing care.

CONCLUSIONS

Snowboarders suffer more significant head injuries compared to skiers in this series and are much more likely than skiers to require an intracranial procedure. In our opinion, this indicates that additional safety measures, in particular the use of mandatory helmets, should be considered by ski areas and their patrons.

[Development of minimal requirements for site assessment and monitoring to estimate exposure in environmental medicine--the Hamburg approach]

As a further step towards quality management in environmental medicine the Hamburg Association of Panel Physicians and the Hamburg Department of Labour, Health and Welfare developed a consensus paper concerning the handling of indoor related problems. It focuses on the cooperation between environmental physicians and engineers. A critical point in the process of environmental health risk assessment is the selection of either human biomonitoring or environmental monitoring. Further well-known problems are quality of measures and process documentation. Accurate, reliable measures of individual exposure are an essential need for physicians who have to judge the potential impact of environmental contaminants on human health. The approach proposed in this paper was chosen to enable the patient and the physician to benefit from the special knowledge of environmental engineers on indoor related problems. The procedure and criteria might help to reduce misclassifications of diseases and the amount of measures with no medical relevance and to establish scientifically valid associations between health outcomes and exposures to environmental contaminants.

Value of postoperative surveillance imaging in the management of children with some common brain tumors

The rationale for obtaining surveillance computerized tomography (CT) scans or magnetic resonance (MR) images in pediatric patients with brain tumors is that early detection of recurrence may result in timely treatment and better outcome. The purpose of this study was to investigate the value of surveillance cranial images in a variety of common pediatric brain tumors managed at a tertiary care pediatric hospital. A retrospective chart review was performed of children with astrocytoma of the cerebral hemisphere, cerebellum, optic chiasm/hypothalamus, or thalamus; cerebellar or supratentorial high-grade glioma; supratentorial ganglioglioma; posterior fossa or supratentorial primitive neuroectodermal tumor (PNET); and posterior fossa ependymoma. Data were analyzed to determine the frequency with which recurrences were identified on a surveillance image and how the type of image at which recurrence was identified related to outcome. In 159 children, 17 of 44 recurrences were diagnosed by surveillance imaging. The percentage of recurrences identified by surveillance imaging was 64% for ependymoma, 50% for supratentorial PNET, 43% for optic/hypothalamic astrocytoma, and less than 30% for other tumors. The rate of diagnosis of recurrence per surveillance image varied from 0% to 11.8% for different tumor types. Only for ependymomas did there appear to be an improved outcome when recurrence was identified prior to symptoms. Our results indicate that, using the protocols outlined in this study, surveillance imaging was not valuable in identifying recurrence of cerebellar astrocytoma or supratentorial ganglioglioma during the study period, but was probably worthwhile in identifying recurrence of posterior fossa ependymoma and optic/hypothalamic astrocytoma and, possibly, medulloblastoma. Surveillance protocols could be made more effective by individualizing them for each type of tumor, based on current data on the patterns of recurrence.

[Staphylococcus aureus in poultry--biochemical characteristics, antibiotic resistance and phage pattern (author's transl)]

In a poultry processing plant in northern Germany 1412 swabs were taken from poultry carcasses together with 608 swabs from the personnel. The broilers came from 22 different chicken farms. The swabs taken from the poultry and those taken from the personnel proved to be 35% and 48% Staph. aureus positive respectively. The swabs taken from the feathers and from the skin were staphylococcal positive at a higher level (47%) than the swabs taken from the cloaca (19%) and the throat (23%). Between 8% and 63% of the animals from the various chicken farms were Staph. aureus positive. The frequency of staphylococcal contamination increased during the course of slaughter. 57% of the swabs taken from the gloves and the hands and 42% from the aprons of the personnel were Staph. aureus positive. Some biochemical properties, the phage patterns, and the antibiotic resistance against oleandomycin, erythromycin, bacitracin, streptomycin, tetracyclin, penicillin, chloramphenicol, virginiamycin and flavomycin were determined from 445 poultry and 345 personnel Staph. aureus isolates. Only small differences could be established between both sources in this way. Only 20% of the personnel and 34% of the chicken strains were resistant to antibiotics. In the strains collected from personnel, penicillin-resistance predominated while the poultry isolates showed predominantly tetracyclin-resistance. Of all antibiotics applied nutritively in the chicken fattening, there was a higher resistance only against oleandomycin (11% of the poultry strains). Between the chicken farms there was a different frequency of resistance (0--68%). The source of the staphylococci could be determined for only some of the strains. Only 2.5% of the chicken isolates showed characteristics described in the literature to be "poultry-specific", whereas 37% of the personnel and 24% of the poultry isolates were shown to be "human-specific" strains. It seems that the vast majority of the staphylococci originated from the slaughterhouse personnel. The rest of the strains differed in varying combinations of their properties from the given species characteristics. Although Staph. aureus was brought into the slaughterhouse by the poultry, the contaminations of the final product seemed to originate mainly from human beings.