Sinonasal mucosal melanoma in The Netherlands between 2001 and 2021: a clinical and epidemiological overview of 320 cases

PURPOSE

Sinonasal mucosal melanoma (SNMM) is a rare malignancy, characterised by high (local) recurrence rates and poor survival. Comprehensive understanding of tumour etiology is currently lacking, which complicates adequate tumour treatment. Besides examining trends in incidence, this study aims to assess the association between clinical characteristics, treatment practices and patient outcomes, with the objective of establishing a baseline from which SNMM management can be enhanced.

METHODS

All newly diagnosed SNMM cases in The Netherlands between 2001 and 2021 were included using data from The Netherlands Cancer Registry (NCR).

RESULTS

A total of 320 patients were included. The annual incidence rate for the overall population was stable over the inclusion period with an annual percentage change (APC) of only - 0.01%. The 5-year overall survival (OS) and relative survival (RS) were 24.5 and 32.4%, respectively. Relative survival did not increase over time. The addition of adjuvant radiotherapy to surgery was not associated with a higher OS and RS compared to surgery alone.

CONCLUSION

Sinonasal mucosal melanoma is a rare disease with stable incidence rates in the Netherlands between 2001 and 2021. There has been no improvement in survival over the course of the inclusion period. The study reaffirms that adjuvant radiotherapy does not seem to improve patient outcomes. Given the generally poor outcomes for SNMM patients, novel therapeutic options ought to be considered in order to improve care.

Systemic therapy timing and use in patients with advanced melanoma at the end of life: A retrospective cohort study

Novel systemic therapies for advanced melanoma improve survival, but carry potential serious side effects and high costs. This study aimed to assess the timing and use of systemic therapies in the months before death. Patients diagnosed with advanced melanoma (July 2017-June 2020) who died before July 2020 were selected from the Netherlands Cancer Registry. We evaluated the timing of systemic therapies within 30 days and 3 months before death, and studied patient and tumor characteristics associated with systemic therapy use between diagnosis and death. Out of 1097 patients 68% received systemic therapy. Almost 25% and 10% started a new therapy within 90 days and within 30 days before death, respectively. Female sex, elevated LDH, BRAF mutation, poor ECOG performance status (≥3), and high comorbidity index reduced the odds of receiving immune therapy. Poor performance status and high comorbidity decreased the odds for both therapies. A considerable number of patients started systemic therapy shortly before death, emphasizing the importance of considering potential benefits and drawbacks through shared decision-making.

Brain metastases in adult patients with melanoma of unknown primary in the Netherlands (2011-2020)

BACKGROUND

Although patients with melanoma of unknown primary (MUP) have a better prognosis than similar-staged melanoma patients with known primary, the occurrence of brain metastases (BM) entails a serious complication. This study provides an overview of the incidence, treatment patterns, and overall survival (OS) of adult patients with BM-MUP in the Netherlands.

METHODS

BM-MUP cases were retrieved from the Netherlands Cancer Registry. Patient, disease and treatment-related characteristics were summarised using descriptive statistics. Overall survival (OS) was calculated by the Kaplan-Meier method, and the impact of prognostic factors on OS was assessed using Cox proportional hazard regression analyses.

RESULTS

Among 1779 MUP patients, 450 were identified as BM-MUP (25.3%). Of these patients, 381 (84.7%) presented with BM along with other metastases, while 69 (15.3%) had BM only. BM-MUP patients were predominantly male (68.2%), and had a median age of 64 years at diagnosis (interquartile range 54-71 years). Over time, the proportion of BM along other metastatic sites increased, and the occurrence of BM decreased (p = 0.01). 1-Year OS improved for the total population, from 30.0% (95% confidence interval (CI): 19.8-40.9%) in 2011-2012 to 43.6% (95%CI: 34.5-52.3%) in 2019-2020, and median OS more than doubled from 4.2 months (95%CI: 3.3-6.2 months) to 9.8 months (95%CI: 7.0-13.2 months). Patient's age, localisation of BM, presence of synchronous liver metastasis and treatment were identified as independent predictors of OS.

CONCLUSION

Notwithstanding the progress made in OS for patients with BM-MUP in the past decade, their overall prognosis remains poor, and further efforts are needed to improve outcomes.

Seasonal variation in diagnosis of cutaneous invasive melanoma and cutaneous squamous cell carcinoma: A nationwide study in the Netherlands

BACKGROUND

Currently, there is no study that has reported on the seasonal trends of skin cancer in the Netherlands. This study aimed to investigate seasonal variation in diagnosis of cutaneous melanoma (CM) and cutaneous squamous cell carcinoma (cSCC) focusing on different subgroups.

METHODS

CM diagnosed from 2001 till 2019 and cSCCs from 2001 till 2015 were selected from the Netherlands Cancer Registry. The monthly distribution of CM and cSCC diagnoses were evaluated. Summer-to-winter ratios (SWRs) were calculated overall and stratified by patient and tumour characteristics.

RESULTS

Significant increases in melanoma incidence were noted over the summer months (SWR 1.39 (CI 1.37-1.40)). This increase was less apparent for cSCCs, as higher incidence rates were observed in the months September-November (SWR 1.13 (CI 1.12-1.14)). The seasonal variation of CM was greater in women and younger people, in superficial spreading melanoma and lentigo maligna melanoma, for the extremities, in thinner lesions, and for stage I at diagnosis. The seasonal variation of cSCC was similar for both sexes, most marked in patients 45-69 and ≥ 70, and for the extremities.

CONCLUSIONS

Our findings showed a pronounced seasonal variation in the diagnosis of CM with a peak in the summer months. For cSCC, no evident peak was observed, but an increase in diagnosis was noted in fall. Both CM and cSCC showed strong seasonal effects for the extremities.

A nationwide study of the incidence and trends of first and multiple basal cell carcinoma in the Netherlands and prediction of future incidence

BACKGROUND

Basal cell carcinoma (BCC) is the most frequently diagnosed malignancy worldwide and an ever increasing annual incidence is observed. However, nationwide registries of BCCs are very rare and often extrapolation of the data was necessary to estimate the absolute number of diagnoses. Since September 2016, all histopathologically confirmed BCCs are registered in the Netherlands, due to developments in automatic notification and import in the Netherlands cancer registry. This offers the unique possibility to assess the nationwide population-based incidence of first and multiple BCC.

OBJECTIVES

The current study aims to assess nationwide incidence and trends of first and multiple BCC in the Netherlands and to predict incidence rates up to 2029.

METHODS

All patients with histopathologically confirmed BCC between 2001 and 2019 were selected from the population-based Netherlands Cancer Registry. Age-standardized incidence rates were calculated and trends were analyzed with use of the estimated annual percentage change. Prediction of BCC incidence rates up to 2029 was based on a regression model.

RESULTS

In total, 601,806 patients were diagnosed with a first BCC over the period 2001-2019. The age-standardized incidence rates for both men and women with a first BCC increased over these years from 158 to 304 and 124 to 274 per 100,000 person-years, respectively. For male and female patients aged between 30-39 years, decreases in annual incidences of -3.6% and -3.0% were found in recent years, respectively. For patients aged 50 years or older an ever increasing trend was found. A quarter of the patients with a first primary BCC developed one or more subsequent BCCs within three years. Increases in incidence of 30.4% (male) and 25.3% (female) is expected in the next 10 years.

CONCLUSIONS

BCC incidence doubled over the past decades. Trends seemed to stabilize in recent years for patients aged below 50 years. This might be a first sign of a decreasing trend. The incidence keeps rising in patients aged 50 years and older. In the next decade a further increase in BCC incidence is expected.

The Risk of Cutaneous Squamous Cell Carcinoma Among Patients with Type 2 Diabetes Receiving Hydrochlorothiazide: A Cohort Study

BACKGROUND

Because of continuous hyperglycemia and hyperinsulinemia and the use of photosensitizing drug, hydrochlorothiazide (HCTZ), the risk of cutaneous squamous cell carcinoma (cSCC) might be increased among patients with diabetes. This study aimed to estimate the risk of cSCC among HCTZ users with type 2 diabetes, and to determine whether thiazide-like diuretics, another drug in the same class with HCTZ, would be safer.

METHODS

We linked the benchmarking database in Dutch primary care, the Netherlands Cancer Registry, and the Dutch Personal Records Database (1998-2019). All 71,648 patients were included, except for those who had a history of skin cancer prior to cohort entry. We used Cox modeling to estimate the HRs and 95% confidence intervals for cSCC. The model was adjusted by cumulative exposure to each antihypertensive, age, sex, smoking, body mass index, blood pressure, serum creatinine, other confounding drug use at cohort entry, and cohort entry year.

RESULTS

There were 1,409 cSCC events (23 among thiazide-like diuretics users), during a follow-up of 679,789 person-years. Compared with no HCTZ use, the adjusted HRs for HCTZ use were 1.18 (1.00-1.40) for ≤2 years, 1.57 (1.32-1.88) for 2 to 4 years, and 2.09 (1.73-2.52) for >4 years. The HR was 0.90 (0.79-1.03) for an additional year of thiazide-like diuretic use.

CONCLUSIONS

In patients with diabetes, exposure to HCTZ for >2 years is associated with an increased risk of cSCC, whereas no increased risk associated with thiazide-like diuretics was observed.

IMPACT

The potential increased risk of cSCC should be a consideration when prescribing HCTZ, with thiazide-like diuretics offering a safer alternative.

Stage-specific trends in incidence and survival of cutaneous melanoma in the Netherlands (2003-2018): A nationwide population-based study

OBJECTIVE

To examine stage-specific trends in the incidence and survival of cutaneous melanoma in the Netherlands between 2003 and 2018, as well as the uptake of the sentinel lymph node biopsy (SLNB) and novel drugs during that period.

METHODS

Data were obtained from the nationwide population-based Netherlands Cancer Registry for all patients diagnosed with invasive primary cutaneous melanoma (n = 60,267). We presented age-standardized incidence rates, the proportion of patients with an SLNB, the proportion of patients who received a novel drug (for their primary diagnosis) and one- and five-year relative survival rates.

RESULTS

Between 2003 and 2018, the incidence rate increased from 10.9 to 23.9 for men and from 15.6 to 27.3 for women. This increase reflected the increasing incidence rate of patients with stage I and III. The proportion of patients with an SLNB increased from 23% to 64%. A reasonable increase was observed in the proportion of patients with a positive outcome (from 2% to 11%). For patients with stage IV, there was a shift from chemotherapy towards novel drugs as from 2013. The five-year relative survival rate increased from 81% to 92% for men and from 88% to 96% for women. This increase reflected the increasing five-year relative survival rate of patients with stage II, III, and IV.

CONCLUSION

We observed an increase in incidence for patients with stage I and III and an improvement in survival for patients with stage II, III and IV. These trends can be partly explained by the introduction of the SLNB and the novel drugs.

Health-Related Quality of Life, Satisfaction with Care, and Cosmetic Results in Relation to Treatment among Patients with Keratinocyte Cancer in the Head and Neck Area: Results from the PROFILES Registry

BACKGROUND

Little is known about the impact of keratinocyte cancer (KC) and its treatment on health-related quality of life (HRQoL).

OBJECTIVES

The objectives of the present study were (1) to evaluate HRQoL among patients with KC in a population-based setting and compare this with an age- end sex-matched normative population and (2) to compare HRQoL, satisfaction with care, and cosmetic results among patients who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy.

METHOD

A random sample of 347 patients diagnosed with cutaneous basal cell or squamous cell carcinoma in the head and neck area between January 1, 2010, and December 31, 2014, were selected from the Netherlands Cancer Registry (NCR) and were invited to complete a questionnaire on HRQoL, satisfaction with care, and cosmetic results. Data were collected within Patient-Reported Outcomes Following Initial Treatment and Long-term Evaluation of Survivorship (PROFILES). Outcomes were compared to an age- and sex-matched normative population.

RESULTS

Two hundred fifteen patients with KC returned a completed questionnaire (62% response). Patients with KC reported better global quality of life (79.6 vs. 73.3, p < 0.01) and less pain (p < 0.01) compared to the normative population. No statistically significant differences in HRQoL, satisfaction with care, and cosmetic results were found between patients with KC who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy.

CONCLUSIONS

The impact of KC and its treatment seems relatively low and more positive than negative as patients reported better HRQoL compared to an age- and sex-matched normative population, probably due to adaptation. No statistically significant differences between treatment types were found concerning HRQoL, patient satisfaction, and cosmetic results. This information could be used by healthcare professionals involved in KC care to improve patients' knowledge about different aspects of the disease as patient's preference is an important factor for treatment choice.

Sex matters: men with melanoma have a worse prognosis than women

BACKGROUND

In Europe, one of the highest melanoma incidences is found in the Netherlands. Like in several other European countries, females are more prone to develop melanoma as compared to males, although survival is worse for men.

OBJECTIVE

To identify clinicopathological gender-related differences that may lead to gender-specific preventive measures.

METHODS

Data from the Dutch Nationwide Network and Registry of Histopathology and Cytopathology (PALGA) were retrieved from patients with primary, cutaneous melanoma in the Netherlands between 2000 and 2014. Patients initially presenting as stage I, II and III without clinically detectable nodal disease were included. Follow-up data were retrieved from the Netherlands Cancer Registry. Gender-related differences were assessed, and to compare relative survival between males and females, multivariable relative excess risks (RER) were calculated.

RESULTS

A total of 54.645 patients were included (43.7% men). In 2000, 41.7% of the cohort was male, as compared to 47.3% in 2014 (P < 0.001). Likewise, in 2000, 51.5% of the deceased cohort was male compared to 60.1% in 2014 (P < 0.001). Men had significantly thicker melanomas at the time of diagnosis [median Breslow thickness 1.00 mm (interquartile range (IQR): 0.60-2.00) vs. 0.82 mm (IQR: 0.50-1.50) for females] and were significantly older at the time of diagnosis, more often had ulcerated melanomas and melanomas localized on the trunk or head and neck. Over time, survival for females improved while that of men decreased (P < 0.001). RER for dying was 1.37 (95% CI: 1.31-1.45) for men in multivariable analysis.

CONCLUSION

There are evident clinicopathological differences between male and female melanoma patients. After multivariable correction for all these differences, relative survival remains worse for men. Clinicians as well as persons at risk for melanoma should be aware of these differences, as awareness and prevention might lead to a lower incidence and mortality of melanoma. This indicates the need of prevention campaigns integrating and targeting specific risk profiles.

Impact of the second reader on screening outcome at blinded double reading of digital screening mammograms

Background

To determine the impact of the second reader on screening outcome at blinded double reading of digital screening mammograms.

Methods

We included a consecutive series of 99,013 digital screening mammograms, obtained between July 2013 and January 2015 and double read in a blinded fashion. During 2-year follow-up, we collected radiology, surgery and pathology reports of recalled women.

Results

Single reading resulted in 2928 recalls and 616 screen-detected cancers (SDCs). The second reader recalled another 612 women, resulting in 82 additional SDCs. Addition of the second reader increased the recall rate (3.0% to 3.6%, p < 0.001), cancer detection rate (6.2–7.0 per 1000 screens, p < 0.001) and false positive recall rate (24.4–28.7 per 1000 screens, p < 0.001). Positive predictive value of recall (21.0% vs. 19.7%, p = 0.20) and of biopsy (52.1% vs. 50.9%, p = 0.56) were comparable for single reading and blinded double reading. Tumour characteristics were comparable for cancers detected by the first reader and cancers additionally detected by the second reader, except of a more favourable tumour grade in the latter group.

Conclusions

At blinded double reading, the second reader significantly increases the cancer detection rate, at the expense of an increased recall rate and false positive recall rate.

Real-world use, safety, and survival of ipilimumab in metastatic cutaneous melanoma in The Netherlands

Phase III trials with ipilimumab showed an improved survival in patients with metastatic melanoma. We evaluated the use and safety of ipilimumab, and the survival of all patients with metastatic cutaneous melanoma (N=807) receiving ipilimumab in real-world clinical practice in The Netherlands using data from the Dutch Melanoma Treatment Registry. Patients who were registered between July 2012 and July 2015 were included and analyzed according to their treatment status: treatment-naive (N=344) versus previously-treated (N=463). Overall, 70% of treatment-naive patients and 62% of previously-treated patients received all four planned doses of ipilimumab. Grade 3 and 4 immune-related adverse events occurred in 29% of treatment-naive patients and 21% of previously-treated patients. No treatment-related deaths occurred. Median time to first event was 5.4 months [95% confidence interval (CI): 4.7-6.5 months] in treatment-naive patients and 4.4 months (95% CI: 4.0-4.7 months) in previously-treated patients. Median overall survival was 14.3 months (95% CI: 11.6-16.7 months) in treatment-naive patients and 8.7 months (95% CI: 7.6-9.6 months) in previously-treated patients. In both patient groups, an elevated lactate dehydrogenase level (hazard ratio: 2.25 and 1.70 in treatment-naive and previously-treated patients, respectively) and American Joint Committee on Cancer M1c-stage disease (hazard ratio: 1.81 and 1.83, respectively) were negatively associated with overall survival. These real-world outcomes of ipilimumab slightly differed from outcomes in phase III trials. Although phase III trials are crucial for establishing efficacy, real-world data are of great added value enhancing the generalizability of outcomes of ipilimumab in clinical practice.

Real-world healthcare costs of ipilimumab in patients with advanced cutaneous melanoma in The Netherlands

There is limited evidence on the costs associated with ipilimumab. We investigated healthcare costs of all Dutch patients with advanced cutaneous melanoma who were treated with ipilimumab. Data were retrieved from the nation-wide Dutch Melanoma Treatment Registry. Costs were determined by applying unit costs to individual patient resource use. A total of 807 patients who were diagnosed between July 2012 and July 2015 received ipilimumab in Dutch practice. The mean (median) episode duration was 6.27 (4.61) months (computed from the start of ipilimumab until the start of a next treatment, death, or the last date of follow-up). The average total healthcare costs amounted to &OV0556;81 484, but varied widely (range: &OV0556;18 131-&OV0556;160 002). Ipilimumab was by far the most important cost driver (&OV0556;73 739). Other costs were related to hospital admissions (&OV0556;3323), hospital visits (&OV0556;1791), diagnostics and imaging (&OV0556;1505), radiotherapy (&OV0556;828), and surgery (&OV0556;297). Monthly costs for resource use other than ipilimumab were &OV0556;1997 (SD: &OV0556;2629). Treatment-naive patients (n=344) had higher total costs compared with previously-treated patients (n=463; &OV0556;85 081 vs. &OV0556;78 811). Although patients with colitis (n=106) had higher costs for resource use other than ipilimumab (&OV0556;11 426) compared with patients with other types of immune-related adverse events (n=90; &OV0556;9850) and patients with no immune-related adverse event (n=611; &OV0556;6796), they had lower total costs (&OV0556;76 075 vs. &OV0556;87 882 and &OV0556;81 480, respectively). In conclusion, this nation-wide study provides valuable insights into the healthcare costs of advanced cutaneous melanoma patients who were treated with ipilimumab in clinical practice. Most of the costs were attributable to ipilimumab, but the costs and its distribution varied considerably across subgroups.

Characteristics of screen-detected cancers following concordant or discordant recalls at blinded double reading in biennial digital screening mammography

OBJECTIVES

To analyse which mammographic and tumour characteristics led to concordant versus discordant recalls at blinded double reading to further optimise our breast cancer screening programme.

METHODS

We included a consecutive series of 99,013 screening mammograms obtained between July 2013 and January 2015. All mammograms were double read in a blinded fashion. Discordant readings were routinely recalled without consensus or arbitration. During the 2-year follow-up, relevant data of the recalled women were collected. We compared mammographic characteristics, screening outcome and tumour characteristics between concordant and discordant recalls.

RESULTS

There were 2,543 concordant recalls (71.4%) and 997 discordant recalls (28.0%). The positive predictive value of a concordant recall was significantly higher (23.5% vs. 10.0%, p < 0.001). The proportion of BI-RADS 0 was significantly higher in the discordant recall group (75.7% vs. 56.3%, p < 0.001). Discordant recalls were more often an asymmetry or architectural distortion (21.8% vs. 13.2% and 9.3% vs. 6.5%, respectively, p < 0.001). There were no differences in the distribution of DCIS and invasive cancers and tumour characteristics were comparable for the two groups, except for a more favourable tumour grade in the discordant recall group (54.7% vs. 39.9% grade I tumours, p = 0.022).

CONCLUSIONS

Screen-detected cancers detected by a discordant reading show a more favourable tumour grade than cancers diagnosed after a concordant recall. The higher proportion of asymmetries and architectural distortions in this group provide a possible target for improving screening programmes by additional training of screening radiologists and the implementation of digital breast tomosynthesis.

KEY POINTS

• With blinded double reading of screening mammograms, screen-detected cancers detected by a discordant reading show a more favourable tumour grade than cancers diagnosed after a concordant recall. • The proportions of asymmetries and architectural distortions are higher in case of a discordant reading. • Possible improvement strategies could target additional training of screening radiologists and the implementation of digital breast tomosynthesis in breast cancer screening programmes.

Frequency and characteristics of contralateral breast abnormalities following recall at screening mammography

PURPOSE

To determine the frequency and characteristics of contralateral, non-recalled breast abnormalities following recall at screening mammography.

METHODS

We included a series of 130,338 screening mammograms performed between 1 January 2014 and 1 January 2016. During the 1-year follow-up, clinical data were collected for all recalls. Screening outcome was determined for recalled women with or without evaluation of contralateral breast abnormalities.

RESULTS

Of 3,995 recalls (recall rate 3.1%), 129 women (3.2%) underwent assessment of a contralateral, non-recalled breast abnormality. Most lesions were detected at clinical mammography and/or breast tomosynthesis (101 women, 78.3%). The biopsy rate was similar for recalled lesions and contralateral, non-recalled lesions, but the positive predictive value of biopsy was higher for recalled lesions (p = 0.01). A comparable proportion of the recalled lesions and contralateral, non-recalled lesions were malignant (p = 0.1). The proportion of ductal carcinoma in situ was similar for both groups, as well as invasive cancer characteristics and type of surgical treatment.

CONCLUSIONS

About 3% of recalled women underwent evaluation of contralateral, non-recalled breast lesions. Evaluation of the contralateral breast after recall is important as we found that 15.5% of contralateral, non-recalled lesions were malignant. Contralateral cancers and screen-detected cancers show similar characteristics, stage and surgical treatment.

KEY POINTS

• 3% of recalled women underwent evaluation of contralateral, non-recalled lesions • One out of seven contralateral, non-recalled lesions was malignant • A contralateral cancer was diagnosed in 0.5% of recalls • Screen-detected cancers and non-recalled, contralateral cancers showed similar histological characteristics • Tumour stage and surgical treatment were similar for both groups.

Trends in incidence of thick, thin and in situ melanoma in Europe

BACKGROUND

We analysed trends in incidence for in situ and invasive melanoma in some European countries during the period 1995-2012, stratifying for lesion thickness.

MATERIAL AND METHODS

Individual anonymised data from population-based European cancer registries (CRs) were collected and combined in a common database, including information on age, sex, year of diagnosis, histological type, tumour location, behaviour (invasive, in situ) and lesion thickness. Mortality data were retrieved from the publicly available World Health Organization database.

RESULTS

Our database covered a population of over 117 million inhabitants and included about 415,000 skin lesions, recorded by 18 European CRs (7 of them with national coverage). During the 1995-2012 period, we observed a statistically significant increase in incidence for both invasive (average annual percent change (AAPC) 4.0% men; 3.0% women) and in situ (AAPC 7.7% men; 6.2% women) cases.

DISCUSSION

The increase in invasive lesions seemed mainly driven by thin melanomas (AAPC 10% men; 8.3% women). The incidence of thick melanomas also increased, although more slowly in recent years. Correction for lesions of unknown thickness enhanced the differences between thin and thick cases and flattened the trends. Incidence trends varied considerably across registries, but only Netherlands presented a marked increase above the boundaries of a funnel plot that weighted estimates by their precision. Mortality from invasive melanoma has continued to increase in Norway, Iceland (but only for elder people), the Netherlands and Slovenia.

Incidence and tumour characteristics of bilateral and unilateral interval breast cancers at screening mammography

BACKGROUND

Detected by screening mammography, bilateral breast cancer has a different pathological profile compared to unilateral breast cancer. We investigated the incidence of bilateral interval breast cancers and compared their characteristics with those of unilateral interval breast cancers.

METHODS

We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all referred women and of all women who presented with interval breast cancer. The tumour with the highest tumour stage (index cancer) was used for comparison with unilateral interval cancers.

RESULTS

A total of 753 interval cancers were detected, of which 24 (3.2%) were bilateral. Among the invasive interval cancers, bilateral cancers more frequently showed a lobular histology than unilateral cancers (37.5% (9/24) vs. 16.1% (111/691), P = .01). There is a trend towards a larger proportion of bilateral than unilateral interval cancers graded 1 (45.8% (11/24) vs. 27.8% (192/691), P = .08). There were no other statistically significant differences in tumour characteristics. Also, the proportion of interval cancers showing significant mammographic abnormalities at the latest screen was comparable for unilateral and bilateral interval cancers (23.0% vs. 25.0%, P = .9).

DISCUSSION

Bilateral interval cancers comprise a small proportion of all interval cancers. Except of a higher proportion of invasive lobular cancers and a more favourable histological grade of invasive cancers, tumour characteristics are comparable for bilateral and unilateral interval breast cancers.

Interval breast cancer characteristics before, during and after the transition from screen-film to full-field digital screening mammography

Background

To determine the proportion of “true” interval cancers and tumor characteristics of interval breast cancers prior to, during and after the transition from screen-film mammography screening (SFM) to full-field digital mammography screening (FFDM).

Methods

We included all women with interval cancers detected between January 2006 and January 2014. Breast imaging reports, biopsy results and breast surgery reports of all women recalled at screening mammography and of all women with interval breast cancers were collected. Two experienced screening radiologists reviewed the diagnostic mammograms, on which the interval cancers were diagnosed, as well as the prior screening mammograms and determined whether or not the interval cancer had been missed on the most recent screening mammogram. If not missed, the cancer was considered an occult (“true”) interval cancer.

Results

A total of 442 interval cancers had been diagnosed, of which 144 at SFM with a prior SFM (SFM-SFM), 159 at FFDM with a prior SFM (FFDM-SFM) and 139 at FFDM with a prior FFDM (FFDM-FFDM). The transition from SFM to FFDM screening resulted in the diagnosis of more occult (“true”) interval cancers at FFDM-SFM than at SFM-SFM (65.4% (104/159) versus 49.3% (71/144), P < 0.01), but this increase was no longer statistically significant in women who had been screened digitally for the second time (57.6% (80/139) at FFDM-FFDM versus 49.3% (71/144) at SFM-SFM). Tumor characteristics were comparable for the three interval cancer cohorts, except of a lower porportion (75.7 and 78.0% versus 67.2% af FFDM-FFDM, P < 0.05) of invasive ductal cancers at FFDM with prior FFDM.

Conclusions

An increase in the proportion of occult interval cancers is observed during the transition from SFM to FFDM screening mammography. However, this increase seems temporary and is no longer detectable after the second round of digital screening. Tumor characteristics and type of surgery are comparable for interval cancers detected prior to, during and after the transition from SFM to FFDM screening mammography, except of a lower proportion of invasive ductal cancers after the transition.

Implementation of the 7th edition AJCC staging system: Effects on staging and survival for pT1 melanoma. A Dutch population based study

In the 7^th edition of the AJCC staging system, the mitotic rate criterion replaced Clark level to increase correct classification of high-risk thin melanoma patients (pT1B). Additionally, sentinel node biopsy (SNB) was recommended for nodal staging of pT1B melanomas. The aim of this article was to evaluate the effects on pT1 substaging and clinical implications in the national pT1 melanoma population. All pT1 melanomas diagnosed in the Netherlands between 2003 and 2014 were selected from the Netherlands Cancer Registry (IKNL). Patients were stratified by cohort according to AJCC edition: (1) 2003-2009 (6^th ) and (2) 2010-2014 (7^th ). Relative survival was calculated to estimate melanoma-specific survival. A total of 29.546 pT1 melanoma patients were included. The pT1b proportion increased from 10.1% in Cohort 1 to 21.5% in Cohort 2. The proportion of performed SNBs per cohort increased: for pT1b melanomas alone from 4.5% to 13.0%. SNB positivity rate decreased from 10.5% to 8.8% for the entire pT1 population, and for pT1b melanomas from 11.3% to 8.6%. At 5 years, the relative survival rate was similar for pT1a and pT1b in both cohorts, namely, pT1a 100% vs pT1b 97% (Cohort 1), and pT1a 100% vs pT1b 98% (Cohort 2). The 7^th edition of the AJCC staging system has caused an increased number of patients to undergo SNB, without an increase in SNB positivity rate. Survival between pT1 subgroups remains similar. The mitotic rate criterion for pT1b classification and the recommendation to perform SNB for pT1b melanomas should be reconsidered.

Second Cancer Risk Up to 40 Years after Treatment for Hodgkin's Lymphoma

BACKGROUND

Survivors of Hodgkin's lymphoma are at increased risk for treatment-related subsequent malignant neoplasms. The effect of less toxic treatments, introduced in the late 1980s, on the long-term risk of a second cancer remains unknown.

METHODS

We enrolled 3905 persons in the Netherlands who had survived for at least 5 years after the initiation of treatment for Hodgkin's lymphoma. Patients had received treatment between 1965 and 2000, when they were 15 to 50 years of age. We compared the risk of a second cancer among these patients with the risk that was expected on the basis of cancer incidence in the general population. Treatment-specific risks were compared within the cohort.

RESULTS

With a median follow-up of 19.1 years, 1055 second cancers were diagnosed in 908 patients, resulting in a standardized incidence ratio (SIR) of 4.6 (95% confidence interval [CI], 4.3 to 4.9) in the study cohort as compared with the general population. The risk was still elevated 35 years or more after treatment (SIR, 3.9; 95% CI, 2.8 to 5.4), and the cumulative incidence of a second cancer in the study cohort at 40 years was 48.5% (95% CI, 45.4 to 51.5). The cumulative incidence of second solid cancers did not differ according to study period (1965-1976, 1977-1988, or 1989-2000) (P=0.71 for heterogeneity). Although the risk of breast cancer was lower among patients who were treated with supradiaphragmatic-field radiotherapy not including the axilla than among those who were exposed to mantle-field irradiation (hazard ratio, 0.37; 95% CI, 0.19 to 0.72), the risk of breast cancer was not lower among patients treated in the 1989-2000 study period than among those treated in the two earlier periods. A cumulative procarbazine dose of 4.3 g or more per square meter of body-surface area (which has been associated with premature menopause) was associated with a significantly lower risk of breast cancer (hazard ratio for the comparison with no chemotherapy, 0.57; 95% CI, 0.39 to 0.84) but a higher risk of gastrointestinal cancer (hazard ratio, 2.70; 95% CI, 1.69 to 4.30).

CONCLUSIONS

The risk of second solid cancers did not appear to be lower among patients treated in the most recent calendar period studied (1989-2000) than among those treated in earlier periods. The awareness of an increased risk of second cancer remains crucial for survivors of Hodgkin's lymphoma. (Funded by the Dutch Cancer Society.).

Trends in surgery for screen-detected and interval breast cancers in a national screening programme

Background

This population-based study aimed to evaluate trends in surgical approach for screen-detected cancer versus interval breast cancer, and to determine the factors associated with positive resection margins.

Methods

Screening mammograms of women aged 50–75 years, who underwent biennial screening in a Dutch breast-screening region between 1997 and 2011, were included. Patient and tumour characteristics were compared between women who underwent mastectomy or breast-conserving surgery (BCS) for screen-detected or interval cancer, and women with a negative or positive resection margin after BCS.

Results

Some 417 013 consecutive screening mammograms were included. A total of 2224 screen-detected and 825 interval cancers were diagnosed. The BCS rate remained stable (mean 6·1 per 1000 screened women; P = 0·099), whereas mastectomy rates increased significantly during the study from 0·9 (1997–1998) to 1·9 (2009–2010) per 1000 screened women (P &lt; 0·001). The proportion of positive resection margins for invasive cancer was 19·6 and 7·6 per cent in 1997–1998 and 2009–2010 respectively (P &lt; 0·001), with significant variation between hospitals. Dense breasts, preoperative magnetic resonance imaging, microcalcifications, architectural distortion, tumour size over 20 mm, axillary lymph node metastasis and treating hospital were independent risk factors for mastectomy. Interval cancer, image-guided tumour localization, microcalcifications, breast parenchyma asymmetry, tumour size greater than 20 mm, lobular tumour histology, low tumour grade, extensive invasive component and treating hospital were independent risk factors for positive resection margins.

Conclusion

Mastectomy rates doubled during a 14-year period of screening mammography and the proportion of positive resection margins decreased, with variation among hospitals. The latter observation stresses the importance of quality control programmes for hospitals treating women with breast cancer.

Impact of the transition from screen-film to digital screening mammography on interval cancer characteristics and treatment - a population based study from the Netherlands

INTRODUCTION

In most breast screening programmes screen-film mammography (SFM) has been replaced by full-field digital mammography (FFDM). We compared interval cancer characteristics at SFM and FFDM screening mammography.

PATIENTS AND METHODS

We included all 297 screen-detected and 104 interval cancers in 60,770 SFM examinations and 427 screen-detected and 124 interval cancers in 63,182 FFDM examinations, in women screened in the period 2008-2010. Breast imaging reports, biopsy results and surgical reports of all cancers were collected. Two radiologists reviewed prior and diagnostic mammograms of all interval cancers. They determined breast density, described mammographic abnormalities and classified interval cancers as missed, showing a minimal sign abnormality or true negative.

RESULTS

The referral rate and cancer detection at SFM were 1.5% and 4.9‰ respectively, compared to 3.0% (p<0.001) and 6.6‰ (p<0.001) at FFDM. Screening sensitivity was 74.1% at SFM (297/401, 95% confidence interval (CI)=69.8-78.4%) and 77.5% at FFDM (427/551, 95% CI=74.0-81.0%). Significantly more interval cancers were true negative at prior FFDM than at prior SFM screening mammography (65.3% (81/124) versus 47.1% (49/104), p=0.02). For interval cancers following SFM or FFDM screening mammography, no significant differences were observed in breast density or mammographic abnormalities at the prior screen, tumour size, lymph node status, receptor status, Nottingham tumour grade or surgical treatment (mastectomy versus breast conserving therapy).

CONCLUSION

FFDM resulted in a significantly higher cancer detection rate, but sensitivity was similar for SFM and FFDM. Interval cancers are more likely to be true negative at prior FFDM than at prior SFM screening mammography, whereas their tumour characteristics and type of surgical treatment are comparable.

Impact of transition from analog screening mammography to digital screening mammography on screening outcome in The Netherlands: a population-based study

BACKGROUND

Full-field digital mammography (FFDM) has replaced screen-film mammography (SFM) in most breast screening programs. We analyzed the impact of this replacement on the screening outcome.

PATIENTS AND METHODS

The study population consisted of a consecutive series of 60 770 analog and 63 182 digital screens. During a 1-year follow-up, we collected breast imaging reports, biopsy results and surgical reports of all the referred women.

RESULTS

The referral rate and the cancer detection rate at FFDM were, respectively, 3.0% and 6,6‰, compared with 1.5% (P < 0.001) and 4.9‰ (P < 0.001) at SFM. Positive predictive values of referral and percutaneous biopsies were lower at FFDM, respectively, 21.9% versus 31.6% (P < 0.001) and 42.9% versus 62.8% (P < 0.001). Per 1000 screened women, there was a significant increase with FFDM versus SFM in the detection rate of low- and intermediate-grade ductal carcinoma in situ (DCIS) (+0.7), invasive T1a-c cancers (+0.9), invasive ductal cancers (+0.9), low-grade (+1.1), node-negative invasive cancers (+1.2), estrogen-receptor or progesterone-receptor-positive invasive cancers (respectively, +0.9 and +1.1) and Her2/Neu-negative (+0.8) invasive cancers. Mastectomy rates were stable at 1.1 per 1,000 screens.

CONCLUSIONS

FFDM significantly increased the referral rate and cancer detection rate, at the expense of a lower positive predictive value of referral and biopsy. Extra tumors detected at FFDM were mostly low-intermediate grade DCIS and smaller invasive tumors, of more favorable tumor characteristics. Mastectomy rates were not increased in the FFDM population, while increased over-diagnosis cannot be excluded.

Characteristics and screening outcome of women referred twice at screening mammography

OBJECTIVES

To determine the characteristics and screening outcome of women referred twice at screening mammography.

METHODS

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

RESULTS

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P = 0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P = 0.004).

CONCLUSIONS

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

KEY POINTS

Cancer risk was 36% for lesions referred twice at screening mammography. The cancer risk was similar for lesions referred only once at screening. Densities at first referral were associated with increased cancer risk at second referral. No biopsy at first referral was associated with increased cancer risk at second referral. Patient and tumour characteristics were similar for women with and without diagnostic delay.

Malpractice claims following screening mammography in The Netherlands

Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symptomatic patients, information on claims at European screening mammography programs is lacking. We determined the type and frequency of malpractice claims at a Dutch breast cancer screening region. We included all 85,274 women (351,009 screens) who underwent biennial screening mammography at a southern breast screening region in The Netherlands between 1997 and 2009. Two screening radiologists reviewed the screening mammograms of all screen detected cancers and interval cancers and determined whether the cancer had been missed at the previous screen or at the latest screen, respectively. We analyzed all correspondence between the screening organization, clinicians and screened women, and collected complaints and claims until September 2011. At review, 20.9% (308/1,475) of screen detected cancers and 24.3% (163/670) of interval cancers were considered to be missed at a previous screen. A total of 19 women (of which 2, 6 and 11 women had been screened between 1997 and 2001 (102,439 screens), 2001 and 2005 (114,740 screens) and 2005 and 2009 (133,830 screens), respectively) had contacted the screening organization for additional information about their screen detected cancer or interval cancer, but filed no claim. Three other women directly initiated an insurance claim for financial compensation of their interval cancer without previously having contacted the screening organization. We conclude that screening-related claims were rarely encountered, although many screen detected cancers and interval cancers had been missed at a previous screen. A small but increasing proportion of women sought additional information about their breast cancer from the screening organization.

[Trends in the use of primary radiotherapy for cancer in the Netherlands in patients with breast, prostate, rectal and lung tumours]

OBJECTIVE

To provide insight in the application of radiotherapy as part of primary treatment of patients with cancer in the Netherlands.

DESIGN

Retrospective, descriptive population-based study.

METHOD

Data concerning patients with breast, prostate, rectal and non-small cell lung cancer were selected from the Netherlands Cancer Registry in 4 regions, covering 50% of the Dutch population. The selection concerned data from 1997-2008 and, except for prostate cancer, only patients without distant metastases were included.

RESULTS

Between 1997 and 2008, the use of primary external radiotherapy increased approximately 7% in breast cancer patients and approximately 30% in rectal cancer patients. In the latter group preoperative radiotherapy strongly increased, while postoperative radiotherapy decreased. For prostate cancer there was an increase in brachytherapy (9%). The use of external beam radiotherapy in patients with prostate cancer and non-small cell lung cancer remained the same. Regional differences in the extent of use of radiotherapy for breast and rectal cancer clearly decreased. These differences remained limited for external beam radiotherapy in prostate and non-small cell lung cancer. Older patients less often received radiotherapy.

CONCLUSION

The increase in use of radiotherapy for breast cancer is explained by the increase in breast conserving surgery. The trends in use in patients with rectal cancer and breast cancer are presumably related to the implementation of multidisciplinary practice guidelines. The implementation of these guidelines probably also contributed to the decrease in regional differences in the use of radiotherapy.

Patient and tumor characteristics of bilateral breast cancer at screening mammography in the Netherlands, a population-based study

Few data are available on bilateral breast cancer in the screening population. The aim of this study was to determine patient and tumor characteristics of women with bilateral breast cancer at screening mammography. We included all 350,637 screening mammography examinations of women participating in a biennial screening program in a southern screening region of the Netherlands between May 1998 and January 2010. For referred women, all breast imaging reports, biopsy results, and surgery reports during one year after referral were collected. We compared patient and tumor characteristics of referred women with a diagnosis of bilateral breast cancer or unilateral breast cancer at workup. Bilateral or unilateral breast cancer had been diagnosed in respectively 40 (2.2%) and 1766 (97.8%) of 1806 referred women. Women with bilateral or unilateral breast cancer did not differ significantly in mean age, mammographic breast density, family history of breast cancer, or use of hormone replacement therapy. Compared with index cancers, contralateral cancers comprised significantly more lobular cancers (P = 0.02). Tumor size, mitotic activity, and estrogen receptor status were comparable for both groups, but contralateral cancers had a significantly lower risk of lymph node metastases (P = 0.03). Compared to unilateral breast cancer, contralateral malignancies in women with bilateral breast cancer comprised significantly more lobular cancers (P = 0.004) and lymph node negative cancers (P = 0.01). Contralateral breast cancers detected at screening comprise more lobular cancers and show less nodal involvement than index cancers or unilateral cancers. No differences are observed with respect to other patient and tumor characteristics.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUND

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.

METHODS

The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles.

RESULTS

Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.

CONCLUSIONS

A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Breast cancer risk in female survivors of Hodgkin's lymphoma: lower risk after smaller radiation volumes

PURPOSE

We assessed the long-term risk of breast cancer (BC) after treatment for Hodgkin's lymphoma (HL). We focused on the volume of breast tissue exposed to radiation and the influence of gonadotoxic chemotherapy (CT).

PATIENTS AND METHODS

We performed a cohort study among 1,122 female 5-year survivors treated for HL before the age of 51 years between 1965 and 1995. We compared the incidence of BC with that in the general population. To assess the risk according to radiation volume and hormone factors, we performed multivariate Cox regression analyses.

RESULTS

After a median follow-up of 17.8 years, 120 women developed BC (standardized incidence ratio [SIR], 5.6; 95% CI, 4.6 to 6.8), absolute excess risk 57 per 10,000 patients per year. The overall cumulative incidence 30 years after treatment was 19% (95% CI, 16% to 23%); for those treated before age 21 years, it was 26% (95% CI, 19% to 33%). The relative risk remained high after prolonged follow-up (> 30 years after treatment: SIR, 9.5; 95% CI, 4.9 to 16.6). Mantle field irradiation (involving the axillary, mediastinal, and neck nodes) was associated with a 2.7-fold increased risk (95% CI, 1.1 to 6.9) compared with similarly dosed (36 to 44 Gy) mediastinal irradiation alone. Women with >or= 20 years of intact ovarian function after radiotherapy at young ages (< 31 years) experienced significantly higher risks for BC than those with fewer than 10 years of intact ovarian function.

CONCLUSION

Reduction of radiation volume appears to decrease the risk for BC after HL. In addition, shorter duration of intact ovarian function after irradiation is associated with a significant reduction of the risk for BC.

[Skin cancer epidemic in the Netherlands]

Despite numerous warnings regarding the dangers of exposure to the sun, the number of skin cancer patients continues to increase rapidly. Dermatologists speak of a 'skin cancer epidemic' and estimate that the number of patients is substantially higher than the number estimated on the basis of cancer registry data. According to the Netherlands and Eindhoven cancer registries, 35.500 Dutch people were newly diagnosed with 'skin cancer' in 2006. Many skin cancer patients develop multiple skin tumours, therefore the total number of skin tumours is much higher than this. One in 6 Dutch people will develop skin cancer in their lifetime, 1 in 50 will develop a melanoma. Despite the good prognosis for most skin tumours, there is a high level of morbidity as a result of treatment. The large number of skin tumours and patients puts a great deal of pressure on the health care system.

Treatment-specific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer

PURPOSE

To compare radiotherapy and chemotherapy effects on long-term risks of second malignant neoplasms (SMNs) and cardiovascular diseases (CVDs) in testicular cancer (TC) survivors.

PATIENTS AND METHODS

In our nationwide cohort comprising 2,707 5-year TC survivors, incidences of SMNs and CVDs were compared with general-population rates by calculating standardized incidence ratios (SIRs) and absolute excess risks (AERs). Treatment effects on risks of SMN and CVD were quantified in multivariable Cox regression and competing risks analyses.

RESULTS

After a median follow-up time of 17.6 years, 270 TC survivors developed SMNs. The SIR of SMN overall was 1.7 (95% CI, 1.5 to 1.9), with an AER of 32.3 excess occurrences per 10,000 person-years. SMN risk was 2.6-fold (95% CI, 1.7- to 4.0-fold) increased after subdiaphragmatic radiotherapy and 2.1-fold (95% CI, 1.4- to 3.1-fold) increased after chemotherapy, compared with surgery only. Subdiaphragmatic radiotherapy increased the risk of a major late complication (SMN or CVD) 1.8-fold (95% CI, 1.3- to 2.4-fold), chemotherapy increased the risk of a major late complication 1.9-fold (95% CI, 1.4- to 2.5-fold), and smoking increased the risk of a major late complication 1.7-fold (95% CI, 1.4- to 2.1-fold), compared with surgery only. The median survival time was 1.4 years after SMN and 4.7 years after CVD.

CONCLUSION

Radiotherapy and chemotherapy increased the risk of developing SMN or CVD to a similar extent as smoking. Subdiaphragmatic radiotherapy strongly increases the risk of SMNs but not of CVD, whereas chemotherapy increases the risks of both SMNs and CVDs. Prolonged follow-up after chemotherapy is needed to reliably compare the late complications of radiotherapy and chemotherapy after 20 years.

Uncommon breast tumors in perspective: incidence, treatment and survival in the Netherlands

The relatively small group of patients with breast tumors other than the ductal, lobular or mixed ducto-lobular types, has reached nonnegligible numbers due to the ongoing increase in the incidence of breast cancer. We investigated stage and grade distribution of uncommon breast tumors using the nation-wide Netherlands Cancer Registry (population 16.5 million) and incidence patterns, treatment and long-term survival (up to 19 years) using the regional Eindhoven Cancer Registry (population 2.4 million). Incidence of all uncommon breast tumors together was 9.2/100,000 person years (age-standardized, ESR). The proportion of stage I tumors was 70% among patients with tubular (n = 3,456) and 40-50% for mucinous (n = 3,482), papillary (n = 1,078), cribriform (n = 503) and neuroendocrine (n = 76) tumors, contrasting to 27, 28 and 36%, respectively among patients with Signet ring cell cancer (n = 75), Paget's disease (n = 818) and the common invasive ductal carcinomas (n = 121,656). A better age-, stage-, and grade-adjusted prognosis was observed for patients with lobular (death risk ratio 0.8, 95%CI: 0.7-0.9), mucinous (0.5, 0.3-0.9), medullary (0.5, 0.3-0.9) and tubular (0.4, 0.2-0.6) carcinoma or phyllodes tumor (0.02, 0.0-0.2), compared with invasive ductal carcinomas. For patients with papillary (0.6, 0.2-1.6) and cribriform (0.1, 0.0-5.1) tumors better prognosis was not statistically significant. In conclusion, histologic type was an essential determinant of survival for about 10% of all newly diagnosed women with invasive breast cancer. Because patients with mucinous, tubular, medullary and phyllodes tumors have such a good prognosis, less aggressive treatment should be considered in some cases whereby specific guidelines are becoming increasingly desirable. Communication to patients with these specific histological types should reflect this.

Oesophageal cancer in The Netherlands: Increasing incidence and mortality but improving survival

AIM

Oesophageal cancer is highly lethal with a 5-year relative survival of 10-15%. An increasing incidence has been reported for several parts of the Western world. We studied time trends in incidence, mortality and survival for oesophageal cancer in the Netherlands during 1989-2003.

METHODS

Data on incidence and survival were obtained from the Netherlands Cancer Registry and mortality data from Statistics Netherlands.

RESULTS

The age standardised incidence increased by 3.4% (p<0.001) and 1.9% (p=0.003) per year for males and females, respectively. This increase was almost exclusively caused by oesophageal adenocarcinomas. Age standardised mortality increased 2.5% (p<0.001) per year among males and 1.7% (p=0.002) per year among females. Relative survival improved significantly from 8.1% in 1989-1993 to 12.6% in 1999-2003 (p<0.001). Adjusted for age, stage, tumour location and surgery, the excess risk of death decreased by 22%.

CONCLUSION

Oesophageal carcinoma incidence is rising in the Netherlands. Mortality increased at a slightly lower pace due to improving survival.

Decreased risk of prostate cancer after skin cancer diagnosis: a protective role of ultraviolet radiation?

Ultraviolet radiation causes skin cancer but may protect against prostate cancer. The authors hypothesized that skin cancer patients had a lower prostate cancer incidence than the general population. In the southeastern part of the Netherlands, a population-based cohort of male skin cancer patients diagnosed since 1970 (2,620 squamous cell carcinomas, 9,501 basal cell carcinomas, and 1,420 cutaneous malignant melanomas) was followed up for incidence of invasive prostate cancer until January 1, 2005, within the framework of the Eindhoven Cancer Registry. The incidence rates of prostate cancer among skin cancer patients were compared with those in the reference population, resulting in standardized incidence ratios. Skin cancer patients were at decreased risk of developing prostate cancer compared with the general population (standardized incidence ratio (SIR) = 0.89, 95% confidence interval (CI): 0.78, 0.99), especially shortly after diagnosis. The risk of advanced prostate cancer was significantly decreased (SIR = 0.73, 95% CI: 0.56, 0.94), indicating a possible antiprogression effect of ultraviolet radiation. Patients with a skin cancer in the chronically ultraviolet radiation-exposed head and neck area (SIR = 0.84, 95% CI: 0.73, 0.97) and those diagnosed after the age of 60 years (SIR = 0.86, 95% CI: 0.75, 0.97) had decreased prostate cancer incidence rates. These results support the hypothesis that ultraviolet radiation protects against prostate cancer.

An overview of prognostic factors for long-term survivors of breast cancer

BACKGROUND

Numerous studies have examined prognostic factors for survival of breast cancer patients, but relatively few have dealt specifically with 10+-year survivors.

METHODS

A review of the PubMed database from 1995 to 2006 was undertaken with the following inclusion criteria: median/mean follow-up time at least 10 years; overall survival and/or disease-specific survival known; and relative risk and statistical probability values reported. In addition, we used data from the long-standing Eindhoven Cancer Registry to illustrate survival probability as indicated by various prognostic factors.

RESULTS

10-year breast cancer survivors showed 90% 5-year relative survival. Tumor size, nodal status and grade remained the most important prognostic factors for long-term survival, although their role decreased over time. Most studies agreed on the long-term prognostic values of MI (mitotic index), LVI (lymphovascular invasion), Her2-positivity, gene profiling and comorbidity for either all or a subgroup of breast cancer patients (node-positive or negative). The roles of age, socioeconomic status, histological type, BRCA and p53 mutation were mixed, often decreasing after correction for stronger prognosticators, thus limiting their clinical value. Local and regional recurrence, metastases and second cancer may substantially impair long-term survival. Healthy lifestyle was consistently related to lower overall mortality.

CONCLUSIONS

Effects of traditional prognostic factors persist in the long term and more recent factors need further follow-up. The prognosis for breast cancer patients who have survived at least 10 years is favourable and increases over time. Improved long-term survival can be achieved by earlier detection, more effective modern therapy and healthier lifestyle.

The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995 to 2002

BACKGROUND

The objective of this study was to study the influence of age and comorbidity on receiving radiotherapy (RT) in primary treatment of cancer.

METHODS

In a population-based setting, the authors calculated the proportion of irradiated patients within 6 months after they received a diagnosis of lung, rectal, breast, or prostate cancer or non-Hodgkin lymphoma (n = 33,369 patients) according to age and comorbidity between 1995 and 2002. Logistic regression analysis was used to adjust for age, comorbidity, gender, and stage.

RESULTS

Patients with localized nonsmall cell lung cancer (NSCLC) ages 65 years to > or = 80 years or with comorbid conditions received RT alone significantly more often compared with younger patients (ages 65-79 years: odds ratio [OR], 3.4; age > or = 80: OR, 12.0) and patients without comorbidities (1 comorbid condition: OR, 2.1; > or = 2 comorbid conditions: OR, 2.4). This also applied to patients with nonlocalized NSCLC ages 65 years to 79 years compared with younger patients (OR, 1.4). RT was administered significantly less often to elderly patients with resected rectal cancers (ages 65-79 years: OR, 0.7; age > or = 80 years: OR, 0.4), patients age > or = 80 years with breast cancer after undergoing conserving surgery (OR, 0.1), and patients age > or = 80 years with clinical T1-T3,N0,M0 prostate cancer age (OR, 0.1) compared with younger patients. Patients with breast cancer who underwent breast-conserving surgery received RT significantly less often in the presence of comorbidities (1 comorbid condition: OR, 0.6; > or = 2 comorbid conditions: OR, 0.4). Older patients with aggressive non-Hodgkin lymphoma received only RT as treatment significantly more often compared with younger patients (OR, 3.4).

CONCLUSIONS

Comorbidity and age did have influence over whether patients received RT, although, for most tumor types, age appeared to be a stronger predicting factor. Under treatment was observed among patients with breast cancer and rectal cancer.

Hypothyroidism might be related to breast cancer in post-menopausal women

An association between breast cancer and thyroid (autoimmune) diseases or the presence of thyroid peroxidase antibodies (TPOAb; a marker of thyroid autoimmune disease) has been suggested. However, little is known about whether women with thyroid (autoimmune) diseases are at increased risk for developing breast cancer. This cross-sectional and prospective cohort study investigated whether the presence of TPOAb or thyroid dysfunction is related to the presence or development of breast cancer. An unselected cohort of 2,775 women around menopause was screened for the thyroid parameters thyrotropin (TSH), free thyroxine (FT(4)), and TPOAb during 1994. Detailed information on previous or actual thyroid disorders and breast cancer, and on putative factors related to breast cancer and thyroid disorders, was obtained. Clinical thyroid dysfunction was defined by both abnormal FT4 and TSH, and subclinical thyroid dysfunction by abnormal TSH (with normal FT4). A TPOAb concentration >or= 100 U/ml was defined as positive (TPOAb(+)). The study group was linked with the Eindhoven Cancer Registry to detect all women with (in situ) breast cancer (ICD-O code 174) diagnosed between 1958 and 1994. Subsequently, in the prospective study, all women who did not have breast cancer in 1994 (n = 2,738) were followed up to July, 2003, and all new cases of (in situ) breast cancer and all cancer-related deaths were registered. Of the 2,775 women, 278 (10.0%) were TPOAb(+). At the 1994 screening, 37 women (1.3%) had breast cancer. TPOAbs were (independently) related to a current diagnosis of breast cancer (OR = 3.3; 95% CI 1.3-8.5). Of the remaining women, 61 (2.2%) developed breast cancer. New breast cancer was related to: (1) an earlier diagnosis of hypothyroidism (OR = 3.8; 95% CI 1.3-10.9); (2) the use of thyroid medication (OR = 3.2; 95% CI 1.0-10.7); and (3) low FT4 (lowest tenth percentile: OR = 2.3; 95% CI 1.2-4.6). In the first 3 years follow up, the relationship between FT4 and log-TSH was disturbed in women with a new breast cancer diagnosis. The presence of TPOAb was not related to breast cancer during follow-up. A direct relationship between thyroid autoimmunity and breast cancer is unlikely. Hypothyroidism and low-normal FT4 are related with an increased risk of breast cancer in post-menopausal women. Studies are needed to clarify the origins of this possible association.

Prognostic impact of increasing age and co-morbidity in cancer patients: A population-based approach

This large population-based study focuses on the prognostic role of increasing age and co-morbidity in cancer patients diagnosed in the southern Netherlands. Data of patients diagnosed between 1995 and 2002 and recorded in the population-based Eindhoven Cancer Registry were used. Older patients (with serious co-morbidity) with non-small cell lung cancer or prostate cancer underwent surgery less often than younger patients. Elderly with stage III colon cancer, small cell lung cancer, FIGO II or III ovarian cancer or non-Hodgkin's lymphoma (NHL) received (adjuvant) chemotherapy less often, probably because of the higher rate of haematological complications. Administration of adjuvant radiotherapy decreased with age and co-morbidity in patients with rectal cancer, limited small cell lung cancer or breast cancer. In general, elderly did not suffer from more complications than younger patients, except for cardiac complications (colorectal cancer and NHL) and postoperative death (non-small cell lung cancer). For most tumours relative survival was lower for the elderly, except for patients with colon cancer, prostate cancer or indolent NHL. Co-morbidity had an independent prognostic effect, except for tumours with a very poor prognosis. Future prospective studies should investigate whether the guidelines for cancer treatment should be adjusted for elderly with serious co-morbidity.

Increasing incidence and improved survival of cancer in children and young adults in Southern Netherlands, 1973–1999

The aim of this study was to describe time trends in incidence, treatment and survival of children (0-14 years) and young adults (15-24 years) with cancer in an area in the Netherlands with a long registration period. Between 1973 and 1999, the population-based Eindhoven Cancer Registry (ECR) recorded 852 children and 1162 young adults with a malignancy and they were actively followed up until 1 July, 2003. The world standardised incidence rates for both children and young adults showed an increasing trend until 1997 and this flattened off afterwards (estimated annual percentage change [EAPC]=3.1%, P=0.66 for children and EAPC=3.6%, P=0.06 for young adults). Lymphomas in children and testicular malignancies and melanomas in young adults seemed to increase in particular. Better detection probably led to higher completeness for gliomas. Initial treatment for leukaemias and lymphomas in children has changed, protocols prescribe more chemotherapy and less radiotherapy. For all cancers combined, the 10-year survival rate for children significantly improved from 53% (95% confidence interval [95% CI] 45-61%) in 1973-1982 to 75% (95% CI 69-81%) in 1993-1999 (P-value<0.05). The 10-year survival rate for young adults significantly improved from 57% (95% CI 49-65%) to 81% (95% CI 77-85%) (P-value<0.05). We demonstrated significantly higher five-year survival rates for children with Hodgkin's disease (HD) and young adults with HD, non-seminoma or melanoma diagnosed in 1993-1999.

Comparison of comorbidity prevalence in oesophageal and gastric carcinoma patients: a population-based study

OBJECTIVE

We investigated the distribution of serious comorbidity in patients with newly diagnosed oesophageal and gastric cancer between 1993 and 2001. Our special interest was comparing distal oesophageal and gastric cardia adenocarcinoma patients since a common origin of these tumours has been suggested.

METHODS

Data on comorbidity (previous cancers, chronic obstructive pulmonary diseases, cardiovascular and cerebrovascular diseases, hypertension, ulcerative digestive tract diseases, liver diseases and diabetes) were derived from a population-based database in The Netherlands to compare risk factor profiles for 479 oesophageal squamous cell carcinomas, 339 distal oesophageal adenocarcinomas, 570 cardia adenocarcinomas and 1965 subcardia cancers.

RESULTS

A comparable age and gender distribution was shown in distal oesophageal and cardia adenocarcinoma patients. After adjustment for age and gender, only the prevalence of previous cancers differed between adenocarcinomas of distal oesophagus and cardia [more frequent in distal oesophageal adenocarcinoma patients, odds ratio (OR) = 1.84, P = 0.01]. Ulcerative and liver diseases were more prevalent in oesophageal squamous cell carcinoma patients as compared with distal oesophageal adenocarcinoma patients (OR = 1.90, P = 0.02 and OR = 8.82, P = 0.04, respectively), whereas diabetes was more prevalent in the latter (OR = 0.56, P = 0.03). Cardia adenocarcinoma patients significantly more often had hypertension as compared with subcardia cancer patients (OR = 1.53, P = 0.001), whereas the latter more often suffered from previous cancers and ulcerative diseases (OR = 0.54, P = 0.0009 and OR = 0.25, P < 0.0001, respectively).

CONCLUSIONS

In terms of comorbidity at diagnosis, cardia adenocarcinoma patients resemble distal oesophageal adenocarcinoma patients rather than gastric subcardia carcinoma patients, with likewise equal age and gender distribution.

Determinants of prognosis in breast cancer patients with tumor involvement of the skin (pT4b)

Determinants of prognosis were studied in patients with breast cancer with histologically proven tumor extension to the skin without clinical evidence of distant metastases (i.e., pT4b N0-3 M0). Data were collected retrospectively on 77 consecutive patients diagnosed in one community teaching hospital over the period from 1980 to 1995. The prognostic factor of tumor size showed a 5-year survival rate for patients with a tumor </=3 cm of 81% compared to 45% for patients with tumors larger than 3 cm (p = 0.002). Achievement of complete remission resulted in a 5-year survival rate of 66%, compared to 27% when complete remission was not achieved (p = 0.005). Another important prognostic factor was the development of local-regional recurrence: the 5-year survival rates for patients with and without local-regional recurrence were 39% and 87%, respectively (p < 0.001). Development of local-regional recurrence was also significantly related to tumor size (p = 0.02). Pathologic tumor size and the achievement of complete remission and local-regional control appear to be the most important prognostic factors for survival in patients with pT4b breast cancer without distant metastases. We conclude that the finding of a pT4b breast cancer does not always imply a dismal prognosis, especially for those patients with a tumor </=3 cm. A favorable prognosis can be expected when treatment is effective in achieving complete remission and in preventing the development of local-regional recurrence.

Increased incidence of adenocarcinomas at the gastro-oesophageal junction in Dutch males since the 1990s

BACKGROUND

Worldwide population-based studies suggest that the incidence of oesophageal and gastric cardia adenocarcinomas has increased since the 1970s.

OBJECTIVE AND METHODS

We studied time trends in mortality and incidence rates of oesophageal and gastric carcinomas according to subsite and histology in the south-east Netherlands since 1978.

RESULTS

The age-adjusted mortality and incidence rates for oesophageal cancer doubled in males over the entire 19-year study period from 2.7 to 5.6 and from 2.4 to 4.8 per 100,000 person years, respectively. In females, a similar trend for the mortality and incidence rates was seen, but at a lower level. The age-adjusted mortality and incidence rates for gastric cancer decreased with time from 20.7 to 12.8 and from 21.6 to 15.9 per 100,000 person years in males, respectively. In females, age-adjusted mortality and incidence rates for gastric cancer also decreased. Analysis of incidence rates by subsite and subtype showed an increase in adenocarcinomas of the oesophagus and gastric cardia, largely restricted to males. In females, the rise in incidence of squamous cell carcinoma of the oesophagus appeared to be more marked than the rise in adenocarcinomas, whereas the incidence of gastric cardia carcinomas has remained stable over the last 10 years. Neither the decrease in the number of unspecified tumours with time, nor the increase in the use of diagnostic endoscopy and imaging techniques, is likely to explain completely the observed increases.

CONCLUSION

The increase in incidence of adenocarcinomas at the gastro-oesophageal junction in the south-eastern Netherlands seems, at least in part, to represent a true underlying increase that is restricted largely to males.