The co-occurrence of ocular and cutaneous melanomas.
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Eye Neoplasms↗
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Early detection of thick melanomas in the United States: beware of the nodular subtype.
BACKGROUND: Incidence and mortality of melanoma in the United States have risen steeply. Part of this mortality increase may be related to late detection of biologically aggressive nodular melanomas. We determined trends in distribution of thin and thick melanoma, with emphasis on the histopathologic subtype nodular melanoma. METHODS: Surveillance, Epidemiology, and End Results melanoma incidence data for whites were obtained for 1988 through 1999 and stratified according to histologic subtype: lentigo maligna melanoma, superficial spreading melanoma, nodular melanoma, other, and not otherwise specified (NOS); thickness: 0-0.99 mm, 1.00 mm-1.99 mm, and > or =2.0 mm; patient age (0-49, 50+); gender; and year (1988-1991, 1992-1995, 1996-1999). Comparison of tumor thickness between strata was defined by year of diagnosis, sex, age, and histologic subtype. RESULTS: The number of new melanoma cases in a 3-year period increased 60% from 1988-1991 (n = 9132) to 1996-1999 (n = 14 575). The proportion of thick melanomas (> or =2 mm) remained relatively stable during the 12 study years. Nodular melanoma comprised 9% of all recorded cases but 34% of melanomas 2 mm or larger, including melanoma not otherwise specified (NOS), and nearly 50% of all melanomas 2 mm or larger when NOS cases were excluded. In contrast, superficial spreading melanoma was almost uniformly diagnosed as an early tumor, mostly (77%) presenting as thin melanoma (<1 mm) and with only 7% presenting as thick melanoma (> or =2 mm). CONCLUSIONS: A substantial number of thick melanomas in the United States are of the nodular subtype, and median thickness of nodular melanoma has not changed during the 12 years of study. New strategies are needed to decrease the incidence of thick melanoma in the United States.
Age Distribution↗
Difference in breast cancer stage, treatment, and survival.
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Adult↗
Delays in breast cancer diagnosis and treatment by racial/ethnic group.
BACKGROUND: Although white women have the highest incidence of breast cancer, African American, followed by Hispanic, American Indian/Alaskan Native, and Asian American or Pacific Islander, women have higher death rates from the disease. Timely initiation of treatment has been shown to improve survival, and may help to lessen the mortality differences among racial/ethnic groups. METHODS: The purpose of this study was to describe time delays in the initial diagnosis and treatment of primary breast carcinoma across diverse ethnic/racial groups. Data are from the Surveillance, Epidemiology, and End Results-Medicare database. Women in this study were diagnosed as having breast cancer between January 1, 1992, and December 31, 1999. Billing claims from outpatient and inpatient visits were used. A total of 49 865 female Medicare recipients 65 years and older were enrolled in the study. Racial/ethnic groups were compared in their diagnostic, treatment, and clinical delay (ie, women with a diagnostic and treatment delay). RESULTS: African American women experienced the greatest diagnostic, treatment, and clinical delay. After controlling for other predictors, compared with white women, African American women had a 1.39-fold odds (95% confidence interval, 1.18-1.63) of diagnostic delay beyond 2 months, a 1.64-fold odds (95% confidence interval, 1.40-1.91) of treatment delay beyond 1 month, and a 2.24-fold odds (95% confidence interval, 1.75-2.86) of having a combined clinical delay. CONCLUSIONS: In a population-based study, African American women experienced the most delays in initial diagnosis and initiation of breast cancer treatment, relative to women of other racial/ethnic subgroups. Despite the limitations of a claims database, the magnitude and direction of the findings are consistent across the research, suggesting the critical importance of reducing these delays.
Black or African American↗
Pediatric head and neck malignancies: US incidence and trends over 2 decades.
BACKGROUND: Recent reports have noted an increase in the overall incidence of pediatric cancer. OBJECTIVE: To determine whether this trend is applicable to malignancies of the head and neck in children. DESIGN: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results tumor database, we determined the incidence of all cancers diagnosed from 1973 through 1996 in children younger than 19 years. This was compared with the incidence of head and neck malignancies within the same population. Rates were then determined for eight 3-year periods from 1973-1975 to 1994-1996 and adjusted by use of three 5-year age groups weighted by the 1970 US standard population. RESULTS: A total of 24,960 malignancies diagnosed in children younger than 19 years were identified for the study period. From this group, 3050 tumors (12%) were located in the head and neck. The average annual rate of all cancer (number of malignancies per 100,000 person-years) in children younger than 15 years rose 25% from 11.22 (95% confidence interval [CI], 10.70-11.74) for 1973-1975 to 14.03 (95% CI, 13.46-14.60) for 1994-1996. Among malignancies of the head and neck, the incidence rate increased 35% from 1.10 (95% CI, 0.94-1.26) to 1.49 (95% CI, 1.30-1.68) during the same period. CONCLUSION: The incidence of head and neck malignancies among children younger than 15 years in the United States from 1973 through 1996 increased at a greater rate than childhood cancer in general.
Adolescent↗
Survival and staging characteristics for non-squamous cell malignancies of the maxillary sinus.
OBJECTIVE: To characterize the clinical behavior of non-squamous cell cancer of the maxillary sinus. METHODS: Cases of non-squamous cell maxillary sinus malignancy during 1988 through 1998 were extracted from the Surveillance, Epidemiology, and End Results database. Data for histologic type of tumor, tumor stage, and survival were analyzed using the Kaplan-Meier method to determine mean, median, and 5-year survival statistics for the overall cohort and for individual histologic types of tumor. The effect of tumor stage on overall survival was assessed. To determine relative survival, the non-squamous cell group was compared with a second group of patients with squamous cell carcinoma, matched according to age at diagnosis, year of diagnosis, and T stage. RESULTS: One hundred eighty-eight cases of non-squamous cell malignancy were identified. The mean patient age was 57.8 years, and 143 patients (76%) presented with T3 or T4 tumors. There were 31 adenocarcinomas, 64 adenoid cystic carcinomas, 15 mucoepidermoid carcinomas, 22 melanomas, 45 sarcomas, and 11 undifferentiated carcinomas. The overall mean survival was 63.4 months, and 5-year survival was 45.6%. Adenoid cystic carcinoma exhibited the best mean survival (79 months), whereas melanoma and undifferentiated carcinoma exhibited poor mean survivals (30.3 and 12.8 months, respectively). T stage did not statistically affect overall survival (P =.86). Survival for patients with non-squamous cell cancer was substantially better than survival for the matched group with squamous cell carcinomas (mean survival, 41.5 months; 5-year survival, 27.4%). CONCLUSIONS: Patients with non-squamous cell carcinoma of the maxillary sinus typically present with advanced T stage but have significantly better survival than patients with similar-stage squamous cell carcinoma of the maxillary sinus. T stage has less effect than histologic type of tumor on prognosis in non-squamous cell carcinoma of the maxillary sinus.
Adenocarcinoma↗
The effect of laparoscopy on survival in pancreatic cancer.
HYPOTHESIS: Exposure to laparoscopy influences survival in patients with unresected pancreatic cancer who have a diagnostic or staging surgical procedure. METHODS: We used the Surveillance, Epidemiology, and End Results Medicare-linked database to identify a cohort of persons 65 years and older, who were newly diagnosed with primary pancreatic cancer between 1991 and 1996 and who had a diagnostic laparoscopy or laparotomy during the course of their disease. Patients with a prior malignancy and those who had a pancreatic resection were excluded. We used proportional-hazards regression to adjust risk estimates for demographic factors, medical comorbidities, tumor characteristics, and the use of other treatment modalities. RESULTS: We identified 112 individuals with pancreatic cancer who had a laparoscopic procedure and 791 who had only conventional surgery. More patients who had laparoscopic surgery had distant metastases at diagnosis (67.9% vs 41.2%; P =.001). Median duration of survival in the laparoscopic surgery group was 4.8 months (95% confidence interval [CI], 4.1-6.8) compared with 5.3 months in the group that had only open surgery (95% CI, 4.9-5.6; P =.83). Compared with patients who only had a laparotomy, patients who had laparoscopic surgery did not have an increased rate of death when adjusted for the effects of age, sex, tumor size, grade, the presence of nodal and distant metastases at diagnosis, and the use of radiation, chemotherapy, therapeutic endoscopic retrograde cholangiopancreatography, and biliary and gastric bypass (adjusted hazard ratio, 0.93; 95% CI, 0.62-1.40). CONCLUSION: Exposure to laparoscopic surgery did not adversely affect survival in a cohort of elderly patients with pancreatic cancer who had a diagnostic procedure but no pancreatic resection.
Aged↗
Racial disparities in rectal cancer treatment: a population-based analysis.
HYPOTHESIS: We hypothesized that there are significant racial disparities in delivery of care to rectal cancer patients. We examined differential surgical and radiation treatment for these patients and determined whether blacks were less likely than whites to undergo sphincter-sparing procedures, which are associated with a higher quality of life than sphincter-ablating procedures. DESIGN: Cross-sectional cohort study. PATIENTS AND SETTING: The Surveillance Epidemiology and End Results database provided population-based data for rectal cancer patients who were diagnosed between 1988 and 1999, were older than 35 years, and had no prior colorectal or other pelvic cancer. MAIN OUTCOME MEASURES: Using logistic regression, we compared receipt and type of surgical therapy and radiation therapy, controlling for age, sex, year, geography, stage, and anatomic location. RESULTS: Among 52 864 patients, 3851 were black and 44 010 were white. Blacks were younger than whites and had more advanced disease (P<.001). Among patients who underwent operation, rates of sphincter-ablating procedure were 37% for whites and 43% for blacks (adjusted odds ratio [AOR], 1.42; 95% confidence interval [CI], 1.23-1.65). Moreover, 53% of whites and 56% of blacks received no radiation therapy for stage II to III disease (AOR, 1.30; 95% CI, 1.15-1.47). CONCLUSIONS: Blacks with rectal cancer were diagnosed at a younger age and more advanced disease stage than whites, implying a need for more aggressive screening. After adjusting for stage and other covariates, surgical and radiation treatment also differed along racial lines. Our data suggest that treatment disparities may contribute to differences in outcome among racial/ethnic groups with rectal cancer, and they highlight the need for improving access to state-of-the-art surgical care for minority patients with rectal cancer.
Adult↗
Surgeon characteristics and variations in treatment for early-stage breast cancer.
HYPOTHESIS: Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics. DESIGN: Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer. MAIN OUTCOME MEASURE: Care adherent to the 1990 National Institutes of Health consensus statement recommendations. RESULTS: Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery. CONCLUSIONS: Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.
Aged↗
Effect of Nancy Reagan's mastectomy on choice of surgery for breast cancer by US women.
CONTEXT: While the actions of popular figures are believed to influence the behavior of the general public, including health care decisions, little research has examined such an effect. OBJECTIVE: To determine whether a temporal association exists between use of breast-conserving surgery (BCS) for treatment of breast cancer and Nancy Reagan's mastectomy in October 1987. DESIGN/SETTING: Population-based observational cohort study. PATIENTS: Two sources of data: (1) 82 230 women aged 30 years and older who were included in the Surveillance, Epidemiology, and End Results tumor registry because of a diagnosis of local or regional breast cancer from 1983 to 1990; and (2) 80057 female Medicare beneficiaries aged 65 to 79 years who received inpatient surgery for local or regional breast cancer in 1987 or 1988. MAIN OUTCOME MEASURE: Percentage of use of BCS vs mastectomy over time. RESULTS: Compared with women undergoing surgery for breast cancer in the third quarter of 1987 (just prior to Mrs Reagan's mastectomy), women were 25% less likely to undergo BCS in the fourth quarter of 1987 (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.66-0.85) and in the first quarter of 1988 (OR, 0.76; 95% CI, 0.67-0.86). In subsequent quarters, the rate returned to the baseline. In multivariate analyses, the decline was significant among white but not nonwhite women. It was most prominent among women aged 50 to 79 years in the central and southern regions of the country, and most sustained among women living in areas with lower levels of income and education. CONCLUSIONS: Celebrity role models can influence decisions about medical care. The influence appears strongest among persons who demographically resemble the celebrity, and those of lower income and educational status.
Adult↗
Impact of hospital volume on operative mortality for major cancer surgery.
CONTEXT: Hospitals that treat a relatively high volume of patients for selected surgical oncology procedures report lower surgical in-hospital mortality rates than hospitals with a low volume of the procedures, but the reports do not take into account length of stay or adjust for case mix. OBJECTIVE: To determine whether hospital volume was inversely associated with 30-day operative mortality, after adjusting for case mix. DESIGN AND SETTING: Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in which the hypothesis was prospectively specified. Surgeons determined in advance the surgical oncology procedures for which the experience of treating a larger volume of patients was most likely to lead to the knowledge or technical expertise that might offset surgical fatalities. PATIENTS: All 5013 patients in the SEER registry aged 65 years or older at cancer diagnosis who underwent pancreatectomy, esophagectomy, pneumonectomy, liver resection, or pelvic exenteration, using incident cancers of the pancreas, esophagus, lung, colon, and rectum, and various genitourinary cancers diagnosed between 1984 and 1993. MAIN OUTCOME MEASURE: Thirty-day mortality in relation to procedure volume, adjusted for comorbidity, patient age, and cancer stage. RESULTS: Higher volume was linked with lower mortality for pancreatectomy (P=.004), esophagectomy (P<.001), liver resection (P=.04), and pelvic exenteration (P=.04), but not for pneumonectomy (P=.32). The most striking results were for esophagectomy, for which the operative mortality rose to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% vs 5.8%. Adjustments for case mix and other patient factors did not change the finding that low volume was strongly associated with excess mortality. CONCLUSIONS: These data support the hypothesis that when complex surgical oncologic procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower.
Aged↗
Increasing risk of melanoma with increasing age.
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Adult↗
Increase in the use of breast-conserving surgery.
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Breast Neoplasms↗
Influence of hospital procedure volume on outcomes following surgery for colon cancer.
CONTEXT: Survival following high-risk cancer surgery, such as pancreatectomy and esophagectomy, is superior at hospitals where high volumes of these procedures are performed. Conflicting evidence exists as to whether the association between hospital experience and favorable health outcomes also applies to more frequently performed operations, such as those for colon cancer. OBJECTIVE: To determine whether hospital procedure volume predicts survival following colon cancer surgery. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of data from the Surveillance, Epidemiology and End Results-Medicare linked database on 27 986 colon cancer patients aged 65 years and older who had surgical resection for primary adenocarcinoma diagnosed between 1991 and 1996. MAIN OUTCOME MEASURES: Thirty-day postoperative mortality and overall and cancer-specific long-term survival, by hospital procedure volume. RESULTS: We found small differences in 30-day postoperative mortality for patients treated at low- vs high-volume hospitals (3. 5% at hospitals in the top-volume quartile vs 5.5% at hospitals in the bottom-volume quartile). However, the correlation was statistically significant and persisted after adjusting for age at diagnosis, sex, race, cancer stage, comorbid illness, socioeconomic status, and acuity of hospitalization (P<.001). The association was evident for subgroups with stage I, II, and III disease. Hospital volume directly correlated with survival beyond 30 days and also was not attributable to differences in case mix (P<.001). The association between hospital volume and long-term survival was concentrated among patients with stage II and III disease (P<.001 for both). Among stage III patients, variation in use of adjuvant chemotherapy did not explain this finding. CONCLUSION: Our data suggest that hospital procedure volume predicts clinical outcomes following surgery for colon cancer, although the absolute magnitudes of these differences are modest in comparison with the variation observed for higher-risk cancer surgeries.
Adenocarcinoma↗
Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older.
CONTEXT: Postmenopausal women aged 55 years and older have 66% of incident breast tumors and experience 77% of breast cancer mortality, but other age-related health problems may affect tumor prognosis and treatment decisions. OBJECTIVE: To document the comorbidity burden of postmenopausal breast cancer patients and evaluate its relationship with age on disease stage, treatment, and early mortality. DESIGN AND SETTING: Data were collected on breast cancer patients' comorbidities by retrospective hospital medical records review and merged with information on patients' tumor characteristics collected from 6 regional National Cancer Institute Surveillance, Epidemiology, and End Results cancer registries. Patients were followed up until death or for 30 months from breast cancer diagnosis. PARTICIPANTS: Population-based random sample of 1800 postmenopausal breast cancer patients diagnosed in 1992 stratified by 3 age groups: 55 to 64 years, 65 to 74 years, and 75 years and older. MAIN OUTCOME MEASURES: Extent of disease, therapy received, comorbidity, cause of death, and survival. RESULTS: Seventy-three percent (1312 of 1800) of the sample was diagnosed with stage I and II breast cancer, 10% (n = 188) with stage III and IV breast cancer, and 17% (n = 300) did not have a stage assignment. Of the 1017 patients with stage I and stage II node-negative breast cancer, 95% received therapy in agreement with the National Institutes of Health consensus statement recommendation for early-stage breast cancer. Patients in older age groups were less likely to receive therapy consistent with the consensus statement (P<.001), and women aged 70 years and older were significantly less likely to receive axillary lymph node dissection as determined by logistic regression analysis (P<.01). Diabetes, renal failure, stroke, liver disease, a previous malignant tumor, and smoking were significant in predicting early mortality in a statistical model that included age and disease stage. Breast cancer was the underlying cause of death for 135 decedents (51.3%). Heart disease (n = 45, 17.1%) and previous cancers (n = 22, 8.4%) were the next major underlying causes. In the 30-month follow-up period, 263 patients (15%) died. CONCLUSION: Patient care decisions occur in the context of breast cancer and other age-related conditions. Comorbidity in older patients may limit the ability to obtain prognostic information (ie, axillary lymph node dissection), tends to minimize treatment options (eg, breast-conserving therapy), and increases the risk of death from causes other than breast cancer.
Age Factors↗
Melanoma incidence and mortality among US whites, 1969-1999.
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Adult↗
Relationship between long durations and different regimens of hormone therapy and risk of breast cancer.
CONTEXT: Women using combined estrogen and progestin hormone replacement therapy (CHRT) have an increased risk of breast cancer; however, data on use for long durations and on risk associated with patterns of use are lacking. OBJECTIVE: To evaluate relationships between durations and patterns of CHRT use and risk of breast cancer by histological type and hormone receptor status. DESIGN: Population-based case-control study. SETTING: Three counties in western Washington State. PARTICIPANTS: Nine hundred seventy-five women 65-79 years of age diagnosed with invasive breast cancer from April 1, 1997, through May 31, 1999 (histology: 196 lobular cases, 656 ductal cases, 114 cases with other histological type, and 9 cases with an unspecified histological type; estrogen receptor (ER)/progesterone receptor (PR) status: 646 ER+/PR+ cases, 147 ER+/PR- cases, and 101 ER-/PR- cases [6 ER-/PR+ cases and 75 cases with unknown ER/PR status were not included in the analyses herein]) and 1007 population controls. MAIN OUTCOME MEASURES: Risks of invasive lobular, ductal, ER+/PR+, ER+/PR-, and ER-/PR- breast carcinomas. RESULTS: Women using unopposed estrogen replacement therapy (ERT) (exclusive ERT use), even for 25 years or longer, had no appreciable increase in risk of breast cancer, although the associated odds ratios were not inconsistent with a possible small effect. Ever users of CHRT (includes CHRT users who also had used ERT) had a 1.7-fold (95% confidence interval [CI], 1.3-2.2) increased risk of breast cancer, including a 2.7-fold (95% CI, 1.7-4.3) increased risk of invasive lobular carcinoma, a 1.5-fold (95% CI, 1.1-2.0) increased risk of invasive ductal carcinoma, and a 2.0-fold (95% CI, 1.5-2.7) increased risk of ER+/PR+ breast cancers. The increase in risk was greatest in those using CHRT for longer durations (users for 5-14.9 years and >or=15 years had 1.5-fold [95% CI, 1.0-2.3] and 1.6-fold [95% CI, 1.0-2.6] increases in risk of invasive ductal carcinoma, respectively, and 3.7-fold [95% CI, 2.0-6.6] and 2.6-fold [95% CI, 1.3-5.3] increases in risk of invasive lobular carcinoma, respectively. Associations of similar magnitudes were seen among users of both sequential and continuous CHRT. Risks of ER+/PR- and ER-/PR- tumors were not increased by use of any form of hormone replacement therapy; however, small numbers of these tumors limited power to detect possible associations. CONCLUSION: These data suggest that use of CHRT is associated with an increased risk of breast cancer, particularly invasive lobular tumors, whether the progestin component was taken in a sequential or in a continuous manner.
Aged↗
Antibiotic use in relation to the risk of breast cancer.
CONTEXT: Use of antibiotics may be associated with risk of breast cancer through effects on immune function, inflammation, and metabolism of estrogen and phytochemicals; however, clinical data on the association between antibiotic use and risk of breast cancer are sparse. OBJECTIVE: To examine the association between use of antibiotics and risk of breast cancer. DESIGN, SETTING, AND PARTICIPANTS: Case-control study among 2266 women older than 19 years with primary, invasive breast cancer (cases) enrolled in a large, nonprofit health plan for at least 1 year between January 1, 1993, and June 30, 2001, and 7953 randomly selected female health plan members (controls), frequency-matched to cases on age and length of enrollment. Cases were ascertained from the Surveillance, Epidemiology, and End Results cancer registry. Antibiotic use was ascertained from computerized pharmacy records. MAIN OUTCOME MEASURE: Association between extent of antibiotic use and risk of breast cancer. RESULTS: Increasing cumulative days of antibiotic use were associated with increased risk of incident breast cancer, adjusted for age and length of enrollment. For categories of increasing use (0, 1-50, 51-100, 101-500, 501-1000, and > or =1001 days), odds ratios (95% confidence intervals) for breast cancer were 1.00 (reference), 1.45 (1.24-1.69), 1.53 (1.28-1.83), 1.68 (1.42-2.00), 2.14 (1.60-2.88), and 2.07 (1.48-2.89) (P<.001 for trend). Increased risk was observed in all antibiotic classes studied and in a subanalysis having breast cancer fatality as the outcome. Among women with the highest levels of tetracycline or macrolide use, risk of breast cancer was not elevated in those using these antibiotics exclusively for acne or rosacea (indications that could be risk factors for breast cancer due to altered hormone levels), compared with those using them exclusively for respiratory tract infections, adjusted for age and length of enrollment (odds ratio, 0.91; 95% confidence interval, 0.44-1.87). CONCLUSIONS: Use of antibiotics is associated with increased risk of incident and fatal breast cancer. It cannot be determined from this study whether antibiotic use is causally related to breast cancer, or whether indication for use, overall weakened immune function, or other factors are pertinent underlying exposures. Although further studies are needed, these findings reinforce the need for prudent long-term use of antibiotics.
Adult↗