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PubMed2006

Population-based analyses of lymph node metastases in colorectal cancer.

BACKGROUND & AIMS: The potential presence of lymph node metastases in patients with colorectal cancer (CRC) limits the application of minimally invasive techniques of resection. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry to better understand the underlying risk of lymph node metastases and factors that influence this risk in a population-based fashion. METHODS: In a cohort of 124,180 CRC patients diagnosed from 1988 through 2002 treated with radical surgery without neoadjuvant irradiation, we assessed the proportion of patients who were lymph node positive and determined factors that influenced the risk of lymph node metastases including patient characteristics, anatomic location, and histopathologic factors. RESULTS: Among all patients, the proportion of lymph node metastases was 34.5%. The overall proportion of node positivity was 8% for T1 tumors, 18.5% for T2 tumors, 42% for T3 tumors, and 50% for T4 tumors. Nodal metastases were noted in 7% of proximal T1 colon tumors, 7.5% of distal T1 colon tumors, and 10.1% of T1 rectal tumors. Patients with poorly differentiated tumors were much more likely to be node positive (52%) than patients with well-differentiated tumors (20%) (P<.0001). CONCLUSIONS: Even patients with superficial CRCs have a significant risk of nodal metastases. This risk should be considered when balancing the risks and benefits of minimally invasive techniques such as local excision or endoscopic resection for the treatment of CRC.

Adenocarcinoma↗
PubMed2004

The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies.

AIMS: The debate on the funding and availability of cytotoxic drugs raises questions about the contribution of curative or adjuvant cytotoxic chemotherapy to survival in adult cancer patients. MATERIALS AND METHODS: We undertook a literature search for randomised clinical trials reporting a 5-year survival benefit attributable solely to cytotoxic chemotherapy in adult malignancies. The total number of newly diagnosed cancer patients for 22 major adult malignancies was determined from cancer registry data in Australia and from the Surveillance Epidemiology and End Results data in the USA for 1998. For each malignancy, the absolute number to benefit was the product of (a) the total number of persons with that malignancy; (b) the proportion or subgroup(s) of that malignancy showing a benefit; and (c) the percentage increase in 5-year survival due solely to cytotoxic chemotherapy. The overall contribution was the sum total of the absolute numbers showing a 5-year survival benefit expressed as a percentage of the total number for the 22 malignancies. RESULTS: The overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in Australia and 2.1% in the USA. CONCLUSION: As the 5-year relative survival rate for cancer in Australia is now over 60%, it is clear that cytotoxic chemotherapy only makes a minor contribution to cancer survival. To justify the continued funding and availability of drugs used in cytotoxic chemotherapy, a rigorous evaluation of the cost-effectiveness and impact on quality of life is urgently required.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2004

Cancers of the prostate, penis, and testicles: epidemiology, prevention, and treatment.

Cancer is a disease that most people fear. Nurses are required to provide information on how to avoid cancer, and, once the diagnosis is made, how to cope with it. Prevention and early detection of the cancers described in this article are in the very early stages of knowledge development, but general health promotion guidance can be offered on how to avoid most cancers (ie, no tobacco use, a high-fiber and low fat diet, exercise, and maintaining a normal weight). Nurses also can advise patients to be screened for colorectal cancer at the appropriate ages and time intervals and to be aware as new developments occur in the scientific base for screenings in the areas of prostate, penile, and testicular cancer. Finally, coping with these forms of cancer often requires the patient to make major lifestyle and psychological changes, especially if surgery in the genital area occurs. Decreased libido, incontinence, and impotence are major complications that can occur with these illnesses. The male cancers described vary tremendously in their prevalence, incidence, mortality, treatment, and survival rates. Within this group, there are remarkably positive outcomes and outcomes much in need of improvement. Penile and testicular cancers are the bright spots in this picture; both are uncommon, and both are eminently treatable. Prostate cancer, on the other hand, is quite common, difficult to screen, difficult to treat without major sexual problems, and yet receives relatively little funding from the NIH. Although as many men die from prostate cancer as women die from breast cancer, NIH funds breast cancer research at much higher levels than prostate cancer. According to the latest data available at the NIH Web site, during the 1990s, the amount of NIH funding varied from four times more for breast cancer (1993) to 2.9 times more in 1999. For fiscal year 2002, NIH is providing $522 million in funding for breast cancer and $278 million for prostate cancer. Private foundation funds for prostate cancer are much smaller than those available for breast cancer. Both types of cancer are extremely important to address, and both should receive adequate research attention. Nurses can advocate for more funding for prostate cancer, from basic science approaches to behavioral science strategies.

Adult↗
PubMed2006

Pancreatic cancer in the general population: Improvements in survival over the last decade.

BACKGROUND: It is unknown whether the improved survival seen at high-volume centers has been translated to all patients with pancreatic cancer. OBJECTIVE: To use the Surveillance, Epidemiology, and End Results (SEER) database to evaluate population-based trends in surgical resection and survival. METHODS: All patients diagnosed with pancreatic cancer from 1988-1999 were identified. The survival and proportion of patients undergoing surgical resection were compared for each of three equal time periods. RESULTS: There were 24,016 patients with pancreatic cancer. 19,533 had stage data available. 9% had localized, 29% had regional, and 62% had distant disease. Resection rates increased for patients with localized and regional disease over the three time periods. Survival increased for patients with regional and distant disease. For regional pancreatic cancer patients, 2-year survival increased from 9.5% to 13.5% (p < 0.0001) and from 21.5% to 28.9% following surgical resection (p = 0.002). For resected local/regional pancreatic cancer, the year of diagnosis was and independent predictor of improved survival (p = 0.0001). CONCLUSIONS: SEER patients with regional and distant pancreatic cancer have improved survival over the past decade in both unadjusted and adjusted models. The improvement is most striking for patients with regional disease and reflects increased resection rates and improved resection techniques over time.

Female↗
PubMed2005

The importance of place of residence in predicting late-stage diagnosis of breast or cervical cancer.

We tested whether inner-city women were at significantly increased risk of late-stage cancer diagnosis because they resided in extremely poor and socially isolated neighborhoods or in neighborhoods meeting the federal definition of a medically underserved area (MUA). Cancer registry data on women in three American cities were matched to Census data. Using logistic regression we found that residence in economically and socially distressed or medically underserved neighborhoods tended to increase the likelihood of late-stage cancer diagnoses. Further, we found that not all areas that are economically and socially distressed receive the federal MUA designation. Consequently, we argue that economically and socially distressed neighborhoods should be automatically designated as MUA.

Adult↗
PubMed2006

Survival benefit associated with adjuvant androgen deprivation therapy combined with radiotherapy for high- and low-risk patients with nonmetastatic prostate cancer.

BACKGROUND: The use of adjuvant androgen deprivation therapy (ADT) combined with radiotherapy has become common in low-risk patients, although clinical trials have focused primarily on high-risk patients. This study examines the effectiveness of adjuvant ADT combined with radiotherapy for a wide range of patients treated in the 1990s. METHODS AND MATERIALS: Prostate cancer survival was examined in a population based cohort of 31,643 patients aged 65 to 85 years who were diagnosed with nonmetastatic prostate cancer and treated with external beam radiotherapy and/or brachytherapy. Instrumental variable analysis methods were used to control for selection bias. RESULTS: Patients with stage T3/T4 disease who received adjuvant ADT experienced improved 5-year and 8-year survival. No survival advantage was observed for men with T1/T2 disease during this interval. CONCLUSION: High-risk patients who receive primary radiotherapy have benefited from adjuvant ADT, whereas low-risk patients with disease confined to the prostate have not yet benefited from adjuvant therapy within the first 8 years after treatment. These findings are consistent with practice guidelines, which recommend adjuvant ADT for patients with high-risk disease.

Aged↗
PubMed2006

Second malignancies after prostate brachytherapy: incidence of bladder and colorectal cancers in patients with 15 years of potential follow-up.

PURPOSE: To report the incidence of second bladder and colorectal cancers after prostate brachytherapy. METHODS AND MATERIALS: This review included 125 patients treated with I-125 brachytherapy alone, and 223 patients who received supplemental external beam radiation therapy. Median follow-up was 10.5 years. Patients were followed for the development of lower genitourinary and colorectal cancers. Second malignancies arising five years after radiation therapy were defined as being potentially associated with treatment; observed rates were then compared with age-matched expected rates according to Surveillance, Epidemiology, and End Results data. RESULTS: Five years out of treatment, there were 15 patients with a second solid tumor, including bladder cancer (n = 11), colorectal cancer (n = 3), and prostatic urethra cancer (n = 1). The incidence of second malignancy was no different in patients treated with brachytherapy alone (1.6%) vs. those receiving external beam radiotherapy (5.8%, p = 0.0623). There were more observed bladder cancers compared with those expected (relative risk, 2.34, 95% confidence interval 0.96-3.72; absolute excess risk 35 cancers per 10,000 patients). Relative risk did not significantly change over increasing follow-up intervals up to 20 years after treatment. CONCLUSIONS: There may be an increased but small risk of developing a second malignancy after radiation therapy for prostate cancer. This outcome could be related to radiation carcinogenesis, but more vigilant screening and thorough workup as a result of radiation side effects and predisposing conditions (e.g., genetic and environmental factors) in many of the patients found to have second malignancies likely contributed to the higher number of observed malignancies than expected.

Adult↗
PubMed2005

Extent of disease and practice patterns for medullary thyroid cancer.

BACKGROUND: There have been significant improvements in the management of medullary thyroid cancer (MTC), and consensus treatment guidelines have been established by numerous international and national societies. It is unclear if the advances in diagnosis and treatment of MTC have led to earlier diagnosis and more complete initial treatment of patients with MTC. STUDY DESIGN: Patients with MTC (n=1,070) were identified in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database from 12 population-based cancer registries between 1973 and 2000. Four equal-time quartiles (group I=1973 to 1979, group II=1980 to 1986, group III=1987 to 1993, and group IV=1994 to 2000) were compared for changes in demographics, extent of disease, and treatment. RESULTS: Mean tumor size was significantly larger in 1988 than in 1989 through 2000 (p=0.044), but there was no significant trend toward smaller tumor size. The number of patients having total or near total thyroidectomy increased significantly in the latter two quartiles (p < 0.001) but not the number of patients having cervical lymph node dissection. Unfortunately, 15% of patients in group IV still had less than total or near total thyroidectomy, and 41% had no cervical lymph node dissection. There were no significant differences in age, gender, rate of lymph node or distant metastasis, SEER stage, TNM stage, and cause-specific mortality among the four time groups and annually. CONCLUSIONS: There was no significant trend toward earlier stage of disease at diagnosis and treatment and no significant increase in the survival of patients with MTC during a 28-year period. A high proportion of patients continue to receive less than optimal initial surgical treatment.

Adolescent↗
PubMed2006

Risk assessment in 457 adrenal cortical carcinomas: how much does tumor size predict the likelihood of malignancy?

BACKGROUND: Laparoscopic adrenalectomy for tumors > 6 cm is controversial because of the risk of malignancy, but data to support this position are mostly from small series. The recent NIH consensus conference did not make a definitive recommendation about management of 4- to 6-cm nonfunctioning incidentalomas. STUDY DESIGN: Adrenocortical carcinomas (ACC) recorded in the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2000) were compared with benign functional or nonfunctional adrenal cortical adenomas (excluding aldosteronomas) operated on at our institution between January 1, 1993, and July 1, 2003. Data were compared using t-tests, chi-square tests, likelihood ratios, and receiver operating characteristic (ROC) curves. RESULTS: We identified 457 patients with ACC and 47 patients with adrenal cortical adenomas; 376 and 44 neoplasms, respectively, had tumor size data available. Tumor size was larger in ACC (12.0 +/- 5.6 versus 4.2 +/- 1.9 cm, mean +/- SD, p < 0.05). For ACC presenting with local disease, the sensitivity, specificity, and likelihood ratios of tumor size to predict malignancy were 96%, 52%, and 2.0, respectively, for tumors > or = 4 cm; 90%, 80%, and 4.4 for tumors > or = 6 cm; 77%, 95%, and 16.9 for tumors > or = 8 cm; and 55%, 98%, and 24.4 for tumors > or = 10 cm. Assuming a pretest probability of malignancy of 5%, the likelihood ratios derived from this study yield a posttest probability of 10%, 19%, and 47% for cancer in adrenal cortical tumors > or = 4 cm, > or = 6 cm, and > or = 8 cm, respectively. CONCLUSIONS: These data suggest that size is useful for predicting malignancy, and that at a size threshold of > or = 4 cm, the likelihood of malignancy doubles (to 10%) and it is more than ninefold higher for tumors > or = 8 cm (47%).

Adolescent↗
PubMed2006

Current incidence and outcomes of gastrointestinal mesenchymal tumors including gastrointestinal stromal tumors.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) have been recognized as the most common mesenchymal tumors of the gastrointestinal tract. The most effective treatment for unresectable tumors is imatinib mesylate, based on two phase II trials. Because no phase III clinical trial has been undertaken, we sought to determine both current population-based incidence and whether improved outcomes noted in both individual centers and clinical trials have also been observed in a large prospective cancer registry earlier and after the introduction of imatinib. STUDY DESIGN: The 13-center cumulative tumor registry (April 2005 release) from the Surveillance, Epidemiology, and End Results (SEER) database was queried from 1992 to 2002 to determine incidence and associated outcomes for patients diagnosed with GIST. Confirmations of incidence trends using the incident Florida Cancer Data System (FCDS, 2005 release) were also determined. RESULTS: A 25-fold age-adjusted increase in incidence of GIST, from 0.028 per 100,000 in 1992 to 0.688 per 100,000 in 2002, was observed. This increase is mostly because smooth-muscle tumors have been reclassified as GISTs, but it also represents a 50% increase in population- and age-adjusted gastrointestinal mesenchymal tumor diagnosis since 1992. Despite rising GIST incidence rates, there has been a marked improvement in survival since 2000, coinciding with the introduction of the tyrosine kinase inhibitor imatinib into clinical practice. CONCLUSIONS: The diagnosis of GIST has dramatically increased since 1992. Survivals have greatly improved since 2000, when imatinib mesylate was FDA approved.

Antineoplastic Agents↗
PubMed2006

Racial disparities in late survival after rectal cancer surgery.

BACKGROUND: African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear. STUDY DESIGN: Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality. RESULTS: African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20). CONCLUSIONS: Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients.

Aged↗
PubMed2005

Self-report by elderly breast cancer patients was an acceptable alternative to surveillance, epidemiology, and end results (SEER) abstract data.

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare breast cancer patients' self-report and surveillance, epidemiology, and end results (SEER) abstract data regarding type of treatment received (radiation, chemotherapy, and hormonal therapies). METHODS AND DESIGN: Patients 65 years of age or older diagnosed during 1999-2001 with stage I-II breast cancer and treated with conserving surgery were identified from the Iowa SEER registry; 307 (41% of those eligible) completed telephone interviews. SEER-registry abstract data also were obtained. RESULTS: Agreement between self-reports and SEER data varied by type of treatment, with almost perfect agreement for chemotherapy (kappa = 0.93) and moderate to substantial agreement for ever use of hormonal therapy (kappa = 0.61), receipt of radiation therapy (kappa = 0.60), and current use of hormonal therapy (kappa = 0.54). If the SEER data are assumed to be the "gold standard," the sensitivity was generally high (>87%) for all types of treatment. Specificity varied according to type of treatment: highest for chemotherapy (98.4%) and lowest for radiation therapy (49.0%). Predictive values positive and negative were above 75% across type of treatment. CONCLUSION: Using self-reported data was an acceptable alternative to reviewing medical records for documenting some types of breast cancer treatment.

Aged↗
PubMed2005

Information on chemotherapy and hormone therapy from tumor registry had moderate agreement with chart reviews.

BACKGROUND: Surveillance, Epidemiology, and End Results (SEER) cancer registries provide accurate information on cancer surgery and radiation, but the validity of registry data on chemotherapy and hormone therapy for breast cancer has not been well studied. We validated the registry data for chemotherapy and hormone therapy against an independent medical chart review. METHODS: We identified 1,228 women diagnosed with breast cancer at age > or = 65 in 1993-1999 in the New Mexico SEER Tumor Registry and completed medical chart reviews. RESULTS: Overall, there was moderate agreement between these two databases on chemotherapy that was received within 6 months of diagnosis. The observed agreement was 96.0%, with a kappa of 0.72 (95% confidence interval: 0.64-0.79). The sensitivity of the registry data for chemotherapy was 70.7% and the specificity was 98.2%. The positive predictive value of the registry data for chemotherapy was 77.8%. The sensitivity of the registry data for hormone therapy was 59.7%, and the specificity was 89.5%. The observed agreement for hormone therapy was 80.0%, with a kappa of 0.52 (0.46-0.57). CONCLUSION: Agreement on chemotherapy and hormone therapy between the New Mexico SEER Tumor Registry and chart reviews was moderate. The preferred approach would be to combine data from different sources to obtain more complete information.

Aged↗