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PubMed1997

Population-based study of long-term survival in patients with clinically localised prostate cancer.

BACKGROUND: Choice of treatment in localised prostate cancer has been hampered by a lack of unbiased, representative data on outcome. Most existing data have come from small cohorts at specialised academic centres; precise overall and cancer-grade-specific data are not available, and the data are subject to differential staging bias. Randomised clinical trials have been undertaken, but the results will not be available for another decade. We have carried out a large population-based study to ascertain overall and prostate-cancer-specific survival in men treated by prostatectomy, radiotherapy, or conservative management. METHODS: Data for 59,876 cancer-registry patients aged 50-79 were analysed. We examined the effect of differential staging of prostate cancer by analysing the data both by intention to treat and by treatment received. Estimated survival was calculated by the Kaplan-Meier method. FINDINGS: By the intention-to-treat approach, 10-year prostate-cancer-specific survival for grade 1 cancer was 94% (95% CI 91-95) after prostatectomy, 90% (87-92) after radiotherapy, and 93% (91-94) after conservative management. The corresponding survival figures in grade 2 cancers were 87% (85-89), 76% (72-79), and 77% (74-80); those in grade 3 cancer were 67% (62-71), 53% (47-58), and 45% (40-51). Although the intention-to-treat and treatment-received analyses yielded similar results for radiotherapy and conservative management, the 10-year disease-specific survival after prostatectomy differed substantially (83% [81-84] by intention to treat vs 89% [87-91] by treatment received). INTERPRETATION: The overall and cancer-grade-specific survival found in this study differ substantially from those in previous studies. Previous studies that used a treatment-received approach have generally overestimated the benefits of radical prostatectomy. We found that grade 3 tumours are highly aggressive irrespective of stage.

Aged↗
PubMed2003

Outcomes research at the National Cancer Institute: measuring, understanding, and improving the outcomes of cancer care.

What is the National Cancer Institute (NCI) doing to enhance the state of the science for measuring and understanding patient-centered outcomes of cancer care and to make this information useful for improved decision making? The NCI has a new focus on research that describes, interprets, and predicts the impact of various influences, especially interventions, on end points that matter to decision makers. The research includes end points such as survival, health-related quality of life, satisfaction and patient experience, and economic burden. To further this work, NCI supports and conducts research to (1) identify valid, reliable, responsive, and feasible end-point measures; (2) collect high-quality evidence about the impact of interventions on the end points of interest; (3) improve our understanding of the effects of other factors that shape this interaction; and (4) expand our capacity to translate research findings into information that is useful to patients, clinical policy makers, payers, regulators, standard setters, and providers of cancer care.

Humans↗
PubMed2002

Post-surgery radiation in early breast cancer: survival analysis of registry data.

BACKGROUND AND PURPOSE: Overviews of randomized trials have shown a small survival advantage with post-surgery radiation in early breast cancer. The present study attempts to extend this observation through a systematic analysis of population data. MATERIALS AND METHODS: This retrospective cohort study used the Surveillance, Epidemiology, and End Results (SEER) data on 83,776 women with breast cancer diagnosed between 1988 and 1997, stage T1-T2, node negative or node positive. The analysis was performed using the proportional hazard models. RESULTS: Radiation was associated with a reduced mortality after breast-conserving surgery in node negative patients (hazard ratio 0.757; 95% confidence interval 0.709-0.809; using total mastectomy without radiation as reference) and in node positive patients (hazard ratio 0.777; 0.717-0.842), and after total mastectomy in node positive patients (hazard ratio 0.885; 0.815-0.961). Radiation was associated with an increased hazard ratio of 1.271 (1.080-1.496) after total mastectomy in node negative patients. Without radiation, breast-conserving surgery in node negative patients was associated with an increased hazard ratio (1.167; 1.036-1.314); a similar increase was not observed in node positive patients (hazard ratio 1.011; 0.884-1.155). In all cases, the best survival rates were found with combined breast-conserving surgery and radiation. CONCLUSION: The available data indicate that post-surgery radiation provides a survival advantage irrespective of the type of surgery in node positive patients. Likewise, survival advantage was observed with post-surgery radiation and breast-conserving procedure in node negative patients.

Adult↗
PubMed2003

Omission of radiotherapy after breast-conserving surgery: survival impact and time trends.

PURPOSE: To evaluate the survival impact of omission of radiotherapy after breast-conserving surgery and the changes with time. MATERIAL AND METHODS: Women aged 40-69 with non-metastasized T1-T2 breast cancer, who underwent breast-conserving surgery with axillary node dissection, with or without post-surgery radiotherapy, selected from the SEER (Surveillance, Epidemiology, and End Results) database. The analysis uses proportional hazards models. RESULTS: Omission of radiotherapy as compared to delivery of radiotherapy was associated with an overall increased mortality hazard ratio of 1.346 (95% confidence interval: 1.204-1.504). Test of constancy showed significant changes with time. The time profile suggested an exponential-like increase from a baseline mortality hazard ratio of 1.17, or 17% excess of relative mortality risk, to a projected hazard ratio of 2.26, or more than doubling of relative mortality risk, for omission of radiotherapy. CONCLUSION: Omission of radiotherapy in breast-conserving surgery is found to be independently associated with an increase in mortality. The data do not give support to omitting radiation or give rationale to clinical trials that would omit radiation.

Adult↗
PubMed2003

Adjuvant radiotherapy after mastectomy for pT1-pT2 node negative (pN0) breast cancer: is it worth the effort?

PURPOSE: Postoperative radiotherapy (RT) for pT1-2 pN0 breast cancer was the standard treatment in our department. Since little data on the importance of RT in this subgroup are known, we reviewed the clinical records with regard to overall survival. MATERIAL AND METHODS: From 1984 until 2000, 1789 files were submitted to retrospective analyses; 731 had a pT1 (n=427) or pT2 (n=304) pN0 lesion. They were treated with breast conserving surgery (BCS) (n=343) or mastectomy (ME) (n=388), axillary lymph node dissection (ALND) and post-operative RT. The outcome was analyzed and compared with the patients included in the SEER-Data 1988-1997 (NCI-Surveillance, Epidemiology and End Results, release 2000) that were treated according to the standard treatment: BCS+ALND+RT, or ME+ALND no RT. RESULTS: The actuarial overall survival (OS) at 5 and 10 years after BCS was 93.3% and 85.1% for pT1 and 88.3% and 75.4% for pT2 tumors. These results are comparable with the SEER (93.9%, 84.9% for pT1, and 87.3%, 76.7% for pT2, respectively). For our ME patients the OS was 91.8% and 79.9%, respectively (pT1 at 5 and 10 years, respectively), and 83.6% and 70.4% (pT2 at 5 and 10 years). In the SEER data the analyses resulted in 89.3% and 73.8% (pT1), and 81.1% and 63.5% (pT2), respectively. DISCUSSION: Although both databases are retrospective, the comparable survival in BCS patients pleads for the similarity of the two populations. The better OS observed in ME patients treated with RT compared to the SEER patients argues in favor of a benefit due to adjuvant radiotherapy. CONCLUSION: Radiotherapy after mastectomy might improve survival in low-risk node negative patients. Our data shows an absolute benefit of between 2.5% and 6.9% OS in favor of post ME radiotherapy, compared to the SEER data.

Actuarial Analysis↗
PubMed2003

Small stage I cancers of the lung: genuineness and curability.

PURPOSE: To assess the genuineness and curability of diagnosed cases of Stage IA non-small-cell lung cancer of diameter 6-15 mm, with a view to screen-diagnosed asymptomatic cases. METHODS: We identified all cases of diagnosed Stage IA (T1N0M0) primary non-small-cell lung cancer documented in the Surveillance, Epidemiology, and End Results (SEER) registry in 1988-1994. There were 885 such cases of diameter 6-15 mm, 33 of them unresected, 1659 of diameter 16-25 mm, and 782 of diameter 26-30 mm. We determined the 8-year cumulative lung-cancer death rates adjusted for competing causes of death, separately for untreated and fully resected cases. Given the relative underdetection of lymph node metastases of the untreated cases, we also documented the case-fatality rates for the resected with inclusion of those with detected intra-pulmonary, hilar or ipsilateral mediastinal lymph node metastases. RESULTS: The 8-year fatality rate for the diagnosed but untreated cases of lung cancer 6-15 mm in diameter was 87%, for 16-25 mm it was 94%, and for 26-30 mm it was 88%. The corresponding estimates of cure rates with resection were 71, 67, and 55%, respectively. The cure rate estimate for the smallest cancers was 66% when adding those with detected lymph node metastases to the resected series, for those 16-25 mm in diameter it was 65%, and for those 26-30 mm in diameter it was 51%. CONCLUSION: Almost all diagnosed cases of Stage IA lung cancer as small as 10 mm in diameter have a malignant natural course, fatal if not treated, thus representing genuine cancer. Most of these cases are curable by resection.

Adult↗
PubMed1997

The independent pathology laboratory as a reporting source for cutaneous melanoma incidence in Iowa, 1977-1994.

BACKGROUND: Health care changes during the past decade have resulted in a greater proportion of cutaneous melanoma (CM) cases diagnosed in nonhospital settings, increasing the potential for cases to be missed by population-based cancer registries. OBJECTIVE: Our purpose was to assess changes in case-finding sources in Iowa from 1977 to 1994 and to determine the extent of underreporting for the State Health Registry of Iowa, a population-based cancer registry. METHODS: This study examines changing trends in the incidence of CM and compares case-finding sources (hospitals/clinics, hospital pathology laboratories, and independent pathology laboratories). A survey of dermatologists serving Iowans provides estimates of underreporting. RESULTS: During the period 1977 to 1994, invasive CM increased 82%, whereas in situ CM increased 900%. The proportion of CM cases diagnosed in independent pathology laboratories increased to 25% of all cases. A range of 10.4% to 17.1% underreporting was estimated based on the survey of dermatologists. CONCLUSION: To improve the accuracy of surveillance, population-based cancer registries need to make a greater effort accessing pathology reports from nonhospital settings.

Dermatology↗
PubMed1998

An estimate of the annual direct cost of treating cutaneous melanoma.

BACKGROUND: Although the survival benefits of early stage melanoma have been clearly documented, the potential economic impact of early versus late stage disease has not been assessed. OBJECTIVE: Our purpose was to estimate the annual direct cost of diagnosing and treating melanoma, based on the number of projected cases of melanoma entering each stage in 1997. METHODS: A model was constructed with assumptions derived from the literature and clinical experience at the Massachusetts General Hospital Melanoma Center and the Boston University Medical Center. Cost estimates were based on 1997 Boston area Medicare reimbursements. RESULTS: The annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be $563 million. Stage I and II disease each comprised about 5% of the total cost; stage III and stage IV disease consumed 34% and 55% of the total cost, respectively. About 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of patients (those patients with advanced disease, that is, stage III and stage IV). CONCLUSION: In addition to the potential survival advantages, aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.

Biopsy↗
PubMed1997

Risk of lung cancer among patients with head and neck cancer.

A cohort of 5180 patients with head and neck cancer, who were part of the tumor registry of the Surveillance, Epidemiology, and End Results area of western Washington State, was followed up for as many as 15 years to determine the risk of lung cancer. A sample of 522 patients from this cohort was interviewed to determine smoking history. Lung cancer developed in 356 (6.9%) of the 5180 patients. The overall annual incidence of lung cancer remained relatively constant between approximately 1.0% and 2.0% during the 15 years of follow-up. Men had an increased risk of lung cancer compared with women (relative risk (RR) = 1.56; 95% confidence interval (CI) = 1.18 to 2.03). Compared with patients with oral cavity cancer (RR = 1.00), the relative risk of lung cancer developing by the site of the index tumor was 0.63 (95% CI = 0.40 to 0.98) for lip, 1.12 (95% CI = 0.81 to 1.56) for intrinsic larynx, 1.73 (95% CI = 1.21 to 2.47) for oropharynx, 1.84 (95% CI = 1.16 to 2.92) for hypopharynx, and 2.28 (95% CI = 1.60 to 3.24) for extrinsic larynx. Among the 522 patients who were interviewed, men smoked more than women (p < 0.0001), and patients with laryngeal or pharyngeal cancer smoked more than patients with cancer of the lip or the oral cavity (p < 0.05). Among patients with head and neck cancer, the risk of lung cancer is highest for men and for patients with cancer of the pharynx or extrinsic larynx. These findings may be explained by differences in smoking consumption.

Adult↗
PubMed2003

Does stage at diagnosis influence the observed relationship between socioeconomic status and breast cancer incidence, case-fatality, and mortality?

Historically, lower socioeconomic status (SES) has been reported to be associated with decreased breast cancer incidence and mortality and increased case-fatality, although recent trends in breast cancer screening and treatment may alter these relationships. This study assessed the associations between SES and breast cancer incidence, case-fatality, and mortality by stage of disease at diagnosis using recent data in the United States. Breast cancer incidence and survival data from the Surveillance, Epidemiology, and End Results (SEER) tumor registry for black and white women aged 55 and above were linked to county level SES and population data based on place of residence. Poisson regression was used to calculate age-adjusted relative rates associated with SES levels and breast cancer incidence, case-fatality, and mortality. As SES decreased, localized breast cancer incidence rates decreased, while incidence rates of distant disease increased. Five-year localized and regional breast cancer case-fatality rates increased as SES decreased. Localized breast cancer mortality rates decreased as SES declined, whereas regional breast cancer mortality rates tended to increase. These results confirm some previously reported findings and suggest that associations between lower SES and lower localized breast cancer mortality rates are influenced mainly by underlying associations between SES and localized breast cancer incidence, whereas regional breast cancer mortality rates appear to reflect the underlying association between SES and regional case-fatality rates.

Aged↗
PubMed2003

Factors affecting survival in maxillary sinus cancer.

PURPOSE: The study goal was to determine survival parameters and clinical factors influencing survival for maxillary sinus malignancies. METHODS: Cases of maxillary sinus malignancy for the time period 1988 to 1998 were extracted from the Surveillance, Epidemiology and End Results database. Cases with distant metastatic disease at presentation were excluded. Clinical information, including tumor histology, grade and stage, and extent of surgery and radiation therapy, were determined. Kaplan-Meier survival and Cox proportional hazards analyses were conducted to determine the influence of these factors on overall survival. RESULTS: The study sample was composed of 650 patients with maxillary sinus cancer (mean age, 64 years; male-to-female ratio, 3:2). The most common histology was squamous cell carcinoma (61.7%), followed by adenoid cystic carcinoma (9.8%). The overall mean (median) survival was 52 months (25 months), and 77.5% and 7.4% of patients presented with advanced (T3/T4) disease or cervical metastasis, respectively. Radiation therapy was administered in 441 patients (67.9%) and significantly improved survival mainly for those with T4 lesions. On multivariate analysis, increasing age, T stage, N stage, and tumor grade independently predicted poorer survival, whereas gender did not. Adenoid cystic carcinoma exhibited a significantly improved overall survival (P <.001). CONCLUSIONS: Survival for patients with maxillary sinus cancer is determined not only by TNM staging but also by tumor histology and grade. TNM staging effectively stratifies patients according to survival. Radiation therapy significantly improves survival for those with T4 lesions.

Carcinoma, Adenoid Cystic↗
PubMed2003

Bilateral asymmetry prediction.

This study predicts asymmetries in lateral organ cancer incidence from text mining of the Medline database. Lung, kidney, teste, and ovary cancers were examined. For each cancer, Medline case report articles focused solely on (1) cancer of the right organ and (2) cancer of the left organ were retrieved. The ratio of right organ to left organ articles was compared to actual patient incidence data obtained from the National Cancer Institute's (NCI) SEER database for the period 1979-1998. The agreement between the Medline record ratios and the NCI's patient incidence data ratios ranged from within 3% for lung cancer to within 1% for teste and ovary cancer. This is the first known study to generate cancer lateral incidence asymmetries from the Medline database. The technique should be applicable to other diseases and other types of system asymmetries.

Female↗
PubMed2002

Trends in, and predictors of, breast-conserving surgery and radiotherapy for breast cancer in Connecticut, 1988-1997.

PURPOSE: To describe the trends in, and predictors of, use of breast-conserving surgery (BCS) vs. mastectomy and use of post-BCS radiotherapy (RT), from 1988 through 1997 among residents of Connecticut. METHODS AND MATERIALS: Data on surgical and RT procedures for 16,676 women diagnosed with early-stage (localized to the breast or with regional lymph node involvement) invasive breast cancer in 1988-1997 were obtained from the population-based Connecticut Tumor Registry. RESULTS: Use of BCS (vs. mastectomy) increased over time and was lower for patients with nodal involvement or larger tumors. The absence of RT facilities at the hospital of first admission was negatively associated with BCS but not with post-BCS RT. Post-BCS RT was low among patients diagnosed at age 80+ years but increased over time only in this age group. CONCLUSION: Absence of RT at the hospital may be a deterrent to BCS. The temporal increase in post-BCS RT among patients diagnosed at age > or =80 years suggests changes in physicians' attitudes and/or patient preferences that require further study.

Aged↗
PubMed2003

Risk of second primary cancer in the contralateral breast in women treated for early-stage breast cancer: a population-based study.

PURPOSE: To study the potential risk factors, including radiotherapy (RT) for contralateral breast cancer (CBC), in patients treated for early-stage breast cancer. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results database (1973-1996) was used to study the incidence of CBC after breast cancer. The Cox proportional hazards regression model was used to estimate the relative risk (RR) of CBC, with adjustment for confounders, including age, race, histologic subtype, and use of RT. Information on the use of hormonal therapy and chemotherapy was not available in the Surveillance, Epidemiology, and End Results database. RESULTS: A CBC was documented in 5679 (4.2%) of the 134501 localized invasive or intraductal breast cancer patients surviving at least 3 months. The 10- and 20-year actuarial rate of CBC was 6.1% and 12%, respectively. In multivariate analysis, medullary carcinoma (RR = 1.18, 95% confidence interval [CI] 1.02-1.37), black race (RR = 1.20, 95% CI 1.08-1.33), and age >55 years at initial diagnosis (RR = 1.15, 95% CI 1.08-1.22) were associated with increased CBC risk. A total of 1234 (3.3%) of 37,379 patients who received RT developed CBC, and 4445 (4.6%) of 97122 patients who did not receive RT developed CBC. Overall, RT was not associated with an increased risk of CBC (RR = 1.04, 95% CI 0.97-1.10) in multivariate analysis. The CBC risk associated with RT varied substantially with the length of follow-up. During the first 5 years of follow-up, RT was not associated with an increased CBC risk (age-adjusted RR = 0.96, 95% CI 0.88-1.04). For patients surviving for >5 years, RT was associated with a 14% increase in CBC risk (RR = 1.14, 95% CI 1.03-1.26). The increased CBC risk with RT was evident in patients aged <45 years (RR = 1.32, p = 0.01) and >55 years (RR = 1.15, p = 0.04) at initial diagnosis. The 5-, 10-, 15-, and 20-year actuarial rate of CBC was 2.9%, 6.5%, 10.2%, and 13.4%, respectively, for patients with RT; the corresponding rates were 3.0%, 6.0%, 8.9%, and 11.8% for patients without RT. The absolute increase in CBC risk associated with RT was 0.5%, 1.3%, and 1.6% in the 10-, 15-, and 20-year actuarial rate, respectively. CONCLUSION: CBC is not uncommon after breast cancer, especially for certain subsets of patients. RT was associated with a very small increased long-term CBC risk. This minimal increase in CBC risk should not affect clinical decision-making in treatment selection for patients with localized invasive breast cancer or ductal carcinoma in situ. Unnecessary radiation exposure to the contralateral breast should be avoided for all patients with early-stage breast cancer.

Age Factors↗
PubMed1998

Sociodemographic analysis of patients in radiation therapy oncology group clinical trials.

PURPOSE: To assess the degree to which the sociodemographic characteristics of patients enrolled in Radiation Therapy Oncology Group (RTOG) clinical trails are representative of the general population. METHODS AND MATERIALS: Sociodemographic data were collected on 4016 patients entered in 33 open RTOG studies between July 1991 and June 1994. The data analyzed included educational attainment, age, gender, and race. For comparison, we obtained similar data from the U.S. Department of Census. We also compared our RTOG data with Surveillance Epidemiology and End Results (SEER) data for patients who received radiation therapy, to determine how RTOG patients compared with cancer patients in general, and with patients with cancers at sites typically treated with radiotherapy. RESULTS: Overall, the sociodemographic characteristics of patients entered in RTOG trials were similar to those of the Census data. We found that, in every age group of African-American men and at nearly every level of educational attainment, the proportion of RTOG trial participants mirrored the proportion in the census data. Significant differences were noted only in the youngest category of African-American men, where the RTOG accrues more in the lower educational categories and fewer with college experience. For African-American women, we found a similar pattern in every age group and at each level of educational attainment. As with men, RTOG trials accrued a considerably larger proportion of younger, less educated African-American women than the census reported. Using SEER for comparison, the RTOG enrolled proportionately more African-American men to trials all cancer sites combined, and for prostate and head and neck cancer. In head and neck trials, the RTOG enrolled nearly twice as many African-American men than would be predicted by SEER data. In lung cancer trials, RTOG underrepresented African-American men significantly; however, there was no difference for brain cancer trials. There were no racial differences in RTOG accrual and SEER incidence data for women on trials in brain, lung, and head and neck cancer. However, the RTOG trials accrued nearly twice the proportion of African-American women in cervical cancer trials and in all sites combined, compared to the SEER data. CONCLUSIONS: Comparisons with the U.S. Census and SEER show that African-Americans are proportionally well represented in cancer clinical trials conducted by the Radiation Therapy Oncology Group. The comparative analysis indicates that all educational levels in each age group of African-Americans generally mirror the U.S. Census, with one exception. The exception is a significant overrepresentation of less-educated African-Americans in the youngest age category. This exception is counter to the expectation that better-educated patients are more likely to enroll in trials. When compared with SEER data, the RTOG trials either parallel or overrepresent African-American men and women, with the only exception being in lung cancer, where men are underrepresented. These results show that, in comparison to the Census and SEER data, the RTOG has fulfilled its commitment to enroll African-American patients in its clinical trials.

Adult↗
PubMed2002

Melanoma incidence trends.

This article describes melanoma as an important health concern because of its rapid and continuous growth in many parts of the world. In the United States, a persistent increase in incidence is seen, which has started to slow in recent years. In some countries, differing trends are seen in younger people, with incidence and mortality rates leveling off or decreasing in this population. This article describes that despite this leveling off, melanoma incidence is likely to continue to rise in the near future, because rates are still increasing in older people who comprise most of those afflicted with melanoma.

Adolescent↗