Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer.

BACKGROUND: Postoperative complications, especially pulmonary complications, affect more than half the patients who undergo open esophagectomy for esophageal cancer. Whether hybrid minimally invasive esophagectomy results in lower morbidity than open esophagectomy is unclear. METHODS: We performed a multicenter, open-label, randomized, controlled trial involving patients 18 to 75 years of age with resectable cancer of the middle or lower third of the esophagus. Patients were randomly assigned to undergo transthoracic open esophagectomy (open procedure) or hybrid minimally invasive esophagectomy (hybrid procedure). Surgical quality assurance was implemented by the credentialing of surgeons, standardization of technique, and monitoring of performance. Hybrid surgery comprised a two-field abdominal-thoracic operation (also called an Ivor-Lewis procedure) with laparoscopic gastric mobilization and open right thoracotomy. The primary end point was intraoperative or postoperative complication of grade II or higher according to the Clavien-Dindo classification (indicating major complication leading to intervention) within 30 days. Analyses were done according to the intention-to-treat principle. RESULTS: From October 2009 through April 2012, we randomly assigned 103 patients to the hybrid-procedure group and 104 to the open-procedure group. A total of 312 serious adverse events were recorded in 110 patients. A total of 37 patients (36%) in the hybrid-procedure group had a major intraoperative or postoperative complication, as compared with 67 (64%) in the open-procedure group (odds ratio, 0.31; 95% confidence interval [CI], 0.18 to 0.55; P<0.001). A total of 18 of 102 patients (18%) in the hybrid-procedure group had a major pulmonary complication, as compared with 31 of 103 (30%) in the open-procedure group. At 3 years, overall survival was 67% (95% CI, 57 to 75) in the hybrid-procedure group, as compared with 55% (95% CI, 45 to 64) in the open-procedure group; disease-free survival was 57% (95% CI, 47 to 66) and 48% (95% CI, 38 to 57), respectively. CONCLUSIONS: We found that hybrid minimally invasive esophagectomy resulted in a lower incidence of intraoperative and postoperative major complications, specifically pulmonary complications, than open esophagectomy, without compromising overall and disease-free survival over a period of 3 years. (Funded by the French National Cancer Institute; ClinicalTrials.gov number, NCT00937456 .).

Utility values and its time to deterioration in breast cancer patients after diagnosis and during treatments.

BACKGROUND: The potential effects of breast cancer (BC) on health-related quality of life (HRQoL) should be considered in clinical and policy decision-making, as the economic burden of BC management is currently assessed. In the last decades, time-to-HRQoL score deterioration (TTD) has been proposed as an approach to the analysis of longitudinal HRQoL in oncology. The main objectives of the current study were to investigate the evolution of the utility values in BC patients after diagnosis and during follow-ups and to evaluate the TTD in utility values among women in all stages of BC. METHODS: Health-state utility values (HSUV) were assessed using the EuroQol 5-Dimension 3-Level at diagnosis, at the end of the first hospitalization and 3 and 6 months after the first hospitalization. For a given baseline score, HSUV was considered to have deteriorated if this score decreased by ≥ 0.08 points of the EQ-5D utility index score and ≥ 7 points of the EQ visual analogue scale. TTD curves were calculated using the Kaplan-Meier estimation method. RESULTS: Overall 381 patients were enrolled between February 2006 and February 2008. The highest proportions of respondents at the baseline and all follow-ups reporting some and extreme problems were in pain discomfort and anxiety/depression dimensions; more than 80% of patients experienced a deterioration in EQ-5D utility index score and EQ VAS score with a median TTD of 3.15 months and 6.24 Months, respectively. CONCLUSIONS: BC patients undergoing therapy need psychological support to cope with their discomfort, pain, depression, anxiety, and fear during the process of diagnosis and treatment to improve their QoL.

Age-related socio-economic and geographic disparities in breast cancer stage at diagnosis: a population-based study.

BACKGROUND: This study aimed to determine the impact of socio-economic and geographic disparities on disease stage at diagnosis according to age in breast cancer (BC) patients. Secondary purpose was to describe survival METHODS: All women with primary invasive BC, diagnosed from 1998 to 2009 in the department of Côte d'Or were retrospectively selected using data from the Côte d'Or BC registry. European transnational ecological deprivation index (French European Deprivation Index) was used to measure the socio-economic environment. Relationships between socio-geographic deprivation and disease stage at diagnosis according to age were assessed by a multilevel ordered logistic regression model. Relative survival rates (RSRs) were given at 5 years according to tumour and patients characteristics. RESULTS: In total, 4364 women were included. In multivariable analysis, socio-economic deprivation was associated with disease stage at diagnosis. Women aged between 50 and 74 years and living in deprived areas were more often diagnosed with advanced tumour stages (stages II/III vs. I or stages IV vs. II/III) with odds ratio = 1.27 (1.01-1.60). RSRs were lowest in women living in the most deprived area compared with those living in most affluent area with RSR = 88.4% (85.9-90.4) and 92.6% (90.5-94.2), respectively. CONCLUSIONS: Socio-economic factors affected tumour stage at diagnosis and survival. Living in a deprived area was linked to advanced-stage BC at diagnosis only in women aged 50-74 years. This is probably due to the socio-economic disparities in participation in organized BC screening programmes. Furthermore, living in deprived area was associated with a poor survival rate.

Breast cancer screening programmes: challenging the coexistence with opportunistic mammography.

OBJECTIVE: This study investigated predictive factors of women's participation in organized mammography screening (OrgMS) and/or opportunistic mammography screening (OppMS) when the two screening modes coexist. METHODS: Questionnaires were sent to 6,000 women aged 51-74 years old invited to attend an OrgMS session between 2010 and 2011 in France. Data collected concerned the women's healthcare behaviour and their socioeconomic characteristics. Women without a personal or family history of breast cancer that could explain their participation in OppMS were retained in the generalized logits analysis. RESULTS: The data of 1,202 women were analysed. Of these, 555 (46.2%) had attended OrgMS only, 105 (8.7%) OppMS only and 542 (45.1%) had performed both OrgMS and OppMS. Multivariable analyses showed that women who had regular gynaecological check-ups were more likely to perform OppMS only or both OrgMS and OppMS, OR 95% CI were 2.1 [1.1-3.9], 1.9 [1.4-2.6], respectively. Being employed also increased participation in OppMS only [OR: 2.1 (1.2-3.7)] or both OrgMS and OppMS [OR: 1.5 (1.1-2.05)]. CONCLUSION AND PRACTICE IMPLICATIONS: In countries where OrgMS and OppMS coexist, strategies involving gynaecologists, referring doctors or company doctors and the organization of healthcare services to promote adequate screening round may help to reduce the overuse of mammography.

Impact of response shift on time to deterioration in quality of life scores in breast cancer patients.

BACKGROUND: This prospective multicenter study aimed to study the impact of the recalibration component of response-shift (RS) on time to deterioration (TTD) in health related quality of life (QoL) scores in breast cancer (BC) patients and the influence of baseline QoL expectations on TTD. METHODS: The EORTC-QLQ-C30 and BR-23 questionnaires were used to assess the QoL in a prospective multicenter study at inclusion (T0), at the end of the first hospitalization (T1) and, three (T2) and 6 months after the first hospitalization (T3). Recalibration was investigated by the then-test method. QoL expectancy was assessed at diagnosis. Deterioration was defined as a 5-point decrease in QoL scores, considered a minimal clinically important difference (MCID). TTD was estimated using the Kaplan-Meier method. Cox regression analyses were used to identify factors influencing TTD. RESULTS: From February 2006 to February 2008, 381 women were included. Recalibration of breast cancer patients' internal standards in the assessment of their QoL had an impact on TTD. Median TTD were significantly shorter when recalibration was not taken into account than when recalibration was taken into account for global health, role-functioning, social-functioning, body-image and side effects of systemic therapy. Cox multivariate analyses showed that for body image, when recalibration was taken into account, radiotherapy was associated with a shorter TTD (HR: 0.60[0.38-0.94], whereas, no significant impact of surgery type on TTD was observed. For global health, cognitive and social functioning dimensions, patients expecting a deterioration in their QoL at baseline had a significantly shorter TTD. CONCLUSIONS: Our results showed that RS and baseline QoL expectations were associated with time to deterioration in breast cancer patients.