Hospitalization burden associated with malignant neoplasia and in situ carcinoma in vulva and vagina during a 5-year period (2009-2013) in Spain: An epidemiological study.

BACKGROUND: Vulvar and vaginal cancers are considered rare cancers in women. Human Papillomavirus is responsible for 30-76% of them. The aim of this study was to describe the burden of hospital admissions by malignant neoplasia (MN) and in situ carcinoma (ISC) of vulva and vagina from 2009 to 2013, in Spain METHODS: This observational, descriptive study used discharge information obtained from the national surveillance system for hospital data, Conjunto Mínimo Básico de Datos, CMBD, provided by the Ministry of Health. RESULTS: From 2009-2013, we found 9,896 hospitalizations coded as MN or ISC of vulva and vagina. Mean age of hospitalization was 69.94 ±â€¯15.16 years; average length of hospital stay (ALOS) was 10.02 ±â€¯12.40 days, and mean hospitalization costs were 5,140.31 ±â€¯3,220.61 euros. Mean hospitalization rate was 9.874 per 100,000 women aged >14 years old (95% CI: 9.689-10.058); mean mortality rate was 0.932 per 100,000 women aged >14 years old (95% CI: 0.872-0.991) and mean case fatality rate was 9.438% (95% CI: 8.862-10.014). CONCLUSION: MN and ISC of vulva and vagina are responsible for a considerable hospitalization burden. Information about these hospitalizations could be useful for cost effectiveness analysis and monitoring of HPV vaccination effectiveness.

Imaging and histologic prognostic factors in triple-negative breast cancer and carcinoma in situ as a prognostic factor. / Valoración de los factores pronósticos radiopatológicos del cáncer de mama triple negativo y análisis del carcinoma in situ como factor pronóstico.

OBJECTIVES: To analyze what factors in magnetic resonance imaging (MRI) and histological study of triple-negative breast cancers are related to tumor recurrence and to shorter disease-free survival. To analyze survival and recurrence in function of the presence of an in situ component. MATERIAL AND METHODS: This was a retrospective study of MRI staging examinations in 122 women with triple-negative breast cancer done from 2007 through 2014. In the MRI, we evaluated morphological variables (size, margins, morphology, internal signal in T2-weighted sequences) and dynamic variables (perfusion and diffusion). In the histological study, we evaluated Ki67, p53, CK5/6, nuclear grade, and Scarff-Bloom grade, as well as the presence of an in situ component and tumor grade (high grade or not high grade). We compared the variables between patients with tumor recurrence and those without, and we conducted a survival analysis. RESULTS: Non-nodular enhancement was more common in patients with tumor recurrence (p=0.038) and was associated with shorter disease-free survival (p=0.023). Neither diffusion restriction (p=0.079) nor ki67 (p=0.052) was associated with a worse prognosis. An in situ component was detected in 44% of triple-negative tumors, and a greater proportion of patients in the group with tumor recurrence had an in situ component; however, the presence of an in situ component was not associated with shorter survival (p = 0.185). CONCLUSION: Non-nodular enhancement was associated with a worse prognosis. Diffusion restriction, ki67, and the presence of an in situ component were not associated with shorter disease-free survival.

Reproducibility of residual cancer burden for prognostic assessment of breast cancer after neoadjuvant chemotherapy.

The residual cancer burden index was developed as a method to quantify residual disease ranging from pathological complete response to extensive residual disease. The aim of this study was to evaluate the inter-Pathologist reproducibility in the residual cancer burden index score and category, and in their long-term prognostic utility. Pathology slides and pathology reports of 100 cases from patients treated in a randomized neoadjuvant trial were reviewed independently by five pathologists. The size of tumor bed, average percent overall tumor cellularity, average percent of the in situ cancer within the tumor bed, size of largest axillary metastasis, and number of involved nodes were assessed separately by each pathologist and residual cancer burden categories were assigned to each case following calculation of the numerical residual cancer burden index score. Inter-Pathologist agreement in the assessment of the continuous residual cancer burden score and its components and agreement in the residual cancer burden category assignments were analyzed. The overall concordance correlation coefficient for the agreement in residual cancer burden score among pathologists was 0.931 (95% confidence interval (CI) 0.908-0.949). Overall accuracy of the residual cancer burden score determination was 0.989. The kappa coefficient for overall agreement in the residual cancer burden category assignments was 0.583 (95% CI 0.539-0.626). The metastatic component of the residual cancer burden index showed stronger concordance between pathologists (overall concordance correlation coefficient=0.980; 95% CI 0.954-0.992), than the primary component (overall concordance correlation coefficient=0.795; 95% CI 0.716-0.853). At a median follow-up of 12 years residual cancer burden determined by each of the pathologists had the same prognostic accuracy for distant recurrence-free and survival (overall concordance correlation coefficient=0.995; 95% CI 0.989-0.998). Residual cancer burden assessment is highly reproducible, with reproducible long-term prognostic significance.

Use of restaging bladder tumor resection for bladder cancer among Medicare beneficiaries.

OBJECTIVE: To evaluate the use and effectiveness of restaging bladder tumor resection using population-based data. Restaging bladder tumor resection improves staging accuracy and the response to intravesical therapy. However, its use outside of a tertiary care setting, and its subsequent clinical implications, are unknown. METHODS: We identified 62 016 patients diagnosed with bladder cancer between 1992 and 2005 using SEER-Medicare data. Restaging bladder tumor resection was defined as 2 or more resections occurring within 60 days of diagnosis. Using multivariable models, we assessed the relationship between the use of restaging resection and cancer-specific survival. RESULTS: Restaging resection was performed in only 3064 (4.9%) of newly diagnosed bladder cancer patients, but was most common among those with high grade (7.7% vs 2.0% in low grade, P < .001) and stage (8.8% in T2 vs 2.8% in Ta/Tis, P < .001) disease. Compared to patients with muscle-invasive cancers who did not undergo restaging at diagnosis, restaging resection was associated with improved 5-year cancer-specific mortality among pathologically staged patients (20.4% vs 28.0%, P = .02), while clinically staged patients trended toward improved mortality (28.2% vs 31.9%, P = .07). CONCLUSION: Restaging transurethral resection for bladder cancer is relatively uncommon and associated with improved survival among patients with muscle invasive bladder cancer. Greater use of restaging warrants further investigation as a simple means of improving outcomes among patients suspected of having muscle invasive disease.

¿Es posible disminuir la mortalidad por cáncer de mama en Chile?: análisis epidemiológico y programático en la región metropolitana, 2000-2007 / Is it possible to decrease breast cancer mortality in Chile?: an analytical study

This analytical study is aimed to analyze breast cancer mortality in the metropohtan región of Santiago serving something more than 6,000,000 people. The hypothesis is that it is possible to decrease breast cancer mortality in Chile (16 million inhabitants) based on the experience of the metropohtan south orient health service (SSMSO) that represents 10 percent of the Chilean population. A comparative analysis of crude and age-adjusted mortality rates for breast cancer in the six metropolitan health services is produced showing the lowest crude and age-adjusted mortality rate in the SSMSO besides to be lower than the mortality rate for Chile. Furthermore the annual proportions of advanced (III and IV) and incipient breast cancers (in situ and I) are established for the SSMSO showing a proportional decrease of advanced stages and a relevant increase of the incipient ones between 1994 and 2007. The authors think that since the population of the metropolitan región represents more than 40 percent of the Chilean population and includes all the socio economic strata the results observed in the SSMSO, the biggest health service in the region besides having both rural and urban districts, may be considered representative for the country as a whole. The original hypothesis has been thus confirmed: it is possible to decrease breast cancer mortality in Chile.

Se trata un estudio analítico sobre la mortalidad por cáncer de mama en la Región Metropolitana. La hipótesis, en base a la experiencia del Servicio de Salud Metropolitano Sur Oriente (SSMSO), señala que es posible disminuir la mortalidad por este cáncer en Chile, extrapolando la experiencia de este servicio de salud con 1,6 millones de población asignada y 1,1 millones de personas inscritas validadas. Ello significa el 10 por ciento de la población chilena. Se hace un análisis comparado de las mortalidades crudas y ajustadas por edad en los seis servicios de salud metropolitanos, período 2000-2007, además de establecer la proporción anual de cánceres de mama avanzados (III y IV) e incipientes (in situ y I) en el total de cánceres mamarios del SSMSO, período 1994-2007. Los seis servicios en conjunto atienden una población que significa algo más del 40 por ciento de la nacional, además de representar todos sus estratos socio-económicos y étnicos. En consecuencia, la comparación entre ellos puede considerarse válida para el país. Los resultados muestran que el SSMSO tiene la mortalidad por cáncer de mama, tasa cruda y ajustada, más baja de la Región Metropolitana, además de inferior a la nacional. Una razón importante es la disminución proporcional de cánceres avanzados y un aumento importante de los incipientes. El programa para cáncer de mama del SSMSO cumple entonces con su objetivo principal: disminuir la mortalidad por este cáncer, ratificando la hipótesis de este estudio. Además, cumple otros objetivos: eficiencia, buena opinión de usuarias y equidad.

Quality of life, functional outcome, and costs of early glottic cancer.

OBJECTIVE: To analyze quality of life, functional outcome, and hidden costs by primary treatment with surgery or radiation therapy in patients with early glottic cancer. STUDY DESIGN: Retrospective study in a tertiary care facility. METHODS: A group of 101 patients with carcinoma in situ and T1 invasive squamous cell carcinoma treated primarily with either surgery or radiation, between January 1990 and December 2000, were identified from searching our tumor registry. Patients completed two previously validated questionnaires and one local questionnaire. Statistical significance was assessed with the rank sum test, chi2 test, or Fisher's Exact test. RESULTS: Questionnaires were completed in 59% (44 of 74) of the surgical cohort and 41% (11 of 27) of the radiation therapy cohort. The primary surgical treatments were endoscopic excision (86%), hemilaryngectomy (12%), and total laryngectomy (1%). Patient-reported problems with swallowing, chewing, speech, taste, saliva, pain, activity, recreation, and appearance showed no difference between the endoscopic excision or radiation therapy cohorts. Comparing endoscopic excision versus radiation therapy, respectively, median number of treatments (2 vs. 35), total median travel distance (150 vs. 660 miles), total median travel time (180 vs. 1440 min), and total median number of hours of work missed (76 vs. 24) all differed significantly (P <.01). CONCLUSIONS: Almost all patients with early glottic cancer, whether treated with surgery or radiation therapy, reported excellent quality of life outcomes and functional results. In addition to actual costs, the hidden costs for radiation therapy versus endoscopic excision were all greater in terms of total number of hours of work missed, total travel time, and total travel distance.

Institutional validation of breast cancer treatment guidelines.

Several groups have developed clinical guidelines for the management of breast cancer, yet little data exist regarding their validation. Therefore, we examined the effect of published National Comprehensive Cancer Network (NCCN) guidelines for invasive breast cancer on survival, quality of life (QOL), and hospital cost. From 260 consecutive breast cancer patients, 129 patients were identified for analysis: 93 patients (72%) were treated according to the guidelines (NCCN+), while the treatment of 36 patients (28%), with a similar stage distribution, deviated from the guidelines (NCCN-). Patients were excluded from analysis with a diagnosis of carcinoma in situ, inflammatory cancer, stage IV disease, and comorbid conditions that affected treatment. The 5-year survival was 87.6% for the NCCN+ patients versus 83.3% for NCCN- patients (P = 0.319 by Kaplan-Meier). Twelve QOL parameters were evaluated using a Likert-type scale (1 = severe and 5 = none). NCCN+ patients had a cumulative QOL score of 4.18 +/- 0.08 versus 4.24 +/- 0.14 for NCCN- patients (P = 0.745). Treatment-related costs were $20,300 +/- 1800 for NCCN+ patients versus $59,700 +/- 25,200 for NCCN- patients (P = 0.016 by t test). Although deviation from NCCN breast cancer guidelines had no effect on perceived quality of life or survival, there was a significant decrease in cost in the NCCN+ group. These findings suggest that adherence to NCCN guidelines can significantly reduce the cost of breast cancer care without adversely affecting either survival or quality of life.

Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics.

OBJECTIVE: To assess the impact of screening on the incidence of and mortality from cervical cancer. DESIGN: Comparison of age specific incidence and mortality before and after the introduction of the national call and recall system in 1988. SETTING: England. SUBJECTS: Women aged over 19 years. RESULTS: From the mid-1960s, the number of smears taken rose continuously to 4.5 million at the end of the 1980s. Between 1988 and 1994, coverage of the target group doubled to around 85%. Registrations of in situ disease increased broadly in parallel with the numbers of smears taken. The overall incidence of invasive disease remained stable up to the end of the 1980s, although there were strong cohort effects; from 1990 incidence fell continuously and in 1995 was 35% lower than in the 1980s. The fall in overall mortality since 1950 accelerated at the end of the 1980s; there were strong cohort effects. Mortality in women under 55 was much lower in the 1990s than would have been expected. CONCLUSIONS: The national call and recall system and incentive payments to general practitioners increased coverage to around 85%. This resulted in falls in incidence of invasive disease in all regions of England and in all age groups from 30 to 74. The falls in mortality in older women were largely unrelated to screening, but without screening there might have been 800 more deaths from cervical cancer in women under 55 in 1997.

Primary bladder carcinoma in situ: assessment of early BCG response as a prognostic factor.

OBJECTIVES: To evaluate the prognosis of primary bladder carcinoma in situ (CIS) according to the response to bacillus Calmette-Guerin (BCG). PATIENTS AND METHODS: Twenty-six cases of primary CIS were treated with BCG. Mean, median and minimum follow-up periods were 47, 56 and 24 months. At 6 months, the patients were evaluated endoscopically and the response was classified as complete, partial or failure. RESULTS: Twenty-one patients (80.8%) showed complete response to BCG, 3 did so after a second course; 28.5% relapsed or progressed at a mean of 44 months. Five patients (19.2%) did not respond initially and all progressed in a period of 6 months. Early response to BCG was the only significant prognostic factor (p < 0.005). CONCLUSIONS: A high- and a low-risk group of bladder CIS can be differentiated according to the response to BCG. CIS of the bladder has a poor prognosis, and the number of patients who developed progressive disease is significantly higher among the nonresponders.

Has radiotherapy become too expensive to be considered a treatment option for early glottic cancer?

BACKGROUND: External beam radiotherapy and surgery produce equivalent long-term survival and tumor control in early glottic cancer. The expense and cost of radiotherapy have been challenged. METHODS: A retrospective review was performed for 57 patients undergoing radiotherapy for glottic cancer. End points included local tumor control, relapse-free survival, cause-specific survival, medical charges, and costs. The results were compared with those of 265 patients who underwent transoral endoscopic removal or an open laryngeal procedure at the same institution. RESULTS: The local control, larynx preservation, re-treatment, voice quality, relapse-free survival, and cancer death results and medical charges and costs are reported by treatment. CONCLUSIONS: Radiotherapy provides at least equivalent, if not superior, local tumor control, larynx preservation, voice quality, and survival, compared with the surgical options. Overall medical charges and costs for radiotherapy are similar to transoral endoscopic resection and less than partial vertical laryngectomy.

Assessment of surgical operations for ductal carcinoma in situ of the breast.

The choice of surgical procedure for the treatment of ductal carcinoma in situ (DCIS) remains clinically based. A meta-analysis was used to synthesize the results of 24 published clinical studies. Partial breast tissue excision appears to be as efficacious as mastectomy for the treatment of DCIS of the breast.

Trade-offs between survival and breast preservation for three initial treatments of ductal carcinoma-in-situ of the breast.

PURPOSE: To assess the trade-offs between survival and breast preservation of currently accepted approaches for ductal carcinoma-in-situ (DCIS) of the breast. PATIENTS AND METHODS: Decision analysis was performed using the Markov model of hypothetical cohorts of 55-year-old white women with nonpalpable mammographic abnormalities found to be DCIS. Strategies were breast-conserving surgery (BCS), BCS with 50-Gy radiation (RT) or initial mastectomy. Recurrence rates were derived from the published literature. Main outcomes were overall, breast cancer-free, and event-free survival plus years of both breasts preserved. RESULTS: Using the conditions defined in this model, the actuarial survival rates at 10 and 20 years were 91.7% and 74.1% for the initial mastectomy strategy, 91.0% and 72.1% for BCS plus RT, and 89.6% and 68.2% for BCS alone. At 20 years, the initial mastectomy strategy also had a greater breast cancer-free survival rate of 74.5%, compared with 63.3% for BCS plus RT, or 46.8% for BCS alone. However, BCS alone had the highest survival rate with both breasts preserved (64.2%) compared with BCS plus RT (56.0%) or initial mastectomy (0%). Of the breast-conserving strategies at 20 years, the breast event-free survival rate (no invasive cancer or DCIS) was greater for BCS plus RT (47.2%) compared with BCS alone (28.4%). Using just survival as the primary end point, mastectomy is the optimal strategy by a small margin. However, if quality-adjusted survival is at issue, mastectomy is the choice only if the yearly reduction in quality of life due to mastectomy is less than 1%. CONCLUSION: BCS with or without radiation compared with mastectomy as initial management of DCIS of the breast trades a slight decrease in survival rates for the value of breast preservation. This model should aid clinicians in matching treatments to their patients' preferences.

Clinical assessment of carcinoma in situ of the human urinary bladder.

Recent interest in intravesical instillation of bacillus Calmette-Guérin for the management of carcinoma in situ (CIS) of the bladder prompted us to review our results of total immediate cystourethrectomy. From 1975 to 1987, we surgically treated 302 patients with primary bladder tumours. Of these, 21 bladder tumours were histologically diagnosed as CIS, and total immediate cystourethrectomy was performed in all cases. The lesions were classified into three types: primary CIS accompanied by neither previous nor simultaneous tumours of the urinary tract (Type 1, 9 patients), concomitant CIS associated with superficial papillary tumour (Type 2, 6 patients), and secondary CIS detected during the follow-up period after treatment of the superficial papillary tumour (Type 3, 6 patients). Primary CIS was more often diagnosed according to subjective symptoms such as micturition pain than concomitant CIS. Secondary CIS was diagnosed in all patients by routine examinations including cytology and cystoscopy. There was no particular relationship between the time of recurrence of the tumour and the occurrence of secondary CIS. Within the same period, 60 patients with stage T1 bladder tumour were treated by total cystourethrectomy. The actuarial 5-year survival rate was 77% for T1 and 75% for CIS. The 5-year survival rate was 71% for Type 1, 83% for Type 2, and 67% for Type 3 CIS with no difference among the CIS types. Tumour invasion to the bladder, prostate, ureter, or lymph nodes was observed in 9 (42.9%) of the 21 patients, although cystourethrectomy was performed within 3 months of the diagnosis. Examination of ABH antigens did not allow prediction of invasion of CIS. Our findings suggest that the invasive potential of CIS may seriously limit the indications of conservative treatment against carcinoma in situ.

Contralateral breast carcinoma: an assessment of risk and prognosis in stage I (T1N0M0) and stage II (T1N1M0) patients with 20-year follow-up.

Among 644 patients with a small (T1) primary breast carcinoma who were followed up for a median of 18.2 years, subsequent contralateral breast carcinomas were detected in 57 of 610 women (9%) who had a contralateral breast at risk. The average annual hazard rate for contralateral carcinomas was 8/1000 patients at risk per year without significant fluctuations throughout the 20 years of follow-up. Recurrences were caused by 9 of 57 (16%) subsequent contralateral carcinomas, and 4 of the 57 patients (7%) died of recurrent contralateral carcinomas. Contralateral carcinomas were responsible for 5.1% (9 of 176) of all recurrences of breast carcinomas and 2.6% (4 of 153) of breast carcinoma deaths. Surveillance of the contralateral breast must continue throughout a patient's lifetime. Detection and treatment of subsequent lesions at an early stage is a beneficial result of follow-up, especially in women whose first carcinoma is likely to have been cured.