Physical Functioning in Older Patients With Breast Cancer: A Prospective Cohort Study in the TEAM Trial.

BACKGROUND: Previous retrospective studies have shown that physical functioning in older cancer survivors is affected after treatment, yet prospective data are lacking. The aim of this study was to assess change in physical functioning in different age groups of patients with hormone receptor-positive breast cancer who were enrolled in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) phase III trial. METHODS: Two physical parameters were assessed. Physical functioning was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire 1 year (T1) and 2 years (T2) after diagnosis. Physical activity was measured in metabolic equivalent of task (MET) hours/week at T1 and T2. Physical activity before diagnosis (T0) was assessed retrospectively at the T1 questionnaire. Patients were divided into three age groups: <60, 60-69, and ≥70 years. Decline in physical functioning was assessed using linear regression analysis. Differences in mean values of physical activity levels were calculated using repeated-measures one-way analysis of variance. RESULTS: A total of 431 patients were included for analysis. In all age groups, physical activity levels at T1 and T2 were significantly lower than prediagnostic physical activity levels (T0) (p < .001 for all age groups). Age ≥70 years was independently associated with decline in physical functioning between T1 and T2 (ß = -4.62, 95% confidence interval -8.73 to -0.51, p = .028). CONCLUSION: Patients aged 70 years or older treated with breast surgery and adjuvant hormonal therapy did not improve between years 1 and 2 after diagnosis to the same extent as did younger patients. IMPLICATIONS FOR PRACTICE: Although older patients constitute a large share of the breast cancer population, little is known about the effect and consequences of treatment of breast cancer in this specific age group. This study revealed that, unlike younger patients, older patients do not regain their physical abilities after surgical and adjuvant treatment for breast cancer. In older adults, the effect of treatment on physical functioning and independency could be more relevant than survival outcomes. Clinicians and older patients should be aware of the impact of treatment on physical functioning and prevent older patients from experiencing physical decline, which could lead to institutionalization and loss of independence. There is a need for age-specific guidelines that take into account the heterogeneity of the older population and for evidence-based treatment that focuses not only on cancer-specific outcomes but also on the consequences of treatment for physical and cognitive functioning and quality of life.

A case series of intestinal adenomatous polyposis of unidentified etiology; a late effect of irradiation?

BACKGROUND: In a large number of patients with multiple gastrointestinal adenomatous polyps, no causal germline mutation can be found. Non-genetic factors may contribute to the development of adenomatous polyps in these unexplained polyposis patients. In the development of gastrointestinal cancer, prior exposure to abdominal radiotherapy has been identified as such a factor, as it increases the gastrointestinal cancer risk in cancer survivors. A relationship of radiotherapy with intestinal polyposis, however, has not yet been described. Despite the increased cancer risk, these cancer survivors do not receive gastrointestinal screening recommendations. This case series describes three patients with adenomatous polyposis after abdominal radiotherapy. CASE PRESENTATION: Patient 1 was diagnosed with testicular cancer at the age of 31 and was treated with hemicastration, radiotherapy and chemotherapy. Thirty-nine years later, he was diagnosed with more than 30 colonic adenomas. Additionally, gastroduodenoscopy revealed a well-differentiated adenocarcinoma in the antrum of the stomach. Patient 2 was diagnosed with a nephroblastoma at the age of 10, which was resected and treated with radiotherapy and chemotherapy. At age 36, a rectal adenocarcinoma was diagnosed and treated by radiotherapy and a total mesorectal excision. During 11 years of surveillance endoscopies, 21 colonic adenomas and three duodenal adenomas were detected. Patient 3 was diagnosed with Hodgkin lymphoma at the age of 20 and treated with radiotherapy, followed by chemotherapy for a recurrence 3 years later. At age 62, a subtotal colectomy was performed because of colonic polyposis: 36 adenomas were detected. During screening gastro-duodenoscopy, three duodenal adenomas were detected. In all three patients, germline analysis did not reveal a mutation in the APC and MYH genes. The gastric and rectal cancer were both microsatellite stable. CONCLUSION: This report describes three patients with adenomatous polyposis, of which two developed a gastrointestinal cancer. The polyposis was not explained by a germline mutation in APC or MYH and all patients received abdominal radiotherapy. Although an etiologic role has not been established, an association between radiotherapy and intestinal adenomatous polyposis and the subsequent development of cancer seems very likely in our patients.

[Childhood cancer after fertility treatments?] / Kinderkanker na vruchtbaarheidsbehandelingen?

Since the introduction of Assisted Reproductive Technology (ART) in 1978, more than 10 million ART-conceived children have been born. Each phase of the ART procedure is substantially different from natural conception and these processes occur in the same timeframe as epigenetic programming. It seems plausible that ART could influence early stages of embryogenesis and thereby permanently influence the development and health of these individuals. Several epidemiological studies investigated the risk of childhood cancer after ART. Overall, results appear reassuring and do not indicate an increased risk. However, for subgroups, including children born after frozen-thawed embryo transfer(FET) there might be a modestly increased risk. There are some biological explanations for an increased risk of cancer after FET. However, as results are based on a small number of cancer cases, results must be replicated in other large cohort studies before translation into clinical practice.

Total cancer incidence and overall mortality are not increased among patients with Barrett's esophagus.

BACKGROUND & AIMS: Barrett's esophagus (BE) increases risk for esophageal adenocarcinoma, but it is not clear how it affects risk for other cancers or overall mortality. We analyzed data from a population-based cohort of subjects with BE. METHODS: The Netherlands Cohort Study was initiated in 1986 and included 120,852 participants (55-69 years old at baseline). Until December 2002, 626 incident cases of BE (excluding nonintestinal metaplasia) were identified by record linkage with the nationwide Pathology Registry. This cohort was followed for a median period of 5.7 years; data on cancer and mortality were obtained from record linkage to the Netherlands Cancer Registry and Statistics Netherlands. The expected number of cases was calculated using national cancer incidence and mortality data. RESULTS: In the BE cohort, 13 individuals developed esophageal cancer and 5 developed gastric cancer. The ratio of observed:expected (O:E) incidence of esophageal and gastric cancer was 10.0 (95% confidence interval [CI], 5.3-17.1) and 1.8 (95% CI, 0.6-4.2), respectively. Total cancer incidence (excluding esophageal and gastric cancer) increased in the BE cohort, although not by a statistically significant amount (O:E, 1.3; 95% CI, 1.0-1.6). Of cancer subtypes, incidences of small intestinal and pancreatic cancer increased in subjects with BE, but not by a statistically significant amount, after exclusion of data from the first 6 months of follow-up. During the follow-up period, 225 individuals with BE died. Mortality from all causes (excluding esophageal and gastric cancer) was not increased among subjects with BE (O:E, 1.0; 95% CI, 0.9-1.2), nor was mortality from specific causes of death. CONCLUSIONS: The incidence of esophageal cancer was increased in a population-based cohort of subjects with BE. However, when esophageal and gastric cancers were excluded, total cancer incidence and overall mortality were not increased among subjects with BE.

Increased risk of breast cancer development after diagnosis of salivary gland tumour.

The aim of this study was to evaluate whether patients with salivary gland tumours are at increased risk of developing breast cancer. A retrospective cohort study was performed. Female patients (n = 439) with a salivary gland tumour (major and minor) were included. The diagnosis was confirmed histologically. The median follow-up was 5.4 years. Fifteen patients out of 439 with a salivary gland tumour subsequently developed breast cancer, with a mean time interval of 64 months. On the basis of incidence rates in the general population 5.93 breast cancers would be expected. The standardised incidence ratio (SIR) was 2.5 (95% confidence interval: 1.4-4.2; P = 0.003). Increased SIRs were also observed for other solid malignancies, but the numbers were small (n < 5). It is concluded that female patients with a salivary gland tumour have a 2.5 times increased risk of developing breast cancer. Breast screening of these patients is therefore recommended.

[Hypofractionated adjuvant radiotherapy for breast cancer: no signs of increased risk of cardiotoxicity]. / Hypofractionering van bestraling voor borstkanker: geen aanwijzingen voor verhoogd risico op hartschade?

Adjuvant radiotherapy is frequently used in women with breast cancer to improve both local control of the tumour and overall survival. Hypofractionated regimens are increasingly being used as they involve fewer treatment sessions and, in terms of tumour control, the effects of conventionally fractionated and hypofractionated radiotherapy seem to be comparable. However, there is concern regarding increased cardiotoxicity following hypofractionated radiotherapy treatment to the left side. In order to determine if cardiac mortality increases with hypofractionation relative to conventional fractionation, a Canadian research group performed a retrospective analysis in 5334 women with breast cancer treated between 1990-1998 with postoperative radiotherapy to the breast/chest wall only. At 15-year follow-up the authors concluded that cardiac mortality was not statistically different among patients with left-sided breast cancer whether treated with hypofractionated or conventionally fractionated whole breast/chest wall irradiation. This commentary discusses the data presented in the paper, puts them into perspective and describes the clinical implications.

[Consent for the secondary use of human residual tissue: the patient is best served by an 'opting-out' procedure]. / Zeggenschap over nader gebruik van lichaamsmateriaal. Patiënt is het best gediend met 'geen bezwaar'-procedure.

In medical scientific research much use is made of human bodily material (residual tissue) which remains after treatment or diagnosis. Using this, relevant research questions can be answered. The way in which patients can consent to the secondary use of residual tissue is now formalised in a code of conduct, which allows such use unless the patient has objected to this use ('opting-out' procedure). A law is being formulated which will probably require the explicit permission of the patient for secondary use of residual tissue. It is expected that this requirement will lead to a lesser and more selective availability of residual tissue for research. Requesting explicit permission also means additional health care work. Patients demonstrate a preference for the 'opting-out' procedure, on condition that they are well informed about the use of the residual tissue. It is concluded that the interests of the patient are best served by the 'opting-out' procedure, provided that patients are well informed.

[Long-term complications following treatment of testicular cancer and Hodgkin lymphoma]. / Langetermijncomplicaties na behandeling voor zaadbalkanker en hodgkinlymfoom.

Patients who were treated in the past with radiotherapy or chemotherapy for testicular cancer or Hodgkin lymphoma are at risk of new malignancies and cardiovascular disease on the long run. Two patient groups who were diagnosed in various hospitals in the Netherlands as having testicular cancer and Hodgkin lymphoma in the period 1965-1995 have survived for a mean period of almost 20 years by now. Both patient groups have higher risks of a new malignancy or cardiovascular disease following radiotherapy and/or chemotherapy than the general population or patients treated without or with less intensive radiotherapy or chemotherapy. As recovery of Hodgkin lymphoma is only achieved by a more intensive treatment approach than the treatment approach for testicular cancer, the risks of a new malignancy or cardiovascular disease are considerably higher among survivors of Hodgkin lymphoma than among survivors of testicular cancer. In both patient groups the long-term risks of new malignancies and cardiovascular disease are still raised in both patient groups up to 25 years after treatment. Because of the relatively high risks of late treatment complications, recommendations for follow-up for survivors of testicular cancer and Hodgkin lymphoma are necessary.

Mobile phones and children: is precaution warranted?

Are there health related arguments to recommend that children limit their use of mobile telephones? The International Expert Group on Mobile Phones from the UK concluded so, but did not come up with convincing scientific data to back this statement. The Health Council of the Netherlands approached the problem by considering whether developmental arguments might be found, i.e., asking if there reason to believe that the heads of children are more susceptible to the electromagnetic fields emitted by mobile telephones than those of adults. It concluded that no major changes in head development occur after the second year of life that might point at a difference in electromagnetic susceptibility between children and adults. The Health Council therefore sees no reason to recommend limiting the use of mobile phones by children.