Nutritional support in patients with GVHD of the digestive tract: state of the art.

An important complication of allo-SCT is GVHD, which commonly affects the skin, liver and digestive tract. Clinical symptoms of GVHD of the digestive tract (GVHD-DT) include excessive diarrhoea, abdominal pain and cramps, nausea and vomiting, gastrointestinal bleeding, dysphagia, and weight loss. Treatment is complicated and regarding nutritional support, only a few guidelines are available. Our aim was to critically appraise the literature on nutritional assessment, nutritional status and nutritional support for patients with GVHD-DT. Evidence shows that GVHD-DT is often associated with malnutrition, protein losing enteropathy, magnesium derangements, and deficiencies of zinc, vitamin B12 and vitamin D. Limited evidence exists on derangements of magnesium, resting energy expenditure, bone mineral density and pancreatic function, and some beneficial effects of n-3 polyunsaturated fatty acids and pancreatic enzyme replacement therapy. Expert opinions recommend adequate amounts of energy, at least 1.5 g protein/kg body weight, supplied by total parenteral nutrition in cases of severe diarrhoea. When diarrhoea is <500 mL a day, a stepwise oral upgrade diet can be followed. No studies exist on probiotics, prebiotics, dietary fibre and immunonutrition in GVHD-DT patients. Future research should focus on absorption capacity, vitamin and mineral status, and nutritional support strategies.

Mapping use of radiotherapy for patients with non-small cell lung cancer in the Netherlands between 1997 and 2008.

AIM: After the publication of several reports that the utilisation rate of radiotherapy for patients with non-small cell lung cancer (NSCLC) varies for both medical and non-medical reasons, the utilisation of radiotherapy was studied in four regions in the Netherlands. MATERIALS AND METHODS: Data from 1997-2008 were collected from the population-based cancer registries of four comprehensive cancer centres ('regions'), which represent about half of the Dutch population, resulting in 24 185 non-metastatic patients with NSCLC. Treatment had to be started or planned within 6 months of diagnosis. We evaluated the utilisation of radiotherapy according to age, gender and period for each region. RESULTS: The utilisation of radiotherapy alone decreased over time (from 35 to 19%), whereas the utilisation of radiotherapy in combination with chemotherapy increased (from 5 to 19%). The total utilisation rate remained rather stable at about 40%. The differences between the four regions remained in general no more than 15%. Elderly patients with stage I and II disease had increased odds of receiving radiotherapy (≥75 versus <50 years: odds ratio 2.6, 95% confidence interval 2.0-3.3, whereas this was the opposite for patients with stage III disease: odds ratio 0.5, 95% confidence interval 0.4-0.6). For 17-24% of all patients, especially the elderly, best supportive care was applied. CONCLUSIONS: In the Netherlands, with good accessibility to medical care and well-implemented national guidelines, variation between the four regions is limited for the treatment of non-metastatic NSCLC with radiotherapy.

Variations in treatment policies and outcome for bladder cancer in the Netherlands.

AIM: To describe the population-based variation in treatment policies and outcome for bladder cancer in the Netherlands. METHODS: All newly diagnosed patients with primary bladder cancers during 2001-2006 were selected from the Netherlands Cancer Registry (n = 29,206). Type of primary treatment was analysed according to Comprehensive Cancer Centre region, hospital type (academic, non-academic teaching or other hospitals) and volume (< or =5, 6-10 or >10 cystectomies yearly). For stage II-III patients undergoing cystectomy we analyzed the proportion of lymph node dissections and 30-days mortality. RESULTS: 44% of patients with stage II-III bladder cancer underwent cystectomy, while 26% were not treated with curative intent. Cystectomy was the preferred option in three of nine regions, radiotherapy in two, and two regions waived curative treatment more often. Between 2001 and 2006 the number of cystectomies increased with 20% (n = 108). Twenty-one percent (n = 663) of these procedures were performed in 44 low-volume hospitals. In 79% of the cystectomies lymph node dissections were performed, more often in high and medium-volume centers (82% and 81% respectively) than in low-volume hospitals (71%, the odds ratio being 1.5). The overall 30-days post-operative mortality rate was 3.4% and increased with older age. It was significantly lower in high-volume centers (1.2%). CONCLUSION: Treatment policies for muscle-invasive bladder cancer in the Netherlands showed regional preferences and a gradual increase of cystectomy. Cystectomy albeit considered as golden standard, was performed in a minority of the muscle-invasive cases. In high-volume institutions, lymph node dissection rates were higher and post-operative mortality rates were lower.

Results of breast cancer screening in first generation migrants in Northwest Netherlands.

To determine breast cancer screening results according to country of birth data were used from the breast cancer screening organization of the Comprehensive Cancer Centre Amsterdam, The Netherlands. Overall (age-adjusted) attendance of the breast cancer screening was 76% for women aged 50-69. Attendance was significantly lower for women born in non-western countries (Surinam 59%, Turkey 44% and Morocco 37%) and for women with residence in Amsterdam (68%). Referral and detection rates for women from non-western countries were 5.1 and 2.2 per 1000 screened women, respectively, compared with 8.8 and 4.0 for women born in The Netherlands (P<0.05). The positive predictive value was 45% for women born in The Netherlands and western countries and 43% for women born in non-western countries. Although women born in non-western countries attend breast cancer screening less frequently than women born in The Netherlands, they also have a low detection rate. The latter finding justifies a passive attitude towards the low attendance.

[Incidence of cervical cancer in women in North-Holland by country of birth from 1988-1998]. / Incidentie van baarmoederhalskanker naar geboorteland bij vrouwen in Noord-Holland in 1988-1998.

OBJECTIVE: To describe the incidence of cervical cancer in women in North-Holland by country of birth. DESIGN: Descriptive epidemiological study based on data from cancer registries. METHOD: The number of cases of cervical cancer in North-Holland for the period 1988-1998 was determined using data from the regional cancer registry of the Comprehensive Cancer Centre, Amsterdam. Based on data from the Netherlands Cancer Registry, a comparison was made between the observed (O) and the expected (E) number of cases by area of residence (i.e., Amsterdam versus the rest of North-Holland) and by the woman's country of birth. RESULTS: In the period 1988-1998, the incidence of cervical cancer among women living in North-Holland was significantly higher than that of the nation as a whole (O/E-ratio: 1.2; 95% CI: 1.1-1.2). In particular, the incidence of cervical cancer for women living in Amsterdam (O/E-ratio: 1.5; 95% CI: 1.4-1.6), and for women born in Morocco (O/E-ratio: 2.1; 95% CI: 1.4-3.1) or Surinam (O/E-ratio: 1.5; 95% CI: 1.1-2.0) was much higher. The country of birth was unknown in 10% of the women. The percentage of patients with extension of the disease outside the uterus (TNM-stages II-IV) did not differ between women born in the Netherlands and those born abroad. CONCLUSION: The incidence of cervical cancer during the period 1988-1998 was significantly higher for women living in Amsterdam and for women born in Morocco or Surinam than that for the Netherlands as a whole. No significant difference in stage of disease at diagnosis was observed between women born in the Netherlands versus those born abroad.

Gender differences in stage-adjusted bladder cancer survival.

OBJECTIVES: Gender differences have been observed in the prognosis of patients with bladder cancer. It has also been suggested that these differences are caused by a worse stage distribution at diagnosis among women. The purpose of this study was to evaluate whether women with bladder cancer have a worse prognosis even after adjustment for disease stage at first presentation. METHODS: Data on patients with bladder cancer diagnosed between 1973 and 1996 and registered by one of the nine population-based Surveillance, Epidemiology, and End Results (SEER) cancer registries in the United States (n = 80,305) were obtained from the National Cancer Institute public domain SEER*Stat 2.0 package. Similar data on patients with bladder cancer diagnosed between 1987 and 1994 and registered by two population-based registries in the Netherlands (n = 1722) were obtained through the Comprehensive Cancer Centers, Amsterdam and South. Survival rates adjusted for mortality owing to other causes (ie, relative survival) were calculated for men and women within each category of the American Joint Committee on Cancer (SEER data) and TNM (Netherlands data) stage groupings.Results. In the United States, the 5-year relative survival rate of male patients with bladder cancer was calculated to be 79.5% (95% confidence interval 79.0% to 80.0%). Among women, the 5-year relative survival rate was significantly worse: 73.1% (95% confidence interval 72.2% to 74.0%). The male versus female 5-year survival rate among stage groups I, II, III, and IV was 96.5% versus 93.7%, 65.5% versus 59.6%, 58.8% versus 49.6%, and 27.1% versus 15.2%, respectively. The (sparser) data from the Netherlands were less conclusive. Women with Stage II and Stage IV disease fared worse than men but the reverse seemed to be true in Stage I disease. CONCLUSIONS: Female patients with bladder cancer have a worse prognosis than male patients. It is unlikely that the difference can explained entirely by the more frequent diagnosis of higher stages at first presentation among women.

[Cancer incidence in the Schiphol area in 1988-1993]. / Incidentie van kanker in de omgeving van Schiphol in 1988-1993.

OBJECTIVE: To calculate the cancer incidence in the region surrounding Schiphol. DESIGN: Descriptive epidemiological study based on cancer registry data. SETTING: Comprehensive Cancer Centre Amsterdam. The Netherlands. METHODS: Using noise levels expressed as Kosten-cenheden (Ke) of the air traffic around Schiphol (Amsterdam International Airport) as well as 4-digit postal code areas, two study areas were defined, a central area and an adjacent zone. All cancer cases diagnosed in 1988-1993 in the study areas were selected from the population-based Amsterdam Cancer Registry. Observed numbers of cancer cases were compared with expected numbers on the basis of national and regional cancer incidence rates. RESULTS: Cancer incidence (4535 cases) in 1988-1993 in the Schiphol region was slightly higher than national incidence rates (observed/expected (O/E) ratio: 1.93; 95% confidence interval; 1.00-1.06) and almost equal to regional rates. This was largely due to relatively high rates for breast (O/E ratio: 1.08) and prostate (O/E ratio: 1.11) cancer in the Schiphol region as well as in the total area covered by the Amsterdam Cancer Registry. In addition, leukaemia, lymphoma/multiple myeloma and bladder cancer were more frequent, the last-named especially in males. The incidence of cancer of the respiratory tract was not the same in the central area and the adjacent zone. As compared with national rates, it was increased in the central area (O/E ratio: 1.19), while it was decreased in the adjacent zone (O/E ratio: 0.86). The incidence of cancer of all sites (O/E ratio: 1.10) was also increased in the central area, largely due to smoking related cancers. CONCLUSION: During 1988-1993, cancer incidence in the area surrounding Schiphol was a little higher than the national incidence rates and almost equal to the regional incidence. We could not demonstrate an association between air traffic and increased cancer risk. It is most likely that the differences for certain types of cancer as well as those between the two study areas were due to differences in lifestyle, such as smoking habits.

[Incidence and treatment of prostatic carcinoma in the region of the Comprehensive Cancer Center Amsterdam, 1989-1994]. / Incidentie en behandeling van prostaatcarcinoom in de regio van het Integraal Kankercentrum Amsterdam, 1989-1994.

OBJECTIVE: To gain insight into the incidence and treatment of prostate cancer. DESIGN: Descriptive. SETTING: Comprehensive Cancer Centre Amsterdam, the Netherlands. METHODS: All prostate cancers diagnosed in 1989-1994 in residents of the region of the CCCA (North Holland and Flevoland) were selected from the regional cancer registry data base. Cases from one hospital were excluded due to incomplete registration. RESULTS: There was a 38% increase in the number of diagnosed prostate carcinomas between 1989 (n = 671) and 1994 (n = 929). Median age at diagnosis was 74 years. The proportion of localized tumours remained at the level of 69% during this period. The percentages of localized T1 tumours and tumours with unknown T stage decreased, while the percentages of localized T2 and T3 tumours increased. There was a sixfold increase in the number of total prostatectomies. 77% of the operated patients were diagnosed with a T2 tumour, 11% with a T3 tumour. At the end of the study period total prostatectomy was the main treatment of T1/2 prostate cancers in men below the age of 60. T3 tumours and men between 60 and 75 years of age were more often treated with radiotherapy, while men over 75 were mainly treated hormonally. The percentage of localized prostate cancers observed strongly increased with age and with lower T stage. CONCLUSION: The sharp rise in the number of prostate cancers during the period 1989-1994 was not confined to early stages. Within a few years total prostatectomy became one of the main treatment modalities in localized prostate cancer. This treatment was mainly restricted to younger men with smaller localized prostate carcinomas.