Right colon cancer: Left behind.

INTRODUCTION: Prognosis of colon cancer (CC) has steadily improved during the past three decades. This trend, however, may vary according to proximal (right) or distal (left) tumor location. We studied if improvement in survival was greater for left than for right CC. METHODS: We included all CC recorded at the Geneva population-based registry between 1980 and 2006. We compared patients, tumor and treatment characteristics between left and right CC by logistic regression and compared CC specific survival by Cox models taking into account putative confounders. We also compared changes in survival between CC location in early and late years of observation. RESULTS: Among the 3396 CC patients, 1334 (39%) had right-sided and 2062 (61%) left-sided tumors. In the early 1980s, 5-year specific survival was identical for right and left CCs (49% vs. 48%). During the study period, a dramatic improvement in survival was observed for patients with left-sided cancers (Hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.29-0.62, p < 0.001) but not for right CC patients (HR: 0.76, 95% CI: 0.50-1.14, p = 0.69). As a consequence, patients with distal CC have a better outcome than patients with proximal CC (HR for left vs. right CC: 0.81, 95% CI: 0.72-0.90, p < 0.001). CONCLUSION: Our data indicate that, contrary to left CC, survival of patients with right CC did not improve since 1980. Of all colon cancer patients, those with right-sided lesions have by far the worse prognosis. Change of strategic management in this subgroup is warranted.

Stage IVB endometrial cancer: clinical course and survival of patients with single and multiple metastases.

OBJECTIVE: Metastatic endometrial cancer (EC) at initial presentation is a rare disease. The present aim was to evaluate prognostic factors and overall survival in patients diagnosed with metastatic EC. STUDY DESIGN: Using data from the Geneva Cancer Registry, the authors included all patients diagnosed with Stage IVB EC from 1980-2007. Estimates of survival were calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: A total of 38 patients were identified. The most frequent metastases were peritoneal or pleural carcinomatosis (66%, n=25) and hematogenous metastases (53%, n=20). Five-year survival rate was 5.7% (95% confidence interval: 0.0-13.3), and median survival was 7.6 months. Survival of patients with a single metastasis at the time of diagnosis was longer than for patients with multiple metastases (16 versus two months, respectively; p < 0.00 1). CONCLUSION: Metastatic EC is rare disease with very poor prognosis particularly for patients with multiple site metastases.

Aggressiveness of cancer treatment in patients hospitalized in a supportive care unit.

PURPOSE: This study aimed at determining the aggressiveness of chemotherapy (CT)in patients hospitalized in a supportive care unit (focusing on mortality, patient profiles, survival, readmissions, and CT near death). METHODS: In a prospective cohort study, 247 consecutive patients were investigated at the admission (disease, treatments, oncologist's theoretical survival prognosis, internist's clinical global impression (CGI)). A 3-and 6-month follow-up was performed. Survival was assessed up to 3 years. RESULTS: Various cancer diagnoses were represented in polymorbid patients. Since disease onset, 69.6 % had received a first line of CT only; 147 patients (59.5 %) had CT at the admission; median CGI was 3 (range = 0-10); and theoretical survival prognosis was <12 months in 65.2 %. In-hospital mortality rate was 21 %. Odds of receiving CT was inversely associated with age (OR for patients ≥ 71 years vs. patients <50 years 0.19; 95 % CI 0.06-0.65; p = 0.02) and number of previous CT lines (OR for patients with 2-4 lines vs. those with 1 line 0.14; 95 % CI 0.06-0.34; p = 0.000). In the multi-adjusted model, 6-month survival remained associated with CT at the admission (HR 1.86; 95 % CI 1.31-2.65; p = 0.001), CGI (per point HR 0.84; 95 % CI 0.73-0.96; p = 0.013), and theoretical survival prognosis (per category HR 0.53; 95 % CI 0.44-0.66; p = 0.000). Very few patients needed readmission related to CT's adverse effects. From admission and throughout follow-up, 24 patients (9.7 %) had received CT during their last 14 days of life. CONCLUSION: This study showed that a supportive care program can benefit a heterogeneous population as it contributes to assess clinical risks and benefits of CT and prevent aggressive care near death.

How many ovarian cancer patients are eligible for fertility-sparing surgery?

OBJECTIVE: To assess how many epithelial ovarian cancer (EOC) patients are eligible for fertility-sparing surgery (FSS) in a population-based study. STUDY DESIGN: Using data from the Geneva Cancer Registry, we conducted a retrospective review of all women diagnosed with epithelial ovarian cancer (EOC) between January 1979 and December 2008. Patients were classified into two age groups ("young group"≤45 years and "old group">45 years) and as "eligible for FSS" (FIGO IA, G1-G2 or unilateral ICG1) and "non-eligible for FSS" (FIGO IA, G3; IC G2-G3; IB or II-IV). Patients and tumor characteristics were tested with the chi-square test. Estimates of survival were calculated using the Kaplan-Meyer method and differences between groups were analyzed by the log-rank test. RESULTS: A total of 888 EOC patients were analyzed. The young group included 87 patients (9.8%): eleven (1.2%) were identified as eligible for FSS and 6 (0.6%) were nulliparous. The annual incidence of EOC women eligible for FSS in Geneva was 0.48/100,000 (0.5 women/year) and the expected annual incidence rate for Switzerland (8 million inhabitants) is 6.5 women/year. CONCLUSION: Only a very small proportion of EOC patients are eligible for FSS. These results highlight the need to centralize FSS data in dedicated European units, in order to maintain expertise and quality of care for these patients.

Breast cancer management and outcome according to surgeon's affiliation: a population-based comparison adjusted for patient's selection bias.

BACKGROUND: Studies have reported that breast cancer (BC) units could increase the quality of care but none has evaluated the efficacy of alternative options such as private BC networks, which is our study objective. PATIENTS AND METHODS: We included all 1404 BC patients operated in the public unit or the private network and recorded at the Geneva Cancer Registry between 2000 and 2005. We compared quality indicators of care between the public BC unit and the private BC network by logistic regression and evaluated the effect of surgeon's affiliation on BC-specific mortality by the Cox model adjusting for the propensity score. RESULTS: Both the groups had high care quality scores. For invasive cancer, histological assessment before surgery and axillary lymph node dissection when indicated were less frequent in the public sector (adjusted odds ratio (OR): 0.4, 95% confidence interval (CI) 0.3-0.7, and OR: 0.4, 95% CI 0.2-0.8, respectively), while radiation therapy after breast-conserving surgery was more frequent (OR: 2.5, 95% CI 1.4-4.8). Surgeon affiliation had no substantial effect on BC-specific mortality (adjusted hazard ratio (HR): 0.8, 95% CI 0.5-1.4). CONCLUSIONS: This study suggests that private BC networks could be an alternative to public BC units with both structures presenting high quality indicators of BC care and similar BC-specific mortality.

Changes in incidence, survival and mortality of prostate cancer in Europe and the United States in the PSA era: additional diagnoses and avoided deaths.

BACKGROUND: We describe changes in prostate cancer incidence, survival and mortality and the resulting impact in additional diagnoses and avoided deaths in European areas and the United States. METHODS: Using data from 12 European cancer registries and the Surveillance, Epidemiology and End Results program, we describe changes in prostate cancer epidemiology between the beginning of the PSA era (USA: 1985-1989, Europe: 1990-1994) and 2002-2006 among patients aged 40-64, 65-74, and 75+. Additionally, we examine changes in yearly numbers of diagnoses and deaths and variation in male life expectancy. RESULTS: Incidence and survival, particularly among patients aged <75, increased dramatically, yet both remain (with few exceptions in incidence) lower in Europe than in the United States. Mortality reductions, ongoing since the mid/late 1990 s, were more consistent in the United States, had a distressingly small absolute impact among patients aged 40-64 and the largest absolute impact among those aged 75+. Overall ratios of additional diagnoses/avoided deaths varied between 3.6 and 27.6, suggesting large differences in the actual impact of prostate cancer incidence and mortality changes. Ten years of remaining life expectancy was reached between 68 and 76 years. CONCLUSION: Policies reflecting variation in population life expectancy, testing preferences, decision aids and guidelines for surveillance-based management are urgently needed.

Omission of excisional therapy is associated with an increased risk of invasive cervical cancer after cervical intraepithelial neoplasia III.

BACKGROUND: Using data from the population-based Geneva Cancer Registry we evaluated the risk of invasive cervical cancer following carcinoma in situ (CIS) or cervical intraepithelial neoplasia (CIN) III according to type of treatment. METHODS: Included in the study were all women diagnosed with CIS/CIN III in Geneva (Switzerland) between 1970 to 2002 (n=2658) and followed for invasive cervical cancer occurrence until 31st December 2008. We calculated age and period standardised incidence ratios (SIR) and multiadjusted hazard ratios (HR) of invasive cervical cancer by treatment groups. RESULTS: During follow-up, 17 women developed invasive cervical cancer, conferring a SIR of 5.1 (95% confidence intervals [CI] 3.0-8.1). The risk of cervical cancer was significantly increased until 10 years after diagnosis. The risk was highest for women ≥ 50 years (SIR=7.3, 95% CI: 2.7-15.8) and for women who did not undergo excisional treatment (SIR=25, 95% CI: 12.0-46.0). The multiadjusted HR of invasive cervical cancer for women who did not undergo surgical excisional treatment was 9.4 (95% CI: 2.8-32.2) compared with women who did. CONCLUSION: Women diagnosed with CIS/CIN III are at increased risk of developing invasive cervical cancer. This risk is particularly high for women who did not have excision of cervical lesions.

Excess of cardiovascular mortality among node-negative breast cancer patients irradiated for inner-quadrant tumors.

BACKGROUND: Radiotherapy of the left breast is associated with higher cardiovascular mortality linked to cardiotoxic effect of irradiation. Radiotherapy of inner quadrants can be associated with greater heart irradiation, but no study has evaluated the effect of inner-quadrant irradiation on cardiovascular mortality. PATIENTS AND METHODS: We identified 1245 women, the majority with breast-conserving surgery, irradiated for primary node-negative breast cancer from 1980 to 2004 registered at the Geneva Cancer Registry. We compared breast cancer-specific and cardiovascular mortality between inner-quadrant (n = 393) versus outer-quadrant tumors (n = 852) by multivariate Cox regression analysis. RESULTS: After a mean follow-up of 7.7 years, 28 women died of cardiovascular disease and 91 of breast cancer. Patients with inner-quadrant tumors had a more than doubled risk of cardiovascular mortality compared with patients with outer-quadrant tumors (adjusted hazard ratio 2.5; 95% confidence interval 1.1-5.4). Risk was particularly increased in the period with higher boost irradiation. Patients with left-sided breast cancer had no excess of cardiovascular mortality compared with patients with right-sided tumors. CONCLUSIONS: Radiotherapy of inner-quadrant breast cancer is associated with an important increase of cardiovascular mortality, a possible result of higher irradiation of the heart. For patients with inner-quadrant tumors, the heart should be radioprotected.

Impact of a positive family history on diagnosis, management, and survival of breast cancer: different effects across socio-economic groups.

BACKGROUND: This study aims to investigate whether increased awareness of breast cancer, due to a positive family history (FH), reduces diagnostic, therapeutic, and survival differences between women of low versus high socio-economic status (SES). METHODS: All breast cancer patients registered between 1990 and 2005 at the population-based Geneva Cancer Registry were included. With multivariate logistic and Cox regression analysis, we estimated the impact of SES and FH on method of detection, treatment, and mortality from breast cancer. RESULTS: SES discrepancies in method of detection and suboptimal treatment, as seen among women without a FH, disappeared in the presence of a positive FH. SES differences in stage and survival remained regardless of the presence of a positive FH. Overall, positive FH was associated with better survival. This effect was the strongest in women of high SES (age-adjusted Hazard Ratio [HR(ageadj)] 0.54 [0.3-1.0]) but less pronounced in women of middle (0.77 [0.6-1.0]), and absent in women of low SES (0.80 [0.5-1.2]). CONCLUSION: A positive FH of breast cancer may reduce SES differences in access to screening and optimal treatment. However, even with better access to early detection and optimal treatment, women of low SES have higher risks of death from their disease than those of high SES.

Estimated dose to the rectum and colon in prostate cancer patients treated with exclusive radiation therapy presenting a secondary colorectal malignancy.

AIMS: To estimate the dose to colorectal structures after external beam radiation therapy (EBRT) delivered to prostate cancer patients who developed secondary colorectal cancers (sCRC). MATERIALS AND METHODS: Using data from a population-based cancer registry of 1134 prostate cancer patients, 11/264 (4.2%) patients treated with EBRT presented a sCRC. To evaluate the dose delivered to the colon and rectum, each individual index patient was matched with a study case and, using the index case treatment characteristics, dose calculations were carried out on the latter. RESULTS: The median maximum, mean and minimum doses delivered to the colon or rectum affected by the sCRC were 39.3 (range 0.2-66.0), 5.4 (range 0.2-41.3) and 0.6 (range 0.2-7.8) Gy, respectively. All but three sCRCs occurred outside the treatment fields. The estimated rectal doses after prostate radiation therapy were substantially higher than those delivered to non-rectal colic structures (mean dose 47.2+/-16.6 vs 9.4+/-6.4 Gy), but only one (9%) patient presented a rectal cancer. The differential mean doses given to the rectosigmoid junction and sigmoid colon, with or without sCRC, were not different. CONCLUSIONS: These data suggest that the administered dose after EBRT for prostate cancer to the colon, excluding the rectum, may be below the Gy unit in sCRC patients.

Characteristics and outcome of prostate cancer with PSA <4 ng/ml at diagnosis: a population-based study.

This population-based study aims to assess prognosis of prostate cancer diagnosed with prostate-specific antigen (PSA) levels <4 ng/ml in routine care. Materials and methods We compared prostate cancer patients with low PSA values (n=59) with other prostate cancer patients (n=1330) by logistic regression and the Cox model using data from the Geneva Cancer Registry. Results Patients with low PSA values more frequently had early-stage and well differentiated tumours. Nevertheless, 35% presented with aggressive tumour characteristics or metastases. After adjustment for other prognostic factors, prostate cancer-specific mortality was similar for both groups (hazard ratio: 1.1; 95%CI: 0.6-2.2). Conclusion We conclude that cancer with low PSA values at diagnosis is not indolent.

Hormonal therapy for oestrogen receptor-negative breast cancer is associated with higher disease-specific mortality.

BACKGROUND: Tamoxifen has a remarkable impact on the outcome of oestrogen receptor (ER)-positive breast cancer. Without proven benefits, tamoxifen is occasionally prescribed for women with ER-negative disease. This population-based study aims to estimate the impact of tamoxifen on the outcome of ER-negative disease. METHODS: We identified all women (n = 528) diagnosed with ER-negative invasive breast cancer between 1995 and 2005. With Cox regression analysis, we calculated breast cancer mortality risks of patients treated with tamoxifen compared with those treated without tamoxifen. We adjusted these risks for the individual probabilities (propensity scores) of having received tamoxifen. RESULTS: Sixty-nine patients (13%) with ER-negative disease were treated with tamoxifen. Five-year disease-specific survival for women treated with versus without tamoxifen were 62% [95% confidence interval (CI) 48% to 76%] and 79% (95% CI 75% to 83%), respectively (P(Log-rank) < 0.001). For ER-negative patients, risk of death from breast cancer was significantly increased in those treated with tamoxifen compared with patients treated without tamoxifen (adjusted hazard ratio = 1.7, 95% CI 1.1-2.9, P = 0.031). CONCLUSION: Our results show that patients with ER-negative breast cancer treated with tamoxifen have an increased risk of death from their disease. Tamoxifen use should be avoided for these patients.

The attitude and knowledge of cervical cancer by Cameroonian women; a clinical survey conducted in Maroua, the capital of Far North Province of Cameroon.

This study was conducted to assess the knowledge, attitudes, and assumption of cervical cancer by women living in Maroua, the capital of the Far North Province of Cameroon. In a 1-month period, 171 women were surveyed as to their socioeconomic status, sexual habits, prior knowledge of cervical cancer, its prevention, and their attitudes toward cervical cancer. Of 171 women, 48 (28%) had prior knowledge of cervical cancer; they were classified as the "aware group" compared with 123 of 171 (72%) women who were uninformed about cervical cancer and they were classified as the "unaware group" (UG). The UG of women tended to be single mothers, illiterate, housewives, and had their first child before the age of 20 (P < 0.005). Despite the awareness of cervical cancer by 28% of women, only a minority of them, 4 of 48 (8.3%), underwent a preventative screening test. Only 71 of 171 (41.5%) women stated that they would be having a screening test in the future. The awareness of cervical cancer by women in Cameroon is still inadequate. Thus, to avoid deaths from cervical cancer, a curable and preventable disease, the need of an aggressive campaign to make Cameroonian women aware of cervical cancer and its prevention is needed.

Hormone replacement therapy, mammography screening and changing age-specific incidence rates of breast cancer: an ecological study comparing two European populations.

BACKGROUND: In 2003, for the first time, US breast cancer incidence rates have fallen. Experts argue whether this is due to the reduced uptake of screening mammography or to lower use of Hormone Replacement Therapy (HRT). This study aims to disentangle the respective impact of screening and HRT on age-incidence rates and histology of breast cancer, by comparing two populations with comparably high levels of screening mammography, but with different prevalence of HRT. METHODS: We included all invasive breast cancers recorded at the Geneva cancer registry (n = 4,909) and the Netherlands Cancer Registry (n = 152,428) between 1989-2003. We compared age-specific incidence rates and trends in histological subtyping between the two populations. RESULTS: Between 1989-1991, incidence rates increased with age in both populations. In 2001-2003, women aged 60-64 years showed highest incidence rates in Geneva, while in the Netherlands incidence rates continued to increase with age. The annual increase in ductal cancer incidence was similar in the Netherlands (2.3%) and Geneva (2.5%), but the annual increase in lobular cancer was sharper in Geneva (10%) than in the Netherlands (5%). CONCLUSION: The sharp differences in age distribution and histological subtyping of breast cancer between two European populations are not attributable to screening, since both populations have a high uptake of mammography screening. Since the prevalence of HRT use is very high in Geneva and rather low in the Netherlands, HRT may explain these discrepancies. However, other etiological factors and differences in histological assessment may also have played a role.

Recent increase of breast cancer incidence among women under the age of forty.

Using data from the Geneva Cancer Registry, we found that in 2002-2004, breast cancer incidence in women aged 25-39 years increased by 46.7% per year (95% CI: 7.1-74.0, P=0.015), which surveillance or detection bias may not fully explain.

Impact of familial risk factors on management and survival of early-onset breast cancer: a population-based study.

This population-based study evaluates the impact of a strong family history of breast cancer on management and survival of women with early-onset disease. We identified all breast cancer patients

Poorer survival of elderly patients with ovarian cancer: a population-based study.

OBJECTIVE: To compare ovarian cancer survival in elderly and young patients. MATERIAL AND METHODS: Using the Geneva Cancer Registry, we identify women diagnosed with primary ovarian cancer between 1980 and 1998. We compared tumors characteristics, treatment patterns of young patients (70 years) by logistic regression. To evaluate the effect of age on prognosis, we compared disease specific survival by Cox proportional hazard analysis, taking into account other prognostic factors. RESULTS: This study included 285 patient aged 70 years and 451

Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management.

OBJECTIVE: To evaluate the efficacy of a treatment programme for patients with fibromyalgia (FM) based on self management, using pool exercises and education. METHODS: Randomised controlled trial with a 6 month follow up to evaluate an outpatient multidisciplinary programme; 164 patients with FM were allocated to an immediate 6 week programme (n = 84) or to a waiting list control group (n = 80). The main outcomes were changes in quality of life, functional consequences, patient satisfaction and pain, using a combination of patient questionnaires and clinical examinations. The questionnaires included the Fibromyalgia Impact Questionnaire (FIQ), Psychological General Well-Being (PGWB) index, regional pain score diagrams, and patient satisfaction measures. RESULTS: 61 participants in the treatment group and 68 controls completed the programme and 6 month follow up examinations. Six months after programme completion, significant improvements in quality of life and functional consequences of FM were seen in the treatment group as compared with the controls and as measured by scores on both the FIQ (total score p = 0.025; fatigue p = 0.003; depression p = 0.031) and PGWB (total score p = 0.032; anxiety p = 0.011; vitality p = 0.013,). All four major areas of patient satisfaction showed greater improvement in the treatment than the control groups; between-group differences were statistically significant for "control of symptoms", "psychosocial factors", and "physical therapy" No change in pain was seen. CONCLUSION: A 6 week self management based programme of pool exercises and education can improve the quality of life of patients with FM and their satisfaction with treatment. These improvements are sustained for at least 6 months after programme completion.

Neurophysiologic evidence for a central sensitization in patients with fibromyalgia.

OBJECTIVE: To determine whether abnormalities of peripheral and central nociceptive sensory input processing exist outside areas of spontaneous pain in patients with fibromyalgia (FM) as compared with controls, by using quantitative sensory testing (QST) and a neurophysiologic paradigm independent from subjective reports. METHODS: A total of 164 outpatients with FM who were attending a self-management program were invited to participate in the study. Data for 85 patients were available and were compared with those for 40 non-FM controls matched for age and sex. QST was performed using thermal, mechanical, and electrical stimuli at locations of nonspontaneous pain. Pain assessment was 2-fold and included use of subjective scales and the spinal nociceptive flexion reflex (NFR), a specific physiologic correlate for the objective evaluation of central nociceptive pathways. Questionnaires regarding quality of life and the impact of FM were available. RESULTS: Participants were mainly middle-aged women, with a mean disease duration of 8 years. Between-group differences were significant for neurophysiologic, clinical, and quality of life measures. In patients with FM, peripheral QST showed significantly altered cold and heat pain thresholds, and tolerance to cold pain was radically reduced. The median NFR threshold in patients with FM (22.7 mA [range 17.5-31.7]) was significantly decreased compared with that in controls (33 mA [range 28.1-41]). A cutoff value of <27.6 mA for NFR provided sensitivity of 73% and specificity of 80% for detecting central allodynia in the setting of FM. CONCLUSION: Our results strongly, although indirectly, point to a state of central hyperexcitability of the nociceptive system in patients with FM. The NFR can be used to assess central allodynia in FM. It may also help discriminate patients who may benefit from use of centrally acting analgesics.