The prevalence of postoperative pain in a sample of 1490 surgical inpatients.

BACKGROUND AND OBJECTIVE: To measure the prevalence of postoperative pain, an assessment was made of 1490 surgical inpatients who were receiving postoperative pain treatment according to an acute pain protocol. METHODS: Measurements of pain (scores from 0 to 100 on a visual analogue scale) were obtained three times a day on the day before surgery and on days 0-4 postoperatively; mean pain intensity scores were calculated. Patients were classified as having no pain (score 0-5), mild pain (score 6-40), moderate pain (score 41-74) or severe pain (score 75-100). RESULTS: Moderate or severe pain was reported by 41% of the patients on day 0, 30% on days 1 and 19%, 16% and 14% on days 2, 3 and 4. The prevalence of moderate or severe pain in the abdominal surgery group was high on postoperative days 0-1 (30-55%). A high prevalence of moderate or severe pain was found during the whole of days 1-4 in the extremity surgery group (20-71%) and in the back/spinal surgery group (30-64%). CONCLUSION: We conclude that despite an acute pain protocol, postoperative pain treatment was unsatisfactory, especially after intermediate and major surgical procedures on an extremity or on the spine.

Age-specific differences in treatment and survival of patients with cervical cancer in the southeast of The Netherlands, 1986-1996.

Age at diagnosis has been proven to be an important determinant of the choice of initial treatment for several sites of cancer. Elderly patients are more likely to receive no treatment or less intensive treatment modalities. This study analysed the influence of age on treatment choice and survival in patients diagnosed with cervical cancer. This population-based study used data on 1176 new cases of invasive cervical cancer diagnosed in the period of 1986-1996 from three regional cancer registries in the Netherlands. All available information on treatment and survival (on 1 January 1998) was recorded. Relative survival rates were calculated according to the Hakulinen method. Relative risks (RR) for excess mortality due to the diagnosis of cervical cancer were calculated with a regression model for relative survival rates. Only 5% of the patients aged 70 years and older (n=224) were diagnosed with stage IA disease, compared with 11 and 30% of the patients aged 50-69 years and 49 years and younger, respectively. Almost 50% of the 70+ patients with stage IB-IIA were treated with radiotherapy as a single treatment modality, whereas 64% of the patients aged < or =49 years were treated with surgery alone. In all age groups, treatment for advanced stage disease (stage > or =IIB) was radiotherapy alone. No treatment was given to 10% of the patients aged 70 years and older, 5% of those aged 50-69 years and 1% of those aged 49 years and younger. Five-year relative survival was 69% (95% Confidence Interval (CI): 66-72%) and differed significantly (P=0.001) with age (70+ years: 49%; 50-69 years 58%; < or =49 years: 81%). Multivariate analyses on a subset of patients showed that age was not an independent prognostic factor, whereas stage and treatment modality were very important prognostic factors. Although elderly cancer patients were sometimes treated differently from younger patients, this was in accordance with the guidelines. Relative survival rates differed significantly by age. The multivariate analyses on the subset of patients also revealed that excess mortality increased with age. However, when adjustment was made for stage and treatment, this difference disappeared. The influence of treatment on survival is likely to be due to the selection of patients based on other characteristics, such as tumour volume, comorbidity and performance status.

Influence of age, comorbidity and performance status on the choice of treatment for patients with non-small cell lung cancer; results of a population-based study.

BACKGROUND: In the Netherlands in 1997, 43% of patients with newly diagnosed lung cancer were over 70. Large age-specific differences in treatment exist. We examined whether age, comorbidity, performance status and pulmonary function influenced treatment. PATIENTS AND METHODS: Data on patients with newly diagnosed non-small cell lung cancer (N = 803) were obtained: comorbidity, performance status, pulmonary function (FEV1) and initial treatment. Age-specific differences in treatment according to the guidelines were examined. Odds ratios were calculated by means of logistic regression analyses. RESULTS: 82% with stage I or II disease received treatment according to the guidelines; this applied to 48% with stage IIIA disease and to 54% with stage IIIB disease. For all stages, this proportion decreased with increasing age. In stage IV disease, 36% did not receive any treatment; this applied to 52% of the elderly patients (75+ years). Multivariate analyses showed associations between comorbidity and treatment choice, but none with performance status. Age of 75+ years appeared to be the most important factor for not receiving treatment according to guidelines. CONCLUSION: A substantial proportion of elderly patients with non-small cell lung cancer did not receive standard treatment. Performance status and comorbidity seldom formed the underlying reason. Calendar rather than biological age seemed to play the most important role in choice of treatment for patients with non-small cell lung cancer.

A blind review and an informed review of interval breast cancer cases in the Limburg screening programme, the Netherlands.

OBJECTIVE: To investigate the proportion of interval breast cancers that could have been detected at the previous screening examination, and to gain more insight into the characteristics of these tumours. SETTING: Breast cancer screening programme in mid- and southern Limburg, the Netherlands. METHOD: Firstly, previous screening mammograms of 92 interval cancer cases were blindly reread by the radiologists from two different units as part of their daily screening workload. Secondly, a separate informed review was conducted, in which all of the cases (except for two) were subclassified into four categories: screening error; minimal signs; radiologically occult both at previous screening and at diagnosis; or radiologically occult at previous screening. Trends in recall rates and false and true positive rates were calculated to study potential changes during and after the blind review. RESULTS: In the blind review, 15% of the interval cancers were detected in both rereadings and 21% in one rereading. In the informed review, 25% were classified as a screening error and 24% as minimal signs present; 74% of the cases classified as a screening error had been recalled at least once in the blind review. Recall rates and false positive rates in daily screening practice increased significantly during and after the study period. CONCLUSIONS: About one third of the interval cancers could have been detected in the previous screening round. In order to diminish the number of avoidable interval cancers, review and classification of interval cancers is an important tool for continuing the education of screening radiologists. Therefore, further development of review training procedures is necessary.

Rising incidence of breast cancer after completion of the first prevalent round of the breast cancer screening programme.

OBJECTIVES: After completion of the prevalent screening round of the breast cancer screening programme in Limburg, The Netherlands, incidences started rising once again. This increase was contrary to expectations, which had predicted a slightly higher, but stable, incidence after the first screening round. The trends in incidence were studied to find explanations for the observed rise in incidence. SETTING: Breast cancer screening programme in mid-Limburg and southern Limburg, the Netherlands. METHODS: The data files of the breast cancer screening programme and the Maastricht cancer registry were linked to evaluate the effect of breast cancer screening. Only the first primary breast tumour was included in the evaluation. RESULTS: The second peak of incidence after the prevalent screening round was 45% higher than the incidences before the start of the screening. Also, the decrease in incidence of large and node positive tumours was interrupted. Compared with national detection rates, the number of screen detected cancers was lower before 1995 and higher after that year. After 1997, incidence decreased again of all breast cancers, but also of large and node positive tumours. The incidence of node positive tumours showed large fluctuations, probably due to the introduction of the sentinel node procedure and immunohistochemistry. In 1999, incidence of large tumours and node positive tumours was 18% and 28%, respectively, lower than before the start of the screening. CONCLUSIONS: An increase in the background incidences and improved detection in the screening programme most likely explain this trend. The improved detection after 1995, and the lower than desirable decrease in large tumours, indicate that the screening performance was not optimal before 1996. The incidence of node positive tumours cannot be used any more as an indicator of the success of the screening programme because of detection bias.

Evaluation of the effect of breast cancer screening by record linkage with the cancer registry, The Netherlands.

OBJECTIVE: To evaluate the effect of a breast cancer screening programme by record linkage with the cancer registry. SETTING: Breast cancer screening programme in mid- and southern Limburg, the Netherlands. METHODS: The data files of the breast cancer screening programme and the Maastricht Cancer Registry were linked in order to evaluate the effect of breast cancer screening. Only the first primary breast tumour was included in the evaluation. RESULTS: From 1990 until 1995 90 001 women participated in the first round of the breast cancer screening programme and 64 637 in subsequent rounds. After the introduction of screening the annual number of breast cancer diagnoses increased by almost 50%. The incidence decreased to previous levels after completion of the first screening round. Record linkage detected 219 interval cancers (within two and a half years of a screening), a proportionate incidence of 31% in the first year and 60% in the second year of the two-year interval between screenings. The incidence of node positive breast cancer was 1% lower in 1994 and 15% lower in 1995 than the incidence in the period 1987-90. CONCLUSIONS: Evaluation of the effect of breast cancer screening in the Netherlands can be performed using routinely available cancer registry data. The results of this evaluation seem promising, but further studies are necessary to find ways to reduce the incidence of interval cancer.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years.

BACKGROUND: Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer. PATIENTS AND METHODS: A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses. RESULTS: Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%). CONCLUSION: Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.

Age-specific differences in the diagnostics and treatment of cancer patients aged 50 years and older in the province of Limburg, The Netherlands.

BACKGROUND: In the Netherlands, 45% of all cancer cases occur in men and women aged 70 years and older. Since the population is ageing and cancer incidence rises with age, the number of new malignancies in the elderly is increasing. It has become apparent that there is a relationship between age at diagnosis and the treatment received. Therefore, age-specific variations in patterns of care for six common forms of cancer in the elderly, are examined. PATIENTS AND METHODS: Patients aged 50 years and older, diagnosed in the period 1988-1992 in Middle and South Limburg with breast, colorectal, lung, ovarian, head and neck cancer and non-Hodgkin lymphoma were included (n = 6911). Data were obtained from the population-based Regional Cancer Registry of the Comprehensive Cancer Centre Limburg. Age-specific differences in diagnostics and treatment were analysed using chi-square analysis (age categories: 50-59, 60-69, 70+). Logistic regression analyses were used to examine the extent to which age increased the chance of not being treated or of receiving less intensive treatment, while controlling for the stage of the disease and the sex of the patient. RESULTS: For all malignancies the stage was unknown in a larger proportion of the patients aged 70 years and older than in the younger patient groups. Compared to their younger counterparts, the diagnosis of elderly breast, colorectal and lung cancer patients was more often based solely on clinical grounds. In the total study population, 16% were not treated. Per age category 50-59 years, 60-69 years and 70+ these percentages were 7%, 12% and 22%, respectively, (P-trend = 0.001). For all malignancies the chance of not receiving treatment increased with increasing age. However, the size and nature of the differences varied with the localisation of the tumour. The proportion of untreated patients was particularly high in the patients with lung cancer and metastatic colorectal and ovarian cancer, and there was an increase with increasing age (P-trend = 0.001). The vast majority of patients with NHL, breast, head and neck and non-metastatic colorectal cancer received treatment, 90%, 94%, 91%, and 99%, respectively. However, elderly patients less often received a combination of treatment modalities. CONCLUSIONS: The diagnostics and choice of treatment for several common types of cancer were dependent on age. This study could not take into account the major problem of co-morbidity which can be a reason to choose for lesser therapy in the elderly. More research is necessary to determine which factors determine the diagnostics and choice of treatment and whether these factors differ between young and elderly patients.

Cancer in the very elderly Dutch population.

BACKGROUND: Cancer incidence and mortality rates rarely are studied in people age > 85 years. Usually, patients ages 65 years, 75 years, and 85 years of age are combined into 1 group because of small numbers. The number of people age > or = 85 years in the Netherlands increased from 99,000 in 1976 to 203,000 in 1995 (an increase of 105%). The growth of the total population in this period was only 13%. This study addressed cancer incidence and mortality rates among the very elderly in the Netherlands. METHODS: Cancer mortality data (1976-1995) and population data were obtained from Statistics Netherlands, whereas cancer incidence data (1989-1995) were provided by the Netherlands Cancer Registry. Cancer incidence and mortality rates were calculated and trends in cancer mortality were studied. RESULTS: Total cancer incidence rates were highest in the age group 85-94 years, in men and women (3466/100,000 person-years and 1604/100,000 person-years, respectively). Prostate carcinoma was the most frequent cancer in men ages 85-94 years, followed by colorectal carcinoma. In women ages 85-94 years, colorectal carcinoma was most frequent, closely followed by breast carcinoma. In the 95+ years age group squamous cell skin carcinoma was the most frequent cancer in both men and women, followed by prostate carcinoma in men and breast carcinoma in women. Cancer mortality rates increased with increasing age to nearly 3700/100,000 person-years in men age 95+ years and 2500/100,000 person-years in women age 95+ years. In men, lung carcinoma was the most frequent cancer-related cause of death in patients age < or = 85 years, whereas in older men this applied to prostate carcinoma. In women, breast carcinoma was the most frequent cancer-related cause of death in all age groups > 55 years. Cancer as a cause of death became less prominent with increasing age. Over the period 1991-1995, 42% of deaths in men ages 55-64 years were attributed to cancer versus 52% of deaths in women (total population); these proportions in the 95+ years age group were 11% and 7%, respectively. CONCLUSIONS: Peak incidence rates of major cancers were found in the very elderly population in the Netherlands. Different trends in age specific mortality rates of individual cancer sites were found, with stable rates in the middle age groups and increasing rates in the oldest age groups. This may reflect a real increase caused for instance by changes in mortality from other diseases and/or an artifactual increase caused by increased cancer detection rates in the (very) elderly.