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.

Effectiveness of organised versus opportunistic mammography screening.

BACKGROUND: Detailed comparison of effectiveness between organised and opportunistic mammography screening operating in the same country has seldom been carried out. PATIENTS AND METHODS: Prognostic indicators, as defined in the European Guidelines, were used to evaluate screening effectiveness in Switzerland. Matching of screening programmes' records with population-based cancer registries enabled to compare indicators of effectiveness by screening and detection modality (organised versus opportunistic screening, unscreened, interval cancers). Comparisons of prognostic profile were also drawn with two Swiss regions uncovered by service screening of low and high prevalence of opportunistic screening, respectively. RESULTS: Opportunistic and organised screening yielded overall little difference in prognostic profile. Both screening types led to substantial stage shifting. Breast cancer prognostic indicators were systematically more favourable in Swiss regions covered by a programme. In regions without a screening programme, the higher the prevalence of opportunistic screening, the better was the prognostic profile. CONCLUSIONS: Organised screening appeared as effective as opportunistic screening. Mammography screening has strongly influenced the stage distribution of breast cancer in Switzerland, and a favourable impact on mortality is anticipated. Extension of organised mammography screening to the whole of Switzerland can be expected to further improve breast cancer prognosis in a cost-effective way.

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.

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.

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.

Increased risk of acute myeloid leukaemia after treatment for breast cancer.

This study evaluates the risk of acute myeloid leukaemia (AML) in patients treated for breast cancer. We included all 6360 breast cancer patients that were recorded at the Geneva Cancer Registry between 1970 and 1999. Patients were followed for AML occurrence until December 2000. We calculated standardized incidence ratios of AML and identified factors modifying the risk of AML by multivariate Cox analysis. Twelve (0.2%) patients developed AML. In general, patients treated for breast cancer had a 3.5-fold (95% confidence interval (CI): 1.8-6.0) increased risk of developing AML compared with the general population. In particular, patients who were older than 70 years at breast cancer diagnosis and those treated with radiotherapy (with or without chemotherapy) had a significantly increased risk of developing AML. This population-based study confirms that radiotherapy increases the risk of AML. Due to the relatively low number of women treated with chemotherapy without radiotherapy and due to the infrequency of the disease, the question of whether chemotherapy alone increases this risk of AML cannot yet be answered.

Prevention of deep venous thrombosis in orthopedic surgery: effects of defibrotide.

The effectiveness of defibrotide was compared with that of calcium heparin and acetylsalicylic acid (ASA) in the prevention of deep venous thrombosis (DVT) resulting from orthopedic surgery. Sixty-three patients scheduled for elective or traumatological surgery, for the most part involving the hip joint, were recruited. The patients were randomly assigned to one of the following treatment groups: defibrotide (400 mg twice daily), administered intramuscularly (n = 19); calcium heparin (5,000 IU thrice daily), administered subcutaneously (n = 25); and ASA (100 mg on alternate days), administered orally (n = 19). Administration of the drug was started one day before surgery and continued until the seventh day after surgery. Each patient was monitored daily by means of the fibrinogen uptake test. The incidence of increased uptake did not differ significantly in the three groups (defibrotide, ten out of 19; calcium heparin, ten out of 25; ASA, seven out of 19). Conversely, a trend in favor of defibrotide was noted in cases of symptomatic DVT (defibrotide, one out of 19; calcium heparin, two out of 25; ASA, four out of 19) and pulmonary embolism (defibrotide, no cases; calcium heparin, one case; ASA two cases). On the strength of these findings, defibrotide therapy qualifies as a valid alternative to conventional DVT prophylaxis in orthopedic surgery.

The impact of coding process on observed cancer mortality trends in Switzerland.

Official cancer mortality in Switzerland decreased by about 16% over the 9-year period 1990-1998 and this trend has often been used to suggest that secondary prevention by screening for breast cancer could be useless. However, the clear downshift observed between 1994 and 1995 for some cancers, such as female breast and prostate, and the simultaneous change in ICD classification used by the Federal Office for Statistics in 1995 (ICD-8 to ICD-10) could be related, suggesting an impact of coding process on the observed trend. For every death occurred between 1980 and 1999, the death certificates have been retrieved, the cause of death has been recoded and site-specific mortality rates have been calculated again for each year during this period. As suggested, the trend appears to be overestimated: in order to be comparable with current rates, the mortality observed before 1995 should be lowered by about 7% for men and 5% for women. The error may be partially due to attributing the cause of death to co-morbidity factors not normally (and nowadays) defined as the underlying cause. Logically, the impact of such a miscoding is more important among older people and for cancer sites with long survival. For instance, the correction should be around 15% for female breast, 12% for prostate and up to 40% for testicular cancer.

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

Surveys on mammography frequency in Geneva.

Two surveys were conducted in Geneva, in 1991 and 1995, to assess the coverage of mammography before the introduction of a breast cancer screening programme. Women who attended for mammographies did so at their own request, or were referred by doctors (more by gynaecologists than general practitioners). In 1995, the total female population was around 200,000, of which the target population for screening (age group 50 to 69) was 46,000 persons. The total number of mammographies observed increased by 23%, with a higher increase for "routine" mammographies (+35%). However, these figures hide certain trends, with a high proportion of educated women performing regular breast investigations. The two year coverage rate for mammography among the 50 to 69 age group is estimated at 38%, which means that about 20,000 women within this target population in Geneva still escape screening.

Recent trends in incidence of cervical cancer in several regions of south-western Europe.

In recent decades, most Western countries have experienced a decline in the incidence of invasive cervical cancer. More recently, a reversal of this trend has been noted in young women, especially in anglo-saxon countries. These trends have been attributed to the beneficial results of cervical cancer screening on the one hand, to the widespread increase of high risk sexual behaviors on the other. Recent trends in Latin European countries have not previously been studied. Time trends of incidence data from 10 regions of South-Western Europe (Geneva, Vaud, Calvados, Doubs, Bas-Rhin, Isère, Ragusa, Varese, Zaragoza and Navarra) were analysed by means of log-linear models. The data were provided for various periods of time between 1970 and 1990. The mean incidence rate varies threefold between Navarra where rates are the lowest to Calvados where they are the highest. The overall decrease rate is of the order of -3% per year but rate changes differ by age group. The reduction seems to concern mostly middle aged women. A definite trend could not be determined among younger women due to low case numbers. Thus, the hypothesis of a rising incidence in young women cannot be confirmed at this time.

[Prognostic factors in survival after cancer: epidemiological model]. / Facteurs pronostiques de survie après cancer: le modèle épidémiologique.

Quality of care assessment is one of the principal issues considered when studying the survival of cancer patients. Survival rates based on hospital series ("clinical survival") essentially aim at evaluating the impact of therapy, taking into account the stage of the tumor. When, on the other hand, survival rates refer to a demographically defined population ("epidemiologic survival") they depend not only on quality of therapy but also on differentials in access to health services which in turn condition partly the stage at time of diagnosis and therapy selection. Since these patterns of access can vary according to socio-cultural characteristics, the epidemiologist is tempted to focus the prognostic analysis of survival on these characteristics. In a cancer registry setting, clinical indicators (stage of the lesions, type of health care institution and therapy) must not be neglected. Rather, these must be analyzed both as co-factors of survival and as phenomena to be explained in their own right. Issues relating to this topic are discussed using the example of breast cancer in Geneva.

Grosse Kempf locked intramedullary nailing in the treatment of diaphyseal fractures of the lower limb. A case review.

After a review of the cases (57 between 1981 and 1988) the authors present the results of treatment of diaphyseal fractures of the lower limb by Grosse Kempf locked intramedullary nailing. The advantages and the effectiveness of the method are emphasized; the method has obtained brilliant results in complex and "boundary" fractures of the femur and tibia; furthermore, some suggestions are made with regard to surgery.

Long-term results of surgery for the treatment of sustentacular fractures of the calcaneus.

The authors reviewed 55 sustentacular fractures of the calcaneus treated between 1979 and 1988. Our therapeutic objective was that of reconstructing the subtalar joint. This purpose was always achieved in a short amount of time; nonetheless, there were some cases of secondary unreduction in time (13% poor results in 4.5 years). Essex-Lopresti closed surgery was used to treat fractures with limited damage of the joint surface; open osteosynthesis with associated grafting was used to treat fractures with more than one fragment.

Long-term results of intersomatic lumbar fusion with a posterior approach.

The authors discuss the advantages of using intersomatic lumbar fusion with a posterior approach for the treatment of low back pain due to discopathy or grade I spondylolisthesis. After a description of the surgical method used, the long-term results obtained in 16 cases are presented. The clinical and radiographic results are good in cases of discopathy, while in those of spondylolisthesis there is disagreement between the clinical evaluation, which is generally satisfactory, and the radiographic evaluation which is not quite as satisfactory.