Long-term survival, prevalence, and cure of cancer: a population-based estimation for 818 902 Italian patients and 26 cancer types.

BACKGROUND: Persons living after a cancer diagnosis represent 4% of the whole population in high-income countries. The aim of the study was to provide estimates of indicators of long-term survival and cure for 26 cancer types, presently lacking. PATIENTS AND METHODS: Data on 818 902 Italian cancer patients diagnosed at age 15-74 years in 1985-2005 were included. Proportions of patients with the same death rates of the general population (cure fractions) and those of prevalent patients who were not at risk of dying as a result of cancer (cure prevalence) were calculated, using validated mixture cure models, by cancer type, sex, and age group. We also estimated complete prevalence, conditional relative survival (CRS), time to reach 5- and 10-year CRS >95%, and proportion of patients living longer than those thresholds. RESULTS: The cure fractions ranged from >90% for patients aged <45 years with thyroid and testis cancers to <10% for liver and pancreatic cancers of all ages. Five- or 10-year CRS >95% were both reached in <10 years by patients with cancers of the stomach, colon-rectum, pancreas, corpus and cervix uteri, brain, and Hodgkin lymphoma. For breast cancer patients, 5- and 10-year CRSs reached >95% after 19 and 25 years, respectively, and in 15 and 18 years for prostate cancer patients. Five-year CRS remained <95% for >25 years after cancer diagnosis in patients with liver and larynx cancers, non-Hodgkin lymphoma, myeloma, and leukaemia. Overall, the cure prevalence was 67% for men and 77% for women. Therefore, 21% of male and 31% of female patients had already reached 5-year CRS >95%, whereas 18% and 25% had reached 10-year CRS >95%. CONCLUSIONS: A quarter of Italian cancer patients can be considered cured. This observation has a high potential impact on health planning, clinical practice, and patients' perspective.

Diet and hip fractures among elderly Europeans in the EPIC cohort.

BACKGROUND/OBJECTIVES: Evidence on the role of diet during adulthood and beyond on fracture occurrence is limited. We investigated diet and hip fracture incidence in a population of elderly Europeans, participants in the European Prospective Investigation into Cancer and nutrition study. SUBJECTS/METHODS: 29, 122 volunteers (10,538 men, 18,584 women) aged 60 years and above (mean age: 64.3) from five countries were followed up for a median of 8 years and 275 incident hip fractures (222 women and 53 men) were recorded. Diet was assessed at baseline through validated dietary questionnaires. Data were analyzed through Cox proportional-hazards regression with adjustment for potential confounders. RESULTS: No food group or nutrient was significantly associated with hip fracture occurrence. There were suggestive inverse associations, however, with vegetable consumption (hazard ratio (HR) per increasing sex-specific quintile: 0.93, 95% confidence interval (CI): 0.85-1.01), fish consumption (HR per increasing sex-specific quintile: 0.93, 95% CI: 0.85-1.02) and polyunsaturated lipid intake (HR per increasing sex-specific quintile: 0.92, 95% CI: 0.82-1.02), whereas saturated lipid intake was positively associated with hip fracture risk (HR per increasing sex-specific quintile: 1.13, 95% CI: 0.99-1.29). Consumption of dairy products did not appear to influence the risk (HR per increasing sex-specific quintile: 1.02, 95% CI: 0.93-1.12). CONCLUSIONS: In a prospective study of the elderly, diet, including consumption of dairy products, alcohol and vitamin D, did not appear to play a major role in hip fracture incidence. There is however, weak and statistically non-significant evidence that vegetable and fish consumption and intake of polyunsaturated lipids may have a beneficial, whereas saturated lipid intake a detrimental effect.

Intake of total, animal and plant proteins, and their food sources in 10 countries in the European Prospective Investigation into Cancer and Nutrition.

OBJECTIVE: To describe dietary protein intakes and their food sources among 27 redefined centres in 10 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). METHODS: Between 1995 and 2000, 36 034 persons, aged between 35 and 74 years, were administered a standardized 24-h dietary recall (24-HDR) using a computerized interview software programme (EPIC-SOFT). Intakes (g/day) of total, animal and plant proteins were estimated using the standardized EPIC Nutrient Database (ENDB). Mean intakes were adjusted for age, and weighted by season and day of recall. RESULTS: Mean total and animal protein intakes were highest in the Spanish centres among men, and in the Spanish and French centres among women; the lowest mean intakes were observed in the UK health-conscious group, in Greek men and women, and in women in Potsdam. Intake of plant protein was highest among the UK health-conscious group, followed by some of the Italian centres and Murcia, whereas Sweden and Potsdam had the lowest intake. Cereals contributed to the highest proportion of plant protein in all centres. The combined intake of legumes, vegetables and fruit contributed to a greater proportion of plant protein in the southern than in the northern centres. Total meat intake (with some heterogeneity across subtypes of meat) was, with few exceptions, the most important contributor to animal protein in all centres, followed by dairy and fish products. CONCLUSIONS: This study shows that intake of protein, especially of animal origin, differs across the 10 European countries, and also shows some differences in food sources of protein across Europe.

Menopause hormone replacement therapy and cancer risk: an Italian record linkage investigation.

BACKGROUND: The effects of persistence with hormone replacement therapy (HRT) on the risk of hospitalization for cancer and of the route of HRT administration on the risk of breast and colorectal cancer were explored in a large cohort study. PATIENTS AND METHODS: The 73 505 women residing in Lombardia (Italy), aged 45-75 years, who received at least one HRT prescription during 1998-2000 were followed until 2005. Among these, 3687 experienced cancer hospitalization. Proportional hazards model was fitted to estimate the association between cumulative HRT persistence and cancer risk. RESULTS: Compared with women who took HRT for <6 months, those exposed for >2 years showed hazard ratios (HR) of 0.78 (95% confidence interval 0.68-0.92) for colorectal cancer and 1.34 (1.13-1.58) for breast cancer. HR for breast cancer associated with long-term use of transdermal and oral HRT were, respectively, 1.27 (1.07-1.51) and 2.14 (1.43-3.21). CONCLUSIONS: Evidence that long-term use of HRT is associated with increased risk of breast cancer and decreased risk of colorectal cancer is supplied from this study from a southern European population. Our findings indicate that transdermal therapy might have lower effect than oral therapy in increasing breast cancer risk.

The EpiLink record linkage software: presentation and results of linkage test on cancer registry files.

OBJECTIVES: Record linkage, the process of bringing together separately compiled but related records from different databases, is essential in many areas of biomedical research. We developed a record linkage program (EpiLink), which employs a simple mathematical approach. We describe the program and present results obtained testing it in a linkage task. METHODS: EpiLink was designed to be flexible with user-friendly settings to tailor linkage and operating parameters to specific linkage tasks, and employ deterministic, probabilistic or sequential deterministic-probabilistic linkage strategies as required. The user can also standardize data format, examine linkage results and accept or discard them. We used EpiLink to link a subset of cases of the Lombardy Cancer Registry (20,724 records) with the Social Security file of the population (1,021,846 records) covered by the registry. The linkage strategy was deterministic, followed by several probabilistic linkage steps. RESULTS: Manual inspection of the results showed that EpiLink achieved 98.8% specificity and 96.5% sensitivity. CONCLUSIONS: EpiLink is a practical and accurate means of linking records from different databases that can be used by non-statisticians and is efficient in terms of human and financial resources.

Prognostic value of morphology and hormone receptor status in breast cancer - a population-based study.

We analysed the 5-year relative survival among 4473 breast cancer cases diagnosed in 1990-1992 from cancer registries in Estonia, France, Italy, Spain, the Netherlands and the UK. Among eight categories based on ICD-O codes (infiltrating ductal carcinoma, lobular plus mixed carcinoma, comedocarcinoma, 'special types', medullary carcinoma, not otherwise specified (NOS) carcinoma, other carcinoma and cancer without microscopic confirmation), the 5-year relative survival ranged from 66% (95% CI 61-71) for NOS carcinoma to 95% (95% CI 90-100) for special types (tubular, apocrine, cribriform, papillary, mucinous and signet ring cell); 27% (95% CI 18-36) for cases without microscopic confirmation. Differences in 5-year relative survival by tumor morphology and hormone receptor status were modelled using a multiple regression approach based on generalised linear models. Morphology and hormone receptor status were confirmed as significant survival predictors in this population-based study, even after adjusting for age and stage at diagnosis.

Colon cancer prevalence and estimation of differing care needs of colon cancer patients.

BACKGROUND: Cancer prevalence-the proportion of people in a population with a diagnosis of cancer-includes groups with widely differing cancer care needs. We estimated the proportions of the prevalent colon cancer cases requiring initial care, terminal care and follow-up. PATIENTS AND METHODS: Prevalence by year since diagnosis was estimated from incidence and vital status data on 243,471 colon cancer cases collected by EUROPREVAL from 36 European population-based cancer registries. The proportions of cured and fatal cases were estimated by applying 'cure' survival models to the dataset. The proportion of recurrence-free cases was estimated by analysis of a representative sample of 278 colon cancer patients from the Lombardy Cancer Registry (LCR), northern Italy. RESULTS: The proportions of total prevalence requiring initial care was estimated at 12% in the LCR and 10% in Italy and Europe. Recurrence-free patients formed 89% of the total prevalence in the LCR and 91% in Italy and Europe. Eleven per cent (LCR) and 9% (Italy, Europe) of the total prevalence had recurred and consisted of patients in the terminal phase of their illness. CONCLUSIONS: In 1992, 660,000 people were living with a diagnosis of colon cancer in Europe. We have estimated the proportions of this prevalence requiring particular types health care in the years following diagnosis, providing data useful for planning the allocation of health-care resources.

Comparability issues of survival data.

This study examines the level of homogeneity in cancer registration and follow up techniques adopted by each registry, in order to ensure a correct evaluation of the data and of the geographical differences observed within Italy. A quality check was performed on the registration techniques, assuring that they met the international standards and yielded correct data, and on follow up methods. Difficulties concerning the assessment of certain tumours emerged from international debates. Thus, registries were requested to fill in a questionnaire to thoroughly examine differences in the management of tumour cases with difficult biological and clinical assessment (e.g. in situ and urinary bladder tumours). Some discrepancies in registration methods were observed. The most significant problems concern urinary bladder tumours, especially in coding procedures of in situ and uncertain behaviour tumours and the proportion of short-term survivors proportions for some geographical areas. Good quality and comparability indices were generally observed (microscopic verification, follow up management). In conclusions, quality standards in cancer registration appear good and allow for a correct geographical comparability. Some important problems regard only a small number of cancer sites (namely urinary bladder), whose results should be examined with caution.

Characteristics of terminal cancer patients who committed suicide during a home palliative care program.

Cancer patients may commit suicide at any stage of the disease and many risk factors of suicide have been described in the literature. To identify the possible vulnerability factors of suicide in five terminal cancer patients who committed suicide while they were cared for at home by well-trained palliative care teams, a psychological autopsy study was carried out by reviewing their medical records; their report of symptoms at the time of care; and with the caregivers', doctors', and nurses' recollection of events by means of a structured interview prepared ad hoc. We collected data regarding the physical, emotional, and social suffering of the patients, their personality profile, and their feelings with respect to the illness and disability. The interviews lasted for a mean of two hours and were performed from 2-8 years after the suicide events by the social worker at the Rehabilitation and Palliative Care Division. The interviews took place between June 1996 and January 1998. All the patients showed great concern about the lack of autonomy and independence, refused dependence on others and had fear/worry of losing their autonomy. Four patients presented functional and physical impairments, uncontrolled pain, awareness of being in the terminal stage, and mild to moderate depression. They had a feeling of hopelessness consequent to their clinical conditions, fear of suffering, and feeling of being a burden on others. They had a strong character and managerial professions. They had isolated themselves from others and they had previously talked about suicide. Before committing suicide, three patients had adverse physical/emotional consequences to the oncological treatments-they showed aggressiveness towards their family and one towards the home care physician. Multiple vulnerability factors were present simultaneously in all patients. However, the loss of, and the fear of losing, autonomy and their independence and of being a burden on others were the most relevant. The identification of a cancer patient at risk of committing suicide forms the first step for the prevention of and the setting up of adequate psychosocial rehabilitation of these patients whenever possible.