Using population-based data to evaluate the impact of adherence to endocrine therapy on survival in breast cancer through the web-application BreCanSurvPred.

We show how the use and interpretation of population-based cancer survival indicators can help oncologists talk with breast cancer (BC) patients about the relationship between their prognosis and their adherence to endocrine therapy (ET). The study population comprised a population-based cohort of estrogen receptor positive BC patients (N = 1268) diagnosed in Girona and Tarragona (Northeastern Spain) and classified according to HER2 status (+ / -), stage at diagnosis (I/II/III) and five-year cumulative adherence rate (adherent > 80%; non-adherent ≤ 80%). Cox regression analysis was performed to identify significant prognostic factors for overall survival, whereas relative survival (RS) was used to estimate the crude probability of death due to BC (PBC). Stage and adherence to ET were the significant factors for predicting all-cause mortality. Compared to stage I, risk of death increased in stage II (hazard ratio [HR] 2.24, 95% confidence interval [CI]: 1.51-3.30) and stage III (HR 5.11, 95% CI 3.46-7.51), and it decreased with adherence to ET (HR 0.57, 95% CI 0.41-0.59). PBC differences were higher in non-adherent patients compared to adherent ones and increased across stages: stage I: 6.61% (95% CI 0.05-13.20); stage II: 9.77% (95% CI 0.59-19.01), and stage III: 22.31% (95% CI 6.34-38.45). The age-adjusted survival curves derived from this modeling were implemented in the web application BreCanSurvPred ( https://pdocomputation.snpstats.net/BreCanSurvPred ). Web applications like BreCanSurvPred can help oncologists discuss the consequences of non-adherence to prescribed ET with patients.

Impact of non-adherence to radiotherapy on 1-year survival in cancer patients in Catalonia, Spain.

BACKGROUND: This study aims to assess the effects of non-adherence to external beam radiation therapy in cancer patients receiving treatment with a curative. METHODS: This retrospective cohort study collected health records data for all cancer patients treated with external beam radiotherapy with curative intent in 2016 in Catalonia, Spain. Adherence was defined as having received at least 90% of the total dose prescribed. A logistic regression model was used to assess factors related to non-adherence, and its association with one-year survival was evaluated using Cox regression. RESULTS: The final sample included 8721 patients (mean age 63.6 years): breast cancer was the most common tumour site (38.1%), followed by prostate and colon/rectum. Treatment interruptions prolonged the total duration of therapy in 70.7% of the patients, and 1.0% were non-adherent. Non-adherence was associated with advanced age, female gender, and some localization of primary tumour (head and neck, urinary bladder, and haematological cancers). The risk of death in non-adherent patients was higher than in adherent patients (hazard ratio [HR] 1.63, 95% confidence interval 0.97-2.74), after adjusting for the potential confounding effect of age, gender, tumour site and comorbidity. CONCLUSION: Non-adherence to radiotherapy, as measured by the received dose, is very low in our setting, and it may have an impact on one-year survival.

Exceso de mortalidad en las pacientes con cáncer de mama en estadios precoces en Tarragona y Gerona (España) / Excess mortality among breast cancer patients in early stages in Tarragona and Gerona (Spain)

OBJETIVO: Analizar la supervivencia poblacional del cáncer de mama (CM) en estadios precoces, estimando la tendencia temporal del exceso de mortalidad (EM) a largo plazo en periodos anuales y quinquenales, y determinando, si es posible, una proporción de pacientes que puedan considerarse curadas. MÉTODO: Se incluyó la cohorte de pacientes diagnosticadas de CM en estadios I y II antes de los 60 años de edad en Gerona y Tarragona (N = 2453). Se calcularon la supervivencia observada (SO) y la supervivencia relativa (SR) al CM hasta los 20 años de seguimiento. Para valorar el EM se estimó la SR a intervalos anuales (SRI) y quinquenales (SR5). Los resultados se presentan por grupos de edad (≤49 y 50-59), estadio (I/II) y periodo de diagnóstico (1985-1994 y 1995-2004). RESULTADOS: En el estadio I, la SO y la SR fueron mayores en 1995-2004 que en 1985-1994: 3,5% a los 15 años de seguimiento y 4,5% a los 20 años. La SO superó el 80% en el estadio I y se mantuvo inferior al 70% en el estadio II. Sin embargo, el EM a largo plazo no desapareció (SRI <1) independientemente del grupo de edad, el estadio y el periodo de diagnóstico. A los 15 años de seguimiento, el EM a 5 años osciló entre el 1-5% en el estadio I (SR5 ≥0,95) y el 5-10% en el estadio II. CONCLUSIONES: En nuestra cohorte, a los 15 años de seguimiento se detectó que el EM anual no desapareció y el quinquenal fue del 1-10%. Por ello, no se pudo determinar una proporción de curación del CM durante el periodo de estudio

OBJECTIVE: To analyze the population-based survival of breast cancer (CM) diagnosed in early stages estimating the time trends of excess mortality (EM) in the long term in annual and five-year time intervals, and to determine, if possible, a proportion of patients who can be considered cured. METHOD: We included women diagnosed with BC under the age of 60 years in stages I and II in Girona and Tarragona (N = 2453). The observed (OS) and relative survival (RS) were calculated up to 20 years of follow-up. RS was also estimated at annual (RSI) and in five-year intervals (RS5) to graphically assess the EM. The results are presented by age groups (≤49 and 50-59), stage (I/II) and diagnostic period (1985-1994 and 1995-2004). RESULTS: In stage I, OS and RS were higher during 1995-2004 compared to 1985-1994: 3.5% at 15 years of follow-up and 4.5% at 20-years of follow-up. In 1995-2004, the OS surpassed 80% in stage I patients whereas in stage II it remained below 70%. During 1995-2004, the long-term EM did not level off towards 0 (RSI <1) independently of age group, stage and period of diagnosis. After 15 years of follow-up, the 5-year EM oscillated between 1 and 5% in stage I (RS5 ≥0.95) and between 5 and 10% in stage II. CONCLUSIONS: In our cohort, after 15 years of follow-up, it was detected that the annual EM did not disappear and the five-year EM remained between 1 and 10%. Therefore, it was not possible to determine a cure rate of BC during the study period

Outcomes and cost of lung cancer patients treated surgically or medically in Catalunya: cost-benefit implications for lung cancer screening programs.

Lung cancer screening programs with computed tomography of the chest reduce mortality by more than 20%. Yet, they have not been implemented widely because of logistic and cost implications. Here, we sought to: (1) use real-life data to compare the outcomes and cost of lung cancer patients with treated medically or surgically in our region and (2) from this data, estimate the cost-benefit ratio of a lung cancer screening program (CRIBAR) soon to be deployed in our region (Catalunya, Spain). We accessed the Catalan Health Surveillance System (CHSS) and analysed data of all patients with a first diagnosis of lung cancer between 1 January 2014 and 31 December 2016. Analysis was carried forward until 30 months (t = 30) after lung cancer diagnosis. Main results showed that: (1) surgically treated lung cancer patients have better survival and return earlier to regular home activities, use less healthcare related resources and cost less tax-payer money and (2) depending on incidence of lung cancer identified and treated in the program (1-2%), the return on investment for CRIBAR is expected to break even at 3-6 years, respectively, after its launch. Surgical treatment of lung cancer is cheaper and offers better outcomes. CRIBAR is estimated to be cost-effective soon after launch.

[Excess mortality among breast cancer patients in early stages in Tarragona and Gerona (Spain)]. / Exceso de mortalidad en las pacientes con cáncer de mama en estadios precoces en Tarragona y Gerona (España).

OBJECTIVE: To analyze the population-based survival of breast cancer (CM) diagnosed in early stages estimating the time trends of excess mortality (EM) in the long term in annual and five-year time intervals, and to determine, if possible, a proportion of patients who can be considered cured. METHOD: We included women diagnosed with BC under the age of 60 years in stages I and II in Girona and Tarragona (N = 2453). The observed (OS) and relative survival (RS) were calculated up to 20 years of follow-up. RS was also estimated at annual (RSI) and in five-year intervals (RS5) to graphically assess the EM. The results are presented by age groups (≤49 and 50-59), stage (I/II) and diagnostic period (1985-1994 and 1995-2004). RESULTS: In stage I, OS and RS were higher during 1995-2004 compared to 1985-1994: 3.5% at 15 years of follow-up and 4.5% at 20-years of follow-up. In 1995-2004, the OS surpassed 80% in stage I patients whereas in stage II it remained below 70%. During 1995-2004, the long-term EM did not level off towards 0 (RSI <1) independently of age group, stage and period of diagnosis. After 15 years of follow-up, the 5-year EM oscillated between 1 and 5% in stage I (RS5 ≥0.95) and between 5 and 10% in stage II. CONCLUSIONS: In our cohort, after 15 years of follow-up, it was detected that the annual EM did not disappear and the five-year EM remained between 1 and 10%. Therefore, it was not possible to determine a cure rate of BC during the study period.

Summary statement on screening for prostate cancer in Europe.

The European Randomised Study of Screening for Prostate Cancer (ERSPC) showed that Prostate-Specific Antigen (PSA) based screening results in a significant prostate cancer mortality reduction. Although there are concerns on overdiagnosis and overtreatment, it has been shown that the benefits can outweigh the harms if screening is stopped in older ages to prevent overdiagnosis. A limited screening program (for example screening at ages 55-59 years), including active surveillance for men with low-risk tumors, can even be cost-saving, compared with testing in an opportunistic setting in the wrong ages, as currently in Europe. Further improvements are expected in the use of active surveillance and in discrimination between indolent and significant disease due to new biomarkers and magnetic resonance imaging. However, these future developments are no reason to postpone feasibility studies of high-quality PSA screening and reduce opportunistic testing at old ages.

Understanding variations in the use of hypofractionated radiotherapy and its specific indications for breast cancer: A mixed-methods study.

BACKGROUND AND PURPOSE: Radiation oncology guidelines favour hypofractionated whole-breast radiotherapy (HWBRT) over more conventional schemes in the conservative treatment of breast cancer, but its adoption still varies in clinical practice. This study assessed the patterns of HWBRT adoption in Catalonia (Spain). MATERIAL AND METHODS: We used a mixed-methods approach based on an explanatory sequential design, first collecting and analysing quantitative data on HWBRT use (>2.5Gy per fraction) in 11 public radiotherapy centres (2005-2015) and then performing 25 semi-structured interviews with all department heads and reference radiation oncologist/s. RESULTS: Of the 34,859 patients fulfiling the study criteria over the study period, just 12% were hypofractionated, reaching a percentage of 29% in 2015 (p<0.001). Our analysis showed a narrowing age gap between patients receiving conventional fractionation and hypofractionation in centres leading adoption. However, there were important differences in clinicians' interpretation of evidence (e.g. regarding the perceived risk of long-term toxicity) and selection of patients for specific indications, both within and between departments. CONCLUSIONS: Differences observed in the rate of adoption of HWBRT could not be tackled only using a rational, evidence-based approach. Factors related to the management of radiotherapy departments play a major role in the diffusion of therapeutic strategies.

Risk of Breast Cancer in Women with False-Positive Results according to Mammographic Features.

Purpose To assess the risk of breast cancer in women with false-positive screening results according to radiologic classification of mammographic features. Materials and Methods Review board approval was obtained, with waiver of informed consent. This retrospective cohort study included 521 200 women aged 50-69 years who underwent screening as part of the Spanish Breast Cancer Screening Program between 1994 and 2010 and who were observed until December 2012. Cox proportional hazards regression analysis was used to estimate the age-adjusted hazard ratio (HR) of breast cancer and the 95% confidence interval (CI) in women with false-positive mammograms as compared with women with negative mammograms. Separate models were adjusted for screen-detected and interval cancers and for screen-film and digital mammography. Time without a breast cancer diagnosis was plotted by using Kaplan-Meier curves. Results When compared with women with negative mammograms, the age-adjusted HR of cancer in women with false-positive results was 1.84 (95% CI: 1.73, 1.95; P < .001). The risk was higher in women who had calcifications, whether they were (HR, 2.73; 95% CI: 2.28, 3.28; P < .001) or were not (HR, 2.24; 95% CI: 2.02, 2.48; P < .001) associated with masses. Women in whom mammographic features showed changes in subsequent false-positive results were those who had the highest risk (HR, 9.13; 95% CI: 8.28, 10.07; P < .001). Conclusion Women with false-positive results had an increased risk of breast cancer, particularly women who had calcifications at mammography. Women who had more than one examination with false-positive findings and in whom the mammographic features changed over time had a highly increased risk of breast cancer. Previous mammographic features might yield useful information for further risk-prediction models and personalized follow-up screening protocols. (©) RSNA, 2016 Online supplemental material is available for this article.

Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.

BACKGROUND: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. METHODS: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts. RESULTS: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. CONCLUSION: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.

Contribution of changes in demography and in the risk factors to the predicted pattern of cancer mortality among Spanish women by 2022.

BACKGROUND: Changes in the burden of cancer mortality are expected to be observed among Spanish women. We predict those changes, in Spain, for breast cancer (BC), colorectal cancer (CRC), lung cancer (LC) and pancreatic cancer (PC) from 2013 to 2022. METHODS: Bayesian age-period-cohort modeling was used to perform projections of the cancer burden in 2013-2022, extrapolating the trend of cancer mortality data from 1998 to 2012. We assessed the time trends of the crude rates (CRs) during 1998-2012, and compared the number of cancer deaths between the periods 2008-2012 and 2018-2022 to assess the contribution of demographic changes and changes in the risk factors for cancer. RESULTS: During 1998-2012, CRs of cancer decreased for BC (0.3% per year) and increased for LC (4.7%), PC (2%) and CRC (0.7%). During 2013-2022, CRs might level off for CRC, whereas the time trends for the remaining cancers might continue at a similar pace. During 2018-2022, BC could be surpassed by CRC as the most frequent cause of cancer mortality among Spanish women, whereas LC could be the most common cause of cancer mortality among women aged 50-69 years (N/year=1960 for BC versus N/year=1981 for LC). Comparing 2018-2022 and 1998-2012, changes in the risk factors for cancer could contribute 37.93% and 18.36% to the burden of LC and PC, respectively, and demographic shifts - mainly due to ageing (19.27%) - will drive the burden of CRC. CONCLUSIONS: During 2018-2022, demographic changes (ageing) and changes in risk factors could have a different impact on the lifetime risk of cancer among Spanish women.

Narrowing the equity gap: the impact of organized versus opportunistic cancer screening in Catalonia (Spain).

OBJECTIVES: To assess the impact on equity of access of an organized breast cancer screening programme, compared with opportunistic breast and cervical cancer screening activities. METHODS: Two cross-sectional health interview surveys conducted in 1994 and 2006 in Catalonia (Spain), with 6382 and 7653 women participating in both surveys. The main outcome measures were having undergone regular mammography, and regular cytology. Age-standardized prevalence rates for both screening tests were computed using the direct method. The relative inequality index was computed to measure changes over time in inequality on screening utilization. RESULTS: Participation among women aged 50-69 has increased after the introduction of the organized breast screening programme; the greatest impact has been observed among those women with lower educational levels (from 17% in 1994 to 79% in 2006). Equity of access by education was particularly increased in the target group for breast cancer screening. CONCLUSION: This study indicates that an organized screening programme could improve participation and equity of access.

Lessons learnt from a population-based pilot programme for colorectal cancer screening in Catalonia (Spain).

STUDY OBJECTIVE: To assess the feasibility of a colorectal cancer population-based screening programme in Catalonia (Spain). DESIGN AND SETTING: A pilot colorectal cancer screening programme based on faecal occult blood (FOB) test was introduced in February 2000 in Hospitalet de Llobregat (Barcelona, Spain), a city of 239,000 inhabitants. PARTICIPANTS: All the residents from the selected area, aged 50-69 years old, were invited by mail to participate in the screening programme. Overall, 63,880 persons were invited to the first screening round and 66,534, to the second round. Colonoscopy was the first choice of procedure for the positive FOB test. RESULTS: The participation rate was 17.2% in the first screening round and 22.3% in the second round. The overall rate of positive FOBT was 3.4% in the first round and 0.8% in the second round. In the first round, the prevalence of screen-detected cancer was 2.1 per 1000 screened people, 7.2 for high-risk adenomas (HRA) and 11.3 for neoplasm (cancer and/or adenoma). The positive predictive value (PPV) was 6.2% for cancer, 21.2% for HRA and 33.3% for advanced neoplasm. In the second round, the prevalence of screen-detected cancer was 0.9 per 1000 people screened, 2.8 per 1000 for HRA and 4.2 per 1000 for neoplasm. The PPV was 10.6% for cancer, 34.1% for HRA and 50.4% for any neoplasm. CONCLUSIONS: Regardless of the moderate participation rate, population-based colorectal cancer screening would be feasible in Catalonia, with good results in terms of prevalence of screen-detected neoplasms.

Cáncer. Evaluación de los objetivos del Plan de Salud de Cataluña para el año 2000 / Cancer. Evaluation of the objectives of the Health Plan for Catalonia for the year 2000

Fundamento y objetivo: Evaluar el grado de consecución de los objetivos de salud en el ámbito del cáncer formulados para Cataluña en el año 2000. Población y método: A partir de la información recogida en el Registro de Mortalidad de Cataluña, el Registro de Cáncer de Tarragona, el Registro de Cáncer de Gerona y encuestas de salud de Cataluña se han evaluado los objetivos de salud para el año 2000 relacionados con el cáncer. Resultado:La mortalidad entre varones de entre 35 y 64 años en 1990, en comparación con 1998, descendió de una tasa ajustada según la edad de 232,3 a 219,1 con una disminución del 5,7%. En mujeres fue de 123,8 en el año 1990 y de 108,2 en 1998, con un descenso del 12,6%; en los años 1990-1998 se advierte un descenso significativo de tumores de mama y de cuello uterino en mujeres y de pulmón en los varones. Conclusión: La evaluación realizada permite afirmar que se han alcanzado los objetivos referidos a la mortalidad por debajo de 65 años en cáncer de mama y cuello uterino en las mujeres, y de cáncer de pulmón en los varones (AU)

Background and objective: To evaluate the degree of achievement of the health objectives related to cancer in the framework of the Catalonian Health Plan 2000. Subjects and method: We have used the information from the Registro de Mortalidad de Cataluña, Registro de Cáncer de Tarragona, Registro de Cáncer de Gerona and health surveys from Catalonia. Results: Men mortality ages 35-64 diminished significantly between 1990 and 1998. The age adjusted mortality rate change was 232.3 to 219.1 (5.7%). In women, it decreased from 123.8 in 1990 to 108.2 in 1998 (12.6%). This period exhibits a significant downward trend of breast and uterine cervical neoplasms in women and lung tumours in men. Conclusion: Our evaluation allows to strengthen that the objectives related to mortality under 65 in breast and uterine cervical cancer in women and lung cancer in men have been achieved (AU)