Changes in chemotherapy usage and outcome of early breast cancer patients in the last decade.

BACKGROUND: During the last decade, neoadjuvant chemotherapy (NACT) of early breast cancer (EBC) evolved from a therapy intended to enable operability to a standard treatment option aiming for increasing cure rates equivalent to adjuvant chemotherapy (ACT). In parallel, improvements in the quality control of breast cancer care have been established in specialized breast care units. PATIENTS AND METHODS: This study analyzed chemotherapy usage in patients with EBC treated at the Heidelberg University Breast Unit between January 2003 and December 2014. RESULTS: Overall, 5703 patients were included in the analysis of whom 2222 (39 %) received chemotherapy, 817 (37 %) as NACT, and 1405 (63 %) as ACT. The chemotherapy usage declined from 48 % in 2003 to 34 % in 2014 of the cohort. Further, the proportion of NACT raised from 42 to 65 % irrespective of tumor subtype. In addition, frequency of pathologic complete response (pCR) defined as no tumor residues in breast and axilla (ypT0 ypN0) at surgery following NACT increased from 12 % in 2003 to 35 % in 2014. The greatest effect was observed in HER2+ breast cancer with an increase in patients achieving pCR from 24 to 68 %. CONCLUSIONS: The results mirror the refined indication for chemotherapy in EBC and its preferred usage as NACT in Germany. The increase in pCR rate over time suggests improvement in outcome accomplished by a multidisciplinary decision-making process and stringent measures for quality control.

Testicular cancer in Europe and the USA: survival still rising among older patients.

BACKGROUND: Despite high curability, some testicular cancer (TC) patient groups may have increased mortality. We provide a detailed age- and histology-specific comparison of population-based relative survival of TC patients in Europe and the USA. Design Using data from 12 European cancer registries and the USA Surveillance, Epidemiology and End Results 9 database, we report survival trends for patients diagnosed with testicular seminomas and nonseminomas between 1993-1997 and 2003-2007. Additionally, a model-based analysis was used to compare survival trends and relative excess risk (RER) of death between Europe and the USA adjusting for differences in age and histology. RESULTS: In 2003-2007, the 5-year relative survival of patients with testicular seminoma was at least 98% among those aged <50 years, survival of patients with nonseminoma remained 3%-6% units lower. Despite improvements in the relative survival of nonseminoma patients aged ≥ 50 years by 13%-18% units, survival remained markedly lower than the survival of seminoma patients of the same age. Model-based analyses showed increased RERs for nonseminomas, older, and European patients. CONCLUSIONS: There remains little room for survival improvement among testicular seminoma patients, especially for those aged <50 years. Older TC patients remain at increased risk of death, which seems mainly attributable to the lower survival among the nonseminoma patients.

Population-based survival of penile cancer patients in Europe and the United States of America: no improvement since 1990.

INTRODUCTION: Penile cancer is a rare neoplasm in Western countries, and detailed studies on trends in population-based survival of penile cancer have never been published before. We examined population-based trends in survival in Europe and the United States of America (USA). METHODS: Data from 3297 European and 1820 American penile cancer patients, contributed by 12 European cancer registries and the Surveillance, Epidemiology, and End Results (SEER) Program of the USA were included in this study. Period analysis techniques were used to examine relative survival trends overall, as well as for four geographic regions in Europe, and for the age groups 15-54, 55-64, 65-74 and 75+ for both populations between 1990-1995 and 2002-2007. Survival trends were assessed in a multiple regression model of relative excess risk including period of diagnosis, age and continent. RESULTS: The 5-year relative survival of penile cancer patients increased statistically non-significantly from 65% to 70% in Europe and decreased (significantly) from 72% to 63% in the USA. Trends in age-specific 5-year relative survival did not find any significant improvement in either Europe or the USA. The multiple regression analysis confirmed the lack of survival trend, and found significantly higher relative excess risk with age, and, apparently due to lower survival before 2002-2007, higher risk in Europe. CONCLUSION: Survival for penile cancer patients has not improved in either Europe or the USA since at least 1990. The reasons for the decrease of survival in the USA remain unknown and to be explored. Stronger international cooperation in clinical research may be important to facilitate clinical progress in treatment and thereby improvement of survival of this rare malignancy.

Survival from colorectal cancer in Germany in the early 21st century.

BACKGROUND: Colorectal cancer is the most common cancer in Germany and the second most common cause of cancer-related deaths in both men and women. The aim of this study is to provide detailed analysis of recent developments in survival of colorectal cancer patients using newly available data on a national basis. METHODS: We included data from 11 German cancer registries covering a population of 33 million inhabitants. Period analysis and modelled period analysis were used to provide most up-to-date estimates of 5-year relative survival in 2002-2006. RESULTS: The analysis was based on records of 164 996 colorectal cancer patients. Five-year relative survival was 63.0% overall, decreased with age and was significantly higher among women than among men in patients under 75 years. Overall age-adjusted 5-year relative survival increased from 60.6 to 65.0% over the period 2002-2006. Significant increase in survival was only observed in patients with localised or regional disease. Highest subsite-specific survival was observed in patients with cancer in descending (67.7%) and ascending (66.5%) colon. CONCLUSION: Survival of patients with colorectal cancer continued to increase in the early 21st century in Germany, with 5-year relative survival reaching 65% in 2006. However, lack of progress still persisted in patients with advanced disease.

Outcome analysis of patients with primary breast cancer initially treated at a certified academic breast unit.

INTRODUCTION: Evaluation of oncological outcome and prognostic factors of patients with primary breast cancer treated at a certified academic breast unit. PATIENTS AND METHODS: We prospectively collected data of 3338 patients, diagnosed with primary breast cancer between 01.01.2003 and 31.12.2010 and treated at the Breast Unit Heidelberg, Germany, in order to analyze outcome in clinical practice. We evaluated local control rate (LCR), disease-free survival (DFS), distant disease-free survival (DDFS), observed overall survival (OS) and age-adjusted relative overall survival (ROS). In addition, the impact of known prognostic factors on these outcome variables was examined in univariate and multivariate analyses. RESULTS: Of all patients, 368 (11.0%) had carcinoma in situ (CIS) and 197 (5.9%) had bilateral cancers. For the 2970 patients with invasive cancer, of which 49 patients (1.7%) had metastastic disease at time of diagnosis, DFS, LCR, DDFS, OS and ROS at 5 years were 79.8%, 84.7%, 81.2%, 86.3%, and 89.8%, respectively. In multivariate analysis age, pT category, nodal status, hormone receptor status and grading were identified as independent prognostic factors for OS. CONCLUSION: Compared with recent population-based reports from Germany, more favourable patient characteristics and nominally higher survival was found among this large cohort of patients with primary breast cancer treated at a single certified breast unit.

Survival from common and rare cancers in Germany in the early 21st century.

BACKGROUND: Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States. PATIENTS AND METHODS: Cancer patients diagnosed in 1997-2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002-2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database. RESULTS: Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin's lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin's lymphoma. CONCLUSIONS: German cancer survival estimates are mostly higher than the 2000-2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

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.

Has there been progress in cancer care in Croatia? Assessing outcomes in a partially complete mortality follow-up setting.

BACKGROUND: We examine the possibility of assessing progress in cancer care with partially complete mortality follow-up information, and report outcomes from Croatia. METHODS: Follow-up based on death certificates indicating cancer as the cause of death was available from the Croatian National Cancer Registry. The effect of partially complete follow-up was first examined with data from the Saarland Cancer Registry by comparing absolute, relative, and cancer death certificate based survival estimates. Survival changes between 2000 and 2006 are reported for 21 common cancers amongst patients aged 15-49 and 50-59 in Croatia. RESULTS: Survival estimates based on cancer death specific follow-up could well approximate absolute and relative survival for patients aged 15-49, and relative survival for patients aged 50-59: overestimation by more than one standard error occurred 1 and 2 and 5 times, respectively, amongst 21 cancers. In Croatia, significant survival increases occurred for patients aged 15-59 with colorectal and breast cancers, patients aged 15-49 with thyroid cancer and patients aged 50-59 with malignant melanoma and prostate cancer. CONCLUSIONS: Outcome evaluation is limited with partially complete follow-up information. Internationally comparable cancer information continues to lack from South-Eastern Europe, and the provision thereof remains a highly important public health task.

Expected long-term survival of patients diagnosed with acute myeloblastic leukemia during 2006-2010.

BACKGROUND: Treatment of acute myeloblastic leukemia (AML) has evolved over the past several decades. Therefore, currently available estimates of long-term survival, which are based on survival for patients treated with potentially now obsolete protocols, may not pertain to patients currently diagnosed. METHODS: Using data from the 1973-2005 database of the Surveillance, Epidemiology, and End Results Program, we empirically validated a novel model-based method to project 5- and 10-year relative survival of AML patients and we applied the method to project relative survival of AML patients in the United States diagnosed during 2006-2010. RESULTS: Empirical evaluation indicated that the modeling approach provides more accurate estimates of currently diagnosed patients than standard methods of survival analysis, such as cohort analysis or period analysis, in the majority of cases. Projected figures for 2006-2010 show 5- and 10-year relative survival estimates of 21.4% and 18.7% for all ages combined, 62.2% and 57.4% for ages 25-34, and 60.6% and 58.1% for ages 35-44. These estimates are substantially higher than the most up-to-date estimates obtained by standard survival analysis. CONCLUSION: Patients diagnosed with AML during 2006-2010 at younger ages have much higher long-term survival expectations than indicated by previously available survival statistics.

periodR - an R package to calculate long-term cancer survival estimates using period analysis.

OBJECTIVE: In this paper, a software package for the R language and system for statistical computing is presented for computation of long-term cancer survival estimates based on the period analysis approach. The period analysis approach provides up-to-date long-term survival estimates of concurrently diagnosed patients, enables early detection of recent changes in long-term prognosis of cancer patients and provides better survival predictions for recently and currently diagnosed patients than traditional cohort-based approaches. METHODS: Computation of absolute and relative survival estimates (both conditional follow-up year-specific and cumulative survival estimates) and their standard errors is based on standard actuarial methodology. For relative survival estimation the "Ederer II" and "Hakulinen" method were implemented. RESULTS: The package may be used for period analysis as well as traditional cohort-based survival estimation. The package further provides functions for the export of survival estimates for use with spreadsheet programs and for plotting survival curves. The application of period analysis is illustrated using stomach cancer data included in the package. CONCLUSION: Application of period analysis has gradually increased in recent years but continues to be limited by availability of affordable and easy-to-use software tools. The presented R package aims at closing this gap and will further facilitate the use of period analysis for the research community working with population-based cancer registry data. The software is freely available for download on the website of the Saarland Cancer Registry at http://www.krebsregister.saarland.de/improve/periodR_en.html.

Cancer survival discrepancies in developed and developing countries: comparisons between the Philippines and the United States.

Despite the availability of population-based cancer survival data from the developed and developing countries, comparisons remain very few. Such comparisons are important to assess the magnitude of survival discrepancies and to disentangle the impact of ethnic background and health care access on cancer survival. Using the SEER 13 database and databases from the Manila and Rizal Cancer Registries in the Philippines, a 5-year relative survival for 9 common cancers in 1998-2002 of Filipino-American cancer patients were compared with both cancer patients from the Philippines, having the same ethnicity, and Caucasians in the United States, being exposed to a similar societal environment and the same health care system. Survival estimates were much higher for the Filipino-Americans than the Philippine resident population, with particularly large differences (more than 20-30% units) for cancers with good prognosis if diagnosed and treated early (colorectal, breast and cervix), or those with expensive treatment regimens (leukaemias). Filipino-Americans and Caucasians showed very similar survival for all cancer sites except stomach cancer (30.7 vs 23.2%) and leukaemias (37.8 vs 48.4%). The very large differences in the survival estimates of Filipino-Americans and the Philippine resident population highlight the importance of the access to and utilisation of diagnostic and therapeutic facilities in developing countries. Survival differences in stomach cancer and leukaemia between Filipino-Americans and Caucasians in the United States most likely reflect biological factors rather than the differences in access to health care.

Trends in cancer survival in 11 European populations from 1990 to 2009: a model-based analysis.

BACKGROUND: The timely provision and interpretation of trends in population-based cancer survival estimates is an important clinical and public health priority. MATERIALS AND METHODS: We examined survival trends between 1990-1994 and 2000-2004 for 15 common cancers in 10 countries from diverse areas of Europe and provide projected survival estimates for 2005-2009, using novel techniques of model-based period analysis. RESULTS: Between 1990-1994 and 2000-2004, the 5-year relative survival increased significantly in all participating registries among patients with prostate, breast, and colorectal cancers and in at least 7 of 11 registries for stomach, corpus uteri, ovarian, kidney, and thyroid cancers, as well as for non-Hodgkin's lymphoma. Projections suggest further substantial increases in survival in the calendar period 2005-2009. For most cancer sites amenable to effective early detection and treatment, major geographical differences persist with lower survival in Eastern European countries. CONCLUSIONS: Model-based period analysis may be useful in providing population-based cancer survival estimates for currently diagnosed cancer patients. Concerted efforts in the organisation and quality control of cancer care will be very important to achieving further improvements in cancer control in Europe, and improving outcomes in Eastern European populations remains a priority.

Recent trends in cancer survival across Europe between 2000 and 2004: a model-based period analysis from 12 cancer registries.

BACKGROUND: Monitoring population-based cancer survival is an essential component in the evaluation of cancer control, but subject to an inherent delay in the reporting of the most recent survival estimates with traditional techniques of analysis. METHODS: We examined survival trends between the years 2000 and 2004 for 20 common cancers based on follow-up data from 12 cancer registries from diverse areas of Europe using model-based period analysis techniques. RESULTS: Between 2000 and 2004, marked rises were seen in 5-year relative survival amongst patients with prostate, breast and colorectal cancer, which were statistically significant in 10, 8 and 7 of the 12 participating cancer registries, respectively. For cancer sites amenable to effective early detection and treatment, major geographical differences in patient prognosis still persisted, with a lower survival generally observed in Eastern European countries. CONCLUSION: Model-based period analysis enables the timely monitoring of recent trends in population-based cancer survival. For colorectal and breast cancers, the identified rises in survival are probably (at least partly) explained by the improvements in clinical care and the management of the disease. Nevertheless, persisting geographic differences do point to the potential for a further reduction in the burden of cancer throughout Europe, towards which improvements in diverse areas of care, including secondary prevention, access to advances in treatment as well as subspecialisation and regionalisation of oncologic care may all contribute.

Determinants of HIV counselling and testing participation in a prevention of mother-to-child transmission programme in rural Burkina Faso.

OBJECTIVES: To analyse the factors associated with the uptake of HIV counselling, HIV testing and returning for test results in a rural hospital setting in Nouna, Burkina Faso. METHODS: Cross sectional survey of 435 pregnant women who visited the district hospital for antenatal care, from July to December 2004. Separate multivariate logistic regression analyses including analysis of reported reasons were performed to identify the factors associated with accepting HIV counselling and testing. RESULTS: HIV testing participation was related to discussing HIV screening with the partner (OR 8.36), and the number of antenatal care (ANC) visits already accomplished (OR 2.23). The quality of pre-test counselling was very poor as 42% did not understand the process. The absence of doctors and mismanagement of time for post-test counselling were the main reasons why women did not receive test results. Analysis of participants by discussion status, counselling and test participation revealed that fewer women dropped out at every stage who discussed HIV testing with their partner. CONCLUSION: Communication with the partner plays a vital role in the uptake of HIV testing. Encouraging women to engage in a discussion about testing with their partners may be a viable intervention to improve participation. Quality of service needs to be better.

Trends in population-based cancer survival in Germany: to what extent does progress reach older patients?

BACKGROUND: The ageing of populations makes outcome monitoring among elderly cancer patients particularly important. PATIENTS AND METHODS: Using data from the population-based Cancer Registry of Saarland, we examined age-specific trends in 5-year relative survival from 1979 to 2003 for patients with 15 common cancers in Germany. Model-based period analysis was applied to estimate 5-year relative survival for four age groups (15-54, 55-64, 65-74, 75+) in the periods 1979-1983, 1984-1988, 1989-1993, 1994-1998, and 1999-2003. RESULTS: Overall, 5-year relative survival improved steadily from 42.2% in 1979-1983 to 56.7% in 1999-2003. From the youngest to the oldest age group, 5-year relative survival increased by 14.5, 12.1, 12.5, and 8.4 percent units, respectively, after adjusting for changes in the spectrum of cancer sites, and survival significantly improved for 10, 12, 11, and 5 cancer sites, respectively. The age gradient particularly increased for cancer sites with major progress in chemotherapeutic treatment regimens, such as ovarian cancer, non-Hodgkin's lymphoma and leukemia. CONCLUSIONS: Relative survival of cancer patients increased considerably for many forms of cancer in Germany from 1979 to 2003. Increases were much less pronounced among elderly patients, leading to an increasing age gradient in prognosis.

Calculating age-adjusted cancer survival estimates when age-specific data are sparse: an empirical evaluation of various methods.

We evaluated empirically the performance of various methods of calculating age-adjusted survival estimates when age-specific data are sparse. We have illustrated that a recently proposed alternative method of age adjustment involving the use of balanced age groups or age truncation may be useful for enhancing calculability and reliability of adjusted survival estimates.

Cancer survival in Kampala, Uganda.

Epidemiological data on the occurrence of cancer in sub-Saharan Africa are sparse, and population-based cancer survival data are even more difficult to obtain due to various logistic difficulties. The population-based Cancer Registry of Kampala, Uganda, has followed up the vital status of all registered cancer patients with one of the 14 most common forms of cancer, who were diagnosed and registered between 1993 and 1997 in the study area. We report 5-year absolute and relative survival estimates of the Ugandan patients and compare them with those of black American patients diagnosed in the same years and included in the SEER Program of the United States. In general, the prognosis of cancer patients in Uganda was very poor. Differences in survival between the two patient populations were particularly dramatic for those cancer types for which early diagnosis and effective treatment is possible. For example, 5-year relative survival was as low as 8.3% for colorectal cancer and 17.7% for cervical cancer in Uganda, compared with 54.2 and 63.9%, respectively, for black American patients. The collection of good-quality follow-up data was possible in the African environment. The very poor prognosis of Ugandan patients is most likely explained by the lack of access to early diagnosis and treatment options in the country. On the policy level, the results underscore the importance of the consistent application of the national cancer control programme guidelines as outlined by the World Health Organization.