Quality of life over 5 years in women with breast cancer after breast-conserving therapy versus mastectomy: a population-based study.

PURPOSE: Breast-conserving therapy (BCT) was developed to improve quality of life (QOL) in early stage breast cancer patients. Except for differences in body image, literature comparing the psychosocial sequelae of BCT with mastectomy is ambiguous and shows a lack of substantial benefits. However, knowledge regarding long term effects of treatment on QOL in breast cancer is very limited as most of the pertinent studies have been performed in the early post-operative period. Therefore we compared QOL in women with breast cancer undergoing BCT versus women undergoing mastectomy over a 5-year period following primary surgery. METHODS: QOL was assessed at 1, 3, and 5 years after diagnosis in a population based cohort of 315 women with early stage breast cancer (UICC stage I-II) from Saarland (Germany) using the EORTC QLQ-C30 questionnaire and the breast cancer specific module BR23. RESULTS: Breast-conserving therapy was performed in 226 women (72%). After control for potential confounding, women with BCT reported better physical and role functioning, were sexually more active and more satisfied with their body image already at 1 year after diagnosis (all P values < 0.05). Differences in overall QOL and social functioning were gradually increasing over time and became statistically significant only at 5 years. CONCLUSIONS: Whereas some, very specific benefits of BCT, such as a better body image, are already visible very timely after completion of therapy, benefits in broader measures such as psychosocial well-being and overall quality of life gradually increase over time and become fully apparent only in the long run.

Changes of cardiovascular risk factors and their implications in subsequent birth cohorts of older adults in Germany: a life course approach.

BACKGROUND: To examine lifetime patterns of cardiovascular risk factors and their implications in subsequent birth cohorts of older adults in Germany, who experienced very different political and socioeconomic conditions at various phases of their lives. DESIGN AND METHODS: Participants of the ESTHER study, a statewide cohort study conducted in Saarland, Germany, were categorized into four birth cohorts: 1925-1934, 1935-1939, 1940-1944, 1945-1952. At baseline, lifetime history of body weight, physical activity, smoking and drinking habits, and of physician-diagnosed diabetes mellitus were documented. The average BMI, the average number of hours of physical activity, prevalence of smoking and alcohol consumption between ages 20 and 50 years were assessed. The relative risks of a first diagnosis of diabetes mellitus before or at the age of 50 years by birth cohorts were assessed by multiple logistic regressions controlling for education and BMI at the age of 20. RESULTS: For both men and women, later birth cohorts had considerably worse lifestyle profiles. The frequency of diabetes mellitus up to the age of 50 years was much higher in the later than in the earlier cohorts. The increase was more pronounced among men than among women. CONCLUSION: Women and men reaching old age in the forthcoming years have more unfavourable lifetime risk factor profiles than earlier birth cohorts. These patterns might have substantial implications for the future burden of chronic disease.

Cancer survival in Germany and the United States at the beginning of the 21st century: an up-to-date comparison by period analysis.

Transatlantic cancer survival comparisons are scarce and involve mostly aggregate European data from the late 1980s. We compare the levels of cancer patient survival achieved in Germany and the United States (US) by the beginning of the 21st century, using data from the Cancer Registry of Saarland/Germany and the SEER Program of the US. Age-adjusted 5- and 10-year relative survival for 23 common forms of cancer derived by period analysis for the 2000-2002 period were calculated, with additional detailed age- and stage-specific analyses for cancers with the highest incidence. Among the 23 cancer sites, 5 (10) year relative survival was significantly higher for 1 (2) and 8 (5) cancers in Germany and the US, respectively. In Germany, survival was significantly higher for patients with stomach cancer, whereas survival was higher in the US for patients with breast, cervical, prostate, colorectal and oral cavity cancer. Among the most common cancers, age-specific survival differences were particularly pronounced for older patients with breast, colorectal and prostate cancer. Survival advantages of breast cancer patients in the US were mainly due to more favorable stage distributions. This comprehensive survival comparison between Germany and the US suggests that although survival was similar for the majority of the compared cancer sites, long-term prognosis of patients continues to be better in the US for many of the most common forms of cancer. Among these, differences between patients with breast and prostate cancer are probably due to more intensive screening activities.

Heavy physical activity: risk or protective factor for cardiovascular disease? A life course perspective.

PURPOSE: The objective of this analysis was to examine the impact of lifetime physical activity (PA) on major cardiovascular disease. METHODS: At the baseline examination of the ESTHER study, a cohort study with 9953 participants, ages 50-74 years, with a lifetime history of PA and a physician-diagnosed myocardial infarction or stroke (major cardiovascular events, MCVE) were documented. The average number of hours per week of light and heavy PA (occupational and leisure time) between 20 and 50 years of age were calculated, and their association with the occurrence of MCVE after the age of 50 years was assessed by multiple logistic regression controlling for age, sex, smoking, body mass index, and education. RESULTS: A total of 569 study participants (6.1%) experienced a MCVE. Participants with no heavy PA at all or >or=40 hours per week had an increased risk for MCVE compared with study participants with PA up to 7 hours per week (odds ratios, 95% confidence intervals: 1.65, 1.10-2.46, and 1.69, 1.17-2.45, respectively). CONCLUSIONS: Both absence and (typically occupation related) excess of heavy PA during adulthood seem to increase the risk of MCVE. Health effects of heavy PA are likely to be a matter of type and of dose.

Report on trends of incidence (1970-2002) of and mortality (1952-2002) from cancer in Germany.

PURPOSE: The paper presents the statistical analysis of current and past trends of cancer mortality rates in Germany in terms of annual percent change, overall and for the major sites, and contrasts them with trends in incidence of the Cancer Registry of the Saarland, the only registry in this country with long-term completeness. It addresses also the issue of a cross-over of cancer mortality and mortality from cardiovascular diseases (CVD) in the near future, as suggested by various authors. MATERIAL AND METHODS: Analyses are based on the mortality data of the official mortality statistics as published by the Federal Statistical Office and reported annually to the WHO, and the regularly reported incidence data of the Cancer Registry of the Saarland. The data was age-standardised and analysed by piecewise regression using a freely available dedicated software package. RESULTS: The report shows a downward trend of mortality rates for all cancers combined based on declining rates for many individual sites with only few exceptions affecting mainly females (e.g. lung cancer). Recently, the long-term increase of cancer incidence also flattened out with rather heterogeneous underlying site-specific trends increasing for some sites (e.g. cancers of the intestine, breast, prostate, or some lymphoma) and decreasing for others (e.g. cancers of the stomach, gall bladder in females, larynx, and lung in males). A crossover of cancer mortality and mortality from CVD might occur-if at all-after 2,020 in males and 2,030 in females. CONCLUSIONS: Depending on cancer site, primary prevention (e.g. lung cancer among males), early detection (cervical cancer), and treatment (e.g. breast and testicular cancer, lymphoma) contributed to the current decline of mortality rates. Absence of a turnaround (e.g. lung cancer among females), slower decline than in other countries (e.g. cervical cancer), or later turnaround (e.g. breast cancer) may be related to failures in promoting prevention (lung cancer among females), early detection programmes (cervical cancer), or delays in the translation of modern treatment into routine health care (breast cancer) and indicate major challenges for current and future health policy.

A population-based study of the impact of specific symptoms on quality of life in women with breast cancer 1 year after diagnosis.

BACKGROUND: Whereas the role of specific symptoms, such as pain and fatigue, for quality of life (QOL) is unquestioned, their relative importance for long-lasting impairments in QOL in cancer patients has rarely been assessed quantitatively. The authors, therefore, aimed to identify symptoms most predictive of limitations to function and overall QOL in women with breast cancer after completion of primary therapy. METHODS: The European Organisation for Research and Treatment of Cancer questionnaire QLQ-C30 and the breast-cancer-specific module QLQ-BR23 were used to measure QOL in a population-based sample from Saarland (Germany) of 314 women with breast cancer 1 year after diagnosis. Symptoms most predictive for limitations to function and overall QOL were identified with a multiple linear regression analysis. RESULTS: Fatigue emerged as the strongest predictor by far of QOL, explaining around 30% to 50% of variability within function scores and overall QOL. Other symptoms, including pain, nausea and/or vomiting, breast symptoms, systemic therapy side effects, and arm symptoms, explained on average <5% of variability of various QOL scales beyond fatigue and age. Sociodemographic and clinical factors had little impact on QOL. CONCLUSIONS: Although QOL is a multidimensional concept, the analysis suggested that fatigue is the symptom that had, by far, the largest impact on limiting function and on overall QOL in breast cancer patients after their completion of primary therapy. Specific interventions to reduce the burden of fatigue may represent a particularly worthwhile effort to improve QOL in women with breast cancer.

Restrictions in quality of life in colorectal cancer patients over three years after diagnosis: a population based study.

Despite the burden and prevalence of colorectal cancer (CRC), there is only limited information regarding quality of life of patients who have survived beyond the first year post treatment. We assessed quality of life in a population-based cohort of 309 patients with CRC from Saarland (Germany) one and three years after diagnosis using the QLQ-C30 questionnaire and the tumour specific module QLQ-CR38. When compared with reference data from the general population, most patients with CRC reported high overall quality of life and only small deficits in physical functioning but deficits in emotional and social functioning persist over years in patients with colorectal cancer. Improvements in quality of life from the first to the third year after diagnosis in patients who remained free of disease were very modest and limited to less financial difficulties, a better future perspective and fewer stoma-related problems.

The diagnosis of a smoking-related disease is a prominent trigger for smoking cessation in a retrospective cohort study.

OBJECTIVE: We evaluated the impact of demographic factors, smoking patterns, and the occurrence of smoking-related diseases on smoking cessation, with a particular emphasis on the temporal relationship between diagnosis of smoking-related diseases and cessation. STUDY DESIGN AND SETTING: A cohort was assembled of participants of a general health screening examination aged 50-74 years. Lifetime smoking habits and medical history were obtained by a self-administered questionnaire. In a retrospective cohort study approach, predictors of cessation among ever-smokers (n = 4,575) were identified using the extended proportional hazards model. RESULTS: Male gender, late onset of smoking, and higher educational level were predictive of cessation. However, the by far strongest predictors of cessation were diagnoses of smoking-related diseases: relative cessation rates in the year of disease occurrence were 11.2 for myocardial infarction (95% confidence interval CI = 8.9-14.0), 7.2 for stroke (95% CI = 5.1-11.6), 2.5 for diabetes mellitus (95% CI = 1.6-4.0) and 4.8 for cancer (95% CI = 3.1-7.4) relative to years before diagnosis of the respective diseases. CONCLUSION: Our results underline the key role of perceived detrimental effects of smoking for cessation. When smokers personally experience the health consequences of smoking, many permanently quit.

The impact of body weight on smoking cessation in German adults.

OBJECTIVE: To assess the relevance of pre-existing body weight for successful smoking cessation among women and men. METHODS: We carried out a retrospective cohort analysis among 4270 ever smoking participants of a general health screening examination in Germany recruited from July 2000 to June 2002 aged 50 to 74, who provided lifetime histories of both body weight and smoking. RESULTS: In the extended Cox model, the relative cessation rate (RCR) increased significantly with increasing body mass index (BMI) among both genders (test for trend: P < 0.01 for women and P < 0.0001 for men). In women, this effect was mainly due to a lower cessation rate in low-weight (BMI <20) smokers (adjusted RCR = 0.76, 95% confidence interval (CI) 0.62-0.95), whereas in men, the effect was mainly due to a higher cessation rate among overweight and obese smokers (adjusted RCR = 1.26, 95% CI 1.11-1.35, and 1.38, 95% CI 1.17-1.63, respectively) compared to normal-weight smokers. CONCLUSIONS: While in men, overweight and obesity are associated with increased smoking cessation, possibly related to increased health concerns, in women, low weight is associated with decreased smoking cessation, possibly related to increased fear of weight gain.

Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer.

PURPOSE: To assess whether detriments in quality of life (QOL) among women with breast cancer persist over years. PATIENTS AND METHODS: QOL was assessed in a population-based cohort of 314 women with breast cancer from Saarland (Germany) 1 and 3 years after diagnosis and compared internally and with reference data from the general population. RESULTS: Three years after diagnosis, deficits in QOL were still apparent for role, emotional, cognitive, and social functioning and for the symptoms of insomnia, fatigue, dyspnea, and financial difficulties. Differences between breast cancer patients and women from the general population were predominantly found in younger ages. Compared with the QOL scores measured 1 year after diagnosis, only minor functional changes were observed, but recurrence of breast cancer during the follow-up interval had a deleterious effect on QOL. CONCLUSION: Deficits in role, emotional, cognitive, and social functioning persist over years in women with breast cancer and predominantly affect younger patients.

Prevalence and determinants of exocrine pancreatic insufficiency among older adults: results of a population-based study.

OBJECTIVE: The prevalence and main determinants of exocrine pancreatic insufficiency were investigated in a large population-based sample of older adults by measuring pancreatic elastase-1 in stool. MATERIAL AND METHODS: The study comprised 914 participants aged 50 to 75 years recruited by their general practitioner during a general health examination. All participants and their physicians were asked to fill out a standardized questionnaire which contained information on socio-demographic and lifestyle factors as well as medical history. Native stool was examined for pancreatic elastase-1 with a commercially available ELISA (ScheBo Tech, Giessen, Germany). RESULTS: Overall, 524 women and 390 men aged 50 to 75 years (mean age 61.9 years) were included in the analysis. In total, 105 (11.5%) of the 914 subjects showed signs of exocrine pancreatic insufficiency (EPI) with =200 microg elastase-1/g stool, and 47 (5.1%) subjects showed signs of a severe exocrine pancreatic insufficiency (SEPI, < 100 microg elastase-1/g stool). There was a clear increase in EPI with age. Patients taking angiotensin-converting enzyme (ACE) inhibitors had a lower prevalence than subjects without this medication; these associations persisted after adjustment for covariates. CONCLUSIONS: Prevalence of EPI increases with age and seems to be tentatively higher in men than in women. However, smoking seems to be an independent risk factor for EPI and SEPI whereas ACE-inhibitor intake might be a protective factor. The latter finding may even point to new options in the treatment of chronic pancreatitis.

Quality of life in patients with colorectal cancer 1 year after diagnosis compared with the general population: a population-based study.

PURPOSE: Quality of life (QOL) has become an important outcome measure for patients with cancer, but long-term results from population-based studies are rare. The objective of our study was to identify specific limitations of QOL in survivors of colorectal cancer in comparison with men and women from the general population 1 year after diagnosis when acute treatment effects are expected to have declined. PATIENTS AND METHODS: QOL was assessed 1 year after diagnosis in a population-based cohort of 439 patients with colorectal cancer from Saarland (Germany) using the EORTC-QLC30 questionnaire. Specific functional and symptom QOL scores were compared with published reference data from the general population. RESULTS: Of 439 patients, 378 of them survived the first year after tumor diagnosis (86.1%). Of these, 309 returned the questionnaire (response rate, 81.7%). Compared with the general population, colorectal cancer patients scored their physical, role, cognitive, and global health functioning only slightly worse. More severe limitations were observed for the emotional and social functioning scales and for the symptom subscales of fatigue, dyspnea, insomnia, constipation, diarrhea, and financial difficulties. The differences regarding functional and symptom scores were predominantly found in younger age groups whereas older cancer patients and controls rated their health and QOL similarly. CONCLUSION: Deficits in emotional and social functioning and specific limitations like fatigue, dyspnea, insomnia, constipation, diarrhea, and financial difficulties are main factors hampering the QOL among colorectal cancer patients and seem to affect predominantly younger patients.

Is Helicobacter pylori infection a necessary condition for noncardia gastric cancer?

Although the association between Helicobacter pylori infection and gastric cancer is well established, this association might have been underestimated in epidemiologic studies because of possible clearance of the infection in the course of disease development. The authors addressed this hypothesis in a case-control study from Saarland, Germany (68 cases first diagnosed between 1996 and 1998 and 360 controls), with serologic assessment of H. pylori infection in which various exclusion criteria were used to minimize potential bias from this source. Joint application of three such exclusion criteria (blood sample taken more than 90 days after gastrectomy, advanced (T4) gastric cancer, and CagA positivity in Western blot analysis despite a negative result in anti-H. pylori immunoglobulin G enzyme-linked immunosorbent assay) increased the odds ratio of noncardia gastric cancer from 3.7 (95% confidence interval (CI): 1.7, 7.9) to 18.3 (95% CI: 2.4, 136.7) for any H. pylori infection and from 5.7 (95% CI: 2.6, 12.8) to 28.4 (95% CI: 3.7, 217.1) for CagA-positive H. pylori infections. Furthermore, there was no single H. pylori-negative patient out of 32 patients with noncardia gastric cancer left after additional exclusion of subjects with borderline levels in immunoglobulin G enzyme-linked immunosorbent assay. The H. pylori-gastric cancer relation may be much stronger than previously thought, and H. pylori infection may even be a (close to) necessary condition for development of noncardia gastric cancer.

Pleural mesothelioma incidence in Europe: evidence of some deceleration in the increasing trends.

OBJECTIVE: To summarize the geographical and temporal variations in incidence of pleural mesothelioma in Europe, using the extensive data available from European general cancer registries, and consider these in light of recent trends in asbestos extraction, use and import in European countries. MATERIAL AND METHODS: The data were extracted from the European Cancer Incidence and Mortality database (EUROCIM). The inclusion criteria was acceptance in Volume VII of Cancer Incidence in Five Continents. Truncated age-standardized rates per 100,000 for the ages 40-74 were used to summarise recent geographical variations. Standardized rate ratios and 95% confidence intervals for the periods 1986-1990 and 1991-1995 were compared to assess geographical variations in risk. To investigate changes in the magnitude of most recent trends, regression models fitted to the latest available 10-year period (1988-1997) were compared with trends in the previous decade. Fitted rates in younger (40-64) and older adults (65-74) in the most recent period were also compared. RESULTS: There was a great deal of geographical variation in the risk of mesothelioma, annual rates ranging from around 8 per 100,000 in Scotland, England and The Netherlands, to lower than 1 per 100,000 in Spain (0.96), Estonia (0.85), Poland (0.85) and Yugoslavia, Vojvodina (0.56) among men. The rank of the rates for women was similar to that observed for men, although rates were considerably lower. Between 1978 and 1987, rates in men significantly increased in all countries (excepting Denmark). In the following 10 years, there was a deceleration in trend, and a significant increase was detectable only in England and France. In addition, the magnitude of recent trends in younger men was generally lower than those estimated for older men, in both national and regional cancer registry settings. CONCLUSIONS: While mesothelioma incidence rates are still rising in Europe, a deceleration has started in some countries. A decrease may begin in the next few years in certain European populations considering the deceleration of observed trends in mesothelioma and asbestos exposure, as well as the recent ban on its use.

Provider delay among patients with breast cancer in Germany: a population-based study.

PURPOSE: Delaying the diagnosis and initiation of treatment of cancer is likely to result in tumor progression and a worse prognosis. We examined sources and consequences of provider delay among female breast cancer patients in a population-based study in Germany. PATIENTS AND METHODS: Three hundred eighty women, who were ages 18 to 80 years and who had invasive breast cancer, were interviewed with respect to the diagnostic process. Provider delay was defined as time from first presentation to a health care provider until initiation of cancer treatment. RESULTS: Median provider delay was 15 days and did not substantially differ by the specialty of first consulted physician. Delays in the diagnostic work-up were mainly because of erroneous initial suspicion of a benign breast disease or because of time constraints by patients or physicians. Provider delay over 3 months was found in 11% of all breast cancer cases and was associated with patient characteristics such as higher education (odds ratio [OR] = 2.6; 95% confidence interval [CI], 1.3 to 5.4), full-time employment (OR = 2.5; 95% CI, 1.1 to 5.5), family history of breast cancer (OR = 2.8; 95% CI, 1.2 to 6.2), and presenting with a non-breast symptom (OR = 4.3; 95% CI, 1.7 to 10.9). The association between duration of diagnostic work-up and stage at diagnosis was U shaped, with the highest proportions of metastasized breast cancer tumors among women with very short (< 7 days) or very long (> 3 months) duration. CONCLUSION: Diagnostic work-up is within reasonably short time limits among most patients with breast cancer in Germany. Although the association between delay and tumor stage seems to be complex, any delay in diagnostic work-up should be kept to a minimum.

Risk of gastric cancer among smokers infected with Helicobacter pylori.

Infection with the gastric bacterium Helicobacter pylori (in particular infection with CagA-positive strains) and smoking have been identified as risk factors for the development of gastric cancer. Both risk factors are typically acquired early in life and prevail over decades if not for life. We assessed the individual and joint impact of both risk factors on gastric cancer risk in a population-based case-control study from Germany including 71 patients with histologically verified gastric cancer and 363 patients with colorectal cancer who served as controls. Information on smoking and potential confounding factors was collected by standardized interviews. H. pylori infection was measured serologically by immunoglobulin G antibody titers against H. pylori. In addition, antibodies against the CagA antigen were determined by Western blot. Twenty-seven percent of cases compared with 15% of controls were smokers, and 43% of cases compared with 23% of controls were infected with CagA-positive H. pylori strains. After control for potential confounders, the relative risk of gastric cancer was 2.6 (95% CI 1.2-5.7) for nonsmoking subjects with CagA-positive H. pylori infections and 7.2 (95% CI 2.2-23.6) for smoking subjects with CagA-positive H. pylori infections compared with subjects without these risk factors. The corresponding relative risks for noncardia gastric cancer were 6.1 ( 95% CI 2.3-16.5) and 16.6 (95% CI 4.3-64.2). We conclude that smoking subjects with CagA-positive H. pylori infections have a strongly increased risk of gastric cancer and may be an important group for targeting efforts of prevention and early detection.