Alberto Quaglia

The cancer survival gap between elderly and middle-aged patients in Europe is widening

The present study is aimed to compare survival and prognostic changes over time between elderly (70-84 years) and middle-aged cancer patients (55-69 years). We considered seven cancer sites (stomach, colon, breast, cervix and corpus uteri, ovary and prostate) and all cancers combined (but excluding prostate and non-melanoma skin cancers). Five-year relative survival was estimated for cohorts of patients diagnosed in 1988-1999 in a pool of 51 European populations covered by cancer registries. Furthermore, we applied the period-analysis method to more recent incidence data from 32 cancer registries to provide 1- and 5-year relative survival estimates for the period of follow-up 2000-2002. A significant survival improvement was observed from 1988 to 1999 for all cancers combined and for every cancer site, except cervical cancer. However, survival increased at a slower rate in the elderly, so that the gap between younger and older patients widened, particularly for prostate cancer in men and for all considered cancers except cervical cancer in women. For breast and prostate cancers, the increasing gap was likely attributable to a larger use of, respectively, mammographic screening and PSA test in middle-aged with respect to the elderly. In the period analysis of the most recent data, relative survival was much higher in middle-aged patients than in the elderly. The differences were higher for breast and gynaecological cancers, and for prostate cancer. Most of this age gap was due to a very large difference in survival after the 1st year following the diagnosis. Differences were much smaller for conditional 5-year relative survival among patients who had already survived the first year. The increase of survival in elderly men is encouraging but the lesser improvement in women and, in particular, the widening gap for breast cancer suggest that many barriers still delay access to care and that enhanced prevention and clinical management remain major issues.

Prostate cancer incidence and mortality trends among elderly and adult Europeans.

Prostate cancer is a common malignancy primarily of elderly men, with incidence rates rapidly increasing, owing to the population ageing and the introduction of more sensitive diagnostic procedures. Although the effectiveness of a screening test remains controversial, the decreasing mortality rates, which recently emerged in the USA, may be partly attributable to the changes of patterns of care, thus suggesting a potential effect of preventive measure. The object of this study is to examine time trends in incidence and mortality from prostate cancer in European Union (EU) countries, with particular attention to possible differences between the elderly (65 years old or over) and younger or middle age adults (35-64 years old). EUROCIM, the data base created by the European Network of Cancer Registries, provided the incidence and mortality data for the 12 EU Countries analysed (namely: Finland, Denmark, Scotland, England and Wales, Ireland and The Netherlands in Northern Europe; Austria, Germany and France in Central Europe; Italy, Spain and Portugal in Southern Europe), for the 1978-1994 period. Incidence and mortality time trends, expressed as mean difference per cent (MD%) per year, were estimated by a Poisson log-linear regression model. Higher resolution analyses were also carried out to check differences in time trends by age class within the two groups under study. Upward mortality trends occurred in several countries, excepting Ireland, Austria and Southern Europe, but only for younger and middle aged adults. Rates increased more rapidly in older age groups; a clear north-south gradient appeared both in the elderly and in younger adults; for the elderly, MD% higher than +1.5 for most countries of Northern Europe, MD% around +1 for Central Europe, and MD% less than +1 for Southern Europe were registered, with lower values for younger people. Incidence rates rose across the period considered, almost in all countries both for elderly and for younger and middle age adults, increasing more rapidly in younger age. Incidence trends showed a less clear geographic pattern than for mortality. In the younger group, high MD%, ranging in Northern Europe from +3.2 in Finland and England and Wales to +5.7 in The Netherlands, were observed, while in the South values ranged between +4.2 and +5.0. In Central Europe, very high MD%, ranging between +8.4 in France and +16.6 in Austria, were noted. No significant trends were observed for Denmark, Ireland and Portugal. For the elderly the increase was generally lower and no significant trend was observed in Germany and Portugal. Interaction between age and calendar period in the older group was observed for most of the considered countries. With reference to mortality, the MD% showed a tendency to rise, with increasing age, while no consistent pattern emerged for incidence. The observed incidence trends are probably a consequence of the different times in which the more recent detection methods were introduced in each country, and of the different policies adopted by each health care system towards the elderly. A comparison with the USA data suggests that in the next future a favourable downward mortality trend could be expected also in some EU Countries and, particularly, for younger age groups, even though prostatic cancer in old patients will remain a great burden, which National Health Care Systems will have to face in the next decades.

Differences in the epidemic rise and decrease of prostate cancer among geographical areas in Southern Europe. an analysis of differential trends in incidence and mortality in France, Italy and Spain.

This is a population-based study aimed at evaluating incidence and mortality trends for prostate cancer in France, Italy and Spain, during the prostate-specific antigen (PSA) era, considering elderly people aged 70 years and over and younger adults aged between 40 and 69 years. Trends were estimated by a log-linear Poisson regression model and expressed as an Estimated Annual Percent Change (EAPC). Incidence increased sharply in almost all areas. Spain showed the lowest increases. Incidence started to rise around 1985 in France and after 1990 in Italy and Spain. Mortality increased until the late 1980s in all countries, then declined in France and Italy (-2.5% in 40-69 year age group), but not in Spain. Younger people showed a much higher rise in incidence than the elderly, while mortality decreased mainly in the younger adults. The decrease in mortality was more marked in those areas and the younger age group where the rise in incidence was higher and started earlier, i.e. in France and in younger people, suggesting that the PSA test may have had a positive effect on mortality, although other clinical advances also have to be taken into account.

The epidemiological revolution of the 20th century

Until 100 years ago the epidemiological scenario of human diseases had substantially remained unchanged. The 20th century has been characterized by a fantastic advance in life expectancy and by a shift from infectious to chronic degenerative diseases as prevailing causes of death. As an example of the epidemiological revolution in a developed country, we reconstructed, year by year from 1901 to 2000, the situation in Italy. Reference to the situation in other countries is also made. Both crude and age‐adjusted mortality data were made available for males and females. A new turning point became evident in the second half of the 20th century with the decline of mortality for cardiovascular diseases and, more recently, for tumors. This review discusses the roots and rationale for these epidemiological changes. The discoveries made in the area of biomedical sciences, the progress in preventive and curative medicine, and the improvement of hygienic conditions have been so spectacular that 1 million lives are saved every year in Italy as compared with the late 19th century. De Flora, S., Quaglia, A., Bennicelli, C., Vercelli, M. The epidemiological revolution of the 20th century. FASEB J. 19, 892–897 (2005)

A wide difference in cancer survival between middle aged and elderly patients in Europe

Nowadays the burden of cancer in elderly people has reached an alarming extent. The purpose of this study is comparing cumulative and conditional relative survival in elderly patients between 65 and 84 years and younger adults aged from 55 to 64. Fifty‐three cancer registries of 22 European countries, participating in the EUROCARE‐3 programme, collected information on the cases diagnosed over the period 1990–1994. We computed cumulative and conditional relative survival for 16 cancer sites. Middle aged patients experienced a better prognosis than the elderly for all cancer sites, in both sexes and the differences were more marked at 1 than 5 years since diagnosis. The very large differences noted in the first period after cancer detection declined in the subsequent years and, when 5‐years conditional survival was considered, for several cancers the elderly and younger adults had the same probabilities of surviving. The death relative excess risks (RERs) in the elderly with respect younger individuals were really very high and markedly larger at 1 than 5 years, and in women than men. Genitourinary and gynaecological cancers showed the highest RERs, around 2.0 and between 1.5 and 2.5 respectively. This very high early mortality could be due not only to clinical aspects: the barriers to health care access and a consequent late diagnosis might represent for elderly patients the main determinant of this very large prognostic disadvantage. In conclusion, clinical management of cancer in the elderly remains a major issue to be faced with complex social and health care policies.

Electrochemotherapy for the management of cutaneous and subcutaneous metastasis: A series of 39 patients treated with palliative intent

Electrochemotherapy (ECT) is technique for local control of skin metastasis. This study is primarily aimed at assessing the clinical activity of ECT in a prospective cohort of patients, and evaluating the association between primary tumor histology, number of metastatic lesions and size of tumor deposits and objective response rate.

Cancer patient survival in the elderly in Italy

Aims and background Italy, like most western populations, is sharply aging and changing its age structure with a striking increase in the oldest segment of the elderly. Since age is related to an exponential growth of cancer incidence rates and to a worsening of prognosis, the progressive aging of the population will constitute, in the future, an issue increasingly more important for public health. The present study is the first effort to present and analyze survival rates in Italian elderly cancer patients in order to provide a starting point for the development of better clinical strategies addressed to the aged. Materials and methods The presented data come from a large data set consisting of survival data relating to 25,798 men and 20,479 women, aged 65–84 years at diagnosis, collected by Italian cancer registries participating in the ITACARE project. Relative survival rates of patients have been calculated by sex, quinquennial age classes and the considered entire age class for overall malignant neoplasms and the 10 most frequent cancer sites in the elderly. Results When all Italian data for all cancers in the 65–84 year age group were pooled, survival rates at 5 years from the diagnosis was 27% and 39% in men and women, respectively. As regards specific sites, survival rates below 50% were observed for lung, stomach and ovary cancer at 1 year from diagnosis. At 5 years from diagnosis, the rates were less than 50% for colon, prostate, cervix, multiple myeloma, non-Hodgkins lymphoma and melanoma (only in men). The best survival at 5 years from diagnosis (above 50%) was in women for melanoma and corpus uteri and breast cancer. For all cancers, the prognosis for women was better in each considered age group even though a dramatic decrease in survival with age was observed in both sexes. In general, a similar decline in survival with increasing age characterized all considered specific sites. However, at closer observation, the patterns of a decrease revealed some differences. The ratio between the survival rates of 55–64 vs 65–84 year age class indicated that the sites with the greatest advantage of survival for younger patients (ratio >1.5) were ovary, lung and melanoma (only in men), whereas the least advantage was observed for colon, corpus uteri, breast and prostate. By calendar periods, excluding non-Hodgkins lymphoma for women, an increase in survival was observed for all considered sites, improving an encouraging successful trend in diagnostic and therapeutic progresses.

The relationship between urban airborne pollution and short-term mortality: quantitative and qualitative aspects.

The influence of airborne pollution on mortality rates has been examined since the well known severe pollution episodes of Pennsylvania (1948) and London (1952). Three main epidemiological approaches are available: transversal studies, time series studies, prospective studies. The most frequently used method is the time series analysis, which retrospectively determines daily mortality rates as compared to daily pollution levels in a defined period. The vast majority of studies applying this approach confirm the existence of a positive correlation between mortality and airborne pollution. The relative risk of death during the most severely polluted days as compared to the least polluted days ranges between 1.02 and 1.13. Airborne pollution affects mortality as related to cardiovascular and chronic obstructive pulmonary diseases mainly in subjects previously affected by these pathologies. The dose–response mortality–pollution curve shows linear increments of mortality at low pollution levels, weak increments at high pollution levels. This phenomenon is attributed to the existence of subjects highly susceptible to pollution induced adverse health effects. These subjects, dying at low pollution levels, are not available to increase mortality rates at high pollution levels. Mortality is mainly related to the concentration of single pollutants, such as suspended particle matter, sulfur oxides, nitric oxides and ozone. Elderly are highly susceptible to pollution-induced mortality increases. Therefore, the study of mortality–pollution correlation is of particular interest in cities characterized by a relative prevalence of the elderly in the population. The latency period between pollution increases and related mortality increases falls in the 1–3 days interval range. The pollution–mortality relationship is influenced by many factors, such as the occurrence of exceedingly high or low environmental temperatures, influenza epidemics, etc. Many hypotheses has been raised to support the causality of the mortality–pollution association, including a direct effect of pollutants on cardiovascular and respiratory apparatus, and the release of inflammatory mediators affecting blood viscosity and pneumocytes homeostasis. On the whole, available data suggest that pollution is able to increase mortality only if associated to other risk factors determining an increased susceptibility in the exposed population.

Incidence and mortality trends for four major cancers in the elderly and middle-aged adults: An international comparison

BACKGROUND Time trends comparisons by age are important to understand the specific needs of elderly cancer patients and to improve clinical procedures. The aim is to compare 1998-2005 cancer incidence and mortality trends in Italy and the US for both sexes and for two age groups, namely 50-69 year old and 70+ year old. METHODS Cancer incidence and mortality data came from 22 Cancer Registries (CRs) of the Italian association of cancer registries (AIRTUM), while the US incidence records were provided by 13 SEER CRs and the mortality statistics provided by the WHO Database. Trends were analysed by the Joinpoint Regression Program in order to obtain Annual Percent Changes and Joinpoints. RESULTS Colorectal cancer incidence trends were favourable in the US for both sexes and in both age groups, whilst the rates increased in Italian elderly individuals and mortality rates fell markedly only in the US. For lung cancer, incidence and mortality decreased in men but increased in women in the two geographical areas. Breast cancer incidence and mortality declined both in Italy and the US for younger women, but the trends were less favourable in the Italian elderly individuals. The increase of prostate incidence slowed down and mortality diminished for every age group in the US, whilst in Italy only in the younger group. CONCLUSIONS For major cancers, the Italian elderly experienced less favourable trends than the middle-aged patients whereas, in the US, the trends were similar for both age groups and favourable also for the elderly.

The combined effect of age and socio-economic status on breast cancer survival

The study aims to investigate the effect of age and socio-economic status (SES) on breast cancer relative survival at 5 years from diagnosis (RS-5%). The Liguria Region Cancer Registry collected clinico-pathological information for 1081 patients resident in Genoa city diagnosed in 1996 and 2000. Patients were divided into three age groups (0-49, 50-69 and ≥70 years) and into quintiles of SES, measured according to a synthetic regional deprivation index built by Census tract variables and validated by comparison with the national deprivation index. The association of prognostic factors and RS-5% was evaluated by bivariate and multivariate analyses. RS-5% was very high for the first two age groups (91%) and decreased in patients aged 70 or older (82%) (unadjusted HR=2.7, P=0.001). The first four SES quintiles had homogeneous RS-5% (89-92%) and only the last very deprived group had lower rates (77%) (unadjusted HR=2.3, P=0.011). Very deprived elderly patients showed a much lower RS-5% (58%). Elderly and very deprived women were more likely to have large tumours, positive lymph nodes and less likely to receive conserving surgery, axillary dissection and adjuvant therapies. After adjusting for tumour characteristics and treatment modalities the increased risk of dying in the elderly disappeared completely, while the higher risk of very deprived women was eliminated only after correction for all the covariates simultaneously. The survival observed for breast cancer patients resident in Genoa was very high, however elderly and very low SES women have to be monitored. These variations are probably due to inequity in healthcare access and to a difficult taken in charge.