C. W. N. Looman

Euthanasia and other medical decisions concerning the end of life

This article presents the first results of the Dutch nationwide study on euthanasia and other medical decisions concerning the end of life (MDEL). The study was done at the request of the Dutch government in preparation for a discussion about legislation on euthanasia. Three studies were undertaken: detailed interviews with 405 physicians, the mailing of questionnaires to the physicians of a sample of 7000 deceased persons, and the collecting of information about 2250 deaths by a prospective survey among the respondents to the interviews. The alleviation of pain and symptoms with such high dosages of opioids that the patients life might be shortened was the most important MDEL in 17.5% of all deaths. In another 17.5% a non-treatment decision was the most important MDEL. Euthanasia by administering lethal drugs at the patients request seems to have been done in 1.8% of all deaths. Since MDEL were taken in 38% of all deaths (and in 54% of all non-acute deaths) we conclude that these decisions are common medical practice and should get more attention in research, teaching, and public debate.

Gastric MALT lymphoma: Epidemiology and high adenocarcinoma risk in a nation-wide study

BACKGROUND Gastric marginal zone non-Hodgkin lymphomas MALT type (gMALT) and gastric adenocarcinomas (GC) are long-term complications of chronic Helicobacter pylori gastritis, however, the incidence of gMALT and the GC risk in these patients is unclear. OBJECTIVE To evaluate epidemiological time trends of gMALT in the Netherlands and to estimate GC risk. METHODS Patients with a first diagnosis of gMALT between 1991 and 2006 were identified in the Dutch nation-wide histopathology registry (PALGA). Age-standardised incidence rates were calculated. The incidences of GC in patients with gMALT and in the Dutch population were compared. Relative risks were calculated by a Poisson Model. RESULTS In total, 1419 patients were newly diagnosed with gMALT, compatible with an incidence of 0.41/100,000/year. GC was diagnosed in 34 (2.4%) patients of the cohort. Patients with gMALT had a sixfold increased risk for GC in comparison with the general population (p<0.001). This risk was 16.6 times higher in gMALT patients aged between 45 and 59 years than in the Dutch population (p<0.001). CONCLUSIONS GC risk in patients with gMALT is six times higher than in the Dutch population and warrants accurate re-evaluation after diagnosis and treatment for gMALT.

Epidemiological trends of pre-malignant gastric lesions; a long-term nationwide study in the Netherlands

Background: The pre-malignant gastric lesions atrophic gastritis (AG), intestinal metaplasia (IM) and dysplasia (DYS) have long been identified as principal risk factors for gastric cancer. Objective: To evaluate epidemiological time trends of pre-malignant gastric lesions in the Netherlands. Methods: Patients with a first diagnosis of AG, IM or DYS between 1991 and 2005 were identified in the Dutch nationwide histopathology registry. The number of new diagnoses per year were evaluated relative to the total number of patients with a first gastric biopsy. Time trends were evaluated with age–period–cohort models using logistic regression analysis. Results: In total, 23 278 patients were newly diagnosed with AG, 65 937 patients with IM, and 8517 patients with DYS. The incidence of AG declined similarly in men and women with 8.2% per year [95% CI 7.9% to 8.6%], and DYS with 8.1% per year [95% CI 7.5% to 8.6%]. The proportional number of new IM cases declined with 2.9% per year [95% CI 2.7% to 3.1%] in men and 2.4% [95% CI 2.2% to 2.6%] in women. With age–period–cohort models a cohort phenomenon was demonstrated for all categories of pre-malignant gastric lesions in men and in women with IM and DYS. Period phenomena with a larger decline in number of diagnoses after 1996 were also demonstrated for AG and IM. Conclusions: The incidence of pre-malignant gastric lesions is declining. Period and cohort phenomena were demonstrated for diagnoses of AG and IM. These findings imply that a further decrease of at least 24% in the incidence of gastric cancer in the coming decade may be anticipated in Western countries without specific intervention.

Regression analysis of recent changes in cardiovascular morbidity and mortality in The Netherlands.

Abstract Objectives: To test whether recent declines in mortality from coronary heart disease were associated with increased mortality from other cardiovascular diseases. Design: Poisson regression analysis of national data on causes of death and hospital discharges. Setting and subjects: Population of the Netherlands, 1969-93. Main outcome measures: Annual changes in mortality from coronary heart disease, stroke, and other cardiovascular diseases and annual changes in hospital discharge rates for acute coronary events, stroke, and congestive heart failures. Results: Patterns of cardiovascular mortality changed abruptly in 1987-93. Annual decline in mortality from coronary heart disease increased sharply for women and men: from −1.9% (95% confidence interval −2.2% to −1.6%) and −1.7% (−1.9% to −1.4%) respectively in 1979-86 to −3.1% (−3.5% to −2.6%) and −4.2% (−4.6% to −3.9%) in 1987-93. The longstanding decline in mortality from stroke levelled off: from annual change of −3.3% (−3.7% to −2.8%) and −3.2% (−3.7% to −2.8%) in 1979-86 to −0.1% (−0.7% to 0.4%) and −1.1% (−1.7% to −0.5%) in 1987-93. Mortality from other cardiovascular diseases, however, started to increase: from −2.0% (−2.4% to −1.6%) and −0.2% (−0.5% to 0.2%) in 1979-86 to 1.5% (1.0% to 2.0%) and 1.9% (1.5% to 2.3%) in 1987-93. Hospital discharge rates for acute coronary heart disease, congestive heart failure, and stroke increased during 1980-6. During 1987-93 discharge rates for stroke and coronary heart disease stabilised but rates for congestive heart failure increased. Conclusion: Improved management of coronary heart disease seems to have reduced mortality, but some of the gains are lost to deaths from stroke and other cardiovascular diseases. The increasing numbers of patients with coronary heart disease who survive will increase demands on health services for long term care.

Screening for colorectal cancer: Comparison of perceived test burden of guaiac-based faecal occult blood test, faecal immunochemical test and flexible sigmoidoscopy

BACKGROUND Perceived burden of colorectal cancer (CRC) screening is an important determinant of participation in subsequent screening rounds and therefore crucial for the effectiveness of a screening programme. This study determined differences in perceived burden and willingness to return for a second screening round among participants of a randomised population-based trial comparing a guaiac-based faecal occult blood test (gFOBT), a faecal immunochemical test (FIT) and flexible sigmoidoscopy (FS) screening. METHODS A representative sample of the Dutch population (aged 50-74years) was randomised to be invited for gFOBT, FIT and FS screening. A random sample of participants of each group was asked to complete a questionnaire about test burden and willingness to return for CRC screening. RESULTS In total 402/481 (84%) gFOBT, 530/659 (80%) FIT and 852/1124 (76%) FS screenees returned the questionnaire. The test was reported as burdensome by 2.5% of gFOBT, 1.4% of FIT and 12.9% of FS screenees (comparing gFOBT versus FIT p=0.05; versus FS p<0.001). In total 94.1% of gFOBT, 94.0% of FIT and 83.8% of FS screenees were willing to attend successive screening rounds (comparing gFOBT versus FIT p=0.84; versus FS p<0.001). Women reported more burden during FS screening than men (18.2% versus 7.7%; p<0.001). CONCLUSIONS FIT slightly outperforms gFOBT with a lower level of reported discomfort and overall burden. Both FOBTs are better accepted than FS screening. All three tests have a high level of acceptance, which may affect uptake of subsequent screening rounds and should be taken into consideration before implementing a CRC screening programme.

Having a Pap smear, quality of life before and after cervical screening: a questionnaire study.

Please cite this paper as: Korfage I, van Ballegooijen M, Wauben B, Looman C, Habbema J, Essink‐Bot M. Having a Pap smear, quality of life before and after cervical screening: a questionnaire study. BJOG 2012;119:936–944.

Mammography requests in general practice during the introduction of nationwide breast cancer screening, 1988-1995.

Introducing an organised breast cancer screening programme for certain age groups in a population might induce opportunistic screening in adjacent (non-invited) age groups and influence health behaviour in the target population. We analysed the effect of the start of the Dutch national screening programme on the number of mammographies requested by 43-45 general practices for the age groups 30-39, 40-49, 50-69 and 70+ years, using logistic regression analysis. In all age groups an immediate increase was observed in the number of mammography requests after the start of the screening, which was largest and statistically significant in the target population of the screening programme (age 50-69 years). More than 2 years after the start of screening, the number of mammography requests in all age groups had decreased to the level before the start and in the age group 50-69 years the number of mammographies was significantly lower than before the screening started. The unexpected increase in mammographies after the start of the breast cancer screening programme might be related to registry problems or to the process of building up the screening programme. Eventually there was a decrease in the number of mammographies in the target population, probably an effect of the introduction of the national screening programme. Opportunistic screening was not clearly demonstrated in adjacent age groups.

Diverging trends in colorectal cancer morbidity and mortality. Earlier diagnosis comes at a price

In developed countries, time trends in the incidence of colorectal cancer differ markedly from trends in mortality. This study sought to explain simultaneously changes in both colorectal cancer incidence and mortality. Data on first admissions, interventions and outcome from the national hospital registry over the period 1978-1989 and data on mortality from Statistics Netherlands over the same period were analysed by age-period models and subsequently entered in a Markov chain model, simulating disease history from first admission to death. Over the period 1978-1989, age adjusted numbers of first admissions and interventions increased by 37% and 32%, respectively, while mortality declined by 8%. For every 100 patients admitted between 1987 and 1989, 13 more will survive compared with 1978-1980. Of these, 3 will be saved by improving results of primary treatment but the other 10 will survive their diagnosis for the subsequent 10 years. Although progress in treatment has been made, therapeutic improvement can account only for the smaller part of the divergence between morbidity and mortality. Increased diagnostic activity, raising incidence and lowering mortality simultaneously, is the most likely cause of the unexplained divergence.

Letters to the EditorLife-terminating acts without explicit request of patient

In the Dutch nationwide study on medical decisions concerning the end of life (MDEL) life-terminating acts without the explicit request of the patient (LAWER) were noted in 0.8% of all deaths. We present here quantitative information and a discussion of the main issues raised by LAWER. In 59% of LAWER the physician had some information about the patients wish; in 41% discussion on the decision would no longer have been possible. In LAWER patients tend to be younger and more likely to be male and to have cancer than in non-acute deaths generally. The physician (specialist or general practitioner) knew the patient on average 2.4 years and 7.2 years, respectively. Life was shortened by between some hours and a week at most in 86%. In 83% the decision has been discussed with relatives and in 70% with a colleague. In nearly all cases, according to the physician, the patient was suffering unbearably, there was no chance of improvement, and palliative possibilities were exhausted. MDEL probably will increase in number in future but interviews with Dutch physicians suggest a possible fall in LAWER, even though there will always be some situations in which a well-considered LAWER decision may have to be made.