G. J. Liefers

Breast cancer in elderly compared to younger patients in the Netherlands: stage at diagnosis, treatment and survival in 127,805 unselected patients.

Breast cancer is the most common type of cancer in several parts of the world and the number of elderly patients is increasing. The aim of this study was to describe stage at diagnosis, treatment, and relative survival of elderly patients compared to younger patients in the Netherlands. Adult female patients with their first primary breast cancer diagnosed between 1995 and 2005 were selected. Stage, treatment, and relative survival were described for young and elderly (≥65xa0years) patients and within the cohort of elderly patients according to 5-year age groups. Overall, 127,805 patients were included. Elderly breast cancer patients were diagnosed with a higher stage of disease. Moreover, within the elderly differences in stage were observed. Elderly underwent less surgery (99.2–41.2%); elderly received hormonal treatment as monotherapy more frequently (0.8–47.3%); and less adjuvant systemic treatment (79–53%). Elderly breast cancer patients with breast cancer had a decreased relative survival. Although relative survival was lower in the elderly, the percentage of patients who die of their breast cancer less than 50% above age 75. In conclusion, the relative survival for the elderly is lower as compared to their younger counterparts while the percentage of deaths due to other causes increases with age. This could indicate that the patient selection is poor and fit patients could suffer from “under treatment”. In the future, specific geriatric screening tools are necessary to identify fit elderly patients who could receive more “aggressive” treatment while best supportive care should be given to frail elderly patients.

Prevention of seroma formation after axillary dissection in breast cancer: a systematic review.

BACKGROUNDnThe most common complication after breast cancer surgery is seroma formation. It is a source of significant morbidity and discomfort. Many articles have been published describing risk factors and preventive measures. The aim of this paper is to provide a systematic review of studies and reports on risk factors and preventive measures. Surgery lies at the core of seroma formation; therefore focus will be placed on surgical ways of reducing seroma.nnnMETHODSnA computer assisted medline search was carried out, followed by manual retrieval of relevant articles found in the reference listings of original articles.nnnRESULTSn136 relevant articles were reviewed. Though the level of evidence remain varied several factors, type of dissection, tools with which dissection is carried out, reduction of dead space, suction drainage, use of fibrin glue and octreotide usage, have been found to correlate with seroma formation and have been shown to significantly reduce seroma rates.nnnCONCLUSIONnSeroma formation after breast cancer surgery cannot be avoided at present. There are however several methods to minimize seroma and associated morbidity. Future research should be directed towards the best ways of reducing seroma by combining proven methods.

Adherence to treatment guidelines and survival in patients with early-stage breast cancer by age at diagnosis

Elderly patients with breast cancer are under‐represented in clinical studies. It is not known whether treatment guidelines, based on clinical trials, can be extrapolated to this population. The aim of this study was to assess adherence to treatment guidelines by age at diagnosis, and to examine age‐specific survival in relation to adherence to guidelines.

Surgery in metastatic breast cancer: Patients with a favorable profile seem to have the most benefit from surgery

INTRODUCTIONnAbout 3-10% of breast cancer patients have distant metastases (Stage IV) at initial presentation; standard treatment (in the Netherlands) of these patients consists of palliative systemic therapy. However, retrospective studies have shown an improved survival in patients who received surgery for their primary tumor. The aim of this study was to assess characteristics associated with surgical treatment and to determine the impact on survival in women with stage IV breast cancer.nnnMETHODSnA cohort of women with a diagnosis of breast cancer and concomitant distant metastases was retrospectively studied. Patient characteristics, treatment and survival distilled from medical files were evaluated using univariate and multivariable analysis.nnnRESULTSnOf 171 patients included in this analysis, 59 underwent surgery. In multivariable analysis lower age, no medication use, lower clinical T-stage and lower grade were associated with receiving surgery. In 21 of the 59 patients (35%) who received surgery it was unknown at the time of surgery that the patient had metastatic disease. Stratified survival analyses showed an association between surgery and improved survival for young patients (HR 0.3; pxa0=xa00.02), without comorbidity (HR 0.4; pxa0=xa00.002), with no medication use (HR 0.5; pxa0=xa00.009), with a small tumor (HR 0.4; pxa0=xa00.01), no regional lymph node involvement (HR 0.4; pxa0=xa00.01), with positive Estrogen (HR 0.6; pxa0=xa00.02) or Progesterone receptor (HR 0.4; pxa0=xa00.03) and with only visceral metastases (HR 0.5; pxa0=xa00.03). In multivariable analyses, younger patients and patients without comorbidity that received surgery had an increased survival (HR 0.3; pxa0=xa00.03 and HR 0.5; pxa0=xa00.03, respectively).nnnCONCLUSIONnThis study showed that patients with the most favorable profile receive local surgery and that a survival gain for operated patients was seen in young patients and in patients without comorbidity.

High non-compliance in the use of letrozole after 2.5 years of extended adjuvant endocrine therapy. Results from the IDEAL randomized trial

AIMSnThe aim of this study was to investigate non-compliance to aromatase inhibitors and factors associated with early treatment discontinuation in the extended adjuvant setting.nnnMETHODSnThe IDEAL trial is a prospective, open-label phase-III trial comparing 2.5 with 5 years of extended adjuvant letrozole (LET) in hormone receptor positive (HR+) postmenopausal early breast-cancer patients after 5 years of adjuvant endocrine therapy (ET). The purpose of this study was to assess non-compliance in the first 2.5 years of extended adjuvant therapy. Non-compliance was defined as early discontinuation of LET for all reasons, excluding death or recurrence.nnnRESULTSnAt 2.5 years, 1215 patients were included in the analysis. Overall non-compliance probability was 18.4%, of which 85.1% discontinued due to toxicities. Analyses showed that patients with prior sequential therapy were less likely to discontinue treatment than when treated with AI or TAM upfront (logrank pxa0=xa00.004). Longer treatment-free intervals also predicted more non-compliance (logrank pxa0=xa00.011). Age was not predictive of non-compliance (pxa0=xa00.571). Prior surgery (mastectomy vs breast conserving surgery), both with or without radiotherapy and/or chemotherapy were also not associated with early treatment discontinuation (pxa0=xa00.228 and pxa0=xa00.585 respectively). Although having fewer than four positive lymph nodes predicted more non-compliance (logrank pxa0=xa00.050), age, tumor type and locoregional treatment did not.nnnCONCLUSIONSnHigh non-compliance to extended ET was confirmed. Toxicities were the major reason for discontinuation, and this was not influenced by age. Longer treatment-free intervals and fewer positive lymph nodes predicted more non-compliance. Patients who underwent sequential therapy were least likely to discontinue extended adjuvant ET.

Expression of cell adhesion molecules and prognosis in breast cancer

Cell adhesion molecules (CAMs) play an important role in the process of metastasis. The prognostic value of tumour expression of N‐cadherin, E‐cadherin, carcinoembryonic antigen (CEA) and epithelial CAM (Ep‐CAM) was evaluated in patients with breast cancer.

Socioeconomic differences in survival among breast cancer patients in the Netherlands not explained by tumor size

There seem to be socioeconomically differences in survival for females with breast cancer, usually associated with a higher stage of disease. However, differences within tumor size have not been studied. Aim of this study is to assess differences in survival according to socioeconomic status (SES), stratified for tumor size and stage at diagnosis, for females with breast cancer in the Netherlands. All females diagnosed with breast cancer (1995–2005) were selected from the Netherlands Cancer Registry. Patients were linked to a SES database according to postal code. A multivariable logistic regression was used to assess factors associated with SES. Overall survival (OS) and relative survival (RS) were calculated. Overall, 127,599 patients were included. Higher SES was associated with lower T-stage (Pxa0<xa00.0001). A decreased survival (OS and RS) was found for patients with a lower SES. Also within different size groups, RS was different. Overall, 10-year OS for the high SES group was 65 and 58% for the low SES group (hazard ratio 1.1, Pxa0<xa00.001) and RS was 79 versus 74% (relative excess risk, RER 1.2; Pxa0<xa00.001). The socioeconomic differences remained statistically significant (Pxa0<xa00.001) after adjustment for age, year of diagnosis, grade, TNM stage, and treatment. For the lowest SES group 777 deaths could be avoided. Socioeconomic differences in survival of breast cancer patients were observed in the Netherlands. Higher stage at diagnosis of patients with a lower SES only partly explains the decreased survival. Policies aimed at the reduction of socioeconomic health inequalities might be important to improve survival of breast cancer.

The survival gap between middle-aged and elderly colon cancer patients. Time trends in treatment and survival

AIMSnFor several types of cancer, including colon cancer, the survival gap between middle-aged patients and elderly patients widened between 1988 and 1999 in Europe. The aim of our study was to describe treatments and compare survival rates over time (1991-2005) between middle-aged (<65 years), aged (65-74 years) and elderly (≥ 75 years) colon cancer patients in the mid-western part of the Netherlands to assess whether this survival gap further increased.nnnMETHODSnAll 8926 patients with invasive colon cancer diagnosed between 1991 and 2005 were selected from the Comprehensive Cancer Centre West. Relative survival was calculated. Relative Excess Risks of death (RER) were estimated using a multivariable generalized linear model with a Poisson distribution.nnnRESULTSnThere were no significant changes in the treatment for stage I and II colon. Patients with stage III and IV more often received chemotherapy over time (from 9.6% to 54.3% and from 7.5% to 44.2% for all ages, respectively), while less stage IV patients were operated on (from 73.1% to 55.2%). Relative 5-year survival increased significantly for middle-aged patients (RER = 0.97, 95%CI = 0.95-0.98, p < 0.001), borderline significantly (RER = 0.98, 95%CI = 0.97-0.99, p = 0.05) for elderly patients and not significantly for aged patients (RER = 0.99, 95%CI = 0.97-1.00, p = 0.08) after adjustment for sex, age, grade, stage, and treatment.nnnCONCLUSIONSnThe survival gap earlier found by the EUROCARE is confirmed for the mid-western part of the Netherlands, even after adjustment for age, sex, grade, stage and treatment. However, present study does not show an increase in the survival gap between middle-aged and elderly patients.

Impact of omission of surgery on survival of older patients with breast cancer

Older patients with breast cancer are often not treated in accordance with guidelines. With the emergence of endocrine therapy, omission of surgery can be considered in some patients. The aim of this population‐based study was to investigate time trends in surgical treatment between 1995 and 2011, and to evaluate the effects of omitting surgery on overall and relative survival in older patients with resectable breast cancer.

Association Between the Most Frequent Complications After Surgery for Stage I–III Colon Cancer and Short-Term Survival, Long-Term Survival, and Recurrences

BackgroundThe purpose of this study was to identify the ten most frequent complications after surgery for stage I–III colon cancer and to assess the association between these complications and overall survival, conditional overall survival, and recurrences.MethodsAll patients who underwent surgery for stage I–III colon cancer in five hospitals in the Western region of the Netherlands were identified. Crude and adjusted Cox proportional hazards models were used to study the association between complications and 1-year overall survival, 5-year overall survival, 5-year conditional overall survival, and 5-year disease-free period.ResultsData from 761 patients were used for the analyses. Complications were associated with decreased 1-year overall survival (hazard ratio (HR) 2.87, 95xa0% confidence interval (CI) 1.82–4.51; pxa0<xa00.001), 5-year overall survival (HR 1.59, 95xa0% CI 1.25–2.04; pxa0<xa00.001), and 5-year conditional overall survival (HR 1.34, 95xa0% CI 1.06–1.69; pxa0=xa00.016), whereas an increasing number of complications had no additional impact. Anastomotic leakage, excessive blood loss, and (abdominal) sepsis were associated with reduced 1-year overall survival, anastomotic leakage, delirium, abscess, and (abdominal) sepsis with reduced 5-year overall survival, and anastomotic leakage, delirium, and abscess with reduced 5-year conditional overall survival. Anastomotic leakage, electrolyte disorders, and abscess were risk factors for recurrence within five years.ConclusionsOur results demonstrate the serious impact of the most frequent complications after surgery for colon cancer on short-term and long-term outcomes. This study confirms the prolonged impact of surgery and demonstrates that complications result not only in reduced 1-year survival, but also in reduced long-term outcomes.