M Louwman

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUNDnUpcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.nnnMETHODSnThe Pubmed database using the MeSH terms Neoplasms or Colorectal Neoplasms and Socioeconomic Factors for articles added between 1995 and 1st October 2009 led to 62 articles.nnnRESULTSnLow SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.nnnCONCLUSIONSnA quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Increased incidence of adenocarcinomas at the gastro-oesophageal junction in Dutch males since the 1990s

Background Worldwide population-based studies suggest that the incidence of oesophageal and gastric cardia adenocarcinomas has increased since the 1970s. Objective and methods We studied time trends in mortality and incidence rates of oesophageal and gastric carcinomas according to subsite and histology in the south-east Netherlands since 1978. Results The age-adjusted mortality and incidence rates for oesophageal cancer doubled in males over the entire 19-year study period from 2.7 to 5.6 and from 2.4 to 4.8 per 100 000 person years, respectively. In females, a similar trend for the mortality and incidence rates was seen, but at a lower level. The age-adjusted mortality and incidence rates for gastric cancer decreased with time from 20.7 to 12.8 and from 21.6 to 15.9 per 100 000 person years in males, respectively. In females, age-adjusted mortality and incidence rates for gastric cancer also decreased. Analysis of incidence rates by subsite and subtype showed an increase in adenocarcinomas of the oesophagus and gastric cardia, largely restricted to males. In females, the rise in incidence of squamous cell carcinoma of the oesophagus appeared to be more marked than the rise in adenocarcinomas, whereas the incidence of gastric cardia carcinomas has remained stable over the last 10 years. Neither the decrease in the number of unspecified tumours with time, nor the increase in the use of diagnostic endoscopy and imaging techniques, is likely to explain completely the observed increases. Conclusion The increase in incidence of adenocarcinomas at the gastro-oesophageal junction in the south-eastern Netherlands seems, at least in part, to represent a true underlying increase that is restricted largely to males.

Uncommon breast tumors in perspective: incidence, treatment and survival in the Netherlands.

The relatively small group of patients with breast tumors other than the ductal, lobular or mixed ducto‐lobular types, has reached nonnegligible numbers due to the ongoing increase in the incidence of breast cancer. We investigated stage and grade distribution of uncommon breast tumors using the nation‐wide Netherlands Cancer Registry (population 16.5 million) and incidence patterns, treatment and long‐term survival (up to 19 years) using the regional Eindhoven Cancer Registry (population 2.4 million). Incidence of all uncommon breast tumors together was 9.2/100,000 person years (age‐standardized, ESR). The proportion of stage I tumors was 70% among patients with tubular (n = 3,456) and 40–50% for mucinous (n = 3,482), papillary (n = 1,078), cribriform (n = 503) and neuroendocrine (n = 76) tumors, contrasting to 27, 28 and 36%, respectively among patients with Signet ring cell cancer (n = 75), Pagets disease (n = 818) and the common invasive ductal carcinomas (n = 121,656). A better age‐, stage‐, and grade‐adjusted prognosis was observed for patients with lobular (death risk ratio 0.8, 95%CI: 0.7–0.9), mucinous (0.5, 0.3–0.9), medullary (0.5, 0.3–0.9) and tubular (0.4, 0.2–0.6) carcinoma or phyllodes tumor (0.02, 0.0–0.2), compared with invasive ductal carcinomas. For patients with papillary (0.6, 0.2–1.6) and cribriform (0.1, 0.0–5.1) tumors better prognosis was not statistically significant. In conclusion, histologic type was an essential determinant of survival for about 10% of all newly diagnosed women with invasive breast cancer. Because patients with mucinous, tubular, medullary and phyllodes tumors have such a good prognosis, less aggressive treatment should be considered in some cases whereby specific guidelines are becoming increasingly desirable. Communication to patients with these specific histological types should reflect this.

Childhood social class and cancer incidence: Results of the globe study

Despite increased recognition of the importance of investigating socio-economic inequalities in health from a life course perspective, little is known about the influence of childhood socio-economic position (SEP) on cancer incidence. The authors studied the association between fathers occupation and adult cancer incidence by linking information from the longitudinal GLOBE study with the regional population-based Eindhoven Cancer Registry (the Netherlands) over a period of 14 years. In 1991, 18,973 participants (response rate 70.1%) of this study responded to a postal questionnaire, including questions on SEP in youth and adulthood. Respondents above the age of 24 were included (N=12,978). Cox regression was used to calculate hazard ratios (HR) for all cancers as well as for the five most frequently occurring cancers by respondents educational level or occupational class, and by fathers occupational class (adjusted for respondents education and occupation). Respondents with a low educational level showed an increased risk of all cancers, lung and breast cancer (in women). Respondents with a low adult occupational level showed an increased risk of lung cancer and a reduced risk of basal cell carcinoma. After adjustment for adult education and occupation, respondents whose father was in a lower occupational class showed an increased risk of colorectal cancer as compared to those with a father in the highest social class. In contrast, respondents whose father was in a lower occupational class, showed a decreased risk of basal cell carcinoma as compared to those with a father in the highest occupational class. The association between childhood SEP and cancer incidence is less consistent than the association between adult SEP and cancer incidence, but may exist for colorectal cancer and basal cell carcinoma.

Progress against cancer in the Netherlands since the late 1980s: an epidemiological evaluation.

Progress against cancer through prevention and treatment is often measured by survival statistics only instead of analyzing trends in incidence, survival and mortality simultaneously because of interactive influences. This study combines these parameters of major cancers to provide an overview of the progress achieved in the Netherlands since 1989 and to establish in which areas action is needed. The population‐based Netherlands Cancer Registry and Statistics Netherlands provided incidence, 5‐year relative survival and mortality of 23 major cancer types. Incidence, survival and mortality changes were calculated as the estimated annual percentage change. Optimal progress was defined as decreasing incidence and/or improving survival accompanied by declining mortality, and deterioration as increasing incidence and/or deteriorating survival accompanied by increasing mortality rates. Optimal progress was observed in 12 of 19 cancer types among males: laryngeal, lung, stomach, gallbladder, colon, rectal, bladder, prostate and thyroid cancer, leukemia, Hodgkin and non‐Hodgkin lymphoma. Among females, optimal progress was observed in 12 of 21 cancers: stomach, gallbladder, colon, rectal, breast, cervical, uterus, ovarian and thyroid cancer, leukemia, Hodgkin and non‐Hodgkin lymphoma. Deterioration occurred in three cancer types among males: skin melanoma, esophageal and kidney cancer, and among females six cancer types: skin melanoma, oral cavity, pharyngeal, esophageal, pancreatic and lung cancer. Our conceptual framework limits misinterpretations from separate trends and generates a more balanced discussion on progress.

Educational inequalities in cancer survival: a role for comorbidities and health behaviours?

Aim To describe educational inequalities in cancer survival and to what extent these can be explained by comorbidity and health behaviours (smoking, physical activity and alcohol consumption). Methods The GLOBE study sent postal questionnaires to individuals in The Netherlands in 1991 resulting in 18u2005973 respondents (response 70%). Questions were asked on education, health and health-related behaviours. Participants were linked for cancer diagnosis (1991–2008), comorbidity and survival (up to 2010) with the population-based Eindhoven Cancer Registry; 1127 tumours were included in the analyses. Results 5-year crude survival was best in highly educated patients as compared with low educated patients for all cancers combined: 49% versus 32% in male subjects (log rank: p<0.0001), 65% versus 49% in female subjects (p=0.0001). Compared with highly educated, low educated prostate cancer patients had an increased risk of death (HR 2.9 (95% CI 1.7 to 5.1), adjusted for age, stage and year). No or inconsistent associations between educational level and risk of death were seen in multivariable analyses for breast, colon and non-small cell lung cancer. Although survival in prostate cancer patients was affected by comorbidities (HR2_vs_0_comorbidities: 2.6 (1.5 to 4.4)), physical activity (HRno/little_vs__moderate_physical__activity: 2.0 (1.2 to 3.4)) and smoking (HRcurrent_vs_never_smokers: 2.6 (1.0–6.8)), these did not contribute to educational inequalities in prostate cancer survival (HRlow_vs_high_education: 3.1 (1.6 to 5.8) with adjustment for comorbidity and lifestyle). Conclusions Compared with low educated, highly educated prostate cancer patients had better survival. Although presence of comorbidities, physical activity levels and smoking status affected survival from prostate cancer, these did not contribute to educational inequalities in survival. The role of other factors for inequalities in cancer survival needs to be explored.

Determinants of prognosis in breast cancer patients with tumor involvement of the skin (pT4b).

Abstract: u2002 Determinants of prognosis were studied in patients with breast cancer with histologically proven tumor extension to the skin without clinical evidence of distant metastases (i.e., pT4b N0–3 M0). Data were collected retrospectively on 77 consecutive patients diagnosed in one community teaching hospital over the period from 1980 to 1995. The prognostic factor of tumor size showed a 5‐year survival rate for patients with a tumor ≤3 cm of 81% compared to 45% for patients with tumors larger than 3 cm (p = 0.002). Achievement of complete remission resulted in a 5‐year survival rate of 66%, compared to 27% when complete remission was not achieved (p = 0.005). Another important prognostic factor was the development of local‐regional recurrence: the 5‐year survival rates for patients with and without local‐regional recurrence were 39% and 87%, respectively (p < 0.001). Development of local‐regional recurrence was also significantly related to tumor size (p = 0.02). Pathologic tumor size and the achievement of complete remission and local‐regional control appear to be the most important prognostic factors for survival in patients with pT4b breast cancer without distant metastases. We conclude that the finding of a pT4b breast cancer does not always imply a dismal prognosis, especially for those patients with a tumor ≤3 cm. A favorable prognosis can be expected when treatment is effective in achieving complete remission and in preventing the development of local‐regional recurrence.u2002

Dutch Melanoma Treatment Registry: Quality assurance in the care of patients with metastatic melanoma in the Netherlands

BACKGROUNDnIn recent years, the treatment of metastatic melanoma has changed dramatically due to the development of immune checkpoint and mitogen-activated protein (MAP) kinase inhibitors. A population-based registry, the Dutch Melanoma Treatment Registry (DMTR), was set up in July 2013 to assure the safety and quality of melanoma care in the Netherlands. This article describes the design and objectives of the DMTR and presents some results of the first 2 years of registration.nnnMETHODSnThe DMTR documents detailed information on all Dutch patients with unresectable stage IIIc or IV melanoma. This includes tumour and patient characteristics, treatment patterns, clinical outcomes, quality of life, healthcare utilisation, informal care and productivity losses. These data are used for clinical auditing, increasing the transparency of melanoma care, providing insights into real-world cost-effectiveness and creating a platform for research.nnnRESULTSnWithin 1 year, all melanoma centres were participating in the DMTR. The quality performance indicators demonstrated that the BRAF inhibitors and ipilimumab have been safely introduced in the Netherlands with toxicity rates that were consistent with the phase III trials conducted. The median overall survival of patients treated with systemic therapy was 10.1 months (95% confidence interval [CI] 9.1-11.1) in the first registration year and 12.7 months (95% CI 11.6-13.7) in the second year.nnnCONCLUSIONnThe DMTR is the first comprehensive multipurpose nationwide registry and its collaboration with all stakeholders involved in melanoma care reflects an integrative view of cancer management. In future, the DMTR will provide insights into challenging questions regarding the definition of possible subsets of patients who benefit most from the new drugs.

Variation in cancer incidence in northeastern Belgium and southeastern Netherlands seems unrelated to cadmium emission of zinc smelters.

Exposure to cadmium has been established to be carcinogenic for humans by the International Agency for Research on Cancer, but this is mainly based on studies with occupational exposures. The substantial 100 year long emission of cadmium by three zinc smelters in the Kempen area across the Dutch–Belgian border might have affected the incidence of cancer in this region. Following a study of increased risks of lung cancer due to cadmium emission (hazard ratio was 4.2 for high vs. low cadmium exposure areas in that study), we used data from the three regional population-based cancer registries, covering an area with 2.9 million inhabitants. Analyses of observed incidence were carried out for all cancers and cancer of the lung, kidney, bladder, prostate, testis, and breast separately. At the municipality level standardized incidence ratios were calculated and smoothed using a Poisson-gamma or a conditional autoregressive model. To detect clusters and to calculate an observed/expected ratio (O/E ratio) for each cluster a spatial scan statistic was applied. Significantly increased cancer incidence rates were found at a multimunicipality level for female lung cancer (O/E ratio=1.2), male and female bladder cancer (O/E ratio male=1.8, O/E ratio female=1.7), and prostate cancer (O/E ratio=1.3), none of these clusters being located specifically around the area of the zinc smelters. Therefore, the long term emission of cadmium by the zinc smelters in the Kempen area did not seem to lead to an increase in the incidence of all cancers, and lung, kidney, bladder, prostate, testicular, or breast cancer.