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Over the past year, the National Cancer Institute has altered its guidelines for early breast cancer screening by omitting any recommendation for mammography and clinical breast examination for women aged 40 to 49 years, while the American Cancer Society has reaffirmed its recommendation for these screening procedures in this age group. This article reviews the process and some of the evidence the American Cancer Society has relied upon in reaffirming its recommended guidelines for early breast cancer detection.
BACKGROUND: Prostate carcinoma incidence has been declining since 1992 after a period of marked increase. Recent data from the National Cancer Data Base (NCDB) were examined to assess changes in prostate carcinoma patient characteristics and disease and treatment patterns coincidental to this decline. The NCDB is a program of the American College of Surgeons Commission on Cancer and the American Cancer Society that collects timely data from institutions representing every level of cancer care. METHODS: Data from 1114 hospitals regarding 103,979 patients diagnosed with prostate carcinoma in 1992 and from 1144 hospitals regarding 72,337 patients diagnosed in 1995 were studied. Patient and disease characteristics studied included age, race, American Joint Committee on Cancer stage, and tumor histologic grade. Trends in treatment and variations in treatment by region also were examined. RESULTS: The average age at diagnosis declined by 2 years over the period studied and the proportion of patients identified as African-American increased from 8.8% to 11.8%. The proportion of patients diagnosed with localized disease and the proportion of tumors of moderately differentiated histologic grade increased. The overall proportion of patients treated by radical prostatectomy increased and the use of external beam radiation treatment decreased. Substantial regional variation in treatment patterns was observed. The Pacific and Mountain state regions of the U. S. had the highest proportions of patients treated by radical prostatectomy although increases were occurring in other regions. Use of external beam radiation treatment was highest in the Northeast and Southeast states and was declining in the majority of regions. Use of brachytherapy radiation treatment by implantation of radioactive seeds was infrequent but increasing. CONCLUSIONS: Comparison of the basic characteristics of prostate carcinoma data from 1992 and 1995 shows that patients are being diagnosed at younger ages and earlier stages, the proportion of African-Americans has increased, and more patients are being treated for cure. Regional differences in patterns of care persist but may be moderating. The annual prostate carcinoma death rate in the U.S. has declined an average of 1% per year since 1990.
BACKGROUND: In combination with other Commission on Cancer programs, the National Cancer Data Base (NCDB), a national electronic registry system currently capturing > 60% of incident cancers in the U. S., offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is proving to be of particular value in capturing clinical information concerning rare cancers. METHODS: For accession years 1985-1995, the NCDB captured prospectively collected demographic, stage, treatment, and outcome information for a national hospital-based sample of 286 parathyroid carcinoma cases (0.005% of the total NCDB cancer cases). This report describes clinical and demographic features as well as patterns of care and 5-year and 10-year relative survival rates. RESULTS: The NCDB's 10-year accrual of parathyroid carcinoma cases exceeded the cumulative number reported in the English literature though 1991. Gender distribution was equal. The authors were unable to detect any disproportionate clustering by race, income level, or geographic region. Treatment overwhelmingly was surgical. The data from the current study suggest that neither tumor size nor lymph node status are significant prognostic factors. Overall relative survival at 5 years and 10 years was 85.5% and 49.1%, respectively. CONCLUSIONS: At 5 years of follow-up, and possibly beyond, neither tumor size nor lymph node status were found to be significant prognostic factors and basing a staging system on them would be useless. Although complete, en bloc resection of all tumor represents the best opportunity for cure, a substantial proportion of patients fail to receive such treatment. The authors speculate that the rarity of this condition and late intraoperative recognition occasionally prevent optimal treatment. [See editorial on pages 378-80, this issue.]
BACKGROUND: Small bowel adenocarcinoma (SBA) accounts for 2% of gastrointestinal (GI) tumors and 1% of GI cancer deaths. The objective of this study was to review the National Cancer Data Base (NCDB) to identify case-mix characteristics, patterns of treatment, and factors influencing survival of patients with SBA. METHODS: NCDB data from patients diagnosed with primary SBA between 1985-1995 were analyzed. Chi-square statistics were used to compare differences between groups. Disease specific survival (DSS) was calculated using the life table method for patients diagnosed between 1985-1990; univariate differences in survival were compared using the Wilcoxon statistic, and multivariate analyses were performed using a Cox regression model. RESULTS: There were 4995 SBA cases reported to the NCDB between 1985-1995, 55% of which occurred in the duodenum, 18% in the jejunum, 13% in the ileum, and 14% in nonspecified sites. The overall 5-year DSS was 30.5%, with a median survival of 19.7 months. By multivariate analysis, factors significantly correlated with DSS included patient age, tumor site, disease stage, and whether cancer-directed surgery was performed. CONCLUSIONS: SBA is found most commonly in the duodenum, and patient DSS is reduced at this site compared with those patients with jejunal or ileal tumors. This reduction in survival was associated with a lower percentage of cancer-directed surgery. Patients age > 75 years had a reduced DSS and more duodenal tumors, and were less frequently treated by cancer-directed surgery than their younger counterparts. This study reflects the experience with SBA from a large cross-section of U.S. hospitals, allowing for the identification of prognostic factors and providing a reference with which results from single institutions may be compared.
BACKGROUND: Cancers and cancer treatments produce multiple symptoms that collectively cause a symptom burden for patients. These symptoms include pain, wasting, fatigue, cognitive impairment, anxiety, and depression, many of which co-occur. There is growing recognition that at least some of these symptoms may share common biologic mechanisms. METHODS: In November 2001, basic and clinical scientists met to consider evidence for a cytokine-immunologic model of symptom expression along with directions for future research. RESULTS: The characteristics of cytokine-induced sickness behavior in animal models have much in common with those of symptomatic cancer patients. Sickness behavior refers to a set of physiologic and behavioral responses observed in animals after the administration of infectious or inflammatory agents or certain proinflammatory cytokines. In some cases, these responses can be prevented by cytokine antagonists. A combination of animal and human research suggests that several cancer-related symptoms may involve the actions of proinflammatory cytokines. CONCLUSIONS: Based on the similarities between cancer symptoms and sickness behavior, the authors discussed approaches to further test the implications of the relationship between inflammatory cytokines and symptoms for both symptom treatment and symptom prevention.
Biopsy materials obtained in the American Cancer Society National Prostate Cancer Detection Project were reviewed at the Central Pathology Laboratory at the Armed Forces Institute of Pathology. Of 265 cases submitted, 177 were diagnosed as prostatic carcinoma, 7 as prostatic intraepithelial neoplasia (PIN), 13 as atypical glands or atypical hyperplasia, and the remaining 68 were benign hyperplasias. Irrespective of the means of detectin or the grading system used (Gleason or WHO-Mostofi), a large majority of the cancers were detected as low-grade tumors. Of 27 cases of PIN reported, 20 were associated with cancer, leaving 7 cases with the sole diagnosis of PIN. These data may indicate the increased use of prostate-specific antigen (PSA), digital rectal examination (DRE), and transrectal ultrasound (TRUS) in the United States is shifting the spectrum of prostate cancer pathology toward early low-grade tumors.
A specific macrophage migration inhibition assay, using patient lymphocytes incubated with a human colonic cancer extract, was studied in 92 patients with proven colorectal cancer and in 134 other individuals (20 normal controls, 80 patients with various nonmalignant gastrointestinal diseases, and 34 patients with extracolonic malignancies). A positive response was obtained in 78 of 92 colorectal cancer patients, but in none of the 20 normal controls. A positive response occurred in four of 34 patients with extracolonic malignancies and in approximately half of patients with colonic adenomas and in one third of patients with ulcerative colitis. The significance of positive results in these patients (with diseases considered premalignant) is unclear, and is being studied further. In patients with previous resection of colorectal cancers, positive responses were frequent during the first year following resection, and rare thereafter. The results suggest that this method may be useful as a clinical marker for colorectal cancer, and warrants further technical refinement and study of specific patient populations.
OBJECTIVE: Tumor registry data were studied to assess the magnitude and nature of the trend toward increased use of radical prostatectomy for the treatment of newly diagnosed localized prostate cancer. METHODS: The Commission on Cancer of the American College of Surgeons National Cancer Data Base aggregates data from hospital tumor registries located throughout the United States. Data from this resource on 4,531 patients treated in 1985, 25,028 treated in 1988, and 21,697 treated in 1990 were reviewed. RESULTS: The data indicate that selection of radical prostatectomy increased markedly over this interval. Use of radical prostatectomy was greatest in younger men in every year studied. The proportion of patients treated by radical prostatectomy was greatest in the western United States and least in New England and the mid-Atlantic region. Radical prostatectomy was associated with patients' socioeconomic status and race as well as with the hospital's caseload of patients with cancer. CONCLUSIONS: The pattern of care for localized prostate cancer is changing significantly. Further research is needed to assess whether these variations reflect differences in access to care or patterns of patient preference.
The Prostate Cancer Prevention Trial was the first clinical trial to show that a direct intervention (5 mg of finasteride daily for 7 years) could reduce a man's risk of developing prostate cancer. Initial results also suggested that men taking finasteride had an increased risk of developing what appeared to be higher-grade disease (Gleason score 7-10). The National Cancer Institute has a congressional mandate to communicate health information to the public and has established methods to reach the public directly and to reach information intermediaries in the media, professional societies, and advocacy groups. The groundbreaking yet complicated results of the Prostate Cancer Prevention Trial were widely disseminated by National Cancer Institute using the social marketing and public-relations strategies and tactics detailed here.
BACKGROUND: The Stockholm I and II randomised trials demonstrated the value of preoperative radiotherapy in preventing local recurrence in rectal cancer. This, study investigated the potential for further improvement by introduction of the concept of total mesorectal excision (TME) to surgeons in Stockholm, Sweden. METHODS: Workshops started in 1994 and included 11 television-based demonstrations and two histopathology sessions. The study population consisted of all patients who underwent abdominal operations for rectal cancer in Stockholm County during 1995-96 (TME project; n=447). Outcomes at 2 years were compared with those from the Stockholm I (n=790) and II (n=542) trials as historical controls. FINDINGS: For patients with curative abdominal resections, there were no differences between the Stockholm I (n=686), Stockholm II (n=481), and TME project (n=381) groups in 30-day mortality (30 [4%], six [1%], and 12 [3%]), anastomotic leakage (27 [10%], 18 [9%], and 23 [9%]), or all complications (204 [30%], 169 [35%], and 134 [35%]). This similarity was achieved despite a decrease in the proportion of abdominoperineal procedures from 55-60% to 27%. Local recurrence occurred in significantly fewer of the TME group than of the Stockholm I and II groups (21 [6%] vs 103 [15%] and 66 [14%], p<0.001) as did cancer-related death (35 [9%] vs 104 [15%] and 77 [16%], p<0.002). INTERPRETATION: A surgical teaching initiative had a major effect on cancer outcomes. The proportion of abdominoperineal procedures and the local recurrence rate decreased by more than 50% and there is already evidence of a decline in rectal-cancer mortality.
Environmental tobacco smoke (ETS) has been classified as a human lung carcinogen by the United States Environmental Protection Agency (EPA), based both on the chemical similarity of sidestream and mainstream smoke and on slightly higher lung cancer risk in never-smokers whose spouses smoke compared with those married to nonsmokers. We evaluated the relation between ETS and lung cancer prospectively in the US, among 114,286 female and 19,549 male never-smokers, married to smokers, compared with about 77,000 female and 77,000 male never-smokers whose spouses did not smoke. Multivariate analyses, based on 247 lung cancer deaths, controlled for age, race, diet, and occupation. Dose-response analyses were restricted to 92,222 women whose husbands provided complete information on cigarette smoking and date of marriage. Lung cancer death rates, adjusted for other factors, were 20 percent higher among women whose husbands ever smoked during the current marriage than among those married to never-smokers (relative risk [RR] = 1.2, 95 percent confidence interval [CI] = 0.8-1.6). For never-smoking men whose wives smoked, the RR was 1.1 (CI = 0.6-1.8). Risk among women was similar or higher when the husband continued to smoke (RR = 1.2, CI = 0.8-1.8), or smoked 40 or more cigarettes per day (RR = 1.9, CI = 1.0-3.6), but did not increase with years of marriage to a smoker. Most CIs included the null. Although generally not statistically significant, these results agree with the EPA summary estimate that spousal smoking increases lung cancer risk by about 20 percent in never-smoking women. Even large prospective studies have limited statistical power to measure precisely the risk from ETS.
There is evidence that predisposition to cancer has a genetic component. Genetic models have suggested that there is at least one highly penetrant gene predisposing to this disease. The oncogene MXI1 on chromosome band 10q24-25 is mutated in a proportion of prostate tumours and loss of heterozygosity occurs at this site, suggesting the location of a tumour suppressor in this region. To investigate the possibility that MXI1 may be involved in inherited susceptibility to prostate cancer, we have sequenced the HLH and ZIP regions of the gene in 38 families with either three cases of prostate cancer or two affected siblings both diagnosed below the age of 67 years. These are the areas within which mutations have been described in some sporadic prostate cancers. No mutations were found in these two important coding regions and we therefore conclude that MXI1 does not make a major contribution to prostate cancer susceptibility.
Newly diagnosed cancer patients (N = 133) were studied to determine gender-based differences in initial adjustment and whether, within the female population, women with gynecological or breast cancer adjust differently. The Brief Symptom Inventory (BSI) and the Rand Health Insurance Study-General Well-Being Schedule (HIS-GWB) were used to measure anxiety, depression, hostility, somatization, and general psychological distress or psychological well-being. There were no gender differences on any of the measures when men were compared with women. However, when gynecological/breast cancer patients were analyzed separately from women with other forms of cancer, they were significantly less depressed, anxious, and hostile; they had less somatization, less psychological distress, and greater psychological well-being. These findings may be related to the perception of their illness as being less serious than that of other females with cancer.
Prostate cancer shows evidence of familial aggregation, particularly at young ages at diagnosis, but the inherited basis of familial prostate cancer is poorly understood. Smith et al. recently found evidence of linkage to markers on 1q, at a locus designated "HPC1," in 91 families with multiple cases of early-onset prostate cancer. Using both parametric and nonparametric methods, we attempted to confirm this finding, in 60 affected related pairs and in 76 families with three or more cases of prostate cancer, but we found no significant evidence of linkage. The estimated proportion of linked families, under a standard autosomal dominant model, was 4%, with an upper 95% confidence limit of 31%. We conclude that the HPC1 locus is responsible for only a minority of familial prostate cancer cases and that it is likely to be most important in families with at least four cases of the disease.
OBJECTIVE: This study compared the UICC classification with the General Rules for Gastric Cancer Study (GRGCS) of the Japanese Research Society by analyzing recent results of gastric cancer surgery in Japan. SUMMARY BACKGROUND DATA: The present UICC stage classification for gastric cancer was published in 1987 and the Japanese GRGCS were published in 1985. Both are based on the results of surveys conducted in the early 1970s. METHODS: The survival curves of 926 patients, who underwent gastric cancer surgery between 1982 and 1985 at Kyoto University Hospital and its 31 associated hospitals, were analyzed according to the UICC classification and the GRGCS using SAS computer software. RESULTS: There was no difference in survival rate between UICC stages IA and IB. GRGCS stage III was found to include UICC stages II, IIIA, and IIIB, and GRGCS stage IV included UICC stages IIIA, IIIB, and IV, with significantly different survival rates. In contrast, each UICC stage included different GRGCS stages with no significant differences in survival rates. The survival rate of stage IV patients of both classifications who underwent gastrectomy was significantly higher than that of stage IV patients receiving bypass or exploratory surgeries. CONCLUSIONS: The UICC classification is better than the GRGCS for classifying gastric cancer in Japan. However, UICC stage I does not need to be subdivided into stages IA and IB, and stage IV should be further subdivided into stages IVA and IVB according to the surgery performed: IVA, gastrectomy, and IVB, bypass or exploratory surgery.
Nonepithelial ovarian cancers are rare, and little is known about their etiology. Of particular interest are the effects of oral contraceptive use and pregnancy, both of which are associated with large decreases in risk for epithelial ovarian cancer. We examined the risk factors for nonepithelial ovarian tumors by combining data from four case-control studies conducted in the United States. We compared personal characteristics of 38 germ cell cases and 45 stromal cases, respectively, with 1,142 and 2,617 general population controls. All subjects were over age 18 years. For germ cell tumors, there was a weak negative association with parity but no consistent pattern of decreasing risk with increasing parity. In contrast, relative to nulligravid women, gravid nulliparous women were at increased risk of developing a germ cell cancer [odds ratio (OR) = 4.8, 95% confidence interval (CI) = 1.2-18.6]. The use of oral contraceptives was also associated with elevated risk (OR = 2.0, 95% CI = 0.77-5.1); however, no clear trends in risk were observed. For stromal tumors, oral contraceptive use was associated with decreased risk (OR = 0.37, 95% CI = 0.16-0.83), whereas pregnancy was associated with a small elevation in risk. A trend of increasing risk with increasing age at first term pregnancy was observed, with an odds ratio of 3.6 (95% CI = 1.0-12.5) for a first birth after age 29 years. Risk factors for nonepithelial ovarian cancers do not appear to parallel each other or those for epithelial ovarian cancer.
Barrett's oesophagus is associated with an increased risk of oesophageal adenocarcinoma. In 1985, Sontag et al reported an association between Barrett's oesophagus and colorectal cancer. This association has become controversial owing to conflicting evidence. Two recent papers indicate that although the prevalence of colon adenomas is the same in persons with Barrett's oesophagus as in the rest of the population, patients have an increased risk of developing colon cancer. A biologically plausible hypothesis is presented which explains the predisposition to both oesophageal and colon cancers. This hypothesis discusses the contribution of environmental factors such as alcohol, smoking and diet. In addition, it is proposed that the increased expression of the cyclo-oxygenase 2 enzyme is central to the predisposition to both oesophageal and colon cancers. Since this enzyme is inhibited by non-steroidal anti-inflammatory drugs such as aspirin and sulindac, these drugs hold promise as cancer chemopreventive agents in Barrett's oesophagus patients. Sulindac is the most promising of these agents owing to its efficacy in regressing colon polyps in patients with familial adenomatous polyposis.