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We reviewed all reports of skin biopsies that had been performed at the Miami Veterans Administration Hospital within a three-year period. A total of 1,115 biopsy specimens of basal cell and squamous cell carcinomas were identified for 558 patients. Patient names, diagnosis, and dates of biopsies were tabulated for computer analysis. We determined that 121 patients (22%) developed at least one new or recurrent skin cancer during the average follow-up period of 1 1/2 years. From a computer review of clinic appointments, we determined that half of the 558 patients were unavailable for follow-up during that three-year period. Thus, the true rate of new and recurrent skin cancer in patients who had at least one skin cancer is no less than 22% and may approach 50% in the first 18 months. This high rate of new occurrences and recurrences of basal cell and squamous cell carcinomas emphasizes the need for repeated examinations of all patients with a history of skin cancer.
BACKGROUND: A diagnosis of cancer provides a teachable moment in which a physician can counsel or teach the patient. The Cancer and Leukemia Group B hypothesized that this teachable moment could also be used to encourage counseling of the patients' relatives who smoke. The authors' first study sought to determine the feasibility of such an intervention, the cooperation of the patients, and the compliance of relatives who were smokers. The long-range goal is to recruit by mail a large population of adult smokers into an intervention program and to assist them in quitting cigarette smoking. METHODS: Oncologists and their clinical research associates asked recently diagnosed cancer patients to identify their relatives who were smokers and assist in persuading them to quit. Consenting patients spoke to relatives and mailed them a personalized motivational leaflet along with a list of the benefits of quitting smoking. Intervention was continued only with relatives who were contacted in this manner. The participating physicians then wrote to the smokers, advising them to quit; enclosed with each physician's letter were the National Cancer Institute booklet "Clearing the Air," which is about quitting smoking, and a questionnaire determining "stage of change" (the stage of the smoker's inaction or action regarding quitting smoking). After 6 months, a postintervention questionnaire was mailed to the relatives. RESULTS: Written consent was obtained from 89% of 144 eligible patients solicited. Eighty percent of patients involved in the study contacted relatives. Sixty-three percent of contacted relatives returned the first questionnaire and 40% answered the second. Nine percent of all contacted relatives reported having quit smoking after the intervention. CONCLUSIONS: The intervention proved to be feasible and will lead to the next study, which will randomize relatives who smoke within a more intensive intervention over 12 months and compare the results with nonintervention controls.
The question whether breast cancer is curable remains controversial. Late recurrences and death from the disease are not infrequent. Long term follow-up of a large patient population is necessary to study this issue. The authors report a study of 14,731 cases of breast cancer reported to the Cancer Registry of Norway with follow-up times ranging from 5 to 18 years. A model in which the logarithms of the survival times were assumed to be normally distributed, the lognormal model, fitted the data well for individual stages, age groups, and periods of treatment. The cured fraction, i.e., consisting of those only subject to normal mortality risks, was estimated from the model to 35 +/- 1% standard error. In Stages 1, 2, 3, and 4 it was 54 +/- 3%, 27 +/- 1%, 19 +/- 2%, and 2 +/- 1%, respectively. It is concluded, however, that the estimated cure rate in Stages 3 and 4 should be regarded with caution in view of the methodological problems involved in the analysis and the small number of patients with long follow-up. The estimated cured fraction in both the individual stages and in the entire material was significantly higher in patients younger than 55 years of age than in older patients. The median survival of non-cured patients was estimated to be 3.6 years for the entire material. In Stage 1, 2, 3, and 4 it was 7.6 years, 3.4 years, 2.1 years, and 0.7 years, respectively. The lognormal model seems to be a good approximation of breast cancer survival. The model is consistent both with late excess mortality and with the presence of a cured fraction. It is noteworthy that an excess mortality was observed during the whole follow-up period. Extrapolations from the model should therefore be cautiously judged until supported by observed data.
The Cancer Family Syndrome of Lynch (CFS) is characterized by the frequent occurrence of multiple types of cancers, often adenocarcinomas of the colon, endometrium, and breast, at early ages in a pedigree pattern suggesting an autosomal dominant mechanism of inheritance. An unusual CFS pedigree is presented in which members exhibited rare cancers, six primary cancers, and prolonged survival.
A multicenter cooperative study was conducted to evaluate the clinical efficacy and safety of cis-diammine(glycolato)platinum (254-S), a second-generation anticancer platinum complex, in the treatment of genitourinary cancers. 254-S was given i.v. at 100 mg/m2 at 4-week intervals. As a result, 2 complete responses (CRs) and 8 partial responses (PRs) were obtained in 35 patients with transitional-cell carcinoma (TCC) of the urinary bladder or pyeloureter, 3 PRs were obtained in 16 subjects with prostatic cancer, and 6 CRs and 6 PRs were obtained in 15 patients with testicular cancer, generating objective response rates of 28.6% [95% confidence interval (CI), 14.6%-46.3%], 18.8% (95% CI, 4.0%-45.6%), and 80.0% (95% CI, 51.9%-95.7%), respectively. Bone marrow suppression was the dose-limiting toxicity, although it was reversible. Although no hydration was performed in approx. 40% of the patients, the incidence of nephrotoxic effects was low and most of those encountered were mild, the exception being one patient who showed severe renal insufficiency after the first treatment. Nausea and vomiting occurred in approx. 70% of the patients, but most gastrointestinal toxicities were controlled without antiemetic treatment. In addition, liver-function impairment was rarely observed. We conclude that 254-S is a promising cisplatin analogue for the treatment of genitourinary cancers and is worthy of further investigation in large-scale, randomized comparative studies with other platinum derivatives in both single-agent and combination regimens.
To support a study of genetic risk factors for breast cancer, the North Carolina Central Cancer Registry has implemented a rapid reporting procedure for hospitals in the study area. This system permits the identification of newly diagnosed breast cancer cases within a very short time period (less than one month). The procedures are straightforward, cost-effective, and greatly benefit the objectives of tissue collection and interviews with the cases. This article describes the rapid reporting procedures and their potential impact for population-based research. For the objective of making generalizable risk statements, the necessity of population-based research is stressed; participation with central cancer registries is endorsed for this and other molecular epidemiologic applications.
If the risk of disease is not the same for all germline mutations in a given gene, or if there are other familial modifiers of risk in carriers, then family-history-based estimates of average risk for detected mutations in that gene will depend on how carriers are sampled. Risk may also depend on the site or type of mutation. We studied 51 families with strong histories of breast cancer who attended Australian family cancer clinics and in which a germline mutation in BRCA1 or BRCA2 had been identified (28 and 23 families, respectively). Breast cancer risk in carriers was estimated under maximum likelihood theory, using information from all family members including those not tested, with adjustment for ascertainment by conditioning on genotype of the proband and family phenotype. The average cumulative risk of breast cancer for mutations in either BRCA1 or BRCA2 was 27% (95% confidence interval 16-43%) to age 50 and 64% (44-83%) to age 70. When grouped, the incidence in carriers was on average 17 (10-30) times that in non-carriers, independent of gene or mutation type (hazard ratios: 11 (4-29) for BRCA1, 23 (12-43) for BRCA2 (P for difference = 0.23); 13 (6-29) for protein-truncating mutations, 30 (9-104) for missense mutations and 30 (10-90) for splice-site mutations). For missense mutations, this was equivalent to a cumulative risk to age 70 of 83% (40-100%) and was due in part, but not totally, to the missense mutations 300 T>G in BRCA1 and 4486 G>T in BRCA2, which were individually found to be associated with high risk (P<0.001). Mutations in the central region of BRCA1 may be associated with a lower risk. The issue of the pathogenicity of specific variants may be addressed analytically providing there are one or more suitably informative families with that mutation.
Resistance to various cancer therapies with survival or recurrence of a malignancy has been ascribed to the inability to "kill" hypoxic cancer cells. The reported resistance of cancer "stem" cells has also been proposed as a major reason for this outcome. In planning therapy, it should be important to know whether these two categories "overlap": do "hypoxic" cells subsume cancer "stem" cells; alternately, are "stem" cells somewhat hypoxic or are these categories distinct? If the former is true and these categories overlap, to what extent do their properties share biochemical elements in common; if the latter is the case, should both properties be "targeted" independently? The inability of a proposed therapy to suppress these foci of resistance could preclude a successful outcome. Results from pre-clinical and clinical laboratory determination of the stem cell/hypoxic cell response may reflect the likely outcome of the proposed clinical treatment.
Screening for prostate cancer and subsequent treatment is of unknown benefit but carries known treatment related morbidity and mortality risks. The recent enthusiasm for screening in the United States contrasts sharply with the more cautious attitudes of the European and Canadian medical communities. Current data from screening series without randomization and controls are inadequate to determine screening benefit. The prostate, lung, colorectal and ovarian cancer (randomized, controlled) screening trial of the National Cancer Institute, to include 74,000 men (and 74,000 women) 60 to 74 years old, has a design power of 90% to determine a 20% reduction of prostate cancer mortality from a baseline and 3 subsequent annual screens using prostate specific antigen and digital rectal examination. Randomization of participants into this trial began on November 16, 1993. Ten screening centers nationwide, a coordinating center, a laboratory and a biorepository are participating under contract.