Axillary ultrasound for preoperative nodal staging in breast cancer patients: is it of added value?

Purpose The number of cancer survivors is increasing, and patients with cancer often experience long-lasting consequences of cancer and its treatment. Because of the variety of health problems and high prevalence of comorbidity, primary care physicians (PCPs) seem obvious candidates to take care of these patients, and insight into primary health care (PHC) use of cancer survivors is needed. We aimed to find determinants for PHC use in cancer survivors. Methods Using data from the Netherlands Information Network of Primary Care, we determined the volume of PHC use in 1,256 adult patients with breast cancer, 503 patients with prostate cancer, and 487 patients with colorectal cancer 2 to 5 years after diagnosis and compared this with age- and sex-matched controls without cancer from the same practice. We also examined whether age, comorbidity, and time since diagnosis were related to PHC use. Results The mean annual number of primary care contacts was increased compared with control patients by 24% in patien...

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Determinants of Increased Primary Health Care Use in Cancer Survivors

For which health problems do cancer survivors visit their General Practitioner

The number of cancer survivors is increasing due to improved treatments. Consequently, general practitioners will treat more and more cancer survivors in the upcoming years. Only little is known about the care needs of these survivors and guidelines to support general practitioners in their treatment of these patients are lacking. The aim of this study was to gain insight in the health care needs of cancer survivors in general practice. A systematic review on cancer survivors’ general practice needs was conducted in PubMed, Embase and the Cochrane Library of Systematic Reviews. Eligible studies could be qualitative or quantitative studies examining cancer survivors’ needs in general practice. Studies of adult survivors, with any cancer type, considered free of active disease and no longer receiving active treatment, were included. For each study a quality score was given using a form developed specifically for this study. Statements about survivors’ general practice needs were collected and corresponding themes were grouped. Fifteen studies were included, of which twelve were qualitative. Most mentioned general practice needs were psychosocial needs, mainly being support received form the GP, followed by a need for help with medical issues, and a need for information on cancer, recovery, late treatment effects and on adjusting to life after treatment. Cancer survivors have different types of general practice needs that are currently not or insufficiently met. This review provides a starting point for the development of new guidelines for general practitioners to support in cancer survivorship.

https://link.springer.com/content/pdf/10.1186%2F1471-2296-15-94.pdf

Health care needs of cancer survivors in general practice: a systematic review.

The 70-gene signature (MammaPrint) has been developed to predict the risk of distant metastases in breast cancer and select those patients who may benefit from adjuvant treatment. Given the strong association between locoregional and distant recurrence, we hypothesize that the 70-gene signature will also be able to predict the risk of locoregional recurrence (LRR). 1,053 breast cancer patients primarily treated with breast-conserving treatment or mastectomy at the Netherlands Cancer Institute between 1984 and 2006 were included. Adjuvant treatment consisted of radiotherapy, chemotherapy, and/or endocrine therapy as indicated by guidelines used at the time. All patients were included in various 70-gene signature validation studies. After a median follow-up of 8.96 years with 87 LRRs, patients with a high-risk 70-gene signature (n = 492) had an LRR risk of 12.6% (95% CI 9.7-15.8) at 10 years, compared to 6.1% (95% CI 4.1-8.5) for low-risk patients (n = 561; P < 0.001). Adjusting the 70-gene signature in a competing risk model for the clinicopathological factors such as age, tumour size, grade, hormone receptor status, LVI, axillary lymph node involvement, surgical treatment, endocrine treatment, and chemotherapy resulted in a multivariable HR of 1.73 (95% CI 1.02-2.93; P = 0.042). Adding the signature to the model based on clinicopathological factors improved the discrimination, albeit non-significantly [C-index through 10 years changed from 0.731 (95% CI 0.682-0.782) to 0.741 (95% CI 0.693-0.790)]. Calibration of the prognostic models was excellent. The 70-gene signature is an independent prognostic factor for LRR. A significantly lower local recurrence risk was seen in patients with a low-risk 70-gene signature compared to those with high-risk 70-gene signature.

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Gene expression profiling to predict the risk of locoregional recurrence in breast cancer: a pooled analysis

OBJECTIVE To describe the percentage of local recurrences within 5 years after surgery for breast cancer as a performance indicator for Dutch hospitals. DESIGN Descriptive, cohort study. METHOD All women diagnosed with a primary invasive breast cancer in 2003 for which they underwent curatively intended surgical treatment (with or without radiotherapy), were selected from the Netherlands Cancer Registry (NCR). NCR registration clerks collected additional information on recurrences within 5 years after initial diagnosis following standardized protocol. Percentages of local recurrences per hospital were estimated using Kaplan Meier analysis and were presented in forest plots and funnel plots. RESULTS In 2003, 9898 women diagnosed with primary breast cancer were curatively treated in one of the 99 Dutch hospitals. 266 patients experienced local recurrences within 5 years. The 5-year percentage of local recurrences was 3.03% (95% CI: 2.69-3.41). Following breast conserving surgery the 5-year percentage of local recurrence was 2.63% (95% CI: 2.21-3.12), and following mastectomy 3.50% (95% CI: 2.97-4.13). Stratification by hospital shows large variation in recurrence rates (0-17%). However, the number of patients treated in most hospitals is too small to provide reliable estimates. CONCLUSION The percentage of local recurrences following surgical treatment for breast cancer in the Netherlands was lower than the accepted standard of 5% within 5 years. Statements on differences in quality of care between hospitals cannot be made on the basis of these data, on account of the low average recurrence rate and the small number of cases per hospital.

Percentage of local recurrence following treatment for breast cancer is not a suitable performance indicator

Objective To gain insight into the survival of cancer patients in order to evaluate any improvement in cancer care. Design A retrospective population-based cohort study. Method Data from the Netherlands Cancer Registry were used for this study. For all patients diagnosed with cancer in the Netherlands between 1989 and 2008, information on vital status was obtained from hospitals, municipalities and the Municipal Personal Records Database. Age-standardised, relative survival rates per cancer type were calculated. Results The 5-year relative survival for all types of cancer combined increased from 47% in 1989-1993 to 59% in 2004-2008. This increase was greater in males than in females (from 40% to 55% and from 55% to 62%, respectively). The most striking improvements in survival were observed in breast, prostate and colorectal cancers, probably for reasons differing for each cancer type. Patients with chronic myeloid leukaemia showed the greatest gain in survival (43%). Survival rates in older patients were generally worse in comparison to those in younger patients, especially in case of head and neck cancer, ovarian cancer and haematological malignancies. The survival gap between older and younger patients has increased over the last 20 years. The 10-year survival rate for most cancer types was not much lower than the 5-year rate, except in chronic and indolent haematological malignancies and cancers that may reoccur after a long time, such as breast and prostate cancer. Conclusion The increase in survival rates of cancer patients in the Netherlands, attributed to early detection and improved treatment, could represent either an increase in the number of patients cured or to cancer patients living longer lives. A potential area for further improvement is especially notable in the elderly. This is even more important given the ageing population.

[Adult cancer patients are surviving longer in the Netherlands: 5-year survival rate increased by 12% between the periods 1989-1993 and 2004-2008].

In this article we give a short overview of new insights into the effects of smoking on health, both on smokers themselves and on those who are exposed to other people's tobacco smoke.- The number of diseases and conditions that are known to be caused by active smoking has now risen to over thirty.- The risk of premature death is not, as previously thought, twice as high in smokers as in non-smokers, but actually three times as high.- Passive smoking too has been shown to have a whole range of negative effects on health.- Further, the causal mechanisms of, amongst other things, the development of cancer, ischaemic heart disease and nicotine dependence under the influence of smoking have been largely unravelled.- Various issues require further investigation; these include the effect of smoking on psychological health and the effects of 'third-hand' smoke. In the meantime, a concerted campaign against this consumer product with its deleterious effects of the health of the population is overdue.

[The effects of smoking on health: growth of knowledge reveals even grimmer picture].

Doel: Inzicht geven in de overleving van kankerpatienten om verbeteringen in de kankerzorg te kunnen volgen.

Opzet: Retrospectieve, bevolkingsbrede cohortstudie.

Methode: Voor dit onderzoek werden gegevens van de Nederlandse Kankerregistratie gebruikt. Van alle gediagnosticeerde kankerpatienten uit de periode 1989-2008 in Nederland werden gegevens over de vitale status verzameld in ziekenhuizen, bevolkingsregisters en de gemeentelijke basisadministratie persoonsgegevens. Per vorm van kanker werden voor de leeftijd gestandaardiseerde relatieve overlevingcijfers berekend.

Resultaten: De 5-jaarsoverleving van alle patienten samen steeg van 47% in 1989-1993 naar 59% in 2004-2008. Bij mannen was de toename in overleving groter dan bij vrouwen, respectievelijk van 40 naar 55% en van 55 naar 62%. Het meest opvallend was de verbetering in overleving bij borst-, prostaat- en darmkanker, waarschijnlijk door oorzaken die voor elk van deze kankersoorten verschillend zijn. Patienten met chronische myeloide leukemie lieten een grote overlevingswinst zien (toename: 43%). De overlevingskansen van oudere patienten waren in het algemeen lager dan die van jongere, vooral bij kanker in het hoofd-halsgebied, eierstokkanker en hematologische maligniteiten. Deze kloof tussen oudere en jongere patienten is de afgelopen 20 jaar groter geworden. De 10-jaarsoverleving was bij veel kankersoorten niet veel lager dan de 5-jaarsoverleving, behalve bij chronische en indolente hematologische maligniteiten en kanker waarbij terugkeer van de ziekte na langere tijd nog kan plaatsvinden, zoals bij borst- en prostaatkanker.

Conclusie: De verbeterde overleving van kankerpatienten in Nederland, door vroege opsporing en verbeterde behandelingen, kan wijzen op een toenemend aandeel genezen patienten of op patienten die langer met kanker leven. Veel winst kan nog behaald worden bij de oudere patient. Dit is extra van belang omdat de bevolking vergrijst.

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Volwassen kankerpatiënten overleven langer in Nederland 5-jaarsoverleving 12% toegenomen tussen 1989-1993 en 2004-2008

Doel: Het beschrijven van het percentage lokaal recidief binnen 5 jaar na operatie van mammacarcinoom als prestatie-indicator van de Nederlandse ziekenhuizen.

Opzet: Beschrijvend, cohortonderzoek.

Methode: Alle vrouwen bij wie in 2003 een eerste invasief mammacarcinoom was gediagnosticeerd en die in opzet curatief waren geopereerd (met of zonder radiotherapie), werden geselecteerd uit de Nederlandse kankerregistratie (NKR). Registratiemedewerkers van de NKR verzamelden gegevens over het optreden van recidieven binnen 5 jaar bij deze patienten aan de hand van een gestandaardiseerd protocol. Recidiefpercentages werden bepaald per ziekenhuis met de kaplan-meier-methode en weergegeven in ‘forest’-plots en ‘funnel’-plots.

Resultaten: In 2003 werden 9898 patienten in 99 Nederlandse ziekenhuizen gediagnosticeerd en curatief behandeld voor een eerste mammacarcinoom. 266 patienten kregen een lokaal recidief binnen 5 jaar. Het 5-jaarsrecidiefpercentage was 3,03 (95%-BI: 2,69-3,41). Na een borstsparende operatie was het 5-jaarsrecidiefpercentage 2,63 (95%-BI: 2,21-3,12); na borstamputatie was dit 3,50% (95%-BI: 2,97-4,13). Er was een grote variatie in recidiefpercentage tussen ziekenhuizen (0-17%). De aantallen behandelde patienten waren in de meeste ziekenhuizen echter te laag om betrouwbare schattingen te geven.

Conclusie: Het percentage lokale recidieven na chirurgische behandeling voor mammacarcinoom lag in Nederland onder de norm van 5% binnen 5 jaar. Het is niet mogelijk om op basis van deze indicator een uitspraak te doen over verschillen in de kwaliteit van zorg tussen ziekenhuizen door de lage gemiddelde recidiefkans en het relatief lage aantal patienten met een lokaal recidief per ziekenhuis.

Ronald Damhuis

Papers

Percentage of local recurrence following treatment for breast cancer is not a suitable performance indicator

[Adult cancer patients are surviving longer in the Netherlands: 5-year survival rate increased by 12% between the periods 1989-1993 and 2004-2008].

[The effects of smoking on health: growth of knowledge reveals even grimmer picture].

Volwassen kankerpatiënten overleven langer in Nederland 5-jaarsoverleving 12% toegenomen tussen 1989-1993 en 2004-2008

Weinig lokaal recidieven na mammachirurgie: goede kwaliteit van de Nederlandse borstkankerzorg