Specific Deaths Research Articles

Is adjuvant chemotherapy beneficial for surgical stage I ovarian clear cell carcinoma?

Data collection and analysis of surgical stage I OCCC patients treated at two tertiary cancer centers was performed. Descriptive statistics, univariate and multivariable analyses and Kaplan-Meier survival probability estimates were completed. Sixty stage I OCCC patients who underwent comprehensive surgical staging were identified. 29 patients received adjuvant chemotherapy and 31 did not. Median follow-up was 4.96 (0.4-16.4) years. The 5-year disease specific survival (DSS) was 84.2%: 95% for stage IA and 76% for stage IB+IC (p=0.16). There were 11 disease specific deaths: 7 in the no adjuvant chemotherapy group (NACG) and 4 in the adjuvant chemotherapy group (ACG). 5-year DSS was 84.2%: 74% in NACG and 93% in ACG, (p=0.13). Seventeen patients recurred: 11 in NACG and 6 in ACG (p=0.2). None of the 21 patients with stage I known negative cytology recurred. 5-year PFS was 74%: 58% in NACG and 86% in ACG (p=0.035). On univariate analysis, no-adjuvant chemotherapy and positive cytology were poor prognostic factors for PFS: HR=2.36, p=0.04 and HR=3.1, p=0.027, respectively. After adjusting for positive cytology, no-adjuvant chemotherapy was still found to significantly correlate with a worse PFS (HR=4, p=0.01). Our data supports the use of adjuvant chemotherapy for surgical stage I OCCC. As no patients in our cohort with surgical stage I known negative cytology recurred, more research on the benefit of adjuvant chemotherapy in this group is warranted.

Area-level socioeconomic deprivation and mortality differentials in Thailand: results from principal component analysis and cluster analysis

BackgroundDespite achievement of universal health coverage in Thailand, socioeconomic inequality in health has been a major policy concern. This study examined mortality patterns across different socioeconomic strata in Thailand.MethodsWe conducted a cross-sectional analysis of the 2010 Population and Housing Census on area-level socioeconomic deprivation against the 2010 mortality from the vital registration database at the super-district level. We used principal components analysis to construct a socioeconomic deprivation index and K-mean cluster analysis to group socioeconomic status and cause-specific mortality.ResultsExcess mortality rates from all diseases, except colorectal cancer, were observed among super-districts with low socioeconomic status. Spatial clustering was evident in the distribution of socioeconomic status and mortality rates. Cluster analysis revealed that super-districts which were predominantly urban tended to have low all-cause standardize mortality ratio but a high colorectal cancer-specific mortality rate. Deaths due to liver cancer, diabetes, and renal diseases were common in the low socioeconomic super-districts which hosted one third of the total Thai population.ConclusionSocially deprived areas have an excess of overall and cause specific deaths. Populations living in more affluent areas, despite low general mortality, still have many preventable deaths such as colorectal cancer. These findings warrant future epidemiological studies investigating various causes of excessive deaths in non-deprived areas and implementation of policies to reduce the mortality gap between rich and poor areas.

Abstract 3278: Particulate matter and traffic-related exposures in relation to breast cancer survival

Abstract Background: Outdoor air pollution is considered a human carcinogen by the International Agency for Research on Cancer, particularly for its influence on lung cancer incidence and prognosis. While air pollution has not been consistently associated with breast cancer incidence, only one study has examined the impacts of air pollution on survival from breast cancer and was unable to consider important predictors of breast cancer mortality. We assessed whether PM exposures (PM2.5, PM2.510, and PM10) were associated with breast cancer specific-death and all-cause mortality. Methods: The Nurses’ Health Studies (NHS and NHSII) are ongoing nationwide cohorts with detailed longitudinal data on medical history, addresses, lifestyle factors, and causes of death. We included women with confirmed Stage I-III breast cancer and collected additional clinical information from medical records. PM was estimated using GIS-based spatio-temporal models linked to addresses between 1989-2007. We performed Cox proportional hazards models to assess associations of breast cancer specific-death and overall mortality with PM exposures starting at diagnosis and updated over follow-up through June 2014. Results: There were 1,211 breast-cancer specific deaths among 8,936 women with Stage I-III breast cancer. Overall, increases in PM were not associated with breast cancer survival (PM2.5: HR=1.09 95% CI 0.87, 1.36; PM2.5-10: HR=1.03 95% CI 0.85, 1.24; PM10: HR=1.05, 95% CI 0.89, 1.24, each per 10 μg/m3). However, each 10 μg/m3 increase in PM2.5 was associated with breast cancer death among participants with Stage I disease after adjusting for clinical, demographics and pre-diagnostic lifestyle factors (HR=1.69 95%CI 1.16, 2.47) and after additionally adjusting for post-diagnostic lifestyle factors (HR=1.64 95% CI 1.11, 2.43). Furthermore, PM exposures were associated with a 9-12% increase in all-cause mortality. Conclusion: Overall, PM exposures were not associated with breast cancer survival; however, increases in PM2.5 did appear to adversely impact prognosis among Stage I breast cancer patients. Acknowledgments: This work was funded by the NIH T32 CA 09001 and by a grant from the Susan G. Komen for the Cure ® (IIR13264020). We thank the NHS and NHSII participants and coordinators. Citation Format: Natalie DuPre, Elizabeth M. Poole, Michelle D. Holmes, Jaime E. Hart, Peter James, Andrew Beck, Peter Kraft, Francine Laden, Rulla Tamimi. Particulate matter and traffic-related exposures in relation to breast cancer survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3278. doi:10.1158/1538-7445.AM2017-3278

Compassion Fatigue: Exploring Early-Career Oncology Nurses' Experiences .

Oncology nurses have a higher risk and rate of compassion fatigue (CF) compared to professionals in other specialties. CF exhibits tangible negative outcomes, affecting nurses' health and professional practice. . Early-career oncology nurses' unique CF experiences lack thorough scientific exploration. This secondary analysis seeks to qualitatively augment this paucity and illuminate targeted interventions. . Open-ended interviews were conducted with five early-career inpatient oncology nurses. Subsequent transcripts were explored for CF themes secondarily using thematic analysis. . Themes indicate that early-career oncology nurses enjoy connecting with patients and families, but over-relating, long patient stays, and high patient mortality rates trigger CF. Symptoms include internalizing patients' and families' pains and fears, being haunted by specific patient deaths, feeling emotionally depleted, assuming that all patients will die, and experiencing burnout, physical exhaustion, and hypervigilance protecting loved ones.

Intermediate-Term Outcomes for Men with Very Low/Low and Intermediate/High Risk Prostate Cancer Managed by Active Surveillance

We compare intermediate term clinical outcomes among men with favorable risk and intermediate/high risk prostate cancer managed by active surveillance. A total of 635 men with localized prostate cancer have been on active surveillance since 2002 at a high volume academic hospital in the United States. Median followup is 50.5 months (IQR 31.1-80.3). Time to event analysis was performed for our clinical end points. Of the cohort 117 men (18.4%) had intermediate/high risk disease. Overall 5 and 10-year all cause survival was 98% and 94%, respectively. Cumulative metastasis-free survival at 5 and 10 years was 99% and 98%, respectively. To date no cancer specific deaths had been observed. Overall freedom from intervention was 61% and 49% at 5 and 10 years, respectively. Overall cumulative freedom from failure of active surveillance, defined as metastasis or biochemical failure after local therapy with curative intent, was 97% and 91% at 5 and 10 years, respectively. Of the men 21 (9.9%) experienced biochemical failure after deferred treatment and the 5-year progression-free probability was 92%. Compared to men with favorable risk disease those with intermediate/high risk cancer experienced no difference in metastases, surveillance failure or curative intervention. However, patients at higher risk were at significantly increased risk for all cause mortality, likely reflecting patient selection factors. These conclusions may be limited by the small number of events and the duration of our study. Patients with localized prostate cancer who are on active surveillance demonstrated a low rate of active surveillance failure, prostate cancer specific mortality and metastases regardless of baseline risk.

Abstract P5-14-03: Adjuvant dose dense doxorubicin-cyclophosphamide (ddAC) or docetaxel-AC (TAC) for high-risk breast cancer: First results of the randomized MATADOR trial (BOOG-2004-04)

Abstract Background: Anthracycline-based adjuvant chemotherapy has substantially improved breast cancer survival. Both the addition of taxanes as well as using a dose dense treatment schedule can further ameliorate outcome, but inter-individual differences exist. Here we present the efficacy and toxicity of dose dense scheduled doxorubicin/cyclophosphamide (ddAC) versus docetaxel/doxorubicin/cyclophosphamide (TAC), which is, to our knowledge, the first direct comparison of these treatment regimens. Methods: In this Dutch, multicenter phase III trial (ISRCTN61893718), patients with pT1-3, pN0-3, M0 breast cancer were randomized between six cycles of either A60C600 every 2 weeks or T75A50C500 every 3 weeks. All patients received pegfilgrastim. Patients were evaluated for recurrence-free survival (RFS) and overall survival (OS). Survival was compared in a Cox regression analysis and adjusted for known prognostic factors. These factors include age, type of surgery, tumor size, histological grade, ER/PR status, HER2 status, and lymph node status. Adverse events were reported according to the common toxicity criteria (CTCAE version 3.0). Results: Between 2004 and 2012, 664 patients were enrolled of whom 531 (80%) had node positive disease. At a median follow up of 5 years, OS was 92% in the ddAC treated subgroup and 93% in the TAC treated subgroup (adjusted hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.42-1.34, intention to treat population). Forty-two breast-cancer specific deaths were equally divided over both treatment arms. Similarly, no significant difference in RFS was observed between both treatment groups (adjusted HR 0.85, 95% CI 0.55-1.32). Molecular subtypes were defined by St. Gallen criteria: 548 patients (83%) had estrogen receptor positive disease and 102 patients (15%) triple negative disease. No heterogeneity regarding treatment efficacy was observed in these subtypes. In particular, there was no survival benefit for ddAC or TAC in the triple negative subtype. Both treatment regimens were well tolerated. Whereas anemia was more frequent in ddAC treated patients (19% vs 4.7%; p<0.001), peripheral neuropathy occurred more frequently in TAC treated patients (4.6% vs 14.4%; p<0.001). The frequency of febrile neutropenia was not significantly different between the treatment arms (11% vs 12.5%; n.s.). Six patients developed congestive heart failure: 2 ddAC treated patients, 4 TAC treated patients. One ddAC treated patient and one TAC treated patient were diagnosed with acute myeloid leukemia after study treatment; another patient in the ddAC treatment group developed myelodysplastic syndrome. Conclusions: At a median follow up of 5 years no significant survival differences were observed between adjuvant ddAC and TAC, in all patients and in molecular subgroups, including triple negative. Our findings are in line with the Oxford overview, which reported no significant differences between taxane-based chemotherapy and more, non-taxane based chemotherapy given in a dose dense schedule. ddAC could be a reasonable alternative for patients with a contra-indication for TAC. Citation Format: van Rossum AGH, Oosterkamp HM, van Werkhoven E, Opdam M, Mandjes IAM, van Leeuwen-Stok E, van Tinteren H, Kok M, Imholz ALT, Portielje JEA, Bos MMEM, van Bochove A, Wesseling J, Rutgers EJ, Rodenhuis S, Linn SC. Adjuvant dose dense doxorubicin-cyclophosphamide (ddAC) or docetaxel-AC (TAC) for high-risk breast cancer: First results of the randomized MATADOR trial (BOOG-2004-04) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-14-03.

Abstract P5-08-13: Phyllodes tumours of the breast: The British Columbia cancer agency experience

Abstract Background Phyllodes tumours (PT) of the breast are uncommon fibroepithelial lesions for which optimal management remains unclear. This population-based study reports treatment and outcomes for patients with PT and evaluates characteristics that influence outcome. Methods Data were analysed on 183 patients with newly diagnosed PT referred to the BC Cancer Agency from 1999-2014. Follow-up was obtained from chart and death records and letters to general practitioners. Five-year Kaplan-Meier (KM) local recurrence (LR) and survival were compared between cohorts with benign (n=83), borderline (n=50) and malignant PT (n=49) histology. Subtype was unknown in 1 patient who did not receive surgery due to severe comorbidity. Univariate analysis was performed using Cox regression modeling. Results Median follow-up was 65 (range 0.5-197) months. Median age was 48 (range 14–87) years. Median tumour size was 4 (range 1-23) cm. Heterologous sarcomatous differentiation was seen in 15 and malignant epithelial transformation in 11 patients. Local excision was performed in 163 (89%) and mastectomy in 19 (10%) patients. Margin status after local excision were: negative (>1mm, n=121, 74%), close (≤1mm, n=21, 13%), positive (tumour touching ink, n=20, 12%), or unknown (n=1, 1%). Margin status after mastectomy were negative (n=14, 74%) or close (n=5, 26%). Tumour borders were pushing (n=62, 34%), intermediate (n=22, 12%), infiltrative (n=38, 21%) or unknown (n=60, 33%). Eleven patients with malignant PT received radiation therapy as part of initial treatment. In these cases median tumour size was 8 cm and heterologous sarcomatous differentiation was present in 46% compared to 4 cm and 16% in malignant cases who did not receive RT. LR occurred in 16 cases (5 benign, 4 borderline and 7 malignant). Distant metastases (DM) occurred in 7 patients with malignant PT leading to 6 cause specific deaths. Five-year KM outcomes among women with benign, borderline, and malignant PT were: LR 6% vs 9% vs 21%, P=0.131; overall survival 96% vs 100% vs 82%, P=0.002; and disease free survival 94% vs 91% vs 67%, P<0.001. DM-free and cause specific survival at 5 years for malignant cases were 82% and 88% respectively. Five-year KM LR among women with negative vs close vs positive margins were 8% vs 6% vs 37%, P<0.001. Corresponding rates for intermediate vs pushing vs infiltrative borders were 6% vs 6% vs 33%, P=0.006. On univariate analyses, large tumour size, postmenopausal status, malignant classification, necrosis, positive margins, and infiltrative borders were factors associated with increased risk of any type of relapse (all P≤0.014). Positive margins and infiltrative tumour border were associated with increased LR (all P≤0.006), and the latter remained significant in exploratory analyses after adjusting for margin status and PT classification. Advanced age at diagnosis and large tumour size were predictors of DM (all P≤0.001). Conclusion In this population-based series, 5-year outcomes among women with PT are comparable to those reported in the literature. Exploratory analysis suggests that infiltrative tumour borders may be used in conjunction with margin status to assess LR risk. While close margin was not associated with increased LR, re-excision is warranted for cases with positive margins. Citation Format: Rodrigues MF, Truong PT, Weir LM, Knowling MA, Wai ES. Phyllodes tumours of the breast: The British Columbia cancer agency experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-13.

A proposed case-control framework to probabilistically classify individual deaths as expected or excess during extreme hot weather events.

BackgroundMost excess deaths that occur during extreme hot weather events do not have natural heat recorded as an underlying or contributing cause. This study aims to identify the specific individuals who died because of hot weather using only secondary data. A novel approach was developed in which the expected number of deaths was repeatedly sampled from all deaths that occurred during a hot weather event, and compared with deaths during a control period. The deaths were compared with respect to five factors known to be associated with hot weather mortality. Individuals were ranked by their presence in significant models over 100 trials of 10,000 repetitions. Those with the highest rankings were identified as probable excess deaths. Sensitivity analyses were performed on a range of model combinations. These methods were applied to a 2009 hot weather event in greater Vancouver, Canada.ResultsThe excess deaths identified were sensitive to differences in model combinations, particularly between univariate and multivariate approaches. One multivariate and one univariate combination were chosen as the best models for further analyses. The individuals identified by multiple combinations suggest that marginalized populations in greater Vancouver are at higher risk of death during hot weather.ConclusionsThis study proposes novel methods for classifying specific deaths as expected or excess during a hot weather event. Further work is needed to evaluate performance of the methods in simulation studies and against clinically identified cases. If confirmed, these methods could be applied to a wide range of populations and events of interest.

10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer

BackgroundThe comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen (PSA) testing remains uncertain.MethodsWe compared active monitoring, radical prostatectomy, and external-beam radiotherapy for the treatment of clinically localized prostate cancer. Between 1999 and 2009, a total of 82,429 men 50 to 69 years of age received a PSA test; 2664 received a diagnosis of localized prostate cancer, and 1643 agreed to undergo randomization to active monitoring (545 men), surgery (553), or radiotherapy (545). The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up. Secondary outcomes included the rates of disease progression, metastases, and all-cause deaths.ResultsThere were 17 prostate-cancer–specific deaths overall: 8 in the active-monitoring group (1.5 deaths per 1000 person-years; 95% confidence interval [CI], 0.7 to 3.0), 5 in the surgery group (0.9 per 1000 person-years; 95% CI, 0.4 to 2.2), and 4 in the radiotherapy group (0.7 per 1000 person-years; 95% CI, 0.3 to 2.0); the difference among the groups was not significant (P=0.48 for the overall comparison). In addition, no significant difference was seen among the groups in the number of deaths from any cause (169 deaths overall; P=0.87 for the comparison among the three groups). Metastases developed in more men in the active-monitoring group (33 men; 6.3 events per 1000 person-years; 95% CI, 4.5 to 8.8) than in the surgery group (13 men; 2.4 per 1000 person-years; 95% CI, 1.4 to 4.2) or the radiotherapy group (16 men; 3.0 per 1000 person-years; 95% CI, 1.9 to 4.9) (P=0.004 for the overall comparison). Higher rates of disease progression were seen in the active-monitoring group (112 men; 22.9 events per 1000 person-years; 95% CI, 19.0 to 27.5) than in the surgery group (46 men; 8.9 events per 1000 person-years; 95% CI, 6.7 to 11.9) or the radiotherapy group (46 men; 9.0 events per 1000 person-years; 95% CI, 6.7 to 12.0) (P<0.001 for the overall comparison).ConclusionsAt a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments. Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring. (Funded by the National Institute for Health Research; ProtecT Current Controlled Trials number, ISRCTN20141297; ClinicalTrials.gov number, NCT02044172.)

Erratum to: Diverging Demography: Hispanic and Non-Hispanic Contributions to U.S. Population Redistribution and Diversity

The substantial growth and geographic dispersion of Hispanics is among the most important demographic trends in recent U.S. demographic history. Our county-level study examines how widespread Hispanic natural increase and net migration has combined with the demographic change among non-Hispanics to produce an increasingly diverse population. This paper uses U.S. Census Bureau data and special tabulations of race/ethnic specific births and deaths from NCHS to highlight the demographic role of Hispanics as an engine of new county population growth and ethnoracial diversity across the U.S. landscape. It highlights key demographic processes—natural increase and net migration—that accounted for 1990–2010 changes in the absolute and relative sizes of the Hispanic and non-Hispanic populations. Hispanics accounted for the majority of all U.S. population growth between 2000 and 2010. Yet, Hispanics represented only 16 % of the U.S. population in 2010. Most previous research has focused on Hispanic immigration; here, we examine how natural increase and net migration among both the Hispanic and non-Hispanic population contribute to the nation’s growing diversity. Indeed, the demographic impact of rapid Hispanic growth has been reinforced by minimal white population growth due to low fertility, fewer women of reproductive age and growing mortality among the aging white population America’s burgeoning Hispanic population has left a large demographic footprint that is magnified by low and declining fertility and increasing mortality among America’s aging non-Hispanic population.

Prognostic Significance of Digital Rectal Examination and Prostate Specific Antigen in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Arm

The absence of definitive data or explicit guidelines regarding the use of digital rectal examination for prostate cancer screening may lead to confusion for physicians and patients alike. We evaluated the prognostic value of abnormal digital rectal examination and prostate specific antigen following the widespread dissemination of prostate specific antigen testing in the U.S. Collectively, men comprising the screening arm of the PLCO cancer screening trial who underwent digital rectal examination screening (35,350) were followed for 314,033 person-years. Adjusted analyses with competing risks regression were performed to assess the association of suspicious (nodularity, induration, asymmetry) digital rectal examination and abnormal prostate specific antigen (4 ng/ml or greater) with the detection of clinically significant prostate cancer, prostate cancer specific mortality and overall mortality. Among all screening encounters with a suspicious digital rectal examination only 15.4% had a concurrently abnormal prostate specific antigen (McNemar's test p <0.001). During followup there were 1,612 clinically significant prostate cancers detected, 64 prostate cancer specific deaths and 4,600 deaths. On multivariable analysis suspicious digital rectal examination and abnormal prostate specific antigen were associated with a greater risk of clinically significant prostate cancer (HR 2.21, 95% CI 1.99-2.44 vs HR 5.48, 95% CI 5.05-5.96, p<0.001 and p <0.001) and prostate cancer specific mortality (HR2.54, 95% CI1.41-4.58 vs HR 5.23, 95% CI 3.08-8.88, p=0.002 and p <0.001), respectively. In a secondary analysis of a contemporary U.S. cohort, suspicious digital rectal examination and abnormal prostate specific antigen on routine screening were independently associated with clinically significant prostate cancer and prostate cancer specific mortality. However, additional research is needed tooptimize screening protocols.

Long term survival in persons with hemophilia and chronic hepatitis C: 40 year outcomes of a large single center cohort.

We studied the course of chronic HCV infections in a cohort of 222 persons with hemophilia (PWH) and von Willebrand disease followed at our center since 1973. Twenty two (10%) developed end stage liver disease (ESLD). Forty years after HCV infection, cumulative incidence of ESLD was 12.3% and overall survival was 45.5%. Those who were infected with HCV only (n = 100) had a survival of 75.2%, while those infected with HIV (n = 122) had a survival of 24% (P < 0.001). Survivals were significantly longer for those infected with HCV at younger age (< 15 years) compared to those infected over age 30 years (P = 0.014). Cause specific deaths for ESLD and bleeding were 8.8% and 8.3% respectively. For HIV negative subjects, the annual hazard of death from ESLD and bleeding was near zero for the first 10 years, and then rose slowly over the next 20 years to 0.4/100py for ESLD and 0.2/100py for bleeding. Sixty subjects completed 79 treatment episodes. Sustained viral response rates increased from 7/21 (33%) between 1990 and 2001, to 17/29 (58%) between 2002 and 2011, and to 27/29 (93%), since 2012 with the advent of the directly acting antiviral agents. These results confirm the very slow ESLD progression rate in HIV negative PWH. However, the risk of death from both ESLD and bleeding increases steadily with longer duration of HCV infection. More aggressive surveillance to detect those with early fibrosis is needed now that curative treatment is possible in >95% of individuals. Am. J. Hematol. 91:E335-E340, 2016. © 2016 Wiley Periodicals, Inc.

Climate Change and Its Impact on the Incarcerated Population: A Descriptive Review

This descriptive review article describes climate change and its detrimental effects on incarcerated populations. Case examples are provided of specific natural disasters and deaths due to overheating temperatures. Because public health and social work aims to improve the health and social welfare of vulnerable populations, the authors explain why climate change should be considered a priority area in both fields. Examples are provided on how to improve conditions for the 2.4 million men, women, and youth who are incarcerated.

MP27-14 LOCATION OF THE TUMOR IN UPPER TRACT UROTHELIAL CARCINOMA (UTUC) IMPACTS ON THE PRESENCE OF CONCOMITANT UROTHELIAL CARCINOMA OF THE BLADDER: A MULTI-INSTITUTIONAL DATABASE STUDY

You have accessJournal of UrologyBladder Cancer: Upper Tract Transitional Cell Carcinoma II1 Apr 2016MP27-14 LOCATION OF THE TUMOR IN UPPER TRACT UROTHELIAL CARCINOMA (UTUC) IMPACTS ON THE PRESENCE OF CONCOMITANT UROTHELIAL CARCINOMA OF THE BLADDER: A MULTI-INSTITUTIONAL DATABASE STUDY Teruo Inamoto, Kiyoshi Takahara, Hideyasu Matsuyama, Kiyohide Fujimoto, Hiroaki Shiina, Shigeru Sakano, Kazuhiro Nagao, Makito Miyake, Yoshihiro Tatsumi, Hiroaki Yasumoto, and Haruhito Azuma Teruo InamotoTeruo Inamoto More articles by this author , Kiyoshi TakaharaKiyoshi Takahara More articles by this author , Hideyasu MatsuyamaHideyasu Matsuyama More articles by this author , Kiyohide FujimotoKiyohide Fujimoto More articles by this author , Hiroaki ShiinaHiroaki Shiina More articles by this author , Shigeru SakanoShigeru Sakano More articles by this author , Kazuhiro NagaoKazuhiro Nagao More articles by this author , Makito MiyakeMakito Miyake More articles by this author , Yoshihiro TatsumiYoshihiro Tatsumi More articles by this author , Hiroaki YasumotoHiroaki Yasumoto More articles by this author , and Haruhito AzumaHaruhito Azuma More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1045AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The predictive impact of primary tumor location for patients with upper-tract urothelial carcinoma (UTUC) on the presence of concomitant urothelial carcinoma of the bladder is still contentious. We precisely evaluated the association between tumor location and concomitant presence of urothelial carcinoma of the bladder, along with urothelial recurrence free survival (URFS) in patients with UTUC. METHODS A total of 1349 patients with localized UTUC (Ta-4N0M0) from a retrospective multi-institutional cohort were studied. We queried 4 UTUC databases. Retrospective clinical series on patients with localized UTUC managed by nephroureterectomy (NU) with bladder cuff, for whom data from the Yamaguchi Uro-Oncology Group and 4 tertiary medical centers registries. Patients with a history of chemotherapy were excluded from the study. Associations between the location of the tumor and subsequent outcome following NU were assessed using COX multivariate analysis. Location of the tumor was verified by pathological samples. Urothelial recurrence was defined as tumor relapse in any local urothelium, and coded apart from distant metastasis. The median follow-up was 34 months. RESULTS Six hundred and three patients had pelvic tumors (45.1%), 123 had ureteral tumors in U1 segment (9.2%), 109 in U2 segment (8.1%), and 263 in U3 segment (19.7%). 240 had multifocal tumors (17.80%) as follows; 14 (1.0%) in pelvis and ureter, 14 (1.0%) in U1+U2, 2(0.1%) in U1+U3, 28 (2.1%) in U2+U3, 9 (0.7%) in U1+U2+U3. 173 (12.9%) had solitary ureteral tumors where the distinct location was not described. Of all, 159 (17.5%) had concomitant bladder tumors. Logistic regression analysis which include gender, age, hydronephrosis, cytology, performance status, grade, lymphovascular invasion (LVI), pT, pN, tumor focality, tumor location was associated with the presence of concomitant bladder cancer (p=0.004, HR; 1.265). When the tumor location was stratified into 8 segments, including multifocal tumors, only U3 segment remained as predictive for the presence of concomitant bladder cancer (p=0.002, HR= 2.872). Kaplan-meier analysis for unifocal disease showed that lower ureter tumors (combinatnion of U2 U3) had the worse prognosis for urothelial recurrence than pelvic tumors or upper ureteral tumors (U1) (p=0.019 for lower ureteral tumors vs. pelvic tumors, p=0.132 for upper ureteral tumor vs. pelvic tumor by log rank). Multivariate analysis showed that lower ureter location remained as a prognostic factor for urothelial recurrence after adjusting for gender, age, hydronephrosis, urine cytology, LVI, pT, and pN (p=0.006, HR=1.761), and similar tendency was found when the analysis was run for patients without concomitant bladder tumors (p=0.002, HR=2.244). Lower ureteral tumors had a higher prevalence of disease specific deaths (HR=2.224) with reference to upper ureter tumors and pelvic tumors. CONCLUSIONS This multi-institutional study showed the primary tumor locations were independently associated with the presence of concomitant bladder tumors and subsequent urothelial recurrence. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e368 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Teruo Inamoto More articles by this author Kiyoshi Takahara More articles by this author Hideyasu Matsuyama More articles by this author Kiyohide Fujimoto More articles by this author Hiroaki Shiina More articles by this author Shigeru Sakano More articles by this author Kazuhiro Nagao More articles by this author Makito Miyake More articles by this author Yoshihiro Tatsumi More articles by this author Hiroaki Yasumoto More articles by this author Haruhito Azuma More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Overtreatment of Low-Grade Ductal Carcinoma In Situ.

Importance: While the prevalence of ductal carcinoma in situ (DCIS) of the breast has increased substantially following the introduction of breast-screening methods, the clinical significance of early detection and treatment for DCIS remains unclear. Objective: To investigate the survival benefit of breast surgery for low-grade DCIS. Design, Setting, and Participants: A retrospective longitudinal cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from October 9, 2014, to January 15, 2015, at the Dana-Farber/Brigham and Women’s Cancer Center. Between 1988 and 2011, 57 222 eligible cases of DCIS with known nuclear grade and surgery status were identified. Exposures: Patients were divided into surgery and nonsurgery groups. Main: Outcomes and Measures Propensity score weighting was used to balance patient backgrounds between groups. A log-rank test and multivariable Cox proportional hazards model was used to assess factors related to overall and breast cancer–specific survival. Results: Of 57 222 cases of DCIS identified in this study, 1169 cases (2.0%) were managed without surgery and 56 053 cases (98.0%) were managed with surgery. With a median follow-up of 72 months from diagnosis, there were 576 breast cancer–specific deaths (1.0%). The weighted 10-year breast cancer–specific survival was 93.4% for the nonsurgery group and 98.5% for the surgery group (log-rank test, P < .001). The degree of survival benefit among those managed surgically differed according to nuclear grade (P = .003). For low-grade DCIS, the weighted 10-year breast cancer–specific survival of the nonsurgery group was 98.8% and that of the surgery group was 98.6% (P = .95). Multivariable analysis showed there was no significant difference in the weighted hazard ratios of breast cancer–specific survival between the surgery and nonsurgery groups for low-grade DCIS. The weighted hazard ratios of intermediate- and high-grade DCIS were significantly different (low grade: hazard ratio, 0.85; 95% CI, 0.21-3.52; intermediate grade: hazard ratio, 0.23; 95% CI, 0.14-0.42; and high grade: hazard ratio, 0.15; 95% CI, 0.11-0.23) and similar results were seen for overall survival. Conclusions and Relevance: The survival benefit of performing breast surgery for low-grade DCIS was lower than that for intermediate- or high-grade DCIS. A prospective clinical trial is warranted to investigate the feasibility of active surveillance for the management of low-grade DCIS.

Burden of stroke attributable to selected lifestyle risk factors in rural South Africa.

BackgroundRural South Africa (SA) is undergoing a rapid health transition characterized by increases in non-communicable diseases; stroke in particular. Knowledge of the relative contribution of modifiable risk factors on disease occurrence is needed for public health prevention efforts and community-oriented health promotion. Our aim was to estimate the burden of stroke in rural SA that is attributable to high blood pressure, excess weight and high blood glucose using World Health Organization’s comparative risk assessment (CRA) framework.MethodsWe estimated current exposure distributions of the risk factors in rural SA using 2010 data from the Agincourt health and demographic surveillance system (HDSS). Relative risks of stroke per unit of exposure were obtained from the Global Burden of Disease Study 2010. We used data from the Agincourt HDSS to estimate age-, sex-, and stroke specific deaths and disability adjusted life years (DALYs). We estimated the proportion of the years of life lost (YLL) and DALY loss attributable to the risk factors and incorporate uncertainty intervals into these estimates.ResultsOverall, 38 % of the documented stroke burden was due to high blood pressure (12 % males; 26 % females). This translated to 520 YLL per year (95 % CI: 325-678) and 540 DALYs (CI: 343-717). Excess Body Mass Index (BMI) was calculated as responsible for 20 % of the stroke burden (3.5 % males; 16 % females). This translated to 260 YLLs (CI: 199-330) and 277 DALYs (CI: 211-350). Burden was disproportionately higher in young females when BMI was assessed.ConclusionsHigh blood pressure and excess weight, which both have effective interventions, are responsible for a significant proportion of the stroke burden in rural SA; the burden varies across age and sex sub-groups. The most effective way forward to reduce the stroke burden requires both population wide policies that have an impact across the age spectra and targeted (health promotion/disease prevention) interventions on women and young people.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-2805-7) contains supplementary material, which is available to authorized users.

Patient Prognostic Score and Associations With Survival Improvement Offered by Radiotherapy After Breast-Conserving Surgery for Ductal Carcinoma In Situ: A Population-Based Longitudinal Cohort Study.

Radiotherapy (RT) after breast-conserving surgery (BCS) is a standard treatment option for the management of ductal carcinoma in situ (DCIS). We sought to determine the survival benefit of RT after BCS on the basis of risk factors for local recurrence. A retrospective longitudinal cohort study was performed to identify patients with DCIS diagnosed between 1988 and 2007 and treated with BCS by using SEER data. Patients were divided into the following two groups: BCS+RT (RT group) and BCS alone (non-RT group). We used a patient prognostic scoring model to stratify patients on the basis of risk of local recurrence. We performed a Cox proportional hazards model with propensity score weighting to evaluate breast cancer mortality between the two groups. We identified 32,144 eligible patients with DCIS, 20,329 (63%) in the RT group and 11,815 (37%) in the non-RT group. Overall, 304 breast cancer-specific deaths occurred over a median follow-up of 96 months, with a cumulative incidence of breast cancer mortality at 10 years in the weighted cohorts of 1.8% (RT group) and 2.1% (non-RT group; hazard ratio, 0.73; 95% CI, 0.62 to 0.88). Significant improvements in survival in the RT group compared with the non-RT group were only observed in patients with higher nuclear grade, younger age, and larger tumor size. The magnitude of the survival difference with RT was significantly correlated with prognostic score (P < .001). In this population-based study, the patient prognostic score for DCIS is associated with the magnitude of improvement in survival offered by RT after BCS, suggesting that decisions for RT could be tailored on the basis of patient factors, tumor biology, and the prognostic score.

Differential effects of patient-related factors on the outcome of radiation therapy for rectal cancer.

The objective of this study was to investigate whether cancer specific survival in rectal cancer patients is affected by patient-related factors, conditional on radiation treatment. 359 invasive rectal cancer patients who consented and provided questionnaire data for a population-based case-control study of colorectal cancer in Metropolitan Detroit were included in this study. Their vital status was ascertained through to the population-based cancer registry. Hazard ratios (HR) for cancer specific and other deaths and 95% confidence intervals (CIs) were calculated according to selected patients' characteristics, stratified by radiation status, using joint Cox proportional hazards models. A total of 159 patients were found to be deceased after the median follow-up of 9.2 years, and 70% of them were considered to be cancer specific. Smoking and a history of diabetes were associated with an increased probability of deaths from other causes (HR 3.20, 95% CI 1.72-5.97 and HR 2.02, 95% CI 0.98-4.16, respectively), while regular use of non-steroidal anti-inflammatory drugs (NSAIDs) was inversely correlated with cancer-specific mortality (HR 0.50, 95% CI 0.30-0.81). Furthermore, the associations of smoking and NSAIDs with the two different types of deaths (cancer vs others) significantly varied with radiation status (P-values for the interactions= 0.014 for both). In addition, we observed a marginally significantly reduced risk of cancer specific deaths in the patients who had the relative ketogenic diet overall (HR=0.49, 95% 0.23-1.02). Further research is warranted to confirm these results in order to develop new interventions to improve outcome from radiation treatment.

Decadal transition of adult mortality pattern at Ballabgarh HDSS: evidence from verbal autopsy data.

BackgroundMortality levels and patterns are significant indicators of population health, and are of importance to prioritize the goals of health systems and efficient resource allocation. We ascertained the decadal transition of mortality pattern in adult population aged 15 years and above during the years 2002–2011.MethodsAll adult deaths aged 15 years and above during the years 2002 to 2011 were included in the study. Cause of death was ascertained by verbal autopsy tool for adults which is a validated questionnaire developed at Ballabgarh Health and Demographic Surveillance System (HDSS). Cause and age specific mortality, and mean age at death was determined for individual years.ResultsA total of 4,276 deaths (≥15 years) occurred in the Ballabgarh HDSS during the years 2002 to 2011. Of these, 96.8 % deaths were investigated using verbal autopsy tool. Of total deaths investigated, 60.6 % were males. Cardiovascular diseases (19.6 %) were the leading cause of death, followed by respiratory diseases (16.5 %). In the age group of 15–59 years, the most common cause of mortality was external causes of mortality (28.9 %). Most common cause of death was senility (20.8 %) in females, whereas cardiovascular diseases were commonest cause (19.6 %) in males. Road traffic injuries contributed 6.7 % deaths in males compared to 1.5 % in females. Over the years, the proportions of mortality due to cardiovascular diseases had increased (12.6 % to 18.8 %). Mortality proportions had decreased for infectious diseases (12.1 % to 9.5 %) and respiratory diseases (24.7 % to 10.9 %). Mortality due to neoplasms remained nearly stagnant (6.6 % to 6.4 %).Mean age at death due to cardiovascular diseases and neoplasm had increased from 57 years (95 % CI: 52.2–62.9) to 62 years (95 % CI: 59.2–65.4) and 58 years (95 % CI: 53.1–63.2) to 62 years (95 % CI: 57.0–66.7), respectively, during the decade. Mean age at death had decreased for road traffic injuries and infectious diseases from 41 years (95 % CI: 31.7–50.8) to 39 years (95 % CI: 34–43.4) and 53 years (95 % CI: 48.3–58.6) to 50 years (95 % CI: 44.1–55.8), respectively over the years.ConclusionMortality surveillance using verbal autopsy tool revealed a transition in cause specific deaths from respiratory diseases to cardiovascular diseases over the decade. The apparent epidemiological transition in the community demands reorientation of healthcare priorities.

Treatment of localized prostate cancer in elderly patients.

Prostate cancer is a disease of the elderly. According to National Cancer Institute, more than 56.7% of incident cases are diagnosed and more than 90% of cancer specific deaths occur in men greater than 65 years of age. Despite equivalent oncologic outcomes with treatment, primary local therapy is often deferred in elderly men with high-risk prostate cancer, in part due to concerns that post surgery quality of life (QOL) functional outcomes compare poorly to younger men. Our aim in this editorial is to discuss the functional and oncological outcomes in management of elderly with localized prostate cancer.