Taiwan National Cancer Registry Research Articles

Five-year survival prognosis of young, middle-aged, and elderly adult female invasive breast cancer patients by clinical and lifestyle characteristics

PurposeEarly-onset breast cancer incidence has been increasing globally and in Taiwan. However, previous studies have not comprehensively examined how clinical and lifestyle characteristics influence the 5-year survival of breast cancer diagnosed at different stages of adulthood.MethodsWe analyzed the Taiwan National Cancer Registry and Cause of Death datasets to understand how clinical factors (including tumor and treatment characteristics) and lifestyle factors (including body mass index, cigarette smoking, and alcohol consumption) were associated with the 5-year survival of 8471 young, 57,695 middle-aged, and 14,074 elderly female adult invasive breast cancer patients respectively diagnosed at age 20–39, 40–64, and ≥ 65 years between 2002 and 2015, with mortality follow-up to 2020. Poisson regression was used for obtaining the crude and adjusted 5-year survival risk ratios.ResultsClinical and lifestyle characteristics were distributed differently but had mostly similar direction of association with 5-year survival for the three age groups. Receiving any treatment was associated with better survival, especially for elderly patients. Being underweight at initial cancer treatment was associated with worse survival than having normal weight, especially for elderly patients. Current smokers had worse survival than never smokers for middle-aged and elderly patients. The 5-year breast cancer-specific survival was not significantly higher for those of age 45–49 years than 40–44 years, despite the recommended starting screening age is 45 years in Taiwan.ConclusionOur findings contribute to the understanding of early-onset and later-onset female breast cancer characteristics and prognosis, which may inform surveillance and treatment strategies to achieve better breast cancer prognosis.

Updated retinoblastoma incidence and outcome in children in Taiwan from 1980 to 2019: a 40-year nationwide study.

Retinoblastoma is a potentially fatal disease, and its incidence and mortality varies among different countries and periods. This is a nationwide population-based retrospective study from January 1980 to December 2019 in Taiwan. Patients diagnosed as retinoblastoma were identified from the Taiwan National Cancer Registry. To update the literature on retinoblastoma incidence, mortality and trends in Taiwan, we analysed changes in incidence and survival rates over time according to sex, diagnostic age, laterality and treatment. During 1980-2019, the incidence of retinoblastoma in Taiwan was 1 per 16 489 live births (95% CI: 13 415-19 564). The diagnostic age decreased from 2.21 ± 0.26 during 1980-1984 to 1.24 ± 0.26 during 1985-2019. Compared with that observed during 1980-1989, the incidence rate observed after 1990 increased significantly in children aged <10 years (RR: 1.62-2.40, P = 0.0049 to < 0.0001). From 1980 to 2019, the incidence rate for the 0-4-year age group increased and that for the 5-9-year age group remained constant. The mean diagnostic age for bilateral retinoblastoma (0.36 ± 0.47 years) was significantly less than that for unilateral retinoblastoma (1.37 ± 0.35 years) during 2007-2019 (P < 0.0001). The 10-year survival rate was highest in the enucleation group (89.8%) compared with radiotherapy (52.2%) and others (70.0%; P < 0.0001). During 1980-2019 in Taiwan, the incidence of retinoblastoma increased significantly, and the diagnostic age decreased, which are similar to the ones from other developed countries. However, the survival rate was still lower than that of most developed countries.

Economic Burden of Cervical and Head and Neck Cancer in Taiwan from a Societal Perspective.

Head and neck cancers (HNC) are increasingly recognized as important human papillomavirus (HPV)-related malignancies in addition to cervical cancer (CC). However, data on the socioeconomic impact of HNC and CC in Taiwan are limited. A retrospective cohort study was conducted to estimate the total direct medical cost and indirect productivity loss from CC and HNC between 2014 and 2015. Patient data from the Taiwan National Cancer Registry were analyzed, with matched non-cancer controls from the Taiwan National Healthcare Reimbursement Database. Indirect costs due to premature deaths were calculated using public data from Taiwanese government reports. In the direct cost analysis, 2083 patients with newly diagnosed CC and 11,078 with newly diagnosed HNC (10,036 males) were identified between 2014 and 2015 and followed up through the end of 2016 or until death. The total direct medical costs incurred in 2014 and 2015 due to HNC were 11.54 times higher in males than in females, and 4.55 times higher than CC. Indirect cost analysis showed the total annual productivity loss was New Taiwan Dollar (NTD) $12 billion in 2019, and 79.99% was attributed to male HNC. In Taiwan, the socioeconomic burden associated with male HNC is high and greater than that seen with CC. While not all HNCs are attributable to HPV infection, prevention of HNC through HPV vaccination should be considered for both sexes.

IJU this issue

This issue contains one Review Article, nine Original Articles and one Urological Note with three Editorial Comments. Although 2-D cell culture and animal models have been widely used to examine tumor genetics and the sensitivity against anticancer drugs, these methods cannot mimic the tumor microenvironment in human bodies, and accurate analysis of anticancer treatment cannot be carried out. Tse et al. (Hong Kong, China) reviewed the development and applications of 3-D organoid cultures in urological cancer, and assessed the future prospects of this model. In this review, the authors discussed the advantage of organoids in drug screening and personalized medicine, the identification of cells of origin for urological cancers, and the tumor microenvironment. The authors concluded that 3-D organoids would have great potential in urological cancer research. Lin et al. (Kaohsiung, Taiwan) reported the incidence and survival variations of 8830 patients with new diagnoses of upper tract urothelial cancer identified from the Taiwan National Cancer Registry Annual Reports. The status of upper tract urothelial cancer in Taiwan was clarified, and what was interesting was that, in contrast to data from other countries, the incidence of upper tract urothelial cancer was considerably higher in women. Although the authors pointed out the possibility of aristolochic acid exposure as the cause, it is still unclear at this time. Iqbal et al. (New York, USA) reported a propensity score-matched analysis of effects on renal function between continent (neobladder; 50 patients) and incontinent (ileal conduit; 87 patients) urinary diversion. As a result of detailed analysis, the authors concluded that ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. To treat urethral stricture, most urologists carry out transurethral treatment. However, stricture recurrence after transurethral treatment is considered to be major problem. In this issue, Ojima et al. (Saitama, Japan) reported a preclinical study on the ability of photocurable gelatin to prevent stricture recurrence after urethral dilation in a rabbit model. The mean lumen ratio differed significantly after dilation between five rabbits with dilation + photocurable gelatin treatment and five rabbits with dilation only (65.5% vs 27.3%). The regenerated urethral epithelium at the stricture site is much better with dilation + photocurable gelatin treatment. I believe that this treatment to prevent stricture recurrence would be attractive from the perspective of showing the possibility of a new minimally invasive treatment for urethral stricture. In the Urological Note, Komai et al. (Tokyo, Japan) presented a proposed protocol for “What should we do next?” in the management of major bleeding during minimally invasive pelvic surgery. I believe that it will be useful clinically, so please take a look at the figure (a protocol for emergent bleeding from veins during minimally invasive pelvic surgery). Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. So, please enjoy them by all means. None declared.

Cancer patterns in nasopharyngeal carcinoma multiplex families over 15 years.

Genetic and environmental factors are important determinants of nasopharyngeal carcinoma (NPC). NPC is associated with Epstein-Barr virus (EBV) infection. Studies have reported familial aggregation of NPC, but evidence has been mixed for elevated rates of cancers other than NPC. The authors reassessed their previous evaluation of familial aggregation of cancer in 348 high-risk Taiwanese multiplex families with 2 or more NPC cases enrolled between 1980 and 2003. Participants were linked to the Taiwan National Cancer Registry and National Death Registry to identify cancers. In all, 2590 individuals contributed 37,959 person-years over an average of 15 years of follow-up; 314 incident cancers were identified. The authors computed multiple primary standardized incidence ratios (MP-SIRs) to evaluate the overall risk and the risk of infection-associated, EBV-associated, and individual cancers. The overall MP-SIR was 1.24 (95% confidence interval [CI], 1.10-1.38). The exclusion of excess NPC risk led to an overall MP-SIR of 1.11 (95% CI, 0.98-1.25). Similarly, the risk of cancers associated with infectious agents was driven by the excess in NPC, and its exclusion led to an MP-SIR of 1.22 (95% CI, 0.99-1.48) for infection-associated cancers and to an MP-SIR of 1.18 (95% CI, 0.72-1.82) for EBV-associated cancers. The authors observed a significant excess of second cancers among NPC cases (oral cancer, mouth cancer, tongue cancer, gum cancer, nasal cavity cancer, bone cancer, and non-Hodgkin lymphoma). This reassessment of the largest NPC multiplex family study confirms the presence of NPC coaggregation within families in Taiwan but does not provide evidence for a broader familial syndrome involving NPC and other tumors. Among NPC cases, elevated rates of secondary cancers, mostly at the, head and neck and hematopoietic cancers suggest radiation treatment effects on subsequent cancer risk.

Optimal Intervals of Ultrasonography Screening for Early Diagnosis of Hepatocellular Carcinoma in Taiwan

There are different clinical practices regarding ultrasonography screening intervals for hepatocellular carcinoma (HCC) despite recommendations from international guidelines. To evaluate whether ultrasonography screening using intervals suggested by international guidelines is associated with cancer stage shifting, reductions in mortality, and improved quality of life (QoL) for patients with HCC. This nationwide comparative effectiveness research study estimated lifetime survival functions using interlinkages of 3 databases from Taiwan-the Taiwan National Health Insurance, Taiwan National Cancer Registry, and National Mortality Registry-combined with QoL measurements obtained from National Cheng Kung University Hospital. In total, 114 022 patients listed as having newly diagnosed HCC from 2002 through 2015 in the Taiwan National Cancer Registry were followed up until 2017. The QoL values of 1059 patients with HCC who visited National Cheng Kung University Hospital were prospectively measured with the European QoL-5 dimensions questionnaire from 2011 through 2019. Patients were categorized based on the time between their last ultrasonography screening and the index date (90 days prior to HCC diagnosis) as 1 of 5 subcohorts: 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months (no screening in the previous 3 years). Data were analyzed from April 2020 to April 2021. Life expectancy, quality-adjusted life expectancy, and loss of life expectancy or loss of quality-adjusted life expectancy compared with age-, sex-, and calendar year-matched cohorts. There were 59 194 patients with Barcelona Clinic Liver Cancer staging information, including 42 081 men (mean [SD] age, 62.2 [12.6] years) and 17 113 women (mean [SD] age, 69.0 [11.2] years). There was a consistent trend showing that the longer the interval between ultrasonography examinations, the higher the loss of life expectancy and loss of quality-adjusted life expectancy for both sexes. Loss of quality-adjusted life expectancy values for male subcohorts were 10.0 (95% CI, 9.1-10.9) quality-adjusted life-years (QALYs) for ultrasonography screening intervals of 6 months, 11.1 (95% CI, 10.4-11.8) QALYs for 12 months, 12.1 (95% CI, 11.5-12.7) QALYs for 24 months, 13.1 (95% CI, 12.6-13.6) QALYs for 36 months, and 14.6 (95% CI, 14.2-15.0) QALYs for longer than 36 months. Loss of quality-adjusted life expectancy values for female subcohorts were 9.0 (95% CI, 8.3-9.6) QALYs for 6 months, 9.7 (95% CI, 9.2-10.2) QALYs for 12 months, 10.3 (95% CI, 9.8-10.7) QALYs for 24 months, 10.7 (95% CI, 10.2-11.1) QALYs for 36 months, and 11.4 (95% CI, 11.0-11.8) QALYs for longer than 36 months. Patients with underlying hepatitis B virus infection or cirrhosis had the greatest improvement in life expectancy with shorter screening intervals. Regular ultrasonography screening with intervals less than 6 to 12 months may be associated with early detection of HCC, save lives, and improve the quality of life for patients with HCC from a lifetime perspective.

Abstract PS13-04: Impact of delayed initiation of adjuvant chemotherapy in early breast cancer: Analysis from Taiwan National breast cancer registry database

Abstract Background:In 2017, there are more than 14,000 cases of newly diagnosed breast cancer in Taiwan. With the popularity of early screening policy and social-awareness, the proportion of early breast cancer has increased significantly in the last decades. For the high risk group with early breast cancer, adjuvant systemic chemotherapy could provide lower breast cancer recurrence rate and better overall survival rate. In Taiwan, every citizen must join the National Health Insurance (NIH), and the NIH would cover the whole expanse of adjuvant chemotherapy. Theoretically, all breast cancer patients could receive their condign chemotherapy regardless of their social economic status. The optimal initiation timing of adjuvant chemotherapy is undiscovered, and the effect of delay initiation is still under contestation. In this study, we try to identify the relationship between initiation time of chemotherapy and survival outcome, and different breast cancer subtypes would be analyzed separately. We also evaluate many associated factors that may delay chemotherapy initiation or survival status.Material and Methods:In this observational, populational-based study using Taiwan national breast cancer registry database, we studied 110,784 patients diagnosed with Stage I~III breast cancer between January 1, 2006 and Deccember 31, 2016. Time to chemotherapy(TCC) was defined as the days between surgery and the initial dose of adjuvant chemotherapy. We categorized patients into initiate chemotherapy within 30 days, 31~60 days, 61~90 days, and more than 91 days. The patient demography, tumor biology, lymph node status, type of breast surgery, receiving reconstructive surgery or not, radiation therapy, immunohistochemistry data (estrogen receptor, progesterone receptor, and human epidermal growth factor 2[HER2]), and we categorized patients according to different breast cancer subtypes. Univariate analysis with Kaplan-Meier method is used to evaluate TTC influence, and log-rank test is used to compare differences between groups. Multivariate logistic regression model is used to identify important factors associated with delayed chemotherapy initiation and survival.Preliminary Results:Totally 72840 patients were enrolled in this study, and the median age at initial diagnosis was 52.4 years old. Delayed wound healing and breast reconstruction are the main factors associated with delated TTC. Comparing with TTC&amp;lt;30 days group, TTC of 31~60 days group showed no difference in disease-free survival and overall survival, while TTC of 61~91 days group had a trend of lower disease-free survival (p=0.12). TTC more than 91 days had worse disease-free survival (HR=1.16, 95%CI=1.03~1.38) and overall survival (HR=1.23, 95%CI=1.08~1.52). We assumed initiate first chemotherapy more than 90 days as delated TTC as generally accepted in previous publications. In subgroup analysis, delayed TTC caused worse disease-free survival especially in triple negative group (HR=1.42, 95%CI=1.21~1.68) and HER2 group (HR=1.38, 95%CI=1.22~1.55).Conclusion:For breast cancer patients who assumed to receive adjuvant systemic chemotherapy, delayed in initiation of chemotherapy (more than 90 days) may result in worse outcome, especially in triple negative breast cancer and HER2 group. Besides the above preliminary result, other multivariate analysis and intergroup comparison are still ongoing. More information will reveal in SABCS 2020. Citation Format: Junping Shiau, Fang-Ming Chen, Ming-Feng Hou. Impact of delayed initiation of adjuvant chemotherapy in early breast cancer: Analysis from Taiwan National breast cancer registry database [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-04.

Is the risk of second primary malignancy increased in multiple myeloma in the novel therapy era? A population-based, retrospective cohort study in Taiwan

Longer survival in patients with multiple myeloma (MM) after treatment with novel agents (NA) such as thalidomide, bortezomib, and lenalidomide may be associated with increased risks of developing second primary malignancies (SPM). Few data describe the risk of SPM in patients with MM in Asia. This population-based retrospective cohort study assessed the risk of SPM in MM using the Taiwan National Cancer Registry and National Health Insurance Research databases from 2000 to 2014. Among 4,327 patients with newly diagnosed MM initiated with either novel agents alone (NA), chemotherapy combined with novel agents (CCNA), or chemotherapy alone (CA), the cumulative incidence of SPM overall was 1.33% at year 3. The SPM incidence per 100 person-years (95% confidence interval [CI]) was 0.914 (0.745–1.123) overall, 0.762 (0.609–1.766) for solid tumours, and 0.149 (0.090–0.247) for haematological malignancies. We compared risks of SPM using a cause-specific Cox regression model considering death as a competing risk for developing SPM. After controlling for age, gender, Charlson Co-morbidity Index, and time-period, the risk of developing any SPM or any haematological malignancy was significantly reduced in patients initiated on NA (2010–2014 period) compared to chemotherapy alone (adjusted hazard ratio 0.24, 95% CI 0.07–0.85, and 0.10, 95% CI 0.02–0.62, respectively). Contemporary treatment regiments using NA (mainly bortezomib) were associated with a lower risk for a SPM in comparison with CA.

Type of Androgen Deprivation Therapy and Risk of Dementia Among Patients With Prostate Cancer in Taiwan

It remains unclear whether androgen deprivation therapy (ADT) is associated with subsequent dementia risk in patients with prostate cancer. There are limited data regarding dementia risk across ADT types. To examine the association between all-cause dementia, including Alzheimer disease (AD), and different ADT types in patients with prostate cancer. This cohort study used linked data from the Taiwan National Cancer Registry, the National Health Insurance Research Database, and the Taiwan National Death Registry. A cohort of 23 651 patients with newly diagnosed prostate cancer between January 1, 2008, and December 31, 2015, was identified and followed up from 1 year after diagnosis until December 31, 2017. Data analysis was performed between January 2019 and May 2020. Patients who received and did not receive ADT, including gonadotropin-releasing hormone (GnRH) agonists, orchiectomy, or antiandrogen monotherapy. The primary outcomes were all-cause dementia or AD. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. The association between dementia and various ADT types was examined using the Cox proportional hazards model. Furthermore, a multivariate Cox proportional model with age as the time scale was conducted for complementary comparison. In the cohort of 23 651 male patients (median [interquartile range] age, 73 [66-79] years), 6904 (29.2%) did not receive ADT, 11 817 (50.0%) received GnRH agonists, 876 (3.7%) received orchiectomy, and 4054 (17.1%) received antiandrogen monotherapy. Overall, 1525 patients were diagnosed with incident dementia (1.72 per 100 person-years) during a median (interquartile range) follow-up of 3.46 (1.92-5.51) years. Compared with those who did not receive ADT, those using antiandrogen monotherapy showed an increased risk of dementia (weighted hazard ratio [HR], 1.34; 95% CI, 1.16-1.55) and AD (weighted HR, 1.52; 95% CI, 1.13-2.04). The risk of dementia was similar between GnRH agonist use or orchiectomy and no ADT use (GnRH agonist: weighted HR, 1.13; 95% CI, 1.00-1.28; orchiectomy: 1.00; 95% CI, 0.74-1.37). Several sensitivity analyses revealed consistent findings for both outcomes. In this study, the use of antiandrogen monotherapy was associated with increased risk of dementia or AD, while GnRH agonist use and orchiectomy had no significant difference compared with patients who did not receive ADT. Further prospective studies are warranted to confirm these findings.

Distinctive incidence patterns of follicular lymphoma in Taiwan: Implications of ethnic differences.

BackgroundFollicular lymphoma (FL) is less prevalent in Asians, but detailed epidemiological analyses were not available. This study aimed to characterize the epidemiologic features of FL in Taiwan to explore the factors relevant to disease development and prognosis.MethodsWe obtained epidemiological data for Taiwanese citizens during 1990‐2012 from Taiwan's National Cancer Registry Database, and the corresponding data for US Caucasians from the Surveillance, Epidemiology, and End Results Program. Changes in incidence rates were evaluated with age‐period‐cohort (APC) analyses. Patient outcomes were compared with 5‐year relative survival rates (RS) estimates.ResultsIncidence rates of FL in Taiwan increased continuously during the study period (0.34 to 0.91 per 100 000 person‐year from 1993‐1997 to 2008‐2012 in men, and from 0.29 [1993‐1997] to 0.81 [2008‐2012] in women), while rates in the US remained stable in both sexes, ranging between 3.73 and 3.96 in men and between 3.24 and 3.55 in women. Estimates of average annual percentage changes in incidence were significantly positive in Taiwan, but not in US Caucasians. Notably, the APC analysis identified a strong birth‐cohort effect in Taiwan, corresponding to environmental alterations present during the study period. The estimated 5‐year RS rates in both populations showed steady improvement, but the RS in Taiwanese patients was consistently 10% lower than in US Caucasians.ConclusionA distinct increasing trend of incidence with a strong birth‐cohort effect was identified in Taiwan, providing evidence of the association between environmental factors and disease development.

Adjuvant radiotherapy after curative surgery for oral cavity squamous cell carcinoma and treatment effect of timing and duration on outcome-A Taiwan Cancer Registry national database analysis.

Conduct an accurate risk assessment of resected oral cavity squamous cell carcinoma (OSCC) patients by accessing a nationwide systemic investigation is pivotal to improve treatment outcomes. In this article, we tried to determine the impact of different prognostic factors for OSCC patients who received adjuvant radiotherapy (RT) after curative surgery, using Taiwan's national cancer registry database (TCR). A nationwide, large population‐based study was conducted using TCR with patients identified from 2007 to 2015. The study variables included age, gender, cancer subsites, stage, histology grade, margin and extra‐nodal extension (ENE) status, treatment type, surgery to RT interval (ORI), total RT treatment time (RTT), and RT dose. Univariate and multivariate analysis were performed to identify predictors of the variables associated with overall survival (OS), cause‐specific survival (CSS), local‐regional relapse‐free survival (LRFS), and distant metastasis‐free survival (DMFS). 8986 OSCC patients treated with surgery and adjuvant RT were analyzed. In multivariate analysis, worse outcomes were associated with males, older age, subsite in the oral tongue, advanced stage, higher histologic grade, involved margin, and positive ENE. ORI only showed an adverse trend in LRFS, when exceeding 7 weeks (P = .06). RTT >8 weeks was a significant poor predictor in OS, CSS and LRFS (P < .001). Extreme RT dose (>70 Gy or ≤50 Gy) also demonstrated an adverse impact on the outcomes. Prolonged RT treatment time and extreme RT doses were identified as significantly poor prognostic predictors in OSCC patients who received adjuvant RT after curative surgery.

Dialysis Increases the Risk of Bladder Recurrence in Patients with Upper Tract UrothelialCancer: A Population-Based Study.

The relation of dialysis to tumor recurrence in patients with upper tract urothelialcancer (UTUC) is unknown; however, a limited number of small-scale studies suggest that patients with renal diseases prior to UTUC are more likely to exhibit bladder recurrence. We performed a population-based analysis to determine the effect of dialysis on bladder recurrence for patients with UTUC. This retrospective cohort study included patients diagnosed with UTUC (2002-2007) from the Taiwan National Cancer Registry and divided them into two groups-dialysis and non-dialysis groups. These patients were followed up until bladder recurrence, death, or the end of 2010. Competing risk analyses adjusting covariates and death were applied to determine the relation of dialysis and bladder recurrence. Of the 5141 eligible patients, 548 (10.7%) were undergoing dialysis. The cumulative bladder recurrence was significantly higher in the dialysis group than in the non-dialysis group (29% vs. 21%, modified log-rank p<0.001). In the multivariable analysis, the dialysis group exhibited a 64% increased bladder recurrence risk (cause-specific hazard ratio 1.64, 95% confidence interval 1.34-2.01, p<0.001), which was confirmed using stratification and propensity score weighting methods. The other prognostic factors for bladder recurrence were sex, diabetes, cardiac disorder, Charlson Comorbidity Index, and tumor grade. Despite unknown reasons, approximately one-tenth of patients with UTUC have experienced dialysis treatment. Patients undergoing dialysis have a higher risk of bladder recurrence. Various treatment and screening strategies should be developed for dialysis and non-dialysis patients.

Screening frequency and histologic type influence the efficacy of cervical cancer screening: A nationwide cohort study

ObjectiveTo evaluate the influence of age, screening interval, and histologic type on the effect of Pap smears in cervical cancer screening. Materials and methodsData were retrieved from the Taiwan National Cancer Registry and Cervical Cancer Screening Registration System for the period from 2002 to 2010. Age, Pap smear interval, FIGO stage, and histology were further analyzed. ResultsA total of 12,294 women with cervical cancer were enrolled, including 10,040 with squamous cell carcinoma (SCC), 1720 with adenocarcinoma (ADC), 401 with adenosquamous carcinoma (ASC), and 133 with small cell neuroendocrine carcinoma (SMC). Women who had a Pap smear at an interval of <3 years had a significantly higher proportion of stage I disease than women who had never undergone cervical cancer screening (p < 0.0001). Greater than 40% of women with SCCs in each age group had never had a Pap smear; however, women with ADCs were predominantly in the younger age and greater than 40% of women with ADCs had Pap smear at intervals < 3 years. ConclusionsPap smear is more effective in screening for cervical SCCs compared to cervical ADCs. Improving adherence to screening recommendations is important for the prevention of cervical SCC, especially in elderly women.

Incidence and mortality of pancreatic cancer on a rapid rise in Taiwan, 1999–2012

BackgroundAccumulating data has revealed a rapidly rising incidence of pancreatic cancer in Western countries, but convincing evidence from the East remains sparse. We aimed to quantify how the incidence and mortality rates of pancreatic malignancy changed over time in Taiwan, and to develop future projection for the next decade. MethodsThis nationwide population-based study analyzed the Taiwan National Cancer Registry and the National Cause of Death Registry to calculate the annual incidence and mortality rates of pancreatic malignancy from 1999 to 2012 in this country. The secular trend of the incidence was also examined by data from the National Health Insurance Research Database. ResultsA total of 21,986 incident cases of pancreatic cancer and 20,720 related deaths occurred during the study period. The age-standardized incidence rate increased from 3.7 per 100,000 in 1999 to 5.0 per 100,000 in 2012, with a significant rising trend (P<0.01). The increase was nationwide, consistently across subgroups stratified by age, gender, geographic region, and urbanization. Data from the National Health Insurance Research Database corroborated the rise of incident pancreatic cancer. Mortality also increased with time, with the age-standardized rate rising from 3.5 per 100,000 in 1999 to 4.1 per 100,000 in 2012 (P<0.01). In accordance with the incidence, the mortality trend was consistent in all subgroups. Both the incidence and mortality were projected to further increase by approximately 20% from 2012 to 2027. ConclusionThe incidence and mortality of pancreatic cancer have been rapidly rising and presumably will continue to rise in Taiwan.

Locoregionally recurrent head and neck squamous cell carcinoma: incidence, survival, prognostic factors, and treatment outcomes.

PurposeFor locoregionally recurrent head and neck squamous cell carcinoma (HNSCC), appropriate therapeutic decisions remain unclear. We examined the treatment outcomes of a national cohort to determine suitable treatments for and prognostic factors in patients with locoregionally recurrent HNSCCs at different stages and sites.Patients and methodsWe analyzed data of >20-year-old patients with HNSCC at American Joint Committee on Cancer clinical stages I–IV without metastasis from Taiwan National Health Insurance and cancer registry databases. The index date was the date of recurrent HNSCC diagnosis. Recurrent HNSCC was defined as the annotation of locoregional recurrence with tissue proof in cancer registry databases. The enrolled patients were categorized into three groups: Group 1 comprised those undergoing chemotherapy (CT) alone; Group 2 comprised those receiving reirradiation (re-RT) alone (total radiation dose ≥ 60 Gy through intensity modulation radiation therapy [IMRT]); Group 3 comprised those receiving concurrent chemoradiotherapy (CCRT) alone (irradiation total dose ≥60 Gy through IMRT); and Group 4 comprised those receiving salvage surgery with or without RT or CT.ResultsWe enrolled 4,839 and 28,664 HNSCC patients with and without locoregional recurrence, respectively (median follow-up, 3.25 years). Locoregional recurrence rate and incidence were 14.44% and 40.73 per 1,000 person-years, respectively. Age ≥ 65 years, Charlson comorbidity index (CCI) score > 6, advanced clinical stage at first diagnosis, and recurrence-free interval < 1 year were significant independent prognostic risk factors for overall survival as per univariate and multivariate Cox regression analyses. After adjusting for age, sex, CCI scores, clinical stage at first diagnosis, and recurrence-free interval, adjusted hazard ratios (aHRs; 95% confidence intervals [CIs]) for overall mortality in recurrent clinical stages I and II were 0.63 (0.45–0.89, p = 0.009), 0.65 (0.52–0.83, p < 0.001), and 0.32 (0.26–0.40, p < 0.001) in Groups 2, 3, and 4, respectively, whereas they were 1.23 (0.99–1.52, p = 0.062), 0.69 (0.60–0.79, p < 0.001), and 0.39 (0.34–0.44, p < 0.001) for Groups 2, 3, and 4, respectively, for overall mortality in recurrent clinical stage III and IV.ConclusionsAge, CCI score, clinical stage at first diagnosis, and recurrence-free interval are significant independent prognostic factors for overall survival of recurrent HNSCC patients. Regardless of recurrence stage or site, salvage surgery is the recommended first recurrent HNSCC treatment choice. Re-RT alone and CCRT are more suitable for inoperable recurrent early-stage oral and nonoral cavity recurrent HNSCCs, respectively.

MA03.03 High Risk for Second Primary Lung Cancer in Taiwanese Early-Onset Female Breast Cancer Patients

Female lung and breast cancers are two distinct disease entities in East Asia. Although studies on second primary cancers following the first breast cancer event have been carried out, no in-depth survey on double primary breast and lung cancers has been done. This study analyzed the association between these two distinct cancer types. In the exploratory cohort study, the data were obtained from the Taiwan National Health Insurance Research Database, which contained information on approximately 24.7 million insured individuals. The Taiwan Population Census and National Cancer Registry Databases were used to identify patients with breast and lung cancers. The cohort included individuals with newly diagnosed primary breast cancer between 2000 and 2011. An age- and sex-matched systematic random-sampling method was used for subject selection in the reference non-breast cancer cohort. Multivariate Cox proportional hazard regression analysis was used to determine the effects of breast cancer on the risk of lung cancer, as shown by hazard ratios (HRs) with 95% CIs. Detailed medical record and pathological reviews were done on the National Taiwan University Hospital (NTUH) patient cohort to validate the national cohort study results. The national lung cancer incidence rate was used as reference incidence rate in the validation cohort. A total of 88,439 patients were diagnosed with female breast cancer between 2000-2011 in the national cohort. The HR for subsequent lung cancer was 1.27 (95% CI, 1.09-1.48). When stratified by age, the HR was 5.29 (95% CI, 2.26-12.4) in the patients aged less than 40 years, 1.67 (95% CI, 1.18-2.30) in the group aged 40-49, 1.27 (95% CI, 0.97-1.67) in the group aged 50-59, 1.09 (95% CI, 0.81-1.49) in the group aged 60-69, and 0.70 (95% CI, 0.48-1.02) in the group older than 70 years. A total of 13,517 primary female breast cancer patients were identified in the NTUH electronic medical record system between 2006-2015. The incidence rate ratio for second primary lung cancer was 16.08 in the patients whose primary breast cancer was diagnosed at age younger than 50 years and 1.43 for those diagnosed at age older than 50 years. These results supported the national cohort study findings that early-onset female breast cancer patients bear a relative high risk for second primary lung cancer. Our findings suggest a relative high risk for second primary lung cancer among patients whose primary female breast cancer is diagnosed at age less than 50 years.

Effects of Arsenic in Drinking Water on Risk of HepatitisorCirrhosis in Persons With and Without ChronicViralHepatitis.

Arsenic in drinking water is associated with hepatomegaly and death from liver cancer. However, confounding factors related to liver diseases have not been carefully studied. We examined associations between exposure of arsenic in drinking water and risk of hepatitis and cirrhosis, and the interaction with chronic viral hepatitis, in people living in the Lanyang Basin of northeastern Taiwan, where well water has an arsenic content that ranges from undetectable to 3590 μg/L. We tested blood samples from 4387 people who lived in arseniasis-endemic areas in northeastern Taiwan from 1991 through 1994 for hepatitis B virus DNA, hepatitis B surface antigen (HBsAg), and antibodies against hepatitis C virus (anti-HCV). We measured arsenic concentrations in well water and collected information on residents' histories of major chronic diseases. Reports of chronic hepatitis or cirrhosis were ascertained using the Taiwan National Health Insurance database. Reports of liver cancer were ascertained using the Taiwan National Cancer Registry. Prevalence odds ratios in the overall study population for chronic hepatitis or cirrhosis for well water arsenic concentrations of ≤10 μg/L were 1.00 (reference), 0.93 for 10.1-49.9 μg/L (95% confidence interval [CI], 0.57-1.52), 1.24 for 50.0-99.9 μg/L (95% CI, 0.68-2.23), 0.98 for 100.0-299.9 (95% CI, 0.52-1.85), and 1.86 for ≥300.0 μg/L (95% CI, 1.08-3.20). Increasing levels of arsenic in drinking water were associated with increasing prevalence of chronic hepatitis or cirrhosis in residents who were seronegative for HBsAg and seronegative for anti-HCV, but not for seropositive for either HBsAg or anti-HCV. In individuals who were seropositive for HBsAg or anti-HCV, we observed an inverse association between hepatitis or cirrhosis and consumption of water with levels of arsenic ≥100.0 μg/L. Among participants who were seropositive for HBsAg or anti-HCV, consumption of water with levels of arsenic ≥100.0 μg/L was associated with a reduced risk of liver cancer (multivariate-adjusted hazard ratio, 0.29;95% CI, 0.09-0.95; P < .05). A higher proportion of individuals exposed to cumulative arsenic level >14,000 μg/L×year were carriers of inactive hepatitis B virus (DNA <10,000 copies/mL) and were positive for HBsAg (60%) than individuals exposed to water below this arsenic level (35%). Concentrations of arsenic concentration in drinking water ≥300.0 μg/L significantly increase risk of hepatitis or cirrhosis in people without chronic viral hepatitis. However, in people with chronic viral hepatitis, levels of arsenic ≥100.0 μg/L in drinking water significantly reduce the risk of chronic hepatitis or cirrhosis.

Parkinson’s disease is associated with most cancers in Taiwan

Using the nationwide Taiwan Population Census and National Cancer Registry Databases, researchers from Taipei examined the relationship between cancer and Parkinson’s disease (PD). Data from 62,023 PD patients and 124,046 without PD diagnosed between 2004 and 2010 were included in this cohort study. Their findings suggested that PD is, in general, a risk factor for cancer.

Association Between Parkinson Disease and Risk of Cancer in Taiwan.

Parkinson disease (PD) has been reported to be associated with a general reduced risk of cancer. These studies were mainly carried out in Western populations and little was known about associations in East Asians. To analyze the association between PD and risk of cancer. In this cohort study, the data were obtained from the Taiwan National Health Insurance Research Database, which contained information on approximately 24.7 million insured individuals. The cohort included individuals with newly diagnosed as having PD between 2004 and 2010. An age- and sex-matched systematic random-sampling method was used for subject selection in the reference non-PD cohort. Multivariate Cox proportional hazard regression analysis was used to determine the effects of PD on the risks of cancer, as shown by hazard ratios (HRs) with 95% CIs. The Taiwan Population Census and National Cancer Registry Databases were used to identify patients with cancer. The last follow-up date was December 31, 2012. In 62 023 patients with PD, the HR for all subsequent cancers combined was 1.58 (95% CI, 1.50-1.65). Of the 19 types of cancer, Parkinson disease was not associated with breast, ovarian, or thyroid cancers. Increased HRs were found in the remaining 16 cancers, including malignant brain tumors (HR, 3.42; 95% CI, 1.84-6.38), gastrointestinal tract cancers (esophageal [HR, 1.81; 95% CI, 1.28-2.57], stomach [HR, 1.59; 95% CI, 1.30-1.94], colorectal [HR, 1.47; 95% CI, 1.31-1.65], liver [HR, 1.89; 95% CI, 1.67-2.14]; gallbladder [HR, 1.73; 95% CI, 1.16-2.57], and pancreas [HR, 1.48; 95% CI, 1.09-2.02]) (P < .05 for all comparisons), lung cancers (HR, 1.56; 95% CI, 1.38-1.76), some hormone-related cancers (uterine [HR, 1.83; 95% CI, 1.12-3.01], cervical [HR, 1.36; 95% CI, 1.05-1.76], and prostate [HR, 1.80; 95% CI, 1.52-2.13; P < .05 for all comparisons), urinary tract cancers (kidney and bladder cancers; HRs, 1.59 and 1.99, respectively; P < .001 for both comparisons), lymphoma and/or leukemia (HR, 1.62; 95% CI, 1.31-2.01), melanoma (HR, 2.75; 95% CI, 1.35-5.59), and other skin cancers (HR, 1.81; 95% CI, 1.46-2.23). For hepatocellular carcinoma, the highest HR resided in the 50- to 59-year-old group (HR, 2.57; 95% CI, 1.7-3.89). Our study concludes that PD is is associated with most cancers in Taiwan. Further studies are needed to clarify whether our findings can be applied to other East Asian populations. The differences between our study and most previous cohorts suggest the importance of ethnicity and environmental exposures in disease pathogenesis.

Helicobacter pylori test-and-treat program can be cost-effective to prevent gastric cancer in Taiwanese adults: referred to the nationwide reimbursement database.

Helicobacter pylori infection increases the risk of gastric cancer. The study aimed to compare cost-effectiveness ratios of H. pylori test-and-treat programs to prevent gastric cancer in Taiwan, referring to the nationwide reimbursement database and expected years of life lost. During 1998-2009, there were 12,857 females and 24,945 males with gastric adenocarcinoma in Taiwan National Cancer Registry. They were followed up to 2010 and linked to the reimbursement database of National Health Insurance and the national mortality registry to determine lifetime health expenditures and expected years of life lost. Cost-effectiveness ratios of H. pylori test-and-treat programs for prevention of gastric adenocarcinoma were compared between screenings with (13) C-urea breath test and with anti-H. pylori IgG. The test-and-treat program with anti-H. pylori IgG to prevent gastric adenocarcinoma had lower incremental cost-effectiveness ratios than that with (13) C-urea breath test in both sexes (females: 244 vs 1071 US dollars/life-year; males: 312 vs 1431 US dollars/life-year). Cost saving would be achieved in an endemic area where H. pylori prevalence was >73.5%, or by selecting subpopulations with high absolute risk reduction rates of cancer after eradication. Moreover, expected years of life lost of gastric adenocarcinoma were higher and the incremental cost-effectiveness ratios of test-and-treat programs were more cost-effective in young adults (30-69 y/o) than in elders (≥70 y/o). The test-and-treat program with anti-H. pylori IgG shall be cost-effective to prevent gastric adenocarcinoma in a high endemic area, especially beginning at 30 years of age when H. pylori prevalence rates become stabilized.