Louwman, W.J.

Socioeconomic inequalities in attending the mass screening for breast cancer in the south of the Netherlands-associations with stage at diagnosis and survival (Article)

2011-07-01T00:00:00Z

The associations of socioeconomic status (SES) and participation in the breast cancer screening program, as well as consequences for stage of disease and prognosis were studied in the Netherlands, where no financial barriers for participating or health care use exist. From 1998 to 2005, 1,067,952 invitations for biennial mammography were sent to women aged 50-75 in the region covered by the Eindhoven Cancer Registry. Screening attendance rates according to SES were calculated. Tumor stage and survival were studied according to SES group for patients diagnosed with breast cancer between 1998 and 2006, whether screen-detected, interval carcinoma or not attended screening at all. Attendance rates were rather high: 79, 85 and 87% in women with low, intermediate and high SES (p < 0.001), respectively. Compared to the low SES group, odds ratios for attendance were 1.5 (95%CI:1.5-1.6) for the intermediate SES group and 1.8 (95%CI:1.7-1.8) for the high SES group. Moreover, women with low SES had an unfavorable tumor-node-metastasis stage compared to those with high SES. This was seen in non-attendees, among women with interval cancers and with screen-detected cancers. Among non-attendees and interval cancers, the socioeconomic survival disparities were largely explained by stage distribution (48 and 35%) and to a lesser degree by therapy (16 and 16%). Comorbidity explained most survival inequalities among screen-detected patients (23%). Despite the absence of financial barriers for participation in the Dutch mass-screening program, socioeconomic inequalities in attendance rates exist, and women with low SES had a significantly worse tumor stage and lower survival rate.

A population-based study on the utilisation rate of primary radiotherapy for prostate cancer in 4 regions in the Netherlands, 1997-2008 (Article)

2011-05-01T00:00:00Z

Aim: The purpose was to study variations in utilisation rates of external beam radiotherapy (EBRT) and brachytherapy (BT) for prostate cancer patients. Materials and methods: We calculated the proportion and number of EBRT and BT given or planned within 6 months of diagnosis in 4 Dutch regions, according to stage and age in a population-based setting including 47,259 prostate cancer patients diagnosed from 1997 until 2008. Results: During this study period, the overall utilisation rate of EBRT remained stable at around 25%, while the rate of BT for non-metastasized patients increased from 1% (95% CI:0-1%) to 12% (11-13%) in 2006 and slightly decreased towards 10% (9-11%) in 2008. From 2001 on, the overall utilisation rate of EBRT decreased significantly in one region (p < 0.05). In this region, a sharp rise in the utilisation rate of BT for non-metastatic patients was noted to 17% (14-20%) in 2008 after a peak of 24% (21-27%) in 2006. For localised disease, BT was used more often at the expense of EBRT while for locally advanced disease the utilisation rate of EBRT increased. In the multivariate analysis, regional differences in the utilisation rate of EBRT persisted with odds ratios ranging from 0.7 to 0.9 compared to the reference region. Moreover, low rates of EBRT were associated with high BT rates. The regional differences could not be explained by differences in risk profiles. Conclusions: The utilisation rate of EBRT remained stable with limited variation between regions while BT was used increasingly with clear regional differences. To cope with this and in view of the increasing incidence of prostate cancer, adequate resources have to be planned for the optimal care of these patients.

A 50% higher prevalence of life-shortening chronic conditions among cancer patients with low socioeconomic status (Article)

2010-11-23T00:00:00Z

Background: Comorbidity and socioeconomic status (SES) may be related among cancer patients. Method : Population-based cancer registry study among 72 153 patients diagnosed during 1997-2006. Results : Low SES patients had 50% higher risk of serious comorbidity than those with high SES. Prevalence was increased for each cancer site. Low SES cancer patients had significantly higher risk of also having cardiovascular disease, chronic obstructive pulmonary diseases, diabetes mellitus, cerebrovascular disease, tuberculosis, dementia, and gastrointestinal disease. One-year survival was significantly worse in lowest vs highest SES, partly explained by comorbidity. Conclusion : This illustrates the enormous heterogeneity of cancer patients and stresses the need for optimal treatment of cancer patients with a variety of concomitant chronic conditions.

Scrotal cancer: Incidence, survival and second primary tumours in the Netherlands since 1989 (Article)

2010-10-28T00:00:00Z

Background: Since the 1970s there have been few epidemiological studies of scrotal cancer. We report on the descriptive epidemiology of scrotal cancer in the Netherlands. Methods: Data on all scrotal cancer patients were obtained from the Netherlands Cancer Registry (NCR) in the period 1989-2006 and age-standardised incidence rates were calculated also according to histology and stage. Relative survival was calculated and multiple primary tumours were studied. Results: The overall incidence rate varied around 1.5 per 1 000 000 person-years, most frequently being squamous cell carcinoma (27%), basal cell carcinoma (19%) and Bowen's disease (15%). Overall 5-year relative survival was 82%, being 77% and 95% for patients with squamous and basal cell carcinoma, respectively. In all, 18% of the patients were diagnosed with a second primary tumour. Conclusion: The incidence rate of scrotal cancer did not decrease, although this was expected; affected patients might benefit from regular checkups for possible new cancers.

Reduction of socioeconomic inequality in cancer incidence in the South of the Netherlands during 1996-2008 (Article)

2010-09-01T00:00:00Z

Background: Cancer incidence varies according to socioeconomic status (SES) and time trends. SES category may thus point to differential effects of lifestyle changes but early detection may also affect this. Patients and methods: We studied patients diagnosed in 1996-2008 and registered in the South Netherlands Cancer registry. Incidence rates and estimated annual percentage changes were calculated according to SES category, age group (25-44, 45-64 and ≥65) and sex. Results: People with a low SES exhibited elevated incidence rates of cancer of the head and neck, upper airways (both sexes), gastro-intestinal tract, squamous cell skin cancer, breast (≥65) and all female genital, bladder, kidney and mature B-cells (all in females only), whereas prostate cancer, basal cell skin cancer (BCC) and melanoma (both except in older females) were most common among those with a high SES. Due to the greater increase in prostate cancer and melanoma in high SES males and the larger reduction of lung cancer in low SES males, incidence of all cancers combined became more elevated among males of ≥45 years with a high and intermediate SES, and approached rates for low SES men aged 45-64. In spite of more marked increases in the incidence of colon, rectal and lung cancer in high SES women, the incidence of all cancers combined remained highest for low SES women of ≥45 years. However, at age 25-44 years, the highest incidence of cancer of the breast and melanoma was observed among high SES females. During 1996-2008 inequalities increased unfavourably among higher SES people for prostate cancer, BCC (except in older women) and melanoma (at middle age), while decreasing favourably among low SES people for cancers of the oesophagus, stomach, pancreas and kidney (both in females only), breast (≥65 years), corpus uteri and ovary. Conclusions: Although those with a low SES exhibited the highest incidence rates of the most common cancers, higher risks were observed among those with high SES for melanoma and BCC (both except older females) and for prostate and breast (young females) cancer. Altogether this might also have contributed to the recent higher cancer awareness in Dutch society which is usually promoted more by patients of high SES and those who know or surround them.

Increase in basal cell carcinoma incidence steepest in individuals with high socioeconomic status: Results of a cancer registry study in the Netherlands (Article)

2009-10-01T00:00:00Z

Background Development of both basal cell carcinoma (BCC) and cutaneous malignant melanoma (MM) is associated with acute and intermittent sun exposure. In contrast to MM, the association between socioeconomic status (SES) and BCC is not well documented. Objectives To investigate the incidence of BCC according to SES, stratifying by age and tumour localization in a large population-based cohort. To assess changes over time in the distribution of the patients with BCC across the SES categories. Methods All patients with a histologically confirmed first primary BCC (n = 27027) diagnosed between 1988 and 2005 in the Southeast of the Netherlands were stratified by sex, age (25-44, 45-64 and ≥ 65 years), period of diagnosis, SES category (based on income and value of housing) and localization of the BCC. Age-standardized BCC incidence rates were calculated for the year 2004 by SES category and localization. Ordinal regression was used to assess changes over time in the proportion of patients with BCC by sex, age and SES. Results For men in all age groups higher BCC incidence in the highest SES category was observed, which remained significant after stratification for tumour localization. For women a consistent relationship was found only in younger women (< 65 years) for truncal BCCs, which occurred more frequently in high SES groups. Between 1990 and 2004, the proportion of BCC patients with high SES increased (+6%) and the proportion with low SES decreased (-7%). Conclusions High SES is associated with increased incidence of BCC among men. Our data suggest that BCC is changing from a disease of the poor to a disease of the rich.

Rising incidence of breast cancer among female cancer survivors: implications for surveillance. (Article)

2009-08-20T00:00:00Z

The number of female cancer survivors has been rising rapidly. We assessed the occurrence of breast cancer in these survivors over time. We computed incidence of primary breast cancer in two cohorts of female cancer survivors with a first diagnosis of cancer at ages 30+ in the periods 1975–1979 and 1990–1994. Cohorts were followed for 10 years through a population-based cancer registry. Over a period of 15 years, the incidence rate of breast cancer among female cancer survivors increased by 30% (age-standardised rate ratio (RR-adj): 1.30; 95% CI: 1.03–1.68). The increase was significant for non-breast cancer survivors (RR-adj: 1.41, 95% CI: 1.04–2.75). During the study period, the rate of second breast cancer stage II tripled (RR-adj: 3.10, 95% CI: 1.73–5.78). Non-breast cancer survivors had a significantly (P value=0.005) more unfavourable stage distribution (62% stage II and III) than breast cancer survivors (32% stage II and III). A marked rise in breast cancer incidence among female cancer survivors was observed. Research to optimise follow-up strategies for these women to detect breast cancer at an early stage is warranted.

Screening caused rising incidence rates of ductal carcinoma in situ of the breast (Article)

2009-05-01T00:00:00Z

The purpose of this study was to examine trends in incidence and detection of ductal carcinoma in situ (DCIS) of the breast in southern Netherlands in the period 1984-2006 and assess the effect of mass screening. All patients with primary DCIS registered between 1984 and 2006 in the population-based Eindhoven Cancer Registry were included (n = 1,767). These data were linked to data from the population-based screening programme. The incidence of DCIS of the breast increased from 3/100,000 to almost 34/100,000 person-years in women aged 50-69 years in southern Netherlands since 1984. Mass screening was responsible for this increase. A stable 60% of DCIS was screen-detected. Over 11% of breast cancer patients have DCIS. In conclusion, the incidence of DCIS increased markedly in southern Netherlands with a clear effect of mammography screening since 1992.

The impact of adjuvant therapy on contralateral breast cancer risk and the prognostic significance of contralateral breast cancer: A population based study in the Netherlands (Article)

2008-07-01T00:00:00Z

Background: The impact of age and adjuvant therapy on contralateral breast cancer (CBC) risk and prognostic significance of CBC were evaluated. Patients and Methods: In 45,229 surgically treated stage I-IIIA patients diagnosed in the Netherlands between 1989 and 2002 CBC risk was quantified using standardised incidence ratios (SIRs), cumulative incidence and Cox regression analysis, adjusted for competing risks. Results: Median follow-up was 5.8 years, in which 624 CBC occurred <6 months after the index cancer (synchronous) and 1,477 thereafter (metachronous). Older age and lobular histology were associated with increased synchronous CBC risk. Standardised incidence ratio (SIR) of CBC was 2.5 (95% confidence interval (95% CI) 2.4-2.7). The SIR of metachronous CBC decreased with index cancer age, from 11.4 (95% CI 8.6-14.8) when <35 to 1.5 (95% CI 1.4-1.7) for ≥60 years. The absolute excess risk of metachronous CBC was 26.8/10,000 person-years. The cumulative incidence increased with 0.4% per year, reaching 5.9% after 15 years. Adjuvant hormonal (Hazard rate ratio (HR) 0.58; 95% CI 0.48-0.69) and chemotherapy (HR 0.73; 95% CI 0.60-0.90) were associated with a markedly decreased CBC risk. A metachronous CBC worsened survival (HR 1.44; 95% CI 1.33-1.56). Conclusion: Young breast cancer patients experience high synchronous and metachronous CBC risk. Adjuvant hormonal or chemotherapy considerably reduced the risk of CBC. CBC occurrence adversely affects prognosis, emphasizing the necessity of long-term surveillance directed at early CBC-detection.

On the rising trends of incidence and prognosis for breast cancer patients diagnosed 1975-2004: A long-term population-based study in southeastern Netherlands (Article)

2008-02-01T00:00:00Z

Background: Much progress has been made in the early diagnosis and treatment of breast cancer. We have assessed the changing burden of this disease, by means of a comprehensive description of trends in incidence, survival, and mortality. Methods: Data on breast cancer patients diagnosed between 1975 and 2004 (n = 26,464) registered in the population-based Eindhoven Cancer Registry were investigated. Results: Incidence for patients aged below 40 and 40-49 has increased by 2.1% and 2.4% annually, since 1995 (p = 0.08 and p = 0.001, respectively). Mortality decreased in all age groups, but most markedly among women aged 50-69 (-1.5% yearly since 1985, p = 0.14). The proportion of stage I tumors increased from 25% to 39%, that of advanced stages (III & IV) decreased from 30% (1975-1984) to 13% in 1995-2004, and the proportion of in situ tumors increased from 1.5% to 10%. Adjuvant systemic treatment was administered to 15% of patients in 1975-1984 vs. 49% in 1995-2004. Relative 10-year survival rates for women aged 50-69 (period analysis) increased from 53% to 75% between 1975 and 2004. The best prognosis was observed for women aged 45-54. Women younger than 35 had a particularly poor prognosis. Conclusion: The observed improvement in survival of breast cancer patients during the last three decades is impressive. The peak in breast cancer incidence is not yet in sight considering the recent trends in exposure to known risk factors and improved diagnosis. The combination of increasing incidence and improved survival rates implies that the number of prevalent cases will continue to increase considerably in the next 10 years.

Impact of a programme of mass mammography screening for breast cancer on socio-economic variation in survival: A population-based study (Article)

2007-11-01T00:00:00Z

Background: After a systematic mass mammography breast cancer screening programme was implemented between 1991 and 1996 (attendance 80%), we evaluated its impact on survival according to socioeconomic status (SES). Methods: We studied survival rates up to 1-1-2005 for all consecutive breast cancer patients aged 50-69 and diagnosed in the period 1983-2002 in the area of the Eindhoven Cancer Registry (n = 4939). Multivariate analyses were performed using Cox regression analysis. Results: The proportion of breast cancer patients with a low SES decreased from 22% in 1983-1990 to 14% in 1997-2002 when attendance was 85%. The proportion of newly diagnosed patients with stage III or IV disease in 1997-2002 was only 10% compared to 14% in 1991-1996 and 26% in 1983-1989 (P < 0.0001). Stage distribution improved for all socio-economic groups (P = 0.01). Survival was similar for all socio-economic groups in 1983-1990, but after the introduction of the screening programme women with low SES had lower age- and stage-adjusted survival rates (HR 2.0, 95%CI: 1.3-3.0). Survival was better for patients diagnosed in 1997-2002 compared to 1983-1990 for all socioeconomic strata; it was substantially better for the high SES group (HR 0.36, 0.2-0.5) compared to the lowest SES (HR 0.77, 0.6-1.1). Conclusion: Although survival improved for women from each of the socio-economic strata, related to the high participation rate of the screening programme, women from lower socio-economic strata clearly benefited less from the breast cancer screening programme. That is also related to the higher prevalence of comorbidity and possibly suboptimal treatment.

A population-based study of radiotherapy in a cohort of patients with rectal cancer diagnosed between 1996 and 2000 (Article)

2007-10-01T00:00:00Z

Aims: To study, in a population-based setting, the use of delayed radiotherapy (RT) in a cohort of 2008 unselected rectal cancer patients diagnosed between 1996 and 2000. Patients and methods: Radiation within 6 months of diagnosis was considered part of the primary treatment (PRT). RT given 6 months or later after diagnosis or after PRT was considered as delayed or secondary RT (SRT). Number, percentage and cumulative proportion of patients receiving SRT were calculated. The odds for receiving SRT (total and for recurrent rectal cancer only) were studied by logistic regression analysis, taking into account age, gender, co-morbidity, socio-economic status, stage, prior PRT and RT department (2 departments, each serving general hospitals only). Results: Forty-six percent of all newly diagnosed patients received RT. Ten percent (n = 203) received at least once SRT, either after PRT or as first RT, of which 96 patients for a relapsed rectal tumour (31 after PRT on the rectal tumour, 65 as a first radiation treatment). In a multivariate analysis of patients with rectal recurrence secondary pelvic irradiation was less often given after primary irradiation (OR: 0.7, 95% CI: 0.4-1.1). Patients with a stage III significantly more often received SRT on a recurrence (OR = 2.5, 95% CI = 1.4-4.5). Generally, patients in the eastern department received more often PRT and less often SRT for recurrence (OR: 0.5, 95% CI: 0.3-0.8). Conclusions: Five percent of all patients with rectal cancer received SRT on a recurrent tumour, with a large variation between the two RT departments in the region.

Clinical epidemiology of breast cancer in the elderly (Article)

2007-10-01T00:00:00Z

Breast cancer will increasingly become a disease affecting the lives of older women, especially in more developed countries, the prevalence rising up to 7% over age 70 in the near future. A review of the population-based literature and an analysis of the data of the Eindhoven Cancer Registry and European data regarding the diagnosis, treatment and prognosis showed that the proportion with unstaged and advanced disease (stages III and IV) is higher among elderly patients compared to younger ones and that their treatment is generally less aggressive, although the proportion receiving chemotherapy is increasing since the early 1990s. Disease specific (or relative) survival of elderly breast cancer patients is generally lower and the prevalence of serious (life expectancy affecting) co-morbidity is higher (>50% in patients over age 70). Because of large individual variations in physical and mental conditions, limited evidence from RCTs and personal preferences prevailing in the decision-making process, treatment of older breast cancer patients seems difficult to fit into guidelines. Therefore, alternative research strategies are needed to understand and improve the care for the elderly breast cancer population, such as descriptive (registry-based) studies and a qualitative, individual-based approach.

A population based study of radiotherapy in a cohort of patients with breast cancer diagnosed between 1996 and 2000 (Article)

2007-09-01T00:00:00Z

We studied the use of radiotherapy (RT) (especially secondary RT) in a cohort of 6561 patients in southern Netherlands with invasive breast cancer diagnosed between 1996 and 2000 (median follow-up: 66 months, range 0-107 months). Radiation within 6 months of diagnosis was considered primary RT (PRT). RT given 6 months or later after diagnosis or after PRT was considered secondary RT (SRT). Of all patients, 67% received RT, 3554 only PRT, 323 only SRT and 503 both. The cumulative use of SRT at 100 months was 17%. The 826 patients receiving SRT underwent 1846 courses 0-105 months (median 36) after diagnosis; the retreat rate was 35%. Elderly patients received SRT significantly less often (ORage 50-69= 0.7, 95%CI = 0.6-0.8, ORage≥70= 0.4, 95%CI = 0.3-0.5). The following factors increased the chance for SRT: patients from the eastern region (OR = 1.3, 95%CI = 1.1-1.6); patients who received PRT (OR = 1.3, 95%CI = 1.0-1.5) and patients who underwent mastectomy including axillary node dissection as well as unresected patients (OR = 1.9, 95%CI = 1.5-2.4, OR = 2.6, 95%CI = 1.7-3.9, respectively). Thirteen percent of all patients with breast cancer received SRT, with a large variation in age and between the 2 RT departments in the region.

Childhood social class and cancer incidence: results of the globe study (Article)

2007-01-01T00:00:00Z

Despite increased recognition of the importance of investigating socio-economic inequalities in health from a life course perspective, little is known about the influence of childhood socio-economic position (SEP) on cancer incidence. The authors studied the association between father's occupation and adult cancer incidence by linking information from the longitudinal GLOBE study with the regional population-based Eindhoven Cancer Registry (the Netherlands) over a period of 14 years. In 1991, 18,973 participants (response rate 70.1%) of this study responded to a postal questionnaire, including questions on SEP in youth and adulthood. Respondents above the age of 24 were included (N = 12,978). Cox regression was used to calculate hazard ratios (HR) for all cancers as well as for the five most frequently occurring cancers by respondent's educational level or occupational class, and by father's occupational class (adjusted for respondent's education and occupation). Respondents with a low educational level showed an increased risk of all cancers, lung and breast cancer (in women). Respondents with a low adult occupational level showed an increased risk of lung cancer and a reduced risk of basal cell carcinoma. After adjustment for adult education and occupation, respondents whose father was in a lower occupational class showed an increased risk of colorectal cancer as compared to those with a father in the highest social class. In contrast, respondents whose father was in a lower occupational class, showed a decreased risk of basal cell carcinoma as compared to those with a father in the highest occupational class. The association between childhood SEP and cancer incidence is less consistent than the association between adult SEP and cancer incidence, but may exist for colorectal cancer and basal cell carcinoma.

Hypertension as a risk factor for glioma? Evidence from a population-based study of comorbidity in glioma patients. (Article)

2004-08-01T00:00:00Z

BACKGROUND: Little is known about the aetiology of glioma. Research is often hampered by the low incidence and high mortality of the disease. Concomitant diseases in glioma patients may indicate possible aetiological pathways. We therefore studied comorbidity in glioma patients. PATIENTS AND METHODS: We performed a case-control study using population-based data from the Eindhoven Cancer Registry. We compared prevalences of concomitant diseases in 510 glioma patients with two reference cancer populations from the same registry. RESULTS: Compared with all other cancer patients, a significantly higher prevalence of hypertension was found in glioma patients for age categories 60-74 years [odds ratio (OR) 1.37; 95% confidence interval (CI) 1.02-1.84] and 75+ years (OR 2.37; 95% CI 1.34-4.21). The association was most pronounced in elderly men and in astrocytic glioma, with a maximum in age category 75+ years (OR 5.86; 95% CI 2.20-15.7). The prevalence of cerebrovascular disease was higher in glioma patients >45 years old (OR 1.67; 95% CI 1.12-2.47), whereas the prevalence of other cancers was lower (OR 0.64; 95% CI 0.48-0.87). No consistent associations were detected for several other concomitant diseases. CONCLUSIONS: Our data suggest an association between hypertension and glioma, although questions remain about causality and the possible mechanisms. We hypothesise that this association is mediated through potentially neurocarcinogenic effects of antihypertensive medication.