Clinical auditing as an instrument to improve care for patients with ovarian cancer: The Dutch Gynecological Oncology Audit (DGOA)

IntroductionThe Dutch Gynecological Oncology Audit (DGOA) was initiated in 2014 to serve as a nationwide audit, which registers the four most prevalent gynecological malignancies. This study presents the first results of clinical auditing for ovarian cancer in the Netherlands.MethodsThe Dutch Gynecological Oncology Audit is facilitated by the Dutch Institute of Clinical Auditing (DICA) and run by a scientific committee. Items are collected through a web-based registration based on a set of predefined quality indicators. Results of quality indicators are shown, and benchmarked information is given back to the user. Data verification was done in 2016.ResultsBetween January 01, 2014 and December 31, 2018, 6535 patients with ovarian cancer were registered. The case ascertainment was 98.3% in 2016. The number of patients with ovarian cancer who start therapy within 28 days decreased over time from 68.7% in 2014 to 62.7% in 2018 (p < 0.001). The percentage of patients with primary cytoreductive surgery decreased over time (57.8%–39.7%, P < 0.001). However, patients with complete primary cytoreductive surgery improved over time (53.5%–69.1%, P < 0.001). Other quality indicators did not significantly change over time.ConclusionThe Dutch Gynecological Oncology Audit provides valuable data on the quality of care on patients with ovarian cancer in the Netherlands. Data show variation between hospitals with regard to pre-determined quality indicators. Results of ‘best practices’ will be shared with all participants of the clinical audit with the aim of improving quality of care nationwide.     

The quality of cancer care initiative in the Netherlands

BackgroundIn 2007 the Dutch Cancer Society formed a ‘Quality of Cancer Care’ taskforce comprising medical specialists, from all disciplines involved in the care for cancer patients. This taskforce was charged with the evaluation of quality of cancer care in the Netherlands and the development of strategies for improvement.ObjectiveThe experts first focused on the relation between procedural volume and patient outcome and later aimed to identify other factors associated with high and low quality of the care provided in different regions and (types of) hospitals in the Netherlands. The question if cancer care in the Netherlands could be organized differently to assure high quality of care for all patients, was the main subject of investigation.MethodsAn extensive review of the literature on infrastructure, volume and specialization on the one hand and outcome on the other was performed. In addition, a meta-analysis of the volume–outcome relationship for pancreatectomies, bladder, lung, colorectal and breast cancer resections was performed. Finally, variation in quality of cancer care between regions, groups of hospitals and individual hospitals in our country was investigated on data from the Netherlands Cancer Registry.ResultsIn the Netherlands quality of care varies by hospital and region. These differences are not limited to surgical procedures and postoperative mortality, but are also demonstrated in other parts of the care process. Differences are only partly explained by differences in infrastructure, procedural volume and specialization between hospitals. Essential information on differences in case mix between these hospitals are lacking from the Netherlands Cancer Registry. More detailed clinical data are needed to reveal the mechanisms behind the differences in quality of care between Dutch hospitals.ConclusionOn a population level, there is potential for improvement of outcome for cancer patients in the Netherlands by reducing variation in optimal treatment rates between hospitals. Not only treatment of tumours with a low incidence but also other complex or high risk cancer procedures should be provided in a specialized setting, with the right infrastructure, sufficient volume and adequate expertise. In addition, outcomes should be monitored continuously and fed back to individual caregivers.     

Treatment strategies and overall survival for incurable metastatic colorectal cancer – A EURECCA international comparison including 21,196 patients from the Netherlands and Norway

BackgroundThe potential benefit of surgery of the primary tumour in patients with asymptomatic metastatic colorectal cancer is debated. This EURECCA international comparison analyses treatment strategies and overall survival in the Netherlands and Norway in patients with incurable metastatic colorectal cancer.MethodsNational cohorts (2007–2013) from the Netherlands and Norway including all patients with synchronous metastatic colorectal cancer were compared on treatment strategy and overall survival. Using country as an instrumental variable, we assessed the effect of different treatment strategies on mortality in the first year.ResultsOf 21,196 patients (16,144 Dutch and 5052 Norwegian), 38.6% Dutch and 51.5% (p < 0.001) Norwegian patients underwent resection of the primary tumour. In the Netherlands, 58.2% received chemotherapy compared with 21.4% in Norway. Radiotherapy was given in 9.5% of Dutch patients and 7.2% of Norwegian patients. Using the Netherlands as reference, the adjusted HR for overall survival was 0.96 (95% CI 0.93–0.99; p = 0.024). Instrumental variable analysis showed an adjusted OR of 1.00 (95% CI 0.99–1.02; p = 0.741).ConclusionsTreatment strategies varied significantly between the Netherlands and Norway, with more surgery and less radiotherapy in Norway. Adjusted overall survival was better in Norway for all patients and patients <75 years, but not for patients ≥75 years. Instrumental variable analysis showed no benefit in one-year mortality for a treatment strategy with a higher proportion of surgery and a lower proportion of radiotherapy. Our findings emphasise the need for further research to select patients with incurable metastatic colorectal cancer for different treatment options.     

Successful centralisation of patients with vulvar carcinoma: a population-based study in The Netherlands

IntroductionIn general, centralisation of care for patients with rare malignancies is advised in order to improve outcome with respect to prognosis and treatment related morbidity. Therefore, centralisation of women with vulvar squamous cell carcinoma (SCC), which is an extremely rare tumour, has been advocated by the national guidelines of the Dutch Society of Obstetrics and Gynaecology in 2000. The objective of this study was to determine whether this advice has been adapted and has led to improved survival.MethodsAll patients diagnosed with vulvar malignancies between 1989 and 2008 in the Eastern part of the Netherlands were retrieved from the population-based cancer registry held by the Comprehensive Cancer Centre, The Netherlands. Patient- and tumour characteristics and vital status until January 2011 were retrieved. Data of patients diagnosed in two periods (before and after release of the guideline; 1989–1999 and 2000–2008) were compared. Relative survival rates were calculated as a good approximation of cause-specific survival.ResultsA total number of 382 patients with vulvar SCC with invasion >1 mm, who had an indication for groin surgery, were included in the analysis. In the first decade 62% (123 of 198 patients) were treated in a specialised oncology centre, which increased to 93% (172 of 184 patients) in the more recent period. Overall, the 5 year relative survival improved slightly from 69% (95% confidence interval (CI) 60–77%) to 75% (95% CI 65–83%). After adjustment for age and stage, being treated in a specialised oncology centre was an independent prognostic factor for survival.ConclusionCentralisation of care for vulvar SCC patients has been well adopted in the Eastern part of the Netherlands. Being treated in a specialised oncology centre was associated with a better survival after adjustment for age and stage.     

First-line BRAF/MEK inhibitors versus anti-PD-1 monotherapy in BRAFV600-mutant advanced melanoma patients: a propensity-matched survival analysis

Background Anti-PD-1 antibodies and BRAF/MEK inhibitors are the two main groups of systemic therapy in the treatment of BRAF^V600-mutant advanced melanoma. Until now, data are inconclusive on which therapy to use as first-line treatment. The aim of this study was to use propensity score matching to compare first-line anti-PD-1 monotherapy vs. BRAF/MEK inhibitors in advanced BRAF^V600-mutant melanoma patients.Methods We selected patients diagnosed between 2014 and 2017 with advanced melanoma and a known BRAF^V600-mutation treated with first-line BRAF/MEK inhibitors or anti-PD-1 antibodies, registered in the Dutch Melanoma Treatment Registry. Patients were matched based on their propensity scores using the nearest neighbour and the optimal matching method.Results Between 2014 and 2017, a total of 330 and 254 advanced melanoma patients received BRAF/MEK inhibitors and anti-PD-1 monotherapy as first-line systemic therapy. In the matched cohort, patients receiving anti-PD-1 antibodies as a first-line treatment had a higher median and 2-year overall survival compared to patients treated with first-line BRAF/MEK inhibitors, 42.3 months (95% CI: 37.3-NE) vs. 19.8 months (95% CI: 16.7–24.3) and 65.4% (95% CI: 58.1–73.6) vs. 41.7% (95% CI: 34.2–51.0).Conclusions Our data suggest that in the matched BRAF^V600-mutant advanced melanoma patients, anti-PD-1 monotherapy is the preferred first-line treatment in patients with relatively favourable patient and tumour characteristics.Subject terms: Melanoma, Melanoma, Melanoma     

Increasing time trends of thin melanomas in The Netherlands: What are the explanations of recent accelerations?

BackgroundA disproportional increase in in situ or thin melanomas may point at underlying causes such as increased melanoma awareness, as well as ‘overdiagnosis’ of melanoma in diagnostically equivocal small lesions.ObjectivesThe purposes of this study were to estimate trends in melanoma incidence by sex, Breslow thickness (thin melanomas subdivided into four subgroups: <0.25 mm, 0.25–0.49 mm, 0.50–0.74 mm, and 0.75–1.0 mm), age and location, and to compare these with trends in subgroups of thicker melanomas.MethodsData on all histologically confirmed in situ and invasive melanomas diagnosed between 1994 and 2010 were retrieved from the Netherlands Cancer Registry. Trends in European standardised rates (ESRs) were assessed using joinpoint analysis, and expressed as estimated annual percentage change (EAPC).ResultsBetween 1994 and 2010, 34,156 persons were diagnosed with an in situ or thin melanoma. The ESR of in situ melanomas doubled for males and females with a recent steeper rise in incidence (EAPC 12% (95% confidence interval [CI]: 8.1–16) and 13% (95% CI: 5.9–20), respectively). ESR for thin melanomas amongst males approximately doubled with a steep, but non-significant acceleration compared to other thickness categories since 2006 for <0.25 mm melanomas (EAPC 26% (95% CI: 2.1–35)). For female patients with thin melanomas the ESRs increased almost two-fold, except for <0.25 mm melanomas.ConclusionsThe incidence rates of in situ, thin and thick melanomas increased similarly between 1994 and 2010. Recently steep increases were found for in situ melanomas and thin melanomas in men. Explanations are ‘overdiagnosis’ in conjunction with increased ultraviolet exposure (natural and artificial) and therefore a ‘true’ increase, increased awareness, early detection, diagnostic drift and changed market forces in the Dutch health care system.     

Gastric MALT lymphoma: epidemiology and high adenocarcinoma risk in a nation-wide study

BackgroundGastric marginal zone non-Hodgkin lymphomas MALT type (gMALT) and gastric adenocarcinomas (GC) are long-term complications of chronic Helicobacter pylori gastritis, however, the incidence of gMALT and the GC risk in these patients is unclear.ObjectiveTo evaluate epidemiological time trends of gMALT in the Netherlands and to estimate GC risk.MethodsPatients with a first diagnosis of gMALT between 1991 and 2006 were identified in the Dutch nation-wide histopathology registry (PALGA). Age-standardised incidence rates were calculated. The incidences of GC in patients with gMALT and in the Dutch population were compared. Relative risks were calculated by a Poisson Model.ResultsIn total, 1419 patients were newly diagnosed with gMALT, compatible with an incidence of 0.41/100,000/year. GC was diagnosed in 34 (2.4%) patients of the cohort. Patients with gMALT had a sixfold increased risk for GC in comparison with the general population (p < 0.001). This risk was 16.6 times higher in gMALT patients aged between 45 and 59 years than in the Dutch population (p < 0.001).ConclusionsGC risk in patients with gMALT is six times higher than in the Dutch population and warrants accurate re-evaluation after diagnosis and treatment for gMALT.     

Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis

BackgroundMelanomas are initially excised in primary care, and rates vary internationally. Until now, there has been no strong evidence one way or the other that excising melanomas in primary care is safe or unsafe. European guidelines make no recommendations, and the United Kingdom (UK) melanoma guidelines require all suspicious skin lesions to be initially treated in secondary care based on an expert consensus, which lacks supporting evidence, that primary care excision represents substandard care. Despite this, studies have found that up to 20% of melanomas in the UK are excised by general practitioners (GPs). Patients receiving primary care melanoma excision may fear that their care is substandard and their long-term survival threatened, neither of which may be justified.MethodsScottish cancer registry data from 9367 people diagnosed with melanoma in Scotland between 2005 and 2013 were linked to pathology records, hospital data and death records. A Cox proportional hazards regression analysis, adjusting for key confounders, explored the association between morbidity and mortality and setting of primary melanoma excision (primary versus secondary care). A pooled estimate of the relative hazard of death of having a melanoma excised in primary versus secondary care including 7116 patients from a similar Irish study was also performed.ResultsThe adjusted hazard ratio (95% CI) of death from melanoma for those having primary care excision was 0.82 (0.61–1.10). Those receiving primary care excision had a median (IQR) of 8 (3–14) out-patient attendances compared to 10 (4–17) for the secondary care group with an adjusted relative risk (RR) (95% CI) of 0.98 (0.96–1.01). Both groups had a median of 1 (0–2) hospital admissions with an adjusted rate ratio of 1.05 (0.98–1.13). In the meta-analysis, with primary care as the reference, the pooled adjusted hazard ratio (HR, 95% CI) was 1.26 (1.07–1.50) indicating a significantly higher all-cause mortality among those with excision in secondary care.ConclusionsThe results of the Scottish and pooled analyses suggest that those receiving an initial excision for melanoma in primary care do not have poorer survival or increased morbidity compared to those being initially treated in secondary care. A randomised controlled trial to inform a greater role for GPs in the initial excision of melanoma is justified in the light of these results.     

The Dutch Surgical Colorectal Audit

Introduction

In 2009, the nationwide Dutch Surgical Colorectal Audit (DSCA) was initiated by the Association of Surgeons of the Netherlands (ASN) to monitor, evaluate and improve colorectal cancer care. The DSCA is currently widely used as a blueprint for the initiation of other audits, coordinated by the Dutch Institute for Clinical Auditing (DICA). This article illustrates key elements of the DSCA and results of three years of auditing.

Methods

Key elements include: a leading role of the professional association with integration of the audit in the national quality assurance policy; web-based registration by medical specialists; weekly updated online feedback to participants; annual external data verification with other data sources; improvement projects.

Results

In two years, all Dutch hospitals participated in the audit. Case-ascertainment was 92% in 2010 and 95% in 2011. External data verification by comparison with the Netherlands Cancer Registry (NCR) showed high concordance of data items. Within three years, guideline compliance for diagnostics, preoperative multidisciplinary meetings and standardised reporting increased; complication-, re-intervention and postoperative mortality rates decreased significantly.

Discussion

The success of the DSCA is the result of effective surgical collaboration. The leading role of the ASN in conducting the audit resulted in full participation of all colorectal surgeons in the Netherlands. By integrating the audit into the ASNs' quality assurance policy, it could be used to set national quality standards. Future challenges include reduction of administrative burden; expansion to a multidisciplinary registration; and addition of financial information and patient reported outcomes to the audit data.     

Uses of cancer registries for public health and clinical research in Europe: Results of the European Network of Cancer Registries survey among 161 population-based cancer registries during 2010–2012

AimTo provide insight into cancer registration coverage, data access and use in Europe. This contributes to data and infrastructure harmonisation and will foster a more prominent role of cancer registries (CRs) within public health, clinical policy and cancer research, whether within or outside the European Research Area.MethodsDuring 2010–12 an extensive survey of cancer registration practices and data use was conducted among 161 population-based CRs across Europe. Responding registries (66%) operated in 33 countries, including 23 with national coverage.ResultsPopulation-based oncological surveillance started during the 1940–50s in the northwest of Europe and from the 1970s to 1990s in other regions. The European Union (EU) protection regulations affected data access, especially in Germany and France, but less in the Netherlands or Belgium. Regular reports were produced by CRs on incidence rates (95%), survival (60%) and stage for selected tumours (80%). Evaluation of cancer control and quality of care remained modest except in a few dedicated CRs. Variables evaluated were support of clinical audits, monitoring adherence to clinical guidelines, improvement of cancer care and evaluation of mass cancer screening. Evaluation of diagnostic imaging tools was only occasional.ConclusionMost population-based CRs are well equipped for strengthening cancer surveillance across Europe. Data quality and intensity of use depend on the role the cancer registry plays in the politico, oncomedical and public health setting within the country. Standard registration methodology could therefore not be translated to equivalent advances in cancer prevention and mass screening, quality of care, translational research of prognosis and survivorship across Europe. Further European collaboration remains essential to ensure access to data and comparability of the results.     

Differences in direct costs of patients with stage I cutaneous melanoma: A real-world data analysis

BackgroundClinical factors, such as tumor thickness, ulceration and growth phase have a role as prognostic factors for stage I melanoma. However, it is still under debate whether these variables influence the related direct costs. We aimed to investigate which clinical factors represent direct health care “cost drivers” for stage I melanoma.Materials and methodAnalyses were conducted on a cohort of patients diagnosed with stage I melanoma. Differences in the costs incurred by different groups of patients were examined using Mann-Whitney or Kruskal-Wallis non-parametric tests. Log linear multivariate analysis was used to identify the clinical drivers of the total direct costs one and two years after diagnosis. The study was conducted from the perspective of Italy's National Health care System.ResultsOne year after diagnosis, patients whose melanomas had a Breslow thickness ≥0.8 mmin (compared with those with lower thickness) and a vertical growth phase (compared with those with radial growth) incurred higher costs for hospitalization, as well as higher overall costs. One year after their diagnosis, treatment of patients with stage I melanoma in the vertical growth phase costs 50% more (95% CI: 22–85%) than their counterparts with a radial growth pattern, resulting in an estimated absolute increase of € 256.23. Having a tumor thicker than 0.8 mm prompted an increase of 91% (95% CI: 43–155%) in the costs (€955.24 in absolute terms).ConclusionOur data indicate a heterogeneity in the direct costs of stage I melanoma patients during the first year after diagnosis, which can be partly explained by clinical prognostic factors, like tumor thickness and growth pattern.     

The value of surveillance mammography of the contralateral breast in patients with a history of breast cancer

PurposeTo determine the contribution of surveillance mammography to the early detection of metachronous contralateral breast cancer (MCBC) and to assess its impact on the survival of breast cancer patients with relation to compliance.MethodBreast cancer patients (5589) were identified using files from the regional cancer registry of the Comprehensive Cancer Centre North Netherlands (CCCN Groningen, The Netherlands). The programme sensitivity and the impact on prognosis of follow-up mammography with relation to compliance were evaluated in 114 patients who developed MCBC during hospital follow-up.ResultsThe cumulative MCBC incidence rate at year 10 was 3.4% (95% CI: 2.8–4.0%). The programme sensitivity of surveillance mammography was 59.6% (95% CI: 50.6–68.7). In patients who complied with annual mammography, sensitivity was increased to 70.8% (95% CI: 61.7–80.0). Patients with MCBCs detected by routine mammography have better survival rates than patients with MCBCs detected by other means (HR: 3.18; 95% CI: 1.59–6.34). Though there was a trend towards improved survival in patients being compliant with regular clinical follow-up (HR: 1.69; 95% CI: 0.72–3.96), this was not the case for patients being compliant with annual mammography (HR:1.02; 95% CI:0.50–2.09).ConclusionMammography is a valuable tool for the early detection of MCBC during hospital follow-up of breast cancer patients and is probably beneficial to survival. The utilisation of follow-up surveillance in breast cancer patients and its potential impact on survival deserve further investigation.     

Socioeconomic Inequalities in Novel NSCLC Treatments During the Era of Tumor Biomarker-Guided Therapy: A Population-Based Cohort Study in a Publicly Funded Health Care System

IntroductionSocioeconomic inequalities in the utilization of conventional NSCLC treatments are well documented. Nevertheless, it is not known whether these inequalities are also observed with novel anticancer therapies. This study evaluated associations between deprivation and utilization of novel anticancer therapies targeting tumor biology, the immune system, or both, within the English national publicly funded health care system.MethodsA retrospective analysis of 90,785 patients diagnosed with having a histologically confirmed stage IV NSCLC from January 1, 2012, to December 31, 2017, sourced from the English national population-based cancer registry and linked Systemic Anti-Cancer Therapy database, was undertaken. Multivariable logistic regression evaluated the likelihood of novel anticancer therapy utilization by deprivation category of area of residence at diagnosis (measured by quintiles of the income domain of the index of multiple deprivation).ResultsMultivariable analyses revealed marked treatment inequalities by deprivation. Patients residing in the most deprived areas were more than half as likely to use any novel therapy (multivariable OR [mvOR] = 0.45, 95% confidence interval [CI]: 0.41–0.49) compared with patients residing in the most affluent areas. Deprivation associations with treatment utilization were slightly stronger with targeted treatments ([most versus least deprived] mvOR = 0.39, 95% CI: 0.35–0.43) than immune checkpoint inhibitors (mvOR = 0.58, 95% CI: 0.51–0.66).ConclusionsThere are marked socioeconomic inequalities in NSCLC novel treatment utilization, even in the English National Health Service where treatment is free at the point of delivery. These findings have important implications for equitable delivery of drugs, which have transformed outcomes in metastatic lung cancer. Further work exploring the underlying causes is now needed.     

Underestimation of pancreatic cancer in the national cancer registry – Reconsidering the incidence and survival rates

BackgroundIn the Netherlands, like in many other European countries, pancreatic cancer mortality was found to be systematically higher than the incidence. This suggests that there is an underestimation of the reported incidence of pancreatic cancer.AimWe aimed to study the incidence of pancreatic cancer in the Rotterdam area and to compare this with the national level.MethodsThis study is embedded in the Rotterdam Study (RS), an ongoing population-based prospective cohort study of people aged 45 years and above, enrolled between 1989 till 2006. Details on incident pancreatic cancer cases were available until 2013. Age-specific incidence rates were calculated and compared with data available in the Netherlands Cancer Registry.ResultsAt baseline 14,922 participants were at risk of developing pancreatic cancer. Median follow-up time was 16.4 person years per person. In total, 113 participants developed pancreatic cancer. Rates increased with age with an incidence rate of 109.9 (95% confidence interval [CI]; 85.7–138.8) per 100,000 person years for people older than 75. This is higher than the currently reported 55.9–89.2 per 100,000 person year. Of the 113 cases identified in the RS, only 67.3% was reported as pancreatic cancer in the Netherlands Cancer Registry. Cases that were not registered were significantly older and had significantly poorer survival.ConclusionThe incidence of pancreatic cancer, as registered by the Netherlands Cancer Registry, is an underestimation. Patients, not registered by the cancer registry, have a significantly poorer survival. Consequently, we probably overestimate the already poor survival of pancreatic cancer.     

Determinants and interpretation of death certificate only proportions in the initial years of newly established cancer registries

BackgroundThe proportion of cases notified by death certificate only (DCO) is a commonly used criterion to judge completeness of cancer registration even though it is affected by additional factors, particularly during initial years of newly established registries.MethodsBased on cancer registry data from the United States, we provide model calculations to demonstrate the magnitude and time course of the impact of the following mechanisms on DCO proportions of “young” registries: registration of cancer deaths from patients diagnosed prior to the registration period and delayed registration by death certificate of patients diagnosed but not reported after initiation of registration.ResultsDCO proportions of up to ?30% can be expected from deaths of previously diagnosed patients during the first year of registration. Although this proportion is expected to gradually diminish over subsequent years, DCO proportions may be dominated for several years by this source, which may still be relevant after 10 or more years of cancer registration for cancers with relatively large proportions of late deaths. Otherwise, however, underreporting during patients’ lifetime is expected to become the predominant source of DCO proportions in the long run.ConclusionsOur results may guide interpretation of DCO proportions of relatively “young” cancer registries.     

Time to diagnosis and treatment for cancer patients in the Netherlands: Room for improvement?

Background & aimReducing the duration of the diagnostic cancer care pathway is intensively pursued. The aim of this study was to chart the diagnostic pathway for the five most common cancers in the Netherlands.MethodsA retrospective cohort study using cancer patients' anonymised primary care data (free text and coded) linked to the Netherlands Cancer Registry. We determined the median duration of the following: 1. Primary care intervals (IPCs): the first cancer-related general practitioner consultation to referral, 2. Referral intervals (IRs): referral to diagnosis, 3. Treatment intervals (ITs): diagnosis to treatment and the overarching intervals, 4. Diagnostic intervals (IDs): IPC and IR combined and 5. Health care intervals (IHCs): IPC, IR and IT combined.ResultsFor 465, 309, 197, 237 and 149 patients diagnosed with breast-, colorectal-, lung-, prostate cancer and melanoma, respectively; median IPC, IR and ID durations were shortest for breast cancer and melanoma (ID duration 7 and 21 days, respectively), intermediate for lung- and colon cancer (ID duration 49 and 54 days) and the longest for prostate cancer (ID duration 137 days). For all cancers, the duration of intervals increased steeply for the 10–25% with longest durations. For colorectal cancer, increasing ID durations showed increasing proportions of time attributable to primary care (IPC).ConclusionApproximately 10–25% of cancer patients show substantially long duration of diagnostic intervals. Reducing primary care delay seems particularly relevant for colorectal cancer.     

Surgical and medical management of small bowel gastrointestinal stromal tumors: A report of the Dutch GIST registry

BackgroundA cohort of 201 patients with small bowel gastrointestinal stromal tumors (GIST) treated between January 1st, 2009 and December 31st, 2016 in five GIST expertise centers in the Netherlands was analyzed. Goal of this study was to describe the clinical, surgical and pathological characteristics of this rare subpopulation of GIST patients, registered in the Dutch GIST registry.MethodsClinical outcomes and risk factors of patients with small bowel GIST who underwent surgery or treated with systemic therapy were analyzed. A classification was made based on disease status at diagnosis (localized vs. metastasized).Results201 patients with small bowel GIST were registered of which 138 patients (69%) were diagnosed with localized disease and 63 patients (31%) with metastatic disease. Approximately 19% of the patients had emergency surgery, and in 22% GIST was an accidental finding. In patients with high risk localized disease, recurrence occurred less often in patients who received adjuvant treatment (4/32) compared to patients who did not (20/31, p < 0.01). Disease progression during palliative imatinib treatment occurred in 23 patients (28%) after a median of 20.7 (range 1.8–47.1) months. Ongoing response was established in 52/82 patients on first line palliative treatment with imatinib after a median treatment time of 30.6 (range 2.5–155.3) months.ConclusionPatients with small-bowel GIST more frequently present with metastatic disease when compared to patients with gastric GIST in literature. We advocate for Prospective registration of these patients and investigate the use of surgery in patients with limited metastatic disease.     

Reduction of socioeconomic inequality in cancer incidence in the South of the Netherlands during 1996–2008

BackgroundCancer 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 methodsWe 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.ResultsPeople 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.ConclusionsAlthough 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.