Publications by authors named "Lydia G M van der Geest"

34 Publications

Age and prognosis in patients with pancreatic cancer: a population-based study.

Acta Oncol 2021 Dec 22:1-8. Epub 2021 Dec 22.

Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands.

Background: The diagnosis of pancreatic ductal adenocarcinoma (PDAC) has an enormous impact on patients, and even more so if they are of younger age. It is unclear how their treatment and outcome compare to older patients. This study compares clinicopathological characteristics and overall survival (OS) of PDAC patients aged <60 years to older PDAC patients.

Method: This is a retrospective, population-based cohort study using Netherlands Cancer Registry data of patients diagnosed with PDAC (1 January 2015-31 December 2018). Kaplan-Meier curves and Cox proportional hazards models were used to assess OS.

Results: Overall, 10,298 patients were included, of whom 1551 (15%) were <60 years. Patients <60 years were more often male, had better performance status, less comorbidities and less stage I disease, and more often received anticancer treatment (67 33%,  < 0.001) than older patients. Patients <60 years underwent resection of the tumour more often (22 14% < 0.001), more often received chemotherapy, and had a better median OS (6.9 3.3 months,  < 0.001) compared to older patients. No differences in median OS were demonstrated between both age groups of patients who underwent resection (19.7 19.4 months,  = 0.123), received chemotherapy alone (7.8 8.5 months,  = 0.191), or received no anticancer treatment (1.8 1.9 months,  = 0.600). Patients <60 years with stage-IV disease receiving chemotherapy had a somewhat better OS (7.5 6.3 months,  = 0.026).

Conclusion: Patients with PDAC <60 years more often underwent resection despite less stage I disease and had superior OS. Stratified for treatment, however, survival was largely similar.
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http://dx.doi.org/10.1080/0284186X.2021.2016949DOI Listing
December 2021

SOURCE-PANC: A Prediction Model for Patients With Metastatic Pancreatic Ductal Adenocarcinoma Based on Nationwide Population-Based Data.

J Natl Compr Canc Netw 2021 Jul 21;19(9):1045-1053. Epub 2021 Jul 21.

1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam.

Background: A prediction model for overall survival (OS) in metastatic pancreatic ductal adenocarcinoma (PDAC) including patient and treatment characteristics is currently not available, but it could be valuable for supporting clinicians in patient communication about expectations and prognosis. We aimed to develop a prediction model for OS in metastatic PDAC, called SOURCE-PANC, based on nationwide population-based data.

Materials And Methods: Data on patients diagnosed with synchronous metastatic PDAC in 2015 through 2018 were retrieved from the Netherlands Cancer Registry. A multivariate Cox regression model was created to predict OS for various treatment strategies. Available patient, tumor, and treatment characteristics were used to compose the model. Treatment strategies were categorized as systemic treatment (subdivided into FOLFIRINOX, gemcitabine/nab-paclitaxel, and gemcitabine monotherapy), biliary drainage, and best supportive care only. Validation was performed according to a temporal internal-external cross-validation scheme. The predictive quality was assessed with the C-index and calibration.

Results: Data for 4,739 patients were included in the model. Sixteen predictors were included: age, sex, performance status, laboratory values (albumin, bilirubin, CA19-9, lactate dehydrogenase), clinical tumor and nodal stage, tumor sublocation, presence of distant lymph node metastases, liver or peritoneal metastases, number of metastatic sites, and treatment strategy. The model demonstrated a C-index of 0.72 in the internal-external cross-validation and showed good calibration, with the intercept and slope 95% confidence intervals including the ideal values of 0 and 1, respectively.

Conclusions: A population-based prediction model for OS was developed for patients with metastatic PDAC and showed good performance. The predictors that were included in the model comprised both baseline patient and tumor characteristics and type of treatment. SOURCE-PANC will be incorporated in an electronic decision support tool to support shared decision-making in clinical practice.
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http://dx.doi.org/10.6004/jnccn.2020.7669DOI Listing
July 2021

Trends in incidence, diagnosis, treatment and survival of hepatocellular carcinoma in a low-incidence country: Data from the Netherlands in the period 2009-2016.

Eur J Cancer 2020 09 13;137:214-223. Epub 2020 Aug 13.

The Netherlands Comprehensive Cancer Organisation, P.O. Box 19079, 3501 DB Utrecht, the Netherlands. Electronic address:

Objective: Evaluation of the trends in incidence, diagnostics, treatment and survival of patients with hepatocellular carcinoma (HCC) in the Netherlands.

Method: Data regarding incidence, diagnostics, primary treatment and survival of patients with HCC in the period 2009-2016 were obtained from the Netherlands Cancer Registry. Trends in incidence, diagnostics, various treatment modalities (except liver transplantation, due to inaccurate data) and regional treatment preferences were analysed. Survival was evaluated using Kaplan-Meier curves and multivariable Cox proportional hazard regression modelling.

Results: In the period of 2009-2016, 3838 patients were diagnosed with HCC. A distinct decrease in the percentage of patients who underwent tumour biopsy was observed (from 51% in 2009-2010 to 42% in 2015-2016). Percentage of patients who underwent cancer treatment increased markedly (from 49% in 2009-2010 to 57% in 2015-2016), mainly because of an increasing use of resection and ablation. The number of hospitals where resections were performed or sorafenib treatment prescribed decreased slightly. The number of hospitals sporadically (<1 ablation per year) performing ablations increased. There were significant differences between regions in the application of resection, ablation and transarterial chemoembolisation /radioembolisation (p < 0.05 after 'case mix'-correction). One-, 3- and 5-year survival of patients with HCC significantly improved in the studied period. Receiving cancer treatment was associated with increased survival, whereas increasing age and an advanced tumour stage were both associated with decreased survival.

Conclusion: From 2009 to 2016, patients with hepatocellular carcinoma more often received cancer treatment and their survival improved. There were significant differences in types of treatment between various regions.
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http://dx.doi.org/10.1016/j.ejca.2020.07.008DOI Listing
September 2020

Treatment and Survival of Elderly Patients with Stage I-II Pancreatic Cancer: A Report of the EURECCA Pancreas Consortium.

Ann Surg Oncol 2020 Dec 9;27(13):5337-5346. Epub 2020 May 9.

Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.

Background: Elderly patients with pancreatic cancer are underrepresented in clinical trials, resulting in a lack of evidence.

Objective: The aim of this study was to compare treatment and overall survival (OS) of patients aged ≥ 70 years with stage I-II pancreatic cancer in the EURECCA Pancreas Consortium.

Methods: This was an observational cohort study of the Belgian (BE), Dutch (NL), and Norwegian (NOR) cancer registries. The primary outcome was OS, while secondary outcomes were resection, 90-day mortality after resection, and (neo)adjuvant and palliative chemotherapy.

Results: In total, 3624 patients were included. Resection (BE: 50.2%; NL: 36.2%; NOR: 41.3%; p < 0.001), use of (neo)adjuvant chemotherapy (BE: 55.9%; NL: 41.9%; NOR: 13.8%; p < 0.001), palliative chemotherapy (BE: 39.5%; NL: 6.0%; NOR: 15.7%; p < 0.001), and 90-day mortality differed (BE: 11.7%; NL: 8.0%; NOR: 5.2%; p < 0.001). Furthermore, median OS in patients with (BE: 17.4; NL: 15.9; NOR: 25.4 months; p < 0.001) and without resection (BE: 7.0; NL: 3.9; NOR: 6.5 months; p < 0.001) also differed.

Conclusions: Differences were observed in treatment and OS in patients aged ≥ 70 years with stage I-II pancreatic cancer, between the population-based cancer registries. Future studies should focus on selection criteria for (non)surgical treatment in older patients so that clinicians can tailor treatment.
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http://dx.doi.org/10.1245/s10434-020-08539-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669775PMC
December 2020

Implementation of contemporary chemotherapy for patients with metastatic pancreatic ductal adenocarcinoma: a population-based analysis.

Acta Oncol 2020 Jun 14;59(6):705-712. Epub 2020 Feb 14.

Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands.

Positive results of randomized trials led to the introduction of FOLFIRINOX in 2012 and gemcitabine with nab-paclitaxel in 2015 for patients with metastatic pancreatic ductal adenocarcinoma. It is unknown to which extent these new chemotherapeutic regimens have been implemented in clinical practice and what the impact has been on overall survival. Patients diagnosed with metastatic pancreatic ductal adenocarcinoma between 2007-2016 were included from the population-based Netherlands Cancer Registry. Multilevel logistic regression and Cox regression analyses, adjusting for patient, tumor, and hospital characteristics, were used to analyze variation of chemotherapy use. In total, 8726 patients were included. The use of chemotherapy increased from 31% in 2007-2011 to 37% in 2012-2016 ( < .001). Variation in the use of any chemotherapy between centers decreased (adjusted range 2007-2011: 12-67%, 2012-2016: 20-54%) whereas overall survival increased from 5.6 months to 6.4 months ( < .001) for patients treated with chemotherapy. Use of FOLFIRINOX and gemcitabine with nab-paclitaxel varied widely in 2015-2016, but both showed a more favorable overall survival compared to gemcitabine monotherapy (median 8.0 vs. 7.0 vs. 3.8 months, respectively). In the period 2015-2016, FOLFIRINOX was used in 60%, gemcitabine with nab-paclitaxel in 9.7% and gemcitabine monotherapy in 25% of patients receiving chemotherapy. Nationwide variation in the use of chemotherapy decreased after the implementation of FOLFIRINOX and gemcitabine with nab-paclitaxel. Still a considerable proportion of patients receives gemcitabine monotherapy. Overall survival did improve, but not clinically relevant. These results emphasize the need for a structured implementation of new chemotherapeutic regimens.
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http://dx.doi.org/10.1080/0284186X.2020.1725241DOI Listing
June 2020

Conditional Survival After Resection for Pancreatic Cancer: A Population-Based Study and Prediction Model.

Ann Surg Oncol 2020 Jul 12;27(7):2516-2524. Epub 2020 Feb 12.

Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Background: Conditional survival is the survival probability after already surviving a predefined time period. This may be informative during follow-up, especially when adjusted for tumor characteristics. Such prediction models for patients with resected pancreatic cancer are lacking and therefore conditional survival was assessed and a nomogram predicting 5-year survival at a predefined period after resection of pancreatic cancer was developed.

Methods: This population-based study included patients with resected pancreatic ductal adenocarcinoma from the Netherlands Cancer Registry (2005-2016). Conditional survival was calculated as the median, and the probability of surviving up to 8 years in patients who already survived 0-5 years after resection was calculated using the Kaplan-Meier method. A prediction model was constructed.

Results: Overall, 3082 patients were included, with a median age of 67 years. Median overall survival was 18 months (95% confidence interval 17-18 months), with a 5-year survival of 15%. The 1-year conditional survival (i.e. probability of surviving the next year) increased from 55 to 74 to 86% at 1, 3, and 5 years after surgery, respectively, while the median overall survival increased from 15 to 40 to 64 months at 1, 3, and 5 years after surgery, respectively. The prediction model demonstrated that the probability of achieving 5-year survival at 1 year after surgery varied from 1 to 58% depending on patient and tumor characteristics.

Conclusions: This population-based study showed that 1-year conditional survival was 55% 1 year after resection and 74% 3 years after resection in patients with pancreatic cancer. The prediction model is available via www.pancreascalculator.com to inform patients and caregivers.
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http://dx.doi.org/10.1245/s10434-020-08235-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311496PMC
July 2020

Nationwide trends in incidence, treatment and survival of pancreatic ductal adenocarcinoma.

Eur J Cancer 2020 01 13;125:83-93. Epub 2019 Dec 13.

Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands. Electronic address:

Background: In recent years, new treatment options have become available for pancreatic ductal adenocarcinoma (PDAC) including 5-fluorouracil, leucovorin, irinotecan and oxaliplatin. The impact hereof has not been assessed in nationwide cohort studies. This population-based study aimed to investigate nationwide trends in incidence, treatment and survival of PDAC.

Materials And Methods: Patients with PDAC (1997-2016) were included from the Netherlands Cancer Registry. Results were categorised by treatment and by period of diagnosis (1997-2000, 2001-2004, 2005-2008, 2009-2012 and 2013-2016). Kaplan-Meier survival analysis was used to calculate overall survival.

Results: In a national cohort of 36,453 patients with PDAC, the incidence increased from 12.1 (1997-2000) to 15.3 (2013-2016) per 100,000 (p < 0.001), whereas median overall survival increased from 3.1 to 3.8 months (p < 0.001). Over time, the resection rate doubled (8.3%-16.6%, p-trend<0.001), more patients received adjuvant chemotherapy (3.0%-56.2%, p-trend<0.001) and 3-year overall survival following resection increased (16.9%-25.4%, p < 0.001). Over time, the proportion of patients with metastatic disease who received palliative chemotherapy increased from 5.3% to 16.1% (p-trend<0.001), whereas 1-year survival improved from 13.3% to 21.2% (p < 0.001). The proportion of patients who only received supportive care decreased from 84% to 61% (p-trend<0.001).

Conclusion: The incidence of PDAC increased in the past two decades. Resection rates and use of adjuvant or palliative chemotherapy increased with improved survival in these patients. In all patients with PDAC, however, the survival benefit of 3 weeks is negligible because the majority of patients only received supportive care.
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http://dx.doi.org/10.1016/j.ejca.2019.11.002DOI Listing
January 2020

Association between primary origin (head, body and tail) of metastasised pancreatic ductal adenocarcinoma and oncologic outcome: A population-based analysis.

Eur J Cancer 2019 01 23;106:99-105. Epub 2018 Nov 23.

Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. Electronic address:

Introduction: The relation between the primary origin of metastasised pancreatic ductal adenocarcinoma (PDAC)-head, body or tail-metastatic patterns and outcomes has not yet been investigated in large population-based studies.

Methods: Patients with metastasised PDAC at diagnosis from the Netherlands Cancer Registry were included (2005-2015). We compared number of metastatic organ sites (1, 2, ≥3) and specific metastatic organ sites (peritoneum, liver, lung and extra-regional lymph nodes) for the different primary tumour locations. Cox regression analyses were used to determine the association of tumour location and metastatic organ site(s) with overall survival.

Results: Overall, we included 9952 patients with metastasised PDAC. The primary origin was head in 5644 (57%), body in 1671 (17%) and tail in 2637 (26%) patients. Differences between primary origins were the number of metastatic organ sites (proportions ≥3 sites for head: 4%, for body: 8% and for tail: 13%, p < 0.0001) and peritoneal metastases (present in 13% for head, 24% for body and 30% for tail; p < 0.0001). Median overall survival was 2.6 months for head PDAC (reference), 2.4 months for body PDAC (HR 1.02 [0.97-1.08]) and 1.9 months for tail PDAC (HR 1.20 [1.15-1.26]). Of patients with one metastatic organ site, the worst survival compared with other sites was seen with liver only metastases (2.5 months vs. 2.7-5.1 months), and the best survival for patients, with extra-regional lymph node only metastases (5.1 months).

Conclusion: Metastatic patterns differ among the primary origins for PDAC with metastasised tail tumours having more metastatic sites, more often peritoneal metastases and worse survival.
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http://dx.doi.org/10.1016/j.ejca.2018.10.008DOI Listing
January 2019

Association of the location of pancreatic ductal adenocarcinoma (head, body, tail) with tumor stage, treatment, and survival: a population-based analysis.

Acta Oncol 2018 Dec 28;57(12):1655-1662. Epub 2018 Sep 28.

b Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC , University of Amsterdam , Amsterdam , Netherlands.

Background: The association between pancreatic ductal adenocarcinoma (PDAC) location (head, body, tail) and tumor stage, treatment and overall survival (OS) is unclear.

Methods: Patients with PDAC diagnosed between 2005 and 2015 were included from the population-based Netherlands Cancer Registry. Patient, tumor and treatment characteristics were compared with the tumor locations. Multivariable logistic and Cox regression analyses were used.

Results: Overall, 19,023 patients were included. PDAC locations were 13,451 (71%) head, 2429 (13%) body and 3143 (16%) tail. Differences were found regarding metastasized disease (head 42%, body 69%, tail 84%, p < .001), size (>4 cm: 21%, 40%, 51%, p < .001) and resection rate (17%, 4%, 7%, p < .001). For patients without metastases, median OS did not differ between head, body, tail (after resection: 16.8, 15.0, 17.3 months, without resection: 5.2, 6.1, 4.6 months, respectively). For patients with metastases, median OS differed slightly (2.6, 2.4, 1.9 months, respectively, adjusted HR body versus head 1.17 (95%CI 1.10-1.23), tail versus head 1.35 (95%CI 1.29-1.41)).

Conclusions: PDAC locations in body and tail are larger, more often metastasized and less often resectable than in the pancreatic head. Whereas survival is similar after resection, survival in metastasized disease is somewhat less for PDAC in the pancreatic body and tail.
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http://dx.doi.org/10.1080/0284186X.2018.1518593DOI Listing
December 2018

Trends in treatment and survival of patients with nonresected, nonmetastatic pancreatic cancer: A population-based study.

Cancer Med 2018 10 6;7(10):4943-4951. Epub 2018 Sep 6.

Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Background: Nonresected, nonmetastatic (NR-M0) pancreatic cancer involves both locally advanced pancreatic cancer and patients who did not undergo resection due to poor health status or patient preference. This study investigates nationwide trends of characteristics, treatment, and survival of patients with NR-M0 pancreatic cancer.

Methods: From the Netherlands Cancer Registry, all patients diagnosed with pancreatic cancer between 2006 and 2014 were selected. Chemotherapy and overall survival (OS) of NR-M0 patients were evaluated for 3-year time periods and 2 age groups using chi-square tests for trend and Cox proportional hazard regression analysis.

Results: Of 18 234 patients, 33% had NR-M0 pancreatic cancer, which decreased over time (in consecutive 3-year periods: 38%-33%-28%, P < 0.001). Of 5964 NR-M0 patients, 52% was over 75 years of age, 16% received chemotherapy, and median OS was 5.1 months. Chemotherapy use increased over time in younger patients (<75 years: from 23 to 36%, P-trend < 0.001, ≥75 years: 3% to 4%, P-trend = 0.053). In multivariable survival analysis, elderly age, low SES, nonconfirmed cancer, stage II-III disease, and earlier years of diagnosis were independently associated with a worse OS. Age of patients who received chemotherapy increased over time (median 62-66 years) and median OS was 10.4 months without significant differences between time periods (P = 0.177) or age groups (P = 0.207).

Conclusions: Overall survival of NR-M0 pancreatic cancer remains poor which is partly related to advanced age of many patients. Despite an increase, chemotherapy is infrequently used. Future research should investigate to what extent the more widespread use of chemotherapy could improve survival in relation to age-related morbidity.
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http://dx.doi.org/10.1002/cam4.1750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198237PMC
October 2018

Patient characteristics and treatment considerations in pancreatic cancer: a population based study in the Netherlands.

Acta Oncol 2018 Sep 9;57(9):1185-1191. Epub 2018 May 9.

a Netherlands Comprehensive Cancer Organisation , Utrecht , The Netherlands.

Background: Pancreatic cancer carries a poor prognosis. To date, there has been little research devoted to decision-making regarding treatment options in pancreatic cancer, including the rationale for choosing to withhold tumor targeting treatment (TTT). This study aims to gain insight into the characteristics of patients receiving no TTT, the reasons for this decision and their survival.

Methods: All patients diagnosed in the Netherlands between 1 January 2014 and 30 June 2015 with a proven pancreatic adenocarcinoma or a pathologically unverified pancreatic tumor were identified in the Netherlands Cancer Registry. Information on initial management, patient characteristics, main reasons for no TTT (as reported in medical charts) and survival were analyzed.

Results: A total of 3090 patients was included. Of these patients, 1818 (59%) received no TTT. Median age of no TTT patients was 74 years (range 35-99) versus 66 years (30-87) for TTT patients. In the no TTT group 77% had a clinical stage III/IV versus 57% of patients who received TTT. Main reasons for not starting TTT were patient's choice (27%) and extensive disease (21%). Median survival of patients who did not receive TTT was 1.9 months, ranging from a median survival of 0.8 months (when main reason to withhold TTT was short life expectancy) to 4.4 months (main reason to withhold TTT: old age). In the latter group, a relatively large proportion of clinical stage I tumors was present (37%).

Conclusion: The majority of patients with pancreatic cancer received no TTT and had a very poor median survival. In most patients, patient's choice not to start treatment was the main reason for withholding treatment, suggesting patient's involvement in decision-making.
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http://dx.doi.org/10.1080/0284186X.2018.1470330DOI Listing
September 2018

Nationwide trends in chemotherapy use and survival of elderly patients with metastatic pancreatic cancer.

Cancer Med 2017 Dec 16;6(12):2840-2849. Epub 2017 Oct 16.

Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands.

Despite an aging population and underrepresentation of elderly patients in clinical trials, studies on elderly patients with metastatic pancreatic cancer are scarce. This study investigated the use of chemotherapy and survival in elderly patients with metastatic pancreatic cancer. From the Netherlands Cancer Registry, all 9407 patients diagnosed with primary metastatic pancreatic adenocarcinoma in 2005-2013 were selected to investigate chemotherapy use and overall survival (OS), using Kaplan-Meier and Cox proportional hazard regression analyses. Over time, chemotherapy use increased in all age groups (<70 years: from 26 to 43%, 70-74 years: 14 to 25%, 75-79 years: 5 to 13%, all P < 0.001, and ≥80 years: 2 to 3% P = 0.56). Median age of 2,180 patients who received chemotherapy was 63 years (range 21-86 years, 1.6% was ≥80 years). In chemotherapy-treated patients, with rising age (<70, 70-74, 75-79, ≥80 years), microscopic tumor verification occurred less frequently (91-88-87-77%, respectively, P = 0.009) and OS diminished (median 25-26-19-16 weeks, P = 0.003). After adjustment for confounding factors, worse survival of treated patients ≥75 years persisted. Despite limited chemotherapy use in elderly age, suggestive of strong selection, elderly patients (≥75 years) who received chemotherapy for metastatic pancreatic cancer exhibited a worse survival compared to younger patients receiving chemotherapy.
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http://dx.doi.org/10.1002/cam4.1240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727341PMC
December 2017

The Impact of Socioeconomic Status, Surgical Resection and Type of Hospital on Survival in Patients with Pancreatic Cancer. A Population-Based Study in The Netherlands.

PLoS One 2016 10;11(11):e0166449. Epub 2016 Nov 10.

Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

The influence of socioeconomic inequalities in pancreatic cancer patients and especially its effect in patients who had a resection is not known. Hospital type in which resection is performed might also influence outcome. Patients diagnosed with pancreatic cancer from 1989 to 2011 (n = 34,757) were selected from the population-based Netherlands Cancer Registry. Postal code was used to determine SES. Multivariable survival analyses using Cox regression were conducted to discriminate independent risk factors for death. Patients living in a high SES neighborhood more often underwent resection and more often were operated in a university hospital. After adjustment for clinicopathological factors, risk of dying was increased independently for patients with intermediate and low SES compared to patients with high SES. After resection, no survival difference was found among patients in the three SES groups. However, survival was better for patients treated in university hospitals compared to patients treated in non-university hospitals. Low SES was an independent risk factor for poor survival in patients with pancreatic cancer. SES was not an adverse risk factor after resection. Resection in non-university hospitals was associated with a worse prognosis.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166449PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5104385PMC
June 2017

Differences between colon and rectal cancer in complications, short-term survival and recurrences.

Int J Colorectal Dis 2016 Oct 6;31(10):1683-91. Epub 2016 Aug 6.

Department of Surgery, Reinier de Graaf Group, P.O. Box 5011, 2600, GA, Delft, the Netherlands.

Purpose: Many apparent differences exist in aetiology, genetics, anatomy and treatment response between colon cancer (CC) and rectal cancer (RC). This study examines the differences in patient characteristics, prevalence of complications and their effect on short-term survival, long-term survival and the rate of recurrence between RC and CC.

Methods: For all stage II-III CC and RC patients who underwent resection with curative intent (2006-2008) in five hospitals in the Netherlands, occurrence of complications, crude survival, relative survival and recurrence rates were compared.

Results: A total of 767 CC and 272 RC patients underwent resection. Significant differences were found for age, gender, emergency surgery, T-stage and grade. CC patients experienced fewer complications compared to RC (p = 0.019), but CC patients had worse short-term mortality rates (1.5 versus 6.7 % for 30-day mortality, p = 0.001 and 5.2 versus 9.5 % for 90-day mortality, p = 0.032). The adjusted HR (overall survival) for CC patients with complications was 1.57 (1.23-2.01; p < 0.001) as compared to patients without complications; for RC, the HR was 1.79 (1.12-2.87; p = 0.015). Relative survival analyses showed high excess mortality in the first months after surgery and a sustained, prolonged negative effect on both CC and RC. Complications were associated with a higher recurrence rate for both CC and RC; adjusted analyses showed a trend towards a significant association.

Conclusion: Large differences exist in patient characteristics and clinical outcomes between CC and RC. CC patients have a significantly higher short-term mortality compared to RC patients due to a more severe effect of complications.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5031780PMC
http://dx.doi.org/10.1007/s00384-016-2633-3DOI Listing
October 2016

Volume-outcome relationships in pancreatoduodenectomy for cancer.

HPB (Oxford) 2016 Apr 11;18(4):317-24. Epub 2016 Feb 11.

Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

Background: Volume-outcome relationships in pancreatic surgery are well established, but an optimal volume remains to be determined. Studies analyzing outcomes in volume categories exceeding 20 procedures annually are lacking.

Study Design: A consecutive 3420 patients underwent PD for primary pancreatic or periampullary carcinoma (2005-2013) and were registered in the Netherlands Cancer Registry. Relationships between hospital volume (< 5, 5-19, 20-39 and ≥ 40 PDs/year) and mortality and survival were explored.

Results: There was a non-significant decrease in 90-day mortality from 8.1 to 6.7% during the study period (p = 0.23). Ninety-day mortality was 9.7% in centers performing < 5 PDs/year (n = 185 patients), 8.9% for 5-19 PDs/year (n = 1432), 7.3% for 20-39 PDs/year (n = 240) and 4.3% for ≥ 40 PDs/year (n = 562, p = 0.004). Within volume categories, 90-day mortality did not change over time. After adjustment for confounding factors, significantly lower mortality was found in the ≥ 40 category compared to 20-39 PDs/year (OR = 1.72 (1.08-2.74)). Overall survival adjusted for confounding factors was better in the ≥ 40 category compared to categories under 20 PDs/year: HR (≥ 40 vs 5-19/year) = 1.24 (1.09-1.42). In the ≥ 40 category significantly more patients received adjuvant chemotherapy and had > 10 lymph nodes retrieved compared to lower volume categories.

Conclusions: Volume-outcome relationships in pancreatic surgery persist in centers performing ≥ 40 PDs annually, regarding both mortality and survival. The volume plateau for pancreatic surgery has yet to be determined.
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http://dx.doi.org/10.1016/j.hpb.2016.01.515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814615PMC
April 2016

Elderly Patients Strongly Benefit from Centralization of Pancreatic Cancer Surgery: A Population-Based Study.

Ann Surg Oncol 2016 06 21;23(6):2002-9. Epub 2016 Jan 21.

Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.

Background: Series from expert centers suggest that pancreas cancer surgery is safe for elderly patients but nationwide data, taking hospital volume into account, are lacking.

Methods: From the Netherlands Cancer Registry, all 3420 patients who underwent pancreatoduodenectomy (PD) for primary pancreatic or periampullary carcinoma in 2005-2013 were selected. Associations between age (<75, ≥75 years), hospital volume (tertiles), and postoperative mortality (30, 90 day) were evaluated by χ (2) tests and logistic regression analyses. Overall survival was investigated by means of Kaplan-Meier and Cox proportional hazard regression analyses.

Results: The proportion of elderly patients (≥75 years) undergoing PD increased from 15 % in 2005-2007 to 20 % in 2011-2013 (p = 0.009). In low (<15 per year), medium (15-28 per year), and high (>28 per year) hospital volume tertiles, the proportion of elderly patients was 16, 20, and 17 %, respectively (p = 0.10). With increasing hospital volume, 30-day postoperative mortality was 6.0-4.5-2.9 % (p = 0.002) and 90-day mortality 9.3-8.0-5.3 % (p = 0.001), respectively. Within each volume tertile, adjusted 30- and 90-day mortality of elderly patients was 1.6-2.5 times higher compared to outcomes of younger patients. Adjusted 30-day mortality in elderly patients was higher in low-volume hospitals (odds ratio = 2.87, 95 % confidence interval 1.15-7.17) compared to high-volume hospitals. Similarly, elderly patients had a worse overall survival in low-volume hospitals (hazard ratio = 1.28, 95 % confidence interval 1.01-1.63). Postoperative mortality of elderly patients in high-volume hospitals was similar to mortality of younger patients in low- and medium-volume hospitals.

Conclusions: Elderly patients benefit from centralization by undergoing PD in high-volume hospitals, both with respect to postoperative mortality and survival. It would seem reasonable to place elderly patients into a high-risk category; they should only undergo surgery in the highest-tertile-volume hospitals.
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http://dx.doi.org/10.1245/s10434-016-5089-3DOI Listing
June 2016

National compliance to an evidence-based multidisciplinary guideline on pancreatic and periampullary carcinoma.

Pancreatology 2016 Jan-Feb;16(1):133-7. Epub 2015 Oct 26.

Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Electronic address:

Background: We evaluated national compliance to selected quality indicators from the Dutch multidisciplinary evidence-based guideline on pancreatic and periampullary carcinoma and identified areas for improvement.

Methods: Compliance to 3 selected quality indicators from the guideline was evaluated before and after implementation of the guideline in 2011: 1) adjuvant chemotherapy after tumor resection for pancreatic carcinoma, 2) discussion of the patient within a multidisciplinary team (MDT) meeting and 3) a maximum 3-week interval between final MDT meeting and start of treatment.

Results: In total 5086 patients with pancreatic or periampullary carcinoma were included. In 2010, 2522 patients were included and in 2012, 2564 patients. 1) Use of adjuvant chemotherapy following resection for pancreatic carcinoma increased significantly from 45% (120 out of 268) in 2010 to 54% (182 out of 336) in 2012 which was mainly caused by an increase in patients aged <75 years. 2) In 2012, 64% (896 of 1396) of patients suspected of a pancreatic or periampullary carcinoma was discussed within a MDT meeting which was higher in patients aged <75 years and patients starting treatment with curative intent. 3) In 2012, the recommended 3 weeks between final MDT meeting and start of treatment was met in 39% (141 of 363) of patients which was not influenced by patient and tumor characteristics.

Conclusion: Compliance to three selected quality indicators in pancreatic cancer care was low in 2012. Areas for improvement were identified. Future compliance will be investigated through structured audit and feedback from the Dutch Pancreatic Cancer Audit.
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http://dx.doi.org/10.1016/j.pan.2015.10.002DOI Listing
December 2016

Pancreatic cancer surgery in elderly patients: Balancing between short-term harm and long-term benefit. A population-based study in the Netherlands.

Acta Oncol 2016 9;55(3):278-85. Epub 2015 Nov 9.

a Department of Research , Netherlands Comprehensive Cancer Organisation (IKNL) , Utrecht , The Netherlands.

Background: At a national level, it is unknown to what degree elderly patients with pancreatic or periampullary carcinoma benefit from surgical treatment compared to their younger counterparts. We investigated resection rates and outcomes after surgical treatment among elderly patients.

Methods: From the Netherlands Cancer Registry, 20 005 patients diagnosed with primary pancreatic or periampullary cancer in 2005-2013 were selected. The associations between age (<70, 70-74, 75-79, ≥80 years) and resection rates were investigated using χ(2) tests, and surgical outcomes (30-, 90-day mortality) were evaluated using logistic regression analysis. Overall survival after resection was investigated by means of Kaplan-Meier and Cox proportional hazard regression analysis.

Results: During the study period, resection rates increased in all age groups (<70 years: 20-30%, p < 0.001; ≥80 years: 2-8%, p < 0.001). Of 3845 patients who underwent tumour resection for pancreatic or periampullary carcinoma, the proportion of octogenarians increased from 3.5% to 5.5% (p = 0.03), whereas postoperative mortality did not increase (30-day: 6-3%, p = 0.06; 90-day: 9-8%, p = 0.21). With rising age, 30-day postoperative mortality increased (4-5-7-8%, respectively, p < 0.001), while 90-day mortality was 6-10-13-12% (p < 0.001) and three-year overall survival rates after surgery were 35-33-28-31%, respectively (p < 0.001). After adjustment for confounding factors, octogenarians who survived 90 days postoperative exhibited an overall survival close to younger patients [hazard ratio (≥80 vs. <70 years) = 1.21, 95% confidence interval (0.99-1.47), p = 0.07].

Conclusion: Despite higher short-term mortality, octogenarians who underwent pancreatic resection showed long-term survival similar to younger patients. With careful patient screening and counselling of elderly patients, a further increase of resection rates may be combined with improved outcomes.
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http://dx.doi.org/10.3109/0284186X.2015.1105381DOI Listing
December 2016

Prognostic factors for the feasibility of chemotherapy and the Geriatric Prognostic Index (GPI) as risk profile for mortality before chemotherapy in the elderly.

Acta Oncol 2016 14;55(1):15-23. Epub 2015 Aug 14.

h Department of Psychiatry , Leiden University Medical Center , Leiden , The Netherlands.

Background: Comprehensive geriatric assessment (CGA) is a multidimensional method to detect frailty in elderly patients. Time saving could be accomplished by identifying those individual items that classify elderly cancer patients at risk for feasibility of chemotherapy and for mortality.

Material And Methods: Patients older than 70 years of age were assessed before the first chemotherapy administration. GA consisted of the Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Predictive individual items for feasibility of chemotherapy and mortality were entered in the multivariable logistic regression and Cox-regression models, and a three-item sum scale was constructed: the Geriatric Prognostic Index (GPI).

Results: The 494 patients had a median age of 75 years (range 70-92 years). The majority of the patients had malignancies of the digestive tract (41.7%) followed by hematological tumors (22.3%). Three items of the MNA ('psychological distress or acute disease in the past three months', 'neuropsychological problems' and 'using > 3 prescript drugs') independently predicted for feasibility of chemotherapy. Two items of the MNA and one of the GFI ('declining food intake in past 3 months', 'using > 3 prescript drugs', and 'dependence in shopping') independently predicted for mortality. In comparison with patients without any positive item on the three-item GPI, patients with one, two or three positive items had hazard ratios (HRs) of 1.58, 2.32, and 5.58, respectively (all p < 0.001).

Conclusions: With only three items of the MNA, feasibility of chemotherapy can be predicted. The three-item GPI may help to identify elderly cancer patients at elevated risk for mortality.
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http://dx.doi.org/10.3109/0284186X.2015.1068446DOI Listing
December 2016

Prognostic factors for the feasibility of chemotherapy and the Geriatric Prognostic Index (GPI) as risk profile for mortality before chemotherapy in the elderly.

Acta Oncol 2016 Jan 14;55(1):15-23. Epub 2015 Aug 14.

h Department of Psychiatry , Leiden University Medical Center , Leiden , The Netherlands.

Background: Comprehensive geriatric assessment (CGA) is a multidimensional method to detect frailty in elderly patients. Time saving could be accomplished by identifying those individual items that classify elderly cancer patients at risk for feasibility of chemotherapy and for mortality.

Material And Methods: Patients older than 70 years of age were assessed before the first chemotherapy administration. GA consisted of the Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Predictive individual items for feasibility of chemotherapy and mortality were entered in the multivariable logistic regression and Cox-regression models, and a three-item sum scale was constructed: the Geriatric Prognostic Index (GPI).

Results: The 494 patients had a median age of 75 years (range 70-92 years). The majority of the patients had malignancies of the digestive tract (41.7%) followed by hematological tumors (22.3%). Three items of the MNA ('psychological distress or acute disease in the past three months', 'neuropsychological problems' and 'using > 3 prescript drugs') independently predicted for feasibility of chemotherapy. Two items of the MNA and one of the GFI ('declining food intake in past 3 months', 'using > 3 prescript drugs', and 'dependence in shopping') independently predicted for mortality. In comparison with patients without any positive item on the three-item GPI, patients with one, two or three positive items had hazard ratios (HRs) of 1.58, 2.32, and 5.58, respectively (all p < 0.001).

Conclusions: With only three items of the MNA, feasibility of chemotherapy can be predicted. The three-item GPI may help to identify elderly cancer patients at elevated risk for mortality.
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http://dx.doi.org/10.3109/0284186X.2015.1068446DOI Listing
January 2016

Nationwide trends in incidence, treatment and survival of colorectal cancer patients with synchronous metastases.

Clin Exp Metastasis 2015 Jun 22;32(5):457-65. Epub 2015 Apr 22.

Netherlands Comprehensive Cancer Organisation (IKNL), P.O. Box 19079, 3501 DB, Utrecht, The Netherlands,

The aim of this study was to determine trends in incidence, treatment and survival of colorectal cancer (CRC) patients with synchronous metastases (Stage IV) in the Netherlands. This nationwide population-based study included 160,278 patients diagnosed with CRC between 1996 and 2011. We evaluated changes in stage distribution, location of synchronous metastases and treatment in four consecutive periods, using Chi square tests for trend. Median survival in months was determined, using Kaplan-Meier analysis. The proportion of Stage IV CRC patients (n = 33,421) increased from 19 % (1996-1999) to 23 % (2008-2011, p < 0.001). This was predominantly due to a major increase in the incidence of lung metastases (1.7-5.0 % of all CRC patients). During the study period, the primary tumor was resected less often in Stage IV patients (65-46 %) and the use of systemic treatment has increased (29-60 %). Also an increase in metastasectomy was found in patients with one metastatic site, especially in patients with liver-only disease (5-18 %, p < 0.001). Median survival of all Stage IV CRC patients increased from 7 to 12 months. Especially in patients with metastases confined to the liver or lungs this improvement in survival was apparent (9-16 and 12-24 months respectively, both p < 0.001). In the last two decades, more lung metastases were detected and an increasing proportion of Stage IV CRC patients was treated with systemic therapy and/or metastasectomy. Survival of patients has significantly improved. However, the prognosis of Stage IV patients becomes increasingly diverse.
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http://dx.doi.org/10.1007/s10585-015-9719-0DOI Listing
June 2015

Survival in relation to hospital type after resection or sorafenib treatment for hepatocellular carcinoma in The Netherlands.

Clin Res Hepatol Gastroenterol 2015 Dec 3;39(6):725-35. Epub 2015 Apr 3.

Departments of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.

Background And Objective: Despite an increase in recent years, hepatocellular carcinoma remains uncommon in the Netherlands. The aim of the current study is to explore potential effects of hospital type and volume on outcomes after resection or sorafenib in patients with hepatocellular carcinoma.

Methods: Initial treatment and survival of patients with hepatocellular carcinoma diagnosed in the period 2005-2011 were based on data of the Netherlands Cancer Registration. Potential risk factors (including hospital type and volume) for 30-days postoperative and long-term mortality in patients who underwent resection and in patients treated with sorafenib were evaluated by uni- and multivariate analyses.

Results: In the period 2005-2011, 2402 patients were diagnosed with hepatocellular carcinoma: 12% received resection and 9% sorafenib. Postoperative mortality was higher in non-university hospitals (13% versus 4%; P=0.01). Resection in non-university hospitals was associated with higher postoperative mortality (odds ratio 3.38, 95% confidence interval 1.37-10.68) and long-term mortality (hazard ratio 1.21, 95% confidence interval 1.04-1.40). Sorafenib treatment in non-university hospitals was also associated with higher long-term mortality (hazard ratio 1.39, 95% confidence interval 1.06-1.82). Hospital volume was not independent predictor for outcome.

Conclusion: In low incidence countries, outcome after resection or sorafenib for hepatocellular carcinoma may differ between various hospital types.
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http://dx.doi.org/10.1016/j.clinre.2015.02.004DOI Listing
December 2015

Guidelines-based diagnostic process does increase hospital delay in a cohort of colorectal cancer patients: a population-based study.

Eur J Cancer Prev 2014 Sep;23(5):344-52

aComprehensive Cancer Centre the Netherlands (IKNL), Utrecht bHaga Hospital, Department of Surgery cRadiotherapy Centre West, The Hague dDiaconessenhuis, Department of Internal Medicine Departments of eClinical Oncology fSurgery, Leiden University Medical Centre, Leiden, The Netherlands.

This is an investigation of factors determining hospital delay until treatment in an unrestricted population of colorectal cancer patients in the western part of the Netherlands. All patients with newly diagnosed colon (n=2146) and rectal carcinoma (n=1036) in the period 2006-2008 were included in analyses of inhospital delay (first hospital visit until first treatment >35 days). One-third of all patients were also available for analyses of prehospital delay (enrollment until first hospital visit >7 days). Patient, tumour and process factors predicting delay were examined in logistic regression models. The median prehospital and inhospital time intervals were 2 days [(p25-p75) 0-16] and 32 days (17-49), respectively, for colon cancer patients and 7 days (1-21) and 43 days (33-60) for rectal cancer patients. After adjustment for patient and tumour factors, colon and rectal cancer patients with first hospital visit before histological confirmation of cancer, complete diagnostic assessment or discussed in a multidisciplinary meeting had a higher probability of increased inhospital delay. Furthermore, first hospital visit before histological confirmation of cancer was associated with decreased prehospital delay in colon and rectal cancer patients. A guidelines-based diagnostic process (considered high quality of care) and multidisciplinary collaboration were associated with increased hospital delay in colorectal cancer patients.
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http://dx.doi.org/10.1097/CEJ.0000000000000050DOI Listing
September 2014

Centralization of esophagectomy: how far should we go?

Ann Surg Oncol 2014 Dec 9;21(13):4068-74. Epub 2014 Jul 9.

Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands,

Background: This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

Methods: Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

Results: Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93).

Conclusions: Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.
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http://dx.doi.org/10.1245/s10434-014-3873-5DOI Listing
December 2014

Prognostic significance of geriatric assessment in combination with laboratory parameters in elderly patients with aggressive non-Hodgkin lymphoma.

Leuk Lymphoma 2015 Apr 19;56(4):927-35. Epub 2015 Feb 19.

Institute of Mental Health , Bouman GGZ Rotterdam , The Netherlands.

The age-adjusted International Prognostic Index (IPI) is an important prognostic factor for patients with non-Hodgkin lymphoma (NHL). We investigated whether a geriatric assessment (GA) is of additional prognostic value in NHL. In this prospective cohort study of 44 patients aged 70 years or older with NHL receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP), a GA was administered before the start of chemotherapy. GA was composed of the Mini Nutritional Assessment (MNA), Groningen Frailty Indicator (GFI), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Mini Mental State Examination (MMSE) and levels of albumin, creatinine, lactate dehydrogenase (LDH) and hemoglobin. Multivariate analyses were performed using logistic regression and the Cox regression model. After adjustment for sex, age, comorbidity and univariate laboratory values with p ≤ 0.1, abnormal MNA and GFI scores and low hemoglobin level were associated with not being able to complete the intended chemotherapy: odds ratio (OR) 8.29 (95% confidence interval [CI]: 1.24-55.6; p = 0.03), 9.17 (95% CI: 1.51-55.8; p = 0.02) and 5.41 (95% CI: 0.99-29.8; p = 0.05), respectively. Adjusted for sex, age, comorbidity, age-adjusted IPI and univariate laboratory values with p ≤ 0.1, frailty by GFI and low hemoglobin were associated with worse survival, with a hazard ratio (HR) of mortality of 2.55 (95% CI: 1.07-6.10; p = 0.04) and 4.90 (95% CI: 1.76-13.7; p = 0.002), respectively. We conclude that (risk of) malnutrition, measured with the MNA, frailty, measured with the GFI, and low hemoglobin level had additional predictive value for early treatment withdrawal, and GFI and hemoglobin were, independent of the age-adjusted IPI, predictive for an increased mortality risk.
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http://dx.doi.org/10.3109/10428194.2014.935364DOI Listing
April 2015

[Diagnostics and treatment of hepatocellular carcinoma: trends in the Netherlands in the period 2003-2011].

Ned Tijdschr Geneeskd 2014 ;158:A7074

Universitair Medisch Centrum Utrecht, afd. Maag- Darm- en Leverziekten, Utrecht.

Objective: To evaluate trends in the distribution of care for patients with hepatocellular carcinoma (HCC) in the past decade.

Design: Retrospective study.

Method: We collected data on diagnostic testing and initial treatment of patients with HCC in the period 2003-2011 from the Dutch Cancer Registry.

Results: In the period 2003-2011, 2915 patients were diagnosed with HCC. The proportion of patients given palliative treatment increased significantly, whereas the proportion of patients treated by resection remained stable (approximately 10%). Tumour biopsies were performed in virtually all hospitals. Despite a significant decrease seen in the period studied, tumour biopsy was still performed in more than 50% of cases. The number of hospitals where any treatment was performed increased significantly (from 33% to 62% of all hospitals) and the contribution of treatments in academic hospitals decreased significantly (from 83% to 75%). Transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and resection were mainly performed in academic hospitals (99%, 95% and 79% respectively), whereas about half of the initial sorafenib treatments were given in non-academic hospitals. Only in a few academic hospitals were a minimum of five resections performed annually and (only during the last three years of the period studied) were a minimum of five patients started on sorafenib annually. Significant differences existed between regions in the use of RFA or TACE - both p < 0.001, after case-mix correction.

Conclusion: In the past decade there was no trend towards centralization of diagnostic testing and treatments for patients with HCC.
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November 2014

Frailty and malnutrition predictive of mortality risk in older patients with advanced colorectal cancer receiving chemotherapy.

J Geriatr Oncol 2013 Jul 30;4(3):218-26. Epub 2013 Apr 30.

Institute of Mental Health, Bouman GGZ Rotterdam, The Netherlands. Electronic address:

Introduction: In general, geriatric assessment (GA) provides the combined information on comorbidity and functional, nutritional and psychosocial status and may be predictive for mortality outcome of cancer patients. The impact of geriatric assessment on the outcome of older patients with colorectal cancer treated with chemotherapy is largely unknown.

Methods: In a prospective study, 143 patients with colorectal cancer who were 70years and older were assessed before chemotherapy by Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE).

Results: Fifty-four (38%) patients received adjuvant chemotherapy and 89 (62%) patients received palliative chemotherapy. Malnutrition and frailty were prevalent in 39 (27%, assessed by MNA) and 34 (24%, by GFI) patients, respectively; whereas cognitive impairment was prevalent in 19 (13%, by IQCODE) and 11 (8%, by MMSE) patients, respectively. In patients with palliative chemotherapy, poor MNA scores were associated with receiving less than 4cycles of chemotherapy (p=0.008). Poor MNA and GFI scores were associated with increased hazard ratios (HR) for mortality for patients with palliative chemotherapy: HR=2.76 (95% confidence interval [CI]: 1.60-4.77; p<0.001) and HR=2.72 (95% CI: 1.58-4.69; p<0.001), respectively, after adjustment for several clinical parameters.

Conclusions: Malnutrition and frailty were strongly associated with an increased mortality risk in patients who underwent palliative chemotherapy. Furthermore, a poor score on MNA was predictive for less tolerance of chemotherapy. Our findings may help the oncologist in future decision making and advice for elderly patients with colorectal cancer.
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http://dx.doi.org/10.1016/j.jgo.2013.04.001DOI Listing
July 2013

Risk factors for excess mortality in the first year after curative surgery for colorectal cancer.

Ann Surg Oncol 2012 Aug 7;19(8):2428-34. Epub 2012 Mar 7.

Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.

Background: Thirty-day mortality after surgery for colorectal cancer may vastly underestimate 1-year mortality. This study aimed to quantify the excess mortality in the first postoperative year of stage I-III colorectal cancer patients and to identify risk factors for excess mortality.

Methods: All 2,131 patients who were operated with curative intent for stage I-III colorectal cancer in the western region of the Netherlands between January 1, 2006, and December 31, 2008, were analyzed. Thirty-day mortality and relative survival were calculated. In addition, relative excess risk (RER) of death was estimated by a multivariable model.

Results: Thirty-day mortality was 4.9%. One-year mortality was 12.4%. Risk factors for excess mortality in the first postoperative year for colon cancer patients were emergency surgery (excess mortality 29.7%, RER 2.5, 95% confidence interval 2.5-5.0), a Charlson score of >1 (excess mortality 12.6%, RER 2.3, 95% confidence interval 1.5-3.7), stage II or III disease (excess mortality 14.9%, RER 3.9, 95% confidence interval 1.9-8.1), and postoperative adverse events (excess mortality 22.6%, RER 2.1, 95% confidence interval 1.4-3.2).

Conclusions: The 30-day mortality rate highly underestimates the risk of dying in the first year after surgery, with excess 1-year mortality rates varying from 15 to 30%. This excess mortality was especially prominent in patients with comorbidities, higher stages of disease, emergency surgery, and postoperative surgical complications.
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http://dx.doi.org/10.1245/s10434-012-2294-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404283PMC
August 2012

Improved guideline compliance after a 3-year audit of multidisciplinary colorectal cancer care in the western part of the Netherlands.

J Surg Oncol 2012 Jul 10;106(1):1-9. Epub 2012 Jan 10.

Comprehensive Cancer Centre the Netherlands (CCCNL), Utrecht, The Netherlands.

Background: From 2006 to 2008, an audit of the multidisciplinary diagnosis and treatment of colorectal cancer patients in the western part of the Netherlands was carried out. We evaluated whether compliance with guidelines had improved.

Methods: All patients with newly diagnosed and surgically treated colon (n = 1,667) and rectal cancer (n = 544) stage I-III were evaluated. Nine quality indicators were derived from the evidence-based guidelines. In order to compare hospital performances, hospital results were adjusted for casemix differences between hospitals.

Results: Colon cancer patients showed an increase in the examination of 10 or more lymph nodes (from 53% to 78%, P < 0.0001). For rectal cancer patients there was an increase in preoperative visualisation of the total colon (63-74%, P = 0.02), MRI (73-85%, P = 0.003), radiotherapy (from 82% to 93% for patients <75 years, P = 0.01) and examination of at least 10 lymph nodes (40-55%, P = 0.004). In 2006, standardised hospital performances differed widely for all quality indicators. Two years later, hospital performances for some quality indicators were more similar.

Conclusions: After the feedback of benchmark information, compliance with guidelines for diagnosis and treatment of colorectal cancer patients improved, and differences between individual hospitals decreased. Although secular trends cannot be ruled out, it is highly likely that these results can be attributed to the audit.
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http://dx.doi.org/10.1002/jso.23038DOI Listing
July 2012
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