Background: Cancer treatment of the elderly patients is an increasingly important concern since the risk for developing breast cancer increases with age. The effects of adjuvant chemotherapy on the breast cancer disease seem to be as good for pre and postmenopausal patients, at least for hormone receptor negative patients. However, very few patients older than 65 years are included in randomised studies. In clinical practice, it is common that elderly women are offered less chemotherapy, because of the unsubstantiated belief that they will experience a larger number and more severe adverse effects as well as poor functional outcomes and significant decrements in health related quality of life (HRQOL). The aim of this study was to follow HRQOL in postmenopausal women (55−80 years) with breast cancer receiving adjuvant treatment after surgery, until five years post-treatment, and compare with a general population.

Patients and Methods: The patient sample included 150 women (adjuvant CT n = 75 and RT n = 75) and two reference samples from the Swedish SF- 36 norm database.

Results: The results showed that at baseline the women in the patient sample experienced significantly higher levels of physical functioning and general health compared to the general population. They also experienced significantly less bodily pain, lower emotional role functioning and mental health. Five years after completion of treatment, the patient sample experienced better HRQOL than the reference sample in all domains, supporting our hypothesis that the impact on HRQOL would have been resolved over time for these patients. Conclusion: Postmenopausal women (55−80 years) seem to successfully manage the effects of adjuvant treatment on HRQOL.

Purpose:

Risk of suicide is increased among men with prostate cancer. We investigated this association among men with low-risk cancer, usually detected by prostate specific antigen (PSA)-testing.

Patients and Methods:

Relative risk (RR) of suicide was calculated by use of Poisson regression analysis within the Prostate Cancer data Base Sweden (PCBaSe) 2.0, a nation-wide, population-based database, comparing 105,736 men diagnosed with prostate cancer between 1997-2009 to 528,658 matched prostate cancer-free men.

Results:

During the first 6 months after diagnosis, there were 38 suicides among men with prostate cancer; incidence rate 0.73 per 1000 person-years (PY) and 30 suicides in the comparison cohort; 0.11 per 1000 PY, corresponding to a RR of suicide of 6.5 (95% confidence interval (CI) 4.0-10). Risk was highest among men with distant metastases, incidence rate 1.25 per 1000 PY, RR 10 (95% CI 5.1-21) but risk was also increased for men with low-risk tumours, incidence rate difference 0.45 per 1000 PY and RR 5.2 (95% CI 2.3-12) and across categories of socioeconomic status and comorbidity. Eighteen months after diagnosis, risk of suicide had decreased to 0.27 per 1000 PY, RR 1.0 (95% CI 0.68-1.5) for low-risk prostate cancer but remained increased among men with metastases, 0.57 per 1000 PY, RR 1.8 (95% CI 1.1-2.9).

Conclusion:

Although the increase in absolute risk of suicide was modest, our findings reflect the severe psychological stress that prostate cancer patients may experience after diagnosis. The increased risk of suicide observed in men with prostate cancer, including low-risk, calls for increased awareness.

We analysed the trends in incidence rates of childhood cancer in Sweden. All cases of malignant diseases and benign brain tumours in children, 0-14 years old, reported to the Swedish Cancer Registry 1960 to 1998 were included, n=9298. Cases were classified according to the International Classification of Childhood Cancer. Average annual change in incidence rate was calculated to +1.01%, (95% confidence interval CI=0.80, 1.22). An increase in incidence rate per year was found for leukaemia, +0.85% (95% CI=0.42, 1.28), lymphomas +1.87% (95% CI=1.17, 2.58), CNS (central nervous system) tumours +1.45% (95% CI=1.02, 1.88), sympathetic nervous system tumours +1.61% (95% CI=0.79, 2.44), hepatic tumours +2.62% (95% CI=2.02, 3.21), and germ cell and gonadal tumours +1.21% (95% CI=0.23, 2.19). Of the CNS tumours, significant changes were seen for low-grade glioma/astrocytoma +2.10% (95% CI=1.41, 2.80), benign brain tumours +3.77% (95% CI=2.47, 5.10), and PNET/medulloblastoma +1.96% (95% CI=0.48, 3.46). Changes in diagnostic criteria and better diagnostic tools may have contributed to these results.

Background: The European Parliamentary Group on Breast Cancer and the European Society of Breast Cancer Specialists state that there is a need for EU agreed guidelines on breast care nursing and training. Therefore the European Oncology Nursing Society (EONS) commissioned the development of a post-basic curriculum for breast cancer nursing. Purpose: The goal was to define a European curriculum for the training of breast care nurses. Methods: The curriculum was developed using a variety of sources, including guidelines from a number of European and other countries world wide, relevant literature and input from an expert panel of senior European nurses with expertise in breast care nursing. Results: An English language, European curriculum of breast care nursing was developed at a postbasic level to provide guidance for the training of breast care nurses throughout Europe. Definitions for breast care nurse roles and activities and levels of practice, as well as indicative content are provided. Conclusions: The training of nurses in breast cancer care should be mandatory and common practice for European countries. To enhance comparability and standard development, the indicative content should be applied in all future post-basic education. (C) 2011 Elsevier Ltd. All rights reserved.

Background: Alterations in habitual sleep/wake patterns (SWP) of women with breast cancer and their informal caregivers may be concurrently exacerbated and co-vary during the patient’s treatment. Taking into consideration the complexity of mechanisms interfering with a care dyad’s sleep, the current study set out to longitudinally explore SWP of patientcaregiver dyads in the context of adjuvant chemotherapy (CTh) for breast cancer.

Material and Methods: In this descriptive, observational, repeatedmeasures dyadic study, 48 newly diagnosed women receiving outpatient adjuvant CTh for early stage breast cancer (stage I−IIIA), and their nominated primary informal caregiver completed self-reported sleep measures at pre-treatment (week prior to CTh), post-CTh cycle 1, post- CTh cycle 4, and approximately 30 days after CTh (total of 6 cycles received). Multivariate hierarchical linear modelling (MHLM) techniques were implemented to analyse dyadic sleep data.

Results: Prior to CTh, 65% of dyads consisted of at least one poor sleeper, a rate further increasing to approximately 88% at CThC4. MHLM revealed curvilinear trajectories for most of dyads’ sleep/wake parameters that nevertheless reached significance (p <. 05) only for patients. In both groups, sleep/wake impairment reached its peak at mid-treatment (CThC4); yet, patients consistently reported significantly more sleep problems than their carers. Partial convergence also emerged as suggested by positive correlations and no between-groups differences in daily disturbance, daytime napping duration (NAPTIME), total sleep time, and overall sleep/ wake disruption at pre-treatment. At CThC4, rates of change in sleep latency and NAPTIME were alsosimilar.

Conclusions: The current study is one of the first studies to show that a dyadic approach in the assessment of SWP in patients with breast cancer and their carers is a promising method to enhance exploration of potentially concurrent sleep-impairment. Replication of the current findings in future dyadic sleep research is an absolute priority. Meanwhile, clinicians will need to engage in concurrent systematic and on-going sleep assessments that synthesise and contrast data to establish a care dyad’s level of sleep quality.

Epidemiologic studies on diabetes and body size in relation to risk of bladder cancer have yielded inconsistent results. We examined prospectively the associations between a history of diabetes, height, weight, body mass index and waist circumference, and the incidence of bladder cancer in the Cohort of Swedish Men, a prospective study of 45,906 men aged 45–79 years at baseline. During follow-up from 1998 through December 2007, 414 incident cases of bladder cancer were ascertained. A history of diabetes was not associated with risk of bladder cancer (multivariate rate ratio=1.16; 95% confidence interval=0.81–1.64). Similarly, no associations were observed for height, weight, body mass index or waist circumference. These findings in men do not support a role for diabetes, height or excess body mass in the aetiology of bladder cancer. 

We investigated the association between physical activity and colorectal cancer risk in a cohort of Swedish men. Information on physical activity was obtained at baseline in 1997 with a self-administered questionnaire from 45,906 men who were cancer-free at enrollment. During a mean follow-up of 7.1 years, 496 cases of colorectal cancer occurred. Leisure-time physical activity was inversely associated with colorectal cancer risk; the multivariate hazard ratio (HR) for 60 min or more per day of leisure-time physical activity compared with less than 10 min per day was 0.57 (95% CI 0.41-0.79; P for trend=0.001). Results were similar for colon (HR=0.56; 95% CI 0.37-0.83) and rectal cancer (HR=0.59; 95% CI 0.34-1.02). Home/housework activity was inversely associated with colon cancer risk (HR=0.68; 95% CI 0.48-0.96). No association was observed for work/occupational activity. These results support a role of physical activity in reducing the risk of colon and rectal cancer.

BACKGROUND: It has been suggested that sunlight through production of vitamin D might have a protective effect on a number of internal cancers. Consequently, in spite of the well known skin cancer risks, some researchers advocate more exposure to ultraviolet radiation, supported by the solarium industry. We estimated the risk of internal cancer before the patient contracted a basal cell carcinoma (BCC) of the skin, the most common cancer in white populations and strongly associated with extensive sun exposure.

METHODS: A nested case control study was undertaken in the whole Swedish population. 115,016 patients with BCC and 987,893 controls were linked to population based registers.

FINDINGS: The cases had an increased risk of getting another form of cancer before the BCC diagnosis: odds ratio (OR)=1.84; 95% confidence interval (CI) 1.81-1.86. This risk was mainly due to skin cancer: OR=4.95; 95% CI 4.81-5.09 but also non-skin cancer risk was elevated: OR=1.37; 95% CI 1.35-1.39. We adjusted the estimates for age, level of income, occupational status in national censuses, place of living and sex, where appropriate. Of the cancers specifically suggested to be related to vitamin D status: colon, prostate, breast, and ovary cancer, all had slightly increased ORs whilst for pancreatic and gastric cancer no increased OR was found.

INTERPRETATION: Patients with BCC, a proxy for extensive sun exposure, run an increased risk of other forms of cancer prior to the diagnosis of BCC. The findings in this study contradict that vitamin D production through extensive sun exposure has any protective effect on internal cancer but emphasise the increased risk for skin cancer.

Survival rates were analysed in 29,055 patients with urinary bladder cancer diagnosed in Sweden from 1960 to 1986 and followed up until 1987. The 2-, 5- and 10-year relative survival rates were 79, 70 and 64% for men and 75, 68 and 63% for women, respectively. Patients with a history of bladder cancer for at least 15 years ran a negligible risk of dying from their disease. Prognosis was consistently better in younger than in older patients; below 50 years of age the 5-year relative survival rate was 90%, as compared with 60% in patients aged 70-79 years. Patients diagnosed between 1960 and 1964 had a 60% 5-year relative survival, as compared to 71% in those diagnosed between 1980 and 1984. Multivariate analyses further confirmed that age but not sex is an important prognostic factor in bladder cancer and, further, that a substantial improvement in survival rates took place during the 1960-1986 period. Compared with 1960-1964 the risk of dying of bladder cancer within 5 years in patients diagnosed between 1980 and 1984 was 51% lower in men [relative risk (RR) = 0.49; 95% confidence interval (C.I.) 0.42-0.57] and 44% lower in women (RR = 0.56; 95% C.I. 0.45-0.70).

The aim of this study was to compare lymph node involvement of breast cancer cases detected at mammography screening with clinically-detected cases. During a 3-year period, 273 primary breast cancers were detected in a population-based screening programme, and 149 primary breast cancers were diagnosed clinically. Lymph node involvement was evaluated in univariate and multivariate logistic regression models correcting for tumour size, histological grade, steroid receptor status and DNA-ploidy. Patients with screen-detected cancers had a low relative risk of having lymph node metastases (univariate, OR = 0.31; 95% confidence interval = 0.19-0.52). In the multivariate logistic regression model, the relative risk was halved (OR = 0.47; 0.28-0.78). The reduced risk was more pronounced for women younger than 50 years of age compared to older women. The risk for screen-detected cases of having lymph node metastases at diagnosis was statistically significantly lower than for clinically-detected cases. The marked reduction, even when correcting for tumour size, makes it less likely that factors such as detection of clinically innocent tumours, length bias sampling or clinical symptoms related to axillary metastases can explain the whole difference. The results indicate at least part of the effect may be explained by tumour progression in the late preclinical detectable phase.

Human neuroblastoma cell lines are established from high-stage, highly malignant tumours. Despite this and the fact that these tumours are arrested at an early, immature stage, many cell lines have the capacity to undergo neuronal differentiation under proper growth conditions. One such cell line is the noradrenergic SH-SY5Y cell line. These cells can be induced to mature by a variety of modalities, resulting in different mature phenotypes. The use of this cell system as a model to study the stem cell character of neuroblastoma is reviewed and discussed. In particular, we focus on growth factor dependencies in the SH-SY5Y system, and compare that to the normal situation, i.e. growth factor control of sympathetic neuronal and neuroendocrine differentiation during human and rat embryogenesis.

Introduction: For immediate and continuous dialogue between patients and caregivers new approaches in modern technology are encouraged today. In cooperation with a Swedish health management company, we developed an interactive mobile phone application for the assessment of symptom distress, evidence-based self-care advice and an alerting function of severe symptoms with instant access to professionals in real time. By using this technique patients can communicate symptoms with instant support while cared for out-side hospital but at the same time reassured that their condition is monitored by the professionals. The objective of this study was to evaluate the feasibility and acceptability of the application for patients with prostate cancer during radiotherapy and for the involved health care staff.

Material and Methods: Evidence-based symptoms and related selfcareadvices were implemented in the application after literature review and interviews with patients and health care professionals. Nine patients diagnosed with prostate cancer undergoing radiotherapy treatment were recruited to test the application for two weeks. The patients reported in the electronic symptom questionnaire daily. After the two weeks they were interviewed about their experience. Nurses directly involved in the care and treatment of the participating patients were interviewed at the end of study.

Results: Overall, patients and nurses reported positive experiences of using the mobile phone system. The patients considered the application helpful and easy to use although there were some suggestions for further development of the electronic questionnaire. Most of the patients had read the self-care advice and found them useful. The alerting system was activated in several cases; the nurses found it useful to identify and manage problematic symptoms early and the patients felt safe and well cared for. Some of the nurses considered the monitoring system time-consuming and made suggestions for improvement.

Conclusions: Both patients and nurses could see the potential for using the mobile application in clinical practice. The system enables the involvement of the patients and the alerts showed problematic symptoms promoting timely interventions. The results support further development and testing of the system in full-scale.

Background: The optimal timing of endocrine therapy in non-metastatic prostate cancer (PCa) is still an issue of debate. Methods: A randomised, double-blind, parallel-group trial comparing bicalutamide 150 mg once daily with placebo in addition to standard care in patients with hormone-naive, non-metastatic PCa. Kaplan-Meier analysis was used to estimate overall survival (OS) and multivariate Cox proportional hazard model was performed to analyse time-to-event (death). Findings: A total of 1218 patients were included into the Scandinavian Prostate Cancer Group (SPCG)-6 study of which 607 were randomised to receive bicalutamide in addition to their standard care and 611 to receive placebo. Median follow-up was 14.6 years. Overall, 866 (71.1%) patients died, 428 (70.5%) in the bicalutamide arm and 438 (71.7%) in the placebo arm, p = 0.87. Bicalutamide significantly improved OS in patient with locally advanced disease (hazard ratios (HR) = 0.77 (95% confidence interval (CI): 0.63-0.94, p = 0.01), regardless of baseline prostate-specific antigen (PSA), with a survival benefit which was apparent throughout the study period. In contrast, survival favoured randomisation to the placebo arm in patients with localised disease (HR = 1.19 (95% CI: 1.00-1.43), p = 0.056). However, a survival gain from bicalutamide therapy was present in patients with localised disease and a baseline PSA greater than 28 ng/mL at randomisation. In multivariate Cox proportional hazard model, only including patients managed on watchful waiting as their standard of care (n = 991) OS depended on age, World Health Organisation (WHO) grade, baseline PSA, clinical stage and randomised treatment. Interpretation: Throughout the 14.6 year follow-up period the addition of early bicalutamide to standard of care resulted in a significant OS benefit in patients with locally advanced PCa. In contrast, patients with localised PCa and low PSA derived no survival benefit from early bicalutamide. The optimal timing for initiating bicalutamide in non-metastatic PCa patients is dependent on disease stage and baseline PSA. (C) 2015 Elsevier Ltd. All rights reserved.

The incidence of malignant melanoma is growing rapidly. Approximately half of the cases are BRAF mutated, making treatment with kinase inhibitors a (MEK and BRAF inhibitors) preferred choice in the advanced setting. The vast majority of these patients will benefit from the treatment. It is therefore of vital importance that the BRAF analysis is reliable and reflects the true nature of the tumour. Intraindividual tumour BRAF heterogeneity may exist, and changes of BRAF status over time might occur. We reviewed the literature by searching the PubMed database and 630 potentially relevant studies were identified. Thereafter, studies that investigated intralesional heterogeneity only, studies with ≤10 patients and studies that did not include adequate data to calculate discrepancy rates were excluded. Twenty-two studies met our inclusion criteria and were included in the meta-analysis. The pooled discrepancy rate between primary and metastatic lesions was 13.4% (95% confidence interval [CI]: 9.2-18.2%) while it was 7.3% (95% CI: 3.3-12.6) between two metastatic lesions. The number of patients whose tumoural BRAF status was changed from mutation to wild type and from wild type to mutation, respectively, was comparable. We conclude that a clinically meaningful discrepancy rate in BRAF status both between primary-metastatic and metastatic-metastatic melanoma lesions exists. Our results support the polyclonal model of melanomas in which subclones with different BRAF status co-exist in the same melanoma lesion. In addition, the results indicate a need for biopsy of a metastatic lesion for subsequent BRAF analysis when treatment with kinase inhibitors is considered.

To assess quality of life (QoL) and symptoms after oesophageal cancer surgery, a prospective nationwide population-based study was conducted in 2001-2005, including most surgically treated oesophageal cancer patients in Sweden. Six months postoperatively patients responded to an EORTC quality of life core questionnaire (QLQ C-30) with an oesophageal-specific module (OES-18). Mean scores were calculated. Mann-Whitney test was used for group comparisons. Among 282 patients, QoL was considerably reduced compared to a reference general population (P < 0.001), and functioning scales were similarly negatively affected; particularly role (P < 0.001) and social (P < 0.001) functions. Younger patients scored worse than older. No gender differences were found. Dominating general symptoms included fatigue, appetite loss, diarrhoea, and dyspnoea, each significantly more pronounced than the general population (P < 0.001). Eating problems, cough, reflux, and oesophageal pain were common oesophageal-specific symptoms. Thus, patients who undergo oesophageal cancer resection suffer greatly from reduced QoL and several general and oesophageal-specific symptoms six months postoperatively. (c) 2006 Elsevier Ltd. All rights reserved.

Background: In the front line in cancer care is to systematically integratepatient reported outcomes (PRO) in clinical practice. The development ofthis research program is based on The Participatory Care Model, and buildson how patients can be integrated in their care. The aim is to evaluate the effects of an interactive e-health solution for assessment of symptom burden, generating instant self-care advice and instant access to health care professionals.

Methods: The hypothesis is that the intervention promotes safe and participatory care and thereby improves clinical management and health care costs. The experimental multicenter studies incorporate a mixedmethod approach. Ongoing studies include patients with pancreatic and prostate cancer using the mobile phone application in comparison to control groups in standard care. Outcomes are collected before and after treatment by questionnaires concerning capacity to understand, communicate health needs and promote healthy behaviors (health literacy), symptom burden and management and quality of life and from records and registers about disease progress and health care costs. Interviews concern participatory and meaningful care. Studies are ongoing for patients with prostate and pancreatic cancer and elderly populations living at home or in care homes.

Results: By using technology patients are able to communicate symptoms and receive instant support while cared for on an outpatient basis and at the same time feel reassured that their condition is monitored by health care professionals facilitating safe and participatory care.

Background: The local authorities for health and welfare support the introduction of Patient Reported Outcome Measures (PROM) in the quality registers in Sweden. Valid and reliable instruments measuring PROM do not exist that could be used throughout the whole breast cancer process. We sought to develop and implement PROM for breast cancer at different stages in the disease course in different Swedish geographic regions for later use in the Swedish National Quality Register for breast cancer. The aim was to develop appropriate PROM to assess symptoms and problems among patients with breast cancer about one year after diagnosis.

Materials and Methods: A scoping review and focus group discussions were conducted with women invited by the breast cancer association Amazona (Stockholm). The symptoms that emerged from the scoping review and focus group discussions formed the basis for the development of a web based questionnaire consisting of validated instruments (EORTC QLQ-C30, BR 23, MSAS) for measuring PROM. The women who participated in the focus group discussions were invited to respond to a pilot version of the web based questionnaire. The results were used to revise the web based questionnaire. An invitation was sent to a national random sample from the Swedish National Breast Cancer Quality Register diagnosed one year earlier to respond to the revised version of the web based questionnaire.

Results: The results will present the work process of the development of the PROM as well as plans for further work on the implementation of the PROM in the Swedish National Quality Register for breast cancer. Preliminary data shows that about 70% responded to the revised version of the web based questionnaire. However, some women requested a paper version of the questionnaire mostly because they did not have access to a computer.

Conclusion: In the development of PROM in quality registers it is important to include patients experiences in order to develop relevant outcome measures to influence the quality of the health care delivery.

Introduction: In recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC). Methods: The content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres. Results: The guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem. Conclusions: Applying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care. (C) 2013 Elsevier Ltd. All rights reserved.