Childhood cancer: patterns of protocol participation in a national survey.

Cancer is still the chief cause of death by disease in children, ages one to 14. As improved survival rates have been reported for pediatric cancer patients who are treated on controlled clinical trials, it is important to understand the national utilization of such protocols. In 1993, a survey of childhood cancer was conducted by the Commission on Cancer of the American College of Surgeons. Data regarding type of disease, protocol participation, age, sex, race, insurance, and geographical region were voluntarily submitted by more than 200 hospital cancer registries. Included in this study were 2,208 children and adolescents 21 years of age or younger who were diagnosed in 1987, and 2,293 who were diagnosed in 1992. Pediatric centers (i.e., members of the Pediatric Oncology Group or Children's Cancer Group) submitted 55.1% of the cases and other institutions, 44.9%. It was found that more patients treated at pediatric centers were on protocols (53.8%) than were those treated at other institutions (25.1%). In general, the younger the patient (five years of age or younger), the greater the chance of being on protocol (pediatric centers, 63.7%; others, 42.0%), with very poor adolescent protocol participation (pediatric centers, 34.8%; others, 12.1%). Nevertheless, overall protocol participation was still lower than expected, even in children younger than five years of age, and adolescent participation in controlled clinical trials was low and similar to adult figures. The percentage of childhood cancer cases seen at pediatric centers was smaller than in other series. It was concluded that pediatric cancer centers need to continue to encourage patient participation in controlled clinical trials, with special emphasis on adolescents.

Evaluating the implications of clinical practice guidelines for patient care.

Patient care evaluation studies have been developed by the Commission on Cancer of the American College of Surgeons. The studies were primarily designed to monitor trends in diagnosis, therapy, and outcome of specific oncologic diseases in hospitals and cancer centers. As they reflect the current standards of patient care, patient care evaluation studies have become valid tools of quality management in medicine. In an international pilot project that began in 1996, this approach was redefined to evaluate the impact of current clinical practice guidelines in oncology. Close cooperation between medical societies in the United States and Germany under the coordination of the Commission on Cancer and the Institute of Medical Informatics at the Justus-Liebig-University of Giessen was established. This infrastructure for data collection, data management, analysis, and interpretation of results allows for the recognition of international differences in patient care. Our results indicate discrepancies between current state-of-the-art patient care represented by clinical practice guidelines and the diagnostic and therapeutic procedures in the clinical routine. Patient care evaluation studies are designed as exploratory, not confirmatory, trials. In contrast with confirmatory trials, their aims may not always lead to predefined hypotheses. They reflect routine practice and are not the basis of the formal proof of efficacy, although they may contribute to the total body of relevant evidence. Without this comprehensive approach to evaluation, the potential of clinical practice guidelines to improve patient care remains unknown.

Analysis of medical-decision making and the use of standards of care in oncology.

Guidelines in medicine have been proposed as a way to assist physicians in the clinical decision-making process. Increasingly, they form the basis for assessing accountability in the delivery of healthcare services. However, experiences with their evaluation, as the most important step in the continuous guidelines process, are rare. Patient Care Evaluation Studies have been developed by the Commission on Cancer in the United States. As they reflect the "real-world" medical practice they are helpful in evaluating the quality of diagnosis, therapy and follow-up of tumor diseases in hospitals and cancer center and the compliance with current standards of care. In this context, they can provide an infrastructure for the analysis of the decision-making process.

Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the united states during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study.

BACKGROUND: The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976. METHODS: Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base. RESULTS: Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hürthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall). CONCLUSIONS: In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes.

Esophageal cancer: results of an American College of Surgeons Patient Care Evaluation Study.

BACKGROUND: The last two decades have seen changes in the prevalence, histologic type, and management algorithms for patients with esophageal cancer. The purpose of this study was to evaluate the presentation, stage distribution, and treatment of patients with esophageal cancer using the National Cancer Database of the American College of Surgeons. STUDY DESIGN: Consecutively accessed patients (n = 5,044) with esophageal cancer from 828 hospitals during 1994 were evaluated in 1997 for case mix, diagnostic tests, and treatment modalities. RESULTS: The mean age of patients was 67.3 years with a male to female ratio of 3:1; non-Hispanic Caucasians made up most patients. Only 16.6% reported no tobacco use. Dysphagia (74%), weight loss (57.3%), gastrointestinal reflux (20.5%), odynophagia (16.6%), and dyspnea (12.1%) were the most common symptoms. Approximately 50% of patients had the tumor in the lower third of the esophagus. Of all patients, 51.6% had squamous cell histology and 41.9% had adenocarcinoma. Barrett's esophagus occurred in 777 patients, or 39% of those with adenocarcinoma. Of those patients that underwent surgery initially, pathology revealed stage I (13.3%), II (34.7%), III (35.7%), and IV (12.3%) disease. For patients with various stages of squamous cell cancer, radiation therapy plus chemotherapy were the most common treatment modalities (39.5%) compared with surgery plus adjuvant therapy (13.2%). For patients with adenocarcinoma, surgery plus adjuvant therapy were the most common treatment methods. Disease-specific overall survival at 1 year was 43%, ranging from 70% to 18% from stages I to IV. CONCLUSIONS: Cancer of the esophagus shows an increasing occurrence of adenocarcinoma in the lower third of the esophagus and is frequently associated with Barrett's esophagus. Choice of treatment was influenced by tumor histology and tumor site. Multimodality (neoadjuvant) therapy was the most common treatment method for patients with esophageal adenocarcinoma. The use of multimodality treatment did not appear to increase postoperative morbidity.

Hodgkin's disease survival by stage and age.

OBJECTIVE: Prior reports on Hodgkin's disease have suggested a biologic behavior difference between young and old patients. A study of 35,033 patients could confirm that older patients do not do as well as young patients regardless of age. METHODS: The National Cancer Data Base provided data from U.S. tumor registries on 35,033 patients newly diagnosed with Hodgkin's disease from 1985 through 1994. For analysis the patients were divided into two time periods, 1985-1989 and 1990-1994. The earlier period provided survival data to assess the impact of age and stage. RESULTS: The overall disease-specific, 5-year survival rate for the 1985-1989 period was 84.9%. For stages I and II, it reached almost 90%. For both observed survival based on all deaths and disease-specific survival, the duration of survival decreased with increasing age. This decrease with age occurred for all stages of the disease. CONCLUSIONS: The data reflect the actual status of management of Hodgkin's disease in the United States rather than the best attainable results. The decreasing survival with increasing age and in all stages further supports the concept of a difference in biologic behavior of Hodgkin's disease associated with age.

Clinical highlights from the National Cancer Data Base, 1999.

The National Cancer Data Base (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, collects and analyzes data from a wide variety of sources throughout the United States, including small community hospitals. Due to this unique reporting system, individual facilities can compare their own data with the aggregate data from the NCDB, using their findings to evaluate local patient care practices. This article highlights the principal findings of the NCDB and Patient Care Evaluation articles published in 1998 on breast, prostate, cervical, endometrial, gallbladder, head and neck, nasopharyngeal, rectal, thyroid, and vaginal cancers, as well as on melanoma, brain tumors, and Hodgkin's disease. With more than five million cancer cases in the NCDB for the years between 1985 and 1995, sufficient numbers of even rare cancers have been accrued to permit some types of epidemiologic and clinical assessments.

Two hundred eighty-six cases of parathyroid carcinoma treated in the U.S. between 1985-1995: a National Cancer Data Base Report. The American College of Surgeons Commission on Cancer and the American Cancer Society.

BACKGROUND: In combination with other Commission on Cancer programs, the National Cancer Data Base (NCDB), a national electronic registry system currently capturing > 60% of incident cancers in the U. S., offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is proving to be of particular value in capturing clinical information concerning rare cancers. METHODS: For accession years 1985-1995, the NCDB captured prospectively collected demographic, stage, treatment, and outcome information for a national hospital-based sample of 286 parathyroid carcinoma cases (0.005% of the total NCDB cancer cases). This report describes clinical and demographic features as well as patterns of care and 5-year and 10-year relative survival rates. RESULTS: The NCDB's 10-year accrual of parathyroid carcinoma cases exceeded the cumulative number reported in the English literature though 1991. Gender distribution was equal. The authors were unable to detect any disproportionate clustering by race, income level, or geographic region. Treatment overwhelmingly was surgical. The data from the current study suggest that neither tumor size nor lymph node status are significant prognostic factors. Overall relative survival at 5 years and 10 years was 85.5% and 49.1%, respectively. CONCLUSIONS: At 5 years of follow-up, and possibly beyond, neither tumor size nor lymph node status were found to be significant prognostic factors and basing a staging system on them would be useless. Although complete, en bloc resection of all tumor represents the best opportunity for cure, a substantial proportion of patients fail to receive such treatment. The authors speculate that the rarity of this condition and late intraoperative recognition occasionally prevent optimal treatment. [See editorial on pages 378-80, this issue.]

Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985-1995, using the National Cancer Database.

BACKGROUND: The National Cancer Database is an electronic registry system sponsored jointly by the American College of Surgeons Commission on Cancer and the American Cancer Society. Patients diagnosed with pancreatic adenocarcinoma from 1985 to 1995 were analyzed for trends in stage of disease, treatment patterns, and outcomes. STUDY DESIGN: Seven annual requests for data were issued by the National Cancer Database from 1989 through 1995. Data on 100,313 patients were voluntarily submitted using a standardized reporting format. RESULTS: The anatomic site distribution was: head, 78%; body, 11%; and tail, 11%. The ratios of limited to advanced disease (Stage I/Stage IV) were 0.70 for tumors in the head, 0.24 for body tumors, and 0.10 for tail tumors. Of all patients, 83% did not have a surgical procedure and 58% did not have cancer-directed treatment. Resection was done for 9,044 (9%) patients, including 22% of those with Stage I disease. The overall 5-year survival rate was 23.4% for patients who had pancreatectomy, compared with 5.2% for those who had no cancer-directed treatment. CONCLUSIONS: Overall survival rates for pancreatic cancer have not changed in 2 decades. A small minority of patients presented with limited, resectable disease, but the best survival rates per stage were achieved after surgical resection. Five-year survival rates after resection reported herein corroborated the improved survival rates of more recent large, single institution studies.

The National Cancer Data Base report on Hodgkin's disease for 1985-1989 and 1990-1994.

BACKGROUND: A national survey of the management of Hodgkin's disease patients based on cases in the National Cancer Data Base (NCDB) provides a basis for evaluating the results of educational and therapeutic programs. These patients are believed to have been drawn from all nationalities, native and migrant, and were reported by hospital cancer registries throughout the United States, including large and small community hospitals, university and other teaching hospitals, military and Veterans Administration (VA) hospitals, and National Cancer Institute (NCI)-Designated Centers. METHODS: Data submitted voluntarily to the NCDB were used to determine trends in patterns of patient care across time. For the period 1985-1994, data from 35,033 patients with newly diagnosed Hodgkin's disease were analyzed and separated into two time periods, 1985-1989 and 1990-1994. RESULTS: Data were analyzed with respect to age, race, histology, stage, treatment, and survival. The majority of patients (83.6%) were white, the age group with the highest incidence was 20-29 years, and nodular sclerosis was the most common histologic type. Staging was reported as a combination of clinical and pathologic stage ("combined stage"). The number of cases of reported stage increased from 51.7% for the years 1985-1989 to 75.7% for the years 1990-1994. Radiation therapy was used primarily to treat patients in Stages I and II, although the overall use of radiotherapy declined by 10% in the later period. The overall observed 5-year survival rate was 83.2%, and the disease specific observed survival rate was 84.9%. Stage for stage, survival was better for younger patients and poorer for older patients. CONCLUSIONS: The survey reflects the actual management of Hodgkin's patients disease. The reported cases for 1994 represent 60.6% of the estimated occurrences for that year in the U.S. There has been a significant improvement in the frequency of use of the staging system. A continuing increase in survival for patients with Hodgkin's disease is occurring. This method of studying disease management provides a measure of educational efforts and guides to developmental research.

Clinical highlights from the National Cancer Data Base, 1998.

The National Cancer Data Base is a community-oriented cancer management and outcomes database that is the joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. This article provides a first look at highlights from the 1998 summary.

Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix.

PURPOSE: The Commission on Cancer of the American College of Surgeons conducts Patient Care Evaluation studies to describe practice patterns and trends in disease management. This report surveys changing strategies in the initial treatment of patients with invasive cancer of the uterine cervix. METHODS AND MATERIALS: Using a standard data collection form designed by a multidisciplinary committee of specialists, cancer registrars at 703 hospitals submitted anonymous data on 11,721 total cervical cancer patients diagnosed in 1984 and 1990. RESULTS: Between the two study years, the use of radiation as all, or a component, of the initial course of therapy declined from 70 to 60.3%, coincident with a 32.3% increase in the use of hysterectomy alone and a 33.7% reduction in the use of radiation alone. The percentage of all patients receiving combined hysterectomy and radiation (preoperative or postoperative) remained virtually unchanged--10.2% in 1984, and 9.3% in 1990. However, women who were treated by hysterectomy in 1990 were less likely to receive radiation as part of their treatment than patients treated by hysterectomy in 1984. Among patients treated by radiation without hysterectomy, the use of intracavitary brachytherapy techniques substantially exceeded interstitial brachytherapy techniques in both study years. Among patients treated by local radiation without hysterectomy, the frequency of adjunctive chemotherapy use increased from 6.9% in 1984 to 24.8% in 1990, with chemotherapy and radiation increasingly administered concurrently rather than sequentially. Although differences based on age, histology, race/ethnicity, and insurance status were observed, these general management trends were seen in all groups. CONCLUSIONS: Changes in the utilization of radiation and surgery may reflect the increasing surgical involvement of gynecologic oncologists in the management of early stage cervical cancer, rather than significant alterations in the demographics of the disease. Although brachytherapy is recognized as an important component of radiation treatment, some patients may not receive the potential benefit of this modality. Despite controversy concerning its efficacy, the use of adjuvant systemic chemotherapy to supplement local treatment modalities appears to be increasing rapidly.

A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see commetns].

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now capturing nearly 60% of incident cancers in the U. S. In combination with other Commission on Cancer programs, the NCDB offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is of particular value in capturing clinical information concerning rare cancers, such as those of the thyroid. METHODS: For the accession years 1985-1995, NCDB captured demographic, patterns-of-care, stage, treatment, and outcome information for a convenience sample of 53,856 thyroid carcinoma cases (1% of total NCDB cases). This article focuses on overall 10-year relative survival and American Joint Committee on Cancer (AJCC) (3rd/4th edition) stage-stratified 5-year relative survival for each histologic type of thyroid carcinoma. Care patterns also are discussed. RESULTS: The 10-year overall relative survival rates for U. S. patients with papillary, follicular, Hürthle cell, medullary, and undifferentiated/anaplastic carcinoma was 93%, 85%, 76%, 75%, and 14%, respectively. For papillary and follicular neoplasms, current AJCC staging failed to discriminate between patients with Stage I and II disease at 5 years. Total thyroidectomy +/- lymph node sampling/dissection represented the dominant method of surgical treatment rendered to patients with papillary and follicular neoplasms. Approximately 38% of such patients receive adjuvant iodine-131 ablation/therapy. At 5 years, variation in surgical treatment (i.e., lobectomy vs. more extensive surgery) failed to translate into compelling differences in survival for any subgroup with papillary or follicular carcinoma, but longer follow-up is required to evaluate this. NCDB data appeared to validate the AMES prognostic system, as applied to papillary cases. Younger age appeared to influence prognosis favorably for all thyroid neoplasms, including medullary and undifferentiated/anaplastic carcinoma. NCDB data also revealed that unusual patients diagnosed with undifferentiated/anaplastic carcinoma before age of 45 years have better survival. CONCLUSIONS: The NCDB system permits analysis of care patterns and survival for large numbers of contemporaneous U. S. patients with relatively rare neoplasms, such as thyroid carcinoma. In this context, it represents an unsurpassed clinical tool for analyzing care, evaluating prognostic models, generating new hypotheses, and overcoming the volume-related drawbacks inherent in the study of such neoplasms. [See editorial on pages 2434-6, this issue.]

Patterns of care for metastatic carcinoma of the prostate gland: results of the American College of Surgeons' patient care evaluation study.

The annual incidence of prostate cancer more than doubled between 1984 and 1990, increasing from an estimated 76 000-200 000 cases respectively. Part of this increase may have been the result of increased detection. This study utilizes data from an American College of Surgeons Patient Care Evaluation (PCE) study to report on changes in the management of metastatic disease. Approximately 2000 hospitals were invited to submit data on a standard collection form designed by a multidisciplinary committee of specialists. Data were received from 730 hospitals on 14 716 patients with newly diagnosed cancer of the prostate in 1984, and from 1035 hospitals for 23 214 patients in 1990. Between 1984 and 1990 there was a decrease in the percentage of reported patients diagnosed with Stage IV disease, falling from 25.3-21.2%. The number of patients receiving a prostate specific antigen (PSA) test increased from 6.3-74.8% and the proportion of abnormal PSA results increased from 82-92.7%. The proportion of patients diagnosed by transurethral resection of the prostate (TURP) and perineal biopsy decreased, while an increase was noted in the proportion of men diagnosed by transrectal biopsy and transrectal ultrasound (TRUS). Treatment by orchiectomy alone increased from 31.8-40.7% of patients, while the administration of exogenous hormone therapy alone declined from 22.3-14.9% of patients. Two and five-year survival rates for the most common forms of therapy were 56.7% and 22.5% respectively for orchiectomy, 57% and 24.6% respectively for exogenous hormone therapy, and 50.3% and 23.5% respectively for no cancer directed therapy. Following a second course of therapy, the two-year survival rate for patients receiving a subsequent orchiectomy was 36.7 vs 17.8% for those receiving secondary exogenous hormone therapy. The percentage of patients diagnosed with Stage IV disease has decreased while prostate cancer diagnoses are being made more frequently utilizing the PSA test and TRUS biopsies. Hormone treatment remains the most common form of therapy with either orchiectomy or exogenous hormone therapy having higher survival rates than other common treatment modalities.

The National Cancer Data Base report on patterns of childhood cancers in the United States.

BACKGROUND: Patterns of and progress against childhood cancer have been reported on multi-institution, regional, national, and international bases by several sources in the past. These sources have included clinical cooperative group trials and population-based registries. In general, the population-based surveys have excluded brain tumors of either benign or uncertain behavior. The authors of this article investigated the patterns of data reported for the period 1985-1993, motivated by their interest in assessing the potential of National Cancer Data Base (NCDB) data to 1) facilitate individual institution review and 2) cover institutions that are not members of the Pediatric Oncology Group or the Children's Cancer Group, which are both national clinical cooperative groups. METHODS: Six annual calls for data, starting with a call for 1985 and 1988 cases, were issued to approximately 2100 hospitals with cancer programs (1340 programs approved by the Commission on Cancer of the American College of Surgeons and 760 other programs). The baseline data items of the NCDB included patient demography, tumor characteristics, initial treatment, and follow-up. The data for each patient were coded in the traditional manner by trained cancer registrars before being transmitted to the NCDB in standard format. RESULTS: In the most recent year for which data were reported, the NCDB included 42% of all estimated U.S. childhood cancers. The cases were reported by institutions that were members of the Pediatric Oncology Group and the Children's Cancer Group as well as nonmember institutions. The distribution of diagnostic groups reported to the NCDB was generally similar to that reported to SEER, except for lymphomas and brain cancer (the NCDB series included benign as well as malignant brain tumors). The distribution of diagnostic groups reported to the NCDB did not change over the 9-year reporting period (1985-1993). With regard to ethnicity, the most varied distribution of diagnostic groups was found among African American patients. For many types of cancer, the survival of those patients reported to the NCDB was similar to that of patients included in the SEER population-based series. These cancers included Wilms' tumor (NCDB 89% vs. SEER 88%), non-Hodgkin's lymphoma (NCDB 74% vs. SEER 70%), soft tissue sarcomas (NCDB rhabdomyosarcomas 70% and sarcomas 79% vs. SEER soft tissue sarcomas 71%), and neuroblastoma (NCDB 58% vs. SEER 57%). CONCLUSIONS: The authors concluded that the number of brain tumors of benign and uncertain behavior being diagnosed were significant enough in number that they should be included in regional and national cancer registries that report data for clinical purposes. They further concluded that for reasons of data inclusion and institutional coverage, the NCDB will be an important data base for pediatric cancers that will warrant increased use by pediatric investigators.

Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on longterm survival.

BACKGROUND: Splenectomy, and in some cases pancreatico splenectomy, has been advocated by surgeons in an effort to improve clearance of metastatic nodes to splenic hilum (node 10) and splenic artery (node 11). Although splenectomy has known effects on increasing morbidity and even mortality after a variety of surgical maneuvers including gastrectomy, the longterm effect on survival is controversial. The purpose of this study is to review and analyze the effect of splenectomy on survival in patients having curative gastrectomy for stomach cancer. METHODS: We reviewed the role of splenectomy in patients having curative gastrectomy in a data base of stomach cancer patients that had been collected in 1987 as part of an American College of Surgeons Patterns of Care Study. This analysis had involved 18,344 patients, of whom 11,252 were first diagnosed in 1982 as part of a longterm study, and 7,092 were first diagnosed in 1987 as part of a shortterm study. From the two data collection periods information was available on 12,439 patients who received cancer directed abdominal surgery; 21.2% of these patients received a splenectomy. Among the 3,477 patients reported as having a curative gastrectomy (pathologically clear margins), 26.2% received a splenectomy. RESULTS: The operative mortality was 9.8% with splenectomy and 8.6% without splenectomy. In patients having a curative gastrectomy, the 5-year observed survival rate was 20.9% in patients having splenectomy versus 31% in patients who did not receive splenectomy (p < 0.0001). Examination of differences in survival by stage of diagnosis showed significantly reduced survival outcomes among patients with stage II and III, but not for those diagnosed with stage I or IV disease. The pattern of recurrence was moderately different with a larger proportion of patients having distant metastases among the group of patients who had undergone splenectomy compared with the patients who had not, 29% and 15.5%, respectively. Whether these differences are inherent in the splenectomy or in the associated cofactors was not determined in this study. CONCLUSIONS: The data suggest elective splenectomy should generally be avoided in patients with stage II and III gastric cancer. In patients with resectable proximal advanced (stage IV) cancer or who have extension to spleen and pancreas or macroscopic nodal metastases to splenic hilum, splenectomy might be necessary to facilitate complete removal of the tumor in an effort to achieve longterm tumor control. The importance of surgical judgment is emphasized as the major deciding factor in determining the need for splenectomy in the individual cancer patient.

Hypopharyngeal cancer patient care evaluation.

A survey was conducted to identify demographics and standards of care for treatment of hypopharyngeal squamous cell carcinoma in the United States. Data were accrued from voluntary submission of cancer registry and medical chart information from 769 hospitals representing 2939 cases diagnosed from 1980 to 1985 and 1990 to 1992. Clinical findings, diagnostic procedures employed, treatment practices, and outcome are presented. Overall, 5-year disease-specific survival was 33.4%, which segregated to 63.1% (stage I), 57.5% (stage II), 41.8% (stage III), and 22% (stage IV). Survival was best for patients treated with surgery only (50.4%), similar with combined surgery and irradiation (48%), and worse with irradiation only (25.8%). This analysis provides a standard to which current treatment practice and future clinical trials may be compared.

Patterns of care for cancer of the larynx in the United States.

OBJECTIVE: To assess case-mix characteristics, treatment patterns, and outcomes for laryngeal cancer using the largest series of patients to date. DESIGN: Analyses performed on retrospectively collected survey data submitted by hospitals for diagnostic periods 1980 through 1985 and 1990 through 1992 (with a 9-year follow-up for the long-term group). SETTING: Broad spectrum of US hospitals (N = 769). PATIENTS: Consecutively accrued series of patients with laryngeal cancer (N = 16,936), with only squamous cell carcinomas (N = 16,213) analyzed. INTERVENTIONS: Surgery, radiation therapy, and chemotherapy. MAIN OUTCOME MEASURES: Descriptive analyses of case-mix, diagnostic, and treatment characteristics plus recurrence and 5-year, disease-specific survival outcomes. RESULTS: There was a slight increase across these years in stage IV disease and in radiation therapy (with or without surgery and/or chemotherapy). Overall diversity of management of this disease (by site and stage) was apparent. Five-year survival rates indicated a large difference between modified groupings of the T and N classifications, separating stages III and IV cases into localized disease (87.5% for T1-T2; 76.0% for T3-T4 cases) and regional metastasis (46.2%). CONCLUSIONS: Regardless of improvements in entering data in hospital records (most commendably, staging), more rigorous standards are needed. Also, the small increase in advanced-stage patients indicates that efforts toward early detection have not been successful. The rise in radiation therapy perhaps reflected an increased use of nonsurgical treatment for early-stage patients and organ-sparing radiochemotherapy protocols for advanced-stage patients. Regrouping stages III and IV cases into localized disease vs regional metastasis appears to predict survival better. Ongoing refinements of the American Joint Committee on Cancer staging scheme will hopefully improve this cancer's classification.

Clinical highlights from the National Cancer Data Base: 1997.

The following highlights summarize the principle findings of the NCDB, which are presented in more detail in other reports, some of which have been published and others of which are in press or submitted awaiting review. Collectively, these findings present a broad pattern of NCDB assessment of cancer patterns of care. In addition to the resulting journal publications, 1,600 NCDB participating hospitals receive a customized summary of similar patterns of care and outcome at their facility compared with national norms, which is then used for quality assurance purposes.