The influence of urbanization, age, ethnicity, and income on the early diagnosis of breast carcinoma: opportunity for screening improvement.

BACKGROUND: Because most risk factors for breast carcinoma are not readily amenable to primary prevention, and early diagnosis is a powerful prognostic determinant, screening for the disease is crucial. Consequently, assessment of the progress and comprehensiveness of screening and other breast carcinoma early detection activities is important. The relative frequency of early diagnosis may provide a useful indicator of such activities. Nationwide, time trends in the early diagnosis of breast carcinoma have been improving for decades, but not all population subgroups may have benefited equally. METHODS: Using 1994-1997 data from the California Cancer Registry (CCR), a review of diagnostic patterns of in situ and local stage breast carcinoma was undertaken. For analytic purposes, the CCR includes 10 regional registries and 36 county reporting groups. Three early diagnostic measures were designated, including in situ breast carcinoma with tumor size < 10 mm in greatest dimension, in situ breast carcinoma, and localized breast carcinoma with tumor size < 21 mm in greatest dimension. These are referred to hereinafter as early diagnosis breast carcinomas. RESULTS: The percentage of early diagnosis breast carcinomas differed markedly by age, ethnicity, diagnosis year, and county of residence. Lower percentages of early diagnosis breast carcinomas were diagnosed in older women age >/= 85 years. Hispanic women were diagnosed with lower levels of in situ breast carcinoma. Hispanic and black women were diagnosed with less localized breast tumors of small size. There was an increase in the percentage of early diagnosis breast carcinomas over the 4-year observation period. Lower percentages of early diagnosis breast carcinomas were reported for the nonurban county/county groups, which were characterized by greater distances, lower population density, and lower household incomes. CONCLUSIONS: The authors conclude that elderly women, Hispanic and black women, and women who reside in nonurban areas should be targeted as high-priority subpopulations for mammographic screening.

National survey of head and neck verrucous carcinoma: patterns of presentation, care, and outcome.

BACKGROUND: Verrucous carcinoma is distinguished by controversy regarding appropriate diagnosis and treatment. This study provides a contemporary survey of demographics, patterns of care, and outcome for this disease in the United States. METHODS: The National Cancer Data Base had 2350 cases of verrucous carcinoma of the head and neck diagnosed between 1985 and 1996. Statistical procedures included chi-square analyses, Student t tests, and relative survival. RESULTS: Tumors originated most frequently in the oral cavity (55.9%) and larynx (35.2%). Although most patients were male (60.0%), oral cavity tumors were more common among older females. The most prevalent treatment was surgery alone (69.7%), followed by surgery combined with irradiation (11.0%) and irradiation alone (10.3%). For oral cavity tumors, surgery alone was more common among early (85.8%) than advanced cases (56.9%); a larger proportion of advanced disease received radiation alone or surgery and irradiation combined. Most laryngeal tumors were treated with surgery (60.3% for early and 55.6% for advanced disease), but a higher proportion received radiation alone or surgery combined with radiation compared with oral cavity cases. Five-year relative survival was 77.9%. For localized disease, survival after surgery was 88.9% compared with 57.6% after irradiation. CONCLUSIONS: Demographic differences implicate different mechanisms of carcinogenesis for verrucous carcinoma arising in the oral cavity and the larynx. Although selection bias may account for the differences observed, patients receiving initial treatment with surgery had better survival than those treated with irradiation, especially for cases originating in the oral cavity.

Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study.

BACKGROUND: Advances in surgical techniques and changes in our understanding of the biology of breast cancer have made immediate or early breast reconstruction a viable option for the majority of women with breast cancer. Little is known about national patterns of use of reconstruction. This study was undertaken to determine national patterns of care and factors that influence the use of breast reconstruction. STUDY DESIGN: A large convenience sample reported to the National Cancer Data Base was studied. Patients coded as undergoing mastectomy between 1985 and 1990 (n = 155,463) and between 1994 and 1995 (n = 68,348) were evaluated. The use of reconstruction in the two time periods was compared, and patient and tumor factors influencing the use of the procedure were compared. RESULTS: Between 1985 and 1990, 3.4% of mastectomy patients had early or immediate reconstruction, increasing to 8.3% in 1994-5. Patient age, income, geographic location, type of hospital where treatment occurred, and tumor stage all influenced the use of reconstruction in univariate analysis. In multivariate analysis, patients age 50 or under had a 4.3-fold greater likelihood of having reconstruction than their older counterparts. Patients with ductal carcinoma in situ were twice as likely as those with invasive cancer to have reconstruction. Family income of $40,000 or more (Odds Ratio 2.0), ethnicity other than African-American (Odds Ratio 1.6), surgery in a National Cancer Institute-designated cancer center (Odds Ratio 1.4), and surgery in a geographic region other than the Midwest or South (Odds Ratio 1.3) remained significant predictors of the use of reconstruction in multivariate analysis. CONCLUSIONS: Breast reconstruction is an underused option in breast cancer management. Predictors of the use of reconstruction do not reflect contraindications to the procedure, and indicate the need for both physician and patient education.

National cancer database report on chondrosarcoma of the head and neck.

BACKGROUND: Management of chondrosarcoma of the head and neck is largely based on single-institution reports with small numbers accrued over several decades. METHODS: The American College of Surgeons' National Cancer Data Base included 400 cases of chondrosarcoma of the head and neck diagnosed between 1985 and 1995. Chi square analyses of selected contingency tables and Wilcoxon regression analyses of selected survival stratifications were performed. RESULTS: Histologic types included conventional (80.8%), myxoid (10.5%), and mesenchymal (8.8%). The mesenchymal and myxoid subtypes were rare among white patients (17.1%) and more common among African-American (31.8%) and Hispanic patients (44.9%). Treatment was most commonly surgery alone (59.5%) and surgery with irradiation (21.0%). Disease-specific survival was 87.2% at 5 years and 70.6% at 10 years. Worse 5-year survival was associated with higher grade (67.3%), regional or distant spread (71.0%), and the myxoid (45.0%) or mesenchymal (53.2%) subtypes. CONCLUSIONS: Chondrosarcoma of the head and neck encompasses a variety of lesions that differ substantially by demographic and tumor characteristics. Individual tumors can be classified further according to site of origin, histologic subtype, and tumor grade, which can be used to predict biologic behavior and prognosis.

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.

The National Cancer Data Base Report on treatment patterns for hepatocellular carcinomas: improved survival of surgically resected patients, 1985-1996.

BACKGROUND: The Commission on Cancer data from the National Cancer Data Base (NCDB) has previously reported data evaluating time trends in various cancers, including such elements as stage of disease at diagnosis, treatment, and survival for multiple tumor sites. In this report, data collected from 1985, 1986, 1990, 1991, 1995, and 1996 for primary hepatocellular carcinoma (HCC) tumors are presented. METHODS: The data presented in this review were collected from hospital cancer registries from across the U.S. Eight calls for data have yielded a total 6.9 million cases for the years 1985-1996, including 1158 HCC cases in 1985-1986, 3319 cases in 1990-1991, and 5683 cases in 1994-1995 from hospital cancer registries across the U. S. These data represent approximately 4.3%, 11.2%, and 14.8% of the estimated cases of carcinomas of the liver and biliary tract diagnosed in the U.S. in each of the three respective time periods. RESULTS: The outcome for patients diagnosed with HCC remains poor, with only 10% of patients with American Joint Committee on Cancer Stage I disease surviving 5 years. Approximately 50% of patients received no therapy for their HCC, even those with early stage disease. Over these three time periods, the use of chemotherapy appears to have decreased. Among patients diagnosed with Stage II and III disease a difference in survival was noted between those treated with surgery only and those treated with chemotherapy only. Women appear to have a limited survival advantage over men. CONCLUSIONS: In spite of an overall poor prognosis, subsets of patients with HCC appear to benefit from surgical resection/ablation of their tumor. The decreasing use of chemotherapy and the early reports of newer ablative techniques (e.g., cryotherapy) suggest that other treatment modalities are emerging. These NCDB data provide a baseline for HCC treatment from which prospective studies are being developed to assess the newer treatments as well as the underlying causes.

The National Cancer Data Base Report on poor survival of U.S. gastric carcinoma patients treated with gastrectomy: Fifth Edition American Joint Committee on Cancer staging, proximal disease, and the "different disease" hypothesis.

BACKGROUND: A high proportion of U.S. patients with gastric carcinoma do not receive surgical treatment. To sharpen staging criteria and facilitate comparisons with surgical series, an analysis of patients whose treatment included gastrectomy was undertaken. In addition, to evaluate the "different disease" hypothesis as an explanation for superior Japanese results, outcomes for Japanese Americans were examined. METHODS: Data were obtained from National Cancer Data Base (NCDB) reports of 50,169 gastric carcinoma cases diagnosed during the years 1985-1996 and treated with gastrectomy. In addition to demographic and treatment information, 5-year and 10-year relative survival rates are presented, with stage defined according to fifth edition American Joint Committee on Cancer (AJCC) staging procedures. RESULTS: Stage-stratified 5-year and 10-year relative survival rates were as follows: Stage IA, 78%/65%; Stage IB, 58%/42%; Stage II, 34%/26%; Stage IIIA, 20%/14%; Stage IIIB, 8%/3%; and Stage IV, 7%/5%. Stage-stratified survival for Japanese Americans was higher. Males had a poorer prognosis than females, and the male-to-female ratio for Japanese Americans was lower. Proximal tumors were associated with a worse prognosis than distal tumors; the proportion of Japanese Americans with proximal disease was less than in the overall patient group. Japanese Americans underwent resection of adjacent organs less frequently. In this series, adjuvant therapy did not substantially affect survival. Overall, 20% were 10-year survivors; of these, 67% were lymph node negative and 98% had /= 15 lymph nodes analyzed. Stage migration was evident in cases with

National Cancer Data Base survey of breast cancer management for patients from low income zip codes.

BACKGROUND: The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcomes data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995-1996) breast cancer data on patients from low income zip codes are described here. METHODS: Since 1989, eight Calls for Data have been issued, yielding a total of 191,714 reports of non-Hispanic white patients with breast cancer for the years analyzed, 1995-1996. A total of 1961 hospital cancer registries have participated in at least one of the Calls for Data. RESULTS: A diverse range of breast cancer cases was reported from a variety of geographic locations and medical care environments. There were general similarities in the treatment of patients from the different income groups; however, some differences were reported. Among patients from lower income zip codes, 60.7% were age 60 years or older, compared with 55.1% from other income zip code groups. The AJCC stage distribution was reported as less favorable for patients from low income zip codes than for other patients. The percentage of patients from low income zip codes diagnosed as Stage 0 or I was 51.2%, compared with 55.9% of patients from the other income zip codes. Of patients from lower income zip codes, 12.1% were reported to have Stage III or IV disease, compared with 10.0% of patients from other income zip codes. Patients from low income zip codes received less tissue-sparing surgery. Of patients from low income zip codes, 14.9% received partial mastectomy with or without radiation or systemic therapy, compared with 18.3% of patients from other income zip codes. The percentage of patients from low income zip codes who received a partial mastectomy with axillary lymph node dissection was 23.3% for patients from other income zip codes, the percentage was 30.5%. Conversely, 49.8% of patients from lower income zip codes received a modified radical mastectomy, compared with 40.5% of patients from other income zip codes. CONCLUSIONS: Further improvements in the early diagnosis and surgical treatment of low income patients can probably be achieved. Programmatic activities that further explain or reduce the apparent nonpreferred treatment of some low income patients should be encouraged.

The American College of Surgeons Commission on Cancer and the American Cancer Society. The National Cancer Data Base report on age, gender, treatment, and outcomes of patients with chronic lymphocytic leukemia.

BACKGROUND: The natural history of chronic lymphocytic leukemia (CLL) is changing, although the reasons (potential changes in the disease's biology or in patterns in patient characteristics, treatment, or referral) are unclear. METHODS: This report uses National Cancer Data Base (NCDB) data, which reflect a hospital-based patient population from a broad spectrum of hospitals in the United States. Age, gender, race/ethnicity, income, treatment, overall survival, and relative survival were evaluated according to time period (1985-1990 and 1991-1995). Comparisons were made with U. S. population figures for 1990 and with series published over the last 70 years. RESULTS: CLL comprised 22.6% of the 108,396 cases of leukemia in the data base. The risk of developing CLL increased progressively with age and did not plateau; the average age was 69.6 years. At the time of initial diagnosis, 60.5% of patients received no treatment (this proportion increased from 58.1% to 62.7% between the 2 time periods). Overall survival was 48.2% at 5 years and 22.5% at 10 years. The 5-year relative survival was 69.5%, 72.2%, 63.1%, and 41.7% for age groups <40, 40-59, 60-79, and 80+ years, respectively; these rates indicated that CLL, and not comorbid disease, caused the greatest percentage of deaths. CONCLUSIONS: The risk of developing CLL increases progressively with age without plateauing and is 2.8 times higher for older men than for older women. There is an increasing trend toward no treatment at the time of initial diagnosis. Long term overall survival of CLL patients is poor. CLL is a more fatal disease among older individuals because of the disease itself, not because of comorbid conditions.

The American College of Surgeons Commission on Cancer and the American Cancer Society. Adenocarcinoma of the small bowel: review of the National Cancer Data Base, 1985-1995.

BACKGROUND: Small bowel adenocarcinoma (SBA) accounts for 2% of gastrointestinal (GI) tumors and 1% of GI cancer deaths. The objective of this study was to review the National Cancer Data Base (NCDB) to identify case-mix characteristics, patterns of treatment, and factors influencing survival of patients with SBA. METHODS: NCDB data from patients diagnosed with primary SBA between 1985-1995 were analyzed. Chi-square statistics were used to compare differences between groups. Disease specific survival (DSS) was calculated using the life table method for patients diagnosed between 1985-1990; univariate differences in survival were compared using the Wilcoxon statistic, and multivariate analyses were performed using a Cox regression model. RESULTS: There were 4995 SBA cases reported to the NCDB between 1985-1995, 55% of which occurred in the duodenum, 18% in the jejunum, 13% in the ileum, and 14% in nonspecified sites. The overall 5-year DSS was 30.5%, with a median survival of 19.7 months. By multivariate analysis, factors significantly correlated with DSS included patient age, tumor site, disease stage, and whether cancer-directed surgery was performed. CONCLUSIONS: SBA is found most commonly in the duodenum, and patient DSS is reduced at this site compared with those patients with jejunal or ileal tumors. This reduction in survival was associated with a lower percentage of cancer-directed surgery. Patients age > 75 years had a reduced DSS and more duodenal tumors, and were less frequently treated by cancer-directed surgery than their younger counterparts. This study reflects the experience with SBA from a large cross-section of U.S. hospitals, allowing for the identification of prognostic factors and providing a reference with which results from single institutions may be compared.

Ten-year survey of lung cancer treatment and survival in hospitals in the United States: a national cancer data base report.

BACKGROUND: Primary lung cancer accounts for approximately 14% of all new cancers and 28% of cancer deaths in the U.S. Previous reviews have shown limited progress in the management or outcome of this devastating disease. METHODS: Reports described in the current study were 713,043 primary lung malignancies diagnosed between 1985 and 1995 and submitted to the National Cancer Data Base. Demographic, tumor, and treatment patterns for 1995 were compared with those for 1985-1987, 1988-1991, and 1992-1994. Ten-year relative survival rates were presented for selected demographic and histologic groups and 5-year relative survival rates were presented by stage and dominant treatment modalities for major carcinoma histologies. RESULTS: Previously observed demographic trends were evident, with increasing proportions of patients being older, female, and African American, and more cases reported to be adenocarcinomas. There was a substantial shift toward more complete staging but no change in the distribution of staged cases. Compared with earlier patients, fewer 1995 patients received cancer-directed treatment. More surgical patients underwent lymph node dissection, and radiation treatment was supplemented more often with chemotherapy. The overall 10-year relative survival rate was 7%. The 5-year survival for American Joint Committee on Cancer Stage I surgical patients was >50% for all nonsmall cell histologic groups. CONCLUSIONS: Recent shifts in treatment, although minimal, are consistent with current literature concerning the effectiveness of lung carcinoma treatment. The authors believe that the overall poor survival of lung carcinoma patients points to a continuing need for improved prevention and treatment measures. The comparatively superior survival of Stage I nonsmall cell lung carcinoma surgical patients indicates that a substantial number of patients have the potential to be treated successfully.

The National Cancer Data base Report on increased use of brachytherapy for the treatment of patients with prostate carcinoma in the U.S.

BACKGROUND: An increase in the proportion of prostate carcinomas diagnosed at early, potentially curable stages has led to several changes in treatment of patients with this disease. Greater use of radical prostatectomy and external beam radiation has been documented, and recent data suggest that the use of radiation implant (brachytherapy) also has increased. Recent results from the National Cancer Data Base (NCDB) are available to explore this trend in greater detail. METHODS: Data provided by 1758 hospital cancer registries for 435,264 patients diagnosed between 1992 and 1996 were studied. Reported use of brachytherapy was analyzed by year of diagnosis, region, patient age at diagnosis, and tumor grade. RESULTS: The proportion of all prostate carcinoma patients treated with brachytherapy increased from 1.4% in 1992 to 3.0% in 1995. Ninety-six percent of brachytherapy patients were American Joint Committee on Cancer Stage I or II (with tumors classified as T1 or T2). As a proportion of patients in a stage group, the use of brachytherapy was greatest in Stage I; 3.7% of patients in this stage were treated by this modality. The increase in brachytherapy also was greatest among Stage I patients, rising from 2.0% in 1992 to 5.8% in 1996. Rates of use were greatest in the northeastern and southeastern U.S. and least frequently reported by institutions in the Midwest and the South. Brachytherapy was used across a wide range of patient age groups. Analysis by grade showed that 89.8% of patients treated with brachytherapy had well-differentiated or moderately differentiated tumors. CONCLUSIONS: Brachytherapy represented a small component of the overall pattern of care for prostate carcinoma patients in the U.S. during the interval studied. However, the rate of use of this modality for patients with localized prostate carcinoma increased substantially over the 5-year interval. This may reflect a trend toward more conservative management of prostate carcinoma. Additional monitoring and analysis of the more recent use of brachytherapy for the treatment of prostate carcinoma patients is warranted.

The National Cancer Data Base report on patterns of care for testicular carcinoma, 1985-1996.

BACKGROUND: Previous Commission on Cancer data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. In the current study data relating to patients diagnosed with testicular carcinoma in 1985, 1986, 1990, 1991, 1995, and 1996 are described. METHODS: The data reported in this review were collected from hospital cancer registries from across the U.S. Case information is submitted to the NCDB following guidelines established by the North American Association of Central Registries. Data items include patient demographics, tumor characteristics, initial course of therapy, and follow-up status. Eight calls for data have yielded a total of 6.9 million cases for the years 1985-1996, including 2280 testicular carcinoma cases in 1985-1986, 5677 cases in 1990-1991, and 7452 cases in 1995-1996. These data represent approximately 22.6%, 47.3%, and 51.4%, respectively, of the estimated cases of testicular carcinoma diagnosed in the U.S. in each of these 3 respective time periods. Cases diagnosed and reported to the NCDB between 1985-1991 and that had been staged according to the 4th edition of the American Joint Committee on Cancer (AJCC) manual for the staging of cancer (1567) were used in the analysis of survival outcomes. RESULTS: Four principle findings are reported. First, young men (age < 25 years) are diagnosed with advanced stage nonseminomatous germ cell tumors more frequently than are older men (age >/= 30 years). Second, although surgery and concomitant radiation are the standard therapy for early stage seminomas, surgery alone increasingly is being used. In the treatment of patients with advanced stage seminomas the use of surgery and radiation has declined slightly whereas surgery with concomitant chemotherapy appears to be employed with greater frequency. Third, surgery alone is the treatment of choice for patients with early stage nonseminomatous germ cell tumors and has been employed with increasing frequency over the three time periods studied. The use of surgery and concomitant chemotherapy has remained relatively stable over time in the treatment of patients with advanced stage nonseminomas. And fourth, survival rates decrease with increasing AJCC stage of disease. CONCLUSIONS: The NCDB data regarding testicular carcinoma highlight a number of important trends in the presentation and management of testicular tumors. These trends not only evaluate new protocols of treatment but also can be used to direct new strategies toward achieving earlier patient presentation.

An analysis of male and female breast cancer treatment and survival among demographically identical pairs of patients.

BACKGROUND: Male breast cancer is rare, and there are no large comparative studies to guide treatment. We used National Cancer Data Base data on 4755 men and 624,174 women who had breast cancer (1985-1994) to identify equivalent groups of male and female breast cancer patients. METHODS: For each man with breast cancer, the next woman treated at the same hospital was sought who matched the man's age (within 5 years), ethnicity, income category, and stage. We identified 3627 closely matched pairs of male and female patients with breast cancer. RESULTS: Men were more likely to be treated with mastectomy (modified radical, 65% of men versus 55.1% of women; radical, 2.5% of men versus 0.9% of women; simple, 7.6% of men versus 3.4% of women; P <.001), and more likely to receive radiation therapy after mastectomy (men, 29%; women, 11%; P <.001). Men treated with lumpectomy were less likely to receive radiation therapy (men, 54%; women, 68%; P <. 001). Men were also less likely to receive chemotherapy (26.7% of men versus 40.6% of women; P <. 001) after any surgical treatment. CONCLUSIONS: This large comparative study is the first to detail stage-specific differences in contemporary treatment strategies for highly comparable groups of men and women treated for breast cancer. Further studies of male breast cancer should focus on identifying prognostic factors and defining optimal therapy.

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.

A survey of hospital management practices for vulvar melanoma.

BACKGROUND: Vulvar melanoma is a very rare form of cancer. The purpose of this study was to describe practice patterns for the management of vulvar melanoma. STUDY DESIGN: The National Cancer Data Base was reviewed from 1985 through 1994 for patient reports submitted with a diagnosis of vulvar melanoma. RESULTS: Five hundred sixty-nine patients with vulvar melanoma were identified. A substantial number of patients were older; during the latter period of this study (1990 to 1994), 50% were 70 years old or older. Surgery was used in more than 90% of patients with stages 0 to III. Local excision was used mainly in early-stage (0 and I) disease. Adjuvant therapy was used infrequently. Lymph node evaluation was performed in more than half of the patients, with greater frequency for patients who had advanced disease. The overall 5-year relative survival rate was 62%. If the lymph nodes contained metastases, survival was poor. Patients with recurrent disease also had poor survival. CONCLUSIONS: Surgery remains the mainstay of therapy for vulvar melanoma. The use of excision and radical operations remained constant during the 10 years of the study.

National Cancer Data Base report on cancer of the head and neck: acinic cell carcinoma.

BACKGROUND: Management of acinic cell carcinoma is based on reports of small numbers of cases accrued over several decades. METHODS: The National Cancer Data Base (NCDB) identified 1353 cases of acinic cell carcinoma of the head and neck for the years 1985 to 1995. Chi square analyses of selected contingency tables and Wilcoxon regression analyses of selected survival stratifications are presented. RESULTS: Five-year survival was 83.3% (observed) and 91.4% (disease specific). Worse survival was associated with high grade (p < .0001), age greater or equal to 30 years (p = .0055), and the presence of metastatic disease (p < .0001). CONCLUSIONS: An aggressive subset of acinic cell carcinoma which is characterized by high grade and advanced stage rarely occurs in patients younger than 30 years old. Although better outcome was not statistically demonstrated for combined therapy, surgery with irradiation is the most common management in the United States for cases with regional metastases, high grade, and microscopic positive margins.