Breast Neoplasms: Hölzel D

Albert US, Altland H, Duda V, Engel J, Geraedts M, Heywang-Köbrunner S, Hölzel D, Kalbheim E, Koller M, König K, Kreienberg R, Kühn T, Lebeau A, Nass-Griegoleit I, Schlake W, Schmutzler R, Schreer I, Schulte H, Schulz-Wendtland R, Wagner U, Kopp I. · Faculty of Medicine, Philipps-University, Marburg, Germany. · J Cancer Res Clin Oncol. · Pubmed #18661152 No free full text.

Abstract: INTRODUCTION: The goal of the 2008 updated guideline: early detection of breast cancer in Germany is to support physicians as well as healthy and affected women in the decision-making process involved in the diagnostic chain for the early detection of breast cancer by providing them with evidence- and consensus-based recommendations. The updated guideline replaces the guideline issued in 2003. MATERIALS AND METHODS: The guideline forms the basis for developing an effective and efficient national early breast cancer detection program that meets the standards set by the Council of Europe and WHO for cancer control programs. The guideline presents the current, evidence- and consensus-based state of scientific knowledge in a multidisciplinary approach for the entire diagnostic chain, consisting of history taking and risk consultation, information on health behavior, clinical breast examination, diagnostic imaging, image-guided percutaneous tissue-acquisition techniques, open surgical excisional biopsy and pathomorphological tissue evaluation. The guideline recommends a set of quality indicators to assure resource availability, performance quality and outcomes enhancing total quality management for early breast cancer diagnosis. CONCLUSION: Currently, early detection of breast cancer offers the most promising possibility to optimize the diagnosis and treatment of breast cancer and, as a result, reduce breast cancer mortality and improve health related quality of life in women.

Albert US, Altland H, Duda V, Engel J, Geraedts M, Heywang-Köbrunner S, Hölzel D, Kalbheim E, Koller M, König K, Kreienberg R, Kühn T, Lebeau A, Nass-Griegoleit I, Schlake W, Schmutzler R, Schreer I, Schulte H, Schulz-Wendtland R, Wagner U, Kopp I. · Planungskommission und Arbeitsgruppenleiter der Konzertierten Aktion Brustkrebs-Früherkennung in Deutschland, Deutschland. · Chirurg. · Pubmed #18463837 No free full text.

Abstract: The updated 2008 German Guideline for Early Detection of Breast Cancer provides evidence-based and consensus-based recommendations of the knowledge gained by the German Society for Surgery and the German Society of Plastic, Aesthetic, and Reconstructive Surgeons together with 29 professional societies, associations, and nonmedical organizations. The guideline is meant to assist physicians, healthy women, and patients in medical decisions with recommendations regarding the diagnostic chain in early detection of breast cancer. In addition to these recommendations, the guideline also includes descriptions of quality assurance for resources, procedures, outcomes, and evaluation using a set of quality indicators. It updates the previous version from 2003. The guideline's recommendations are presented. They are described in detail in the full publication (in German) Geburtsh Frauenh 2008; 68:251-261. The long version of the Guideline, methods report, and evidence report are available on the internet at www.awmf-leitlinien.de (reg. no. 077/001) with free access.

Albert US, Altland H, Duda V, Engel J, Geraedts M, Heywang-Köbrunner S, Hölzel D, Kalbheim E, Koller M, König K, Kreienberg R, Kühn T, Lebeau A, Nass-Griegoleit I, Schlake W, Schmutzler R, Schreer I, Schulte H, Schulz-Wendtland R, Wagner U, Kopp I. · Planungskommission und Arbeitsgruppenleiter der Konzertierten Aktion Brustkrebs-Früherkennung in Deutschland. · Rofo. · Pubmed #18438746 No free full text.

This publication has no abstract.

Engel J, Ludwig MS, Schubert-Fritschle G, Tretter W, Hölzel D. · Munich Cancer Registry of the Comprehensive Cancer Center Munich, Department for Medical Informatics, Biometry and Epidemiology (IBE), Ludwig Maximilian University, Marchioninistrasse 15, 81377 Munich, Germany. · J Cancer Res Clin Oncol. · Pubmed #11414192 No free full text.

Abstract: "Because they know what they do" should be the contribution of cancer registration to prevention. The public should be informed about the successes and failures of prevention. In addition, each doctor and each hospital should know the long-term results for its patients despite the complex interdisciplinary health care provision. At the same time, the regional results should be available and contrasted with clinical studies and international standards. An important criterion is also the quality of life of the patients, whose cooperation is more than overdue. According to the possibilities of prevention, six important levels can be differentiated. On each level the outcome should be evaluated on the basis of slightly differing criteria. Primary prevention has the largest incidence-, and thus, mortality-reduction potential, essentially caused by the giving up of smoking. However, the primary prevention of the tumor depends upon what kind of tumor it is, as primary prevention is possible to different extents. Often, secondary prevention is the earliest intervention possible, that is, the early detection of cancer in prognostically favorable stages. However, early detection only offers a chance of cure, albeit a smaller one, for some kinds of tumor. The third prevention level comprises primary care according to the state-of-the-art standards, followed by posttreatment care (disease-free phase) even when the disease is running a fatal course (palliative phase). In the terminal phase, adequate tumor-pain therapy and symptom-oriented measures stand for the sixth prevention level. Even the quality of life of the dying can be optimized. At the beginning of treatment at the latest, the quality of life should also be added to the outcome criteria. In this paper, the individual levels of prevention and possible evaluation criteria for successful prevention, which a modern cancer registration should submit, are discussed and examples given. If the evaluation of the quality of treatment and its significance for health care provision becomes the central tasks of the cancer registers, they will need to be transformed into service centers for hospitals, doctors, and patients.

Willgeroth F, Baumann M, Blaser D, Crispin A, Froschauer S, de Waal J, Heywang-Köbrunner S, Hölzel D, Kääb V, Rothe R, Stich V, Thomaschewski S, Walter D. · Lenkungsausschuss BMS, Universitätsfrauenklinik Innenstadt, Maistr. 11, 80337 München. · Radiologe. · Pubmed #15747148 No free full text.

Abstract: In Bavaria since the 1st April 2003 we have been conducting a high quality mammography-screening carried out in individual practises (BMS). We have used the European and the S 3 guidelines.The best diagnosis is an early diagnosis of the breast carcinoma to save human life. Because of this and the high mortality rate due to this disease it is essential to have a mammogram screening program. There is no single one ideal way of constructing a screening program, it is always based on compromise within the particular health care-systems. Arising problems cannot be avoided, it is only possible when all parties work closely together that the BMS works properly.

Hölzel D, Schubert-Fritschle G. · Tumorregister des Tumorzentrums München am IBE, Institut für Med. Informationsverarbeitung, Biometrie und Epidemiologie, München. · Zentralbl Chir. · Pubmed #18278696 No free full text.

Abstract: Evidence-based medicine (ebm) is the answer to the postulate to grade the basis of scientific knowledge in medical care and to protect it against proceedings of unjustifiable arbitrariness. The ranking of controlled clinical trials, the evaluation of publications, meta-analyses, and references to "levels of evidence" in medical guidelines are well established. This is not inconsistent with the fact that many diagnostic and therapeutic measures are not evidence-based and that, even in reputable scientific journals, marketing intentions come into conflict with evidence-based facts. The demand for implementing ebm is furthermore an unsustainable ethical pretension as long as ebm itself is not evidence-based. In many cases better results from ebm are not supported by outcome studies. Health services research which, amongst others, evaluates implementation of study results under everyday conditions should be seen as an essential part of ebm. In oncology, cancer registries contribute to this type of transparency. Cancer registries show to what extent ebm is established as an encouraging future programme for the daily cancer health-care delivery and whether ebm exists as a barely realisable parallel world of promising controlled clinical trials.

Klein CA, Hölzel D. · Institut für Immunologie, Ludwig-Maximilians-Universität, München, Germany. · Cell Cycle. · Pubmed #16929175 No free full text.

Abstract: Metastatic progression is thought to result from genetically advanced "fully-malignant" tumor cells. Within the concept the prevailing view holds that such cells disseminate mostly from large tumors and are capable of growing into metastases once they arrive at a distant site. Support for this scenario comes from numerous mouse models in which transplanted tumor cells grow into metastases within days or weeks. However, the assumption of such fully-malignant disseminating cells in human cancer is misleading and is neither supported by mathematical modeling of survival data from cancer patients nor by ex-vivo genomic data from disseminated cancer cells. For example, in breast cancer the growth of metastases is highly homogeneous and takes on average six years, the number of disseminated tumor cells before diagnosis of metastasis is similar for different tumor stages, and the genomic aberrations of disseminated cancer cells do rarely correspond to those in the primary tumor. Since these facts question conventional concepts of metastatic progression we provide a model of cancer progression in which time considerations and direct ex-vivo data form a starting point. In the proposed model tumor dormancy is a characteristic of almost all migrated tumor cells and metastatic growth is a rare, stochastic, evolutionary process of selection and mutation of cells that often disseminate shortly after transformation at the primary site.

Nährig J, Höfler H, Heywang-Köbrunner SH, Prat N, Hölzel D, Wünsch PH, Lebeau A. · Institut für Allgemeine Pathologie und Pathologische Anatomie, Technische Universität, Ismaninger Strasse 22, 81675, München, Germany. · Pathologe. · Pubmed #16858556 No free full text.

Abstract: The Bavarian Mammography Screening Program started in April 2003. A detailed analysis of the consistency of diagnosis in the evaluation of vacuum-assisted stereotactic or core needle breast biopsies is presented. A total of 32 pathologists participated in a blinded evaluation of the biopsies. Each case was evaluated independently by two participating pathologists. A total of 1,357 cases were reviewed. The histopathological reports of the biopsies made by the two consulting pathologists were compared. The concordance rate of the first and second consulting pathologist was 93% for the B-classification. In general, the level of diagnostic agreement was very high for well defined, benign and malignant lesions. Some of the discrepancies resulted from the incorrect application of the B-classification. Discrepancies in the reports were also due to divergent interpretation of benign and "borderline" lesions. The protocol for the blinded evaluation of breast biopsies in two rounds assured a high level of quality. In conclusion, prerequisites for the success of a mammography screening program are interdisciplinary consensus conferences and audit rounds involving pathologists.

Prechtel K, de Waal J, Nerlich A, Hölzel D, Weitz J. · Gemeinschaftspraxis Pathologie, Starnberg, Germany. · Pathologe. · Pubmed #16317554 No free full text.

Abstract: Percutaneous large core biopsy of the breast with a 14-gauge needle, supported by sonographic and mammographic procedures, shows a high degree of safety during the collection for benign and malignant lesions. All malignant diagnoses (B 5) with a portion of 44% (267/604) were confirmed surgically, whereby the typing with 79% and grading with 58% were congruent. In 3.3% (20/604), there was uncertainty (B 3 and B 4), with the necessity for further clarification by open biopsy. This was supported by the fact that in 10/16 operated cases carcinoma was found. In the B 2-category, with a portion of nearly 44% (264/604), four cases of cancer were verified--not due to a wrongly negative histology but to non-representative material. In 8.8% (53/604), a questionable representative histology (B 1) occurred, but no cancer was found after surgical intervention (n=7). The indication for surgery is not only the punch biopsy result, but additionally negative histology and suspect or malignant clinical findings.

Engel J, Lebeau A, Sauer H, Hölzel D. · Munich Cancer Registry of the Munich Comprehensive Cancer Centre, Institute of Medical Informatics, Biometry and Epidemiology, Clinical Centre of the Ludwig-Maximilians-University, Germany. · Breast. · Pubmed #16054813 No free full text.

Abstract: Originally, surgery for breast cancer involved removing the pectoral muscles and the regional lymph nodes. This drastic technique was based on Halsted's paradigm of continuous tumour spread via the lymph nodes. In the last century, the amount of surgery has gradually decreased as breast cancer has been recognised as a primary systemic, or partially systemic, disease. Nowadays, breast-conserving therapy is widely used, but axillary lymph node dissection (ALND) and the sentinel technique are still common. Can the patient also be spared such axillary surgery? We have assembled convincing arguments against ALND (and therefore also against the sentinel technique) based on the probability that positive lymph nodes are unlikely to metastasise and that removing them is redundant. At least a discussion of this topic is more than overdue, even if it may be too early to change behaviour.

Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Hölzel D. · Munich Field Study, Munich Cancer Registry, Ludwig-Maximilians-University, Munich, Germany. · Breast J. · Pubmed #15125749 No free full text.

Abstract: There are many conflicting results in the literature comparing quality of life following breast-conserving therapy (BCT) and mastectomy. This study compared long-term quality of life between breast cancer patients treated by BCT or mastectomy in three age groups. Patients (n = 990) completed a quality of life survey, including the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), at regular intervals over 5 years. In the cross-sectional data, mastectomy patients had significantly (p < 0.01) lower body image, role, and sexual functioning scores and their lives were more disrupted than BCT patients. Emotional and social functioning and financial and future health worries were significantly (p < 0.01) worse for younger patients. There were no differences in body image and lifestyle scores between age groups. There was also no interaction between age and surgery method. Even patients > or =70 years of age reported higher body image and lifestyle scores when treated with BCT. The repeated measures analysis indicated that four functioning scores, half the symptom scores, future health, and global quality of life improved significantly (p < 0.01) over time. All these variables increased significantly for BCT patients and those 50 to 69 years of age. Body image, sexual functioning, and lifestyle disruption scores did not improve over time. BCT should be encouraged in all age groups. Coping with appearance change should be addressed in patient interventions.

Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Hölzel D. · Munich Field Study and the Munich Cancer Registry, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany. · Acta Oncol. · Pubmed #14690156 No free full text.

Abstract: Research has indicated that several demographic and clinical factors may affect the quality of life of breast cancer patients. Few studies, however, have sufficient sample sizes for multivariate analyses to be tested. Furthermore, several important factors, such as arm morbidity, communication and comorbid illness, have not been included in quality of life models The aim of this study was to predict the simultaneous effect of these factors on long-term quality of life. Breast cancer patients (n = 990) completed a quality of life survey, including the EORTC QLQ-C30, over five years. Clinical details were registered in the Munich Cancer Registry. Eleven predictors across eight quality of life domains were analyzed over a period of five years using a logistic regression model. Arm problems, communication, comorbidity, age, surgery. and, to a lesser extent, marital, educational and employment status were significantly associated with quality of life. Adjuvant therapy, medical insurance and pT category were not significant predictors. This study is the first to demonstrate the consistency and strength of arm dysfunction and doctor-patient communication on breast cancer patients' quality of life. These important factors in breast cancer care can be improved and should be regarded as a priority.

Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Hölzel D. · Munich Field Study, Munich Cancer Registry, Ludwig-Maximilians-University, Marchioninistrasse 15, D-81377 Munich, Germany. · Eur J Cancer Care (Engl). · Pubmed #12919300 No free full text.

Abstract: This paper compares quality of life in breast and rectal cancer patients. The Munich Cancer Registry records clinical details of all cancer patients in the region. Over a 2-year period, cooperating clinicians recruited patients who were sent quality of life questionnaires, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - C30 over 4 years. Breast cancer patients were compared to both male and female rectal cancer patients. A total of 1315 patients returned questionnaires (988 breast cancer, 327 rectal cancer). More breast cancer patients were under 70 years old, received adjuvant therapy, had a good prognosis, took medication and rated psychological support as important. Breast cancer patients reported poorer quality of life than rectal cancer patients in more than half the variables. In particular, they suffered significantly worse emotional functioning, fatigue, pain and sleeplessness. Female rectal cancer patients did not suffer the same problems. Both age groups and those with or without adjuvant therapy indicated the same trend, with breast cancer patients reporting lower scores. Breast cancer patients, despite better prognoses, appear to suffer more psychological problems than rectal cancer patients. Gender, age and therapy did not seem to explain these differences. The negative public perception of breast cancer may play a role.

Engel J, Eckel R, Kerr J, Schmidt M, Fürstenberger G, Richter R, Sauer H, Senn HJ, Hölzel D. · Tumorregister am Tumorzentrum München, Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie (IBE), Klinikum der Ludwig-Maximilians-Universität, Grosshadern, D-München, Germany. · Eur J Cancer. · Pubmed #12888376 No free full text.

Abstract: To investigate the process of metastasis, primary clinical data and disease events such as metastases, local recurrence and survival (median follow-up 9.4 years) from the Munich Cancer Registry from 1978 to 1996 were analysed. Since metastases, even from small tumours, may be initiated before the diagnosis of the primary tumour, the growth of the primary tumour and metastasisation may be two autonomous processes. In our data, survival following metastases was almost unrelated to primary tumour size. However, the number of M1 cases and the time to metastasisation depended on the tumour diameter at diagnosis. The time from initiation of metastases to its diagnosis was estimated as 5.8 years. The growth of metastases was almost homogeneous. However, the growth time following metastasisation-depending on the metastases-free time, receptor status and histological grade-only varied by approximately a factor of 2. Local recurrence, above all, was an indicator of metastases. Furthermore, local recurrence may also have the potential to metastasise. Excess mortality due to local recurrence was estimated up to 9.3 years after diagnosis. Our hypothesised metastases model illustrates the importance of early detection, the concept of breast-conserving therapy and additional metastases from local recurrence. It highlights the benefits of optimal local therapy of the primary tumour and the limitations of systemic therapy. It also questions the use of axilla dissection and lymph node irradiation. Its generalisation to solid tumours may help to clarify many of the current controversial debates.

Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Hölzel D. · Munich Field Study, Munich Cancer Registry, Munich, Germany. · Breast Cancer Res Treat. · Pubmed #12779081 No free full text.

Abstract: No long-term prospective study has investigated arm morbidity and patient quality of life. It is unclear to what extent breast cancer patients suffer from arm problems, how long such problems affect their lives, and whether quality of life improves as arm problems abate. This prospective cohort study aims to provide data on the clinical factors associated with arm dysfunction, to estimate its prevalence and to relate arm morbidity to quality of life. The Munich Cancer Registry records clinical details of all cancer patients in and around Munich. Quality of life information was provided directly by breast cancer patients (n = 990) over 5 years. Arm morbidity, including movement limitations, swelling and lymph drainage, and quality of life (EORTC QLQ-C30) were assessed. Up to 5 years after diagnosis, 38% of patients were still experiencing arm problems (swelling and limited movement). Consistently over the 5 years, quality of life was significantly (p < 0.001) lower for patients with arm difficulties. For those whose arm problems dissipated, quality of life significantly improved (p < 0.01). A logistic regression analysis showed that extent of axilla surgery (p < 0.003), comorbidity (CVD and diabetes) (p < 0.003), employment (p < 0.01), younger age (p < 0.02), and operating clinic (p < 0.05) significantly contributed to arm problems. Axilla surgery should be re-evaluated since arm morbidity has such a profound effect on patient quality of life.

Engel J, Eckel R, Aydemir U, Aydemir S, Kerr J, Schlesinger-Raab A, Dirschedl P, Hölzel D. · Munich Cancer Registry of the Munich Comprehensive Cancer Center, Department of Medical Informatics, Biometry and Epidemiology, Ludwig Maximilians-University, Munich, Germany. · Int J Radiat Oncol Biol Phys. · Pubmed #12654426 No free full text.

Abstract: PURPOSE: To describe locoregional and distant progression in a population-based breast cancer sample. METHODS AND MATERIALS: Between 1978 and 1998, the Munich Cancer Registry evaluated 14,429 patients. The mean follow-up of survivors was 8.3 years. Metastases (MET), local recurrence (LR), and lymph node recurrence (LNR) were considered as outcome measures. The prognostic factor for, and effects of, LR and MET were assessed multivariately by the Cox and dynamic Aalen models. RESULTS: The LR and MET rate increased with increasing tumor size, with the latter described by pT category. Distant MET occurred earlier than local progression. MET was recorded even earlier for MET alone. The mean time from diagnosis to MET for MET and LR was 54.9, 43.4, 29.4, and 24.7 months and for MET only was 36.5, 31.0, 22.6, and 12.9 months for pT1, pT2, pT3, and pT4, respectively. After MET, survival varied only slightly by pT stage; after LR, a more favorable prognosis, especially for pT1 and pT2, was evident. The prognosis after MET depended mainly on the MET location; 50% of patients with cerebral or nervous system MET survived <1 year and 50% of those with skeletal MET survived >2 years. In the Cox model, the relative risk of LR for MET was 3.0. In the Aalen model, after 30 months, when the hazard rates of MET began to decline, there was still an excess risk of MET after LR. CONCLUSION: This disease description highlights the importance of long-term observational studies. Empiric evidence that LR is both an indicator for, and in part a cause of, MET has been provided. In the future, the MET location should be reported. Variations in guidelines or health care systems that influence the time to MET and survival after MET through different diagnostic procedures should also be considered.

Kerr J, Engel J, Schlesinger-Raab A, Sauer H, Hölzel D. · Munich Cancer Registry, Munich, Germany. · Ann Oncol. · Pubmed #12598348 links to  free full text

Abstract: BACKGROUND: Previous studies have employed short follow-up periods or examined only certain aspects of quality of life (QoL). This study aimed to examine the effect of communication on breast cancer patients' QoL and to investigate the role of age in this relationship. PATIENTS AND METHODS: In a prospective, observational study breast cancer patients were sent questionnaires, including the European Organisation for Research and Treatment of Cancer QLQ-C30, over 5 years. RESULTS: Forty-five per cent of the sample reported that some aspect of the communication they received was unclear and 59% wanted to speak with medical staff more. Patients under 50 years rated social and psychological help as more important, they were more aware of such services, had greater contact with support groups but were less satisfied with the information they received. Seventeen of the 27 QoL variables were significantly worse (P <0.01), up to 4 years after diagnosis, for those patients reporting unclear information. For patients over 50 years, QoL was significantly (P <0.001) worse when communication was unsatisfactory. Operation method or arm problems did not mitigate the association between communication and QoL. CONCLUSIONS: Communication is clearly a vital clinical skill that may play a role in patient QoL.

Hölzel D, Engel J. · No affiliation provided · Strahlenther Onkol. · Pubmed #11942037 No free full text.

This publication has no abstract.

Engel J, Nagel G, Breuer E, Meisner C, Albert US, Strelocke K, Sauer H, Katenkamp D, Mittermayer Ch, Heidemann E, Schulz KD, Kunath H, Lorenz W, Hölzel D. · Cancer Registry of the Comprehensive Cancer Center Munich, Marchioninistrasse 15, 81377, Munich, Germany. · Eur J Cancer. · Pubmed #11872353 No free full text.

Abstract: Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.

Engel J, Hölzel D. · No affiliation provided · Strahlenther Onkol. · Pubmed #11505623 No free full text.

Abstract: BACKGROUND: Dysphagia after radiotherapy of thoracic tumors may be caused by recurrences or by radiation damage to the esophagus. CASE REPORT: A 75-year-old patient presented with a complete obstruction of the esophagus 5 months after CHARTWEL radiotherapy for a non-small cell lung cancer. During the last week of radiotherapy mild dysphagia (Grade 1 EORTC/RTOG, Grade 2 MRC-CHART-Score) occurred that persisted over the following months. X-ray and endoscopic investigations revealed an easily removable food bolus without evidence of esophageal stricture or ulceration. CONCLUSION: The case report describes a mild but prolonged early radiation reaction of the esophagus. In comparison with conventional fractionation the incidence of dysphagia is higher after accelerated fractionation schedules. The pathophysiologic mechanisms underlying persistent dysphagia are currently unknown. Beside of recurrences, radiation effects to the esophagus should be considered if dysphagia after irradiation of thoracic tumors occurs, because, as in this case, therapy may rapidly improve the symptoms.

Hölzel D, Engel J, Schmidt M, Sauer H. · Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie (IBE). · Strahlenther Onkol. · Pubmed #11200108 No free full text.

Abstract: BACKGROUND: An adjuvant locoregional radiotherapy after radical surgery results in a survival advantage for breast cancer patients. The advantage starts with a delay and reaches about 10% 15 years after diagnosis. What could explain such a delayed efficacy? METHODS: A population-based cohort from 1996 to 1998 and the Munich Cancer Registry with courses of breast cancer disease since 1977 are the empirical basis. The analysis concerns survival rates and survival times in respect to metastases, local and lymph node recurrencies. A metastatic model is derived from the data. RESULTS: A cohort of 9,347 patients with a mean follow-up of 6.5 years and 2,587 courses with metastases and/or local recurrencies were registered. The overall survival after 15 years was for pT1 57.6%, pT2 37.9%, pT3 24.4% and for pT4 10.5%. Five years after metastasization 20.1 to 12.4% survived, 10 years 6% independent on pT. Ten years after local recurrencies the survival was dependent on pT of the primary tumor: pT1 36.3%, pT2 21.0%, pT3 13.1% und pT4 4.6%. A local recurrency is a prognostic factor for metastasization of the primary tumor, but local recurrencies can also cause metastases. The mean survival time after metastasization of the primary pT1 tumor is estimated about 61 months, after metastasization by local recurrencies about 99 months with a mean time to local recurrencies of 38 months. Further results of the metastatic model are: the development of metastasization is homogeneous and independent on pT-category, the metastatic initiation starts up to 5 years before diagnosis, metastatic-free survival time and progression survival time are independent and an impact of lymph node recurrencies on survival could not be detected. CONCLUSIONS: The reduction of local recurrencies by high-quality primary therapy with radiotherapy and also the early detection of local recurrencies may reduce secondary metastasization and therefore improve survival. The metastasization model also explains the limitation of the therapeutical strategies and the almost mandatory chance of early detection programs of breast cancer.

Engel J, Anker G, Hölzel D, Jauch KW, Roder J. · Feldstudie/Tumorregister München am IBE (Institut für Informationsverarbeitung, Biometrie und Epidemiologie), Klinikum Grosshadern, Ludwig-Maximilians-Universität München. · Zentralbl Chir. · Pubmed #11190611 No free full text.

Abstract: BACKGROUND: Different approaches for an effective quality management are funded by the Ministry of health to verify, and if necessary to optimize, the quality of health care using the tracer diagnosis breast, rectal and lung cancer in 8 regions in Germany. The aim of the study is to develop a model for description and support of high quality health care for cancer patients. The conception, initial findings and inter-hospital variations are shown for some aspects of the primary therapy of rectal cancer in the region of Munich (population 2.3 million). PATIENTS AND METHODS: The field study is a population based cohort study. The recruitment phase started in April 1996 and finished March 1998. Established documentation sheets of the tumor registry along with original reports (reports of the doctors, pathologists etc.) are used for documentation. RESULTS: 26 surgical departments, 12 pathology departments, 9 radiotherapy departments and about 300 general practitioners have documented for this study. So far a sample of 809 have been analyzed. After an almost complete documentation the crude incidence will be about 23/100.000. 57% of all patients were men and 43% were women. 765 patients have been operated, 44 not. PT-categories (for the operated patients) are distributed as follows: pTis and pT1 10.7%, pT2 25%, pT3 54.5%, pT4 9.8%. Distribution of tumor localization: < 4 cm 6.7%, 4 bis < 8 cm 36.2%, 8 bis < 12 cm 30.8%, > or = 12 cm 26.3%. Local excision was performed in 4%, sphincter conserving therapy (SCT) in 71.5% (protective stoma: 23.7%), not sphincter conserving therapy (nSCT) in 18.4% and a palliative operation in 6%. The large surgical departments (> 25 patients per year) treated 53.8% of all patients. The proportion of older patients is significant higher in the smaller departments (< 10 patients per year). There are no differences in pTNM-distribution. No variations exist in the operation method between the department groups. More or less varying inter-hospital differences exist between the individual departments for all epidemiological and therapeutical parameters. CONCLUSIONS: Variations of medical care exist more between the individual hospitals than between department groups, divided by workload. To support the quality of health care a feedback of the results has to be available for each physician and each department.

Engel J, Hölzel D. · No affiliation provided · Strahlenther Onkol. · Pubmed #11001742 No free full text.

This publication has no abstract.

Engel J, Baumert J, Hölzel D. · Tumorzentrum München, Klinikum Grosshadern, München. · Radiologe. · Pubmed #10758633 No free full text.

Abstract: In Germany there is still an urgent need for action in regard to screening for breast cancer. The announcement of research projects for mammography screening proves this. The following reports the results of the Munich field study. In 2 years, 2489 breast cancer cases were registered (status 6/98). Screening data were available for 1319 patients. The reduction in mortality, found in randomized studies, due to mammography in women over 50 years old was confirmed. A relative reduction of 44.8% in 10-year mortality could be estimated through mammography and 25.1% through palpation, in comparison with "doing nothing." We could also estimate the participation of screening and the used methods in the Munich region. If the mammographies carried out today were used at 2-year intervals for women aged between 50 and 70 years, then the mammography screening could be performed with no additional costs for 70% of the women. The known facts regarding the population-based mortality and regarding the acceptance of the palpation screening and frequency of mammography are additional aspects for inclusion in the discussion of what research projects in Germany are and what they should fulfill.

Munker R, Grützner S, Hiller E, Aydemir U, Enne W, Dietzfelbinger H, Busch M, Haas R, Emmerich B, Schmidt M, Dühmke E, Hölzel D, Wilmanns W. · Medizinische Klinik III der Ludwig-Maximilian-Universität, Klinikum Grosshadern, Munich, Germany. · Ann Hematol. · Pubmed #10647878 No free full text.

Abstract: The occurrence of second malignancies (SM) is an important late event following the treatment of Hodgkin's disease (HD). We sought to determine the incidence, the risk factors, and the prognosis of SM in our population of patients with HD. A total of 1120 patients diagnosed with HD were registered at six participating institutions in Munich (calendar period 1974-1994). The mean follow-up for the development of SM was 9.1 years. A cumulative treatment score was calculated for both radio- and chemotherapy. The relative and absolute risks of SM were established. All SM were investigated for response to treatment and outcome. We observed 85 SM [eight leukemias, 22 non-Hodgkin's lymphomas (NHL), two plasma cell neoplasias, and 53 solid tumors]. Five patients developed third malignancies. The relative risk of developing a second neoplasm was compared with that within the normal population and was 3.1-fold. The risk varied according to the category of SM. Higher relative risks (20.5 and 25.9-fold), but lower absolute risks were observed for leukemias and non-Hodgkin's lymphomas. Solid tumors had lower relative risks (1.8-fold). Splenectomy increased the risk of SM (relative risk 4.4-fold versus 2.7-fold). The risk of SM did not correlate with the initial treatment (radio- or chemotherapy) and did not decrease with prolonged follow-up. The cumulative intensity of radiotherapy, chemotherapy, or the two modalities combined correlated with the risk of SM. Since some cases occurred early after diagnosis, not all second neoplasms can be considered treatment-associated. After 15 years, an actuarial risk of 11.7% was calculated for all SM, of 1.0% for leukemias, of 3.0% for NHL, and of 7.7% for solid tumors. The prognosis of SM varied between good (thyroid cancer, melanoma: median survival 5+ years), average (breast cancer, NHL), and poor (acute myeloid leukemias, lung cancers: median survival 9 months). With the exception of NHL, second cancers often occurred in topographic relation to the field of previous radiotherapy. Taken together, in our patient population, we observed all three categories of SM (solid tumors, leukemias, NHL). The risk for second leukemias is lower than in previous studies, whereas the risk of second NHL is somewhat higher. We confirm that splenectomy is a possible risk factor for SM. Even after correction for the age-specific cancer incidence, treatment intensity is associated with the development of second malignant tumors. Continued follow-up is mandatory after treatment for HD. Since the prognosis of most SM is unfavorable, early recognition and prevention are of the utmost importance.