Gunnar Steineck Clinical Cancer Epidemiology

Transcription

1 Gunnar Steineck Clinical Cancer Epidemiology

2 Causal factor Modifying factor Outcome Future intervention Radiotherapy Dose of ionizing radiation to volume of normal tissue Inherited sensitivity (polymorphisms) Social effects Surgery Cutting, cauterization, tearing of normal tissue Reactions in normal tissue (pathophysiological processes) Long-lasting physical symptoms Chemotherapy Cumulative dose of chemotherapy in normal tissue Age, smoking, diet, intercurrent morbidity Psychological effects

3 Sweden Europe Cancer survivors 390 thousand 20 million Fecal leakage 18 thousand 1 million Sceletal pain 9 thousand 500 thousand Urinary leakage 35 thousand 1.8 million Sexual dysfunction, men 27 thousand 1.4 million Sexual dysfunction, women 20 thousand 1 million

4 SPCG randomized and alive 326 (87%) Participation 166 Radical prostatectomy 160 Watchful waiting

5 SPCG-4 Prostate cancer death at 10 years Radical prostatectomy 10% Watchful waiting 15% Difference: 5%

6 Symptom after: 2-3 years 6-8 years Erectile dysfunction Radical prostatectomy 80% 83% Watchful waiting 37% 55% Urinary leakage 42% 56% 11% 25%

7 Self-assessed quality of life similar between groups

8 Self-assessed quality of Life (1-7) SPCG Radical-prostatectomy group 3 Watchful-waiting group 2 1 No Number of symptoms One Two Three (erectile dysfunction, weak urinary stream and urinary leakage)

9 % of patients in group High quality of life 0 WW RP Androgen WW RP Non-androgen deprived deprived WW=watchful waiting. RP=radical prostatectomy High quality of life (6-7) on a 1-7 visual digital scale.

10 Urinvägar och Hälsa Interviews Developed a questionnaire Face-to-face validation Postal questionnaire Population-based study Return of a questionnaire

11 Urinary leakage at orgasm Dry afterwards Short Penis Hernia

12 Probability of urinary incontinence (%) Probability of urinary incontinence (%) Probability of urinary incontinence (%) Probability of urinary incontinence (%) A B Age at surgery Age at surgery C D 9 y rs y rs 13 y rs Age at surgery Age at surgery

13 Cervical cancer survivors 35 % Painful intercourse Controls, no sexual abuse Controls, sexually abused Cervical cancer, no sexual abuse Cervical cancer and sexually abused Bergmark et al N Engl J Med 1999; 340:1383-9

14 Moment during surgery Urinary leakage Traumatized urethra? Yes 12/17 (71 %) No 131/402 (33 %) Prevalence ratio: 2.1 ( )

15 Dunberger et al, 2009

16 Frequency (%) Men treated with radiotherapy for prostate cancer Never smokers Current smokers Abdominal cramps Abdominal pain Sensation of bowel not emptied after defecation Sudden emptying of all stools into clothing

17 Toilet dependency Cancer survivors with emptying of all stools without forewarning Cancer survivors without emptying of all stools without forewarning Control women Individuals in percent < 1minute 1-5 minutes 5-10 minutes minutes > 30 minutes/not applicable Dunberger et al, 2009 CCK Vinterviken

18 Pain in one or both hips at least once per week Number with symptom/ total number (%) Age-adjusted Relative Risk (95% CI) Controls 20/ 244 (8) Reference EBRT 44/266 (17) 1.8 ( ) EBRT-BT 55/343 (16) 1.9 ( ) Post-operative 29/185 (16) 2.0 ( )

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20 Förekomst av symtom Förekomst av symtom Förekomst av symtom Förekomst av symtom Förekomst av symtom Förekomst av symtom Förekomst av symtom... In-depth interviews Face-to-face validation Pilot study Reactivated earlier dose plan Questionnaire Population based study Combining data from various sources Reconstruktion of dose to delineated risk organs D (Gy) V (%) Data concerning long-lasting symptoms Dose/volume data Prediction of long-lasting XX X X X X Symtom symptoms based on dose/volume data XX X X XX Inga Symtom Stråldos till riskorgan(gy) Optimization All relationships for tumor and normal tissue considered simultaneously: future dose plan Future patients Stråldos till riskorgan(gy) Stråldos till riskorgan(gy) Stråldos till riskorgan(gy) Stråldos till riskorgan(gy) Stråldos till riskorgan(gy) Stråldos till riskorgan(gy)

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22 Lind, Alevronta, et al 2009 Sudden emptying of stools without forewarning

23 Excess incidence the year after diagnosis

24 % men waking up with anxiety Neg thoughts before surgery - waking up with anxiety before surgery Negative thoughts before surgery - waking up with anxiety 3 months after surgery Negative thoughts 3 months after surgery - waking up with anxiety 3 months after surgery Frequency of negative thoughts

25 Single widowers have higher risks than others Controls Widowers in new relationship Widowers - single 60 % Depression VDS Anxiety VDS Emotional numbness Low/moderate meaningful life Difficulty falling asleep

26 Rehabilitation New diseases New pathophysiological processes Need for new remedies Somatic Psychologically Intrusive thoughts target?