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Anell A.,Lund University | Hagberg O.,Regional Cancer Center South | Liedberg F.,Skåne University Hospital | Liedberg F.,Lund University | Ryden S.,Regional Cancer Center South
International Journal for Quality in Health Care | Year: 2016

Objective: Comparison of provider performance is commonly used to inform health care decisionmaking. Little attention has been paid to how data presentations influence decisions. This study analyzes differences in suggested actions by decision-makers informed by league tables or funnel plots. Design: Decision-makers were invited to a survey and randomized to compare hospital performance using either league tables or funnel plots for four different measures within the area of cancer care. For each measure, decision-makers were asked to suggest actions towards 12-16 hospitals (no action, ask for more information, intervene) and provide feedback related to whether the information provided had been useful. Setting: Swedish health care. Participants: Two hundred and twenty-one decision-makers at administrative and clinical levels. Intervention: Data presentations in the form of league tables or funnel plots. Main outcome measures: Number of actions suggested by participants. Proportion of appropriate actions. Results: For all four measures, decision-makers tended to suggest more actions based on the information provided in league tables compared to funnel plots (44% vs. 21%, P < 0.001). Actions were on average more appropriate for funnel plots. However, when using funnel plots, decisionmakers more often missed to react even when appropriate. Conclusions: The form of data presentation had an influence on decision-making. With league tables, decision-makers tended to suggest more actions compared to funnel plots. A difference in sensitivity and specificity conditioned by the form of presentation could also be identified, with different implications depending on the purpose of comparisons. Explanations and visualization aids are needed to support appropriate actions. © The Author 2016.


Leon O.,Skåne University Hospital | Guren M.,University of Oslo | Hagberg O.,Regional Cancer Center South | Glimelius B.,Uppsala Academic Hospital | And 13 more authors.
Radiotherapy and Oncology | Year: 2014

Objective To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines. MaterialClinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54-64 Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage.Results High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation.Conclusions Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors. © 2014 Elsevier Ireland Ltd.


Jerlstrom T.,Örebro University | Gardmark T.,Danderyd Hospital | Carringer M.,Örebro University | Holmang S.,Sahlgrenska University Hospital | And 6 more authors.
Scandinavian Journal of Urology | Year: 2014

Objective. Cystectomy combined with pelvic lymph-node dissection and urinary diversion entails high morbidity and mortality. Improvements are needed, and a first step is to collect information on the current situation. In 2011, this group took the initiative to start a population-based database in Sweden (population 9.5 million in 2011) with prospective registration of patients and complications until 90 days after cystectomy. This article reports findings from the first year of registration. Material and methods. Participation was voluntary, and data were reported by local urologists or research nurses. Perioperative parameters and early complications classified according to the modified Clavien system were registered, and selected variables of possible importance for complications were analysed by univariate and multivariate logistic regression. Results. During 2011, 285 (65%) of 435 cystectomies performed in Sweden were registered in the database, the majority reported by the seven academic centres. Median blood loss was 1000 ml, operating time 318 min, and length of hospital stay 15 days. Any complications were registered for 103 patients (36%). Clavien grades 1-2 and 3-5 were noted in 19% and 15%, respectively. Thirty-seven patients (13%) were reoperated on at least once. In logistic regression analysis elevated risk of complications was significantly associated with operating time exceeding 318 min in both univariate and multivariate analysis, and with age 76-89 years only in multivariate analysis. Conclusions. It was feasible to start a national population-based registry of radical cystectomies for bladder cancer. The evaluation of the first year shows an increased risk of complications in patients with longer operating time and higher age. The results agree with some previously published series but should be interpreted with caution considering the relatively low coverage, which is expected to be higher in the future. © 2014 Informa Healthcare.


Aaltonen K.E.,Lund University | Rosendahl A.H.,Lund University | Rosendahl A.H.,Skåne University Hospital | Olsson H.,Ostergotland County Council | And 6 more authors.
BMC Cancer | Year: 2014

Background: Resistance towards endocrine therapy is a great concern in breast cancer treatment and may partly be explained by the activation of compensatory signaling pathways. The aim of the present study was to investigate if the insulin-like growth factor-1 receptor (IGF1R) signaling pathway was activated or deregulated in breast cancer patients and to explore if any of the markers were prognostic, with or without adjuvant tamoxifen. This signaling pathway has been suggested to cause estrogen independent cell growth and thus contribute to resistance to endocrine treatment in estrogen receptor (ER) positive breast cancer. Methods: The protein expression of IGF1R, phosphorylated Mammalian Target of Rapamycin (p-mTOR) and phosphorylated S6 ribosomal protein (p-S6rp) were investigated by immunohistochemistry using tissue microarrays in two patient cohorts. Cohort I (N = 264) consisted of mainly postmenopausal women with stage II breast cancer treated with tamoxifen for 2 years irrespective of ER status. Cohort II (N = 206) consisted of mainly medically untreated, premenopausal patients with node-negative breast cancer. Distant disease-free survival (DDFS) at 5 years was used as end-point for survival analyses. Results: We found that lower IGF1R expression was associated with worse prognosis for tamoxifen treated, postmenopausal women (HR = 0.70, 95% CI = 0.52 - 0.94, p = 0.016). The effect was seen mainly in ER-negative patients where the prognostic effect was retained after adjustment for other prognostic markers (adjusted HR = 0.49, 95% CI = 0.29 - 0.82, p = 0.007). Expression of IGF1R was associated with ER positivity (p < 0.001) in the same patient cohort. Conclusions: Our results support previous studies indicating that IGF1R positivity reflects a well differentiated tumor with low metastatic capacity. An association between lack of IGF1R expression and worse prognosis was mainly seen in the ER-negative part of Cohort I. The lack of co-activation of downstream markers (p-mTOR and p-S6rp) in the IGF1R pathway suggested that the prognostic effect was not due to complete activation of this pathway. Thus, no evidence could be found for a compensatory function of IGF1R signaling in the investigated cohorts.


Johansson H.,Lund University | Bjelkenkrantz K.,Regional Cancer Center South | Darlin L.,Skåne University Hospital | Dilllner J.,Karolinska Institutet | Forslund O.,Lund University
PLoS ONE | Year: 2015

Objective: Continuous expression of E6- and E7-oncogenes of high-risk human papillomavirus (HPV) types is necessary for the development and maintenance of the dysplastic phenotype. The aim of the study was to determine the sensitivity and specificity of the APTIMA HPV mRNA assay (Hologic) in predicting future development of high-grade cervical intraepithelial neoplasia (CIN) among high-risk HPV-DNA-positive women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous epithelial lesion (LSIL) cytology. Methods: Archived SurePath cervical samples of women ≥ 35 years of age with high-risk HPV DNA-positive ASCUS (n = 211) or LSIL, (n = 131) were tested for the presence of high-risk HPV E6/E7 mRNA using the APTIMA HPV assay, and the women were monitored for development of histopathologically verified CIN2+. Results: Twenty-nine percent (61/211) of the women in the ASCUS group, and 34.3%(45/131) in the LSIL group developed CIN2+ within 4.5 years of follow-up. The prevalence of HPV mRNA was 90.0%(95% CI 85.9-94.0) among women with ASCUS and 95.4% (95% CI 91.8-99.0) among women with LSIL. The presence of HPV E6/E7 mRNA was associated with future development of CIN2+ among women with ASCUS and LSIL (p=0.02). The mRNA assay demonstrated high sensitivity in predicting future CIN2+ and CIN3 for index ASCUS (96.7%; 95% CI 87.6-99.4 and 100%; 95%CI 82.2-100, respectively) and LSIL (97.8%, 95%CI 86.8-99.9 and 100%, 95%CI 79.9-100, respectively). The corresponding specificity was low, 12.7% (95% CI 7.9-19.3) and 5.8%(95%CI 2.2-13.6), for future CIN2+, respectively. The negative predictive value of the HPV mRNA assay for detecting future CIN3 was 100%, since no mRNA-negative woman developed CIN3 (0/27) as compared to 13.6%(43/315) of the mRNA-positive women (p = 0.03). Conclusion: The APTIMA mRNA assay demonstrated high sensitivity but low specificity in predicting future CIN2+ among women with minor cytological abnormalities. The assay had high negative predictive value for future CIN3, indicating that HPV-mRNA-negative women are at low risk of progression to high grade CIN. © 2015 Johansson et al.


Sartor H.,Skåne University Hospital | Borgquist S.,Lund University | Borgquist S.,Skåne University Hospital | Hartman L.,Lund University | And 4 more authors.
Acta Radiologica | Year: 2015

Background Breast density and mammographic tumor features of breast cancer may carry prognostic information. The potential benefit of using the combined information obtained from breast density, mammographic tumor features, and pathological tumor characteristics has not been extensively studied. Purpose To investigate how mammographic tumor features relate to breast density and pathological tumor characteristics. Material and Methods This retrospective study was carried out within the Malmö Diet and Cancer Study: a population-based cohort study recruiting 17,035 women during 1991-1996. A total of 826 incident breast cancers were identified during follow-up. Mammography images were collected and analyzed according to breast density and tumor features at diagnosis. Pathological data were retrieved from medical reports. Mammographic tumor features in relation to invasiveness, tumor size, and axillary lymph node involvement were analyzed using logistic regression yielding odds ratios (OR) with 95% confidence intervals (CI) and adjusted for age at diagnosis, mode of detection, and breast density. Results Tumors presenting as an ill-defined mass or calcifications were more common in dense breasts than tumors presenting as a distinct mass or with spiculated appearance. Invasive cancer was more common in tumors with spiculated appearance than tumors presenting as a distinct mass (adjusted OR, 5.68 [1.81-17.84]). Among invasive tumors, an ill-defined mass was more often large (>20 mm) compared with a distinct mass, (adjusted OR, 3.16 [1.80-5.55]). Conclusion Tumors presenting as an ill-defined mass or calcifications were more common in dense breasts. Spiculated appearance was related to invasiveness, and ill-defined mass to larger tumor size, regardless of mode of detection and breast density. The potential role of mammographic tumor features in clinical decision-making warrants further investigation. © The Foundation Acta Radiologica 2014.


PubMed | Lund University, Skåne University Hospital, Lundbergsgatan Primary Healthcare Center and Regional Cancer Center South
Type: Journal Article | Journal: British journal of cancer | Year: 2016

The delay between onset of macroscopic haematuria and diagnosis of bladder cancer is often long.We evaluated timely diagnosis and health-care costs for patients with macroscopic haematuria given fast-track access to diagnostics. During a 15-month period, a telephone hotline for fast-track diagnostics was provided in nine Swedish municipalities for patients aged 50 years with macroscopic haematuria. The control group comprised 101 patients diagnosed with bladder cancer in the same catchment area with macroscopic haematuria who underwent regular diagnostic process.In all 275 patients who called the Red Phone hotline were investigated, and 47 of them (17%) were diagnosed with cancer and 36 of those had bladder cancer. Median time from patient-reported haematuria to diagnosis was 29 (interquartile range (IQR) 14-104) days and 50 (IQR 27-165) days in the intervention and the control group, respectively (P=0.03). The median health-care costs were lower in the intervention group (655 (IQR 655-655) EUR) than in the control group (767 (IQR 490-1096) EUR) (P=0.002).Direct access to urologic expertise and fast-track diagnostics is motivated for patients with macroscopic haematuria to reduce diagnostic intervals and lower health-care expenditures.


PubMed | Karolinska Institutet, Lund University, Skåne University Hospital and Regional Cancer Center South
Type: Journal Article | Journal: PloS one | Year: 2015

Continuous expression of E6- and E7-oncogenes of high-risk human papillomavirus (HPV) types is necessary for the development and maintenance of the dysplastic phenotype. The aim of the study was to determine the sensitivity and specificity of the APTIMA HPV mRNA assay (Hologic) in predicting future development of high-grade cervical intraepithelial neoplasia (CIN) among high-risk HPV-DNA-positive women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous epithelial lesion (LSIL) cytology.Archived SurePath cervical samples of women 35 years of age with high-risk HPV DNA-positive ASCUS (n = 211) or LSIL, (n = 131) were tested for the presence of high-risk HPV E6/E7 mRNA using the APTIMA HPV assay, and the women were monitored for development of histopathologically verified CIN2+.Twenty-nine percent (61/211) of the women in the ASCUS group, and 34.3% (45/131) in the LSIL group developed CIN2+ within 4.5 years of follow-up. The prevalence of HPV mRNA was 90.0% (95% CI 85.9-94.0) among women with ASCUS and 95.4% (95% CI 91.8-99.0) among women with LSIL. The presence of HPV E6/E7 mRNA was associated with future development of CIN2+ among women with ASCUS and LSIL (p=0.02). The mRNA assay demonstrated high sensitivity in predicting future CIN2+ and CIN3 for index ASCUS (96.7%; 95% CI 87.6-99.4 and 100%; 95% CI 82.2-100, respectively) and LSIL (97.8%, 95% CI 86.8-99.9 and 100%, 95% CI 79.9-100, respectively). The corresponding specificity was low, 12.7% (95% CI 7.9-19.3) and 5.8% (95% CI 2.2-13.6), for future CIN2+, respectively. The negative predictive value of the HPV mRNA assay for detecting future CIN3 was 100%, since no mRNA-negative woman developed CIN3 (0/27) as compared to 13.6% (43/315) of the mRNA-positive women (p = 0.03).The APTIMA mRNA assay demonstrated high sensitivity but low specificity in predicting future CIN2+ among women with minor cytological abnormalities. The assay had high negative predictive value for future CIN3, indicating that HPV-mRNA-negative women are at low risk of progression to high grade CIN.


Stromberg U.,Gothenburg University | Stromberg U.,Lund University | Holmen A.,Development and Education | Peterson S.,Regional Cancer Center South
Spatial and Spatio-temporal Epidemiology | Year: 2016

Screening strategies need to consider differences in late-stage disease detection linked to socio-demographic and geographic factors. We specifically addressed disparity in melanoma stage at diagnosis linked to residential municipality, gender and marital status within the middle- and old-age population of southern and western Sweden. Population-based registers were used to identify the melanoma cases diagnosed in 2004-2013 (n=7,417). Disease mapping for each population group based on gender and marital status showed marked spatial disparities in melanoma incidences and the overall patterns differed by stage at diagnosis. The incidence of early-stage melanoma was markedly higher in the western region, whereas the incidence of late-stage melanoma was markedly higher in the southern region except for married women. Excess mortality among cases was observed to be higher in the southern than in the western region, with significant regional differences for the married male cases and the unmarried female cases. © 2016 Elsevier Ltd.


PubMed | Lund University, Regional Cancer Center South and Development and Education
Type: | Journal: Spatial and spatio-temporal epidemiology | Year: 2016

Screening strategies need to consider differences in late-stage disease detection linked to socio-demographic and geographic factors. We specifically addressed disparity in melanoma stage at diagnosis linked to residential municipality, gender and marital status within the middle- and old-age population of southern and western Sweden. Population-based registers were used to identify the melanoma cases diagnosed in 2004-2013 (n=7,417). Disease mapping for each population group based on gender and marital status showed marked spatial disparities in melanoma incidences and the overall patterns differed by stage at diagnosis. The incidence of early-stage melanoma was markedly higher in the western region, whereas the incidence of late-stage melanoma was markedly higher in the southern region except for married women. Excess mortality among cases was observed to be higher in the southern than in the western region, with significant regional differences for the married male cases and the unmarried female cases.

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