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Objective: All Dutch hospitals are obliged to report their 5-year ipsilateral breast tumor recurrence (IBTR) rate after breast cancer surgery. Experts decided that these rates should not exceed 5%. This study determined the value of IBTR as an indicator to compare quality of care between hospitals., Design: Cohort study, Method: All patients with breast cancer (pT1-3, any N, M0) who underwent surgery in 1 of 92 Dutch hospitals from 2003 to 2006 were identified in the Netherlands Cancer Registry. Data of recurrence was retrieved from hospital records. Five-year IBTR rates for breast-conserving surgery (BCS) and mastectomy were calculated using the Kaplan-Meier method. Hospital variation was presented in funnel plots . Multivariate analysis was used to assess hospital characteristics associated with IBTR rates., Result: A total of 40,892 breast cancer patients were included. The overall 5-year IBTR rate was 2.85% (95%-CI 2.68-3.03) and was significantly lower for BCS than for mastectomy (2.38% vs 3.45%, p < 0.001). IBTR rates decreased over time in both groups. Rates varied between 0.77 and 5.70% between hospitals. When random variation is taken into account, only extremely high IBTR rates can be detected as deviant from the target value of 5%. Adjusting for tumor and patient characteristics, analyses showed that a higher volume of mastectomies is associated with lower IBTR rates., Conclusion: Our population-based findings show that IBTR rates in the Netherlands are low and have improved over time. The 5-year IBTR rate as an indicator for quality of care of individual hospitals is of limited value.

Objective: To calculate the proportion of cancer cases in the Netherlands in 2010 that were attributable to lifestyle factors by using the most recent data., Design: Secondary analysis., Method: Lifestyle risk factors studied were tobacco smoking, alcohol consumption, overweight, lack of physical exercise, and six elements of diet (consumption of vegetables, fruit, processed meat and red meat, and calcium and fibre intake). The lifestyle factors were organised so that the group with the highest risk (e.g. smokers) could be compared with the groups with the lowest risk (e.g. ex-smokers, non-smokers). Cut-off points were in line with Dutch public health messages. We obtained prevalence data on risk factors from national databases. Relative risks for the relationship between lifestyle and cancer were based on the international literature. Incidence and mortality data for cancer in 2010 were obtained through the Netherlands Cancer Registry. We calculated percentages of new cancer cases and deaths for men and women and for each type of cancer individually; these were then summed., Results: We estimated that of the 98,971 newly-diagnosed cases of cancer among persons aged ≥ 20 years in the Netherlands in 2010, 29,938 (30%) were attributable to the above-mentioned lifestyle factors. Smoking was the most important contributory risk factor (19% of all new cancer cases), followed by sub-optimal dietary habits (10%), overweight (4%), alcohol consumption (3%), and lack of physical activity (2%). Of cancer deaths in 2010, an estimated 38% were attributable to lifestyle factors. Projections for 2020 show that lack of exercise and consumption of alcohol and meat will contribute less to the development of cancer while overweight and a reduction in inadequate dietary fibre intake and inadequate fruit and vegetable consumption will contribute more., Conclusion: Almost one-third of all cases of cancer and almost 40% of deaths from cancer can be attributed to a less healthy lifestyle.

Petra Peeters has had Parkinson's disease since she was 44 years old. Deeply unhappy due to her symptoms and the lack of effect from her medication, ten years on she chose to undergo deep brain stimulation treatment. She reports on the stereotactic procedure, her initial euphoria and the ups and downs that followed. How bionic does she feel?

The ACRIN 6666 trial has shown that the addition of ultrasound or MRI to mammography screening detects more breast cancers in women with dense breasts and at least one other breast cancer risk factor. This higher detection yield is accompanied by an increase in false-positive findings. Unfortunately, this study was not randomized into groups with and without the addition of ultrasound and MRI. It is therefore impossible to investigate if the improved detection rate also results in a smaller number of interval tumours which would be the best indication of the ultimate goal - a decrease in breast cancer mortality. Before any new and costly imaging is added to the breast cancer screening program, it is necessary to investigate if this will not merely increase the detection of indolent tumours. If additional imaging is implemented too hastily it will be hard to turn it back, and impossible to assess it in a randomized study.

Prevention of breast cancer is difficult, as most risk factors are difficult to control. Therefore, we have not been able to stop breast cancer incidence rates from rising over past decades. Chemoprevention using aromatase inhibitors, such as exemestane, may change this situation. Aromatase inhibitors are very effective and safe in preventing recurrent disease in postmenopausal breast cancer. A recent randomised placebo-controlled trial showed that in healthy women at moderately increased risk of breast cancer, use of exemestane over a 3-year period reduced the risk of breast cancer by 65%. The reduction was from 0.55% to 0.19% per year, with no adverse events or measurable effect on quality of life. If confirmed by larger studies with longer duration of follow-up, preventive use of exemestane may turn out to be the first acceptable alternative for women at increased risk of developing breast cancer. On a population level, implementation of prevention using aromatase inhibitors has the potential to reduce the incidence of breast cancer. However, currently in the Dutch population, 140 women would need to use exemestane for three years in order to prevent one invasive breast tumour. Therefore, large-scale implementation of exemestane is not advised, but the evidence is sufficient to start studies with exemestane.

The Dutch Cancer Society developed the 'KWF Kanker Risico Test' (Cancer Risk Test) to improve the information available to the Dutch population regarding cancer risk factors. This Internet test, based under licence on the American 'Your Disease Risk' test, informs users about risk factors for 12 common types of cancer. The test provides an estimate of individual risk of a specific type of cancer and gives specific lifestyle advice that could lower that risk. This paper describes the development of the test, how it works, and its strengths and limitations.

It is estimated that nationwide screening for colorectal cancer in the Netherlands will necessitate 66,000 colonoscopies per year. The quality of a colonoscopy depends on the operator. Recently, quality indicators for colonoscopies performed by 5 endoscopists at a large Dutch hospital were compared. The percentage of successful colonoscopies per endoscopist ranged from 88-97% and the adenoma detection rate (ADR) between 27-52%. The authors concluded that the variation between these operators was great, but within proposed quality limits. The number of procedures each operator had performed, however, is too small to draw this conclusion. In addition, ADRs were not adjusted for important differences between the patients. The study shows that, in addition to operator expertise, several other factors determine the quality of a colonoscopy. Given its central role in national colon cancer screening, methods for assuring the quality of colonoscopy are urgently needed.

Objective: To describe the percentage of local recurrences within 5 years after surgery for breast cancer as a performance indicator for Dutch hospitals., Design: Descriptive, cohort study., Method: All women diagnosed with a primary invasive breast cancer in 2003 for which they underwent curatively intended surgical treatment (with or without radiotherapy), were selected from the Netherlands Cancer Registry (NCR). NCR registration clerks collected additional information on recurrences within 5 years after initial diagnosis following standardized protocol. Percentages of local recurrences per hospital were estimated using Kaplan Meier analysis and were presented in forest plots and funnel plots., Results: In 2003, 9898 women diagnosed with primary breast cancer were curatively treated in one of the 99 Dutch hospitals. 266 patients experienced local recurrences within 5 years. The 5-year percentage of local recurrences was 3.03% (95% CI: 2.69-3.41). Following breast conserving surgery the 5-year percentage of local recurrence was 2.63% (95% CI: 2.21-3.12), and following mastectomy 3.50% (95% CI: 2.97-4.13). Stratification by hospital shows large variation in recurrence rates (0-17%). However, the number of patients treated in most hospitals is too small to provide reliable estimates., Conclusion: The percentage of local recurrences following surgical treatment for breast cancer in the Netherlands was lower than the accepted standard of 5% within 5 years. Statements on differences in quality of care between hospitals cannot be made on the basis of these data, on account of the low average recurrence rate and the small number of cases per hospital.