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Objective: To give insight into the fight against cancer in the Netherlands., Design: Nationwide observational cohort study., Method: Data from the Netherlands Cancer Registry on standardized incidence rates and relative survival were analysed. Mortality data was obtained from Statistics Netherlands., Results: Between 1989 and 2017 the number of newly-diagnosed cancers doubled to 111,582. The standardized incidence (ESR) increased from 377 per 100,000 inhabitants in 1989 to 481 in 2011, and stabilized thereafter (459 in 2017). In 2018 the five most common types of cancer were skin cancer (excl. basal cell carcinoma, n = 21,000), breast cancer (n = 15,000), colorectal cancer (n = 14,000), lung cancer (n = 13,000) and prostate cancer (n = 13,000). The incidence of skin cancer rose the fastest (melanoma from 11 to 32 per 100,000; squamous cell carcinoma from 14 to 49 per 100,000). The largest shift to local disease (T1-T2 according to the TNM) was seen in breast cancer (from 50% to 75%). The 5-year survival improved from 50% in patients diagnosed with cancer in 1991-1996 to 65% in 2011-2016. Of the most common cancer types, survival of acute myeloid leukaemia increased the most (from 10% to 25%). The absolute number of deaths increased (from 35,000 in 1989 to 45,000 in 2017), but after standardization this decreased from 234 to 169., Conclusion: The incidence of cancer in absolute numbers is still increasing due to the ageing population. However, taking population demographics into account, the standardized incidence has not increased since 2011. This is related to the decrease in smoking-related cancers, amongst other things. The increase in survival is related to early detection and improved treatment. The decrease in mortality is mainly related to the decrease in lung cancer mortality in men.

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 assess influence of stage at breast cancer diagnosis, tumour biology, and therapy on survival in contemporary times of better (neo-)adjuvant systemic therapy., Design: Prospective nationwide population based study., Method: Female primary breast cancer patients diagnosed between 1999 and 2012 (173,797). Participants were subdivided into two time cohorts on the basis of breast cancer diagnosis; 1999 through 2005 (n = 80,228) and 2006 through 2012 (n = 93,569). Main outcome measures were relative survival, compared between both cohorts, and the influence of traditional prognostic factors on overall mortality, analyzed with Cox regression for both cohorts separately., Results: Compared to 1999-2005 patients from 2006-2012 had smaller ( ≤ T1 65 vs. 60%; p < 0.001), more often lymph node negative (N0 68 vs. 65%; p < 0.001) tumours, but they received more chemotherapy, hormonal therapy, and targeted therapy (neo-adjuvant/adjuvant systemic therapy 60 vs. 53%; p < 0.001). Median follow-up was 9.8 years for 1999-2005 and 3.9 years for 2006-2012. Relative 5-years survival rate was 96% in 2006-2012, improved in all tumour and nodal stages compared to 1999-2005, and 100% in tumours ≤ 1 cm. With multivariable analyses, adjusted for age and tumour type, overall mortality decreased by surgery (especially breast conserving), radiotherapy and systemic therapies. Mortality increased with progressing tumour size in both cohorts (2006-2012 T1c vs. T1a HR 1.54, 95% CI 1.33 to 1.78), but without significant difference in invasive breast cancers until 1 cm (2006-2012 T1b vs. T1a HR 1.04, 95% CI 0.88 to 1.22), and independently with progressing number of positive lymph nodes (2006-2012 N1 vs. N0 HR 1.25, 95% CI 1.17 to 1.32)., Conclusion: Tumour stage at breast cancer diagnosis influences overall survival significantly also in the current era of effective systemic therapy. Early tumour stage at breast cancer diagnosis remains vital.

Liver metastases have the poorest prognosis of all types of breast cancer metastases, with a 5-year survival rate of 0 to 12%. In comparison, the 5-year overall survival rate of patients with colorectal liver metastases undergoing curative liver resection is approximately 30 to 40% and even 50% in selected patients. Partial liver resection in combination with systemic treatment for patients with hepatogenic metastases from breast cancer may lead to improved survival rates for selected patients.

Objective: To gain insight into the survival of cancer patients in order to evaluate any improvement in cancer care., Design: A retrospective population-based cohort study., Method: Data from the Netherlands Cancer Registry were used for this study. For all patients diagnosed with cancer in the Netherlands between 1989 and 2008, information on vital status was obtained from hospitals, municipalities and the Municipal Personal Records Database. Age-standardised, relative survival rates per cancer type were calculated., Results: The 5-year relative survival for all types of cancer combined increased from 47% in 1989-1993 to 59% in 2004-2008. This increase was greater in males than in females (from 40% to 55% and from 55% to 62%, respectively). The most striking improvements in survival were observed in breast, prostate and colorectal cancers, probably for reasons differing for each cancer type. Patients with chronic myeloid leukaemia showed the greatest gain in survival (43%). Survival rates in older patients were generally worse in comparison to those in younger patients, especially in case of head and neck cancer, ovarian cancer and haematological malignancies. The survival gap between older and younger patients has increased over the last 20 years. The 10-year survival rate for most cancer types was not much lower than the 5-year rate, except in chronic and indolent haematological malignancies and cancers that may reoccur after a long time, such as breast and prostate cancer., Conclusion: The increase in survival rates of cancer patients in the Netherlands, attributed to early detection and improved treatment, could represent either an increase in the number of patients cured or to cancer patients living longer lives. A potential area for further improvement is especially notable in the elderly. This is even more important given the ageing population.

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.

Objective: To determine whether a disease cluster of 22 additional cases of pleural mesothelioma among women could be attributed to environmental asbestos exposure due to asbestos fibers from waste material on roads and property yards. The women studied were observed in an area with substantial environmental exposure to asbestos during the period 1989-2002., Design: Ecological study., Method: In the study period of 1989-2002, all cases of mesothelioma among women, based on a strict histopathologic definition, occurring in the region of Twente, The Netherlands (n = 59) were provided by the regional cancer register. Additional information was collected on the occupational histories of the cases and their partners and addresses of residence through medical records, general practitioners, and next-of-kin. Environmental asbestos exposure was assigned to all cases that had had a long-term stay in a house in the area around Goor with demonstrated local environmental asbestos pollution and where any contact with asbestos through occupation or in the household had been excluded., Results: In the risk area around Goor, out ofa total of 28 cases ofwomen with pleural mesothelioma, asbestos in the environment was found to be the only source of asbestos exposure for to women. In a further 4 women, environmental asbestos exposure was found to be the most likely cause of pleural mesothelioma. The average cumulative exposure was around 0.11 fiber/ml x exposure years. The observed extra incidence of 22 cases was attributed to the environmental exposure to asbestos in 64% (14/22) of cases., Conclusion: The environmental pollution to asbestos waste materials in the area around Goor was the main cause of the strongly increased incidence of pleural mesothelioma among women in this area. Taking into account an equal risk among men, the consequences of asbestos exposure in the area around Goor in the next 25 years are likely to result in 2 cases of pleural mesothelioma each year.

Objective: To provide insight into the changing nature and size of the cancer burden within The Netherlands., Design: Retrospective., Method: Data on incidence and death relating to various forms of cancer are calculated on the basis of registered data concerning the incidence (Netherlands Cancer Registration; NCR) of and death (Statistics Netherlands) from cancer in the Netherlands from 1989 until 2003., Results: From the start in 1989 up to 2003, more than one million new cases of cancer were registered with the NCR. The total number of new patients with a primary tumour increased from 56,335 in 1989 to 73,188 in 2003 (30%). The most frequently occurring tumours in 2003 were of the breast, colon, lung and prostate. The age standardized incidence rate for males and females combined, increased from 381 per 100,000 in 1989 to 400 per 100,000 person years in 2003 (+5%). There was an increase in breast, prostate, skin and oesophagus cancer, and also lung cancer in females. Major decreases were seen in lung cancer in males, as well as stomach, ovary and gallbladder cancer. The number of cancer deaths in the Netherlands increased from 35,420 in 1989 to 38,454 in 2003 (+8%). The age and sex standardized mortality rate declined from 234 per 100,000 in 1989 to 201 per 100,000 in 2003 (-14%)., Conclusion: Despite a slight increase in the incidence of cancer and an increase in mortality from lung cancer (in females), oesophageal cancer and melanomas, the death rate from cancer has dropped considerably. The changes in incidence and mortality may be explained by changes in lifestyle in the 1970s and 80s, in particular use of tobacco and alcohol. Also early detection and screening programmes have resulted in an increase in the incidence of tumours with a better prognosis, which has led to a decrease in mortality. The downward trend in mortality was also influenced by treatment-improving prognoses.

Objective: To give an overview of the trends and variation in breast-conserving surgery in patients with a breast tumour < or = 2 cm (pT1) or > 2 and < or = 5 cm (pT2), treated in general hospitals in the southeast and east of the Netherlands., Design: Descriptive., Method: Data from the regional cancer registries of the Comprehensive Cancer Centre South (CS) and the Comprehensive Cancer Centre Stedendriehoek Twente (CST) were used to study trends and variations in the use of breast-conserving surgery in 12,985 pT1 tumours and 8,893 pT2 tumours in the period 1990-2002., Results: The mean percentage of patients that underwent breast-conserving surgery from 1990-2002 was 54 in the CS region and 43 in the CST region. In patients < 50 years old with a pT1 tumour a decrease in the percentage of breast-conserving surgery from 73 to 64 was seen in the CS region, and in the CST region this percentage decreased from 72 to 51. In pT2 tumours a decrease from 47 to 37 was seen in the CS region and from 34 to 31 in the CST region. In patients of 50 to 69 years of age with a pT1 tumour, the percentage of breast-conserving surgery increased in the CS region from 67 to 74 and in the CST region from 54 to 61. In pT2 tumours it increased from 40 to 44 and from 25 to 37. In patients > or = 70 years the percentage of breast-conserving surgery in pT1 tumours increased from 37 to 59 in the CS region and in the CST region from 42 to 50. In pT2 tumours it increased from 20 to 31 in the CS region whereas it remained 17 in the CST region. The variation in breast-conserving surgery between hospitals in the period 1999-2002 was large. The percentage of breast-conserving surgery in patients with pT1 tumours varied between 47 and 86 in the hospitals in the CS region and between 54 and 71 in the CST region. In patients with a pT2 tumour the percentages varied between 25 and 43 in the CST region and between 16 and 64 in the CS region., Conclusion: More than 20 years after the introduction of breast-conserving surgery a large regional variation still exists in the use of this treatment, in the CS region in particular. There is also wide inter-hospital variation.

Objective: To describe and interpret changes in incidence, mortality and survival of lung cancer in the Netherlands in the period 1989-1997., Design: Secondary data analysis., Methods: Data on the incidence of lung cancer were collected from the Dutch Cancer Registration (1989-1997), on mortality from Statistics Netherlands (CBS; 1989-1994), on the incidence of lung cancer in other European countries from EUROCIM (1990-1994), on survival of Dutch lung cancer patients from the Comprehensive Cancer Centre Amsterdam (1988-1997) and the Comprehensive Cancer Centre South (1988-1992) and on survival of other European lung cancer patients from EUROCARE (1985-1989). Incidence rates were calculated per 100,000 person years and standardized by age according to the European population structure. Survival was calculated as the ratio of observed survival among the lung cancer patients and the expected survival of the general population., Results: The incidence of lung cancer among men decreased from 109 to 93, whereas that among women increased from 18 to 23. The incidence of lung cancer among Dutch men was high in comparison to other European countries, whereas that among women was average. The trends in lung cancer incidence were probably related to the trends in past smoking behaviour. Mortality decreased among men from 106 to 91 and increased among women from 15 to 20. Survival was better for younger patients, a localised tumour, and better for squamous cell carcinoma or adenocarcinoma than for large-cell undifferentiated or small-cell carcinoma. The relative 5-year survival was 12%, the relative 1-year survival 39%; these were good in comparison with other European countries., Conclusion: The incidence and mortality of lung cancer among Dutch men decreased, but still in 1997 almost 20 men in the Netherlands died each day of lung cancer. Among women the end of the increase is not in sight and in 1997 over 5 women died each day of lung cancer.