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The objective of this study was to present trends in colorectal cancer incidence by sex and subsite in a well-defined French population. All of the 4486 large bowel cancer cases registered between 1976 and 1995 in the Burgundy registry of digestive tract cancers was included in this study. Time trends in colorectal cancer incidence were analysed over the 1976-95 period. The effects of age, period and cohort were evaluated using a log-linear Poisson model. The incidence rates for right colon cancer increased over time: + 21.6% (95% CI: + 13.5; + 29.7) per 5-year period in males and +10.4% (95% CI: + 3.4; + 17.3) in females. Left colon cancer rates increased in males (+ 10.6% 95% CI: + 4.6; + 16.6). Left colon cancer in females and rectal cancer incidence rates did not significantly change. Between the 1901 cohort to the 1941 cohort, estimated cumulative risks for right colon cancer increased sharply. The increase was less marked for left colon and the cumulative risk for rectal cancer remained almost stable. Temporal trends were different by subsites and sexes. In conclusion, our results confirm the existence of different trends in colorectal cancer incidence between subsites and sexes. These differences probably reflect aetiological distinctions.

Background: Cancer registries recording all cases diagnosed in a well defined population represent the only way to assess real changes in the management of colon cancer at the population level., Aims: To determine trends over a 23 year period in treatment, stage at diagnosis, and prognosis of colon cancer in the Côte-d'Or region, France., Patients: A total of 3389 patients with colon cancer diagnosed between 1976 and 1998., Methods: Time trends in clinical presentation, surgical treatment, chemotherapy treatment, stage at diagnosis, postoperative mortality, and survival were studied. A non-conditional logistic regression was performed to obtain an odds ratio for each period adjusted for the other variables. To estimate the independent effect of the period on prognosis, a relative survival analysis was performed., Results: Between 1976 and 1991, the resection rate increased from 69.3% to 91.9% and then remained stable. This increase was particularly marked in the older age group (56.4% to 90.5%). The proportion of stage III patients treated with adjuvant chemotherapy rose from 4.1% for the 1989-1990 period to 45.7% for the 1997-1998 period. Over the 23 years of the study the proportion of stage I and II patients increased from 39.6% to 56.6%, associated with a corresponding decrease in the proportion of patients with advanced stages. Postoperative mortality decreased from 19.5% to 7.3%. This led to an improvement in five year relative survival (from 33.0% for the 1976-1979 period to 55.3% for the 1992-1995 period)., Conclusions: Advances in the management of colon cancer have resulted in improving the prognosis of this disease. However, progress is still possible, particularly in the older age group.

IN THE ABSENCE OF ENDOSCOPIC MONITORING: The risk of colorectal cancer is higher than in the general population in patients presenting an adenoma with a diameter of more than 1 cm, and/or comprising villous structures and/or severe dysplasia. The risk is not increased in the presence of one or two tubular adenomas measuring less than 1 cm and without severe dysplasia. It has been demonstrated that endoscopic monitoring decreases the incidence and mortality of colorectal cancers in these patients. MONITORING MODALITIES: A control colonoscopy, 3 years after polypectomy is sufficient in most cases. Colonoscopy is recommended within the 3 months following exeresis of a transformed sessile adenoma, in order to check that the polypectomy was complete. A control colonoscopy can be performed 1 year later in the rare cases presenting more than 3 adenomas, with one measuring more than 1 cm. When the control colonoscopy is normal, one can wait at least five years before conducting a further control.

Background: Few data are available from population-based statistics on the risk of local recurrence after surgery for rectal cancer. The aims of this study were to determine factors influencing local control and to analyse treatment and prognosis of recurrences in a well defined population., Methods: Data were obtained from the cancer registry of the Côte d'Or (France). From 1976 to 1995, 682 patients resected for cure for a rectal carcinoma were included. Recurrence rates and survival rates were calculated using actuarial methods. A relative survival analysis and Cox multivariate analysis were performed., Results: During the study 135 local recurrences were registered. The 5-year cumulative local recurrence rate was 22.7 per cent. In multivariate analysis the two variables significantly associated with local recurrence risk were stage at diagnosis and the macroscopic type of growth. There was a non-significant decrease in local recurrence rate in patients treated by preoperative radiotherapy compared with that in patients treated by surgery alone. The proportion of patients re-resected for cure was 25.2 per cent, and increased from 13.0 per cent in 1976-1985 to 37.9 per cent in 1986-1995 (P = 0.001). The 5-year relative survival rate was 13.6 per cent overall and 40.6 per cent after resection for cure (P < 0.001)., Conclusion: Local recurrence of rectal cancer following resection remains a substantial problem. Improvement can be expected from better care and earlier diagnosis.

3 controlled cohorts of mass-screening for colorectal cancer using a biennial faecal occult blood (HemoccultII test on well-defined European populations have demonstrated a 14% to 18% reduction in specific mortality. We aimed to estimate the sensitivity (S) of this HemoccultII test and and also mean sojourn time (MST) from French colorectal mass-screening programme data. 6 biennial screening rounds were performed from 1988 to 1998 in 45 603 individuals aged 45-74 years in Saône-et-Loire (Burgundy, France). The prevalent/incidence ratio was calculated in order to obtain a direct estimate of the product S.MST. The analysis of the proportional incidence and its modelling was used to derive an indirect estimate of S and MST. The product S.MST was higher for males than females and higher for left colon than either the right colon or rectum. The analysis of the proportional incidence confirmed the result for subsites but no other significant differences were found. The sensitivity was estimated at 0.57 and the MST at 2.56 years. This study confirms that the sensitivity of the Hemoccult test is relatively low and that the relatively short sojourn time is in favour of annual screening., (Copyright 2001 Cancer Research Campaign.)

Mutations of the p53 gene are the most common genetic alteration in malignant human tumors. A cyclin-dependent kinase inhibitor, p21WAF1/CIP1, is thought to be an important mediator of p53-induced cell cycle arrest. Although numerous studies have reported p53 expression and mutation in colorectal cancer few of them have correlated p53 expression with that of its downstream effector p21 and with the proliferation index as measured by expression of the Ki67 nuclear antigen. We studied p53, p21 and Ki67 expression by immunohistochemistry and molecular biology in 35 colorectal carcinomas. We compared these findings with each other and with clinical factors. Sixty three percent of tumors expressed p53 whereas seventy one percent expressed p21WAF1/CIP1. In adenocarcinomas, p21 staining was heterogeneous: p21-reactive cells were seen in the most differentiated areas. There was no correlation between p21WAF1/CIP1 and p53 expression, p53 mutation, Ki67 expression or clinical factors such as sex or location of the tumor. On the other hand, there was a statistical relationship between p21 expression and survival: our results indicated an association between high p21 expression and lower stages p21WAF1/CIP1 appears to be induced independently of p53 in these tumors and may be associated with differentiation rather than proliferation.

Purpose: Little is known about colorectal cancer in young patients at a population level, and the behavior, characteristics, and prognosis of such tumors continue to be debated., Methods: A population-based series of 4,643 new cases of colorectal adenocarcinomas diagnosed between 1976 and 1996 in C te d'Or, France, was used to describe time trends in incidence, predisposing conditions, location, stage, and treatment and to evaluate the prognosis of such tumors in patients under 45 years of age (n = 146). Prognosis was determined using relative survival rates and predictive factors using a multivariate relative survival model., Results: Before the age of 45 years, age-standardized incidence rates were 1.9 per 100,000 in males and 1.4 per 100,000 in females. Incidence rates almost doubled from 1976 to 1982 and from 1983 to 1989 in both genders and stabilized thereafter. The frequency of predisposing conditions was significantly higher before the age of 45 years (11.7 vs. 0.4 percent; P < 0.001). TNM Stage III tumors were more frequent in younger patients, and Stage II tumors were more frequent in older patients. The postoperative mortality rate was lower in the 0-to-44 age group, 2.1 percent, compared with 8.4 percent for the 45-and-over age group (P = 0.004). Five-year relative survival rates were 51.9, 49.2, and 41.4 percent, respectively. In both overall and stage-for-stage comparisons, patients before the age of 45 years had a better survival rate than older patients. Gender and stage at diagnosis were the only independent prognostic factors of survival for young patients., Conclusions: This study confirms the high frequency of predisposing conditions in young patients and that young age is not a poor prognostic factor for colorectal cancer. This underlines the importance of family screening, aggressive surveillance, and treatment in the young with known predisposing conditions.

The prevalence in France of patients with colorectal cancer was estimated using data from five population-based cancer registries. At the end of 1994, the number of cases diagnosed in France no more than 5 years before was approximately 95000, of whom 12180 had suffered metastasis and 9746 a local recurrence. This type of cancer is the most common in both men and women and these results enable the need for care or surveillance to be evaluated more accurately.

Background and Purpose: To assess the use of adjuvant radiotherapy in treating rectal cancers at a population level., Materials and Methods: From 1976 to 1996, the influence of the period of diagnosis, sex, age, type of surgical resection, place of surgical resection on the use of radiotherapy was studied. A non-conditional logistic regression was performed to obtain the odds radio for each studied period adjusted for the other variables., Results: The use of adjuvant radiotherapy increased over time from 14.3% in 1976-1978 to 61.7% in 1994-1996 (odds ratio (OR): 28.0 for the 1994-1996 period compared with 1976-1978). It was also influenced by age (OR: 0.26 for patients >74 years compared with those <65 years), type of resection (OR: 3.42 for abdominoperineal resection compared with anterior resection) and place of surgery (OR: 0.39 for non-university hospitals compared with university hospitals). The nature of adjuvant radiotherapy altered over time: most adjuvant radiotherapy being done postoperatively before 1988, then preoperatively subsequently., Conclusions: Substantial changes have occurred in both the degree of use of adjuvant radiotherapy and in its timing. Some progress is still possible, in particular in older patients and in patients treated in non-university hospitals.

Objectives: To compare the characteristics of patients with anti-hepatitis C virus antibodies followed in a University Hospital Department of Hepatogastroenterology with those in patients who received medical care elsewhere., Methods: Since 1994, a specialized viral hepatitis register has recorded since 1994 all new cases of anti-hepatitis C virus antibodies diagnosed in inhabitants of the French department of Côte-d'Or (493931). The factors correlated with the type of medical care in patients followed in the University Department were studied by logistical regression., Results: One hundred of the 498 new patients with anti-hepatitis C virus antibodies diagnosed in the Côte-d'Or between 1994 and 1996 were followed in a University Hospital Department. Multivariate analysis showed that age (<60), contamination due to transfusion, elevated ALT levels and no excessive alcohol consumption were factors significantly correlated with follow-up at the University Department. Liver biopsy was more often performed (66%) and a treatment was more often prescribed (34%) in patients followed in a University Department of Hepatogastroenterology patients than in other patients (20.4%; P <0.0001 et 7.5%; P <0.0001 respectively)., Conclusions: This study shows that patients with anti-hepatitis C virus antibodies who are followed by a specialised University Department are a selected group; these patients are more likely to be treated than others. This study emphasizes that the greatest care must be taken when extending the extension of results of hospital series to a non-selected population.

It is not well known if the improvement in operative mortality after surgery for gastric cancer reported in hospital series can be extrapolated to the whole population. The aim of this study was to determine trends in operative mortality over a 20-year period in a nonselected community-based series of patients. A database of 648 patients with gastric cancer resected with curative intent between 1976 and 1995 in a region with a half-million population was divided into two periods: 1976-1983 and 1984-1995. Nonconditional logistic regression was performed to estimate the independent effects of the studied factors. Operative mortality was higher during the 1976-1983 period than during the 1984-1995 period (17.1% vs. 7.1%; p < 0.0001). When comparing the two study periods, operative mortality decreased dramatically from 26.2% to 10.0% in patients over age 70, from 31.8% to 7.9% after total gastrectomy, and from 30.7% to 6.3% after proximal esophagogastrectomy. Operative mortality after total gastrectomy was nearly the same as that after distal gastrectomy (7.9% vs 5.9%) during the second study period. During the first study period, operative mortality was independently associated with age at diagnosis, type of gastrectomy, and to a lesser degree stage at diagnosis; during the second study period, only age and stage at diagnosis were associated with the risk of operative mortality. This study indicates that in this well defined population operative mortality after curative resection for gastric cancer has decreased during the last 20 years. The results should encourage aggressive management of patients with gastric cancer, even in patients over 70 years of age.

Background: Little is known, at a population level, about the incidence and management of gallbladder carcinoma. The objective of this study was to determine trends in incidence, treatment, stage at diagnosis, and prognosis of gallbladder carcinoma in a well defined population., Methods: A series of 484 patients diagnosed over a 20-year period (1976-1995) in a French well defined population was used. Incidence rates were calculated by gender, age groups, and 5-year periods. Prognosis was determined using crude and relative survival rates. A multivariate relative survival analysis was performed., Results: Age-standardized incidence rates were 0.8 per 100,000 inhabitants for men and 1.5 per 100,000 inhabitants for women. There were no significant time trends in incidence in both genders. The proportion of cases resected for cure increased from 18. 1% (1976-1980) to 42.4% (1991-1995) (P < 0.001) as well as the proportion of cases limited to the gallbladder wall, respectively from 15.7% to 27.8% (P < 0.001). Relative survival rates were 16.6% at 1 year and 6.2% at 5 years. Age, stage at diagnosis, and period of diagnosis significantly influenced the prognosis of gallbladder carcinoma. The 5-year relative survival rate rose from 2.7% (1976-1985) to 10.2% (1986-1995). The multivariate analysis showed that age and stage at diagnosis were independent prognostic factors., Conclusions: This study demonstrated that gallbladder carcinoma incidence is stable in France and that substantial advances in its management have been achieved, but there is evidence that further improvements are necessary to increase survival., (Copyright 2000 American Cancer Society.)

Aims: The aim of this study was to determine long term prognostic factors of gastric cancer in a population-based series., Methods: Out of 1 462 gastric cancers diagnosed in the Côte-d'Or area (494 000 residents) over a 20-year period (1976-1995), 649 (44.4 %) were resected for cure. Prognostic factors were determined using the actuarial method and relative survival and a multidimensional relative survival model., Results: The 10-year crude survival rate was 8.7 % and the corresponding relative survival rate was 14.9 %. Age, stage and period of diagnosis were independent prognostic factors. After surgery for cure, operative mortality decreased from 18.3 % (1976-1979) to 6.6 % (1988-1991) and 10-year relative survival increased from 30.8 % to 37.2 % (NS). After resection for cure (postoperative mortality excluded), the 10-year survival rate remained stable over time. Stage at diagnosis was the main prognostic factor: the relative risk of death was more than 10 times higher at stages IIIB and IV than at stage I. Age, site and macroscopic type of growth were prognostic factors independently of stage. Prognosis did not improve over time after resection for cure., Conclusion: Although improving, the overall prognosis of gastric cancer remains poor. Improvement in prognosis was mainly due to decrease in operative mortality. Earlier diagnosis and effective adjuvant treatment represent two ways to improve prognosis.

The aim of this study was to document patterns of survival after resection for cure for gastric cancer in a well-defined population. A population-based series of 649 gastric cancers resected for cure between 1976 and 1995 in a 494000 population, was used. Resection for cure was performed in 44.4% of the diagnosed cases. This proportion increased from 36.8% (1976-1979) to 45.0% (1992-1995) (P=0.03) whilst operative mortality decreased from 18.3 to 12.7% (P=0.003). The overall crude 5-year survival rate (excluding operative mortality) was 32.6% (95% confidence interval (CI) 28.7-36. 5) and the corresponding relative survival rate was 40.9%. Prognosis did not improve during the study period. Stage at diagnosis was the most important prognostic factor, the 5-year relative survival rate being 81.2% (+/-5.9) in TNM stage IA, 76.9% (+/-8.0) in stage IB, 50. 4% (+/-4.6) in stage II, 24.4% (+/-3.7) in stage IIIA, 5.6% (+/-3.2) in stage IIIB and 5.2% (+/- 2.2) in stage IV. Stage at diagnosis, age, subsite and macroscopic type of growth were independent prognostic factors, in a multivariate relative survival model. Earlier detection or development of an effective adjuvant therapy could contribute to improvement in prognosis.

Analysis of survival of patients with cancer sets particular epidemiological and statistical problems, especially when one wants to take into account metastasis or local recurrences. Cox's model does not allow modeling multiple events. Wei et al. have proposed an extension of Cox's model, by formulating the marginal distributions of multivariate failure times, which allows testing covariates effects on different events. We applied these methods to data from the Registry of Digestive Tumors of Burgundy, France. Prognostic factors of recurrence are rectal location of tumor and advanced stage at diagnosis. Prognostic factors of death are male gender, age greater than 75, rectal location and advanced stages. However, relative risk of recurrence for advanced stages is significantly greater than relative risk of death (p=4.10(-3)), while tumor location has the same influence on the two events.

The knowledge of descriptive epidemiology of colorectal cancer is a prerequisite essential to a better understanding of the aetiology of the disease and the development of prevention strategies. This work provides an update of descriptive epidemiological data on colorectal cancer incidence in the world. In 1988-1992, incidence rates of colorectal cancer varied from 15- to 25-fold according to the geographical area. The highest rates were observed in Western countries, especially in North America, Australasia and, to a lesser extent, in northern and western Europe. The geographical distribution of colorectal cancer was similar in men and women. An examination of incidence data by subsites showed that the magnitude of geographical variations was more important for colon cancer than for rectal cancer. Contrasting with the male predominance for rectal cancer and, to a lesser degree, for left colon cancer, cancers of the right colon were found to be as frequent in women as in men. Examination of time trends during the last decades reveals a sharp increase in incidence of colorectal cancer in Japan and in eastern and southern Europe. On the other hand, incidence rates show some stagnation in North America and western Europe in recent years. In fact, there are some suggestions for differential time trends according to the anatomical subsite, with a recent proximal shift in the distribution of cancers of the large bowel in Western countries. In conclusion, descriptive epidemiological data support the notion that distinct pathogenic mechanisms may be involved in the carcinogenesis of the proximal and distal bowel.

Objectives: Information about the incidence of cancer in the national territory is a necessity for decision makers in public health. The aim of this study was to estimate for the first time the incidence of digestive tract cancers in each region of France in 1992 as well as trends in incidence between 1985 and 1995., Methods: The incidence/mortality ratio established by sex, by age group and by localization in the departments covered by a cancer registry was applied to the mortality of each region studied. The mortality data were fit by applying a log linear model., Results: The highest incidence rates of esophageal cancer were found in the North, in Brittany, Normandy and Picardy. The lowest rates were found in the regions of Midi-Pyrénées, Languedoc-Roussillon, Provence-Alpes-Côte d'Azur, Aquitaine and Poitou-Charentes. The incidence of this cancer decreased slightly between 1985 and 1995. Brittany and Normandy were also high risk regions for gastric cancer, while Provence-Alpes-Côte d'Azur, Midi-Pyrénées and Poitou-Charente were low risk regions. The incidence of gastric cancer also decreased more markedly than that of esophageal cancer. Colorectal cancer was more frequent in Alsace, Lorraine and in the North, it was less common in Provence-Alpes-Côte d'Azur, Midi-Pyrénées and Franche-Comté. The incidence of this cancer increased little over the 10 years of the study., Conclusion: There are regional disparities in the incidence and trends of digestive cancer incidence. These are more marked for esophageal cancer and gastric cancer than for colorectal cancer. The data supplied are of use both in the planning of health care and in the study of the causes or the prevention of digestive cancers.

Objectives: The aim of this population-based study was to specify the positivity rate, the positive predictive value of Hemoccult test as well as the characteristics of the cancers and adenomas screened during the successive colorectal cancer screening campaigns., Methods: This study focused on five colorectal cancer mass screening campaigns by Hemoccult test carried out between 1988 and 1996. The test was offered every two years to a cohort of subjects born between 1914 and 1943 and living in some districts of the Saône-et-Loire administrative area., Results: The positivity rate of the test was higher in the first campaign (2.1%) than in the subsequent ones (mean 1.3%). It was also higher in males than in females and it increased with age. After a positive test, 85.4% of the subjects had a colonic exploration. The exploration rate was higher when the test was offered by general practitioners (88.0%) than when it was mailed (77.8%) (P < 0.01). Through this test, cancer was detected in 168 patients, and one adenoma or more in 414 patients. The positive predictive value was 11.4% for cancer, 17.1% for adenoma > or = 1 cm and 11.1 for adenoma < 1 cm. It was higher in males than in females and it increased with age. Depending on the campaigns, 35.9% to 47.3% of the subjects explored after a positive test had a cancer or an adenoma. The screened cancers or adenomas were more often localized in the sigmoid or the rectum. Three quarters of screened cancers were stage I or II (TNM classification). All together, 82.7% of cancers were treated with surgical resection for cure and 10.1% with endoscopic resection., Conclusions: This work confirms the feasibility of carrying out regular colorectal cancer screening campaigns, through which a few subjects can be selected for undergoing colonic explorations. These latter can detect a cancer or adenoma in 40% of cases.

Interval cancers represent the major limitation of screening for colorectal cancer with the faecal occult blood test. The aim of this study was to describe the characteristics of interval cancers and the sensitivity of the screening programme in a well-defined French population. During five screening rounds, 398 cancers were diagnosed in those of the population having performed at least one screening test; 57.8% of them were interval cancers. The proportion of interval cancers was higher among cancers of the rectal ampulla (72.2%) than among cancers of other sites (52.9%) (P < 0.001). The proportion of TNM stage I and II were higher among screen-detected cancers (73.8%) than among interval cancers (57.4%). The overall sensitivity of the screening programme was 62.9% within 1 year, and 48.7% within 2 years. An improvement in the sensitivity of the faecal occult blood test for colorectal cancer screening is needed, without an unacceptable loss of specificity.

Background: Over the past 20 years there have been many changes in the management of rectal cancer. Their impact on the overall population is not well known., Aims: To determine trends in management and prognosis of rectal cancer in two French regions., Subjects: 1978 patients with a rectal carcinoma diagnosed between 1978 and 1993., Methods: Time trends in treatment, stage at diagnosis, operative mortality, and survival were studied on a four year basis. A non-conditional logistic regression was performed to obtain an odds ratio for each period adjusted for the other variables. To estimate the independent effect of the period a multivariate relative survival analysis was performed., Results: Over the 16 year period resection rates increased from 66.0% to 80.1%; the increase was particularly noticeable for sphincter saving procedures (+30.6% per four years, p=0.03). The percentage of patients receiving adjuvant radiotherapy increased from 24.0% to 40.0% (p=0.02). The proportion of patients with Dukes' type A cancer increased from 17. 7% to 30.6% with a corresponding decrease in those with more advanced disease. Operative mortality decreased by 31.1% per four years (p=0.03). All these improvements have resulted in a dramatic increase in relative survival (from 35.4% for the 1978-1981 period to 57.0% for the 1985-1989 period)., Conclusions: Substantial advances in the management of rectal cancer have been achieved, but there is evidence that further improvements can be made in order to increase survival.

To estimate the efficacy of screening on colorectal cancer mortality, a population-based case-control study was conducted in well-defined areas of Burgundy (France). Screening by faecal occult blood test prior to diagnosis in cases born between 1914 and 1943 and who died of colorectal cancer diagnosed in 1988-94 was compared with screening in controls matched with the case for age, sex and place of residence. Cases were less likely to have been screened than controls, with an odds ratio (OR) of 0.67 [95% confidence interval (CI) 0.48-0.94]. The negative overall association did not differ by gender or by anatomical location. The odds ratio of death from colorectal cancer was 0.64 (95% CI 0.46-0.91) for those screened within 3 years of case diagnosis compared with those not screened. It was 1.14 (95% CI 0.50-2.63) for those screened more than 3 years before case diagnosis. There was a negative association between the risk of death from colorectal cancer and the number of participations in the screening campaigns. The inverse association between screening for faecal occult blood and fatal colorectal cancer suggests that screening can reduce colorectal cancer mortality. This report further supports recommendations for population-based mass screening with faecal occult blood test.

Aims: To determine the epidemiological characteristics and management of cancers of the small bowel, on a population-based survey., Methods: The registry of digestive tumors of Burgundy recorded all new cases of cancers of the small intestine in the departments of Côte d'Or and Saône et Loire (1,052,000 inhabitants)., Results: Two hundred and ten new cases of malignant tumors of the small intestine were recorded between 1976 and 1995 including 4 main histological types: adenocarcinomas (39.5%), carcinoids (26.2%), lymphomas (18.6%) and sarcomas (10.5%). Age-standardized incidence rates for males and females were respectively 8.8 and 5.6 per 1,000,000 inhabitants. There was evidence of lymph node invasion in 29.5% and visceral metastasis in 31.4%. Treatment was primarily surgical (90.5%), with a post-operative death rate of 17.1%. The rate of curative surgery remained constant over time, averaging 58.6%, 20% of the patients underwent chemotherapy, with a high proportion of lymphomas, often in association with surgery. The relative survival rates at 1, 3 and 5 years were 51.2, 38.3 and 32.7%, respectively. The multivariate analysis showed that survival was linked to age, and strongly to histological type and stage of diagnosis., Conclusion: Cancers of the small intestine are an heterogeneous group of rare tumors, often diagnosed at advanced stage. No significant improvement has been achieved in their management over the past 20 years.

Our aim was to study the relationship between the level of positivity of the Hemoccult colorectal cancer screening test and the positive predictive value on one hand, and the characteristics of the screened neoplasms on the other. This study focuses on four successive colorectal cancer screening campaigns in a population of 45,642 subjects born between 1914 and 1943. There were 1 or 2 positive slides in 50.1% of cases, 3 or 4 in 30.7% of cases and 5 or 6 in 19.2% of cases. The positive predictive value was 11.1% for cancer, 17.4% for adenoma > or = at 1 cm and 10.1% for adenoma < 1 cm. For a cancer or adenoma > or = at 1 cm, the positive predictive value varied between 18.6% when there were 1 or 2 positive slides, and 52.5% when there were 5 or 6 positive slides. Dukes A cancers are less likely to have 5 or 6 positive slides than more advanced cancers. On the contrary, neither cancer localisation nor characteristics of adenomas > or = at 1 cm (localisation, size, degree of dysplasia) influenced the number of positive slides. Owing to intermittent colorectal cancer bleeding, it seems necessary to take several successive samples. Two samples per stool over three successive stools seem like a good compromise. The informative value of the test increases with the number of positive slides.

Background/aims: There is growing interest worldwide in primary liver cancer. The aim of this study was to describe the incidence of this cancer over a 20-year period in a well-defined French population., Methods: Time trends by 4-year period were studied by sex, age group, place of residence, histological type and associated cirrhosis. Trends were also analysed using the age-period-cohort model., Results: Primary liver cancer incidence in men increased from 7.5/100000 for the period 1976-79 to 10.2/100000 for the period 1992-95. The mean annual variation was +2.2%, (p<0.05). The increase in incidence was seen mainly in the 55-64 and 65-74 age groups and concerned hepatocellular carcinomas. In men, the increase in incidence rates with time was observed mainly in rural areas, whereas incidence rates in urban areas remained stable. The rise in incidence was due mostly to an increase in primary liver cancer with cirrhosis, in relation to a progressive increase in post-hepatitic cirrhosis and a recent increase in alcoholic cirrhosis. The estimated cumulative risk for the life span 30-74 years increased from 0.8% for the 1904-1908 cohort to 2.1% for the 1934-1938 cohort. There was no significant trend in female rates., Conclusions: In France, incidence rates for primary liver cancer are increasing in men, whilst they are remaining stable in women. Our data confirm the primary importance of alcohol in the aetiology of this cancer. Further studies are necessary to unravel the respective roles of alcohol and hepatitis C virus in the increasing incidence of primary liver cancer.

A protocol is proposed to allow linkage of anonymous medical information within the framework of epidemiological follow-up studies. The protocol is composed of two steps; the first concerns the irreversible transformation of identification data, using a one-way hash function which is used after spelling processing. To avoid dictionary attacks, two large random files of keys, called pads, are introduced. The second step consists in the linkage of files rendered anonymous. The weight given to each linkage field is estimated by a mixture model, the likelihood of which being maximized with the Expectation and Maximization (EM) algorithm. The performance of this method has been assessed by comparing record linkage, based on exclusive use of the automatic procedure, with a manual linkage, obtained by the Burgundy Registry of Digestive Cancers. The result of the linkage of a file of 2,847 cancers with a file of 388,614 hospitalization stays in the Dijon university hospital showed a sensitivity of 97% and a specificity of 93%.

A computerised record hash coding and linkage procedure is proposed to allow the chaining of medical information within the framework of epidemiological follow-up. Before their extraction, files are rendered anonymous using a one-way hash coding based on the standard hash algorithm (SHA) function, in order to respect the legislation on data privacy and security. To avoid dictionary attacks. two keys have been added to SHA coding. Once rendered anonymous, the linkage of patient information can be accomplished by means of a statistical model, taking into account several identification variables. Quality assessment of this anonymous record linkage procedure shows a specificity of 100% and a sensitivity of 95%.

Objectives: The aim of this study was to analyse the incidence, treatment and prognosis of early gastric cancer in a population-based series and to draw a picture of time trends., Methods: Over a 20-year period (1976-1995), 80 early gastric cancers were diagnosed in the Côte-d'Or area (493,000 residents). Incidence rates were calculated by sex, age groups and 5-year periods. Prognostic factors were determined using the Kaplan-Meier method and the Cox model., Results: Age-standardized incidence rates were 0.8/100,000 in men and 0.3/100,000 in women. Incidence increased slightly over time (NS) and their proportion among gastric cancers increased from 3.4% (1976-1980) to 7.9% (1991-1995) (P < 0.01). Among these cancers, 25 were intramucosal (31.3%), 55 were submucosal (68.8%) and 8 had lymph node metastases (10.0%). Overall 21 patients (24.1%) had already been treated for a peptic ulcer. The 5-year crude survival rate was 63.1% and the corresponding net survival rate was 86.3%. Lymph node metastases, location, sex and cancer extension and age were independent prognostic factors., Conclusions: Though it is on the increase, the proportion of early gastric cancers remains low among gastric cancers. This study confirms the importance of performing a gastroscopy with biopsy upon each bout of ulcer and that the prognosis is lower than suggested by hospital based series.

Background: Gastric cancer remains a common cancer with a poor prognosis. Improving trends seen in Japan have not yet been observed in Western countries., Methods: A population-based series of 1329 patients with gastric cancer diagnosed over an 18-year period in Côte d'Or, France, was used to establish time trends in diagnostic strategy, treatment and prognosis., Results: The use of endoscopy alone increased from 2.7 per cent in 1976-1978 to 76.6 per cent in 1991-1993 (P < 0.0001). This trend was associated at first with a significant decrease in the use of radiography alone, then by a significant decrease in the use of both radiography and endoscopy. The proportion of resections for cure increased from 37.9 per cent in 1976-1978 to 50.0 per cent in 1991-1993 (mean 3-year variation + 5.8 per cent, P < 0.01). The proportion of cases confined to the gastric wall increased from 6.1 to 11.7 per cent (mean 3-year variation + 13.1 per cent, P < 0.01), while the proportion of other stages remained stable. The operative mortality rate decreased dramatically from 25.6 per cent in 1976-1978 to 13.6 per cent in 1991-1993 (P < 0.001) and the 5-year relative survival rate rose from 12.8 per cent in 1976-1978 to 26.4 per cent in 1988-1990 (P < 0.001)., Conclusion: This study has demonstrated that improvements in the care of patients with gastric cancer have been achieved, but that further progress may be made.

Stomach cancer remains a common type of cancer, though its incidence has been halved in the last forty years. It is unevenly distributed throughout the world. In France, it holds fifth place among cancers and there are 8700 new cases each year. Helicobacter pylori infection, a high salt intake as well as an inadequate diet take part in the first stages of carcinogenesis. Later on, nitrates and nitrites, polycyclic hydrocarbons, alcohol, tobacco and bilc acids are incriminated. The protective role of vegetables and fruit has been well established. The protective role of vitamin C and beta-carotene is currently undergoing evaluation in subjects suffering from precancerous conditions such as dysplasia and incomplete intestinal metaplasia. The development of a vaccine against Helicobacter pylori induced infection also represents an important goal.

The impact of changes in diagnostic strategies for gastric cancer and attitudes towards surgery in elderly patients is not known. A population-based series of 842 gastric cancers diagnosed between 1976 and 1993 in patients aged 70 and older in Côte-dOr, France, was used to establish trends in diagnostic strategy, treatment, and prognosis. The use of endoscopy alone increased from 3% (1976-78) to 81% (1991-93). This trend was initially associated with a decrease in the use of x-ray alone, then with a decrease in the use of both x-ray and endoscopy. The proportion of resection for cure increased from 26% during 1976-78 to 43% during 1991-93 (P < 0.001). The proportion of cancers not extending beyond the gastric wall increased from 12% to 24% (P < 0.05). Operative mortality decreased from 38.7% (1976-78) to 13.3% (1991-93) and the corresponding 3-year crude survival rate rose from 7% to 18%. Improvements in the care of gastric cancer in elderly patients have been achieved, but further progress is warranted.

Considering the present state of knowledge on the question, only the strategy of screening for intestinal tumours at the asymptomatic stage would seem capable of reducing such a problem as colorectal cancer. Detection of occult blood in stool is currently being evaluated through a mass screening test. Methods used to obtain a high participation rate are now well-defined. In France, to achieve this goal, the test must be proposed by GPs and then mailed to those who do not consult GPs. Four case-control studies and one randomized study conducted among volunteers suggest the efficacy of screening with faecal occult blood testing to reduce mortality from colorectal cancer but they do not indicate effectiveness within a population. Four population-based studies have been set up in Europe (Denmark, England, Sweden and France). Results will be available within one to three years. They should lead to a national screening strategy.