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Purpose Growing primary breast cancers (PT) can initiate local recurrences (LR), regional lymph nodes (pLN) and distant metastases (MET). Components of these progressions are initiation, frequency, growth duration, and survival. These characteristics describe principles which proposed molecular concepts and hypotheses must align with. Methods In a population-based retrospective modeling approach using data from the Munich Cancer Registry key steps and factors associated with metastasis were identified and quantified. Analysis of 66.800 patient datasets over four time periods since 1978, reliable evidence is obtained even in small subgroups. Together with results of clinical trials on prevention and adjuvant treatment (AT) principles for the MET process and AT are derived. Results The median growth periods for PT/MET/LR/pLN comes to 12.5/8.8/5/3.5 years, respectively. Even if 30% of METs only appear after 10 years, a pre-diagnosis MET initiation principle not a delayed one should be true. The growth times of PTs and METs vary by a factor of 10 or more but their ratio is robust at about 1.4. Principles of AT are 50% PT eradication, the selective and partial eradication of bone and lung METs. This cannot be improved by extending the duration of the previously known ATs. Conclusion A paradigm of ten principles for the MET process and ATs is derived from real world data and clinical trials indicates that there is no rationale for the long-term application of endocrine ATs, risk of PTs by hormone replacement therapies, or cascading initiation of METs. The principles show limits and opportunities for innovation also through alternative interpretations of well-known studies. The outlined MET process should be generalizable to all solid tumors.

BackgroundGrowing primary breast cancers (PT) can initiate local (LR), regional (pLN), and distant metastases (MET). Characteristics of these progressions such as initiation, frequency, growth duration and treatment success describe principles of these processes. They are bottlenecks through which scientific and molecular biological concepts and hypotheses must fit.MethodsPopulation-based data from the Munich Cancer Registry over 4 time periods since 1978 with the most important prognostic factors and an up to date follow-up are analyzed. With 66.818 patients, reliable data are obtained on initiation on METs, growth time und survival even in small subgroups. Together with results of clinical trials on prevention and adjuvant treatment (AT) principles for tumor growth, MET process and AT are derived.ResultsThe median growth periods for PT/ MET/LR/pLN result in 12.5/8.8/5/3.5 years. Even if 30% of METs only appear after 10 years of MET-free time, a delayed initiation or cascade like initiation of METs, e.g. from pLNs cannot be derived from the data. That is an immediate MET initiation principle by PT. The growth rate of the PT can vary by a factor of 10 or more and can be transferred to the MET. Nevertheless, the relation of the growth times PT/MET results in a less varying value of 1.4. Principles of AT are the 50% eradication of 1st and 2ndPTs, the selective and partial eradication of bone and lung METs with successful ATs, which cannot be improved by extending the duration of ATs. These principles reveal, among other things, that there is no rationale for the accepted for long-term endocrine ATs, breast cancer risk by hormone replacement therapies, or cascading initiation of METs.ConclusionA paradigm with ten principles for the MET process and ATs can be derived from real world data and clinical trials. The principles show limits and opportunities for innovation also through alternative interpretations of well-known studies. The outlined MET process should be generalizable to all solid tumors.

To date, it remains unclear whether locally advanced adenocarcinoma of the gastroesophageal junction (AEG) should be treated with neoadjuvant chemoradiation (nCRT), analogous to esophageal cancer, or with perioperative chemotherapy (pCT), analogous to gastric cancer. The purpose of this study was to analyze the data of the Munich Cancer Registry (MCR) and to compare pCT and nCRT in AEG patients. A total of 2,992 AEG patients, treated between 1998 and 2014, were included in the study. Baseline and tumor parameters as well as overall survival (OS) and tumor recurrence were compared between 56 patients undergoing nCRT and 64 patients undergoing pCT with UICC stage II/III cancer. In addition, uni- and multivariate analyses using Cox regression models were performed to evaluate the effect of tumor characteristics and treatment regimens on OS. In patients with UICC stage II/III AEG treated with either nCRT or pCT, no significant differences were seen for baseline and tumor characteristics. While there was a significantly higher cumulative incidence of locoregional treatment failure after pCT (32.8%; 95% CI: 18.0–48.4%) compared with nCRT (7.4%; 95% CI: 2.3–16.5%; p = 0.007), there was no significant difference for distant treatment failure (52.9%; 95% CI: 35.4–67.7% and 38.4%; 95% CI: 23.7–52.9%; p = 0.347). When analyzing the whole cohort, patients who received pCT were younger (58.3 years vs. 63.0 years; p = 0.016), had a higher chance of complete tumor resection (81% vs. 67%; p = 0.033), more resected lymph nodes (p = 0.036), and fewer lymph node metastases (p = 0.038) compared with patients who received nCRT. Nevertheless, there was still a strong trend toward a higher incidence of local treatment failure after pCT (25.8%; 95% CI: 14.7–38.3% vs. 12.6%; 95% CI: 5.5–22.8%; p = 0.053). Comparable to the results for patients with UICC stage II/III, no difference was seen for the incidence of distant treatment failure. When excluding patients with UICC stage IV cancer, no significant difference was found for OS. For UICC stage II/III carcinoma, nCRT was associated with an improved locoregional tumor control compared with pCT, while no further significant differences were seen between nCRT and pCT for UICC stage II/III AEG. Moreover, there was a strong trend toward improved locoregional tumor control after nCRT when analyzing all patients treated with nCRT or pCT, despite these patients having higher risk factors.

Background Mucosal melanoma (MM) is a rare but diverse cancer entity. Prognostic factors are not well established for Caucasians with MM. Patients and methods We analysed the disease course of 444 patients from 15 German skin cancer centres. Disease progression was determined with the cumulative incidence function. Survival times were estimated with the Kaplan–Meier method. Prognostic parameters were identified with multivariate Cox regression analysis. Results Common anatomic sites of primary tumours were head and neck (MMHN, 37.2%), female genital tract (MMFG, 30.4%) and anorectal region (MMAN, 21.8%). MMAN patients showed the highest vertical tumour thickness (p = 0.001), had a more advanced nodal status (p = 0.014) and a higher percentage of metastatic disease (p = 0.001) at diagnosis. Mutations of NRAS (13.8%), KIT (8.6%) and BRAF (6.4%) were evenly distributed across all tumour site groups. Local relapses were observed in 32.4% and most commonly occurred in the MMHN group (p = 0.016). Male gender (p = 0.047), advanced tumour stage (p = 0.001), nodal disease (p = 0.001) and incomplete resection status (p = 0.001) were independent risk factors for disease progression. Overall survival (OS) was highest in the MMFG group (p = 0.030) and in patients without ulceration (p = 0.004). Multivariate risk factors for OS were M stage at diagnosis (p = 0.002) and incomplete resection of the primary tumour (p = 0.001). Conclusion In this large series of MM patients in a European population, anorectal MM was associated with the poorest prognosis.

Systemic therapies (ATHs) in early breast cancer have improved the survival of breast cancer (BC) patients in recent decades. The magnitude of the changes in overall, metastasis-free (MFS) and post-metastatic (PMS) survival and in the metastasis (MET) pattern will be described. We analysed 60,227 patients with a diagnosis of T-N-M0 BC between 1978 and 2013 and 11,983 patients with metastases (MET) in the Munich Cancer Registry. Patients will be divided into four time periods to identify relationships between BC and METs. Survival was estimated using Kaplan–Meier curves, and Cox proportional hazards models were used to explore the impact of the BC subtype and MET status on survival with the time periods as surrogate markers for ATH evolution. During the observation period, 5-year relative survival has improved from 80.3 to 93.6% with an adjusted hazard ratio of 0.54 (P

De novo stage IV breast cancer patients (BCIV) depict a clinical picture not influenced by adjuvant therapy. Therefore, the time-dependent impact of changes in diagnostics and treatments on progression and survival can best be evaluated in this subgroup. BCIV patients from 1978 to 2013 registered in the Munich Cancer Registry were divided into four periods, and the trends were analysed. Survival was estimated by Kaplan–Meier methods, and prognostic factors were fitted with Cox proportional hazard models. Between 1978 and 2013, 88,759 patients were diagnosed with 92,807 cases of invasive and non-invasive BC. Of these patients, 4756 patients had distant metastases (MET) at diagnosis. The 5-year survival rate improved from 17.4 to 24.7%, while the pattern of metastases did not change. Improved staging diagnostics, a screening programme and primary systemic therapy changed the composition of prognostic strata. Patients with a similar composition as the 1978–1987 cohort exhibited a median survival difference of 13 months; however, neither univariate nor multivariate analysis showed a survival effect for the four periods as a surrogate indicator for changing treatments. HER2+ patients have with 27.6 months a slightly longer survival than all other BCIV patients. Survival of de novo BCIV has only modestly improved since the late 1970s, partially masked by changing distributions of prognostic factors due to changes in diagnostics.

Der Gesetzgeber definierte im SGB V (Sozialgesetzbuch V) detailliert klinische Krebsregister (KKR), die in Deutschland bis zum Jahr 2017 flachendeckend etabliert werden sollen. Die personenbezogene Erfassung in regional festgelegten Einzugsgebieten, die Ruckmeldung der Auswertungsergebnisse und Qualitatssicherung sind das Fundament, das die Arbeitsweise der KKR und die Nutzung der Daten weitgehend festlegt. Sektorubergreifend ubermitteln alle Fachgebiete nur noch ihre eigenen Befunde und Therapiebeitrage, die im KKR den Weg der Patienten durch regionale Versorgungsnetzwerke beschreiben. Das befreit Kliniken von der Dokumentation, die wegen der vielen Daten, die auser Haus anfallen, muhevoll, unvollstandig und – wenn die Versorgung in einzelnen Regionen transparent werden soll – zudem nicht effektiv ist. Nach erfolgreicher Implementierung des KKR konnen sich interessierte Arzte und Kliniken verstarkt der Nutzung aussagekraftiger Daten widmen, also die Versorgungsqualitat der Region, die Umsetzung innovativer Therapien und deren Verbesserung aufzeigen oder Hypothesen formulieren, die Impulse fur die Forschung geben.

Der Gesetzgeber definierte im SGB V (Sozialgesetzbuch V) detailliert klinische Krebsregister (KKR), die in Deutschland bis zum Jahr 2017 flachendeckend etabliert werden sollen. Die personenbezogene Erfassung in regional festgelegten Einzugsgebieten, die Ruckmeldung der Auswertungsergebnisse und Qualitatssicherung sind das Fundament, das die Arbeitsweise der KKR und die Nutzung der Daten weitgehend festlegt. Sektorubergreifend ubermitteln alle Fachgebiete nur noch ihre eigenen Befunde und Therapiebeitrage, die im KKR den Weg der Patienten durch regionale Versorgungsnetzwerke beschreiben. Das befreit Kliniken von der Dokumentation, die wegen der vielen Daten, die auser Haus anfallen, muhevoll, unvollstandig und – wenn die Versorgung in einzelnen Regionen transparent werden soll – zudem nicht effektiv ist. Nach erfolgreicher Implementierung des KKR konnen sich interessierte Arzte und Kliniken verstarkt der Nutzung aussagekraftiger Daten widmen, also die Versorgungsqualitat der Region, die Umsetzung innovativer Therapien und deren Verbesserung aufzeigen oder Hypothesen formulieren, die Impulse fur die Forschung geben.

The purpose of this retrospective outcome study was to validate the effectiveness of postoperative radiotherapy in breast conserving therapy (BCT) and to evaluate possible causes for omission of radiotherapy after breast conserving surgery (BCS) in a non-trial population.Data were provided by the population-based Munich Cancer Registry. The study included epidemiological data of 30.811 patients diagnosed with breast cancer from 1998 to 2012. The effect of omitting radiotherapy was analysed using Kaplan-Meier-estimates and Cox proportional hazard regression. Variables predicting omission of radiotherapy were analysed using multivariate logistic regression.Use of postoperative radiotherapy after BCS was associated with significant improvements in local control and survival. 10-year loco-regional recurrence-free-survival was 90.8% with postoperative radiotherapy vs. 77.6% with surgery alone (p0.001). 10-year overall survival rates were 55.2% with surgery alone vs. 82.2% following postoperative radiotherapy (p0.001). Variables predicting omission of postoperative radiotherapy included advanced age (women ⩾80 years; OR: 0.082; 95% CI: 0.071-0.094, p0.001).This study shows a decrease in local control and a survival disadvantage if postoperative radiotherapy after breast conserving surgery is omitted in an unselected cohort of primary breast cancer patients. Due to its epidemiological nature, it cannot answer the question in whom postoperative radiotherapy can be safely omitted.

Besides classical colorectal adenocarcinomas (AC), mucinous adenocarcinomas (MAC) and signet-ring cell carcinomas (SC) occur. Controversy remains regarding their prognostic role. Aim of this study was to define prognostic and histopathological specifications of mucinous and signet-ring cell colorectal cancer. A total of 28,056 patients with AC, MAC, and SC between 1998 and 2012 in the catchment area of the Munich Cancer Registry were analyzed. Time to locoregional recurrence and distant recurrence was calculated by cumulative incidence. Survival was analyzed by the Kaplan–Meier method, calculation of relative survival, and Cox proportional hazards regression. AC occurred in 25,172 patients (90 %), MAC in 2724 (9.7 %), and SC in 160 (0.6 %). AC were less frequently localized in the proximal colon (34 %) compared to MAC (57 %, p

The objective of the present population-based study was to evaluate the role and effectiveness of postmastectomy radiation therapy (PMRT) in clinical practice.The study included 16,675 patients diagnosed with invasive breast cancer from 1988 to 2012 and resident within the catchment area of the Munich Cancer Registry. Use of PMRT, local recurrence-free survival (LRFS), cumulative incidence of time to local recurrence, relative survival and conditional overall survival (cOS), were analysed for different time periods (1988-1997 and 1998-2012).Variables favouring the use of PMRT on multivariate logistic regression analysis included young age, large tumour size, positive resection margin and positive nodal status. Over time, a significant increase of PMRT was registered for patients with ⩾4 positive lymph nodes. Moreover, the present findings track a less frequent use of PMRT in elderly patients. After adjusting for age, tumour characteristics and therapies, the Cox regression analysis for LRFS identified PMRT as an independent predictor for improved local control (HR: 2.145; 95% CI: 1.787-2.574, p0.0001). Patients with 1-3 involved lymph nodes had a 10-year cumulative incidence of local recurrence of 13.7% following mastectomy, compared to 6.5% following PMRT (p=0.0001). Comparable findings were obtained for patients presenting with ⩾4 positive lymph nodes. All effects were smaller or extinct in elderly patients aged ⩾70years. On multivariate analysis for cOS, no significant advantage for PMRT could be detected (HR: 1.084; 95% CI: 0.986-1.191, p=0.095).The present study was useful in providing an overview on trends in the adoption of PMRT over a 25-year period. An increase in the use of PMRT from 1988 to 2012 was observed, especially in high-risk patients with ⩾4 positive lymph nodes. Patients selected for PMRT had an improved local control and an equivalent relative survival compared to patients who had no indication for PMRT.

Female melanoma patients generally exhibit significantly longer survival than male patients. This population-based cohort study aimed to investigate gender differences in survival and disease progression across all stages of cutaneous melanoma. A total of 11,774 melanoma cases extracted from the Munich Cancer Registry (Germany), diagnosed between 1978 and September 2007, were eligible to enter the study. Hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for tumor and patient characteristics, were estimated for the end points of survival, regional and systemic progression, and survival after progression. A significant female advantage was observed for melanoma-specific survival (adjusted HR 0.62; 95% CI 0.56-0.70). Women were at a lower risk of progression (HR 0.68; 95% CI 0.62-0.75), including a lower risk of lymph node metastasis (HR 0.58; 95% CI 0.51-0.65) and visceral metastases (HR 0.56; 95% CI 0.49-0.65). They retained a significant survival advantage after first progression (HR 0.81; 95% CI 0.71-0.92) and lymph node metastasis (HR 0.80; 95% CI 0.66-0.96), but this became borderline significant (HR 0.88; 95% CI 0.76-1.03) after visceral metastasis. Localized melanomas in women had a lower propensity to metastasize, resulting in a better survival when compared with men, even after first disease progression. These results suggest differences in tumor-host interaction across gender.

Little is known about time trends in metastases in the patients treated in routine health care facilities without metastases at diagnosis (M0) and about survival after these metastases. Data on 33,771 M0 patients with primary breast cancer diagnosed between 1978 and 2003 were obtained from the Munich Cancer Registry. Survival analyses were restricted to the patients with metastases within 5 years of the initial diagnosis. The incident number of the patients approximately doubled each period and 5-year overall survival increased from 77% in the first to 82% percent in the last period. 5490 (16%) M0 patients developed metastases within 5 years after the initial diagnosis. The hazard of developing metastases was lowest in the most recent period compared to the first period (HR = 0.50, P < 0.001). The hazard of dying after metastases was equal for patients diagnosed between 1978-1984 and 1995-2003 (HR 1.08, P = 0.3). The percentage of the patients that developed bone metastases decreased each time period, but the percentage primary liver and CNS metastases increased. Exclusion of site of metastases in the multivariate analysis led to a 20% (P = 0.02) higher hazard of dying following metastases in the last versus the first period. In the period 1978-2008, unfavourable changes in the pattern of metastases were exhibited and no improvement was observed in survival of the patients after occurrence of metastases. An explanation might be the increased use of adjuvant systemic treatment, which has less effect on the highly lethal liver and CNS metastases than on bone metastases. The increased use also appeared to contribute to the overall prevention of metastases in breast cancer and therefore to improve overall survival.

Distant metastases (MET) are for most solid cancers decisive life-threatening events. Data about MET-free survival and survival after MET show a strong dependency on the kind of cancer and the prognostic features. Nonetheless, within biological subgroups, the MET process is very homogenous. Therefore, the growth rate can be estimated from initiation of MET to MET diagnosis and to time of death. Based on the known volume doubling time of breast cancer, the time of the first possible dissemination can also be estimated. Important consequences of these MET-initiation estimates are the hypotheses that almost all MET are initiated before removal of the primary tumor and that MET do not metastasize in a clinically relevant magnitude. Although breast cancer data were primarily used to form these hypotheses, the discussed MET process can be generalized to all solid cancers. The impact of these hypotheses on diagnostic, curative and palliative treatment, aftercare, and especially on clinical research would be important.

Fragestellung Die Metastasierung (MET) bestimmt beim kolorektalen Karzinom in etwa 50% einen schicksalhaften Krankheitsverlauf. Was beeinflusst die Uberlebenszeit ab MET und was folgt aus dem Zeitablauf der MET?

Salivary gland carcinomas comprise a rare group of malignant tumors which are difficult to diagnose and treat due to their histopathologic diversity, variable clinical course and anatomic location, particularly with respect to the facial nerve. The present paper summarizes important features of these tumors, including recent advances in their management, i.e., diagnosis, surgery of the primary tumor, neck dissection, radiation therapy, and updates risk factors, criteria of malignancy, and prognostic variables, taking into account the relevant literature. Additionally, the present paper highlights briefly the survival rates of patients suffering from salivary gland carcinomas. The present overview is divided into two parts: the first is focused on epidemiology, etiology, criteria of malignancy, prognostic factors, and tumor classification, while part II discusses the diagnosis and therapy of salivary gland carcinomas.

Salivary gland carcinomas comprise a rare group of malignant tumors which are difficult to diagnose and treat due to their histopathologic diversity, variable clinical course and anatomic location, particularly with respect to the facial nerve. The present paper summarizes important features of these tumors, including recent advances in their management, i.e., diagnosis, surgery of the primary tumor, neck dissection, radiation therapy, and updates risk factors, criteria of malignancy, and prognostic variables, taking into account the relevant literature. Additionally, the present paper highlights briefly the survival rates of patients suffering from salivary gland carcinomas. The present overview is divided into two parts: the first is focused on epidemiology, etiology, criteria of malignancy, prognostic factors, and tumor classification, while part II discusses the diagnosis and therapy of salivary gland carcinomas.

Background Population-based cancer registry data are important because they reflect routine care, present long-term follow-up, can show differences in treatment, outcomes and health care over time, and can be used for comparisons between regions and countries. Patients and methods Details of all cancer patients in the Munich region are recorded by the Munich Cancer Registry. Rectal cancer patients with an invasive primary tumor diagnosed between 1996 and 1998 were included in this analysis (n = 936). Observed and relative survival are presented. Observed survival was also investigated with a Cox proportional hazards regression model. Results Median follow-up time of survivors was 5.7 years. Five-year relative survival for the whole sample was 62.2%. International Union Against Cancer (UICC) stage was the most important prognostic factor in the multivariate analysis. Compared with the 1992–1999 Surveillance Epidemiology and End Results (SEER) data (62.4%), relative survival for each disease stage and the whole sample were very similar. In comparison with other European registries, Munich patients had slightly higher survival rates per stage (for example, 5-year relative survival in UICC III was 58.3% in Munich, 54.6% in South East Netherlands, 33.3% in Modena and 47.4% in Cote d'Or); however, more patients in Munich were in higher disease stages with worse prognoses, indicating poorer early detection. Conclusions These results indicate that treatment of rectal cancer in Munich is good, but early detection could be improved. Cancer registries should publish their population-based stage data to ensure quality of care and provide regular feedback to health-care workers and decision makers. Comparisons between countries without stage data should be conducted cautiously.

Variations in compliance with rectal cancer treatment guidelines and the effect of quality indicators on long-term outcomes were investigated with data from the Munich Cancer Registry. Patients diagnosed between 1996 and 1998 with an invasive primary rectal tumor which was resected were included in these analyses (n=884). Median follow up was 5.7 years. Relative and overall survival was examined. Adjusted survival was predicted by UICC stage, grade, age, local recurrence, and residual tumor status. UICC III patients receiving the recommended adjuvant therapy had a significant survival advantage in the multivariate model; UICC II patients did not. Even if there were no significant survival differences there were significant treatment and outcome (regarding local recurrence) variations between hospitals. The variations between hospitals refer to different quality indicators in the individual hospitals. The outcome (regarding survival) appears good in Munich and is comparable with other population studies. Fewer local recurrences, better reporting of the TME technique, greater use of combined therapy and fewer stomas, however, may improve the quality of care in Munich. Variations in care between hospitals should therefore be monitored and controlled. Detailed and frequent feedback to the clinicians is vital to improve quality of care and is possible with cancer registries.

Purpose To describe locoregional and distant progression in a population-based breast cancer sample. Methods and materials Between 1978 and 1998, the Munich Cancer Registry evaluated 14,429 patients. The mean follow-up of survivors was 8.3 years. Metastases (MET), local recurrence (LR), and lymph node recurrence (LNR) were considered as outcome measures. The prognostic factor for, and effects of, LR and MET were assessed multivariately by the Cox and dynamic Aalen models. Results The LR and MET rate increased with increasing tumor size, with the latter described by pT category. Distant MET occurred earlier than local progression. MET was recorded even earlier for MET alone. The mean time from diagnosis to MET for MET and LR was 54.9, 43.4, 29.4, and 24.7 months and for MET only was 36.5, 31.0, 22.6, and 12.9 months for pT1, pT2, pT3, and pT4, respectively. After MET, survival varied only slightly by pT stage; after LR, a more favorable prognosis, especially for pT1 and pT2, was evident. The prognosis after MET depended mainly on the MET location; 50% of patients with cerebral or nervous system MET survived 2 years. In the Cox model, the relative risk of LR for MET was 3.0. In the Aalen model, after 30 months, when the hazard rates of MET began to decline, there was still an excess risk of MET after LR. Conclusion This disease description highlights the importance of long-term observational studies. Empiric evidence that LR is both an indicator for, and in part a cause of, MET has been provided. In the future, the MET location should be reported. Variations in guidelines or health care systems that influence the time to MET and survival after MET through different diagnostic procedures should also be considered.

Late progressions can be observed with all solid cancers. With the term dormancy a potential cause is offered for these observations. In this article we present a point of view from a cancer registry and analyze clinical data about metastasis (MET)-free survival, post-MET survival, and overall survival to quantify late progressions. If dormancy is a characteristic of the MET process then all types of MET, including local recurrences, regional MET in the lymph nodes, or distant MET in organs, must be considered. First, it can be deduced from clinical data that the initiation of secondary foci is a temporally sequential process, which can begin years, or days, before a R0-resection. Second, the growth time of these different MET can be estimated from the survival time and generally takes years. Third, remarkable growth differences of these secondary foci must be considered which already can be correlated, in part, with molecular subgroups. Within these subgroups, growth is quite homogeneous. These three factors of MET growth largely explain the variability of observed relapse-free survival times. In contrast, the term dormancy is vague. It is an appealing metaphor with strong analogies such as circulating tumor cells of hematological neoplasms or dormant tumor cells in transplanted organs. But late MET can be the result of a number of very different causes. Where a disseminated tumor cell lodges, in niches or in specific organs, how long a tumor cell circulates before settling and establishing a focus, or whether the tumor cell has differential growth or even cell quiescence phases, determined by a dynamic equilibrium of divisions and apoptosis, could all contribute to the differential occurrence of MET. MET detection may also be delayed by adjuvant treatment, and all causal variants can be functionally equivalent, delay MET diagnosis, and appear as a slow growing tumor. But time of initiation and the growth of tiny foci are inaccessible and impossible to measure in humans. Therefore, the term tumor dormancy conceals our ignorance of the multi-step MET process. Because it is such a cloudy and elusive term it cannot be clinically relevant. It is a hypothetical construct that fails to offer new research perspectives, additional prognostic factors or an opportunity for novel therapy.

Research has indicated that several demographic and clinical factors may affect the quality of life of breast cancer patients. Few studies, however, have sufficient sample sizes for multivariate analyses to be tested. Furthermore, several important factors, such as arm morbidity, communication and comorbid illness, have not been included in quality of life models The aim of this study was to predict the simultaneous effect of these factors on long-term quality of life. Breast cancer patients (n = 990) completed a quality of life survey, including the EORTC QLQ-C30, over five years. Clinical details were registered in the Munich Cancer Registry. Eleven predictors across eight quality of life domains were analyzed over a period of five years using a logistic regression model. Arm problems, communication, comorbidity, age, surgery. and, to a lesser extent, marital, educational and employment status were significantly associated with quality of life. Adjuvant therapy, medical insurance and pT category were not significant predictors. This study is the first to demonstrate the consistency and strength of arm dysfunction and doctor-patient communication on breast cancer patients' quality of life. These important factors in breast cancer care can be improved and should be regarded as a priority.

Colorectal cancer is one of the most common cancers in Western industrialized countries.1,2 In the United States, 135,400 new cases have been estimated for 2001.3 Mortality rates for colon and rectal cancer, however, have declined in both the United States and Germany.4 Improvements in treatment and early detection indicate that more patients will live with the consequences of this disease.5,6 Rectal cancer surgery, however, is often complicated and can result in bowel and sexual function problems.7 Therefore, it is important to assess rectal cancer patients’ quality of life to determine whether such impairments disrupt everyday life. Changes in operation techniques must also be evaluated for their effect on quality of life.8 The main factors determining patient quality of life seem to be operation technique, abdominoperineal extirpation (APE) versus anterior resection (AR), tumor location, and the presence of a stoma or not. In general, stoma and APE patients experience poorer quality of life, although there are exceptions.2,9–12 Compared with breast cancer, for example, there are relatively few studies that have investigated quality of life in rectal cancer patients. Long-term prospective studies of rectal cancer survivors are sparse.1 A large proportion of papers report only specific functional status, such as sphincter function,5,13,14 not overall quality of life. A frequent limitation of rectal cancer studies is the small sample sizes. Few studies, therefore, have been able to compare effects such as age and gender.15,16 Further, results of comparisons between operation methods should be treated with caution because of low patient numbers. This study aims to rectify some of the shortfalls of the previous literature by presenting results of a large, 4-year, prospective study of rectal cancer patients’ quality of life, as assessed by the European Organization for Research and Treatment of Cancer (EORTC) generic and rectal-specific cancer questionnaires. The issues of time, operation method, and stoma will be addressed.