ArticlePDF Available

What if cancer survival in Britain were the same as in Europe: How many deaths are avoidable

Authors:
  • Public Health Scotland

Abstract

To estimate the number of deaths among cancer patients diagnosed in Great Britain that would be avoidable within 5 years of diagnosis if the mean (or highest) survival in Europe for patients diagnosed during 1985-1989, 1990-1994 and 1995-1999 were achieved. Five-year relative survival for cancers in Great Britain compared with that from other countries in the EUROCARE-2, -3 and -4 studies. Calculation of excess deaths (those more than expected from mortality in the general population) that would be avoidable among cancer patients in Britain if relative survival were the same as in Europe. Great Britain (England, Wales, Scotland) and 13 other European countries. 2.8 million adults diagnosed in Britain with 1 of 39 cancers during 1985-1989 (followed up to 1994), 1990-1994 (followed up to 1999) and 1995-1999 (followed up to 2003). Annual number of avoidable deaths within 5 years of diagnosis. Percentage of the excess (cancer-related) deaths among cancer patients that would be avoidable. Compared with the mean European 5-year relative survival, the largest numbers of avoidable deaths for patients diagnosed during 1985-1989 were for cancers of the breast (about 18% of the excess mortality from this cancer, 7541 deaths), prostate (14%, 4285), colon (9%, 4090), stomach (8%, 3483) and lung (2%, 3548). For 1990-1994, the largest numbers of avoidable deaths were for cancers of the prostate (20%, 7335), breast (15%, 6165), colon (9%, 4376), stomach (9%, 3672), lung (2%, 3735) and kidney (22%, 2644). For 1995-1999, most of the avoidable deaths were for cancers of the prostate (17%, 5758), breast (15%, 5475), lung (3%, 4923), colon (10%, 4295), stomach (9%, 3137) and kidney (21%, 2686).Overall, some 6600-7500 premature deaths would have been avoided each year among cancer patients diagnosed in Britain during 1985-1999 if the mean survival in Europe had been achieved. This represents 6-7% of cancer-related mortality. Compared with the highest European survival, avoidable premature mortality among cancer patients fell from about 12 800 deaths a year (12.2% of cancer-related mortality) to about 11 400 deaths a year (10.6%) over the same period.A large component of the avoidable mortality is due to prostate cancer: excluding this cancer from comparison with the European mean survival reduces the annual number of avoidable deaths by 1000-1500, and the percentage of excess mortality by up to 1%. Compared with the highest survival, the annual number of avoidable deaths would be 1500-2000 fewer, and 1-2% lower as a percentage of excess mortality, but the overall trend in avoidable premature mortality among cancer patients would be similar, falling from 11.4% (1985-1989) to 10.3% (1990-1994) and 9.7% for those diagnosed during 1995-1999.For several cancers, survival in Britain was slightly higher than the mean survival in Europe; this represented some 110-180 premature deaths avoided each year during the period 1985-2003. Avoidable premature mortality among cancer patients diagnosed in Britain during 1985-1999 has represented 6-7% of cancer-related mortality compared with the mean survival in Europe. Compared with the highest levels of survival in Europe, the reduction from 12.2% to 10.6% of cancer-related mortality reflects small but steady progress over the period 1985-2003.
Full Paper
What if cancer survival in Britain were the same as in Europe:
how many deaths are avoidable?
M Abdel-Rahman
1,2
, D Stockton
3
, B Rachet
1
, T Hakulinen
4
and MP Coleman*
,1
1
Cancer Research UK Cancer Survival Group, Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Population Health,
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK;
2
Faculty of Mathematical Sciences, University of Khartoum,
Khartoum, Sudan;
3
Scottish Public Health Observatory, Information Services Division (ISD) Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh,
Scotland, UK;
4
Finnish Cancer Registry, Pieni Roobertinkatu 9, Helsinki, Finland
OBJECTIVE: To estimate the number of deaths among cancer patients diagnosed in Great Britain that would be avoidable within 5 years
of diagnosis if the mean (or highest) survival in Europe for patients diagnosed during 1985 1989, 1990– 1994 and 1995– 1999 were
achieved.
DESIGN: Five-year relative survival for cancers in Great Britain compared with that from other countries in the EUROCARE-2, -3 and -
4 studies. Calculation of excess deaths (those more than expected from mortality in the general population) that would be avoidable
among cancer patients in Britain if relative survival were the same as in Europe.
SETTING: Great Britain (England, Wales, Scotland) and 13 other European countries.
SUBJECTS: 2.8 million adults diagnosed in Britain with 1 of 39 cancers during 1985 1989 (followed up to 1994), 1990– 1994 (followed
up to 1999) and 1995–1999 (followed up to 2003).
MAIN OUTCOME MEASURES: Annual number of avoidable deaths within 5 years of diagnosis. Percentage of the excess
(cancer-related) deaths among cancer patients that would be avoidable.
RESULTS: Compared with the mean European 5-year relative survival, the largest numbers of avoidable deaths for patients diagnosed
during 1985–1989 were for cancers of the breast (about 18% of the excess mortality from this cancer, 7541 deaths), prostate (14%,
4285), colon (9%, 4090), stomach (8%, 3483) and lung (2%, 3548). For 1990 1994, the largest numbers of avoidable deaths were
for cancers of the prostate (20%, 7335), breast (15%, 6165), colon (9%, 4376), stomach (9%, 3672), lung (2%, 3735) and kidney
(22%, 2644). For 1995 1999, most of the avoidable deaths were for cancers of the prostate (17%, 5758), breast (15%, 5475), lung
(3%, 4923), colon (10%, 4295), stomach (9%, 3137) and kidney (21%, 2686).
Overall, some 6600 7500 premature deaths would have been avoided each year among cancer patients diagnosed in Britain during
1985–1999 if the mean survival in Europe had been achieved. This represents 6–7% of cancer-related mortality. Compared with the
highest European survival, avoidable premature mortality among cancer patients fell from about 12 800 deaths a year (12.2% of
cancer-related mortality) to about 11 400 deaths a year (10.6%) over the same period.
A large component of the avoidable mortality is due to prostate cancer: excluding this cancer from comparison with the European
mean survival reduces the annual number of avoidable deaths by 1000–1500, and the percentage of excess mortality by up to 1%.
Compared with the highest survival, the annual number of avoidable deaths would be 1500 2000 fewer, and 1–2% lower as a
percentage of excess mortality, but the overall trend in avoidable premature mortality among cancer patients would be similar, falling
from 11.4% (1985–1989) to 10.3% (1990 1994) and 9.7% for those diagnosed during 1995 1999.
For several cancers, survival in Britain was slightly higher than the mean survival in Europe; this represented some 110 180 premature
deaths avoided each year during the period 1985 2003.
CONCLUSIONS: Avoidable premature mortality among cancer patients diagnosed in Britain during 1985 1999 has represented
6–7% of cancer-related mortality compared with the mean survival in Europe. Compared with the highest levels of survival
in Europe, the reduction from 12.2% to 10.6% of cancer-related mortality reflects small but steady progress over the period
1985–2003.
British Journal of Cancer (2009) 101, S115 – S124. doi:10.1038/sj.bjc.6605401 www.bjcancer.com
&2009 Cancer Research UK
Keywords: Britain; Europe; survival; avoidable mortality; health policy
The EUROCARE study has provided population-based survival
estimates for up to 20 European countries for adults (15 99 years)
diagnosed with cancer since 1978 (Berrino et al, 1995b, 1999b,
2003, 2007). It has shown continuing increases in survival but large
and persistent international variations across Europe. Data from
England and Scotland have been included in all the EUROCARE
studies, data from Wales for patients diagnosed since 1990, and
from Northern Ireland since 1995. Survival for most adult cancers
*Correspondence: Professor MP Coleman;
E-mail: michel.coleman@lshtm.ac.uk
British Journal of Cancer (2009) 101, S115 – S124
&
2009 Cancer Research UK All rights reserved 0007 – 0920/09
$
32.00
www.bjcancer.com
in the United Kingdom has generally been lower than in
comparable western European countries.
Concern about the cancer survival deficit in Britain (Department
of Health, 1999) contributed to development of the NHS Cancer Plan
(Department of Health, 2000), which envisaged a 20% reduction in
cancer death rates under age 75 by 2010. It has been suggested that
10 000 lives a year would have been saved if 5-year survival for
patients diagnosed in Britain during 1985–1989 had reached the
European average, and 25 000 lives a year if survival were as high as
the best in Europe, but no details were given (Sikora, 1999). The
question of how many cancer deaths would be avoidable if survival
in Britain were at the level seen in other EU countries has been raised
in Parliament. It could not be answered (Kelly, 2002).
The EUROCARE-4 study provided relative survival estimates
from 20 European countries for adults diagnosed with 1 of 39
different malignancies during 1995 1999 and followed up to 2001.
This enables assessment of trends in avoidable cancer mortality in
Britain over the period 1985 1999, based on data from the
EUROCARE-2, -3 and -4 studies.
We set out to estimate how many cancer deaths would have been
avoided within 5 years of diagnosis if survival among patients
diagnosed in Great Britain (England, Scotland and Wales) during
1985–1989, 1990 1994 and 1995 1999 had been equivalent either
to the mean survival or to the highest survival seen in other
European countries. Cancer survival has been improving in most
European countries, so comparison with a shifting baseline is
appropriate. Trends in avoidable mortality can be seen as an
overall comparative measure of progress in cancer control between
Britain and the rest of Europe.
MATERIALS AND METHODS
Detailed cancer survival data from the EUROCARE-2, -3 and -4
studies are available by sex and age at diagnosis (15 44, 45– 54,
55–64, 65 74, 7599 years) (Berrino et al, 1999a, 2007; Carrani
et al, 1999; Roazzi et al, 2003). The cancers included represent
about 93% of all malignant neoplasms (excluding non-melanoma
skin cancer) diagnosed in adults in Britain during 1985 1999; the
remaining 7% are mostly ill defined, and avoidable deaths from
these cancers were not estimated.
Thirteen of the 19 European countries outside the United
Kingdom that participated in EUROCARE-4 also participated in
the EUROCARE-2 and EUROCARE-3 studies. We used data from
these 13 countries to simplify the interpretation of changes in
avoidable mortality. Population coverage by contributing registries
was unchanged in four countries with national coverage, but it
changed (usually increased) between successive EUROCARE studies
in the other nine countries (Table 1). We used all the data from these
13 countries, rather than restrict the comparison to the individual
cancer registries that contributed to all three studies.
The European mean 5-year survival was calculated for each
cancer, age group and sex, as the mean of the survival estimates
from the 13 countries, weighted by the proportion of patients
included in the EUROCARE-4 data for that country, for that cancer
and that sex. This simply reflects the different size of the data sets
from each country: it does not assume that regional survival
figures can be extrapolated nationally. Using a fixed set of weights
avoids the artificial change in the European mean survival that
would otherwise occur as a result of the varying proportional
contributions by different countries to successive EUROCARE
studies. To avoid bias, data from England, Scotland and Wales
were not used in calculating the European mean survival, because
they constituted a large fraction of the total data for Europe. For
the less common cancers in some of the smaller data sets, age sex
cells occasionally contained small numbers of patients: if the
5-year survival estimate in such cells was zero or missing, we
substituted the survival estimate for the adjacent age group for that
country, cancer and sex.
Table 1 National population (thousands), coverage (%) by participating registries and contribution to European ‘highest’ survival, by calendar period:
countries included in EUROCARE-2, EUROCARE-3 and EUROCARE-4 studies
1985 – 1989 (EUROCARE-2) 1990 – 1994 (EUROCARE-3) 1995 – 1999 (EUROCARE-4)
Country Population Coverage
Highest
survival
a
Population Coverage
Highest
survival
a
Population Coverage
Highest
survival
a
Change in
coverage
Austria 8030 7.8 NA 7930 8.0 NA 7965 100.0 NA Yes
b
Denmark 5140 100.0 9 5205 100.0 4 5275 100.0 5 No
England 51 000 49.6 49 310 62.6 49 331 100.0 Yes
b
Finland 4986 100.0 12 5023 100.0 12 5132 100.0 14 No
France
c
56 735 3.0 – 5.6 15 56 567 2.9 – 5.6 15 58 738 10.5 – 14.7 14 Yes
b
Germany 62 702 1.7 9 82 183 2.8 14 82 012 1.3 17 Yes
b
Iceland 255 100.0 8 267 100.0 9 271 100.0 7 No
Italy 57 661 9.7 12 56 318 15.3 10 56 876 25.3 –27.4 12 Yes
b
Netherlands
d
14 951 5.7 – 20.5 12 15 047 23.7 14 15 567 34.0 16 Yes
b
Poland 38 119 6.2 2 38 370 6.1 0 38 639 9.0 4 Yes
b
Scotland 5100 100.0 5119 100.0 5086 100.0 No
Slovenia 2000 100.0 3 2072 100.0 1 1987 100.0 4 No
Spain
d
38 959 9.6 – 12.9 14 38 714 9.6 – 14.4 17 39 525 12.2 – 16.3 7 Yes
b
Sweden 8414 17.5 22 8918 100.0 22 8844 100.0 17 Yes
b
Switzerland
d
6712 11.8 NA 6914 11.9 NA 7081 27.1 – 46.8 NA Yes
b
Wales NA 2925 100.0 2901 100.0 Yes
b
360 764 380 882 385 232
Abbreviation: NA ¼not applicable. The following countries did not participate in all three studies, so their data were not included (see text): Belgium (58% coverage of the
national population of 10.2 million in EUROCARE-4), Czech Republic (8% ,10.2 million), Ireland (100%, 4.1 million), Malta (100% , 0.4 million), Northern Ireland (100% , 1.7
million), Norway (100%, 4.6 million) and Portugal (43% , 10.5 million).
a
Number of cancers included in the analyses for which this country contributed one of the three highest
age-standardised relative survival estimates in the EUROCARE study (both sexes combined) for this period. Switzerland and Austria are excluded from the ‘highest’ analysis (see
text).
b
Change between successive EUROCARE studies: Austria: Tyrol (E2, E3); national (E4). England: 7 registries (E2); 8 registries (E3); national (E4). France: 5 registries (E2);
4 registries (E3); 14 registries (E4). Germany: Saarland (E2), plus Munich (E3); minus Munich (E4). Italy: 9 registries (E2); 13 registries (E3); 21 registries (E4). Netherlands:2
registries (E2); 2 registries (E3); 3 registries (E4). Poland: 2 registries (E2, E3); 3 registries (E4). Spain: 6 registries (E2); 6 registries (E3); 8 registries (E4). Sweden: Southern Region
(E2); national (E3, E4). Switzerland: 2 registries (E2, E3); 7 registries (E4). Wales: not included in E2, national (E3, E4), see text for details.
c
These include specialised cancer registries
for certain cancers.
d
Data for selected cancers in one or more periods.
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S116
British Journal of Cancer (2009) 101(S2), S115 – S124 &2009 Cancer Research UK
The ‘highest’ European survival in each calendar period was
identified as follows. First, as with the European mean survival, we
excluded survival in England, Scotland and Wales. Second, to
avoid criticism levelled at the data from Austria and Switzerland,
where survival has tended to be high, we also excluded data from
those countries. Further, to avoid giving undue emphasis to
extremely high survival observed in any one region or country
among the remaining 11 countries, we identified, for each cancer,
the three countries with the highest age sex-standardised relative
survival. The frequency with which countries contributed to the
highest European survival estimate under these constraints is
shown in Table 1. For a given cancer, age group and sex, the
highest European survival was then taken as the average of the
survival estimates in those three countries, weighted by their
contribution to the EUROCARE-4 data. If a component estimate
was not available, the same tactic was used as for the mean
European survival.
National data (100% coverage) were available from Scotland
for all three studies. In England, 7 of the then 11 English
regional cancer registries contributed data on adults diagnosed
during 1985–1989 to the EUROCARE-2 study (49.6%
population coverage). Survival in the English regions that
contributed to EUROCARE-2 was generally similar to that in
England and Wales as a whole. Coverage of England rose to 62.6%
for EUROCARE-3 (1990–1994) and to 100% for EUROCARE-4
(1995–1999).
Data for Wales were not included in EUROCARE-2, but national
data (100% coverage) were included in EUROCARE-3 and -4. The
population of Wales (2.9 million) is about 6% that of England, and
differences in survival between Wales and England for most
cancers were not large, either for patients diagnosed during the
period 1980–1990 (Coleman et al, 1999), or for those diagnosed
during 1990–1994 (Sant et al, 2003). To estimate avoidable cancer
deaths during 1985–1989 for Great Britain as a whole, including
Wales, we assumed that cancer incidence and survival in Wales in
that period had been the same as in England for each cancer, sex
and age group. In effect, the number of avoidable deaths estimated
for England for the period 1985 1989 was inflated by some 6% to
account for the population of Wales. We checked the impact of this
approach by using it for 1990 1994 (EUROCARE-3) and 1995–
1999 (EUROCARE-4): it gave very similar results to those obtained
from the data that were actually contributed by Wales to those
studies (results not shown).
The overall mortality in a cohort of cancer patients can be
divided into two components, the background mortality (expected
from all-cause death rates in the general population), and the
excess mortality, which is then attributable to the cancer (Figure 1).
Relative survival reflects the excess mortality among cancer
patients, over and above the background mortality in the country
or region where they live (Berkson and Gage, 1950; Este
`ve et al,
1990, 1994); background mortality varies two-fold or more across
Europe (Micheli et al, 1999). ‘Avoidable’ deaths are then the
component of excess (cancer-related) mortality that would not
occur if relative survival were at the higher level seen in a
comparator population, instead of what was actually observed. In
Figure 1, for example, avoidable deaths comprise 27% of the
overall excess mortality.
The number of avoidable deaths was calculated separately for
England, Scotland and Wales, for each age group and sex, and for
each cancer, against both the mean and the highest survival in
Europe. Avoidable deaths within 5 years of diagnosis are expressed
both as the absolute number of deaths per year and as the
percentage of the excess mortality for each cancer and calendar
period. We refer to this avoidable mortality within 5 years of
diagnosis as the number or proportion of ‘avoidable premature
deaths’ in cancer patients.
A standardisation approach was used (Richards et al, 2000).
Briefly, for each cancer, sex and age group, the number of
avoidable deaths within 5 years of diagnosis was calculated as the
difference in 5-year relative survival between the value for
England, or Scotland, or Wales, and the corresponding aggregate
(mean or highest) value for Europe, multiplied by the expected
survival and the total number of incident cases in England,
Scotland or Wales for that age group and sex (see Appendix). As
cancer patients may die of causes other than cancer, the number of
avoidable deaths is calculated by applying the difference in relative
survival only to the expected number of survivors based on the
background mortality, and not to the total number of patients. The
avoidable deaths for each cancer, age group, sex and country were
then summed to produce the total for Britain.
It has been argued that the EUROCARE study produces under-
estimates of the true level of survival in Britain (or conversely that
survival in other countries is too high). We therefore carried out
some sensitivity analyses, by re-computing the avoidable mortality
after assuming that 5-year relative survival in England, Scotland
and Wales was either 2% or 3% higher, for each cancer and for
each sex and age group, than was actually reported in the
EUROCARE studies.
Results are presented separately for 22 common malignancies,
including the four main types of leukaemia combined (Table 2).
Results for 17 less common cancers examined in the EUROCARE
study were calculated separately, but are presented as a combined
group (‘other cancers’).
RESULTS
European mean survival
Among the 839 551 adults (15 99 years) diagnosed with one of the
cancers included in the study in Great Britain during the 5 years
1985 –1989, there were 526 270 deaths in excess of the background
mortality in the general population within 5 years of diagnosis. For
those cancers with lower 5-year survival in Britain than in Europe,
33 071 of these excess deaths would have been avoided if European
mean survival had been achieved for each cancer in each sex and
age group (Table 2; Figure 2). This represents 6614 premature
cancer deaths per year, or 6.3% of the overall excess mortality for
these cancers. For those cancers for which 5-year survival was
generally higher in Britain, 568 premature deaths were avoided, or
114 deaths per year.
0
2000
4000
6000
8000
10,000
12,000
14,000
16,000
Annual no. of deaths within 5 years
of diagnosis
Excess
Expected
Avoidable
Total
Expected
27%
73%
Excess deaths reduced
to zero –theoretical level if all
cancer patients were cured
Excess deaths reduced to the
level seen in a population with
higher survival
Excess deaths among cancer
patients in Britain
Figure 1 Partition of the annual number of deaths in cancer patients
within 5 years of diagnosis into the number expected from background
mortality and the excess deaths (attributable to cancer), showing the
proportion of the excess deaths that would be avoidable (27%) if relative
survival had reached the higher level seen in a comparator population.
Note: numbers are of deaths occurring in cancer patients, not deaths
certified as due to the cancer in question (see text).
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S117
British Journal of Cancer (2009) 101(S2), S115 – S124&2009 Cancer Research UK
Among the 966 518 cancer patients diagnosed during
1990 –1994, there were 560 718 excess deaths within 5 years of
diagnosis. For the cancers with lower survival in Britain, 37 620 of
these excess deaths would have been avoided if the mean 5-year
relative survival observed in the 13 other European countries had
been achieved. This represents 7524 premature deaths per year, or
6.7% of the excess mortality in cancer patients within 5 years.
Where survival in Britain was generally higher than in Europe, 903
premature deaths were avoided, or 181 per year.
Of the 1 020 786 cancer patients diagnosed during 1995 1999,
539 934 excess deaths occurred within 5 years of diagnosis. For
cancers with lower survival in Br itain, about 34 841 of these excess
deaths would have been avoided if the mean European survival had
been achieved. This represents 6968 premature deaths a year, or
6.5% of the overall excess mortality from these cancers. Among the
several cancers for which survival in Britain was generally higher
than in Europe, 850 premature deaths were avoided, or 170 per year.
For patients diagnosed during 1985–1989, the largest numbers
of avoidable deaths within 5 years of diagnosis arose for cancers of
the breast (7541, about 18% of excess deaths from this cancer),
prostate (4285, 14%), colon (4090, 9%), lung (3548, 2%) and
stomach (3483, 8%). Over 10% of excess deaths were also
potentially avoidable for cancers of the kidney (1682, 17%), testis
(102, 17%) and uterus (598, 12%), and for Hodgkin disease (189,
12%) and myeloma (986, 11%).
For patients diagnosed during 1990–1994, the largest numbers
of avoidable deaths were seen for cancers of the prostate (7335,
20%), breast (6165, 15%), colon (4376, 9%), lung (3735, 2%),
stomach (3672, 9%) and kidney (2644, 22%). More than 10% of
excess deaths within 5 years of diagnosis were also potentially
Table 2 Avoidable deaths – number of deaths (and percentage of excess deaths
a
) that would be avoidable in Great Britain within 5 years of diagnosis,
based on the mean (or the highest) survival estimates for 13 other countries in Europe: selected cancers, adults (15–99 years) diagnosed during 1985
1989, 1990 – 1994 and 1995 – 1999
Patients diagnosed in Great Britain
during 1985 – 1989
Patients diagnosed in Great Britain
during 1990 – 1994
Patients diagnosed in Great Britain
during 1995 – 1999
Avoidable deaths
based on:
Avoidable deaths
based on:
Avoidable deaths
based on:
Mean
European
survival
b
Highest
European
survival
b
Mean
European
survival
b
Highest
European
survival
b
Mean
European
survival
b
Highest
European
survival
b
Malignancy
No. of
patients
Excess
deaths
a
No. % No. %
No. of
patients
Excess
deaths
a
No. % No. %
No. of
patients
Excess
deaths
a
No. % No. %
Oral cavity 4107 2164 43 2.0 558 25.8 4993 2349 239 10.2 119 5.1 5527 2544 188 7.4 257 10.1
Oesophagus 21 959 20 161 247 1.2 282 1.4 27 409 24 965 163 0.7 363 1.5 29 078 26 418 246 0.9 665 2.5
Stomach 48 192 42 851 3483 8.1 5059 11.8 46 755 40 725 3672 9.0 5013 12.3 41 705 35 632 3137 8.8 4143 11.6
Colon 74 591 43 995 4090 9.3 7303 16.6 86 095 47 109 4376 9.3 6889 14.6 88 908 45 354 4295 9.5 5581 12.3
Rectum 46 859 28 200 1691 6.0 3600 12.8 52 605 29 179 1662 5.7 4144 14.2 56 312 27 866 1220 4.4 2848 10.2
Pancreas 24 822 24 014 193 0.8 133 0.6 26 462 25 360 76 0.3 95 0.4 26 002 25 085 124 0.5 363 1.4
Larynx 8019 2759 186 6.8 582 21.1 8934 3145 181 5.7 327 10.4 9761 3530 111 3.2 585 16.6
Lung 163 781 153415 3548 2.3 6432 4.2 168 693 156 651 3735 2.4 7270 4.6 156 854 145 571 4923 3.4 6550 4.5
Melanoma 17 526 3722 152 4.1 969 26.0 22 059 4247 354 8.3 1358 32.0 26 469 4205 220 5.2 926 22.0
Breast 124 499 41 907 7541 18.0 14 483 34.6 153 354 40 937 6165 15.1 10 619 25.9 170 651 36 632 5475 14.9 9831 26.8
Cervix uteri 20 656 7748 302 3.9 1116 14.4 18 170 6611 204 3.1 983 14.9 14 253 5293 462 8.7 899 17.0
Corpus uteri 17 562 4967 598 12.0 1518 30.6 19 170 5182 811 15.7 1191 23.0 20 711 4923 524 10.6 1230 25.0
Ovary 22 861 16 102 1064 6.6 2431 15.1 25 241 17 567 1670 9.5 2377 13.5 26 261 17 754 1801 10.1 2394 13.5
Prostate 54 318 30 015 4285 14.3 7422 24.7 77 728 36 221 7335 20.3 11 739 32.4 103 045 33 219 5758 17.3 7958 24.0
Testis 6098 600 102 17.1 123 20.5 7311 499 80 16.0 89 17.8 8676 392 39 10.0 14 3.4
Bladder 52 697 19 429 232 1.2 2910 15.0 59 173 19 650 1048 5.3 2136 10.9 55 925 20 320 752 3.7 1462 7.2
Kidney 15 922 9887 1682 17.0 2007 20.3 20 445 12 093 2644 21.9 3183 26.3 23 212 12 697 2686 21.2 3521 27.7
Brain 12 714 10 778 367 3.4 602 5.6 15 331 12 872 262 2.0 836 6.5 16 224 13 872 295 2.1 1127 8.1
Hodgkin disease 5830 1628 189 11.6 244 15.0 5987 1482 214 14.4 245 16.5 6122 1218 132 10.8 247 20.3
Non-Hodgkin lymphoma 25 195 14 130 603 4.3 1224 8.7 32 180 16 967 1311 7.7 1475 8.7 36 941 18 014 632 3.5 1625 9.0
Multiple myeloma 11 497 9200 986 10.7 1049 11.4 13 193 10 147 847 8.4 1731 17.1 14 507 10 581 703 6.6 1238 11.7
Leukaemia 16 352 11 832 535 4.5 1828 15.4 22 894 14 797 224 1.5 1376 9.3 25 703 15 018 191 1.3 1201 8.0
Other cancers
c
GB survival higher
d
7211 2592 150 5.8 108 4.2 15 214 6459 244 3.8 0NA 22 406 11 215 623 5.6 107 1.0
GB survival lower
d
36 283 24 174 1370 5.7 2328 9.6 37 122 25 504 1006 3.9 1976 7.7 35 533 22 581 1154 5.1 2468 10.9
All cancers (over 5-year period)
GB survival higher
d
67 927 24 780 568 0.1 108 0.0 83 012 62 278 903 0.2 00.0 36 609 14 151 850 0.2 121 0.0
GB survival lower
d
771 624 501 490 33 071 6.3 64 203 12.2 883506 498 440 37 620 6.7 65 534 11.7 984 177 525 783 34 841 6.5 57 119 10.6
Total 839 551 526 270 966 518 560 718 1 020 786 539 934
All cancers (annual avoidable deaths)
GB survival higher
d
114 22 181 0 170 24
GB survival lower
d
100 298 6614 12 841 99 688 7524 13 107 105 157 6968 11 424
a
Difference between the number of deaths observed among cancer patients within 5 years of diagnosis, and the number expected from background mortality by age and sex in
Britain (see text).
b
Based on relative survival estimates from EUROCARE-2 study for 1985 89 patients, EUROCARE-3 study for 1990– 94 patients and EUROCARE-4 study for
1995 – 99 patients (see text).
c
Sum for 17 other cancers, analysed separately (data not shown).
d
Numbers of avoidable deaths summed separately according to whether survival
in Great Britain was higher or lower than the mean (or highest) European survival estimate.
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S118
British Journal of Cancer (2009) 101(S2), S115 – S124 &2009 Cancer Research UK
avoidable for cancers of the uterus (811, 16%) and testis (80, 16%),
and for Hodgkin disease (213, 14%).
For patients diagnosed during 1995 1999, most of the avoidable
deaths within 5 years arose for cancers of the prostate (5758, 17%),
breast (5475, 15%), lung (4923, 3%), colon (4295, 10%), stomach
(3137, 9%) and kidney (2686, 21%). At least 10% of excess deaths
were also potentially avoidable for cancers of the uterus (524, 11%)
and ovary (1801, 10%), and Hodgkin disease (132, 11%).
Compared with the mean survival in 13 European countries that
contributed data to the three most recent EUROCARE studies (-2, -3
and -4), avoidable cancer mortality within 5 years of diagnosis in
Britain changed from 6614 deaths a year for patients diagnosed during
1985–1989, to 7524 deaths a year for 1990 1994 and 6968 deaths a
year for 1995–1999. As a percentage of the overall excess mortality
among patients diagnosed with cancers for which there was a survival
deficit, avoidable premature mortality was about 6–7% of the total
excess mortality within 5 years of diagnosis for all three periods.
Most of the avoidable premature deaths occurred for cancers of
the breast, prostate, colon, stomach, lung and kidney. Avoidable
mortality has fallen for breast cancer, increased for cancer of the
lung, and remained more or less stable for stomach and colon
cancers (Figure 2).
For prostate cancer, avoidable mortality rose from the late 1980s
to the early 1990s, but fell in the late 1990s. Prostate cancer
contributes a large number of avoidable deaths. Compared with
the mean survival in Europe, the number of avoidable deaths for
all other cancers would change from 6600 (6.3%) to 5757 (5.8%)
for patients diagnosed 1985 1989; from 7524 (6.7%) to 6057
(5.8%) for 1990–1994 and from 6968 (6.5%) to 5817 (5.7%) for
1995–1999 (results not shown).
Highest European survival
Among patients diagnosed during 1985–1989, the highest
European survival was higher than in Britain for all the 22
common cancers and for all but two of the 17 less common cancers
(oropharynx, choroid). Overall, 64 203 excess deaths (over and
above background mortality) within 5 years of diagnosis among
patients diagnosed in Great Britain would have been avoided if the
highest European survival had been achieved for all cancers
diagnosed during this period. This represents some 12 841
avoidable premature cancer deaths per year, or about 12.2% of
the excess mortality (Table 2; Figure 3).
For patients diagnosed during 1990–1994, the highest European
survival was higher than in Britain for all 39 cancers examined.
Overall, 65 534 deaths within 5 years of diagnosis would have been
avoided if the highest European survival had been achieved for all
cancers. This represents 13 107 premature cancer deaths per year,
or about 11.7% of the excess mortality.
For patients diagnosed during 1995–1999, the highest European
survival was higher than in Britain for all but one of the 22 common
cancers. For testicular cancer, survival in Britain was slightly higher
(14 premature deaths avoided, or 3% of the excess mortality).
Survival was also slightly higher for two of the 17 less common
cancers (choroid, and the vagina and vulva). In all, 57 119 deaths
within 5 years of diagnosis would have been avoided if survival in
Britain had reached the highest levels observed in the 13 comparator
countries. This represents 11 424 premature cancer deaths a year, or
some 10.6% of the excess mortality from these cancers.
Compared with the highest survival in Europe, avoidable cancer
mortality in Britain fell slightly from about 13 000 deaths a year for
patients diagnosed during the 10-year period 1985–1994 to about
11 400 deaths a year for those diagnosed during 1995 –1999. As a
percentage of the overall excess mortality among cancer patients in
Britain, avoidable premature mortality fell from 12.2% to 11.7% to
10.6% over these three periods.
The annual number of avoidable deaths has fallen steadily for
cancers of the breast, colon and bladder, and the leukaemias, and
to a lesser extent for cancers of the stomach, uterus and cervix.
Avoidable premature mortality has risen to some extent for
–200 200 400 600 800 1,000 1,200 1,400 1,6000
Oral cavity
Oesophagus
Stomach
Colon
Rectum
Pancreas
Larynx
Lung
Melanoma
Breast
Annual no. of avoidable premature deaths vs mean European survival
Cervix uteri
Corpus uteri
Ovary
Prostate
Testis
Bladder
Kidney
Brain
Hodgkin disease
Non-Hodgkin lymphoma
Multiple myeloma
Leukaemia
1985–89
1990– 94
1995– 99
Figure 2 Annual number of deaths within 5 years of diagnosis that would be avoidable among cancer patients in Britain if relative survival were equal to
the mean European survival: 22 common cancers, patients diagnosed 1985 – 1989, 1990 – 1994, 1995 – 1999,
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S119
British Journal of Cancer (2009) 101(S2), S115 – S124&2009 Cancer Research UK
tumours of the oesophagus, pancreas, kidney and brain, and for
non-Hodgkin lymphoma.
Compared with the highest survival in Europe, avoidable
mortality for prostate cancer rose in the early 1990s, but fell in
the late 1990s. Exclusion of prostate cancer would reduce the
overall estimate of the annual number of avoidable deaths by
1500–2000. The percentage of avoidable premature mortality
among all the other cancers would be 1 2% lower, but the
downward trend similar, falling from 11.4% for patients diagnosed
during 1985– 1989 to 10.3% for 1990–1994 and 9.7% for 1995 1999
(results not shown).
Sensitivity analyses
After adding 2% to the 5-year relative survival estimates for each
country in Great Britain, for each sex and age group, and for each
cancer, the estimated number of premature avoidable deaths,
compared with the European mean survival, was 5813 per year
(5.6%) among patients diagnosed during 1985 1989. The number
increased slightly to 6384 deaths per year (5.8%) for patients
diagnosed during 1990–1994 and fell to 5600 deaths per year
(5.3%) for patients diagnosed during 1995 1999.
After adding 3% to the 5-year relative survival estimates in
Britain, similar calculations suggest 5467 avoidable premature
deaths per year among patients diagnosed during 1985 1989,
representing 5.3% of the total excess mortality among cancer
patients diagnosed in that period. The number increased to 5849
(5.3%) for 1990–1994, but fell to 4954 (4.7%) for patients
diagnosed during 1995–1999.
DISCUSSION
The number of deaths among cancer patients within 5 years of
diagnosis (‘premature deaths’) that would be avoidable if relative
survival in Great Britain were as high as elsewhere in Europe helps
to quantify the public health importance of the survival deficit. It
tells us how much the excess cancer mortality could be reduced if
the mean (or highest) levels of cancer survival in Europe were to be
achieved in Britain. For each cancer, the comparison takes account
of the level and trends in survival by age and sex in the 13 other
European countries we considered, as well as the differences and
trends in background mortality between each of those countries
and England, Scotland and Wales.
The estimates of avoidable cancer mortality start from the
number of patients who were diagnosed each year during the
15 years 1985–1999, and the proportion who survived up to 5 years,
after correction for death from other causes. Reducing the number of
premature deaths in cancer patients by improving their survival is
thus distinct from cancer prevention, which involves long-term
reduction in carcinogenic exposures and is evaluated by reduction in
the numbers of new cancer patients actually being diagnosed each
year. By contrast, reduction of avoidable premature mortality in
patients who do develop cancer requires earlier diagnosis and faster
access to optimal treatment for all patients.
The number of avoidable deaths depends on both the deficit in
relative survival and the number of cancer patients diagnosed in
Britain. Thus, if the population were one-half of what it is, but
incidence and survival remained constant, the number of
avoidable deaths would also be reduced by half, but the percentage
of avoidable deaths would be the same. This percentage refers to
the number of deaths in cancer patients in excess of the expected
mortality, not to the overall number of deaths in cancer patients.
This is because we cannot seek to reduce overall mortality in
cancer patients to zero. By contrast, the excess mortality would
indeed fall to zero if overall mortality among cancer patients were
no different from the level in the general population; in other
words, if all cancer patients were cured (see Figure 1). In the
medium term, the proportion of deaths that would be avoidable if
0 500 1,000 1,500 2,000 2,500 3,000 3,500
Oral cavity
Oesophagus
Stomach
Colon
Rectum
Pancreas
Larynx
Lung
Melanoma
Breast
Annual no. of avoidable premature deaths vs highest European survival
Cervix uteri
Corpus uteri
Ovary
Prostate
Testis
Bladder
Kidney
Brain
Hodgkin disease
Non-Hodgkin lymphoma
Multiple myeloma
Leukaemia
1985–89
1990–94
1995–99
Figure 3 Annual number of deaths within 5 years of diagnosis that would be avoidable among cancer patients in Britain if relative survival were equal to
the highest European survival: 22 common cancers, patients diagnosed 1985 – 1989, 1990 – 1994, 1995 – 1999.
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S120
British Journal of Cancer (2009) 101(S2), S115 – S124 &2009 Cancer Research UK
some target level of survival were achieved in Britain, such as the
mean survival in other European countries, provides a useful guide
to the public health importance of reducing the survival deficit.
Five-year survival is the most widely used measure for
international survival comparisons. We therefore estimated the
number of excess deaths within the 5 years after a cancer
diagnosis.
We were conservative in defining the mean survival in Europe,
by including only those countries that contributed to three
consecutive EUROCARE studies (-2, -3 and -4). We were also
conservative in defining the highest survival in Europe, taking the
average of the three highest estimates by age, sex and cancer
after the exclusion of Austria and Switzerland. We only weighted
the estimates of the mean and highest survival in Europe by
the proportion of cases contributed by a given country to the
EUROCARE-4 study, and not by the total number of cases
diagnosed in that country.
Comparisons of cancer survival in the EUROCARE study
between Britain and the rest of Europe have often been criticised
as unfair to Britain, either because cancer registries in other
countries supposedly create artefactually high survival (for
example by failing to follow up adequately those patients
with the lowest survival), or because the registries that contribute
to EUROCARE are not ‘representative’ of the whole country.
These arguments are weak. All cancer registries contributing to
EUROCARE meet the international quality criteria for inclusion in
the WHO compendium Cancer Incidence in Five Continents
(Curado et al, 2007). All data sets in the EUROCARE study are
subjected to the same quality control procedures. There is little
evidence that cancer registration data are of higher quality in
Britain than in most other European countries (Capocaccia et al,
2003).
For some countries, only a small proportion of the population
was covered by registries contributing to EUROCARE, and critics
have suggested that survival from these registries may not
adequately reflect national survival (Moran et al, 2000; Threlfall
et al, 2001). The mean European survival estimates used here,
however, were weighted only by the numbers of cases actually
included in the EUROCARE study, not by the size of the national
population: in other words, we made no assumption that survival
estimates based on sub-national data sets were representative of
the whole country.
Restricting the analyses to countries that have contributed to
EUROCARE with national cancer registration coverage would not
make the comparison more ‘representative’ of Europe. Only
Denmark, Finland, Iceland and Slovenia contributed national data
to all three EUROCARE studies considered here, while Austria,
Estonia, Ireland, Malta, Norway, Slovakia and Sweden either
attained national registration coverage since 1985, or did not
contribute national data to all three studies. Apart from the United
Kingdom, 9 of the 19 countries in EUROCARE-3 and EUROCARE-
4 contributed national data. All five Nordic countries contributed
national data, and survival in those countries is generally high, but
three of the five eastern European countries, where survival is
generally low, also contributed national data (Berrino et al, 2003).
Similarly, though survival in France is generally high, and the
French data in EUROCARE have covered about 6% of the national
population, a large national study covering 14 de
´partements (20%
of the population) for patients diagnosed up to 1997 showed very
similar survival estimates to those reported in the EUROCARE
studies (Grosclaude et al, 2007).
For most cancers, even the highest cancer survival estimates for
any English region in the late 1980s were below the mean European
survival from EUROCARE-2. Even the survival among the most
affluent fifth of all English cancer patients, regardless of their
region of residence, was lower than the mean European survival.
The highest European survival estimates for patients diagnosed
with one of eight major cancers (lung, breast, colon, prostate,
bladder, stomach, oesophagus and cervix) during the late 1980s
were equal to or higher than the highest survival estimates for
patients diagnosed in any of the eight NHS Regions of England, or
in Scotland, and higher even than in most of the 95 English Health
Authorities, where variation was greater (Romanengo et al, 2002),
or in the 15 Scottish Health Boards during the 1990s (Scottish
Cancer Intelligence Unit, 2000). It follows that neither the
inclusion of sub-national data for England in EUROCARE-2 and
-3 nor the increased coverage of other countries in the later
EUROCARE studies is likely to have altered the comparative
pattern very much.
Nevertheless, we sought to address these criticisms in several
ways.
For trends in the number of avoidable deaths compared with the
European average, we examined the impact of further restricting
the comparison to Denmark, Finland, Iceland and Sweden
(Norway only joined from EUROCARE-3), because their cancer
registration systems have national coverage and excellent quality
(Parkin et al, 1997) and their health systems are broadly similar to
that of the United Kingdom. Comparison with the average survival
for these four Nordic countries suggested an annual figure of 7465
(7.1%) avoidable cancer deaths in Great Britain within 5 years of
diagnosis for patients diagnosed in 19851989 (Supplementary
Table 1), not massively discrepant with the estimate of 6614 (6.3%)
avoidable deaths a year derived by including the data from all the
13 countries considered here.
The estimates of avoidable cancer mortality do depend on the
comparability of survival estimates between Britain and the rest of
Europe. Avoidable mortality estimates could thus be biased, to the
extent that artefacts (e.g. differences between Britain and other
countries in diagnostic criteria and investigations, quality of
cancer registration data and follow-up, and lead-time bias for
cancers subject to mass screening) contribute to the international
differences in survival (Berrino et al, 1995a, 1997; Coleman, 1999).
However, survival in Britain for melanoma of the skin and cancers
of the cervix and uterus has often been as high or higher than the
European average, and for testicular cancer, as good as the best.
Survival for patients aged 15 44 years in Britain is generally as
high as the European mean survival, and differences in survival for
children are small (S
ˇteliarova
´-Foucher et al, 2004). Since the
differences in survival are not systematic, as one might expect if
they were entirely attributable to artefacts of data collection or
analysis, this provides some evidence against those who simply
assert that the EUROCARE findings are incredible (Cookson, 2000;
Wilkinson, 2009).
To assess trends in avoidable mortality compared with ‘the
best in Europe’, as envisaged by the NHS Cancer Plan (Department
of Health, 2000) and the Cancer Reform Strategy (Department
of Health, 2007), we were conservative. First, we excluded data
from two countries that most often had the highest survival in
Europe (Switzerland and Austria). Then, for each cancer, age
group and sex, we used a weighted average of the relative survival
in the three countries with the highest age-standardised survival
for that cancer, to avoid undue influence of the most extreme
survival observed in Europe on the estimates of avoidable
mortality.
We could also have assumed that both incidence and survival in
regional cancer registries contributing to EUROCARE were indeed
‘representative’ of the entire country. That would have produced
higher values for the European mean survival, by giving greater
weight to data from large countries with low population coverage,
such as Germany, which often had higher survival than the
European mean survival as we actually defined it. Estimates of
avoidable mortality in Britain would have been higher if we had
done this.
National ‘representativeness’ should not arise: this is not an
international contest between rival national teams. Some registries
with national coverage report lower survival than in Britain, and
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S121
British Journal of Cancer (2009) 101(S2), S115 – S124&2009 Cancer Research UK
others higher, but it is irrational to dismiss population-based
survival estimates for the purpose of comparison solely because
they are regional rather than national (Coleman et al, 2003). The
central issue is whether the estimates of cancer survival in a given
country (or a region of a country) that are higher than in Britain
can be considered reliable, and whether artefact and/or bias can
explain all the differences. If several large populations have
attained a level of cancer survival that Britain would wish to
emulate, then we need to quantify and explain that difference in
terms that help policymakers reduce it. Here, we compared
survival in Britain with data from both regional and national
registries in 13 European countries. Restricting the comparison to
countries with 100% population coverage by registration (or just
the Nordic countries) alters the estimate of avoidable mortality,
but does not abolish it.
Assuming that survival in Britain was 2 3% higher for each
cancer than actually reported in EUROCARE also reduces the
estimates of avoidable mortality, but the annual numbers of
avoidable deaths are still considerable (Supplementary Tables
2–3). The possible range of avoidable cancer mortality in Britain is
highly unlikely to include zero.
Our estimates of the annual number of avoidable cancer deaths
are certainly large, whether assessed against the mean or the
highest European survival, but they are well below the previous
estimates (10 000 and 25 000 deaths a year, respectively), which
were acknowledged as crude (Sikora, 1999), and are clearly not
plausible.
Prostate cancer contributed a large proportion of the avoidable
deaths in each period. If we exclude prostate cancer, the number of
avoidable premature deaths a year assessed against the European
mean becomes 5800–6000 (5.7 5.8%), compared with 6600–7500
a year using all the data (6.3– 6.7%). Assessed against the highest
European survival, avoidable premature deaths excluding prostate
cancer fell steadily from 11 400 a year (11.4%) to 9800 deaths a year
(9.7%). In proportionate terms, this trend is similar to the full
estimate: from about 12 800 (12.2%) to 11 400 (10.6%). The rise
and fall of avoidable deaths from prostate cancer may reflect the
fact that PSA testing became widespread in Britain some 5 years
later than in most of the comparator countries (except Denmark),
and that the survival deficit between Britain and other European
countries for men diagnosed with prostate cancer in the early
1990s had narrowed by the late 1990s.
The estimates of avoidable deaths cover an arbitrary interval of 5
years since diagnosis because 5-year survival data were readily
available. If survival differences persist beyond 5 years after
diagnosis, the numbers of avoidable deaths will continue to
increase with time since diagnosis, and our figures will under-
estimate the total avoidable mortality. Conversely, if differences in
relative survival decline with time since diagnosis, our figures will
over-estimate the total avoidable mortality. Ideally, the number of
avoidable deaths would be calculated for each cancer at a time
since diagnosis when the survivors have no further excess
mortality relative to the general population: the point of ‘cure’
(De Angelis et al, 1999). The point of cure varies between
cancers, however, and for some cancers it is difficult to identify.
Systematic estimates of the proportion of cancer patients cured in
Europe have only recently become available: these are limited to
patients diagnosed during the period 1995 1999 (Francisci et al,
2009).
These analyses suggest that for adult cancer patients diagnosed
in Britain during 1995 – 1999, some 6.5% (6968) of the 105 157
cancer-related deaths that occurred each year within 5 years of
diagnosis would have been avoided if cancer survival had
been equivalent to the mean European level, and 10.6% (11 424)
of the deaths if survival had been equivalent to the highest survival
in Europe. Trends in avoidable cancer mortality in Britain
by comparison with the European mean survival have been
fairly steady over the 15 years 1985 1999, reflecting the fact that
survival in Britain has often been rising in parallel with the
European mean survival (Verdecchia et al, 2009). Trends in
avoidable mortality compared with the highest European survival
are more favourable, however, reflecting a small but steady
improvement in Britain towards the highest levels of cancer
survival in Europe.
We have previously estimated that about 2500 deaths a year
would have been avoided among adults diagnosed with 1 of 47
cancers in England and Wales during 1986 1990 if socio-
economic inequalities in 5-year relative survival had not existed
(Coleman et al, 2001). There were some differences from the study
reported here in method, geographic coverage, calendar period
and the cancers included, but those results suggest that socio-
economic differences in survival in Britain may represent up to
half the avoidable premature mortality compared with the mean
survival in Europe.
The results reported here relate to cancer patients in Britain who
were all diagnosed before 2000, when the first national cancer plan
was introduced. The results will need updating to examine any
impact on avoidable mortality of the national cancer plans in
England (Department of Health, 2000), Scotland (Scottish Execu-
tive Health Department, 2001) and Wales (Cancer Services
Co-ordinating Group, 2006).
ACKNOWLEDGEMENTS
We thank Dr Roberta De Angelis and Dr Riccardo Capocaccia,
(Istituto Superiore di Sanita
`, Rome, Italy), for help in checking
Table 1 and providing additional data, respectively. We thank
Sara Hiom (Cancer Research UK) for expert editorial advice.
Dr Stockton was partially funded by the Children with Leukaemia
Jane Davidson and Paul O’Gorman Scholarship at the London
School of Hygiene and Tropical Medicine.
Conflict of interest
The authors declare no conflict of interest.
Supplementary Information accompanies the paper on British
Journal of Cancer website (http://www.nature.com/bjc)
REFERENCES
Berkson J, Gage RP (1950) Calculation of survival rates for cancer. Proc
Staff Meet Mayo Clinic 25: 270 – 286
Berrino F, Capocaccia R, Coleman MP, Este
`ve J, Gatta G, Hakulinen T,
Micheli A, Sant M, Verdecchia A (eds) (2003) EUROCARE-3: the survival
of cancer patients diagnosed in Europe during 1990 – 1994. Ann Oncol
14(Suppl 5):1 – 155
Berrino F, Capocaccia R, Este
`ve J, Gatta G, Hakulinen T, Micheli A, Sant M,
Verdecchia A, EUROCARE Working Group (1999a) Survival of Cancer
Patients in Europe: the EUROCARE-2 Study (CDROM). International
Agency for Research on Cancer (WHO): Lyon
Berrino F, Capocaccia R, Este
`ve J, Gatta G, Hakulinen T, Micheli M, Sant M,
Verdecchia A (eds) (1999b) Survival of Cancer Patients in Europe: the
EUROCARE-2 Study (IARC Scientific Publications No. 151). International
Agency for Research on Cancer: Lyon
Berrino F, De Angelis R, Sant M, Rosso S, Lasota MB, Coebergh JWW,
Santaquilani M, EUROCARE Working Group (2007) Survival for eight
major cancers and all cancers combined for European adults diagnosed in
1995 – 1999: results of the EUROCARE-4 study. Lancet Oncol 8: 773 – 783
Berrino F, Este
`ve J, Coleman MP (1995a) Basic issues in the estimation and
comparison of cancer patient survival. In Survival of Cancer Patients in
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S122
British Journal of Cancer (2009) 101(S2), S115 – S124 &2009 Cancer Research UK
Europe: the EUROCARE Study (IARC Scientific Publications No. 132),
Berrino F, Sant M, Verdecchia A, Capocaccia R, Hakulinen T, Este
`ve J
(eds), pp 1 – 14. International Agency for Research on Cancer (WHO):
Lyon
Berrino F, Micheli A, Sant M, Capocaccia R (1997) Interpreting survival
differences and trends. Tumori 83: 9–16
Berrino F, Sant M, Verdecchia A, Capocaccia R, Hakulinen T, Este
`ve J (eds)
(1995b) Survival of Cancer Patients in Europe: the EUROCARE Study
(IARC Scientific Publications No. 132). International Agency for Research
on Cancer: Lyon
Cancer Services Co-ordinating Group (2006) Designed to Tackle Cancer in
Wales: A Welsh Assembly Government Policy Statement. Welsh Assembly
Government: Cardiff
Capocaccia R, Gatta G, Roazzi P, Carrani E, Santaquilani M,
De Angelis R, Tavilla A, EUROCARE Working Group (2003)
The EUROCARE-3 database: methodology of data collection, standardi-
sation, quality control and statistical analysis. Ann Oncol 14(Suppl 5):
14 – 27
Carrani E, Roazzi P, Capocaccia R (1999) Organization and use of the
EUROCARE-2 compact disk. In Survival of Cancer Patients in Europe:
the EUROCARE-2 Study (IARC Scientific Publications No. 151), Berrino F,
Capocaccia R, Este
`ve J, Gatta G, Hakulinen T, Micheli M, Sant M,
Verdecchia A (eds), pp 569–572. International Agency for Research on
Cancer: Lyon
Coleman MP (1999) Why the variation in breast cancer survival in Europe?
Breast Cancer Res 1(Suppl 1):22 – 26; http://breast-cancer-research.com/
vol1no1/07oct99/editorial/3
Coleman MP, Babb P, Damiecki P, Grosclaude PC, Honjo S, Jones J, Knerer
G, Pitard A, Quinn MJ, Sloggett A, De Stavola BL (1999) Cancer Survival
Trends in England and Wales 1971 – 1995: Deprivation and NHS Region
(Studies on Medical and Population Subjects No. 61). The Stationery
Office: London
Coleman MP, Babb P, Quinn MJ, Sloggett A, De Stavola BL (2001) Socio-
economic inequalities in cancer survival in England and Wales. Cancer
91: 208 – 216
Coleman MP, Gatta G, Verdecchia A, Este
`ve J, Sant M, Storm HH, Allemani
C, Ciccolallo L, Santaquilani M, Berrino F, EUROCARE Working Group
(2003) EUROCARE-3 summary: cancer survival in Europe at the end of
the 20th century. Ann Oncol 14(Suppl 5):128 – 149
Cookson JB (2000) Cancer survival. Lancet 356: 1611
Curado MP, Edwards BK, Shin HR, Storm HH, Ferlay J, Heanue M, Boyle P
(eds) (2007) Cancer Incidence in Five Continents. Vol. IX. IARC Scientific
Publications No. 160. IARC: Lyon
De Angelis R, Capocaccia R, Hakulinen T, Soderman B, Verdecchia A
(1999) Mixture models for cancer survival analysis: application to
population-based data with covariates. Stat Med 18: 441 – 454
Department of Health (1999) Challenging Cancer. Department of Health:
London
Department of Health (2000) The NHS Cancer Plan. Department of Health:
London
Department of Health (2007) Cancer Reform Strategy. Department of
Health: London
Este
`ve J, Benhamou E, Croasdale M, Raymond L (1990) Relative survival
and the estimation of net survival: elements for further discussion. Stat
Med 9: 529 – 538
Este
`ve J, Benhamou E, Raymond L (1994) Statistical Methods in
Cancer Research, Vol. IV. Descriptive Epidemiology (IARC Scientific
Publications No. 128). International Agency for Research on Cancer:
Lyon
Francisci S, Capocaccia R, Grande E, Santaquilani M, Simonetti A, Allemani
C, Gatta G, Sant M, Zigon G, Bray F, Janssen-Heijnen MLG, EUROCARE-
4 Working Group (2009) The cure of cancer: a European perspective. Eur
J Cancer 45: 1067 – 1079
Grosclaude PC, Bossard N, Remontet L, Belot A, Arveux P, Bouvier A-M,
Launoy G, Maynadie
´M, Velten M, Faivre J, Este
`ve J (eds) (2007) Survie
des patients atteints de cancer en France: e
´tude des registres du re
´seau
FRANCIM [French Cancer Registry Network], pp 1 – 406. Springer: Lyon
Kelly R (2002) Cancer deaths. Commons Hansard [Parliamentary Record]
11 March: c703W–c704W
Micheli A, De Angelis G, Giorgi Rossi A, Capocaccia R (1999) General
mortality and the survival of cancer patients in Europe. In Survival of
Cancer Patients in Europe: the EUROCARE-2 Study (IARC Scientific
Publications No. 151), Berrino F, Capocaccia R, Este
`ve J, Gatta G,
Hakulinen T, Micheli A, Sant M, Verdecchia A (eds), pp 63 – 71.
International Agency for Research on Cancer: Lyon
Moran T, Collins S, Gibbs A, Woodman CBJ (2000) Survival of patients
with colon cancer in Europe: a cautionary tale. Colorect Dis 2: 190 – 192
Parkin DM, Whelan SL, Ferlay J, Raymond L, Young JL (eds) (1997) Cancer
Incidence in Five Continents, Vol. VII (IARC Scientific Publications
No. 143). International Agency for Research on Cancer: Lyon
Richards MA, Stockton DL, Babb P, Coleman MP (2000) How many deaths
have been avoided through improvements in cancer survival? Br Med J
320: 895 – 898
Roazzi P, Capocaccia R, Santaquilani M, Carrani E, EUROCARE Working
Group (2003) Electronic availability of EUROCARE-3 data: a tool for
further analysis. Ann Oncol 14(Suppl 5):150 – 155
Romanengo M, Cooper N, Robinson C, Malalgoda M, Quinn MJ,
Coleman MP (2002) Cancer survival in the health authorities of England,
1993 – 2000. Health Stat Q 13: 95 – 103
Sant M, Aareleid T, Berrino F, Bielska Lasota M, Carli P-M, Faivre J,
Grosclaude PC, He
´delin G, Matsuda T, Møller H, Moller T, Verdecchia A,
Capocaccia R, Gatta G, Micheli A, Santaquilani M, Roazzi P, Lisi D,
EUROCARE Working Group (2003) EUROCARE-3: survival of cancer
patients diagnosed 1990 – 1994 results and commentary. Ann Oncol
14(Suppl 5):61 – 118
Scottish Cancer Intelligence Unit (2000) Trends in Cancer Survival in
Scotland 1971–1995. Information and Statistics Division: Edinburgh
Scottish Executive Health Department (2001) Cancer in Scotland: Action for
Change. Scottish Executive Health Department: Edinburgh
Sikora K (1999) Cancer survival in Britain: is poorer than that of her
comparable European neighbours. Br Med J 319: 461 – 462
S
ˇteliarova
´-Foucher E, Stiller CA, Kaatsch P, Berrino F, Coebergh JWW,
Lacour B, Parkin DM (2004) Geographical patterns and time trends of
cancer incidence and survival among children and adolescents in Europe
since the 1970s (the ACCIS project): an epidemiological study. Lancet
364: 2097 – 2105
Threlfall AG, Collins S, Woodman CBJ (2001) ‘Avoided deaths’ may not be
useful for predicting mortality reductions from cancer. Br Med J 321: 1470
Verdecchia A, Guzzanti S, Francisci S, De Angelis R, Bray F, Allemani C,
Tavilla A, Santaquilani M, Sant M, EUROCARE Working Group (2009)
Survival trends in European cancer patients diagnosed from 1988 to
1999. Eur J Cancer 45: 1042 – 1066
Wilkinson E (2009) Questions remain over validity of EUROCARE data.
Lancet 374: 964 – 965
Appendix
For each cancer, we first calculate a weight for each age, sex
and country, w
ijm
, as the number of patients, n, of that age and
sex in that country, divided by the total number of cases (all
countries):
wijm ¼nijm=X
ijm
nijm
where iindexes age, jsex and mcountry.
If there were no cases (and thus no survival estimate) in a
given age–sex group, we assumed that there was one case,
for the purposes of calculation of the weight, and that survival
was equal to that in the adjacent age group. This enabled
calculation of a full set of weights, but gave virtually zero
weight to the imputed survival for that age sex group in the
weighted European average. This approach ensured that for a
given cancer, the sum of the weights in a given calendar period
was always unity. The weights from the EUROCARE-4 data
were applied to the data for each calendar period. For bone
cancer, however, the youngest age group was 20 44 years for the
first two studies, but 15 44 years in EUROCARE-4, so the
EUROCARE-3 weights were applied to both EUROCARE-2 and
-3 data.
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S123
British Journal of Cancer (2009) 101(S2), S115 – S124&2009 Cancer Research UK
For a given cancer, the European mean (or highest) relative
survival, RS
E
, in each age and sex group, is then the weighted
sum across countries of the age-sex-specific relative survival
estimates:
RSEij ¼X
m
½wijm RSijm
where m¼13 countries for the mean European survival and 3 for
the highest European survival.
Then, for each cancer and each calendar period of diagnosis
(1985–1989, 1990 1994, 1995–1999) and each country (England,
Scotland, Wales), the number of avoidable deaths within 5 years of
diagnosis in each age group and sex is calculated as the product of
the number of cases, the expected survival and the difference
between the mean (or highest) 5-year relative survival for each age
and sex group in Europe and the corresponding relative survival in
England, Scotland, Wales. This product is summed over age, sex
and country in Great Britain for each 5-year period, and divided by
5 to present an annual number of avoidable deaths:
Avoidable deaths per yearGB ¼1=5
X
CX
ij
NCij ESCij fRSEij RSCij g
"#
where, for each age group iand each sex j:
N
C
is the number of cases diagnosed in country C (England,
Scotland or Wales) during the 5-year periods 1985 1989, 1990–
1994 or 1995–1999. For 1985 –1989, the number of cases for Wales
was assumed to be 6% of the number for England, and survival in
Wales was assumed to be the same as in England; ES
C
is the
expected survival for country C(England, Scotland or Wales); RS
E
is the mean or highest relative survival, as defined (see text), in
EUROCARE-2 (1985–1989), EUROCARE-3 (1990 1994) or
EUROCARE-4 (1995–1999); RS
C
is the relative survival for country
C(England, Scotland or Wales).
What if cancer survival in Britain were the same as in Europe?
M Abdel-Rahman et al
S124
British Journal of Cancer (2009) 101(S2), S115 – S124 &2009 Cancer Research UK
... Although primary prevention through eliminating cariogenic exposure at the population level could reduce cancer incidence by 40% to 45%, it is still an unachievable goal, particularly for developing countries (3). Therefore, low and middle-income countries should pay more attention to early detection of cancer as the second primary approach of cancer prevention to increase the efficiency of their cancer control programs (2,4,5). ...
... It has been firmly confirmed that full and equal access to cancer screening facilities, along with public awareness about cancer symptoms, lead to an increase in cancer survival through reducing the incidence of advanced cases of cancer (6,7). Reducing the time between early symptoms of cancer and cancer diagnosis provides less complicated therapeutic options and makes them more effective as well (4,5). However, it cannot be achieved unless the majority of patients with cancer are diagnosed through regular screening programs before the appearance of early symptoms (6). ...
Article
Full-text available
Background: The impact of socioeconomic status on cancer survival has already been proven. Early diagnosis of cancer is one of the main reason of this improved survival among high socioeconomic status (SES) people. High SES people are more likely to take part in cancer screening programs for several reason and it seems that diagnosis of cancer is earlier among these people. Despite growing evidence on inequal in cancer survival, diagnosis, and treatment over the past decades there is a lack of evidence on volume and direction of socioeconomic inequality regarding early diagnosis of cancer in Iran. Objectives: To assess socioeconomic inequality in colorectal cancer stage at diagnosis time in Qazvin city, Iran during 2014 - 2016. Methods: A cross-sectional study was conducted on 200 patients who were diagnosed with colorectal cancer (CRC) at the Vellayat hospital of the Qazvin city. The Principal Component Analysis (PCA) approach was used to combine household assets as a proxy of SES. Cancer staging information was extracted from the patient's medical records and then a pathology specialist performed cancer staging. Descriptive statistics and a multiple logistic regression model were used to illustrate an association between CRC late diagnosis and socioeconomic status adjusted for age, sex, and residence of the area. We applied the standardized Concentration Index as a measure of socioeconomic inequality in CRC late diagnosis. Results: The overall percentage of late CRC diagnosis was 40.5% (95% confidence interval (CI) 33.8, 47.5), which was slightly higher among women (47.1%, 95% CI 36.8, 57.6) than men (35.4%, 95% CI, 27.0, 44.7). Logistic regression results spotted an association between SES and the late diagnosis of CRC. In Iranian women, CRC tended to be diagnosed at more advanced stages among the third (Odds Ratio (OR) = 7.68), forth (Low) (OR = 17.86) and fifth (Lowest) (OR = 25.60) SES quintiles, while in men it was only significant for the fifth quintiles (OR = 4.17). Furthermore, the concentration index implied that late CRC diagnosis is concentrated among deprived subgroups in Qazvin city, and it was statistically significant (Overall concentration index = -0.33, 95% CI -0.38, -0.28). It was estimated at -0.35 and -0.29 in Iranian women and men, respectively. Conclusions: According to this survey, CRC tends to be diagnosed at more advanced stages among low socioeconomic status groups, and the observed discrimination is more severe in Iranian women.
... We estimated average 5-year survival for the ten countries under observation, adjusting for the different size of the datasets from each country, using the method of Abdel-Rahman et al. [33]. In brief: we weighted the mean of the 5-year survival from each country by the number of prostate cancer patients included as a proportion of the total cases for that country, as estimated by GLOBOCAN 2018 [1]. ...
Article
Full-text available
Objectives To estimate observed and relative survival of prostate cancer patients in sub-Saharan Africa (SSA) and to examine the influence of age, stage at diagnosis and the Human Development Index (HDI). Patients and methods In this comparative registry study, we selected a random sample of 1752 incident cases of malign prostatic neoplasm from 12 population-based cancer registries from 10 SSA countries, registered between 2005 and 2015. We analyzed the data using Kaplan-Meier and Ederer II methods to obtain outcome estimates and flexible Poisson regression modeling to calculate the excess hazards of death Results For the 1406 patients included in the survival analyses, 763 deaths occurred during 3614 person-years of observation. Of patients with known stage, 45.2% had stage IV disease, 31.2% stage III and only 23.6% stage I and II. The 1 and 5-year relative survival for the entire cohort was 78.0% (75.4–80.7) and 60.0% (55.7–64.6), while varying between the registries. Late presentation was associated with increased excess hazards and a 0.1 increase in the HDI was associated with a 20% lower excess hazard of death, while for age at diagnosis no association was found. Conclusions We found poor survival of SSA prostatic tumor patients, as well as high proportions of late stage presentation, which are associated with inferior outcome. This calls for investment in health-care systems and action regarding projects to raise awareness among the population to achieve earlier diagnosis and improve survival.
... Cancer survival in the UK is below that of European counterparts. 1 One factor leading to poor outcome is the stage of cancer at diagnosis, a later stage at diagnosis makes optimum treatment more difficult. An ambition of The National Health Service (NHS) Long-Term Plan is to diagnose 75% of cancers at stage 1 or 2 by 2028. 2 Improvements in rates of smoking and obesity aim to reduce the lifetime risk of developing cancer and, improving uptake of screening aims to diagnose presymptomatic cancers. ...
Article
Full-text available
Objective Clinical Cancer Decision Tools (CCDTs) aim to alert general practitioners (GPs) to signs and symptoms of cancer, supporting prompt investigation and onward referral. CCDTs are available in primary care in the UK but are not widely utilised. Qualitative research has highlighted the complexities and mechanisms surrounding their implementation and use; this has focused on specific cancer types, formats, systems or settings. This study aims to synthesise qualitative data of GPs’ attitudes to and experience with a range of CCDTs to gain better understanding of the factors shaping their implementation and use. Design A systematic search of the published (MEDLINE, CINAHL, Web of Science and EMBASE) and grey literature (July 2020). Following screening, selection and assessment of suitability, the data were analysed and synthesised using normalisation process theory. Results Six studies (2011 to 2019), exploring the views of GPs were included for analysis. Studies focused on the use of several different types of CCDTs (Risk Assessment Tools (RAT) or electronic version of RAT (eRAT), QCancer and the 7-point checklist). GPs agreed CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. They had concerns about the impact on trust in their own clinical acumen, whether secondary care clinicians would consider referrals generated by CCDT as valid and whether integration of the CCDTs within existing systems was achievable. Conclusions CCDTs might be a helpful adjunct to clinical work in primary care, but without careful development to legitimise their use GPs are likely to give precedence to clinical acumen and gut instinct. Stakeholder consultation with secondary care clinicians and consideration of how the CCDTs fit into a GP consultation are crucial to successful uptake. The role and responsibilities of a GP as a clinician, gatekeeper, health promoter and resource manager affect the interaction with and implementation of innovations such as CCDTs.
... Therefore, we used avoidable excess deaths to quantify the impact of deprivation on survival disparities. It indicates the number of excess deaths that could have been avoided if in all regions the patients had the same prognosis as in the most affluent regions [32]. For total cancer, it is additionally sensitive to differences in the distribution of the individual cancer sites and, thus, deprivation-associated differences in the risk of cancer. ...
Article
Full-text available
Many countries have reported survival inequalities due to regional socioeconomic deprivation. To quantify the potential gain from eliminating cancer survival disadvantages associated with area-based deprivation in Germany, we calculated the number of avoidable excess deaths. We used population-based cancer registry data from 11 of 16 German federal states. Patients aged ≥15 years diagnosed with an invasive malignant tumor between 2008 and 2017 were included. Area-based socioeconomic deprivation was assessed using the quintiles of the German Index of Multiple Deprivation (GIMD) 2010 on a municipality level nationwide. Five-year age-standardized relative survival for 25 most common cancer sites and for total cancer were calculated using period analysis. Incidence and number of avoidable excess deaths in Germany in 2013–2016 were estimated. Summed over the 25 cancer sites, 4100 annual excess deaths (3.0% of all excess deaths) could have been avoided each year in Germany during the period 2013–2016 if relative survival were in all regions comparable with the least deprived regions. Colorectal, oral and pharynx, prostate, and bladder cancer contributed the largest numbers of avoidable excess deaths. Our results provide a good basis to estimate the potential of intervention programs for reducing socioeconomic inequalities in cancer burden in Germany.
... The EUROCARE-4 study demonstrated that age-adjusted 5-year CRC mortality in the United Kingdom is significantly higher than that in the Nordic countries and Central Europe [2]. Abdel-Rahman et al [3] found that CRC accounted for the largest number of avoidable cancer-related deaths in the United Kingdom, with approximately 4090 avoidable cases. ...
Article
Full-text available
Background The United Kingdom has lower survival figures for all types of cancers compared to many European countries despite similar national expenditures on health. This discrepancy may be linked to long diagnostic and treatment delays. Objective The aim of this study was to determine whether delays experienced by patients with colorectal cancer (CRC) affect their survival. Methods This observational study utilized the Somerset Cancer Register to identify patients with CRC who were diagnosed on the basis of positive histology findings. The effects of diagnostic and treatment delays and their subdivisions on outcomes were investigated using Cox proportional hazards regression. Kaplan-Meier plots were used to illustrate group differences. Results A total of 648 patients (375 males, 57.9% males) were included in this study. We found that neither diagnostic delay nor treatment delay had an effect on the overall survival in patients with CRC (χ23=1.5, P=.68; χ23=0.6, P=.90, respectively). Similarly, treatment delays did not affect the outcomes in patients with CRC (χ23=5.5, P=.14). The initial Cox regression analysis showed that patients with CRC who had short diagnostic delays were less likely to die than those experiencing long delays (hazard ratio 0.165, 95% CI 0.044-0.616; P=.007). However, this result was nonsignificant following sensitivity analysis. Conclusions Diagnostic and treatment delays had no effect on the survival of this cohort of patients with CRC. The utility of the 2-week wait referral system is therefore questioned. Timely screening with subsequent early referral and access to diagnostics may have a more beneficial effect.
Article
Full-text available
Background: Benchmarking international cancer survival differences is necessary to evaluate and improve healthcare systems. Our aim was to assess the potential regional differences in outcomes among patients with metastatic colorectal cancer (mCRC) participating in international randomized clinical trials (RCTs). Design: Countries were grouped into 11 regions according to the World Health Organization and the EUROCARE model. Meta-analyses based on individual patient data were used to synthesize data across studies and regions and to conduct comparisons for outcomes in a two-stage random-effects model after adjusting for age, sex, performance status, and time period. We used mCRC patients enrolled in the first-line RCTs from the ARCAD database, which provided enrolling country information. There were 21,509 patients in 27 RCTs included across the 11 regions. Results: Main outcomes were overall survival (OS) and progression-free survival (PFS). Compared with other regions, patients from the United Kingdom (UK) and Ireland were proportionaly over-represented, older, with higher performance status, more frequently male, and more commonly not treated with biological therapies. Cohorts from central Europe and the United States (USA) had significantly longer OS compared with those from UK and Ireland (p = 0.0034 and p < 0.001, respectively), with median difference of 3-4 months. The survival deficits in the UK and Ireland cohorts were, at most, 15% at 1 year. No evidence of a regional disparity was observed for PFS. Among those treated without biological therapies, patients from the UK and Ireland had shorter OS than central Europe patients (p < 0.001). Conclusions: Significant international disparities in the OS of cohorts of mCRC patients enrolled in RCTs were found. Survival of mCRC patients included in RCTs was consistently lower in the UK and Ireland regions than in central Europe, southern Europe, and the USA, potentially attributed to greater overall population representation, delayed diagnosis, and reduced availability of therapies.
Article
Full-text available
There are limited population-based survival data for colorectal cancer (CRC) in sub-Saharan Africa. Here, 1707 persons diagnosed with CRC from 2005-2015 were randomly selected from 13 population-based cancer registries operating in 11 countries in sub-Saharan Africa. Vital status was ascertained from medical charts or through next of kin. 1-, 3-, and 5-year overall and relative survival rates for all registries and for each registry were calculated using the Kaplan-Meier estimator. Multivariable analysis was used to examine the associations of 5-year relative survival with age at diagnosis, stage, and country-level Human Development Index (HDI). Observed survival for 1448 patients with CRC across all registries combined was 72.0% (95% CI 69.5-74.4%) at 1 year, 50.4% (95% CI 47.6-53.2%) at 3 years, and 43.5% (95% CI 40.6-46.3%) at 5 years. We estimate that relative survival at five years in these registry populations is 48.2%. Factors associated with poorer survival included living in a country with lower HDI, late stage at diagnosis, and younger or older age at diagnosis (<50 or ≥ 70 years). For example, the risk of death was 1.6 (95% CI 1.2-2.1) times higher for patients residing in medium-HDI and 2.7 (95% CI 2.2-3.4) times higher for patients residing in low-HDI compared with those residing in high-HDI countries. Survival for CRC remains low in sub-Saharan African countries, though estimates vary considerably by HDI. Strengthening health systems to ensure access to prevention, early diagnosis, and appropriate treatment is critical in improving outcomes of CRC in the region. This article is protected by copyright. All rights reserved.
Article
Full-text available
Background Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy’s RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. Methods We evaluated all patients referred to Guy’s RDC between December 2016 and June 2019 ( n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service. Results There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)—with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15–47) and treatment 56 days (IQR 32–84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%). Conclusions RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%—justifying the RDC approach in vague symptom patients.
Article
Background: Monitoring regional variation in population-based cancer survival is useful for assessing equity in national health-care system. This study quantifies variation in survival between municipalities and hospital districts responsible for primary care and for specialised care, respectively, in Finland. Material and methods: Five-year relative survival of 11 cancers and close to 700,000 patients was estimated by municipality in Finland over 1962–2016 using hierarchical Bayesian modelling. Variation (i) between hospital districts, (ii) between municipalities within hospital districts, and (iii) between all municipalities (total variation) were quantified by the standard deviation of 5-year relative survival standardised by the average survival level. Results: In 2007–2016, the largest variation in 5-year relative survival between all municipalities was in stomach, prostate, kidney and liver cancer and skin melanoma. In male skin melanoma, prostate, and kidney cancer and in male and female pancreatic cancer, there was substantial and statistically significant variation between hospital districts, too. Variation within hospital districts was on average 67% (95% posterior interval [58%,76%]) out of the total variation and had decreased by 18% [2%, 33%] from 1997–2006. Conclusion: The decrease in variation within hospital districts suggests that equity in diagnostics and primary care has improved in Finland. However, the variation between hospital districts in skin melanoma, prostate and kidney cancer reflects differences in early diagnostics. In pancreatic cancer, substantial variation between hospital districts may relate to regional differences in the accessibility and the quality of cancer treatments.
Article
Full-text available
Background Delays in referral for patients with colorectal cancer may occur if the presenting symptom is falsely attributed to a benign condition. Aim To investigate whether delays in referral from primary care are associated with a later stage of cancer at diagnosis and worse prognosis. Design and setting A national retrospective cohort study in England including adult patients with colorectal cancer identified from the cancer registry with linkage to Clinical Practice Research Datalink, who had been referred following presentation to their GP with a ‘red flag’ or ‘non-specific’ symptom. Method The hazard ratios (HR) of death were calculated for delays in referral of between 2 weeks and 3 months, and >3 months, compared with referrals within 2 weeks. Results A total of 4527 (63.5%) patients with colon cancer and 2603 (36.5%) patients with rectal cancer were included in the study. The percentage of patients presenting with red-flag symptoms who experienced a delay of >3 months before referral was 16.9% of those with colon cancer and 13.5% of those with rectal cancer, compared with 35.7% of patients with colon cancer and 42.9% of patients with rectal cancer who presented with non-specific symptoms. Patients referred after 3 months with red-flag symptoms demonstrated a significantly worse prognosis than patients who were referred within 2 weeks (colon cancer: HR 1.53; 95% confidence interval [CI] = 1.29 to 1.81; rectal cancer: HR 1.30; 95% CI = 1.06 to 1.60). This association was not seen for patients presenting with non-specific symptoms. Delays in referral were associated with a significantly higher proportion of late-stage cancers. Conclusion The first presentation to the GP provides a referral opportunity to identify the underlying cancer, which, if missed, is associated with a later stage in diagnosis and worse survival.
Article
The interest in estimating the probability of cure has been increasing in cancer survival analysis as the curability of many cancer diseases is becoming a reality. Mixture survival models provide a way of modelling time to death when cure is possible, simultaneously estimating death hazard of fatal cases and the proportion of cured case. In this paper we propose an application of a parametric mixture model to relative survival rates of colon cancer patients from the Finnish population‐based cancer registry, and including major survival determinants as explicative covariates. Disentangling survival into two different components greatly facilitates the analysis and the interpretation of the role of prognostic factors on survival patterns. For example, age plays a different role in determining, from one side, the probability of cure, and, from the other side, the life expectancy of fatal cases. The results support the hypothesis that observed survival trends are really due to a real prognostic gain for more recently diagnosed patients. Copyright © 1999 John Wiley & Sons, Ltd.
Book
Le réseau Francim regroupe l’ensemble des registres français des cancers. Il a mis en œuvre un observatoire des pathologies cancéreuses en France, dont la finalité est de fournir à la communauté les indicateurs épidémiologiques utiles à la connaissance et à la prise en charge de cette pathologie, en lien avec différents partenaires institutionnels. Une première production de cet observatoire a été de fournir des estimations de l’incidence du cancer en France en 2000. Sa seconde production est rapportée dans cet ouvrage, et concerne la survie des patients atteints de cancer, telle qu’elle a pu être estimée à partir de tous les cas de cancers enregistrés de 1989 à 1997 dans 20 registres départementaux français. Pour atteindre ces objectifs, le réseau s’est associé au service de biostatistique des hospices civils de Lyon, qui a assuré l’analyse statistique des données collectées par les différents registres. Les procédures qui ont été mises en place pour les différentes phases de ce travail peuvent être mises en œuvre de façon régulière, pour des estimations ultérieures. Elles se prêtent aussi à la mise en œuvre d’études plus approfondies qui s’avèrent nécessaires pour certains cancers. Ces données dites de «population» viennent compléter utilement les résultats issus des études menées dans le domaine de la recherche clinique. Un outil supplémentaire de surveillance épidémiologique du cancer est donc à présent disponible en France, grâce au soutien de la Ligue nationale contre le cancer.
Article
The interest in estimating the probability of cure has been increasing in cancer survival analysis as the curability of many cancer diseases is becoming a reality. Mixture survival models provide a way of modelling time to death when cure is possible, simultaneously estimating death hazard of fatal cases and the proportion of cured case. In this paper we propose an application of a parametric mixture model to relative survival rates of colon cancer patients from the Finnish population-based cancer registry, and including major survival determinants as explicative covariates. Disentangling survival into two different components greatly facilitates the analysis and the interpretation of the role of prognostic factors on survival patterns. For example, age plays a different role in determining, from one side, the probability of cure, and, from the other side, the life expectancy of fatal cases. The results support the hypothesis that observed survival trends are really due to a real prognostic gain for more recently diagnosed patients. Copyright © 1999 John Wiley & Sons, Ltd.
Article
EUROCARE-3 analysed the survival of 1815584 adult cancer patients diagnosed from 1990 to 1994 in 22 European countries. The results are reported in tables, one per cancer site, coded according to the International Classification of Diseases (ICD)-9 classification. The main findings of the tables are summarised and commented on in this article. For most solid cancers, wide differences in survival between different European populations were found, as also reported by EUROCARE-1 and EUROCARE-2, despite a remarkable (10%) overall increase in cancer survival from 1985 to 1994. Survival was highest in northern Europe (Sweden, Norway, Finland and Iceland), and fairly good in central-southern Europe (France, Switzerland, Austria and Spain). Survival was particularly low in eastern Europe, low in Denmark and the UK, and fairly low in Portugal and Malta. The mix of tumour stage at diagnosis explains much of the survival differences for cancers of the digestive tract, female reproductive system, breast, thyroid, and also skin melanoma. For tumours of the urinary tract and prostate, the differences were explained mainly by differences in diagnostic criteria and procedures. The case mix by anatomic subsite largely explains differences in survival for head and neck cancers. For oesophagus, pancreas, liver and brain cancer, with poor prognoses, survival differences were limited. Tumours, for which highly effective treatments are available, such as testicular cancer, Hodgkin's lymphoma and some haematological malignancies, had fairly uniform survival across Europe. Survival for all tumours combined (an indicator of the overall cancer care performance of a nation's health system) was better in young than old patients, and better in women than men. The affluence of countries influenced overall cancer survival through the availability of adequate diagnostic and treatment procedures, and screening programmes.
Article
: Cancer survival analyses based on cancer registry data do not provide direct information on the main aim of cancer treatment, the cure of the patient. In fact, classic survival indicators do not distinguish between patients who are cured, and patients who will die of their disease and in whom prolongation of survival is the main objective of treatment. In this study, we applied parametric cure models to the cancer incidence and follow-up data provided by 49 EUROCARE-4 (European Cancer Registry-based study, fourth edition) cancer registries, with the aims of providing additional insights into the survival of European cancer patients diagnosed from 1988 to 1999, and of investigating between-population differences. Between-country estimates the proportion of cured patients varied from about 4-13% for lung cancer, from 9% to 30% for stomach cancer, from 25% to 49% for colon and rectum cancer, and from 55% to 73% for breast cancer. For all cancers combined, estimates varied between 21% and 47% in men, and 38% and 59% in women and were influenced by the distribution of cases by cancer site. Countries with high proportions of cured and long fatal case survival times for all cancers combined were characterised by generally favourable case mix. For the European pool of cases both the proportion of cured and the survival time of fatal cases were associated with age, and increased from the early to the latest diagnosis period. The increases over time in the proportions of Europeans estimated cured of lung, stomach and colon and rectum cancers are noteworthy and suggest genuine progress in cancer control. The proportion of cured of all cancers combined is a useful general indicator of cancer control as it reflects progress in diagnosis and treatment, as well as success in the prevention of rapidly fatal cancers.