Understanding the link between health systems and cancer survival: A novel methodological approach using a system-level conceptual model

Factors associated with diagnostic and treatment intervals in colorectal cancer: A linked data study

This research aimed to assess the length of intervals before diagnosis and treatment for colorectal cancer in Australia using linked datasets, and to determine any factors associated with interval length. A colorectal cancer clinical registry was linked to general practice electronic medical record data and routinely collected hospital referral datasets to determine the length of four key intervals in the time before first treatment. Cox proportional hazards regression was used to assess associations between individual characteristics (sociodemographic variables such as age and sex, and disease characteristics such as cancer subtype and treatment approach) and the length of each interval. Sample sizes available for analysis varied by interval, ranging from 99 to 9359. The median interval length ranged from 21 (IQR 5-38) days for the time between diagnosis and treatment to 63 (IQR 24-218) days for the time between first presentation and diagnosis. Overall, few measured characteristics were associated with the lengths of any of the intervals. Of note, shorter diagnostic intervals were associated with presenting to the general practitioner with alarm symptoms, and people proceeding to surgery as initial treatment had shorter times to treatment than any other treatment modality. Given disease and medical system factors were associated with interval length, broad improvements to the overall efficient functioning of the healthcare system are likely to improve timeliness. More targeted interventions could focus on processes at the transitions between different levels of the healthcare system and implementing recommended maximum lengths of intervals along the diagnostic and treatment pathway.

Understanding the health system drivers of delayed cancer diagnosis in public healthcare networks of Chile, Colombia and Ecuador: A qualitative study with health professionals, managers and policymakers

Although the greatest delays in cancer diagnosis in Latin America occur in the provider interval little is known about the related factors. This study aims to analyze factors influencing access to cancer diagnosis -from initial contact with health services to confirmation- from institutional stakeholders' perspective in public healthcare networks of Chile, Colombia, and Ecuador. A qualitative, descriptive-interpretative study was conducted in two networks per country, using semi-structured individual interviews (n = 118; 23 to 58, per country) with a criterion sample of health professionals and administrative personnel from primary care (PC) (n = 41) and secondary/tertiary care hospitals (n = 47), network managers and policymakers (n = 30). The final sample size was reached through saturation. Thematic content analysis was performed, segmented by country. The analysis reveals interacting factors that cause cumulative delays throughout the patient's diagnostic pathway within healthcare networks, with differences between countries. In all three, informants identify similar characteristics of the networks: structural (deficits in diagnostic resources; geographical accessibility), organizational factors (long waiting times, especially after referral), and the limited knowledge and experience of PC doctors, which all lead to delayed diagnosis. In Chile and Colombia, health policy barriers related to care rationing/prioritization policies that hampered access to tests, and in Chile, increased delays for non-prioritized conditions. Country-specific barriers related to the organization of healthcare system also emerge: in Chile, private services subcontracting and the voucher system for using them; in Colombia, the management of care by insurers (care authorizations; fragmented and short-term contracting of providers); and in Ecuador, underfunding of the system. The barriers most affect the elderly, those with low socioeconomic status, with limited support networks, and rural areas residents. The results reveal relevant barriers in access to timely cancer diagnosis which can and should be addressed with specific cancer diagnosis policies and general measures that strengthen public healthcare systems and networks.

NHS cancer services and systems-ten pressure points a UK cancer control plan needs to address

In this Policy Review we discuss ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence we provide points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.

Factors Associated with Primary Liver Cancer Survival in a Southern Italian Setting in a Changing Epidemiological Scenario

A retrospective observational study utilising cancer incidence data from a population-based registry investigated determinants affecting primary liver cancer survival in a southern Italian region with high hepatitis viral infection rates and obesity prevalence. Among 2687 patients diagnosed between 2006 and 2019 (65.3% male), a flexible hazard-based regression model revealed factors influencing 5-year survival rates. High deprivation levels [HR = 1.41 (95%CI = 1.15-1.76); p < 0.001], poor access to care [HR = 1.99 (95%IC = 1.70-2.35); p < 0.0001], age between 65 and 75 [HR = 1.48 (95%IC = 1.09-2.01); p < 0.05] or >75 [HR = 2.21 (95%CI = 1.62-3.01); p < 0.0001] and residing in non-urban areas [HR = 1.35 (95%CI = 1.08-1.69); p < 0.01] were associated with poorer survival estimates. While deprivation appeared to be a risk factor for primary liver cancer patients residing within the urban area, the geographic distance from specialised treatment centres emerged as a potential determinant of lower survival estimates for residents in the non-urban areas. After balancing the groups of easy and poor access to care using a propensity score approach, poor access to care and a lower socioeconomic status resulted in potentially having a negative impact on primary liver cancer survival, particularly among urban residents. We emphasise the need to interoperate cancer registries with other data sources and to deploy innovative digital solutions to improve cancer prevention.

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

Comparison of Cancer Mortality and Incidence Between New Zealand and Australia and Reflection on Differences in Cancer Care: An Ecological Cross-Sectional Study of 2014-2018

BACKGROUND

Despite many background similarities, New Zealand showed excess cancer deaths compared to Australia in previous studies. This study extends this comparison using the most recent data of 2014-2018.

METHODS

This study used publicly available cancer mortality and incidence data of New Zealand Ministry of Health and Australian Institute of Health and Welfare, and resident population data of Statistics New Zealand. Australian cancer mortality and incidence rates were applied to New Zealand population, by site of cancer, year, age and sex, to estimate the expected numbers, which were compared with the New Zealand observed numbers.

RESULTS

For total cancers in 2014-2018, New Zealand had 780 excess deaths in women (17.1% of the annual total 4549; 95% confidence interval (CI) 15.8-18.4%), and 281 excess deaths in men (5.5% of the annual total 5105; 95% CI 4.3-6.7%) compared to Australia. The excess was contributed by many major cancers including colorectal, melanoma, and stomach cancer in both sexes; lung, uterine, and breast cancer in women, and prostate cancer in men. New Zealand's total cancer incidences were lower than those expected from Australia's in both women and men: average annual difference of 419 cases (-3.6% of the annual total 11 505; 95% CI -4.5 to -2.8%), and 1485 (-11.7% of the annual total 12 669; 95% CI -12.5 to -10.9%), respectively. Comparing time periods, the excesses in total cancer deaths in women were 15.1% in 2000-07, and 17.5% in 1996-1997; and in men 4.7% in 2000-2007 and 5.6% in 1996-1997. The differences by time period were non-significant.

CONCLUSION

Excess mortality from all cancers combined and several common cancers in New Zealand, compared to Australia, persisted in 2014-2018, being similar to excesses in 2000-2007 and 1996-1997. It cannot be explained by differences in incidence, but may be attributable to various aspects of health systems governance and performance.

European Groundshot-addressing Europe's cancer research challenges: a Lancet Oncology Commission

Cancer research is a crucial pillar for countries to deliver more affordable, higher quality, and more equitable cancer care. Patients treated in research-active hospitals have better outcomes than patients who are not treated in these settings. However, cancer in Europe is at a crossroads. Cancer was already a leading cause of premature death before the COVID-19 pandemic, and the disastrous effects of the pandemic on early diagnosis and treatment will probably set back cancer outcomes in Europe by almost a decade. Recognising the pivotal importance of research not just to mitigate the pandemic today, but to build better European cancer services and systems for patients tomorrow, the Lancet Oncology European Groundshot Commission on cancer research brings together a wide range of experts, together with detailed new data on cancer research activity across Europe during the past 12 years. We have deployed this knowledge to help inform Europe's Beating Cancer Plan and the EU Cancer Mission, and to set out an evidence-driven, patient-centred cancer research roadmap for Europe. The high-resolution cancer research data we have generated show current activities, captured through different metrics, including by region, disease burden, research domain, and effect on outcomes. We have also included granular data on research collaboration, gender of researchers, and research funding. The inclusion of granular data has facilitated the identification of areas that are perhaps overemphasised in current cancer research in Europe, while also highlighting domains that are underserved. Our detailed data emphasise the need for more information-driven and data-driven cancer research strategies and planning going forward. A particular focus must be on central and eastern Europe, because our findings emphasise the widening gap in cancer research activity, and capacity and outcomes, compared with the rest of Europe. Citizens and patients, no matter where they are, must benefit from advances in cancer research. This Commission also highlights that the narrow focus on discovery science and biopharmaceutical research in Europe needs to be widened to include such areas as prevention and early diagnosis; treatment modalities such as radiotherapy and surgery; and a larger concentration on developing a research and innovation strategy for the 20 million Europeans living beyond a cancer diagnosis. Our data highlight the important role of comprehensive cancer centres in driving the European cancer research agenda. Crucial to a functioning cancer research strategy and its translation into patient benefit is the need for a greater emphasis on health policy and systems research, including implementation science, so that the innovative technological outputs from cancer research have a clear pathway to delivery. This European cancer research Commission has identified 12 key recommendations within a call to action to reimagine cancer research and its implementation in Europe. We hope this call to action will help to achieve our ambitious 70:35 target: 70% average 10-year survival for all European cancer patients by 2035.

Exploring the link between cancer policies and cancer survival: a comparison of International Cancer Benchmarking Partnership countries

Cancer policy differences might help to explain international variation in cancer survival, but empirical evidence is scarce. We reviewed cancer policies in 20 International Cancer Benchmarking Partnership jurisdictions in seven countries and did exploratory analyses linking an index of cancer policy consistency over time, with monitoring and implementation mechanisms, to survival from seven cancers in a subset of ten jurisdictions from 1995 to 2014. All ten jurisdictions had structures in place to oversee or deliver cancer control policies and had published at least one major cancer plan. Few cancer plans had explicit budgets for implementation or mandated external evaluation. Cancer policy consistency was positively correlated with improvements in survival over time for six of the seven cancer sites. Jurisdictions that scored the highest on policy consistency had large improvements in survival for most sites. Our analysis provides an important first step to systematically capture and evaluate what are inherently complex policy processes. The findings can help guide policy makers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.

An International Consensus on Actions to Improve Lung Cancer Survival: A Modified Delphi Method Among Clinical Experts in the International Cancer Benchmarking Partnership

BACKGROUND

Research from the International Cancer Benchmarking Partnership (ICBP) demonstrates that international variation in lung cancer survival persists, particularly within early stage disease. There is a lack of international consensus on the critical contributing components to variation in lung cancer outcomes and the steps needed to optimise lung cancer services. These are needed to improve the quality of options for and equitable access to treatment, and ultimately improve survival.

METHODS

Semi-structured interviews were conducted with 9 key informants from ICBP countries. An international clinical network representing 6 ICBP countries (Australia, Canada, Denmark, England, Ireland, New Zealand, Northern Ireland, Scotland & Wales) was established to share local clinical insights and examples of best practice. Using a modified Delphi consensus model, network members suggested and rated recommendations to optimise the management of lung cancer. Calls to Action were developed via Delphi voting as the most crucial recommendations, with Good Practice Points included to support their implementation.

RESULTS

Five Calls to Action and thirteen Good Practice Points applicable to high income, comparable countries were developed and achieved 100% consensus. Calls to Action include (1) Implement cost-effective, clinically efficacious, and equitable lung cancer screening initiatives; (2) Ensure diagnosis of lung cancer within 30 days of referral; (3) Develop Thoracic Centres of Excellence; (4) Undertake an international audit of lung cancer care; and (5) Recognise improvements in lung cancer care and outcomes as a priority in cancer policy.

CONCLUSION

The recommendations presented are the voice of an expert international lung cancer clinical network, and signpost key considerations for policymakers in countries within the ICBP but also in other comparable high-income countries. These define a roadmap to help align and focus efforts in improving outcomes and management of lung cancer patients globally.

Variation in suspected cancer referral pathways in primary care: comparative analysis across the International Benchmarking Cancer Partnership

BACKGROUND

International variations in cancer outcomes persist and may be influenced by differences in the accessibility and organisation of cancer patient pathways. More evidence is needed to understand to what extent variations in the structure of primary care referral pathways for cancer investigation contribute to differences in the timeliness of diagnoses and cancer outcomes in different countries.

AIM

To explore the variation in primary care referral pathways for the management of suspected cancer across different countries.

DESIGN AND SETTING

Descriptive comparative analysis using mixed methods across the International Cancer Benchmarking Partnership (ICBP) countries.

METHOD

Schematics of primary care referral pathways were developed across 10 ICBP jurisdictions. The schematics were initially developed using the Aarhus statement (a resource providing greater insight and precision into early cancer diagnosis research) and were further supplemented with expert insights through consulting leading experts in primary care and cancer, existing ICBP data, a focused review of existing evidence on the management of suspected cancer, published primary care cancer guidelines, and evaluations of referral tools and initiatives in primary care.

RESULTS

Referral pathway schematics for 10 ICBP jurisdictions were presented alongside a descriptive comparison of the organisation of primary care management of suspected cancer. Several key areas of variation across countries were identified: inflexibility of referral pathways, lack of a managed route for non-specific symptoms, primary care practitioner decision-making autonomy, direct access to investigations, and use of emergency routes.

CONCLUSION

Analysing the differences in referral processes can prompt further research to better understand the impact of variation on the timeliness of diagnoses and cancer outcomes. Studying these schematics in local contexts may help to identify opportunities to improve care and facilitate discussions on what may constitute best referral practice.

Exploring the Role of Leadership in Facilitating Change to Improve Cancer Survival: An Analysis of Experiences in Seven High Income Countries in the International Cancer Benchmarking Partnership (ICBP)

BACKGROUND

The differences in cancer survival across countries and over time are well recognised, with progress varying even among high-income countries with comparable health systems. Previous research has examined several possible explanations, but the role of leadership in systems providing cancer care has attracted little attention. As part of the International Cancer Benchmarking Partnership (ICBP), this study looked at diverse aspects of leadership to identify drivers of change and opportunities for improvement across seven high-income countries.

METHODS

Key informants in 13 jurisdictions were interviewed: Australia (2 states), Canada (3 provinces), Denmark, Ireland, New Zealand, Norway and United Kingdom (4 countries). Participants represented a range of stakeholders at different tiers of the system. They were recruited through a combination of purposive and 'snowball' strategies and participated in semi-structured telephone interviews. Interview transcripts were analysed thematically drawing on the World Health Organization (WHO) health systems framework and previous work analysing national cancer control programmes (NCCPs).

RESULTS

Several facets of leadership were perceived as important for improving outcomes. These included political leadership to initiate and maintain progress, intellectual leadership to support those engaged in local implementation of national policies and drive change, and a coherent vision from leaders at different levels of the system. Clinical leadership was also viewed as vital for translating policy into action.

CONCLUSION

Certain aspects of cancer care leadership emerged as underpinning and sustaining improvements, such as appointing a central agency, involving clinicians at every stage, ensuring strong leadership of cancer care with a consistent political mandate. Improving cancer outcomes is challenging and complex, but it is unlikely to be achieved without effective leadership, both political and clinical.

"There's Not Enough Bodies to Do the Demand": An Exploration of Key Stakeholder Views on the Role of Health Service Capacity in Shaping Cancer Outcomes in 7 International Cancer Benchmarking Partnership Countries

BACKGROUND

Differences in cancer survival are shaped by differences in health system capacity in workforce and infrastructure. Part of the International Cancer Benchmarking Partnership (ICBP), this study explored stakeholders' perceptions of the role of health system capacity necessary for cancer care in influencing cancer survival in 7 high-income countries.

METHODS

We conducted semi-structured interviews with 79 key informants from national, regional, and local tiers of health systems, professional bodies, patient associations, and academic experts in Australia, Canada, Denmark, Ireland, New Zealand, Norway, and the United Kingdom. Data collection was guided by a conceptual model linking characteristics of health systems and cancer survival along the cancer patient journey, from recognition of symptoms at pre-diagnostic stages through to survivorship or death. Data were analysed using a thematic approach.

RESULTS

We identified 3 themes as important in shaping cancer outcomes: primary care and access to diagnostic evaluation, specialist care and access to treatment, and workforce pertaining to diagnostic and treatment phases. Improved infrastructure for diagnosis and treatment had improved cancer outcomes in all jurisdictions. However, this was seen as insufficient if staffing was inadequate. Consolidation of services and greater surgical specialisation was important in some jurisdictions if accompanied by a reconfiguration of services, in particular the creation of specialist multidisciplinary teams, along with supporting capacity in the wider health system. Staff shortages were commonly cited as reasons why some jurisdictions lagged behind others.

CONCLUSION

Continued improvement in cancer outcomes will require sustained investment in plans to deliver and maintain the workforce engaged in cancer care and in the infrastructure on which they depend. However, strategic plans must recognise that systems for cancer care do not work in isolation from the rest of the health system and a whole systems approach is essential if we are to improve outcomes for an ageing, increasingly multimorbid population.

Risk factors and prognostic implications of diagnosis of cancer within 30 days after an emergency hospital admission (emergency presentation): an International Cancer Benchmarking Partnership (ICBP) population-based study

BACKGROUND

Greater understanding of international cancer survival differences is needed. We aimed to identify predictors and consequences of cancer diagnosis through emergency presentation in different international jurisdictions in six high-income countries.

METHODS

Using a federated analysis model, in this cross-sectional population-based study, we analysed cancer registration and linked hospital admissions data from 14 jurisdictions in six countries (Australia, Canada, Denmark, New Zealand, Norway, and the UK), including patients with primary diagnosis of invasive oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer during study periods from Jan 1, 2012, to Dec 31, 2017. Data were collected on cancer site, age group, sex, year of diagnosis, and stage at diagnosis. Emergency presentation was defined as diagnosis of cancer within 30 days after an emergency hospital admission. Using logistic regression, we examined variables associated with emergency presentation and associations between emergency presentation and short-term mortality. We meta-analysed estimates across jurisdictions and explored jurisdiction-level associations between cancer survival and the percentage of patients diagnosed as emergencies.

FINDINGS

In 857 068 patients across 14 jurisdictions, considering all of the eight cancer sites together, the percentage of diagnoses through emergency presentation ranged from 24·0% (9165 of 38 212 patients) to 42·5% (12 238 of 28 794 patients). There was consistently large variation in the percentage of emergency presentations by cancer site across jurisdictions. Pancreatic cancer diagnoses had the highest percentage of emergency presentations on average overall (46·1% [30 972 of 67 173 patients]), with the jurisdictional range being 34·1% (1083 of 3172 patients) to 60·4% (1317 of 2182 patients). Rectal cancer had the lowest percentage of emergency presentations on average overall (12·1% [10 051 of 83 325 patients]), with a jurisdictional range of 9·1% (403 of 4438 patients) to 19·8% (643 of 3247 patients). Across the jurisdictions, older age (ie, 75-84 years and 85 years or older, compared with younger patients) and advanced stage at diagnosis compared with non-advanced stage were consistently associated with increased emergency presentation risk, with the percentage of emergency presentations being highest in the oldest age group (85 years or older) for 110 (98%) of 112 jurisdiction-cancer site strata, and in the most advanced (distant spread) stage category for 98 (97%) of 101 jurisdiction-cancer site strata with available information. Across the jurisdictions, and despite heterogeneity in association size (I2=93%), emergency presenters consistently had substantially greater risk of 12-month mortality than non-emergency presenters (odds ratio >1·9 for 112 [100%] of 112 jurisdiction-cancer site strata, with the minimum lower bound of the related 95% CIs being 1·26). There were negative associations between jurisdiction-level percentage of emergency presentations and jurisdiction-level 1-year survival for colon, stomach, lung, liver, pancreatic, and ovarian cancer, with a 10% increase in percentage of emergency presentations in a jurisdiction being associated with a decrease in 1-year net survival of between 2·5% (95% CI 0·28-4·7) and 7·0% (1·2-13·0).

INTERPRETATION

Internationally, notable proportions of patients with cancer are diagnosed through emergency presentation. Specific types of cancer, older age, and advanced stage at diagnosis are consistently associated with an increased risk of emergency presentation, which strongly predicts worse prognosis and probably contributes to international differences in cancer survival. Monitoring emergency presentations, and identifying and acting on contributing behavioural and health-care factors, is a global priority for cancer control.

FUNDING

Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Institute New South Wales; Cancer Research UK; Danish Cancer Society; National Cancer Registry Ireland; The Cancer Society of New Zealand; National Health Service England; Norwegian Cancer Society; Public Health Agency Northern Ireland, on behalf of the Northern Ireland Cancer Registry; the Scottish Government; Western Australia Department of Health; and Wales Cancer Network.

The use of national reimbursement reports to support formulary decisions of the hospital's Drug and Therapeutics Committee: a comparative analysis

Background New therapies that do not reach patients in need, have not achieved their goal. Drug and Therapeutics Committees in hospitals ensure access to patients by compiling a formulary on rational grounds. An evolving landscape of innovative molecules challenges timely formulary adaptation after national reimbursement. Aim To integrate national reimbursement reports in the hospital's appraisal, thereby promoting access for patients without delay. Method For 2019, the rationale for new molecules at Ghent University Hospital, Belgium, was compared with the public assessment report of the National Institute for Health and Disability Insurance, assessing a medicine in a specific indication following a reimbursement request by the manufacturer. Decision criteria (therapeutic value and cost) between matching medicines in both databases (national & hospital) were retrospectively compared [no (%), mean (SD)]. Results Two-hundred public reports and 30 formulary decisions were analysed (with antineoplastic & immunomodulating as most prevalent class: 41.0% resp. 36.7%). National decision often concerned hospital-only medicines (89; 44.5%) without patient co-payment (101; 50.5%). Of 13 matched medicines (same indication), time delay between national decision and formulary admission was on average 3.1 (SD 2.3) months. Comparative analysis showed that assessment in both committees was mostly based on the efficacy endpoints of Randomised Controlled Trials. Literature used in hospital appraisals was of more recent publication date: + 0.78 (SD 2.2) years. Using public reports as a horizon scan could enable quick identification of new indications. Conclusion To speed up patient access, the scientific evidence of national reimbursement reports can be used for the purpose of hospital formulary decisions.

Does access to care play a role in liver cancer survival? The ten-year (2006-2015) experience from a population-based cancer registry in Southern Italy

Background

Hepatocellular carcinoma (HCC) is the most frequent primary invasive cancer of the liver. During the last decade, the epidemiology of HCC has been continuously changing in developed countries, due to more effective primary prevention and to successful treatment of virus-related liver diseases.

The study aims to examine survival by level of access to care in patients with HCC, for all patients combined and by age.

Methods

We included 2018 adult patients (15–99 years) diagnosed with a primary liver tumour, registered in the Palermo Province Cancer Registry during 2006–2015, and followed-up to 30 October 2019. We obtained a proxy measure of access to care by linking each record to the Hospital Discharge Records and the Ambulatory Discharge Records.

We estimated net survival up to 5 years after diagnosis by access to care (“easy access to care” versus “poor access to care”), using the Pohar-Perme estimator. Estimates were age-standardised using International Cancer Survival Standard (ICSS) weights. We also examined survival by access to care and age (15–64, 65–74 and ≥ 75 years).

Results

Among the 2018 patients, 62.4% were morphologically verified and 37.6% clinically diagnosed. Morphologically verified tumours were more frequent in patients aged 65–74 years (41.6%), while tumours diagnosed clinically were more frequent in patients aged 75 years or over (50.2%). During 2006–2015, age-standardised net survival was higher among HCC patients with “easy access to care” than in those with “poor access to care” (68% vs. 48% at 1 year, 29% vs. 11% at 5 years; p < 0.0001). Net survival up to 5 years was higher for patients with “easy access to care” in each age group (p < 0.0001). Moreover, survival increased slightly for patients with easier access to care, while it remained relatively stable for patients with poor access to care.

Conclusions

During 2006–2015, 5-year survival was higher for HCC patients with easier access to care, probably reflecting progressive improvement in the effectiveness of health care services offered to these patients.

Our linkage algorithm could provide valuable evidence to support healthcare decision-making in the context of the evolving epidemiology of hepatocellular carcinoma.