The EUROCARE study of survival of cancer patients in Europe: aims, current status, strengths and weaknesses

[Cancer registries in Germany: what does the future hold for urology?]

Cancer registries are defined as systematically collected information in the form of a database on tumour diseases. They can provide information about the quality of oncological care or progress in the treatment of individual cancers over time. Since 1995, all German federal states have been required by law to establish and maintain a cancer registry. The Center for Cancer Registry Data (ZfKD) at Robert Koch Institute has collected this nationwide data since 2009 and compiled it into an annually audited dataset available for research purposes. By virtue of the Cancer Early Detection and Registry Act (KFRG), which was passed in 2013, the cancer registries were given a new perspective. Since then, they have made a central contribution to the quality assurance of oncological care. The cancer registries are mainly financed by the health insurance funds. An upcoming expansion of the dataset including clinical variables and earlier provision by the ZfKD starting next year offers new opportunities for the scientific use of cancer registry data. In particular, the course of the disease will now be mapped in considerable detail. Apart from the cancer registries, there are not many useful supplemental datasets in Germany for the assessment of the nationwide healthcare situation and treatment reality on a national level. The DRG database (case-based hospital statistics) of the Federal Statistics Office records all billing data of all German hospitals with few exceptions. Another interesting supplement to the cancer registry data are the datasets of the structured quality reports, which have been mandatory for hospitals since 2003. In the future, the scientific role of cancer registries is to be further enhanced by the Act on the Pooling of Cancer Registry Data, which was passed in 2021.

Under-Treatment of Older Patients with Newly Diagnosed Epithelial Ovarian Cancer Remains an Issue

Older women with ovarian cancer have disproportionately poorer survival outcomes than their younger counterparts and receive less treatment. In order to understand where the gaps lie in the treatment of older patients, studies incorporating more detailed assessment of baseline characteristics and treatment delivery beyond the scope of most cancer registries are required. We aimed to assess the proportion of women over the age of 65 who are offered and receive standard of care for first-line ovarian cancer at two UK NHS Cancer Centres over a 5-year period (December 2009 to August 2015). Standard of care treatment was defined as a combination of cytoreductive surgery and if indicated platinum-based chemotherapy (combination or single-agent). Sixty-five percent of patients aged 65 and above received standard of care treatment. Increasing age was associated with lower rates of receiving standard of care (35% > 80 years old versus 78% of 65-69-year-olds, p = 0.000). Older women were less likely to complete the planned chemotherapy course (p = 0.034). The oldest women continue to receive lower rates of standard care compared to younger women. Once adjusted for Federation of Gynaecology and Obstetrics (FIGO) stage, Eastern Cooperative Oncology Group (ECOG) performance status and first-line treatment received, age was no longer an independent risk factor for poorer overall survival. Optimisation of vulnerable patients utilising a comprehensive geriatric assessment and directed interventions to facilitate the delivery of standard of care treatment could help narrow the survival discrepancy between the oldest patients and their younger counterparts.

Pre-diagnostic delays caused by gastrointestinal investigations do not affect outcomes in pancreatic cancer

Background

Pancreatic ductal adenocarcinomas are poor prognostic cancers accounting for 3% of all cancer cases in the UK. They often present late in the course of the disease process with non-specific symptoms, including gastro-intestinal(GI) symptoms. Delays in diagnosis occur when investigations are carried out in a primary care setting for GI symptoms. The aim of this study was to assess delays in pancreatic cancer diagnosis when patients were referred for GI investigations and evaluate its effect on survival.

Methods

Retrospective cohort study of all patients diagnosed with pancreatic adenocarcinoma in a Scottish district general hospital over a seven year period from January 2010 to December 2016. Patients were divided into two groups, those who had a GI investigation 18 months prior to the pancreatic cancer diagnosis and those who did not have GI investigations. Data on demographics, symptoms on referral, stage of disease at diagnosis, treatment undergone and length of survival collected and analysed.

Results

One hundred and fifty-three patients were diagnosed with pancreatic cancer in the study period. Forty (26%) of the 153 underwent gastrointestinal investigations in the 18 months prior to diagnosis. The remaining 113 (74%) had no gastro-intestinal investigations in the same time period. Demographic data were comparable. Significant delays occurred from referral to diagnosis in the GI investigated group compared to those who did not have GI investigations. (64.5days vs 9 days, p = 0.001). No difference was noted in disease stage or treatments undergone between the groups. There was no difference in the average survival after diagnosis between the two groups with median of 108 days for those who underwent GI investigations to 97 days for those who did not.(U = 2079.5, p = 0.454).

Conclusion

Delays caused by pre-diagnostic GI investigations do not appear to contribute to the poor prognosis of pancreatic cancer. Recently updated NICE Guidelines recommends early ultrasound or CT in patients with GI symptoms and weight loss which may reduce delays in diagnosis. Screening tests in future may become cost effective and diagnose this condition at a curable stage which in turn may improve survival rates.

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Patients often present with gastro-intestinal symptoms.

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This triggers endoscopic gastro-intestinal investigations that delay diagnosis.

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These delays do not affect survival outcomes.

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Population based, cost effective screening tests need to be developed to diagnose this condition at a curable stage.

Epidemiology and pathophysiology of malignancy in common variable immunodeficiency?

Common variable immunodeficiency (CVID) is a diagnostic category of primary immunodeficiency (PID) which may present with heterogeneous disorders including recurrent infections, autoimmunity, granulomatous diseases, lymphoid and other types of malignancies. Generally, the incidence of malignancy in CVID patients is around 1.5-20.7% and usually occurs during the 4th-6th decade of life. Non-Hodgkin lymphoma is the most frequent malignancy, followed by epithelial tumours of stomach, breast, bladder and cervix. The exact pathological mechanisms for cancer development in CVID are not fully determined; however, several mechanisms including impaired genetic stability, genetic predisposition, immune dysregulation, impaired clearance of oncogenic viruses and bacterial infections, and iatrogenic causes have been proposed to contribute to the high susceptibility of these patients to malignancies.

Incidence, mortality and survival of female breast cancer during 2003-2011 in Jiangsu province, China

OBJECTIVE

To assess the incidence, mortality and survival status of female breast cancer in Jiangsu province of China.

METHODS

Population-based cancer registry data in Jiangsu province were collected during 2003-2011. Crude rates, age-specific rates, age-standardized rates and annual percent changes of incidence and mortality were calculated to describe the epidemiologic characteristics and time trends. Patients diagnosed from 2003 to 2005 were chosen for analyzing the survival status of breast cancer.

RESULTS

From 2003 to 2011, 17,605 females were diagnosed with breast cancer and 4,883 died in selected registry areas in Jiangsu province. The crude incidence rate was 25.18/100,000, and the age-standardized rates by Chinese population (ASRC) and by world population (ASRW) were 19.03/100,000 and 17.92/100,000, respectively. During the same period, the crude mortality rate was 6.98/100,000 and the ASRC and ASRW were 4.93/100,000 and 4.80/100,000, respectively. From 2003 to 2011, the incidence and mortality increased with annual percent change of 11.37% and 5.78%, respectively. For survival analysis, 1,392 patients in 7 areas were identified in 2003-2005 and finished 5 years of follow-up. Survival rates were found to decrease with survival years, the 5-year observed survival rate was 45.9% and the relative survival rate was 52.0%. We also found that the survival rate varied across the province, which was lower in the north and higher in the south of Jiangsu province.

CONCLUSIONS

Breast cancer has become a significant public health problem in Jiangsu province and China. More resources should be invested in primary prevention, earlier diagnosis and better health services in order to increase survival rates among Chinese females.

Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study

Background:

To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care.

Methods:

Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF).

Results:

There were 639 064 patients with a first-time admission for cancer, with 139 351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15–44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32–1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91–0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04–1.11) and being less able to offer appointments within 48 h were associated with higher odds.

Conclusion:

We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.

Magnetic resonance imaging for lung cancer detection: experience in a population of more than 10,000 healthy individuals

BACKGROUND

Recent refinements of lung MRI techniques have reduced the examination time and improved diagnostic sensitivity and specificity. We conducted a study to assess the feasibility of MRI for the detection of primary lung cancer in asymptomatic individuals.

METHODS

A retrospective chart review was performed on images of lung parenchyma, which were extracted from whole-body MRI examinations between October 2000 and December 2007. 11,766 consecutive healthy individuals (mean age, 50.4 years; 56.8% male) were scanned using one of two 1.5-T scanners (Sonata and Sonata Maestro, Siemens Medical Solutions, Erlangen, Germany). The standard protocol included a quick whole-lung survey with T2-weighted 2-dimensional half Fourier acquisition single shot turbo spin echo (HASTE) and 3-dimensional volumetric interpolated breath-hold examination (VIBE). Total examination time was less than 10 minutes, and scanning time was only 5 minutes. Prompt referrals and follow-ups were arranged in cases of suspicious lung nodules.

RESULTS

A total of 559 individuals (4.8%) had suspicious lung nodules. A total of 49 primary lung cancers were diagnosed in 46 individuals: 41 prevalence cancers and 8 incidence cancers. The overall detection rate of primary lung cancers was 0.4%. For smokers aged 51 to 70 years, the detection rate was 1.4%. TNM stage I disease accounted for 37 (75.5%). The mean size of detected lung cancers was 1.98 cm (median, 1.5 cm; range, 0.5-8.2 cm). The most histological types were adenocarcinoma in 38 (77.6%).

CONCLUSION

Rapid zero-dose MRI can be used for lung cancer detection in a healthy population.

Review of gastric cancer risk factors in patients with common variable immunodeficiency disorders, resulting in a proposal for a surveillance programme

Common variable immunodeficiency disorders (CVIDs) are the most frequent symptomatic primary immunodeficiencies in adults. They comprise a heterogeneous group of pathologies, with frequent non-infectious complications in addition to the bacterial infections that usually characterize their presentation. Complications include a high risk of malignancy, especially lymphoma and gastric cancer. Helicobacter pylori infection and pernicious anaemia are risk predictors for gastric cancer in the general population and probably in patients with CVIDs. Screening for gastric cancer in a high-risk population appears to improve survival. Given the increased risk of gastric cancer in patients with CVIDs and prompted by a case of advanced gastric malignancy in a patient with a CVID and concomitant pernicious anaemia, we performed a review of the literature for gastric cancer and conducted a cohort study of gastric pathology in 116 patients with CVIDs under long-term follow-up in Oxford. Regardless of the presence of pernicious anaemia or H. pylori infection, patients with CVIDs have a 10-fold increased risk of gastric cancer and are therefore a high-risk population. Although endoscopic screening of all patients with CVIDs could be considered, a more selective approach is appropriate and we propose a surveillance protocol that should reduce modifiable risk factors such as H. pylori, in order to improve the management of patients with CVIDs at risk of gastric malignancy.

Long-term toxic effects of adjuvant chemotherapy in breast cancer

Breast cancer is the most common malignant tumor affecting women. Adjuvant systemic therapies have been shown to have a significant impact on reducing the risk for breast cancer recurrence and overall mortality. Chemotherapy remains an important and frequently used treatment option in the adjuvant setting, and the associated short-term adverse events are very well described. However, there is insufficient information regarding the long-term sequelae of most chemotherapeutic agents. In this review, we describe different potential long-term adverse events associated with adjuvant chemotherapy in breast cancer, with a particular focus on long-term cardiac toxicity, secondary leukemia, cognitive function, and neurotoxicity. In addition, we discuss the effect of adjuvant chemotherapy on fertility and sexual function of young breast cancer patients. These adverse events are frequently overshadowed by the well-demonstrated clinical efficacy and/or reassuring short-term safety profiles of the different chemotherapy regimens commonly used today. We believe that a proper understanding and appreciation of these adverse events will enable us to refine our strategies for managing breast cancer. The fact that adjuvant chemotherapy is often given to patients who might not really need it urges us to consider the whole spectrum of chemotherapy risks versus benefits to maximize benefit without compromising quality of life.

The state of the art of cancer control in 30 European countries in 2008

Inequalities in cancer incidence, mortality and survival represent a major challenge for public health. Addressing this challenge requires complex and multidisciplinary approaches. Sharing successful experiences from across Europe may therefore be of benefit. We describe the state of the art of cancer control structures in the 27 European Union countries, plus Iceland, Norway and Switzerland, at the beginning of 2008. Information on cancer plans, cancer registries, cancer screening, Human Papillomavirus (HPV) vaccination and smoking restrictions in each country was identified through PubMed, the official websites of national and international organizations and Google searches. Experts and/or health authorities from each country completed and validated the information. Sixteen countries had implemented national cancer plans in 2008. Twenty four countries had population-based cancer registries with 100% coverage. The exceptions were Greece and Luxembourg (no population-based registry yet), France, Italy and Spain (<50%), and Switzerland (62%). In 9 countries, population coverage of breast cancer screening was 100% with participation ranging from 26 to 87%; 8 countries did not have organized programmes. Seven countries had cervical cancer screening programmes with 100% coverage with participation ranging from 10 to 80%; 8 countries had no organized programme. Nine countries had announced national HPV vaccination policies by early 2008. Six countries had organized colorectal cancer screening programmes. Five countries had complete bans on smoking in public places. There is wide international heterogeneity in cancer control structures in Europe. This provides considerable scope and motivation for cooperation and sharing of experience.

Leaving home after cancer in childhood: a measure of social independence in early adulthood

BACKGROUND

Previous studies on psychosocial outcomes for childhood and adolescent cancer survivors have found diverse results concerning social independence. As a measure of social independence, we investigated whether cancer survivors displayed the same patterns of leaving home as population-based control group.

PROCEDURE

We identified 1,597 patients in the Danish Cancer Register, born in 1965-1980, in whom a primary cancer was diagnosed before they reached the age of 20 in the period 1965-1995. The patients were compared with a random sample of the general population (n = 43,905) frequency matched on sex and date of birth. By linking the two cohorts to registers in Statistics Denmark, we obtained socioeconomic data for the period 1980-1997. The relative risk for leaving home was estimated with discrete-time Cox regression models.

RESULTS

The risk for leaving home of survivors of hematological malignancies and solid tumors did not differ significantly from that of the control cohort. Adjustments for possible socioeconomic confounders did not change this pattern. In contrast, survivors of central nervous system (CNS) tumors had a significantly reduced risk for leaving home, which was most pronounced for men (relative risk, men: 0.66; 95% confidence interval, 0.55-0.80; women: 0.88, 95% confidence interval, 0.80-0.97).

CONCLUSION

Overall, the psychosocial effects of cancer in childhood or adolescence and its treatment on the survivor and family did not appear to impede social independence in early adulthood, except for survivors of CNS tumors.

Delays in the diagnosis of six cancers: analysis of data from the National Survey of NHS Patients: Cancer

The aim of this paper is to describe and compare components of diagnostic delay (patient, primary care, referral, secondary care) for six cancers (breast, colorectal, lung, ovarian, prostate and non-Hodgkin's lymphoma), and to compare delays in patients who saw their GP prior to diagnosis with those who did not. Secondary data analysis of The National Survey of NHS Patients: Cancer was undertaken (65 192 patients). Breast cancer patients experienced the shortest total delays (mean 55.2 days), followed by lung (88.5), ovarian (90.3), non-Hodgkin's lymphoma (102.8), colorectal (125.7) and prostate (148.5). Trends were similar for all components of delay. Compared with patient and primary care delays, referral delays and secondary care delays were much shorter. Patients who saw their GP prior to diagnosis experienced considerably longer total diagnostic delays than those who did not. There were significant differences in all components of delay between the six cancers. Reducing diagnostic delays with the intention of increasing the proportion of early stage cancers may improve cancer survival in the UK, which is poorer than most other European countries. Interventions aimed at reducing patient and primary care delays need to be developed and their effect on diagnostic stage and psychological distress evaluated.

Survival patterns for the top four cancers in Canada: the effects of age, region and period

This study examined the variations in survival rates (1989-1991) and the trends (1969-1991), by sex, age and province, for patients diagnosed with breast, colorectal, lung or prostate cancer in Canada and compared the Canadian rates with those of nine American SEER registries. Five-year age-standardized relative survival rates (ASRs) were calculated, and the trends were estimated from variance-weighted linear regression of the ASRs for five periods of diagnosis (1969-1973, 1974-1978, 1979-1983, 1984-1988 and 1989-1991). In 1989-1991, the ASR varied among provinces for each cancer except female colorectal cancer. The lowest survival rates were observed in the youngest patients (15-44) for breast and prostate cancers, and in the oldest patients (75-99) of both sexes for lung and colorectal cancers. Over the five periods, a major trend toward improved survival was observed for breast, prostate and colorectal cancers (P<0.008), whereas no changes were seen for lung cancer. The ASRs in the western region were higher than in the Atlantic region over time (P<0.02) for each cancer. From the third period onward, the ASRs for Canadian patients with lung cancer were similar to those for the US patients and lower than for Canadian patients with breast, prostate or colorectal cancer. The observed increases in ASR for breast and prostate cancer are likely due to the increased use of screenings and the improved treatment modalities.

Educational attainment among survivors of childhood cancer: a population-based cohort study in Denmark

We identified 2384 patients in the Danish Cancer Register in whom cancer had been diagnosed in 1960–1996 before they reached the age of 20 and compared them with 53 143 sex- and age-matched controls identified from the Register of Population Statistics. Complete education records and demographic and socioeconomic information for the period 1980–2000 were obtained for both cohorts from Statistics Denmark. The rate ratio (RR) for educational attainment was estimated by discrete-time Cox regression analyses. An overall reduction in attaining basic education was found (RR, 0.90; 95% confidence interval, 0.83–0.96). Female survivors of central nervous system (CNS) tumours showed the largest educational deficit (RR, 0.55; 95% confidence interval, 0.37–0.82). Non-CNS tumour survivors attained education as controls at most levels. When the analyses were conditioned on completion of youth education, further educational attainment was not reduced for any group of survivors. These findings confirm that only survivors of CNS tumours in childhood experience significant educational deficits. The deficit was mainly seen among persons whose tumour was diagnosed before they reached the level of secondary education.

The EUROCARE-3 database: methodology of data collection, standardisation, quality control and statistical analysis

The EUROCARE database contains data on 6.5 million cancer patients diagnosed from 1978 to 1994 in populations covered by 67 cancer registries in 22 European countries. The quality-checked entries specify age, sex, diagnosis date, cancer site, morphology, microscopic confirmation and vital status, as well as containing broad indicators of stage. For EUROCARE-3, which refers to diagnoses from 1990 to 1994, 3389 cases with major data problems and 142,525 second or subsequent cancers were removed, leaving more than 2 million cases for analysis. From these data, observed and relative survival for each cancer site and country were calculated at 1, 3 and 5 years from diagnosis. Overall European survival for each cancer site and for all cancers combined were calculated combining country-specific survival figures. Overall, 1.1% of cases were lost to follow-up, 4.2% were known from death certificates only and 1.2% were known at autopsy only. The percentage of microscopically confirmed cases varied with cancer site and country, and was always higher in northern European countries. Comparison of quality indicators for the EUROCARE-3 database with earlier EUROCARE databases indicates that data quality and standardisation have improved.

Improvements in survival for women with breast cancer in Scotland between 1987 and 1993: impact of earlier diagnosis and changes in treatment

We investigated changes in survival, and their causes, in women with early breast cancer diagnosed in Scotland. The Scottish Cancer Registry identified 1617 and 2077 such women, without metastases at diagnosis who underwent surgery as part of their primary treatment, diagnosed in 1987 and 1993, respectively. There was a statistically significant 11% improvement in 8-year survival between 1987 and 1993. Survival improved across almost all clinical/pathological, treatment and health care delivery/deprivation categories; improvement was not limited to those women diagnosed through the screening programme. In a multivariate model, improved survival appeared to be explained largely by screening and clinical/pathological prognostic factors. Deprivation also had an adverse effect on survival; however, the geographical variation in survival observed for women diagnosed in 1987 was not apparent by 1993. We did not demonstrate a significant independent effect of surgical caseload on survival. We conclude that survival has increased partly as a consequence of screening and earlier diagnosis, but also due to improvements in the organisation and delivery of care.

Breast carcinoma survival in Europe and the United States

BACKGROUND

Breast carcinoma survival rates were found to be higher in the U.S. than in Europe.

METHODS

Multiple regression analysis of breast carcinoma survival rates among women diagnosed between 1990 and 1992 was performed using clinical data from population-based case series from the Surveillance, Epidemiogy, and End Results (SEER) program (13,172 women) and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project (4478 women).

RESULTS

Early-stage tumors (T1N0M0) were more frequent in the SEER data (41% of cases) than in the EUROCARE data (29%). In the SEER data, early tumors were more frequent in women age > or = 65 years (43%) than in younger women (38%), whereas the reverse was true in the European data (25% vs. 31%). In both case series, > 90% of women underwent surgery and 81-82% underwent lymphadenectomy, but the number of axillary lymph nodes evaluated was higher in the SEER data than in the EUROCARE data. The 5-year survival rate was higher in the U.S. case series (89%) than in the European series (79%). This differential was observed for each stage category evaluated: early (T1N0M0), large lymph node-negative (T2-3N0M0), lymph node-positive (T1-3N+M0), locally advanced (T4M0), and metastatic (M1) tumors. The overall relative excess risk (RER) of death was significantly higher (RER, 1.37; 95% confidence interval [95% CI], 1.25-1.50) among European women compared with U.S. women (referent group). Adjustment for stage, age, surgery, and the number of lymph nodes evaluated explained most of the excess risk (RER, 1.07; 95% CI, 0.98-1.17).

CONCLUSIONS

Transatlantic differences in the 5-year survival rates for women diagnosed with breast carcinoma between 1990 and 1992 were attributable mainly to differences in stage of disease. Resources should be invested to achieve earlier diagnosis of breast carcinoma in Europe, especially for elderly women.

Differences in colorectal cancer survival between European and US populations: the importance of sub-site and morphology

A previous study has shown a lower survival for colorectal cancer in Europe than in the United States of America (USA). It is of interest to examine the extent to which anatomical location and morphological type influence this difference in colorectal cancer survival. We analysed survival for 151,244 European and 53,884 US patients diagnosed with colorectal cancer aged 15-99 years during the period of 1985-1989, obtained from 40 cancer registries that contribute to the EUROCARE study from 17 countries, and nine Surveillance, Epidemiology and End-Results (SEER) registries in the USA. Cases included in the analysis were first primary malignant tumours (ICD-O behaviour code 3 or higher). Relative survival was estimated to correct for competing causes of mortality. The Hakulinen-Tenkanen multiple regression approach was used to examine the prognostic impact of sub-site and ICD-O histology codes. Relative excess risks (RERs) derived from this approach estimate the extent to which the hazard of death differs from that in a reference region after adjustment for mortality in the general population. In order to explore geographical variation, we defined three groups of European registries within which survival rates were known to be broadly similar. The proportion of cases with unspecified sub-site was higher in Europe than the USA (10% versus 2%), but sub-site distributions were broadly similar in the two populations. With the exception of appendix, 5-year survival was 13-22% higher in the USA than in Europe for each anatomical sub-site. The proportion of non-microscopically-verified cases was higher in Europe than the USA (16 versus 3%). Adenocarcinomas arising in a polyp (ICD-O-2 8210, 8261, 8263) were more frequent in the USA than Europe (13 versus 2%). Five-year survival was higher in the USA than Europe for each morphological group, with the exception of non-microscopically-verified cases. When age, gender and sub-site were considered, RERs ranged from 1.52 to 2.40 for the European populations (with the USA as a reference). After inclusion of morphology codes, the range of RERs fell to between 1.28 and 1.86, mainly because of the high frequency of adenocarcinoma in polyps in the USA. This analysis suggests that the large survival advantage for colorectal cancer patients in the USA can only marginally be explained by differences in the distribution of sub-site and morphology. The main explanatory difference is the proportion of adenocarcinoma in polyps.

Childhood cancer survival in Europe

BACKGROUND

EUROCARE-3 collected data from 45 population-based cancer registries in 20 countries on 24 620 European children aged from 0 to 14 years diagnosed with malignancy in the period 1990-1994.

METHODS

Five-year survival between countries was compared for all malignancies and for the major diagnostic categories, adjusting for age, and estimated average European survival weighting for differences in childhood populations.

RESULTS

For all cancers combined, survival variation was large (45% in Estonia to 90% in Iceland), and was generally low (60-70%) in eastern Europe and high (> or =75%) in Switzerland, Germany and the Nordic countries (except Denmark). The Nordic countries had the highest survival for four of the seven major tumour types: nephroblastoma (92%), acute lymphoid leukaemia (85%), CNS tumours (73%) and acute non-lymphocytic leukaemia (62%). The eastern countries had lowest survival: 89% for Hodgkin's disease, 71% for nephroblastoma, 68% for acute lymphoid leukaemia, 61% for non-Hodgkin's lymphoma, 57% for central nervous system (CNS) tumours and 29% for acute non-lymphocytic leukaemia.

CONCLUSIONS

The Nordic countries represent a survival gold standard to which other countries can aspire. Since most childhood cancers respond well to treatment, survival differences are attributable to differences in access (including referral and timely diagnosis) and use of modern treatments; however, the obstacles to access and application of standard treatments probably vary markedly with country.

Cancer in women

Incidence, mortality and survival trends for the most frequent cancers affecting women are presented on a worldwide basis. Data sources are represented by several different cancer databases, as no single world cancer database covers these epidemiological measures. Monitoring cancer incidence, mortality and survival are fundamental indicators which allow estimates and predictions of geographical and temporal changes of these diseases, enabling the design and set-up of adequate cancer control activities and national health programs. The observed differences in cancer incidence, mortality and survival in more developed countries compared with less developed countries (as defined by WHO) are mainly due to different individual and social risk factors between the two geo-political areas. For some cancers, advancements in screening, diagnosis and treatment in the more developed areas were the most effective factors in reducing incidence and mortality as well as prolonging survival. These effects were not detected in the less developed areas because of the limited access to primary and specialist care.