European health systems and cancer care

Effects of organized screening programs on breast cancer screening, incidence, and mortality in Europe

We link data on regional Organized Screening Programs (OSPs) throughout Europe with survey data and population-based cancer registries to estimate effects of OSPs on breast cancer screening (mammography), incidence, and mortality. Identification is from regional variation in the existence and timing of OSPs, and in their age-eligibility criteria. We estimate that OSPs, on average, increase mammography by 25 percentage points, increase breast cancer incidence by 16% five years after the OSPs implementation, and reduce breast cancer mortality by about 10% ten years after.

Melanoma Mortality Trends in 28 European Countries: A Retrospective Analysis for the Years 1960-2020

BACKGROUND

In 2020, in 27 European Union (EU) Member States, melanoma accounted for 4% of all new cancer cases and 1.3% of all cancer deaths, making melanoma the fifth most common malignancy and placing it in the 15 most frequent causes of cancer deaths in the EU-27. The main aim of our study was to investigate melanoma mortality trends in 25 EU Member States and three non-EU countries (Norway, Russia, and Switzerland) in a broad time perspective (1960-2020) in a younger (45-74 years old) vs. older age group (75+).

METHODS

We identified melanoma deaths defined by ICD-10 codes C-43 for individuals aged 45-74 and 75+ years old between 1960-2020 in 25 EU Member States (excluding Iceland, Luxembourg, and Malta) and in 3 non-EU countries-Norway, Russia, and Switzerland. Age-standardized melanoma mortality rates (ASR) were computed using the direct age-standardization for Segi's World Standard Population. To determine melanoma-mortality trends with 95% confidence intervals (CI), Joinpoint regression was applied. Our analysis used the Join-point Regression Program, version 4.3.1.0 (National Cancer Institute, Bethesda, MD, USA).

RESULTS

Regardless of the considered age groups, in all investigated countries, in general, melanoma standardized mortality rates were higher for men than women. Considering the age group 45-74, the highest number of countries was characterized by decreasing melanoma-mortality trends in both sexes-14 countries. Contrarily, the highest representation of countries in the age group 75+ was connected with increasing melanoma-mortality trends in both sexes-26 countries. Moreover, considering the older age group-75+-there was no country with a decreasing melanoma mortality in both sexes.

CONCLUSIONS

Investigated melanoma-mortality trends vary in individual countries and age groups; however, a highly concerning phenomenon-increasing melanoma-mortality rates in both sexes-was observed in 7 countries for the younger age group and in as many as 26 countries for the older age group. There is a need for coordinated public-health actions to address this issue.

Comparison of Prices and Affordability of Cancer Medicines in 16 Countries in Europe and Latin America

BACKGROUND

There are concerns that high prices of cancer medicines may limit patient access. Since information on prices for cancer medicines and their impact on affordability is lacking for several countries, particularly for lower income countries, this study surveys prices of originator cancer medicines in Europe and Latin America and assesses their affordability.

METHODS

For 19 cancer medicines, public procurement and ex-factory prices, as of 2017, were surveyed in five Latin American (LATAM) countries (Brazil, Chile, Colombia, Mexico, and Peru) and 11 European countries (Austria, France, Germany, Greece, Hungary, the Netherlands, Poland, Romania, Spain, Sweden, and the UK). Price data (public procurement prices in LATAM and ex-factory prices in Europe) in US dollar purchasing power parities (PPP) were analyzed per defined daily dose. Affordability was measured by setting medicines prices in relation to national minimum wages.

RESULTS

The prices of cancer medicines varied considerably between countries. In European countries with higher levels of income, PPP-adjusted prices tended to be lower than in European countries of lower income and LATAM countries. Except for one medicine, all surveyed medicines were considered unaffordable in most countries. In European countries of lower income and LATAM countries, more than 15 days' worth of minimum wages would be required by a worker to purchase one defined daily dose of several of the studied medicines.

CONCLUSIONS

The high prices and large unaffordability of cancer medicines call for strengthening pricing policies with the aim of ensuring affordable treatment in cancer care.

Cancer Pain Management-A European Perspective

Cancer pain management is a major challenge in both Europe and the United States. Recent studies show that the incidence of cancer pain remains high and even increases at an advanced stage of the disease.

Phase- and gender-specific, lifetime, and future costs of cancer: A retrospective population-based registry study

Valid estimates of cancer treatment costs are import for priority setting, but few studies have examined costs of multiple cancers in the same setting.We performed a retrospective population-based registry study to evaluate phase-specific (initial, continuing, and terminal phase) direct medical costs and lifetime costs for 13 cancers and all cancers combined in Norway. Mean monthly cancer attributable costs were estimated using nationwide activity data from all Norwegian hospitals. Mean lifetime costs were estimated by combining phase-specific monthly costs and survival times from the national cancer registry. Scenarios for future costs were developed from the lifetime costs and the expected number of new cancer cases toward 2034 estimated by NORDCAN.For all cancers combined, mean discounted per patient direct medical costs were Euros (EUR) 21,808 in the initial 12 months, EUR 4347 in the subsequent continuing phase, and EUR 12,085 in the terminal phase (last 12 months). Lifetime costs were higher for cancers with a 5-year relative survival between 50% and 70% (myeloma: EUR 89,686, mouth/pharynx: EUR 66,619, and non-Hodgkin lymphoma: EUR 65,528). The scenario analyses indicate that future cancer costs are highly dependent on future cancer incidence, changes in death risk, and cancer-specific unit costs.Gender- and cancer-specific estimates of treatment costs are important for assessing equity of care and to better understand resource consumption associated with different cancers.Cancers with an intermediate prognosis (50%-70% 5-year relative survival) are associated with higher direct medical costs than those with relatively good or poor prognosis.

Societal cost of cancer in Norway -Results of taking a broader cost perspective

BACKGROUND

The broader cost consequences of diseases may be of interest for a wide range of stakeholders. We aimed to estimate all relevant societal costs of cancer and to provide insight into the relative magnitude of the different cost categories.

METHOD

We used data from eight different health and work-related registries in Norway. Direct, indirect, and intangible costs (value of lost life years) were estimated over a period of one year with a combination of a top-down and a bottom-up costing approach.

RESULTS

The indirect costs (EUR 1,997 million per year) are almost as high as direct costs (EUR 2,154 million), and the value of lost life years and quality of life represents the greatest cost related to cancer (EUR 18,200 million). In addition, cancer is associated with other costs which are commonly omitted from cost-of-illness analyses, including informal nursing (EUR 306 million), patient time costs (EUR 85 million), and excess costs of using public funds (EUR 439 million). Breast and cervical cancer had relatively high work absenteeism costs, while pancreatic and lung cancer had relatively high production costs due to premature deaths.

DISCUSSION

Direct health care costs represent small proportions of the total societal costs of cancer. Costs commonly omitted in cost-of-illness analyses represent a significant cost and should be measured and valued in these analyses.

Patient's travel distance to specialised cancer diagnostics and the association with the general practitioner's diagnostic strategy and satisfaction with the access to diagnostic procedures: an observational study in Denmark

Background

Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP’s suspicion of cancer, we investigated the association between: 1) cancer patient’s travel distance to the first specialised diagnostic facility and the GP’s diagnostic strategy and 2) cancer patient’s travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations.

Method

This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient’s travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP’s satisfaction with the waiting times and the available investigations were assessed from GP questionnaires.

Results

When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using ‘wait-and-see’ approach and ‘medical treatment’ as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20–3.28).

Conclusion

A insignificant tendency to use ‘wait-and-see’ and ‘medical treatment’ were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Factors Related to the Post-operative Recurrence of Atypical Meningiomas

Aim: This study aimed to investigate the relationship between clinicopathological characteristics of atypical meningiomas (AM) and its post-operative recurrence.

Materials and Methods: The clinicopathological characteristics and findings from follow up were retrospectively reviewed and compared between AM and benign meningioma (BM) patients. Univariate and multivariate analyses were employed to identify the factors related to the post-operative recurrence of AM.

Results: More BM patients were females and received complete resection; the recurrence rate was significantly lower in BM patients as compared to AM patients. The progesterone receptor (PR), E-cadherin protein (E-Ca) and β-catenin positive rates and Ki67 labeling index were significantly different between two groups. Univariate analysis showed the age, tumor size, tumor invasiveness, E-Ca expression, and extent of resection were related to the post-operative recurrence of AM. However, multivariate analysis showed only the extent of resection and tumor invasiveness were the independent factors associated with the post-operative recurrence of AM.

Conclusions: The extent of resection and tumor invasiveness are related to the post-operative recurrence of AM. To improve the surgical procedures to maximize the tumor resection is important to improve the prognosis of AM patients.

Psychometric validation of the Turkish version of the Supportive Care Needs Survey for Partners and Caregivers (SCNS-P&C-T) of cancer patients

OBJECTIVE

To evaluate the validity and reliability study of the Supportive Care Needs Survey for partners and caregivers of cancer patients in Turkish society (SCNS-P&C-T).

METHODS

This cross-sectional survey followed by a test-retest reliability and psychometric validation study was conducted with 270 participants. The research data were collected using a patient and caregiver demographic survey, the SCNS-P&C-T, the Caregiver Strain Index, and the Hospital Anxiety and Depression Scale.

RESULTS

Ten expert opinions were found to be consistent for content validity of the scale (I-CVI = 0.993, S-CVI = 0.956). The confirmatory factor analysis could not confirm the factor structure of the original scale. Therefore, an exploratory factor analysis was performed and the scale factor structure was determined. These factor structures are (a) psychological and emotional needs, (b) health care and information, (c) work and social needs, (d) communication and family needs.

CONCLUSION

The SCNS-P&C-T is a valid and reliable tool which can be used to identify unmet needs among caregivers in Turkish populations.

National Estimates of Cancer Patients Survival in Italy: A Model-Based Method

Aims and background

To provide model-based estimates of all cancers patient survival in Italy and in Italian large geographical areas (North-West, North-East, Center, South), where only partial coverage of cancer registries data is available, and to describe them in terms of time trends. Moreover, to measure the degree of representativeness of cancer patient survival obtained from Italian cancer registries data.

Methods

Relative survival in the four main Italian geographical areas was estimated by a parametric mixture model belonging to the class of “cure” survival models. Data used are from Italian cancer registries, stratified by sex, period of diagnosis and age. The Italian national survival was obtained as a weighted average of these area-specific estimates, with weights proportional to the number of estimated incident cases in every area. The model takes into account also differences in survival temporal trends between the areas.

Results

Relative survival for all cancers combined in Italian patients diagnosed in 1990-1994 was estimated to be higher in women (53%) than in men (38%) at 5 years from the diagnosis. The survival trend is increasing by period and decreasing creasing by age, both for men and women. The greatest gain in terms of survival was obtained by the elderly, with annual mean growth rates in the period 1978-1994 equal to 3.5% and 3.2% for men and women, respectively. More than 50% of the youngest cancer patients were “cured”, whereas for the elderly this proportion dropped to 15% and 25% for men and women, respectively. The South of Italy had the lowest survival and the North the most pronounced increase.

Conclusions

The obtained national survival estimates are similar, but not identical, to previously published estimates, in which Italian registries’ data were pooled without any adjustment for geographical representativeness. The four Italian areas have different survival levels and trends, showing variability within the country. The differences in survival between men and women may be explained by the different proportion of lethal cancers. Among males, most cases had a poor prognosis (lung and stomach cancers), whereas among females the largest proportion was made up of curable and less lethal cancers (breast cancer).

Comorbidities, age and period of diagnosis influence treatment and outcomes in early breast cancer

Survival for breast cancer (BC) is lower in eastern than northern/central Europe, and in older than younger women. We analysed how comorbidities at diagnosis affected whether selected standard treatments (STs) were given, across Europe and over time, also assessing consequences for survival/relapse. We analysed 7581 stage I/IIA cases diagnosed in 9 European countries in 2009-2013, and 4 STs: surgery; breast-conserving surgery plus radiotherapy (BCS + RT); reconstruction after mastectomy; and prompt treatment (≤6 weeks after diagnosis). Covariate-adjusted models estimated odds of receiving STs and risks of death/relapse, according to comorbidities. Pearson's R assessed correlations between odds and risks. The z-test assessed the significance of time-trends. Most women received surgery: 72% BCS; 24% mastectomy. Mastectomied patients were older with more comorbidities than BCS patients (p < 0.001). Women given breast reconstruction (25% of mastectomies) were younger with fewer comorbidities than those without reconstruction (p < 0.001). Women treated promptly (45%) were younger than those treated later (p = 0.001), and more often without comorbidities (p < 0.001). Receiving surgery/BCS + RT correlated strongly (R = -0.9), but prompt treatment weakly (R = -0.01/-0.02), with reduced death/relapse risks. The proportion receiving BCS + RT increased significantly (p < 0.001) with time in most countries. This appears to be the first analysis of the influence of comorbidities on receiving STs, and of consequences for outcomes. Increase in BCS + RT with time is encouraging. Although women without comorbidities usually received STs, elderly patients often received non-standard less prompt treatments, irrespective of comorbidities, with increased risk of mortality/relapse. All women, particularly the elderly, should receive ST wherever possible to maximise the benefits of modern evidence-based treatments.

Tackling cancer burden in low-income and middle-income countries: Morocco as an exemplar

Examples of successful implementations of national cancer control plans in low-income or middle-income countries remain rare. Morocco, a country where cancer is already the second leading cause of death after cardiovascular diseases, is one exception in this regard. Population ageing and lifestyle changes are the major drivers that are further increasing the cancer burden in the country. Facing this challenge, the Moroccan Ministry of Health has developed a we l planned and pragmatic National Plan for Cancer Prevention and Control (NPCPC) that, since 2010, has been implemented with government financial support to provide basic cancer care services across the entire range of cancer control. Several features of the development and implementation of the NPCPC and health-care financing in Morocco provide exemplars for other low-income and middle-income countries to follow. Additionally, from the first 5 years of NPCPC, several areas were shown to require further focus through implementation research, notably in strengthening cancer awareness, risk reduction, and the referral pathways for prevention, early detection, treatment, and follow-up care. Working together with a wide range of stakeholders, and engagement with stakeholders outside the health-care system on a more holistic approach can provide further opportunities for the national authorities to build on their successes and realise the full potential of present and future cancer control efforts in Morocco.

Life Tables for World-Wide Comparison of Relative Survival for Cancer (CONCORD Study)

Background

The CONCORD study compares population-based relative survival from cancer using data from cancer registries in five continents. To estimate relative survival, general mortality life tables are required. Available statistics are incomplete, so various approaches are used to construct complete life tables. This article outlines how the life tables were constructed for CONCORD; it compares life expectancy at birth between 101 populations covered by cancer registries in 31 countries and compares the impact of two approaches to the deployment of life tables in relative survival analysis.

Methods

The CONCORD approach, using specific mathematical methods, produced complete (single-year-of-age) life tables by sex, cancer registry area, calendar year (1990–1999) and race (only in the USA). In order to study the impact of different approaches, we compared relative survival in the USA using the US national life table, centered on the relevant census years, and the CONCORD approach. We estimated relative survival in each American participating cancer registry for patients diagnosed with breast (women), colorectal or prostate cancer during 1990–1994 and followed up to 1999.

Results

Average life expectancy at birth during 1990–1999 varied in CONCORD cancer registry areas from 64 to 78 years in males and from 71 to 84 years in females. It increased during the 1990s more in men than in women. In the USA, it was lower in blacks than in whites. Relative survival in American populations was lower with the CONCORD approach, which incorporates trends and geographic variation in background mortality, than with the USA census life tables.

Conclusions

International variation in background mortality by geographic area, calendar time, race, age and sex is wide. We suggest that in international comparisons of cancer relative survival, complete life tables that are specific for cancer registry area, calendar year and race should be used.

Use of socio-economic factors and healthcare resources to estimate cancer survival in European countries with partial national cancer registration

Background and aims

Cancer is a chronic disease whose clinical history has a strong relationship with socio-economic indicators, and it could be defined as a real “social disease”. For this reason, socio-economic factors can be used to project survival rates by means of ecological models. The present study had two main aims: to generalize to all adult patients study of the association between survival and socio-economic and healthcare technologies and related medical resources factors; to provide insights on the possible bias in giving national meaning to survival rates based on pools of regional cancer registries where national coverage is not available.

Material and methods

The EUROCARE 3 Study provided age-standardized survival rates at 5 years from the diagnosis for 10 major cancer sites collected by 52 cancer registries from 21 European countries for the period 1990–1994. For each area and country, socio-economic and health-related variables were collected for the period 1993–1995. Multiple linear regression models were used to compute predicted survival rates in countries totally covered by registration, starting from the correlation between socio-economic and health-related variables and observed survival rates. For those areas not totally covered by cancer registry activity, a correctional parameter coming from the previous linear regression models was computed in order to estimate survival at a national level also in these countries.

Results

Predicted survival rates were very close to the observed rates for countries totally covered by cancer registries. The estimates were also good for nations with partial national cancer registration, with less convergence in results for countries where socio-economic differences between the whole territory and the covered area were relevant.

Conclusions

In the light of these findings, evaluation of the role of socio-economic and health-related factors and the estimation of survival is of utmost importance in order to evaluate healthcare outcomes and to support planners in allocating resources in a more effective and egalitarian way.

Pegfilgrastim Versus Filgrastim for Primary Prophylaxis of Febrile Neutropenia in Patients with non-Hodgkin’s Lymphoma: A Cost-Effectiveness Study

Aim:

One method to deal with febrile neutropenia is the use of granulocyte colony stimulating factors (G-CSFs). Pegfilgrastim or Filgrastim injection can lead to a reduction in febrile neutropenia and severe neutropenia in patients receiving chemotherapy. This study aimed to compare the cost-effectiveness of using Pegfilgrastim, 3-day Filgrastim and 1-day Filgrastim medication strategies for the primary prophylaxis of febrile neutropenia in patients with relapsed non-Hodgkin’s lymphoma after salvage chemotherapy who referred to two referral centers affiliated to Iran, Shiraz University of Medical Sciences in 2014.

Method:

This cost-effectiveness study was conducted on 131 patients with non-Hodgkin’s lymphoma. The outcome of the study was the prevention of febrile neutropenia. The cost data were collected from the health payer’s perspective for each medication strategy by reviewing the patients’ medical records and using expert opinion. The results were presented in terms of the incremental cost-effectiveness ratio (ICER) and the sensitivity analysis was used to assess the robustness of results. In this study, the collected data were analyzed using Excel 2007 and Tree-age 2011.

Results:

The results showed that the degrees of febrile neutropenia prevented by Pegfilgrastim, 3-day Filgrastim and 1-day Filgrastim strategies were 0.97, 0.95 and 0.83, respectively, and the average annual costs of hospitalization per patient were, 5299, 4959 and 5808 PPP$.

Conclusion:

The results showed that while 1-day Filgrastim was absolutely predominant, using the 3-day Filgrastim and Pegfilgrastim strategies were more cost-effective. Therefore, they can be recommended respectively as the first and second treatment priorities in patients with non-Hodgkin’s lymphoma after salvage chemotherapy.

Cost-Utility Analysis of Single-Fraction Versus Multiple-Fraction Radiotherapy in Patients with Painful Bone Metastases: An Iranian Patient's Perspective Study

OBJECTIVES

To evaluate two of the various treatment strategies of bone metastasis- single-fraction radiotherapy and multiple-fraction radiotherapy.

METHODS

A multistage Markov decision model was applied to assess the incremental costs per quality-adjusted life-year (QALY) gained of single fraction against multiple fractions. The model had a monthly cycle length over a lifetime horizon with 1000 hypothetical cohort samples. The EuroQol five-dimensional questionnaire was used to estimate the health-related quality of life in patients. To cope with parameters of uncertainty, we conducted a probabilistic sensitivity analysis using a Monte-Carlo simulation technique. Both cost and utility variables were discounted by 3% in the base model. Strategies were assessed considering a willingness-to-pay threshold of US $6578 per QALY gained.

RESULTS

The expected mean cost and quality-adjusted life-years were, respectively, US $447.28 and 5.95 months for patients receiving single-fraction radiotherapy and US $1269.66 and 7.87 months for those receiving multiple-fraction radiotherapy. The incremental cost-utility ratio was US $428.38 per QALY. Considering the Iranian gross domestic product per capita (US $6578) as the recommended willingness to pay for 1 QALY gained, the multiple-fraction method was found to be a cost-effective strategy.

CONCLUSIONS

Policymakers should advocate the multiple-fraction method instead of the single-fraction method in the treatment of patients with painful bone metastases.

Immediate referral to colposcopy versus cytological surveillance for minor cervical cytological abnormalities in the absence of HPV test

BACKGROUND

A significant number of women are diagnosed with minor cytological abnormalities on cervical screening. Many authorities recommend surveillance as spontaneous regression might occur. However, attendance for cytological follow-up decreases with time and might put some women at risk of developing invasive disease.

OBJECTIVES

To assess the optimum management strategy for women with minor cervical cytological abnormalities (atypical squamous cells of undetermined significance - ASCUS or low-grade squamous intra-epithelial lesions - LSIL) at primary screening in the absence of HPV (human papillomavirus) DNA test.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2016), MEDLINE (1946 to April week 2 2016) and Embase (1980 to 2016 week 16).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing immediate colposcopy to cytological surveillance in women with atypical squamous cells of undetermined significance (ASCUS/borderline) or low-grade squamous intra-epithelial lesions (LSIL/mild dyskaryosis).

DATA COLLECTION AND ANALYSIS

The primary outcome measure studied was the occurrence of cervical intra-epithelial neoplasia (CIN). The secondary outcome measures studied included default rate, clinically significant anxiety and depression, and other self-reported adverse effects.We classified studies according to period of surveillance, at 6, 12, 24 or 36 months, as well as at 18 months, excluding a possible exit-examination. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using a random-effects model with inverse variance weighting. Inter-study heterogeneity was assessed with I² statistics.

MAIN RESULTS

We identified five RCTs with 11,466 participants that fulfilled the inclusion criteria. There were 18 cases of invasive cervical cancer, seven in the immediate colposcopy and 11 in the cytological surveillance groups, respectively. Although immediate colposcopy detects CIN2+ and CIN3+ earlier than cytology, the differences were no longer observed at 24 months (CIN2+: 3 studies, 4331 women; 17.9% versus 18.3%, RR 1.14, CI 0.66 to 1.97; CIN3+: 3 studies, 4331 women; 10.3% versus 11.9%, RR 1.02, CI 0.53 to 1.97). The inter-study heterogeneity was considerable (I² greater than 90%). Furthermore, the inclusion of the results of the exit examinations at 24 months, which could inflate the CIN detection rate of cytological surveillance, may have led to study design-derived bias; we therefore considered the evidence to be of low quality.When we excluded the exit examination, the detection rate of high-grade lesions at the 18-month follow-up was higher after immediate colposcopy (CIN2+: 2 studies, 4028 women; 14.3% versus 10.1%, RR 1.50, CI 1.12 to 2.01; CIN3+: 2 studies, 4028 women, 7.8% versus 6.9%, RR 1.24, CI 0.77 to 1.98) both had substantial inter-study heterogeneity (I² greater than 60%) and we considered the evidence to be of moderate quality).The meta-analysis revealed that immediate referral to colposcopy significantly increased the detection of clinically insignificant cervical abnormalities, as opposed to repeat cytology after 24 months of surveillance (occurrence of koilocytosis: 2 studies, 656 women; 32% versus 21%, RR 1.49, 95% CI 1.17 to 1.90; moderate-quality evidence) incidence of any CIN: 2 studies, 656 women; 64% versus 32%, RR 2.02, 95% CI 1.33 to 3.08, low-quality evidence; incidence of CIN1: 2 studies, 656 women; 21% versus 8%, RR 2.58, 95% CI 1.69 to 3.94, moderate-quality evidence).Due to differences in trial designs and settings, there was large variation in default rates between the included studies. The risk for default was higher for the repeat cytology group, with a four-fold increase at 6 months, a six-fold at 12 and a 19-fold at 24 months (6 months: 3 studies, 5117 women; 6.3% versus 13.3%, RR 3.85, 95% CI 1.27 to 11.63, moderate-quality evidence; 12 months: 3 studies, 5115 women; 6.3% versus 14.8%, RR 6.39, 95% CI 1.49 to 29.29, moderate-quality evidence; 24 months: 3 studies, 4331 women; 0.9% versus 16.1%, RR 19.1, 95% CI 9.02 to 40.43, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Based on low- or moderate-quality evidence using the GRADE approach and generally low risk of bias, the detection rate of CIN2+ or CIN3+ after two years does not appear to differ between immediate colposcopy and cytological surveillance in the absence of HPV testing, although women may default from follow-up. Immediate colposcopy probably leads to earlier detection of high-grade lesions, but also detects more clinically insignificant low-grade lesions. Colposcopy may therefore be the first choice when good compliance is not assured. These results emphasize the need for an accurate reflex HPV triage test to distinguish women who need diagnostic follow-up from those who can return safely to routine recall.

Relationship between survival and age in patients with idiopathic pulmonary fibrosis

BACKGROUND

There is a debate that older patients with idiopathic pulmonary fibrosis (IPF) have a worse prognosis. We evaluated whether age affects the survival of patients with IPF.

METHODS

The Korean Interstitial Lung Disease (ILD) Research Group conducted a national survey to evaluate the clinical, physiological, radiological, and survival characteristics of patients with IPF. A total of 1,663 patients with IPF were stratified into three groups according to age: (I) <60 years (n=309); (II) 60-69 years (n=613); and (III) ≥70 years (n=741).

RESULTS

The 1-, 3- and 5-year observed survival rates were 83.0%, 62.6%, and 49.2% in the total population, respectively. The 1-, 3-, and 5-year relative survival rates were 85.7%, 69.1%, and 58.0% in all patients, respectively. The observed survival rate of the group ≥70 years of age was significantly lower than those of the other groups (P<0.001). In contrast, no significant difference in relative survival rate was detected among the three age groups. Compared with patients less than 60 years of age, patients with above 70 years of age had not increased risk of worse relative survival [P=0.252; hazard ratio (HR), 1.11; 95% confidence interval (CI), 0.76-1.64].

CONCLUSIONS

The prognosis of patients above 70 years of age with IPF was not different to that of patients less than 60 years of age, using relative survival rate. Age may not affect survival in patients with IPF.

Inequalities in cancer incidence and mortality across medium to highly developed countries in the twenty-first century

PURPOSE

Inequalities in the burden of cancer have been well documented, and a variety of measures exist to analyse disease disparities. While previous studies have focused on inequalities within countries, the aim of the present study was to quantify existing inequalities in cancer incidence and mortality between countries.

METHODS

Data on total and site-specific cancer incidence and mortality in 2003-2007 were obtained for 43 countries with medium-to-high levels of human development via Cancer Incidence in Five Continents Vol. X and the WHO Mortality Database. We calculated the concentration index as a summary measure of socioeconomic-related inequality between countries.

RESULTS

Inequalities in cancer burden differed markedly by site; the concentration index for all sites combined was 0.03 for incidence and 0.02 for mortality, pointing towards a slightly higher burden in countries with higher levels of the human development index (HDI). For both incidence and mortality, this pattern was most pronounced for melanoma. In contrast, the burden of cervical cancer was disproportionally high in countries with lower HDI levels. Prostate, lung and breast cancer contributed most to inequalities in overall cancer incidence in countries with higher HDI levels, while for mortality these were mostly driven by lung cancer in higher HDI countries and stomach cancer in countries with lower HDI levels.

CONCLUSION

Global inequalities in the burden of cancer remain evident at the beginning of the twenty-first century: with a disproportionate burden of lifestyle-related cancers in countries classified as high HDI, while infection-related cancers continue to predominate in transitioning countries with lower levels of HDI.

Age and case mix-standardised survival for all cancer patients in Europe 1999-2007: Results of EUROCARE-5, a population-based study

BACKGROUND

Overall survival after cancer is frequently used when assessing a health care service's performance as a whole. It is mainly used by the public, politicians and the media, and is often dismissed by clinicians because of the heterogeneous mix of different cancers, risk factors and treatment modalities. Here we give survival details for all cancers combined in Europe, correlating it with economic variables to suggest reasons for differences.

METHODS

We computed age and cancer site case-mix standardised relative survival for all cancers combined (ACRS) for 29 countries participating in the EUROCARE-5 project with data on more than 7.5million cancer cases from 87 population-based cancer registries, using complete and period approach.

RESULTS

Denmark, United Kingdom (UK) and Eastern European countries had lower survival than neighbouring countries. Five-year ACRS has been increasing throughout Europe, and substantial increases, between 1999-2001 and 2005-2007, have been achieved in countries where survival was lower in the past. Five-year ACRS for men and women are positively correlated with macro-economic variables like the Gross Domestic Product (GDP) and Total National Expenditure on Health (TNEH) (R² about 70%). Countries with recent larger increases in GDP and TNEH had greater increases in cancer survival.

CONCLUSIONS

ACRS serves to compare all cancer survival in Europe taking account of the geographical variability in case-mixes. The EUROCARE-5 data on ACRS confirm previous EUROCARE findings. Survival appears to correlate with macro-economic determinants, particularly with investments in the health care system.

On-going improvement and persistent differences in the survival for patients with colon and rectum cancer across Europe 1999-2007 - Results from the EUROCARE-5 study

BACKGROUND

Previous population-based studies revealed major variation in survival for patients with colorectal cancer (CRC) in Europe by age and between different countries and regions, but also a sustained improvement in survival for patients with CRC in recent years. This EUROCARE-5 paper aims to update available knowledge from previous studies and to provide the latest survival estimates for CRC patients from Europe.

METHODS

The study analysed data of patients diagnosed with CRC from population-based cancer registries diagnosed in 29 European countries. Estimates of 1-year and 5-year relative survival (RS) were derived for patients diagnosed in 2000-2007 by European region, country and age at diagnosis. Additionally to these cohort estimates, time trends in 5-year RS were obtained for the calendar periods 1999-2001 and 2005-2007, using the period analysis methodology.

RESULTS

European average 5-year RS for patients diagnosed with colon and rectum cancer was 57% and 56%, respectively. The analyses showed persistent differences in cancer survival across Europe with lowest survival for CRC patients observed in Eastern Europe. The analyses further showed a strong gradient in age-specific survival. Even though the study revealed sustained improvement in patient survival between 1999-2001 and 2005-2007 (absolute increase of 4 and 6 percentage points for colon and rectum, respectively), the differences in the survival for CRC patients observed at the beginning of the millennium persisted over time.

CONCLUSION

Although survival for CRC patients in Europe improved markedly in the study period, significant geographic variations and a strong age gradient still persisted. Enhanced access to effective diagnostic procedures and treatment options might be the keys to reducing the existing disparities in the survival of CRC patients across Europe.

Evaluation of North American Association of Central Cancer Registries' (NAACCR) data for use in population-based cancer survival studies

Follow-up procedures vary among cancer registries in North America. US registries are funded by the Surveillance, Epidemiology, and End Results (SEER) Program and/or the National Program of Cancer Registries (NPCR). SEER registries ascertain vital status and date of last contact to meet follow-up standards. NPCR and Canadian registries primarily conduct linkages with local and national death records to ascertain deaths. Data on patients diagnosed between 2002 through 2006 and followed through 2007 were obtained from 51 registries. Registries that met follow-up standards or, at a minimum, conducted linkages with local and national death records had comparable age-standardized five-year survival estimates (all sites and races combined): 63.9% SEER, 63.1% NPCR, and 62.6% Canada. Estimates varied by cancer site. Survival data from registries using different follow-up procedures are comparable if death ascertainment is complete and all nondeceased patients are presumed to be alive to the end of the study period.

Challenges in organizing effective oncology service: inter-European variability in the example of head and neck cancers

The increasing worldwide burden of cancer makes it imperative that every country develop a comprehensive cancer control programme. In the past, cancer control in Central and Eastern Europe was inadequate, particularly when compared to many wealthier Western European countries. We analyse interregional differences in Europe to the approach to comprehensive cancer care, with a focus on head and neck squamous cell carcinoma using the case of Poland as a representative example. Due to national plans major improvements have been achieved in the field of prevention and in radiotherapy delivery having a measurable and positive impact on treatment outcomes. In head and neck cancers a notable move towards multidisciplinary approach has been made, combining surgery, radiotherapy and chemotherapy accompanied by rehabilitation and social support. In Poland and several other Eastern and Central European countries a shortage of physicians in the field of oncology was noted. The main conclusion is that the special plans are needed in Central and Eastern Europe or those existing must be extended for another decade to fulfil the EU requirement of providing all European citizens with equal access to quality cancer care.

How might healthcare systems influence speed of cancer diagnosis: a narrative review

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health.

For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems.

It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research.

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We examined cancer outcomes in six developed countries with comparable healthcare systems.

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Clear differences exist in cancer outcomes between countries with comparable healthcare systems.

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Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential.

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Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

The financial cost of preventive and curative programs for breast cancer: a case study of women in Shiraz-Iran

BACKGROUND

This cross-sectional study was conducted to compare the average costs of breast cancer screening and treatment among women with the age of 25 and over in Shiraz-Iran.

METHODS

Three majors hospitals affiliated with Shiraz University of Medical Sciences (SUMS) were selected for data collection. Financial documents and interviews with the hospitals' financial officers were used for data collection.

RESULTS

Finding shows that the total cost of screening would be 5,847,544.96 US dollars for age groups of 25-34 and 35 and above, demonstrating the huge expense of screening programs. On the other hand, the average cost of breast cancer treatment for each patient would be 3608.47, 996.89, and 311.47 US dollars for mastectomy, radiotherapy, and chemotherapy, respectively. In addition, the total average cost for treatment of 2217 patients would be 1,466,988.9 US dollars, which is much less than screening programs expenses.

CONCLUSION

It is concluded that although screening can be effective for improving quality of life and treatment effectiveness, considering the high costs of screening, it is not economical in Iran. Screening methods within suitable intervals, and also considering patients' medical history have been recommended by the present study.

Variations in cancer survival and patterns of care across Europe: roles of wealth and health-care organization

Cancer survival varies markedly across Europe. We analyzed variations in all-cancer 5-year relative survival in relation to macroeconomic and health-care indicators, and 5-year relative survival for three major cancers (colorectal, prostate, breast) in relation to application of standard treatments, to serve as baseline for monitoring the efficacy of new European initiatives to improve cancer survival. Five-year relative survival data were from the European cancer registry-based study of cancer patients' survival and care (EUROCARE-4). Macroeconomic and health system data were from the Organisation for Economic Co-operation and Development, and European Observatory on Health Care Systems. Information on treatments given was from EUROCARE studies. Total national health spending varied widely across Europe and correlated linearly with survival (R = 0.8). Countries with high spending had high numbers of diagnostic and radiotherapy units, and 5-year relative survival was good (>50%). The treatments given for major cancers also varied; advanced stage at diagnosis was associated with poor 5-year relative survival and low odds of receiving standard treatment for breast and colorectal cancer.

Cancer survival: global surveillance will stimulate health policy and improve equity

Millions of people will continue to be diagnosed with cancer every year for the foreseeable future. These patients all need access to optimum health care. Population-based cancer survival is a key measure of the overall effectiveness of health systems in management of cancer. Survival varies very widely around the world. Global surveillance of cancer survival is needed, because unless these avoidable inequalities are measured, and reported on regularly, nothing will be done explicitly to reduce them.

Persons with disabilities, cancer screening and related factors

The scope of this article is to describe persons with disabilities (PwD) being subjected to cancer screening and the relationship between some social variables and inequalities in performing these tests. A cross-sectional study of cancer screening among PwD was conducted in 2007 with 333 participants interviewed in residence in 4 cities of São Paulo. Variables in the practice of cancer screening, disabilities, gender, age, income of main family breadwinner, ethnicity, use of health services, assistance required, private health insurance, and coverage by the family health program were studied. Frequencies, χ²-test, trend χ² percentages and the Odds Ratios (OR) were used for data analysis. 44% of PwD attended at least one cancer screening at the appropriate time. Persons with visual disabilities and with hearing disabilities were subjected to more screening examinations than those with mobility disabilities and women were attended in screening exams more than men. Persons between the ages of 21 and 60 reported cancer screening more frequently than those between 80 and 97 years of age. The outcomes indicate that PwD have different attitudes toward cancer screening according to the type of disability, gender, and age, which were the variables that directly influenced cancer screening exams.

Cancer incidence in ethnic German migrants from the Former Soviet Union in comparison to the host population

AIM

To investigate cancer incidence patterns among ethnic German migrants (Aussiedler) from the Former Soviet Union, a large migrant group in Germany, in comparison to autochthonous Saarland population over a 20 year observation period.

METHODS

Data were obtained from a cohort of Aussiedler residing in the federal state of Saarland (n=18,619). Cancer incidence and vital status were ascertained through record linkage with the Saarland Cancer Registry and local population registries.

RESULTS

During the follow up period from 1990 to 2009 we observed 638 incident diagnoses of malignant neoplasms (except non-melanoma skin cancer). The overall standardized incidence ratio (SIR) was 0.98 (95% confidence interval 0.92, 1.04). However, site-specific SIRs revealed great variation. Stomach cancer incidence was significantly higher among Aussiedler. Lung cancer was elevated for males, but lower among females. Additionally, diagnoses for colorectal cancer among males were significantly lower. Age-standardized rates (ASRs) over time show not all cancer rates of Aussiedler attenuate as expected to Saarland rates. For example, lung and prostate cancer incidence rates show increasing disparity from Saarland rates and female breast cancer incidence develops in parallel. Furthermore, ASR for overall cancer incidence of Aussiedler shows a yearly decrease (p=0.06) whereas Saarland rates remain stable.

DISCUSSION

Aussiedler incidence rates reflect incidence pattern observed in their countries of origin.

Long-term net survival in patients with colorectal cancer in France: an informative contribution of recent methodology

BACKGROUND

Net survival, the survival that might occur if cancer was the only cause of death, is a major epidemiological indicator. Recent findings have shown that the classical methods used for the estimation of net survival from cancer registry data, referred as to "relative-survival methods," provided biased estimates.

OBJECTIVES

The aim of this study was to provide, for the first time, long-term net survival rates for colorectal cancer by using a population-based digestive cancer registry.

DESIGN

This study is a population-based cancer registry analysis. The recently proposed unbiased nonparametric Pohar-Perme estimator was used.

PATIENTS

Overall, 14,715 colorectal cancers diagnosed between 1976 and 2005 and registered in the population-based digestive cancer registry of Burgundy (France) were included.

MAIN OUTCOME MEASURES

The primary outcome measured was cancer net survival, ie, the survival that might occur if all risks of dying of other causes than cancer were removed

RESULTS

: Ten-year net survival increased from 31% during the 1976 to 1985 period to 47% during the 1986 to 1995 period and then leveled out (48% during the 1996-2005 period). There was a major improvement in 10-year net survival after resection for cure and for stage I to III. It was striking for stage III cancers, for which 10-year net survival increased from 21% (1976-1985) to 49% (1996-2005). The corresponding net survivals were 70% and 87% for stage I and 49% and 65% for stage II. These trends can be related to the decrease in operative mortality, the increase in the proportion of patients resected for cure, and the improvement in stage at diagnosis. They were mainly seen between 1976 and 1995, explaining why survival leveled out after 1995.

LIMITATIONS

The study was limited by its retrospective and population-based nature.

CONCLUSIONS

Further improvements for colorectal cancer management can be expected from more effective treatments and from the implementation of organized cancer screening.

EURECCA colorectal: multidisciplinary mission statement on better care for patients with colon and rectal cancer in Europe

BACKGROUND

Care for patients with colon and rectal cancer has improved in the last twenty years however still considerable variation exists in cancer management and outcome between European countries. Therefore, EURECCA, which is the acronym of European Registration of cancer care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012 the first multidisciplinary consensus conference about colon and rectum was held looking for multidisciplinary consensus. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries.

METHODS

The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Experts commented and voted on the two web-based online voting rounds before the meeting (between 4th and 25th October and between the 20th November and 3rd December 2012) as well as one online round after the meeting (4th-20th March 2013) and were invited to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. All sentences that were voted on are available on the EURECCA website www.canceraudit.eu. The consensus document was divided in sections describing evidence based algorithms of diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and stage IV separately. Consensus was achieved using the Delphi method.

RESULTS

The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members.

CONCLUSIONS

It is feasible to achieve European Consensus on key diagnostic and treatment issues using the Delphi method. This consensus embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe.

Health systems performance and cancer outcomes

Do the characteristics of health systems influence cancer outcomes? Although caveats are required when undertaking international comparisons of both health systems and cancer outcomes, observed differences cannot solely be explained by data problems or economic development. Health systems can influence cancer outcomes through three mechanisms: coverage, innovation, and quality of care. First, in countries where population coverage is incomplete, patients may find certain services excluded or face substantial copayments or deductibles. Second, there are variations in the rate at which innovative treatments are introduced, reflecting in particular the need for publicly funded health systems to compare costs and benefits of increasingly expensive treatments given demands for other treatments. Third, systematic differences in quality of care (early diagnosis, timely and equitable access to specialist care, and existence of systematic coordination between these activities) may lead to variations in cancer outcomes.

Socio-economic inequalities: a review of methodological issues and the relationships with cancer survival

During the past few decades, many studies on socio-economic factors and health outcomes have been developed using various methodologies with differing approaches. A bibliographic research in MEDLINE/PubMed and SCOPUS was carried out for the period 2000-2011 to describe the influence of socio-economic status (SES) on cancer survival, in particular with reference to the outcome of European research results and the results of some cases of other Western studies. This review is divided into two sections: the first describing the different approaches of the study on individuals and populations of the concept of "social class" as well as methods used to measure the association between deprivation and health (i.e. ecological level studies, deprivation indexes, etc.); and the second discussing the association between socio-economic factors and cancer survival, describing the roles of various determinants of differences in survival, such as clinical and pathological prognostic factors, together with consideration of diagnosis and treatment and some patients' characteristics.

The impact of National Death Index linkages on population-based cancer survival rates in the United States

BACKGROUND

In order to ensure accurate survival estimates, population-based cancer registries must ascertain all, or nearly all, patients diagnosed with cancer in their catchment area, and obtain complete follow-up information on all deaths that occurred among registered cancer patients. In the US, linkage with state death records may not be sufficient to ascertain all deaths. Since 1979, all state vital statistics offices have reported their death certificate information to the National Death Index (NDI).

OBJECTIVE

This study was designed to measure the impact of linkage with the NDI on population-based relative and cancer cause-specific survival rates in the US.

METHODS

Central cancer registry records for patients diagnosed 1993-1995 from California, Colorado, and Idaho were linked with death certificate information (deaths 1993-2004) from their individual state vital statistics offices and with the NDI. Two databases were created: one contained incident records with deceased patients linked only to state death records and the second database contained incident records with deceased patients linked to both state death records and the NDI. Survival estimates and 95% confidence intervals from each database were compared by state and primary site category.

RESULTS

At 60 months follow-up, 42.1-48.1% of incident records linked with state death records and an additional 0.7-3.4% of records linked with the NDI. Survival point estimates from the analysis without NDI were not contained within the corresponding 95% CIs from the NDI augmented analysis for all sites combined and colorectal, pancreas, lung and bronchus, breast, prostate, non-Hodgkin lymphoma, and Kaposi sarcoma cases in all 3 states using relative survival methods. Additional combinations of state and primary site had significant survival estimate differences, which differed by method (relative versus cause-specific survival).

CONCLUSION

To ensure accurate population-based cancer survival rates, linkage with the National Death Index to ascertain out of state and late registered deaths is a necessary process for US central cancer registries.

Cancer in the Azores: initial results from a recently established population-based cancer registry

INTRODUCTION: The Azores archipelago has long been the Portuguese region that presents the highest mortality rates for certain cancers. Lack of incidence data has prevented the evaluation of the actual burden of this disease in the Azorean population. METHODS: Malignant tumours (ICD-O 5th Digit /3) initially diagnosed between the January 1st 2000 and December 31st 2002 were retrieved from the database of the recently established population-based cancer registry. Crude, age-specific and age-standardized rates were calculated and confidence intervals were estimated using Poisson approximation. Relative risks of developing cancer in the Azores when compared to mainland Portugal have been represented by standardized ratios. Quality indicators, including Mortality:Incidence (M:I) ratios, were also assessed. RESULTS: Overall, the data shows a high incidence rate for some malignant diseases, specifically in men. Compared to those living in mainland Portugal, both Azorean men (RR 1.412; 99% CI 1.407-1.416) and women (1.127; 1.125-1.129) presented a significantly higher risk of developing cancer, all sites combined. When compared with other cancer registries, a less favourable cancer survival pattern is reported in the Azores, as emphasized by higher M:I ratios for several cancer sites. CONCLUSIONS: A preliminary analysis of the results suggests the presence of some major risk factors in the Azorean population, namely tobacco smoking in men. Higher M:I ratios would also point to survival disparities between the Azores archipelago and the continent, which should be further studied.

Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems

BACKGROUND

The principal aim of this study was to determine the feasibility of a large-scale comparative study, between the UK, the Netherlands and Sweden, to investigate whether delays in the diagnostic pathway of cancer might explain differences in cancer survival between countries.

METHODS

Following a planning meeting to agree the format of a data collection instrument, data on delays in the cancer diagnostic pathway were abstracted from primary care-held medical records. Data were collected on 50 cases each (total of 150) from practices in each of Grampian, Northeast Scotland; Maastricht, the Netherlands and Skane, Sweden. Data were entered into SPSS 18.0 for analysis.

RESULTS

Data on delays in the cancer diagnostic pathway were readily available from primary care-held case records. However, data on demographic variables, cancer stage at diagnosis and treatment were less well recorded. There was no significant difference between countries in the way in which cases were referred from primary to secondary care. There was no significant difference between countries in the time delay between a patient presenting in primary care and being referred to secondary care. Median delay between referral and first appointment in secondary care [19 (8.0-47.5) days] was significantly longer in Scotland that in Sweden [1.0 (0-31.5) days] and the Netherlands [5.5 (0-31.5) days] (P < 0.001). Secondary care delay (between first appointment in secondary care and diagnosis) in Scotland [22.5 (0-39.5) days] was also significantly longer than in Sweden [14.0 (4.5-31.5) days] and the Netherlands [3.5 (0-16.5) days] (P = 0.003). Finally, overall delay in Scotland [53.5 (30.3-96.3) days] was also significantly longer than in Sweden [32.0 (14.0-71.0) days] and the Netherlands [22.0 (7.0-60.3) days] (P = 0.003).

CONCLUSIONS

A large-scale study comparing cancer delays in European countries and based on primary care-held records is feasible but would require supplementary sources of data in order to maximize information on demographic variables, the cancer stage at diagnosis and treatment details. Such a large-scale study is timely and desirable since our findings suggest systematic differences in the way cancer is managed in the three countries.

Burden of testicular, paratesticular and extragonadal germ cell tumours in Europe

We provide updated estimates of survival, incidence, complete prevalence, and proportion cured for patients with testicular/paratesticular and extragonadal germ cell cancers in Europe, grouped according to the new list of cancer types developed by RARECARE. We collected data, archived in European cancer registries, with vital status information available to 31st December 2003. We analysed 26,000 cases of testicular, paratesticular and extragonadal germ cell cancers diagnosed 1995-2002, estimating that about 15,600 new testicular/paratesticular and 630 new extragonadal cancer cases occurred per year in EU27, with annual incidence rates of 31.5/1,000,000 and 1.27/1,000,000, respectively. Slightly more than 436,000 persons were alive at the beginning of 2008 with a diagnosis of testicular/paratesticular cancer, and about 17,000 with a diagnosis of extragonadal germ cell cancer. Five-year relative survival was 96% for testicular/paratesticular cancer and 71% for extragonadal germ cell cancer; the proportions cured were 95% and 69%, respectively. We found limited variation in survival between European regions except for non-seminomatous testicular cancer, for which five-year relative survival ranged from 86% in Eastern Europe to 96% in Northern Europe. Survival for all cancer types considered decreased with increasing age at diagnosis. Further investigation is required to establish the real reasons for the lower survival in Eastern Europe. Considering the high prevalence of these highly curable cancers, it is important to monitor patients long-term, so as to quantify treatment-related risks and develop treatments having limited impact on quality of life.

Incidence and survival of rare urogenital cancers in Europe

BACKGROUND

The RARECARE project aims at increasing knowledge of rare cancers in Europe. This manuscript describes the epidemiology (incidence, prevalence, survival) of rare urogenital cancers, taking into account the morphological characterisation of these tumours.

METHODS

We used data gathered by RARECARE on cancer patients diagnosed from 1995 to 2002 and archived in 64 European population-based cancer registries, followed up to December 31st, 2003 or later.

RESULTS

The annual number of males that develop penile cancer in the EU is estimated at 3100, which is equivalent to an age standardised rate (ASR) of 12 per million males. The 5-year relative survival rate is 69%, while squamous cell carcinoma is the predominant morphological entity. Each year around 650 persons in the EU develop cancer of the urethra and 7200 develop cancer of the renal pelvis or ureter (RPU). The ASR for cancer of the urethra and RPU is 1.1 (males 1.6; females 0.6) and 12 (males 16; females 7) per million inhabitants, respectively. The 5-year relative survival rate for cancer of the urethra and RPU is 54% and 51%, respectively. Transitional cell carcinoma is the predominant morphological entity of cancer of the urethra and RPU.

CONCLUSIONS

In view of the low number of cases and the fact that one third to one half of the patients die of their disease, centralisation of treatment of these rare tumours to a select number of specialist centres should be promoted.

The incidence and survival of acute de novo leukemias in Estonia and in a well-defined region of western Sweden during 1997-2001: a survey of patients aged 16-64 years

BACKGROUND

In a recent retrospective study, we investigated the incidence and survival of de novo acute leukemia (AL) patients aged 16-64 years over three 5-year periods (1982-1996) in Estonia and in the Western Swedish Health Care Region. The incidence rates were similar in the two countries, but the survival data were highly different. Thus, relative survival at 5 years for de novo AL patients in Estonia was virtually negligible, whereas the corresponding figures for the Swedish patients increased from 20.3 to 38.9% during the study period.

AIM

To prospectively compare the results for incidence and outcome of de novo AL between the two countries during 1997-2001.

RESULTS

Incidence rates for de novo AL were lower in Estonia than in western Sweden but not significantly so. However, the survival for de novo AL patients in Estonia had improved considerably, with the relative survival at 5 years being 16.4%; such improvement was particularly seen in acute myeloid leukemia patients. For the Swedish patients, no change in survival was recorded.

CONCLUSION

In Estonia, a remarkable improvement in outcome for young de novo AL patients was seen after 1996. Nevertheless, relative survival for the Estonian patients had still not reached the levels found in the Swedish cohort.

Progress in colorectal cancer survival in Europe from the late 1980s to the early 21st century: the EUROCARE study

Colorectal cancer (CRC) is the second most common cause of death due to cancer causing death in Europe, accounting for more than 200,000 deaths per year. Prognosis strongly depends on stage at diagnosis, and the disease can be cured in most cases if diagnosed at an early stage. We aimed to assess trends and recent developments in 5-year relative survival in European countries, with a special focus on age, stage at diagnosis and anatomical cancer subsite. Data from 25 population-based cancer registries from 16 European countries collected in the context of the EUROCARE-4 project were analyzed. Using period analysis, age-adjusted and age-specific 5-year relative survival was calculated by country, European region, stage and cancer subsite for time periods from 1988-1990 to 2000-2002. Survival substantially increased over time in all European regions. In general, increases were more pronounced in younger than in older patients, for earlier than for more advanced cancer stages and for rectum than for colon cancer. Substantial variation of CRC survival between European countries and between age groups persisted and even tentatively increased over time. There is a huge potential for reducing the burden of CRC in Europe by more widespread and equal delivery of existing options of effective early detection and curative treatment to the European population.

Cervical screening participation and risk among Swedish-born and immigrant women in Sweden

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high-income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish-born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish-born women. The degree of participation was 62% and 49% among Swedish-born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish-born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish-born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.