Worldwide trends in esophageal cancer survival, by sub-site, morphology, and sex: an analysis of 696,974 adults diagnosed in 60 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Esophageal cancer survival is poor worldwide, though there is some variation. Differences in the distribution of anatomical sub-site and morphological sub-type may help explain international differences in survival for all esophageal cancers combined. We estimated survival by anatomic sub-site and morphological sub-type to understand further the impact of topography and morphology on international comparisons of esophageal cancer survival.

METHODS

We estimated age-standardized one-year and five-year net survival among adults (15-99 years) diagnosed with esophageal cancer in each of 60 participating countries to monitor survival trends by calendar period of diagnosis (2000-2004, 2005-2009, 2010-2014), sub-site, morphology, and sex.

RESULTS

For adults diagnosed during 2010-2014, tumors in the lower third of the esophagus were the most common, followed by tumors of overlapping sub-site and sub-site not otherwise specified. The proportion of squamous cell carcinomas diagnosed during 2010-2014 was generally higher in Asian countries (50%-90%), while adenocarcinomas were more common in Europe, North America and Oceania (50%-60%). From 2000-2004 to 2010-2014, the proportion of squamous cell carcinoma generally decreased, and the proportion of adenocarcinoma increased. Over time, there were few improvements in age-standardized five-year survival for each sub-site. Age-standardized one-year survival was highest in Japan for both squamous cell carcinoma (67.7%) and adenocarcinoma (69.0%), ranging between 20%-60% in most other countries. Age-standardized five-year survival from squamous cell carcinoma and adenocarcinoma was similar for most countries included, around 15%-20% for adults diagnosed during 2010-2014, though international variation was wider for squamous cell carcinoma. In most countries, survival for both squamous cell carcinoma and adenocarcinoma increased by less than 5% between 2000-2004 and 2010-2014.

CONCLUSIONS

Esophageal cancer survival remains poor in many countries. The distributions of sub-site and morphological sub-type vary between countries, but these differences do not fully explain international variation in esophageal cancer survival.

Implementing and monitoring the right to health in breast cancer: selection of indicators using a Delphi process

BACKGROUND

Women with breast cancer have different chances of surviving their disease, depending on where they live. Variations in survival may stem from unequal access to prompt diagnosis, treatment and care. Implementation of the right to health may help remedy such inequalities. The right to health is enshrined in international human rights law, notably Article 12 of the International Covenant on Economic, Social and Cultural Rights. A human rights-based approach to health requires a robust, just and efficient health system, with access to adequate health services and medicines on a non-discriminatory basis. However, it may prove challenging for health policymakers and cancer management specialists to implement and monitor this right in national health systems.

METHOD

This article presents the results of a Delphi study designed to select indicators of implementation of the right to health to inform breast cancer care and management. In a systematic process, 13 experts examined an initial list of 151 indicators.

RESULTS

After two rounds, 54 indicators were selected by consensus, three were rejected, three were added, and 97 remained open for debate. For breast cancer, right-to-health features selected as worth implementing and monitoring included the formal recognition of the right to health in breast cancer strategies; a population-based screening programme, prompt diagnosis, strong referral systems and limited waiting times; the provision of palliative, survivorship and end-of-life care; the availability, accessibility, acceptability and quality (AAAQ) of breast cancer services and medicines; the provision of a system of accountability; and the collection of anonymised individual data to target patterns of discrimination.

CONCLUSION

We propose a set of indicators as a guide for health policy experts seeking to design national cancer plans that are based on a human rights-based approach to health, and for cancer specialists aiming to implement principles of the right to health in their practice. The 54 indicators selected may be used in High-Income Countries, or member states of the OECD who also have signed the International Covenant on Economic, Social and Cultural Rights to monitor progress towards implementation of the right to health for women with breast cancer.

Excess mortality among essential workers in England and Wales during the COVID-19 pandemic: an updated analysis

BACKGROUND

Excess mortality from all causes combined during the COVID-19 pandemic in England and Wales in 2020 was predominantly higher for essential workers. In 2021, the vaccination programme had begun, new SARS-CoV-2 variants were identified and different policy approaches were used. We have updated our previous analyses of excess mortality in England and Wales to include trends in excess mortality by occupation for 2021.

METHODS

We estimated excess mortality for working age adults living in England and Wales by occupational group for each month in 2021 and for the year as a whole.

RESULTS

During 2021, excess mortality remained higher for most groups of essential workers than for non-essential workers. It peaked in January 2021 when all-cause mortality was 44.6% higher than expected for all occupational groups combined. Excess mortality was highest for adults working in social care (86.9% higher than expected).

CONCLUSION

Previously, we reported excess mortality in 2020, with this paper providing an update to include 2021 data. Excess mortality was predominantly higher for essential workers during 2021. However, unlike the first year of the pandemic, when healthcare workers experienced the highest mortality, the highest excess mortality during 2021 was experienced by social care workers.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Global survival trends for brain tumors, by histology: Analysis of individual records for 67,776 children diagnosed in 61 countries during 2000-2014 (CONCORD-3)

INTRODUCTION

Tumors of the central nervous system are among the leading causes of cancer-related death in children. Population-based cancer survival reflects the overall effectiveness of a health care system in managing cancer. Inequity in access to care world-wide may result in survival disparities.

METHODS

We considered children (0-14 years) diagnosed with a brain tumor during 2000-2014, regardless of tumor behavior. Data underwent a rigorous, three-phase quality control as part of CONCORD-3. We implemented a revised version of the International Classification of Childhood Cancer (third edition) to control for under-registration of non-malignant astrocytic tumors. We estimated net survival using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 67,776 children. We estimated survival for 12 histology groups, each based on relevant ICD-O-3 codes. Age-standardized 5-year net survival for low-grade astrocytoma ranged between 84% and 100% world-wide during 2000-2014. In most countries, 5-year survival was 90% or more during 2000-2004, 2005-2009, and 2010-2014. Global variation in survival for medulloblastoma was much wider, with age-standardized 5-year net survival between 47% and 86% for children diagnosed during 2010-2014.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors in children, by histology. We devised an enhanced version of ICCC-3 to account for differences in cancer registration practices world-wide. Our findings may have public health implications, because low-grade glioma is 1 of the 6 index childhood cancers included by WHO in the Global Initiative for Childhood Cancer.

Cancer treatment data available in European cancer registries: Where are we and where are we going?

Population-based cancer registries are responsible for collecting incidence and survival data on all reportable neoplasms within a defined geographical area. During the last decades, the role of cancer registries has evolved beyond monitoring epidemiological indicators, as they are expanding their activities to studies on cancer aetiology, prevention, and quality of care. This expansion relies also on the collection of additional clinical data, such as stage at diagnosis and cancer treatment. While the collection of data on stage, according to international reference classification, is consolidated almost everywhere, data collection on treatment is still very heterogeneous in Europe. This article combines data from a literature review and conference proceedings together with data from 125 European cancer registries contributing to the 2015 ENCR-JRC data call to provide an overview of the status of using and reporting treatment data in population-based cancer registries. The literature review shows that there is an increase in published data on cancer treatment by population-based cancer registries over the years. In addition, the review indicates that treatment data are most often collected for breast cancer, the most frequent cancer in women in Europe, followed by colorectal, prostate and lung cancers, which are also more common. Treatment data are increasingly being reported by cancer registries, though further improvements are required to ensure their complete and harmonised collection. Sufficient financial and human resources are needed to collect and analyse treatment data. Clear registration guidelines are to be made available to increase the availability of real-world treatment data in a harmonised way across Europe.

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

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

How does Linkage to the National Death Index Affect Population-Based Net Survival Estimates for Women with Cervical Cancer in Saudi Arabia?

BACKGROUND

Population-based cancer survival is a key metric for the assessment of cancer control strategies. Accurate estimation of cancer survival requires complete follow-up data for all patients.

AIM

To explore the impact of linking national cancer registry data to the national death index on net survival estimates for women diagnosed with cervical cancer in Saudi Arabia during 2005-2016.

METHODS

We acquired data on 1,250 Saudi women diagnosed with invasive cervical cancer during the 12- year period 2005-2016 from the Saudi Cancer Registry. These included the woman's last known vital status and the date of last known vital status, but this was restricted to information from clinical records and death certificates that mention cancer as a cause of death ("registry follow-up"). We submitted available national ID numbers to the National Information Center (NIC) of the Ministry of Interior, to ascertain the date of death, from any cause of death, for women who had died up until 31 December 2018 ("NIC follow-up"). We estimated age-standardised 5-year net survival using the Pohar-Perme estimator under five different scenarios using the two sources of follow-up, and censoring at the date of last contact with the registry versus extending survival until the closing date if no information on death was obtained.

RESULTS

1,219 women were eligible for survival analysis. Five-year net survival was lowest when using NIC followup only (56.8%; 95%CI 53.5 - 60.1%), and highest when registry follow-up only was used and survival time was extended until closure date for those with no information on death (81.8%; 95%CI 79.6 - 84%).

CONCLUSION

Reliance solely on information from deaths certified as due to cancer and clinical records leads to a high proportion of missing deaths in the national cancer registry. This is probably due to low quality of certification of the cause of death in Saudi Arabia. Linkage of the national cancer registry to the national death index at the NIC identifies virtually all deaths, providing more reliable survival estimates, and it eliminates the ambiguity in determining the underlying cause of death. Therefore, this should become the standard approach to estimating cancer survival in Saudi Arabia.

Pancreatic cancer survival trends in the US from 2001 to 2014: a CONCORD-3 study

BACKGROUND

Survival from pancreatic cancer is low worldwide. In the US, the 5-year relative survival has been slightly higher for women, whites and younger patients than for their counterparts, and differences in age and stage at diagnosis [Corrections added Nov 16, 2022, after first online publication: a new affiliation is added to Maja Nikšić] may contribute to this pattern. We aimed to examine trends in survival by race, stage, age and sex for adults (15-99 years) diagnosed with pancreatic cancer in the US.

METHODS

This population-based study included 399,427 adults registered with pancreatic cancer in 41 US state cancer registries during 2001-2014, with follow-up to December 31, 2014. We estimated age-specific and age-standardized net survival at 1 and 5 years.

RESULTS

Overall, 12.3% of patients were blacks, and 84.2% were whites. About 9.5% of patients were diagnosed with localized disease, but 50.5% were diagnosed at an advanced stage; slightly more among blacks, mainly among men. No substantial changes were seen over time (2001-2003, 2004-2008, 2009-2014). In general, 1-year net survival was higher in whites than in blacks (26.1% vs. 22.1% during 2001-2003, 35.1% vs. 31.4% during 2009-2014). This difference was particularly evident among patients with localized disease (49.6% in whites vs. 44.6% in blacks during 2001-2003, 60.1% vs. 55.3% during 2009-2014). The survival gap between blacks and whites with localized disease was persistent at 5 years after diagnosis, and it widened over time (from 24.0% vs. 21.3% during 2001-2003 to 39.7% vs. 31.0% during 2009-2014). The survival gap was wider among men than among women.

CONCLUSIONS

Gaps in 1- and 5-year survival between blacks and whites were persistent throughout 2001-2014, especially for patients diagnosed with a localized tumor, for which surgery is currently the only treatment modality with the potential for cure.

How should implementation of the human right to health be assessed? A scoping review of the public health literature from 2000 to 2021

The human right to health is a critical legal tool to achieve health justice, and universal health coverage is included among the Sustainable Development Goals. However, the content and meaning of the right to health may not be used adequately in public health research. We conducted a scoping review of the literature to discover the extent to which the legal principles underlying the right to health are used in public health. We mapped the various attempts to assess implementation of this right since its legal content was clarified in 2000.

The first studies emerged in 2006, with an increase and a wider variety of investigations since 2015. We observe that some key principles do form the basis of right-to-health assessments, but some concepts remain unfamiliar. Critically, public health academics may have limited access to human rights research on health, which creates a gap in knowledge between the two disciplines.

Does the morphology of cutaneous melanoma help to explain the international differences in survival? Results from 1 578 482 adults diagnosed during 2000-2014 in 59 countries (CONCORD-3)

BACKGROUND

CONCORD-3 highlighted wide disparities in population-based 5-year net survival for cutaneous melanoma during 2000-2014. Clinical evidence suggests marked international differences in the proportion of lethal acral and nodular subtypes of cutaneous melanoma.

OBJECTIVES

We aimed to assess whether the differences in morphology may explain global variation in survival.

METHODS

Patients with melanoma were grouped into the following seven morphological categories: malignant melanoma, not otherwise specified (International Classification of Diseases for Oncology, third revision morphology code 8720), superficial spreading melanoma (8743), lentigo maligna melanoma (8742), nodular melanoma (8721), acral lentiginous melanoma (8744), desmoplastic melanoma (8745) and other morphologies (8722-8723, 8726-8727, 8730, 8740-8741, 8746, 8761, 8770-8774, 8780). We estimated net survival using the nonparametric Pohar Perme estimator, correcting for background mortality by single year of age, sex and calendar year in each country or region. All-ages survival estimates were standardized using the International Cancer Survival Standard weights. We fitted a flexible parametric model to estimate the effect of morphology on the hazard of death.

RESULTS

Worldwide, the proportion of nodular melanoma ranged between 7% and 13%. Acral lentiginous melanoma accounted for less than 2% of all registrations but was more common in Asia (6%) and Central and South America (7%). Overall, 36% of tumours were classified as superficial spreading melanoma. During 2010-2014, age-standardized 5-year net survival for superficial spreading melanoma was 95% or higher in Oceania, North America and most European countries, but was only 71% in Taiwan. Survival for acral lentiginous melanoma ranged between 66% and 95%. Nodular melanoma had the poorest prognosis in all countries. The multivariable analysis of data from registries with complete information on stage and morphology found that sex, age and stage at diagnosis only partially explain the higher risk of death for nodular and acral lentiginous subtypes.

CONCLUSIONS

This study provides the broadest picture of distribution and population-based survival trends for the main morphological subtypes of cutaneous melanoma in 59 countries. The poorer prognosis for nodular and acral lentiginous melanomas, more frequent in Asia and Latin America, suggests the need for health policies aimed at specific populations to improve awareness, early diagnosis and access to treatment. What is already known about this topic? The histopathological features of cutaneous melanoma vary markedly worldwide. The proportion of melanomas with the more aggressive acral lentiginous or nodular histological subtypes is higher in populations with predominantly dark skin than in populations with predominantly fair skin. What does this study add? We aimed to assess the extent to which these differences in morphology may explain international variation in survival when all histological subtypes are combined. This study provides, for the first time, international comparisons of population-based survival at 5 years for the main histological subtypes of melanoma for over 1.5 million adults diagnosed during 2000-2014. This study highlights the less favourable distribution of histological subtypes in Asia and Central and South America, and the poorer prognosis for nodular and acral lentiginous melanomas. We found that later stage at diagnosis does not fully explain the higher excess risk of death for nodular and acral lentiginous melanoma compared with superficial spreading melanoma.

Survival from five common cancers in Georgia, 2015-2019 (CONCORD)

BACKGROUND

Population-based cancer survival is a key metric of the effectiveness of health systems in managing cancer. Data from population-based cancer registries are essential for producing reliable and robust cancer survival estimates. Georgia established a national population-based cancer registry on 1 January 2015. This is the first analysis of population-based cancer survival from Georgia.

METHODS

Data were available from the national cancer registry for 16,359 adults who were diagnosed with a cancer of the stomach, colon, rectum, breast (women) or cervix during 2015-2019. We estimated age-specific and age-standardised net survival at one, two and three years after diagnosis for each cancer, by sex.

RESULTS

The data were of extremely high quality, with less than 2% of data excluded from each dataset. For the patients included in analyses, at least 80% of the tumours were microscopically verified. Age-standardised three-year survival from stomach cancer was 30.6%, similar in men and women. For colon cancer, three-year survival was 60.1%, with survival 4% higher for men than for women. Three-year survival from rectal cancer was similar for men and women, at 54.7%. For women diagnosed with breast cancer, three-year survival was 84.4%, but three-year survival from cervical cancer was only 67.2%.

CONCLUSION

Establishment of a national cancer registry with obligatory cancer registration has enabled the first examination of population-based cancer survival in Georgia. Maintenance of the registry will facilitate continued surveillance of both cancer incidence and survival in the country.

World-wide trends in net survival from pancreatic cancer by morphological sub-type: An analysis of 1,258,329 adults diagnosed in 58 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Ductal adenocarcinomas and neuroendocrine tumours are the two main morphological sub-types of pancreatic cancer. Using data from CONCORD-3, we examined whether the distribution of morphological sub-types could help explain international variations in pancreatic cancer survival for all morphologies combined. We also examined world-wide survival trends from pancreatic cancer, by morphological sub-type and country.

METHODS

We estimated age-standardised one- and five-year net survival by country, calendar period of diagnosis (2000-2004, 2005-2009, 2010-2014) and morphological sub-type, using data from 295 population-based cancer registries in 58 countries for 1,258,329 adults (aged 15-99 years) diagnosed with pancreatic cancer during 2000-2014 and followed up until 31 December 2014.

RESULTS

Carcinomas were by far the most common morphological sub-type, comprising 90% or more of all pancreatic tumours in all countries. Neuroendocrine tumours were rare, generally 0-10% of all tumours. During 2010-2014, age-standardised one-year net survival ranged from 10% to 30% for carcinomas, while it was much higher for neuroendocrine tumours (40% to 80%). Age-standardised five-year survival was generally poor (less than 10 %) for carcinomas, but it ranged from 20% to 50% for neuroendocrine tumours.

CONCLUSIONS

Survival from pancreatic carcinoma remains poor world-wide and trends showed little improvement during 2000-2014. Despite slight declines in the proportion of carcinomas, they continue to comprise the majority of pancreatic tumours. Increases in survival from neuroendocrine tumours were greater than those for carcinomas, indicating that enhancements in diagnostic techniques and treatments have helped improve survival over time.

Occupation and COVID-19 mortality in England: a national linked data study of 14.3 million adults

OBJECTIVES

To estimate occupational differences in COVID-19 mortality and test whether these are confounded by factors such as regional differences, ethnicity and education or due to non-workplace factors, such as deprivation or prepandemic health.

METHODS

Using a cohort study of over 14 million people aged 40-64 years living in England, we analysed occupational differences in death involving COVID-19, assessed between 24 January 2020 and 28 December 2020.We estimated age-standardised mortality rates (ASMRs) per 100 000 person-years at risk stratified by sex and occupation. We estimated the effect of occupation on COVID-19 mortality using Cox proportional hazard models adjusted for confounding factors. We further adjusted for non-workplace factors and interpreted the residual effects of occupation as being due to workplace exposures to SARS-CoV-2.

RESULTS

In men, the ASMRs were highest among those working as taxi and cab drivers or chauffeurs at 119.7 deaths per 100 000 (95% CI 98.0 to 141.4), followed by other elementary occupations at 106.5 (84.5 to 132.4) and care workers and home carers at 99.2 (74.5 to 129.4). Adjusting for confounding factors strongly attenuated the HRs for many occupations, but many remained at elevated risk. Adjusting for living conditions reduced further the HRs, and many occupations were no longer at excess risk. For most occupations, confounding factors and mediators other than workplace exposure to SARS-CoV-2 explained 70%-80% of the excess age-adjusted occupational differences.

CONCLUSIONS

Working conditions play a role in COVID-19 mortality, particularly in occupations involving contact with patients or the public. However, there is also a substantial contribution from non-workplace factors.

Worldwide trends in population-based survival for children, adolescents, and young adults diagnosed with leukaemia, by subtype, during 2000-14 (CONCORD-3): analysis of individual data from 258 cancer registries in 61 countries

BACKGROUND

Leukaemias comprise a heterogenous group of haematological malignancies. In CONCORD-3, we analysed data for children (aged 0-14 years) and adults (aged 15-99 years) diagnosed with a haematological malignancy during 2000-14 in 61 countries. Here, we aimed to examine worldwide trends in survival from leukaemia, by age and morphology, in young patients (aged 0-24 years).

METHODS

We analysed data from 258 population-based cancer registries in 61 countries participating in CONCORD-3 that submitted data on patients diagnosed with leukaemia. We grouped patients by age as children (0-14 years), adolescents (15-19 years), and young adults (20-24 years). We categorised leukaemia subtypes according to the International Classification of Childhood Cancer (ICCC-3), updated with International Classification of Diseases for Oncology, third edition (ICD-O-3) codes. We estimated 5-year net survival by age and morphology, with 95% CIs, using the non-parametric Pohar-Perme estimator. To control for background mortality, we used life tables by country or region, single year of age, single calendar year and sex, and, where possible, by race or ethnicity. All-age survival estimates were standardised to the marginal distribution of young people with leukaemia included in the analysis.

FINDINGS

164 563 young people were included in this analysis: 121 328 (73·7%) children, 22 963 (14·0%) adolescents, and 20 272 (12·3%) young adults. In 2010-14, the most common subtypes were lymphoid leukaemia (28 205 [68·2%] patients) and acute myeloid leukaemia (7863 [19·0%] patients). Age-standardised 5-year net survival in children, adolescents, and young adults for all leukaemias combined during 2010-14 varied widely, ranging from 46% in Mexico to more than 85% in Canada, Cyprus, Belgium, Denmark, Finland, and Australia. Individuals with lymphoid leukaemia had better age-standardised survival (from 43% in Ecuador to ≥80% in parts of Europe, North America, Oceania, and Asia) than those with acute myeloid leukaemia (from 32% in Peru to ≥70% in most high-income countries in Europe, North America, and Oceania). Throughout 2000-14, survival from all leukaemias combined remained consistently higher for children than adolescents and young adults, and minimal improvement was seen for adolescents and young adults in most countries.

INTERPRETATION

This study offers the first worldwide picture of population-based survival from leukaemia in children, adolescents, and young adults. Adolescents and young adults diagnosed with leukaemia continue to have lower survival than children. Trends in survival from leukaemia for adolescents and young adults are important indicators of the quality of cancer management in this age group.

FUNDING

Children with Cancer UK, the Institut National du Cancer, La Ligue Contre le Cancer, Centers for Disease Control and Prevention, Swiss Re, Swiss Cancer Research foundation, Swiss Cancer League, Rossy Family Foundation, US National Cancer Institute, and the American Cancer Society.

Excess mortality among essential workers in England and Wales during the COVID-19 pandemic

BACKGROUND

Exposure to SARS-CoV-2, subsequent development of COVID-19 and death from COVID-19 may vary by occupation, and the risks may be higher for those categorised as 'essential workers'.

METHODS

We estimated excess mortality by occupational group and sex separately for each month in 2020 and for the entire 12 months overall.

RESULTS

Mortality for all adults of working age was similar to the annual average over the previous 5 years. Monthly excess mortality peaked in April, when the number of deaths was 54.2% higher than expected and was lowest in December when deaths were 30.0% lower than expected.Essential workers had consistently higher excess mortality than other groups throughout 2020. There were also large differences in excess mortality between the categories of essential workers, with healthcare workers having the highest excess mortality and social care and education workers having the lowest. Excess mortality also varied widely between men and women, even within the same occupational group. Generally, excess mortality was higher in men.

CONCLUSIONS

In summary, excess mortality was consistently higher for essential workers throughout 2020, particularly for healthcare workers. Further research is needed to examine excess mortality by occupational group, while controlling for important confounders such as ethnicity and socioeconomic status. For non-essential workers, the lockdowns, encouragement to work from home and to maintain social distancing are likely to have prevented a number of deaths from COVID-19 and from other causes.

Population-Based Cancer Survival in Canada and the United States by Socioeconomic Status: Findings from the CONCORD-2 Study

Background

Population-based cancer survival provides insight into the effectiveness of health systems to care for all residents with cancer, including those in marginalized groups.

Methods

Using CONCORD-2 data, we estimated 5-year net survival among patients diagnosed 2004-2009 with one of 10 common cancers, and children diagnosed with acute lymphoblastic leukemia (ALL), by socioeconomic status (SES) quintile, age (0-14, 15-64, ≥65 years), and country (Canada or United States).

Results

In the lowest SES quintile, survival was higher among younger Canadian adults diagnosed with liver (23% vs 15%) and cervical (78% vs 68%) cancers and with leukemia (62% vs 56%), including children diagnosed with ALL (92% vs 86%); and higher among older Americans diagnosed with colon (62% vs 56%), female breast (87% vs 80%), and prostate (97% vs 85%) cancers. In the highest SES quintile, survival was higher among younger Americans diagnosed with stomach cancer (33% vs 27%) and younger Canadians diagnosed with liver cancer (31% vs 23%); and higher among older Americans diagnosed with stomach (27% vs 22%) and prostate (99% vs 92%) cancers.

Conclusions

Among younger Canadian cancer patients in the lowest SES group, greater access to health care may have resulted in higher cancer survival, while higher screening prevalence and access to health insurance (Medicare) among older Americans during the period of this study may have resulted in higher survival for some screen-detected cancers. Higher survival in the highest SES group for stomach and liver may relate to treatment differences. Survival differences by age and SES between Canada and the United States may help inform cancer control strategies.

The economic burden of colorectal cancer across Europe: a population-based cost-of-illness study

BACKGROUND

Colorectal cancer is one of the leading causes of cancer morbidity and mortality in Europe. We aimed to ascertain the economic burden of colorectal cancer across Europe using a population-based cost-of-illness approach.

METHODS

In this population-based cost-of-illness study, we obtained 2015 activity and costing data for colorectal cancer in 33 European countries (EUR-33) from global and national sources. Country-specific aggregate data were acquired for health-care, mortality, morbidity, and informal care costs. We calculated primary, outpatient, emergency, and hospital care, and systemic anti-cancer therapy (SACT) costs, as well as the costs of premature death, temporary and permanent absence from work, and unpaid informal care due to colorectal cancer. Colorectal cancer health-care costs per case were compared with colorectal cancer survival and colorectal cancer personnel, equipment, and resources across EUR-33 using univariable and multivariable regression. We also compared hospital care and SACT costs against 2009 data for the 27 EU countries.

FINDINGS

The economic burden of colorectal cancer across Europe in 2015 was €19·1 billion. The total non-health-care cost of €11·6 billion (60·6% of total economic burden) consisted of loss of productivity due to disability (€6·3 billion [33·0%]), premature death (€3·0 billion [15·9%]), and opportunity costs for informal carers (€2·2 billion [11·6%]). The €7·5 billion (39·4% of total economic burden) of direct health-care costs consisted of hospital care (€3·3 billion [43·4%] of health-care costs), SACT (€1·9 billion [25·6%]), and outpatient care (€1·3 billion [17·7%]), primary care (€0·7 billion [9·3%]), and emergency care (€0·3 billion [3·9%]). The mean cost for managing a patient with colorectal cancer varied widely between countries (€259-36 295). Hospital-care costs as a proportion of health-care costs varied considerably (24·1-84·8%), with a decrease of 21·2% from 2009 to 2015 in the EU. Overall, hospital care was the largest proportion (43·4%) of health-care expenditure, but pharmaceutical expenditure was far higher than hospital-care expenditure in some countries. Countries with similar gross domestic product per capita had widely varying health-care costs. In the EU, overall expenditure on pharmaceuticals increased by 213·7% from 2009 to 2015.

INTERPRETATION

Although the data analysed include non-homogenous sources from some countries and should be interpreted with caution, this study is the most comprehensive analysis to date of the economic burden of colorectal cancer in Europe. Overall spend on health care in some countries did not seem to correspond with patient outcomes. Spending on improving outcomes must be appropriately matched to the challenges in each country, to ensure tangible benefits. Our results have major implications for guiding policy and improving outcomes for this common malignancy.

FUNDING

Department for Employment and Learning of Northern Ireland, Medical Research Council, Cancer Research UK, Health Data Research UK, and DATA-CAN.

Disparities in cervical cancer survival in the United States by race and stage at diagnosis: An analysis of 138,883 women diagnosed between 2001 and 2014 (CONCORD-3)

OBJECTIVE

During 2000-2014, age-standardized five-year net survival for cervical cancer was 63-64% in the United States. Using data from CONCORD-3, we analyzed cervical cancer survival trends by race, stage and period of diagnosis.

METHODS

Data from 41 state-wide population-based cancer registries on 138,883 women diagnosed with cervical cancer during 2001-2014 were available. Vital status was followed up until December 31, 2014. We estimated age-standardized five-year net survival, by race (Black or White), stage and calendar period of diagnosis (2001-2003, 2004-2008, 2009-2014) in each state, and for all participating states combined.

RESULTS

White women were most commonly diagnosed with localized tumors (45-50%). However, for Black women, localized tumors were the most common stage (43.0%) only during 2001-2003. A smaller proportion of Black women received cancer-directed surgery than White women. For all stages combined, five-year survival decreased between 2001-2003 and 2009-2014 for both White (64.7% to 63.0%) and Black (56.7% to 55.8%) women. For localized and regional tumors, survival increased over the same period for both White (by 2-3%) and Black women (by 5%). Survival did not change for Black women diagnosed with distant tumors but increased by around 2% for White women.

CONCLUSIONS

Despite similar screening coverage for both Black and White women and improvements in stage-specific survival, Black women still have poorer survival than White women. This may be partially explained by inequities in access to optimal treatment. The results from this study highlight the continuing need to address the disparity in cervical cancer survival between White and Black women in the United States.

New Frontiers for Fairer Breast Cancer Care in a Globalized World

In early 2020, the book "Breast cancer: Global Quality Care" was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: "A call for Fairer Breast Cancer Care for all Women in a Globalized World." Special attention is paid to increasing the "value-based healthcare" putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered "the jewel in the crown" of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer across the globe.

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

Background

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

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

Methods

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

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

Results

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

Conclusions

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

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

The histology of brain tumours for 67,331 children and 671,085 adults diagnosed in 60 countries during 2000-2014: a global, population-based study (CONCORD-3)

INTRODUCTION

Global variations in survival for brain tumours are very wide when all histological types are considered together. Appraisal of international differences should be informed by the distribution of histology, but little is known beyond Europe and North America.

PATIENTS AND METHODS

The source for the analysis was the CONCORD data base, a programme of global surveillance of cancer survival trends, which includes the tumour records of individual patients from more than 300 population-based cancer registries. We considered all patients aged 0-99 years who were diagnosed with a primary brain tumour during 2000-2014, whether malignant or non-malignant. We presented the histology distribution of these tumours, for patients diagnosed during 2000-2004, 2005-2009, and 2010-2014.

RESULTS

Records were submitted from 60 countries on five continents, 67,331 for children and 671,085 for adults. After exclusion of irrelevant morphology codes, the final study population comprised 60,783 children and 602,112 adults. Only 59 of 60 countries covered in CONCORD-3 were included, because none of the Mexican records were eligible. We defined 12 histology groups for children, and 11 histology groups for adults. In children (0-14 years), the proportion of low-grade astrocytomas ranged between 6% and 50%. Medulloblastoma was the most common sub-type in countries where low-grade astrocytoma was less commonly reported. In adults (15-99 years), the proportion of glioblastomas varied between 9% and 69%. International comparisons were made difficult by wide differences in the proportion of tumours with unspecified histology, which accounted for up to 52% of diagnoses in children and up to 65% in adults.

CONCLUSIONS

To our knowledge, this is the first account of the global histology distribution of brain tumours, in children and adults. Our findings provide insights into the practices and the quality of cancer registration worldwide.

Trends in short-term survival from distant-stage cutaneous melanoma in the United States, 2001-2013 (CONCORD-3)

Background

Survival from metastatic cutaneous melanoma is substantially lower than for localized disease. Treatments for metastatic melanoma have been limited, but remarkable clinical improvements have been reported in clinical trials in the last decade. We described the characteristics of US patients diagnosed with cutaneous melanoma during 2001-2013 and assessed trends in short-term survival for distant-stage disease.

Methods

Trends in 1-year net survival were estimated using the Pohar Perme estimator, controlling for background mortality with life tables of all-cause mortality rates by county of residence, single year of age, sex, and race for each year 2001-2013. We fitted a flexible parametric survival model on the log-hazard scale to estimate the effect of race on the hazard of death because of melanoma and estimated 1-year net survival by race.

Results

Only 4.4% of the 425 915 melanomas were diagnosed at a distant stage, cases diagnosed at a distant stage are more commonly men, older patients, and African Americans. Age-standardized, 1-year net survival for distant-stage disease was stable at approximately 43% during 2001-2010. From 2010 onward, survival improved rapidly, reaching 58.9% (95% confidence interval = 56.6% to 61.2%) for patients diagnosed in 2013. Younger patients experienced the largest improvement. Survival for distant-stage disease increased in both Blacks and Whites but was consistently lower in Blacks.

Conclusions

One-year survival for distant-stage melanoma improved during 2001-2013, particularly in younger patients and those diagnosed since 2010. This improvement may be a consequence of the introduction of immune-checkpoint-inhibitors and other targeted treatments for metastatic and unresectable disease. Persistent survival inequalities exist between Blacks and Whites, suggesting differential access to treatment.

The Right to Health in Times of Pandemic: What Can We Learn from the UK's Response to the COVID-19 Outbreak?

The UK's response to COVID-19 has been widely criticized by scientists and the public. According to EuroMOMO, a European mortality monitoring initiative, the excess mortality that may be attributable to COVID-19 in England is one of the highest in Europe, second only to Spain. While critiqued from a public health perspective, much less attention is given to the implications of the pandemic outbreak for the right to health as defined under international human rights law and ratified by member states. Using the UK as a case study, we examine critically the extent to which the government's response to COVID-19 complied with the legal framework of the right to health. We review further key states' obligations on the right to health and assess its suitability in times of pandemic. Finally, we offer some recommendations for an update of the right to health. This paper adds to the body of literature on the right to health and human rights based-approaches to health.

Global Trends in Survival From Astrocytic Tumors in Adolescents and Young Adults: A Systematic Review

Background

Brain tumors represent an important cause of cancer-related death in adolescents and young adults. Most are diagnosed in low-income and middle-income countries. We aimed to conduct the first, to our knowledge, systematic review of time trends and geographical variation in survival in this age group.

Methods

We included observational studies describing population-based survival from astrocytic tumors in patients aged 15-39 years. We queried 6 electronic databases from database inception to December 31, 2019. This review is registered with PROSPERO, number CRD42018111981.

Results

Among 5640 retrieved records, 20 studies fulfilled the inclusion criteria. All but 1 study focused on high-income countries. Five-year survival from astrocytoma (broad morphology group) mostly varied between 48.0% and 71.0% (1973-2004) without clear trends or geographic differences. Adolescents with astrocytoma had better outcomes than young adults, but survival values were similar when nonmalignant tumors were excluded. During 2002-2007, 5-year survival for World Health Organization grade I-II tumors was in the range of 72.6%-89.1% in England, Germany, and the United States but lower in Southeastern Europe (59.0%). Five-year survival for anaplastic astrocytoma varied between 39.6% and 55.4% (2002-2007). Five-year survival from glioblastoma was in the range of 14.2%-23.1% (1991-2009).

Conclusions

Survival from astrocytic tumors remained somewhat steady over time, with little change between 1973 and 2009. Survival disparities were difficult to examine, because nearly all the studies were conducted in affluent countries. Studies often adopted the International Classification of Childhood Cancer, which, however, did not allow to accurately describe variation in survival. Larger studies are warranted, including underrepresented populations and providing more recent survival estimates.

Breast Cancer: global quality care optimizing care delivery with existing financial and personnel resources

Our vision about breast cancer quality care within a global health framework was recently published by Oxford University Press. The aim of our work was to reflect on the potential to achieve a world-wide improvement in quality care, assessing value for money. The population-based survival estimates from the CONCORD programme and the Breast Health Global Initiative (BHGI) are valuable tools for this global effort. Because cancer care delivery is becoming unsustainable in many countries assessing healthcare value for the cost is becoming increasingly important. Recommendations are made for better global quality care for patients with breast cancer.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Worldwide Trends in Survival From Common Childhood Brain Tumors: A Systematic Review

PURPOSE

The histology of brain tumors determines treatment and predicts outcome. Population-based survival reflects the effectiveness of a health care system in managing cancer. No systematic review of worldwide variation and time trends in survival from brain tumors in children is currently available.

PATIENTS AND METHODS

We considered longitudinal, observational studies comprising children diagnosed with intracranial astrocytic or embryonal tumors. We searched six electronic databases from database inception to September 30, 2018, using complex search strategies. The outcome measure was 5-year survival, estimated through a time-to-event analysis. This study is registered with PROSPERO, number CRD42018111981.

RESULTS

Among 5,244 studies, we identified 47 eligible articles that provided 228 survival estimates. Only five studies were entirely or partially conducted in low-income or middle-income countries. Five-year survival from embryonal tumors increased from 37% in 1980 to approximately 60% in 2009. Although survival for medulloblastoma improved substantially (from 29% to 73% during 1959-2009), survival for primitive neuroectodermal tumors wavered over time (1973-2009) and between countries. Five-year survival from astrocytoma changed very little over the 27 years between 1982 and 2009 (from 78% to 89%). Interpretation of the literature was made difficult by the heterogeneity of study designs.

CONCLUSION

Survival has improved for embryonal tumors, but little change has been observed for astrocytic tumors. We found a striking gap in knowledge about survival from childhood brain tumor subtypes in middle-income and low-income countries, where half of these tumors are diagnosed. Larger studies are needed, including in under-represented countries and based on standardized data collection, to provide up-to-date survival estimates.

Cancer Survival by Stage at Diagnosis in Kuwait: A Population-Based Study

OBJECTIVE

To examine the distribution of stage at diagnosis for 12 cancers in Kuwait, to estimate stage-specific net survival at 1 and 5 years after diagnosis, and to assess differences in stage-specific survival between Kuwait and the United States.

MATERIAL AND METHODS

Data were obtained from the Kuwait Cancer Registry, for Kuwaiti patients diagnosed during 2000-2013, with follow-up to 31 December 2015. The distribution of Surveillance Epidemiology and End Results (SEER) Summary Stage for 12 malignancies was examined. We estimated net survival by stage up to 5 years after diagnosis, controlling for background mortality with life tables of all-cause mortality in the general population by single year of age, sex, and calendar period. Survival estimates were age-standardised using the International Cancer Survival Standard (ICSS) weights.

RESULTS

Only 14.2% of patients were diagnosed at a localised stage and 38.9% at the regional stage. The proportion of patients with known stage was 88.9% during 2000-2004 but fell to 59.4% during 2010-2013. During 2005-2009, 1- and 5-year survival for colon, rectal, breast, cervical, and prostate cancer was about 90% or higher for patients diagnosed at the localised stage. During 2004-2009, the proportion of patients diagnosed at a localised stage was lower in Kuwait than in the US for colon, breast, and lung cancer. Age-standardised 5-year net survival for all stages combined was lower in Kuwait than the US for colon, lung, and breast cancer, but stage-specific survival was similar.

CONCLUSION

Since stage-specific survival is similar in Kuwait and the US, late stage at diagnosis is likely to be a major contributing factor to the overall lower survival in Kuwait than in the US. Increasing public awareness of cancer risk factors and symptoms and investment in early detection will be vital to reduce the proportion of patients diagnosed at a late stage and to improve survival.

A Novel Approach to Obtain Follow-up Data on the Vital Status of Registered Cancer Patients: The Kuwait Cancer Registry Experience

OBJECTIVE

We present an approach to obtain accurate and complete data on the last known vital status, and the date of last known vital status of all Kuwaiti cancer patients. These data are essential for robust estimation of population-based cancer survival.

METHODS

Government-issued Civil ID numbers (IDs) of patients registered during 2000-2013 were obtained from the Kuwait Cancer Registry. Missing IDs were traced using the Ministry of Health's Information System or the patient's medical records. IDs were manually entered in the Public Authority of Civil Information (PACI) database to ascertain vital status for patients whose vital status was not known in the registry. To obtain the date of death for deceased patients, IDs were then manually entered and searched in the electronic archive of "Death Announcements" at the Ministry of Health's Central Records Department of Births and Deaths. Patients not found in the "Death Announcements" archive were considered alive as on 31 December 2015.

RESULTS

The traditional method to obtain data on cancer patients' vital status, restricted to patients whose death was certified as due to cancer, had captured only 62% of all patients' deaths. This new approach resolved the vital status for 98.3% of patients for whom it was previously unknown. The impact was substantial: the proportion of patients known to be dead rose from 27.9% to 45.0%, while the proportion presumed alive dropped from 72.1% to 53.7%. Only 1.3% of the patients remained lost to follow-up.

CONCLUSION

This approach substantially improved the quality and completeness of follow-up data for all Kuwaiti cancer patients. We recommend that this approach should be performed routinely in Kuwait to enable accurate estimation and monitoring of population-based survival trends.

Cancer survival trends in Kuwait, 2000-2013: A population-based study

OBJECTIVE

To examine population-based cancer survival trends in Kuwait; to facilitate public assessment of cancer control.

METHODS

Data were obtained from the Kuwait Cancer Registry for Kuwaiti adults (15-99 years) and children (0-14 years) diagnosed with one of 18 common cancers during 2000-2013 and followed up to 31 December 2014. Net survival was estimated at 1, 3, and 5 years by sex. To control for background mortality, life tables of all-cause mortality in the general population were constructed by single year of age, sex, and calendar year of death ("complete" life tables). Net survival estimates were age-standardised using the International Cancer Survival Standard weights.

RESULTS

Cancers with the highest net survival throughout the 14-year period were prostate, breast (women) and rectum in adults, and lymphoma in children. Survival was lowest for liver, pancreas and lung cancer in adults, and brain tumours in children. During 2010-2013, one year survival was over 80% for cancers of the prostate, breast, rectum, cervix and colon. Five-year survival was above 80% only for prostate cancer. For children, one and five-year survival was above 80% only for acute lymphoblastic leukaemia (ALL) and lymphoma. Survival was generally higher for women than men, and declined faster in women than men between 1 and 3 years after diagnosis. Differences between boys and girls were small.

CONCLUSION

Cancer survival improved for most Kuwaiti adults and children over the 14-year period, with women generally having a more favourable prognosis than men. Continuous surveillance is required to monitor cancers for which survival did not improve, and to dissect the underlying causes for the differences in survival between Kuwait and other countries.

Childhood cancer burden: a review of global estimates

5-year net survival of children and adolescents diagnosed with cancer is approximately 80% in many high-income countries. This estimate is encouraging as it shows the substantial progress that has been made in the diagnosis and treatment of childhood cancer. Unfortunately, scarce data are available for low-income and middle-income countries (LMICs), where nearly 90% of children with cancer reside, suggesting that global survival estimates are substantially worse in these regions. As LMICs are undergoing a rapid epidemiological transition, with a shifting burden from infectious diseases to non-communicable diseases, cancer care for all ages has become a global focus. To improve outcomes for children and adolescents diagnosed with cancer worldwide, an accurate appraisal of the global burden of childhood cancer is a necessary first step. In this Review, we analyse four studies of the global cancer burden that included data for children and adolescents. Each study used various overlapping and non-overlapping statistical approaches and outcome metrics. Moreover, to provide guidance on improving future estimates of the childhood global cancer burden, we propose several recommendations to strengthen data collection and standardise analyses. Ultimately, these data could help stakeholders to develop plans for national and institutional cancer programmes, with the overall aim of helping to reduce the global burden of cancer in children and adolescents.

Women's Cancers: Prospects for a World-Wide High-Resolution Study Targeted to Cancer Control

Background: Breast, ovarian and cervical cancers are a major public health problem world-wide. CONCORD-3 has updated cancer survival trends to 2014 for 18 malignancies, including breast (women), cervix and ovary (15-99 years). World-wide differences in survival from these cancers are striking. Inequalities in survival also exist between and within high-income countries. Aim: The aim is to assess the extent to which variations in the patterns of care explain the world-wide inequalities in survival and the number of avoidable premature deaths. Methods: The CONCORD-3 database includes incidence and follow-up data from 322 population-based registries in 71 countries for 37,513,025 patients diagnosed with one of 18 malignancies during the 15 years 2000-2014, including 7,948,798 women diagnosed with a cancer of the breast, cervix or ovary. I propose to enhance the CONCORD database: 1) by collecting and analyzing detailed data from the medical records (e.g., stage at diagnosis, staging procedures, first course of treatment and, where available, prognostic biomarkers) of women diagnosed with breast, ovarian or cervical cancer in at least two countries per continent, in the most recent year during 2010-2014 for which data are available. 2) by estimating the number of avoidable premature deaths that are attributable to inequalities in five-year survival between and within countries. Results: I will present the protocol for data collection and analysis for discussion. This will include plans for a pilot study to assess the availability of high-resolution data world-wide. Conclusion: The UICC World Cancer Congress will be an ideal platform to discuss and refine the study design with cancer registry colleagues and experts in cancer control and public health from 150 countries. The insights from this project will contribute to the planning and implementation of cancer control strategies for women's cancers.

Adult leukemia survival trends in the United States by subtype: A population-based registry study of 370,994 patients diagnosed during 1995-2009

BACKGROUND

The lifetime risk of developing leukemia in the United States is 1.5%. There are challenges in the estimation of population-based survival using registry data because treatments and prognosis vary greatly by subtype. The objective of the current study was to determine leukemia survival estimates in the United States from 1995 to 2009 according to subtype, sex, geographical area, and race.

METHODS

Five-year net survival was estimated using data for 370,994 patients from 43 registries in 37 states and in 6 metropolitan areas, covering approximately 81% of the adult (15-99 years) US population. Leukemia was categorized according to principal subtype (chronic lymphocytic leukemia, acute myeloid leukemia, and acute lymphocytic leukemia), and subcategorized in accordance with the HAEMACARE protocol. We analyzed age-standardized 5-year net survival by calendar period (1995-1999, 2000-2004, and 2005-2009), leukemia subtype, sex, race, and US state.

RESULTS

The age-standardized 5-year net survival estimates increased from 45.0% for patients diagnosed during 1995-1999 to 49.0% for those diagnosed during 2000-2004 and 52.0% for those diagnosed during 2005-2009. For patients diagnosed during 2005-2009, 5-year survival was 18.2% (95% confidence interval [95% CI], 17.8%-18.6%) for acute myeloid leukemia, 44.0% (95% CI, 43.2%-44.8%) for acute lymphocytic leukemia, and 77.3% (95% CI, 76.9%-77.7%) for chronic lymphocytic leukemia. For nearly all leukemia subtypes, survival declined in successive age groups above 45 to 54 years. Men were found to have slightly lower survival than women; however, this discrepancy was noted to have fallen in successive calendar periods. Net survival was substantially higher in white than black patients in all calendar periods. There were large differences in survival noted between states and metropolitan areas.

CONCLUSIONS

Survival from leukemia in US adults improved during 1995-2009. Some geographical differences in survival may be related to access to care. We found disparities in survival by sex and between black and white patients.

Abstract A56: Racial disparities in colon cancer survival--United States, 2001-2009

Background: In the first CONCORD study, five-year survival for colon cancers diagnosed during 1990-1994 in the U.S. was among the highest in the world (60%), but there were large racial disparities in most participating states. The CONCORD-2 study updated these findings to determine survival trends up to 2009 by race and stage.

Methods: We analyzed data from 37 state population-based cancer registries, covering approximately 80% of the U.S. population, for patients diagnosed with colon cancer during 2001-2009 and followed through 2009. Survival up to five years was adjusted for background mortality (net survival) using state- and race-specific life tables, and age-standardized using the International Cancer Survival Standard weights. Survival is presented by race (all, black, white), stage, state, and calendar period (2001–03 and 2004–09) to account for changes in methods used to collect stage.

Results: Five-year net survival was 63.7% for those diagnosed during 2001-2003 and 64.6% for 2004-2009. More black than white patients were diagnosed at distant stage, both in 2001-2003 (21.5% vs. 17.2%, respectively) and in 2004-2009 (23.3% vs 18.8%). Survival varied widely between states and there was a slight increase in many states. Survival improved for both blacks and whites, but blacks had lower survival than whites diagnosed during 2001-2003 (54.7% vs. 64.5%) and 2004-2009 (56.6% vs. 65.4%).

Conclusion: Five-year net survival from colon cancer remained stable over time. Survival remained lower in blacks than in whites but the gap narrowed. These finding suggest a need for more targeted efforts to improve screening and to ensure timely, appropriate treatment.

Citation Format: Arica White, Djenaba Joseph, Sun Hee Rim, Christopher J. Johnson, Michel Coleman, Claudia Allemani. Racial disparities in colon cancer survival--United States, 2001-2009 [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A56.

Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries

BACKGROUND

In 2015, the second cycle of the CONCORD programme established global surveillance of cancer survival as a metric of the effectiveness of health systems and to inform global policy on cancer control. CONCORD-3 updates the worldwide surveillance of cancer survival to 2014.

METHODS

CONCORD-3 includes individual records for 37·5 million patients diagnosed with cancer during the 15-year period 2000-14. Data were provided by 322 population-based cancer registries in 71 countries and territories, 47 of which provided data with 100% population coverage. The study includes 18 cancers or groups of cancers: oesophagus, stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate, and melanoma of the skin in adults, and brain tumours, leukaemias, and lymphomas in both adults and children. Standardised quality control procedures were applied; errors were rectified by the registry concerned. We estimated 5-year net survival. Estimates were age-standardised with the International Cancer Survival Standard weights.

FINDINGS

For most cancers, 5-year net survival remains among the highest in the world in the USA and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway, and Sweden. For many cancers, Denmark is closing the survival gap with the other Nordic countries. Survival trends are generally increasing, even for some of the more lethal cancers: in some countries, survival has increased by up to 5% for cancers of the liver, pancreas, and lung. For women diagnosed during 2010-14, 5-year survival for breast cancer is now 89·5% in Australia and 90·2% in the USA, but international differences remain very wide, with levels as low as 66·1% in India. For gastrointestinal cancers, the highest levels of 5-year survival are seen in southeast Asia: in South Korea for cancers of the stomach (68·9%), colon (71·8%), and rectum (71·1%); in Japan for oesophageal cancer (36·0%); and in Taiwan for liver cancer (27·9%). By contrast, in the same world region, survival is generally lower than elsewhere for melanoma of the skin (59·9% in South Korea, 52·1% in Taiwan, and 49·6% in China), and for both lymphoid malignancies (52·5%, 50·5%, and 38·3%) and myeloid malignancies (45·9%, 33·4%, and 24·8%). For children diagnosed during 2010-14, 5-year survival for acute lymphoblastic leukaemia ranged from 49·8% in Ecuador to 95·2% in Finland. 5-year survival from brain tumours in children is higher than for adults but the global range is very wide (from 28·9% in Brazil to nearly 80% in Sweden and Denmark).

INTERPRETATION

The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 cancers that collectively represent 75% of all cancers diagnosed worldwide every year. It contributes to the evidence base for global policy on cancer control. Since 2017, the Organisation for Economic Co-operation and Development has used findings from the CONCORD programme as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries worldwide. Governments must recognise population-based cancer registries as key policy tools that can be used to evaluate both the impact of cancer prevention strategies and the effectiveness of health systems for all patients diagnosed with cancer.

FUNDING

American Cancer Society; Centers for Disease Control and Prevention; Swiss Re; Swiss Cancer Research foundation; Swiss Cancer League; Institut National du Cancer; La Ligue Contre le Cancer; Rossy Family Foundation; US National Cancer Institute; and the Susan G Komen Foundation.

Do Pre-Diagnostic Drinking Habits Influence Breast Cancer Survival?

Aims and background

Alcohol consumption increases the risk of developing breast cancer and may also be associated with late diagnosis, recurrence, distant metastases and death. Many studies have examined the role of alcohol as a risk factor for the development of breast cancer, but very few studies have addressed the role of alcohol as a prognostic factor for survival among women diagnosed with breast cancer. The aim of this study was to investigate the survival of women with breast cancer in relation to pre-diagnostic alcohol intake and other factors known to influence prognosis.

Methods

We analyzed data for 264 women in the EUROCARE and ORDET studies who were diagnosed with breast cancer from 1987 up to 31 December 2001 and for whom information was available on follow-up, stage at diagnosis, HER-2 and hormone receptor status, and pre-diagnostic dietary alcohol intake, categorized as zero (0 g/day, non-drinkers), moderate (up to 13 g/day, about 1 serving) and high (>13 g/day). Ten-year relative survival was estimated using the maximum-likelihood approach. The excess risk of death within 10 years of diagnosis was modeled by level of alcohol intake, adjusting separately for age, stage, body mass index and tumor subtype.

Results

Ten-year relative survival was lowerin women who drank more than 13g/day (65%; 95% CI, 47–78) than in non-drinkers (88%; 95% CI, 75–95). The excess risk of death within 10 years was significantly higher in women who drank more than 13 g/day than non-drinkers (relative excess risk, 4.13; 95% CI, 1.69–10.10) and was not altered by adjustment for other prognostic factors. The excess risk within 10 years was higher for women with a body mass index of 25 kg/m2 or higher (relative excess risk, 2.20; 95% CI, 1.01–4.70) and higher for those with more advanced disease.

Conclusions

Women who drank more than 13 g alcohol per day had lower survival than non-drinkers. The excess risk of death within 10 years of diagnosis was unaffected by other known risk factors. High alcohol consumption may be an adverse prognostic factor for breast cancer.

Public health surveillance of cancer survival in the United States and worldwide: The contribution of the CONCORD programme

CONCORD is a programme for the global surveillance of cancer survival. In 2015, the second cycle of the program (CONCORD-2) established long-term surveillance of cancer survival worldwide, for the first time, in the largest cancer survival study published to date. CONCORD-2 provided cancer survival trends for 25,676,887 patients diagnosed during the 15-year period between 1995 and 2009 with 1 of 10 common cancers that collectively represented 63% of the global cancer burden in 2009. Herein, the authors summarize the past, describe the present, and outline the future of the CONCORD programme. They discuss the difference between population-based studies and clinical trials, and review the importance of international comparisons of population-based cancer survival. This study will focus on the United States. The authors explain why population-based survival estimates are crucial for driving effective cancer control strategies to reduce the wide and persistent disparities in cancer survival between white and black patients, which are likely to be attributable to differences in access to early diagnosis and optimal treatment. Cancer 2017;123:4977-81. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Colon cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

In the first CONCORD study (2008), 5-year survival for patients diagnosed with colon cancer between 1990 and 1994 in the United States was among the highest in the world (60%), but there were large racial disparities in most participating states. The CONCORD-2 study (2015) enabled the examination of survival trends between 1995 and 2009 for US states by race and stage.

METHODS

The authors analyzed data from 37 state population-based cancer registries, covering approximately 80% of the US population, for patients who were diagnosed with colon cancer between 2001 and 2009 and were followed through 2009. Survival up to 5 years was corrected for background mortality (net survival) using state-specific and race-specific life tables and age-standardized using the International Cancer Survival Standard weights. Survival is presented by race (all, black, white), stage, state, and calendar period (2001-2003 and 2004-2009) to account for changes in methods used to collect stage.

RESULTS

Five-year net survival increased by 0.9%, from 63.7% between 2001 and 2003 to 64.6% between 2004 and 2009. More black than white patients were diagnosed with distant-stage disease between 2001 and 2003 (21.5% vs 17.2%) and between 2004 and 2009 (23.3% vs 18.8%). Survival improved for both blacks and whites, but 5-year net survival was 9-10% lower for blacks than for whites both between 2001 and 2003 (54.7% vs 64.5%) and between 2004 and 2009 (56.6% vs 65.4%). The absolute difference between blacks and whites decreased by only 1% during the decade.

CONCLUSIONS

Five-year net survival from colon cancer increased slightly over time. Survival among blacks diagnosed between 2004 and 2009 had still not reached the level of that among whites diagnosed between 1990 and 1994, some 15 to 20 years earlier. These findings suggest a need for more targeted efforts to improve screening and to ensure timely, appropriate treatment, especially for blacks, to reduce this large and persistent disparity in survival. Cancer 2017;123:5014-36. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Population-based cancer survival in the United States: Data, quality control, and statistical methods

BACKGROUND

Robust comparisons of population-based cancer survival estimates require tight adherence to the study protocol, standardized quality control, appropriate life tables of background mortality, and centralized analysis. The CONCORD program established worldwide surveillance of population-based cancer survival in 2015, analyzing individual data on 26 million patients (including 10 million US patients) diagnosed between 1995 and 2009 with 1 of 10 common malignancies.

METHODS

In this Cancer supplement, we analyzed data from 37 state cancer registries that participated in the second cycle of the CONCORD program (CONCORD-2), covering approximately 80% of the US population. Data quality checks were performed in 3 consecutive phases: protocol adherence, exclusions, and editorial checks. One-, 3-, and 5-year age-standardized net survival was estimated using the Pohar Perme estimator and state- and race-specific life tables of all-cause mortality for each year. The cohort approach was adopted for patients diagnosed between 2001 and 2003, and the complete approach for patients diagnosed between 2004 and 2009.

RESULTS

Articles in this supplement report population coverage, data quality indicators, and age-standardized 5-year net survival by state, race, and stage at diagnosis. Examples of tables, bar charts, and funnel plots are provided in this article.

CONCLUSIONS

Population-based cancer survival is a key measure of the overall effectiveness of services in providing equitable health care. The high quality of US cancer registry data, 80% population coverage, and use of an unbiased net survival estimator ensure that the survival trends reported in this supplement are robustly comparable by race and state. The results can be used by policymakers to identify and address inequities in cancer survival in each state and for the United States nationally. Cancer 2017;123:4982-93. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Disparities in breast cancer survival in the United States (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

Reducing breast cancer incidence and achieving equity in breast cancer outcomes remains a priority for public health practitioners, health care providers, policy makers, and health advocates. Monitoring breast cancer survival can help evaluate the effectiveness of health services, quantify inequities in outcomes between states or population subgroups, and inform efforts to improve the effectiveness of cancer management and treatment.

METHODS

We analyzed breast cancer survival using individual patient records from 37 statewide registries that participated in the CONCORD-2 study, covering approximately 80% of the US population. Females were diagnosed between 2001 and 2009 and were followed through December 31, 2009. Age-standardized net survival at 1 year, 3 years, and 5 years after diagnosis was estimated by state, race (white, black), stage at diagnosis, and calendar period (2001-2003 and 2004-2009).

RESULTS

Overall, 5-year breast cancer net survival was very high (88.2%). Survival remained remarkably high from 2001 through 2009. Between 2001 and 2003, survival was 89.1% for white females and 76.9% for black females. Between 2004 and 2009, survival was 89.6% for white females and 78.4% for black females.

CONCLUSIONS

Breast cancer survival was more than 10 percentage points lower for black females than for white females, and this difference persisted over time. Reducing racial disparities in survival remains a challenge that requires broad, coordinated efforts at the federal, state, and local levels. Monitoring trends in breast cancer survival can highlight populations in need of improved cancer management and treatment. Cancer 2017;123:5100-18. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Cervical cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

Overall, cervical cancer survival in the United States has been reported to be among the highest in the world, despite slight decreases over the last decade. Objective of the current study was to describe cervical cancer survival trends among US women and examine differences by race and stage.

METHODS

This study used data from the CONCORD-2 study to compare survival among women (aged 15-99 years) diagnosed in 37 states covering 80% of the US population. Survival was adjusted for background mortality (net survival) with state- and race-specific life tables and was age-standardized with the International Cancer Survival Standard weights. Five-year survival was compared by race (all races, blacks, and whites). Two time periods, 2001-2003 and 2004-2009, were considered because of changes in how the staging variable was collected.

RESULTS

From 2001 to 2009, 90,620 women were diagnosed with invasive cervical cancer. The proportion of cancers diagnosed at a regional or distant stage increased over time in most states. Overall, the 5-year survival was 63.5% in 2001-2003 and 62.8% in 2004-2009. The survival was lower for black women versus white women in both calendar periods and in most states; black women had a higher proportion of distant-stage cancers.

CONCLUSIONS

The stability of the overall survival over time and the persistent differences in survival between white and black women in all US states suggest that there is a need for targeted interventions and improved access to screening, timely treatment, and follow-up care, especially among black women. Cancer 2017;123:5119-37. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Lung cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

Results from the second CONCORD study (CONCORD-2) indicated that 5-year net survival for lung cancer was low (range, 10%-20%) between 1995 and 2009 in most countries, including the United States, which was at the higher end of this range.

METHODS

Data from CONCORD-2 were used to analyze net survival among patients with lung cancer (aged 15-99 years) who were diagnosed in 37 states covering 80% of the US population. Survival was corrected for background mortality using state-specific and race-specific life tables and age-standardized using International Cancer Survival Standard weights. Net survival was estimated for patients diagnosed between 2001 and 2003 and between 2004 and 2009 at 1, 3, and 5 years after diagnosis by race (all races, black, and white); Surveillance, Epidemiology, and End Results Summary Stage 2000; and US state.

RESULTS

Five-year net survival increased from 16.4% (95% confidence interval, 16.3%-16.5%) for patients diagnosed 2001-2003 to 19.0% (18.8%-19.1%) for those diagnosed 2004-2009, with increases in most states and among both blacks and whites. Between 2004 and 2009, 5-year survival was lower among blacks (14.9%) than among whites (19.4%) and ranged by state from 14.5% to 25.2%.

CONCLUSIONS

Lung cancer survival improved slightly between the periods 2001-2003 and 2004-2009 but was still low, with variation between states, and persistently lower survival among blacks than whites. Efforts to control well established risk factors would be expected to have the greatest impact on reducing the burden of lung cancer, and efforts to ensure that all patients receive timely and appropriate treatment should reduce the differences in survival by race and state. Cancer 2017;123:5079-99. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.