Survival for oesophageal, stomach and small intestine cancers in Europe 1999-2007: Results from EUROCARE-5

BACKGROUND

European regional variation in cancer survival was reported in the EUROCARE-4 study for patients diagnosed in 1995-1999. Relative survival (RS) estimates are here updated for patients diagnosed with cancer of the oesophagus, stomach and small intestine from 2000 to 2007. Trends in RS from 1999-2001 to 2005-2007 are presented to monitor and discuss improvements in patient survival in Europe.

MATERIALS AND METHODS

EUROCARE-5 data from 29 countries (87 cancer registries) were used to investigate 1- and 5-year RS. Using registry-specific life-tables stratified by age, gender and calendar year, age-standardised 'complete analysis' RS estimates by country and region were calculated for Northern, Southern, Eastern and Central Europe, and for Ireland and United Kingdom (UK). Survival trends of patients in periods 1999-2001, 2002-2004 and 2005-2007 were investigated using the 'period' RS approach. We computed the 5-year RS conditional on surviving the first year (5-year conditional survival), as the ratio of age-standardised 5-year RS to 1-year RS.

RESULTS

Oesophageal cancer 1- and 5-year RS (40% and 12%, respectively) remained poor in Europe. Patient survival was worst in Eastern (8%), Northern (11%) and Southern Europe (10%). Europe-wide, there was a 3% improvement in oesophageal cancer 5-year survival by 2005-2007, with Ireland and the UK (3%), and Central Europe (4%) showing large improvements. Europe-wide, stomach cancer 5-year RS was 25%. Ireland and UK (17%) and Eastern Europe (19%) had the poorest 5-year patient survival. Southern Europe had the best 5-year survival (30%), though only showing an improvement of 2% by 2005-2007. Small intestine cancer 5-year RS for Europe was 48%, with Central Europe having the best (54%), and Ireland and UK the poorest (37%). Five-year patient survival improvement for Europe was 8% by 2005-2007, with Central, Southern and Eastern Europe showing the greatest increases (⩾9%).

CONCLUSIONS

Survival for these cancer sites, particularly oesophageal cancer, remains poor in Europe with wide variation. Further investigation into the wide variation, including analysis by histology and anatomical sub-site, will yield insights to better monitor and explain the improvements in survival observed over time.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Operative mortality after gastric cancer resection and long-term survival differences across Europe

BACKGROUND

: Little is known at a population level about operative mortality after surgery for gastric cancer and whether differences between countries can explain differences in long-term survival. This study compared operative mortality recorded by ten cancer registries in seven European countries.

METHODS

: Non-conditional logistic regression analysis was performed to estimate the independent effect of the studied factors on mortality within 30 days of surgery. A multivariable survival model was employed with and without operative mortality.

RESULTS

: The overall operative mortality rate in 1611 patients studied was 8.9 (range 5.2-16) per cent. Country of residence was a significant prognostic factor in the multivariable analysis. The likelihood of operative mortality was lower in Italy, France and the UK than in the Netherlands, Spain, Slovenia and Poland. Age, type of gastrectomy and stage at diagnosis were also significant factors. Cancer site was not found to be significant in the multivariable analysis. The overall 5-year relative survival rate varied between 42.0 per cent (Italy) and 24 per cent (Poland); after excluding operative mortality, the 5-year survival rate was 44.3 and 28 per cent respectively.

CONCLUSION

: Within Europe, the substantial differences in operative mortality after gastrectomy only partly explain marked differences in survival after gastric cancer resection.

Thromboprophylaxis for caesarean section—how can uptake and coverage be improved?

The objective of this study was to determine the proportion of patients requiring thromboprophylaxis and evaluate adherence to local protocols on thromboprophylaxis after caesarean section. This was a retrospective audit of 200 consecutive patients undergoing caesarean section between January and March 2002. The study was carried out at two obstetric units in Hull. We evaluated the proportion of patients requiring prophylaxis, appropriate and inappropriate treatment given and those omitted from receiving prophylaxis. Adherence to a risk assessment protocol was also assessed. The majority of women (84.5%) had at least one risk factor for thromboembolism. Use of a checklist did not increase the appropriate use of thromboprophylaxis and did not reduce inappropriate use. The checklist was used appropriately in only 54% of cases. Thromboprophylaxis has not been associated with problems if given after operation, thus the inappropriate administration is probably not a serious mistake. Universal prophylaxis with low molecular weight heparin would prevent at-risk women being missed and should be considered.

Prognostic value of morphology and hormone receptor status in breast cancer - a population-based study

We analysed the 5-year relative survival among 4473 breast cancer cases diagnosed in 1990–1992 from cancer registries in Estonia, France, Italy, Spain, the Netherlands and the UK. Among eight categories based on ICD-O codes (infiltrating ductal carcinoma, lobular plus mixed carcinoma, comedocarcinoma, ‘special types’, medullary carcinoma, not otherwise specified (NOS) carcinoma, other carcinoma and cancer without microscopic confirmation), the 5-year relative survival ranged from 66% (95% CI 61–71) for NOS carcinoma to 95% (95% CI 90–100) for special types (tubular, apocrine, cribriform, papillary, mucinous and signet ring cell); 27% (95% CI 18–36) for cases without microscopic confirmation. Differences in 5-year relative survival by tumor morphology and hormone receptor status were modelled using a multiple regression approach based on generalised linear models. Morphology and hormone receptor status were confirmed as significant survival predictors in this population-based study, even after adjusting for age and stage at diagnosis.

EUROCARE-3: survival of cancer patients diagnosed 1990-94--results and commentary

EUROCARE-3 analysed the survival of 1815584 adult cancer patients diagnosed from 1990 to 1994 in 22 European countries. The results are reported in tables, one per cancer site, coded according to the International Classification of Diseases (ICD)-9 classification. The main findings of the tables are summarised and commented on in this article. For most solid cancers, wide differences in survival between different European populations were found, as also reported by EUROCARE-1 and EUROCARE-2, despite a remarkable (10%) overall increase in cancer survival from 1985 to 1994. Survival was highest in northern Europe (Sweden, Norway, Finland and Iceland), and fairly good in central-southern Europe (France, Switzerland, Austria and Spain). Survival was particularly low in eastern Europe, low in Denmark and the UK, and fairly low in Portugal and Malta. The mix of tumour stage at diagnosis explains much of the survival differences for cancers of the digestive tract, female reproductive system, breast, thyroid, and also skin melanoma. For tumours of the urinary tract and prostate, the differences were explained mainly by differences in diagnostic criteria and procedures. The case mix by anatomic subsite largely explains differences in survival for head and neck cancers. For oesophagus, pancreas, liver and brain cancer, with poor prognoses, survival differences were limited. Tumours, for which highly effective treatments are available, such as testicular cancer, Hodgkin's lymphoma and some haematological malignancies, had fairly uniform survival across Europe. Survival for all tumours combined (an indicator of the overall cancer care performance of a nation's health system) was better in young than old patients, and better in women than men. The affluence of countries influenced overall cancer survival through the availability of adequate diagnostic and treatment procedures, and screening programmes.

European health systems and cancer care

INTRODUCTION

Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s.

OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS

The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal.

CONCLUSIONS

Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.

Differences in stage and therapy for breast cancer across Europe

We examined variations in stage, diagnostic workup and therapy for breast cancer across Europe. Seventeen cancer registries in six European countries contributed 4,480 cases diagnosed in 1990-91. The clinical records of these cases were examined, and the distribution of stage, diagnostic examinations and therapy were analyzed. Stage was earliest in the French registries, followed by those of Italy and Eindhoven (Netherlands). The proportion of stage I cancers was highest in the French areas with screening in place. Estonia, the English registries and Granada (Spain) had the most advanced stage at diagnosis. Use of liver ultrasonography varied from 84% (Italian registries) to 18% (Granada). Bone scan use varied from 81% (Italian registries) to 15% (Mersey, UK). The highest proportions treated by breast-conserving surgery were in the French (57%) and English registries (63%); the lowest were in Estonia (6%) and Granada (11%). The highest proportions of Halsted mastectomies were in Italy (19%) and Granada (8%). In all countries except England, 90% of operations included axillary lymphadenectomy. Medical treatment only was given to 8% of (mostly advanced) cases overall. Estonia (21%) and the English registries (14%) had the highest proportions of patients given medication only. Chemotherapy was given to low proportions of node-positive cases in the Italian (76%) and English (74%) areas; breast-conserving surgery for stage I tumors varied from 24% in Granada to 84% in England. These wide differences in breast cancer care across Europe in the early 1990s indicate a need for continual monitoring of past treatments to help ensure application of the most effective protocols.

Cancer survival increases in Europe, but international differences remain wide

The EUROCARE project analysed cancer survival data from 45 population-based cancer registries in 17 European countries, revealing wide international differences in cancer survival. We calculated 5-year relative survival for 1836287 patients diagnosed with one of 13 cancers during the period 1978-1989. The data, from 20 cancer registries in 13 countries, were grouped into four regions: Finland, Sweden, Iceland (Northern Europe); Denmark, England and Scotland (UK and Denmark); France, The Netherlands, Germany, Italy and Switzerland (Western Europe); Estonia and Poland (Eastern Europe), and broken down into four periods (1978-1980, 1981-1983, 1984-1986, 1987-1989). For each cancer, mean European and regional survival was estimated as the weighted mean of 5-year relative survival in each country. Survival increased with time for all tumours, particularly for cancers of testis (12% increase, i.e. from 79.9 to 91.9%), breast, large bowel, skin melanoma (approximately 9-10%), and lymphomas (approximately 7%). For most solid tumours, survival was highest in Northern Europe and lowest in Eastern Europe, and also low in the UK and Denmark. Regional variation was less marked for the lymphomas. Survival improved more in Western than Northern Europe, and the differences between these regions fell for bowel cancer (from 8.0% for those diagnosed in 1978-1980 to 2% for those diagnosed in 1987-1989), breast cancer (from 7.4% to 3.9%), skin melanoma (from 13.4% to 11.0%) and Hodgkin's disease (from 7.2 to 0.6%). For potentially curable malignancies such as Hodgkin's disease, large bowel, breast and testicular cancers, there were substantial increases in survival, suggesting an earlier diagnosis and more effective treatment. The persisting regional differences suggest there are corresponding differences in the availability of diagnostic and therapeutic facilities, and in the effectiveness of healthcare systems.

Incidence and prevalence of all cancerous diseases in Italy

The burden of cancer in ageing populations is causing great concern, particularly in Italy with Europe's fastest growing elderly population. Studying all cancers combined in one group, although of limited medical value, is of great interest from the viewpoints of public health, epidemiology and the economy. Using mortality data and an estimate of cancer patients' survival we have estimated and projected incidence and prevalence in Italy of all cancers combined in one group. Five major phenomena are highlighted in the paper: (1) the decrease in the age-adjusted cancer mortality rates among females and the stable mortality rates among males since 1990; (2) the changing pattern of cancer incidence since 1990, it has started to decrease for females and is stabilising for males; (3) the decrease in cancer incidence among males and females born after 1940; (4) the increase in the proportion of cancer patients that are cured with calendar years of diagnosis; (5) the increase in the total and the healthy life expectancy (i.e. cancer-free) among the Italian population since 1970. The declining and flat trends in age-adjusted cancer incidence and mortality rates since 1990 is the combined effect of survival improvements and cancer risk reduction for younger cohort groups, after 1940. These favourable trends contribute to the increase in healthy life expectation, thus supporting the idea that we live longer and healthier.

Survival for retinoblastoma in Europe

The survival of 954 cases of retinoblastoma, diagnosed between 1978 and 1989 in 28 populations belonging to 17 European countries and covered by cancer registration, is analysed in this study. Data were collected in the framework of the EUROCARE study following a common protocol and data-check procedures and were analysed centrally by the Kaplan-Meier method and by the Cox regression model. Overall 5-year survival in the European pool was 93% (95% confidence interval (CI): 91--95%), for both sexes. Five-, 10- and 18-year survival for a subset of 235 patients diagnosed in 1978--1981 was 91, 89 and 86%, respectively. Children diagnosed in their first year of age had a slightly higher survival (94%) than those diagnosed subsequently (92%). Survival rates lower than the European average were found in the Eastern European countries, Italy, England and Wales, Scotland, Spain and Denmark. Higher survival was found in the other Nordic countries and in Central European countries. However, none of these differences was statistically significant. There was statistically significant effect related to the period of diagnosis, with a 50% reduction in the relative risk (RR) for children diagnosed in 1986--1989 compared with those diagnosed in 1978-1981.

Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study

BACKGROUND

Marked differences in population based survival across Europe were found for colorectal cancers diagnosed in 1985-1989.

AIMS

To understand the reasons for these differences in survival in a new analysis of colorectal cancers diagnosed between 1988 and 1991.

SUBJECTS

A total of 2720 patients with adenocarcinoma of the large bowel from 11 European cancer registries (CRs).

METHODS

We obtained information on stage at diagnosis, diagnostic determinants, and surgical treatment (not routinely collected by CRs) and analysed the data in relation to three year observed survival, calculating relative risks (RRs) of death and adjusting for age, sex, site, stage, and determinants of stage.

RESULTS

Three year observed survival rates ranged from 25% (Cracow) to 59% (Modena), and were low in the Thames area (UK) (38%). Survival rates between registries for "resected" patients varied less than those for all patients. When age, sex, and site were considered, RRs ranged from 0.7 (95% confidence intervals (CI) 0.6-0.9) (Modena) to 2.3 (95% CI 1.9-2.9) (Cracow). After further adjustment by stage, between registry RR variation was between 0.8 (95% CI 0.6-0.9) and 1.8 (95% CI 1.5-2.2). Inter-registry RR differences were slightly reduced when the determinants of stage (number of nodes examined and liver imaging) were included in the model. The reduction was marked for the UK registries.

CONCLUSIONS

The wide differences across Europe in colorectal cancer survival depend to a large extent on differences in stage at diagnosis. There are wide variations in diagnostic and surgical practices. There was a twofold range in the risk of death from colorectal cancer even after adjustment for surgery and disease stage.

Toward a comparison of survival in American and European cancer patients

BACKGROUND

Only recently have extensive population-based cancer survival data become available in Europe, providing an opportunity to compare survival in Europe and the United States.

METHODS

The authors considered 12 cancers: lung, breast, stomach, colon, rectum, melanoma, cervix uteri, corpus uteri, ovary, prostate, Hodgkin disease, and non-Hodgkin lymphoma. The authors analyzed 738,076 European and 282,398 U.S. patients, whose disease was diagnosed in 1985-1989, obtained from 41 EUROCARE cancer registries in 17 countries and 9 U.S. SEER registries. Relative survival was estimated to correct for competing causes of mortality.

RESULTS

Europeans had significantly lower survival rates than U.S. patients for most cancers. Differences in 5-year relative survival rates were higher for prostate (56% vs. 81%), skin melanoma (76% vs. 86%), colon (47% vs. 60%), rectum (43% vs. 57%), breast (73% vs. 82%), and corpus uteri (73% vs. 83%). Survival declined with increasing age at diagnosis for most cancers in both the U.S. and Europe but was more marked in Europe.

CONCLUSIONS

Survival for most major cancers was worse in Europe than the U.S. especially for older patients. Differences in data collection, analysis, and quality apparently had only marginal influences on survival rate differences. Further research is required to clarify the reasons for the survival rate differences.