How many deaths would be avoidable if socioeconomic inequalities in cancer survival in England were eliminated? A national population-based study, 1996-2006

AIM

Inequalities in survival between rich and poor have been reported for most adult cancers in England. This study aims to quantify the public health impact of these inequalities by estimating the number of cancer-related deaths that would be avoidable if all patients were to have the same cancer survival as the most affluent patients.

METHODS

National Cancer Registry data for all adults diagnosed with one of 21 common cancers in England were used to estimate relative survival. We estimated the number of excess (cancer-related) deaths that would be avoidable within three years after diagnosis if relative survival for patients in all deprivation groups was as high as the most affluent group.

RESULTS

For patients diagnosed during 2004-2006, 7122 of the 64,940 excess deaths a year (11%) would have been avoidable if three-year survival for all patients had been as high as in the most affluent group. The annual number of avoidable deaths fell from 8435 (13%) a year for patients diagnosed during 1996-2000. Over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups.

CONCLUSION

The downward trend in the annual number of avoidable deaths reflects more an improvement in survival in England overall, rather than a narrowing of the deficit in cancer survival between poor and rich. The lack of any substantial change in the percentage of avoidable excess deaths highlights the persistent nature of the deficit in survival between affluent and deprived groups.

Evidence against the proposition that "UK cancer survival statistics are misleading": simulation study with National Cancer Registry data

OBJECTIVES

To simulate each of two hypothesised errors in the National Cancer Registry (recording of the date of recurrence of cancer, instead of the date of diagnosis, for registrations initiated from a death certificate; long term survivors who are never notified to the registry), to estimate their possible effect on relative survival, and to establish whether lower survival in the UK might be due to one or both of these errors.

DESIGN

Simulation study.

SETTING

National Cancer Registry of England and Wales. Population Patients diagnosed as having breast (women), lung, or colorectal cancer during 1995-2007 in England and Wales, with follow-up to 31 December 2007.

MAIN OUTCOME MEASURE

Mean absolute percentage change in one year and five year relative survival associated with each simulated error.

RESULTS

To explain the differences in one year survival after breast cancer between England and Sweden, under the first hypothesis, date of diagnosis would have to have been incorrectly recorded by an average of more than a year for more than 70% of women known to be dead. Alternatively, under the second hypothesis, failure to register even 40% of long term survivors would explain less than half the difference in one year survival. Results were similar for lung and colorectal cancers.

CONCLUSIONS

Even implausibly extreme levels of the hypothesised errors in the cancer registry data could not explain the international differences in survival observed between the UK and other European countries.

Thirty-day postoperative mortality after colorectal cancer surgery in England

OBJECTIVES

To assess the variation in risk-adjusted 30-day postoperative mortality for patients with colorectal cancer between hospital trusts within the English NHS.

DESIGN

Retrospective cross-sectional population-based study of data extracted from the National Cancer Data Repository.

SETTING

All providers of major colorectal cancer surgery within the English NHS.

PARTICIPANTS

All 160,920 individuals who underwent major resection for colorectal cancer diagnosed between 1998 and 2006 in the English NHS. Main outcome measures National patterns of 30-day postoperative mortality were examined and logistic binary regression was used to study factors associated with death within 30 days of surgery. Funnel plots were used to show variation between trusts in risk-adjusted mortality.

RESULTS

Overall 30-day mortality was 6.7% but decreased over time from 6.8% in 1998 to 5.8% in 2006. The largest reduction in mortality was seen in 2005 and 2006. Postoperative mortality increased with age (15.0% (95% CI 14.1% to 15.9%) for those aged >80 years), comorbidity (24.2% (95% CI 22.0% to 26.5%) for those with a Charlson comorbidity score ≥ 3), stage of disease (9.9% (95% CI 9.3% to 10.6%) for patients with Dukes' D disease), socioeconomic deprivation (7.8% (95% CI 7.2% to 8.4%) for residents of the most deprived quintile) and operative urgency (14.9% (95% CI 14.2% to 15.7%) for patients undergoing emergency resection). Risk-adjusted control charts showed that one trust had consistently significantly better outcomes and three had significantly worse outcomes than the population mean.

CONCLUSIONS

Significant variation in 30-day postoperative mortality following major colorectal cancer surgery existed between NHS hospitals in England throughout the period 1998-2006. Understanding the underlying causes of this variation between surgical providers will make it possible to identify and spread best practice, improve outcomes and, ultimately, reduce 30-day postoperative mortality following colorectal cancer surgery.

Geographical variation in cancer survival in England, 1991-2006: an analysis by Cancer Network

Background

Reducing geographical inequalities in cancer survival in England was a key aim of the Calman–Hine Report (1995) and the NHS Cancer Plan (2000). This study assesses whether geographical inequalities changed following these policy developments by analysing the trend in 1-year relative survival in the 28 cancer networks of England.

Methods

Population-based age-standardised relative survival at 1 year is estimated for 1.4 million patients diagnosed with cancer of the oesophagus, stomach, colon, lung, breast (women) or cervix in England during 1991–2006 and followed up to 2007. Regional and deprivation-specific life tables are built to adjust survival estimates for differences in background mortality. Analysis is divided into three calendar periods: 1991–5, 1996–2000 and 2001–6. Funnel plots are used to assess geographical variation in survival over time.

Results

One-year relative survival improved for all cancers except cervical cancer. There was a wide geographical variation in survival with generally lower estimates in northern England. This north–south divide became less marked over time, although the overall number of cancer networks that were lower outliers compared with the England value remained stable. Breast cancer was the only cancer for which there was a marked reduction in geographical inequality in survival over time.

Conclusion

Policy changes over the past two decades coincided with improved relative survival, without an increase in geographical variation. The north–south divide in relative survival became less pronounced over time but geographical inequalities persist. The reduction in geographical inequality in breast cancer survival may be followed by a similar trend for other cancers, provided government recommendations are implemented similarly.

Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data

BACKGROUND

Cancer survival is a key measure of the effectiveness of health-care systems. Persistent regional and international differences in survival represent many avoidable deaths. Differences in survival have prompted or guided cancer control strategies. This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.

METHODS

Data from population-based cancer registries in 12 jurisdictions in six countries were provided for 2·4 million adults diagnosed with primary colorectal, lung, breast (women), or ovarian cancer during 1995-2007, with follow-up to Dec 31, 2007. Data quality control and analyses were done centrally with a common protocol, overseen by external experts. We estimated 1-year and 5-year relative survival, constructing 252 complete life tables to control for background mortality by age, sex, and calendar year. We report age-specific and age-standardised relative survival at 1 and 5 years, and 5-year survival conditional on survival to the first anniversary of diagnosis. We also examined incidence and mortality trends during 1985-2005.

FINDINGS

Relative survival improved during 1995-2007 for all four cancers in all jurisdictions. Survival was persistently higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark, England, Northern Ireland, and Wales, particularly in the first year after diagnosis and for patients aged 65 years and older. International differences narrowed at all ages for breast cancer, from about 9% to 5% at 1 year and from about 14% to 8% at 5 years, but less or not at all for the other cancers. For colorectal cancer, the international range narrowed only for patients aged 65 years and older, by 2-6% at 1 year and by 2-3% at 5 years.

INTERPRETATION

Up-to-date survival trends show increases but persistent differences between countries. Trends in cancer incidence and mortality are broadly consistent with these trends in survival. Data quality and changes in classification are not likely explanations. The patterns are consistent with later diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older.

FUNDING

Department of Health, England; and Cancer Research UK.

Does the timing of comorbidity affect colorectal cancer survival? A population based study

OBJECTIVES

Comorbid conditions in colorectal cancer patients can influence both clinical eligibility for treatment and survival. We aimed to evaluate the effect of comorbidity on 1 year survival from colorectal cancer, and to assess whether this effect varied with the timing of the comorbidity in relation to the cancer diagnosis.

STUDY DESIGN AND SETTING

A population based cohort of 29,563 colorectal cancer patients diagnosed between 1997 and 2004 in the North West of England was evaluated. The excess hazard of death up to 1 year after diagnosis was estimated using deprivation and region specific life tables to adjust for background mortality. Results were adjusted for age and stage at diagnosis.

RESULTS

Comorbid conditions diagnosed during the period 18 to 6 months before the diagnosis of colorectal cancer were strongly associated with lower survival at 1 year. Stage and age remained the strongest predictors of cancer related mortality even after adjustment for comorbidity.

CONCLUSIONS

Administrative data provide a good estimate of the prevalence of most comorbid conditions but may be biased for some comorbid conditions that can be contra-indicators for cancer treatment. The time window in which a comorbid condition occurs in relation to the cancer diagnosis should be taken into account. Adjustment should be carried out, where possible, to provide more robust and clinically appropriate comparisons of population based cancer patient survival.

Two countries divided by a common language: health systems in the UK and USA

Despite the historic significance of the healthcare reform bill that was passed into law by President Obama in March 2010, the debate still rages. The UK National Health Service (NHS) has featured prominently in the current American debate on healthcare reform, with critics calling attention to its perceived shortcomings. Some of these, such as the existence of 'death panels', can easily be dismissed, but others, such as the cancer survival deficit, cannot. This paper reviews the evidence on outcomes from cancer and other chronic non-communicable diseases, the two leading causes of death in both countries. The headline figures showing better cancer survival in the USA are exaggerated by methodological issues, but a gap remains, due in large part to better outcomes among older people. Outcomes among younger people with chronic disease are, however, much worse in the USA. Paradoxically, given the nature of the debate in the USA so far, those parts of the US health system that get the best results, such as the Veterans' Administration, or the elderly on Medicare, are those that most closely resemble the British NHS - but which are funded somewhat more generously.

Cancer mortality in ethnic South Asian migrants in England and Wales (1993-2003): patterns in the overall population and in first and subsequent generations

BACKGROUND

Cancer mortality has been examined among ethnic South Asian migrants in England and Wales, but not by generation of migration.

METHODS

Using South Asian mortality records, identified by a name-recognition algorithm, and census information, age-standardised rates among South Asians, and South Asian vs non-South Asian rate ratios, were calculated.

RESULTS AND CONCLUSIONS

All-cancer rates in ethnic South Asians were half of those in non-South Asians in first-generation (all-cancer-standardised mortality ratio (SMR) in males 0.51 and in females 0.56) and subsequent-generation South Asians (SMR in males 0.43 and in females 0.36). The higher mortality in first-generation South Asians for liver (both sexes), oral cavity and gallbladder cancer (females), particularly marked among Bangladeshis, was reduced in subsequent generations.

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

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

What if cancer survival in Britain were the same as in Europe: how many deaths are avoidable?

Objective:

To estimate the number of deaths among cancer patients diagnosed in Great Britain that would be avoidable within 5 years of diagnosis if the mean (or highest) survival in Europe for patients diagnosed during 1985–1989, 1990–1994 and 1995–1999 were achieved.

Design:

Five-year relative survival for cancers in Great Britain compared with that from other countries in the EUROCARE-2, -3 and -4 studies. Calculation of excess deaths (those more than expected from mortality in the general population) that would be avoidable among cancer patients in Britain if relative survival were the same as in Europe.

Setting:

Great Britain (England, Wales, Scotland) and 13 other European countries.

Subjects:

2.8 million adults diagnosed in Britain with 1 of 39 cancers during 1985–1989 (followed up to 1994), 1990–1994 (followed up to 1999) and 1995–1999 (followed up to 2003).

Main outcome measure:

Annual number of avoidable deaths within 5 years of diagnosis. Percentage of the excess (cancer-related) deaths among cancer patients that would be avoidable.

Results:

Compared with the mean European 5-year relative survival, the largest numbers of avoidable deaths for patients diagnosed during 1985–1989 were for cancers of the breast (about 18% of the excess mortality from this cancer, 7541 deaths), prostate (14%, 4285), colon (9%, 4090), stomach (8%, 3483) and lung (2%, 3548). For 1990–1994, the largest numbers of avoidable deaths were for cancers of the prostate (20%, 7335), breast (15%, 6165), colon (9%, 4376), stomach (9%, 3672), lung (2%, 3735) and kidney (22%, 2644). For 1995–1999, most of the avoidable deaths were for cancers of the prostate (17%, 5758), breast (15%, 5475), lung (3%, 4923), colon (10%, 4295), stomach (9%, 3137) and kidney (21%, 2686).

Overall, some 6600–7500 premature deaths would have been avoided each year among cancer patients diagnosed in Britain during 1985–1999 if the mean survival in Europe had been achieved. This represents 6–7% of cancer-related mortality. Compared with the highest European survival, avoidable premature mortality among cancer patients fell from about 12 800 deaths a year (12.2% of cancer-related mortality) to about 11 400 deaths a year (10.6%) over the same period.

A large component of the avoidable mortality is due to prostate cancer: excluding this cancer from comparison with the European mean survival reduces the annual number of avoidable deaths by 1000–1500, and the percentage of excess mortality by up to 1%. Compared with the highest survival, the annual number of avoidable deaths would be 1500–2000 fewer, and 1–2% lower as a percentage of excess mortality, but the overall trend in avoidable premature mortality among cancer patients would be similar, falling from 11.4% (1985–1989) to 10.3% (1990–1994) and 9.7% for those diagnosed during 1995–1999.

For several cancers, survival in Britain was slightly higher than the mean survival in Europe; this represented some 110–180 premature deaths avoided each year during the period 1985–2003.

Conclusions:

Avoidable premature mortality among cancer patients diagnosed in Britain during 1985–1999 has represented 6–7% of cancer-related mortality compared with the mean survival in Europe. Compared with the highest levels of survival in Europe, the reduction from 12.2% to 10.6% of cancer-related mortality reflects small but steady progress over the period 1985–2003.

Inequalities in cancer survival: Spearhead Primary Care Trusts are appropriate geographic units of analyses

BACKGROUND

Cancer survival in Spearhead Primary Care trusts (PCTs) is lower than in the rest of England for most common cancers, but differences are smaller than the more substantial survival gradients between deprived and affluent populations using small-area measures of deprivation. The way in which Spearhead PCTs were designated may give an unduly favourable image of inequalities in cancer survival.

METHODS

Five-year age-standardised relative survival for 10 common cancers was estimated separately for patients resident in Spearhead local authorities (LAs), Spearhead PCTs, and the rest of England. Differences in survival between Spearhead and other LAs and the corresponding differences between Spearhead and other PCTs were compared.

RESULTS

Cancer survival was consistently lower for patients resident in Spearhead areas than in the rest of England for the majority of cancers, regardless of the geographic unit used. Survival was lower in Spearhead LAs than Spearhead PCTs for 11 of the 16 cancer-sex combinations examined. As a consequence, the survival gap between the Spearhead areas and the rest of England was slightly wider when the definition of Spearhead was based on LAs rather than PCTs, but the two contrasts provide a very similar picture.

CONCLUSIONS

Small differences were found between using Spearhead LAs and Spearhead PCTs in the estimation of cancer survival, but results were inconsistent. Although the overlap between the two geographies is imperfect, Spearhead PCTs are appropriate geographic units for monitoring inequalities in cancer survival. However, given the instability of NHS geographical boundaries, Spearhead LAs could be a suitable alternative geographic unit.

Trends in cancer incidence and mortality

Time trends in cancer risk have often been summarised by the observation that mortality from cancers associated with tobacco is increasing rapidly, while mortality from all other cancers is either stable or falling slightly, this slight decline being dominated by the decrease in mortality from stomach cancer. Until recently, and with some variation between the sexes, this simple summary of cancer mortality trends would have been broadly correct for a number of developed countries, and it remains useful in dismissing claims of an impending and unexplained epidemic of cancer, but it does not apply to all countries, and in some there have recently been striking changes in the trends in mortality from cancers associated with tobacco. Cancer mortality has been widely accepted as the most important measure of progress against cancer, since it reflects the impact of cancer on people, and has been considered less subject to distortion than incidence or survival, although this is open to question. Cancer mortality also reflects trends in incidence and survival to a greater or lesser extent. There has been controversy, however, over how cancer mortality trends should be interpreted, as well as over which measures should be used to assess progress in cancer control. An overall summary of trends in mortality from all cancers combined is of limited value in assessing progress against cancer, in any case. Increases in a common lethal cancer may numerically dominate overall mortality trends, perhaps concealing declines in less common or less lethal cancers, while opposite trends in cancers of the lung and stomach, for example, might lead to an overall impression that little has changed. Further, up to a third of cancer patients will not die of cancer, and cancer mortality statistics do not reflect their experience at all. Cancer mortality trends only indirectly reflect trends in the number of people who are diagnosed with cancer in a given year, and those who do die of cancer in a given year may have been diagnosed more than 3 years previously, even though many die earlier: this blurs the responsiveness of routine cancer mortality statistics as a measure of recent progress, and alternative measures have been proposed. Trends in competing risks of death, especially at higher ages, may also complicate the interpretation of cancer mortality trends. The chance of developing cancer, and in that event, the chances of surviving it, are of direct interest to individuals.(ABSTRACT TRUNCATED AT 400 WORDS)

WldS can delay Wallerian degeneration in mice when interaction with valosin-containing protein is weakened

Axon degeneration is an early event in many neurodegenerative disorders. In some, the mechanism is related to injury-induced Wallerian degeneration, a proactive death program that can be strongly delayed by the neuroprotective slow Wallerian degeneration protein (Wld(S)) protein. Thus, it is important to understand the Wallerian degeneration mechanism and how Wld(S) blocks it. Wld(S) location is influenced by binding to valosin-containing protein (VCP), an essential protein for many cellular processes including membrane fusion and endoplasmic reticulum-associated degradation. In mice, the N-terminal 16 amino acids (N16), which mediate VCP binding, are essential for Wld(S) to protect axons, a role which another VCP binding sequence can substitute. In Drosophila, the Wld(S) phenotype is weakened by a similar N-terminal truncation and by knocking down the VCP homologue ter94. Neither null nor floxed VCP mice are viable so it is difficult to confirm the requirement for VCP binding in mammals in vivo. However, the hypothesis can be tested further by introducing a Wld(S) missense mutation, altering its affinity for VCP but minimizing the risk of disturbing other aspects of its structure or function. We introduced the R10A mutation, which weakens VCP binding in vitro, and expressed it in transgenic mice. R10AWld(S) fails to co-immunoprecipitate VCP from mouse brain, and only occasionally and faintly accumulates in nuclear foci for which VCP binding is necessary but not sufficient. Surprisingly however, axon protection remains robust and indistinguishable from that in spontaneous Wld(S) mice. We suggest that either N16 has an additional, VCP-independent function in mammals, or that the phenotype requires only weak VCP binding which may be driven forwards in vivo by the high VCP concentration.

Leukaemia survival trends in children with Down's syndrome in Great Britain, 1971-2000: a population-based study

BACKGROUND

Children with Down's syndrome (DS) who developed leukaemia have had a worse prognosis than other children with leukaemia in the past. In the 1970s and early 1980s, some children with DS who developed leukaemia received fewer cycles of chemotherapy or were advised not to have treatment.

METHODS

In this population-based study, trends in 5-year survival from leukaemia were evaluated for children with and without DS who were diagnosed in Great Britain during 1971-2000 and followed to the end of 2004.

RESULTS

For all children, with and without DS, survival has increased dramatically over the 30 year study period. For lymphoid leukaemia, survival in children with DS increased, but remains lower than for other children (5-year survival 59% vs 83% during 1996-2000). For acute non-lymphoblastic leukaemia (ANLL), however, 5-year survival improved substantially for children with DS, from less than 1% in the early 1970s to over 80% in the 1990s. For other children, survival increased from 6% to 64% during the same period.

CONCLUSION

Survival for all children diagnosed with leukaemia has improved during the last three decades. For lymphoid leukaemia, the inferior outcome observed on more recent treatment protocols in children with DS remains an area for concern. For ANLL, the improvement in survival for children with DS is due to a number of factors, namely increased recruitment of these children to clinical trials, changes in clinical practice and important differences in the biology of myeloid leukaemia in young children with DS, resulting in a better response to some chemotherapeutic agents.

Regional differences in population-based cancer survival between six prefectures in Japan: application of relative survival models with funnel plots

We used new methods to examine differences in population-based cancer survival between six prefectures in Japan, after adjustment for age and stage at diagnosis. We applied regression models for relative survival to data from population-based cancer registries covering each prefecture for patients diagnosed with stomach, lung, or breast cancer during 1993-1996. Funnel plots were used to display the excess hazard ratio (EHR) for each prefecture, defined as the excess hazard of death from each cancer within 5 years of diagnosis relative to the mean excess hazard (in excess of national background mortality by age and sex) in all six prefectures combined. The contribution of age and stage to the EHR in each prefecture was assessed from differences in deviance-based R(2) between the various models. No significant differences were seen between prefectures in 5-year survival from breast cancer. For cancers of the stomach and lung, EHR in Osaka prefecture were above the upper 95% control limits. For stomach cancer, the age- and stage-adjusted EHR in Osaka were 1.29 for men and 1.43 for women, compared with Fukui and Yamagata. Differences in the stage at diagnosis of stomach cancer appeared to explain most of this excess hazard (61.3% for men, 56.8% for women), whereas differences in age at diagnosis explained very little (0.8%, 1.3%). This approach offers the potential to quantify the impact of differences in stage at diagnosis on time trends and regional differences in cancer survival. It underlines the utility of population-based cancer registries for improving cancer control.

'Cure' from breast cancer among two populations of women followed for 23 years after diagnosis

BACKGROUND

Although survival from breast cancer has greatly improved over the past three decades, there is little consensus as to whether a population of women diagnosed with breast cancer can ever be considered 'cured' of the disease.

PATIENTS AND METHODS

We examined population 'cure' among women aged 15-99 years diagnosed with breast cancer from 1980 to 1995 in the West Midlands (England) and New South Wales (Australia). We calculated interval-specific excess mortality rates and fitted a number of statistical models to evaluate 'cure'.

RESULTS

There was little evidence that these women could ever be considered cured of the disease because excess mortality due to breast cancer was evident among young and middle-aged women up to 23 years after their diagnosis. Older women diagnosed in New South Wales displayed some evidence of 'cure'. However, this was estimated to occur only after the women's 75th birthday.

CONCLUSIONS

There is no strong evidence of the existence of a 'cured' subpopulation among young or middle-aged women diagnosed with breast cancer in either West Midlands or New South Wales during the period 1980-1995. Additional follow-up data would permit 'cure' to be assessed for women diagnosed more recently than 1995.

Large differences in patterns of breast cancer survival between Australia and England: a comparative study using cancer registry data

Survival from breast cancer in the UK is lower than in other countries in Western Europe, the USA and Australia. However, these international differences have not yet been examined in relation to tumor characteristics, treatment, screening history or other prognostic factors. We calculated relative survival by age, period of diagnosis, category of unemployment and extent of disease for women diagnosed with breast cancer during the period 1980-2002 in New South Wales (Australia) and West Midlands (England). National cancer registry data for each country for the period 1990-1994 were also examined. The excess hazard ratio was modeled as a function of prognostic covariables. Survival in Australia and New South Wales was higher than in England and West Midlands, respectively. In both regions, survival was lower for more deprived women and for the elderly. These differences were greater in West Midlands. Survival from localized and regional disease in New South Wales was higher than in West Midlands, but survival from metastatic disease was similar. Differences in breast cancer survival are unlikely to be entirely due to differences in data quality or to limitations of the analyses, although the measure of extent of disease used may not have been adequate to elucidate the effect of stage fully. One possible causal explanation is that the management of breast cancer differs between these regions. Further research should acquire better data on stage and investigate the effect of comorbidity and of patterns of care upon the difference in breast cancer survival between England and Australia.

Would compliance with cancer care standards improve survival for breast, colorectal and lung cancers?

OBJECTIVE

To investigate whether cancer service standards are associated with survival for breast, colorectal and lung cancers at population level.

METHODS

Standards of hospital cancer services in England, measured in 2001, were aggregated for 30 cancer networks covering populations of between 500 000 and 3 million people, and compared with 1-year and 5-year relative cancer survival for the incident period 1996-2001, using rank correlation.

RESULTS

Relative survival and the cancer standards each showed statistically significant differences across cancer networks. For tumour-specific services, the total score of 35 standards was associated with longer relative survival for both colorectal and lung cancers (p<0.05), but not breast cancer, while colorectal cancer survival was strongly (p<0.01) associated with the specific standard "written agreement describing referral guidelines", and lung cancer (p<0.05) with two other guideline standards. There were also associations of longer survival with two measures of nursing staff specialist qualifications. Compliance with general standards for cancer services was not associated with survival for breast cancer, and showed only borderline (p<0.1) associations for colo-rectal cancer, while some standards on medical and management lead staff were significantly associated (p<0.05) with poorer survival for lung cancer. Overall, compliance with standards for hospital pathology and radiology services also showed no associations with survival.

CONCLUSION

This study suggests that compliance with some clinical service standards, such as guidelines, could contribute to better survival at population level, while more general organisational aspects of cancer services may not directly improve survival.