Cure by age and stage at diagnosis for colorectal cancer patients in North West England, 1997-2004: a population-based study

Cure indicators and prevalence by stage at diagnosis for breast and colorectal cancer patients: A population-based study in Italy

People alive many years after breast (BC) or colorectal cancer (CRC) diagnoses are increasing. This paper aimed to estimate the indicators of cancer cure and complete prevalence for Italian patients with BC and CRC by stage and age. A total of 31 Italian Cancer Registries (47% of the population) data until 2017 were included. Mixture cure models allowed estimation of net survival (NS); cure fraction (CF); time to cure (TTC, 5-year conditional NS >95%); cure prevalence (who will not die of cancer); and already cured (prevalent patients living longer than TTC). 2.6% of all Italian women (806,410) were alive in 2018 after BC and 88% will not die of BC. For those diagnosed in 2010, CF was 73%, 99% when diagnosed at stage I, 81% at stage II, and 36% at stages III-IV. For all stages combined, TTC was >10 years under 45 and over 65 years and for women with advanced stages, but ≤1 year for all BC patients at stage I. The proportion of already cured prevalent BC women was 75% (94% at stage I). Prevalent CRC cases were 422,407 (0.7% of the Italian population), 90% will not die of CRC. For CRC patients, CF was 56%, 92% at stage I, 71% at stage II, and 35% at stages III-IV. TTC was ≤10 years for all age groups and stages. Already cured were 59% of all prevalent CRC patients (93% at stage I). Cancer cure indicators by stage may contribute to appropriate follow-up in the years after diagnosis, thus avoiding patients' discrimination.

Prognostic Factors for Post-Recurrence Survival in Stage II and III Colorectal Carcinoma Patients

Background and objectives: This study aimed to evaluate prognostic factors for post-recurrence survival in local and locally advanced colorectal cancer patients. Materials and Methods: A total of 273 patients with stage III and high-risk stage II colorectal cancer were prospectively enrolled. All patients underwent operative treatment of the primary tumor and adjuvant fluorouracil-based chemotherapy. Results: Over the three-year period (2008–2010), a cohort of 273 patients with stage III and high-risk stage II colorectal cancer had been screened. During follow up, 105 (38.5%) patients had disease recurrence. Survival rates 1-, 3- and 5-year after recurrence were 53.9, 18.2 and 6.5%, respectively, and the median post-recurrence survival time was 13 months. Survival analysis showed that age at diagnosis (p < 0.01), gender (p < 0.05), elevated postoperative Ca19-9 (p < 0.01), tumor histology (adenocarcinoma vs. mucinous vs. signet ring tumors, p < 0.01) and tumor stage (II vs. III, p < 0.05) had a significant influence on post-recurrence survival. Recurrence interval and metastatic site were not related to survival following recurrence. Multivariate analysis showed that older age (HR 2.43), mucinous tumors (HR 1.51) and tumors expressing Ca19-9 at baseline (HR 3.51) were independently associated with survival following recurrence. Conclusions: Baseline patient and tumor characteristics largely predicted patient outcomes after disease recurrence. Recurrence intervals in local and locally advanced colorectal cancer were not found to be prognostic factors for post-recurrence survival. Older age, male gender, stage III and mucinous histology were poor prognostic factors after the disease had recurred. Stage II patients had remarkable post-recurrence survival compared to stage III patients.

Characterisation of long-term cancer survivors and application of statistical cure models: a protocol for an observational follow-up study in patients with colorectal cancer

BACKGROUND

Improved colorectal cancer (CRC) survival rates have been reported over the last years, with more than half of these patients surviving more than 5 years after the initial diagnosis. Better understanding these so-called long-term survivors could be very useful to further improve their prognosis as well as to detect other problems that may cause a significant deterioration in their health-related quality of life (HRQoL). Cure models provide novel statistical tools to better estimate the long-term survival rate for cancer and to identify characteristics that are differentially associated with a short or long-term prognosis. The aim of this study will be to investigate the long-term prognosis of CRC patients, characterise long-term CRC survivors and their HRQoL, and demonstrate the utility of statistical cure models to analyse survival and other associated factors in these patients.

METHODS

This is a single-centre, ambispective, observational follow-up study in a cohort of n = 1945 patients with CRC diagnosed between 2006 and 2013. A HRQoL sub-study will be performed in the survivors of a subset of n = 485 CRC patients for which baseline HRQoL data from the time of their diagnosis is already available. Information obtained from interviews and the clinical records for each patient in the cohort is already available in a computerised database from previous studies. This data includes sociodemographic characteristics, family history of cancer, comorbidities, perceived symptoms, tumour characteristics at diagnosis, type of treatment, and diagnosis and treatment delay intervals. For the follow-up, information regarding local recurrences, development of metastases, new tumours, and mortality will be updated using hospital records. The HRQoL for long-term survivors will be assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires. An analysis of global and specific survival (competitive risk models) will be performed. Relative survival will be estimated and mixture cure models will be applied. Finally, HRQoL will be analysed through multivariate regression models.

DISCUSSION

We expect the results from this study to help us to more accurately determine the long-term survival of CRC, identify the needs and clinical situation of long-term CRC survivors, and could be used to propose new models of care for the follow-up of CRC patients.

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.

Population-level cure of colorectal cancer in Malta: An analysis of patients diagnosed between 1995 and 2004

AIM

The aim of this study was to estimate the population-level 'cure' of Maltese colorectal cancer patients diagnosed between 1995 and 2004, and to estimate the median survival time for the 'uncured' patients.

METHODS AND STUDY POPULATION

Analysis was conducted on 1470 cases registered by the Malta National Cancer Register between 1995 and 2004 and followed up to end of 2010. The mean age of the patients was 66.4 (95%CI 65.8-67.1), and the number of men and women were equal. Background mortality for 1995-2010 was extracted from publicly available life tables. A mixture model with Weibull survival distribution and identity link was used to model 'cure'.

RESULTS

The overall 'cured' proportion for the patients diagnosed in 1995-1999 was 45.3% (95%CI 40.2-50.5) while the 'cured' proportion for the patients diagnosed in 2000-2004 was 52.3% (95%CI 47.2-57.5). Median survival time for the 'uncured' patients increased in the second calendar period from 1.25 years (95%CI 1.04-1.45) to 1.42 years (95%CI 1.15-1.76).

CONCLUSION

In Malta, as in the rest of Europe, improvements have been made in short- and long-term survival over the 15-year period under study. To continue this improvement, differences by age that still persist must be investigated and efforts focused to reduce any gaps between Malta and other European countries.

Colorectal cancer survival by stage of cases diagnosed in Mallorca, Spain, between 2006 and 2011 and factors associated with survival

OBJECTIVES

To establish cause-specific survival by stage of colorectal cancer up to 8 years from diagnosis, and to identify factors which explain and predict the likelihood of survival.

METHODOLOGY

Retrospective follow-up study of people diagnosed with invasive colorectal cancer during 2006-2011, identified through the Mallorca Cancer Registry. DCO and lymphomas were excluded. Sex, age, diagnostic method, site, histology, T, N, M, and stage, date of diagnosis, date of follow-up or death, and cause of death were collected. End point of follow-up was 31st December 2013. Multiple imputation (MI) method was performed to obtain stage when unknown. Actuarial and Kaplan-Meier methods were used for survival analysis. Extended Cox models were built to identify factors that explain and predict survival.

RESULTS

2889 cases were identified, 41.7% in women and 58.3% in men, with a mean age of 70.5 years. Unknown stage represented 15.3% of cases. After MI, 15% were in stage I, 26.7% were in II, 32.7% in III, and 25.6% in IV. Survival was 56% at the end of the 5th year. Survival by stage changed significantly after MI and was estimated to 83% at stage I, 73% at II, 62% at III, and 16% at IV. Extended Cox model showed that survival worsened with age, mucinous histology, and stage. Risk of dying was 17.0 times higher in stage IV compared to stage I, 3.7 times in stage III, and 1.6 times in stage II.

CONCLUSIONS

More than half of colorectal cancer patients will survive 5 years after diagnosis, but only if diagnosed in stages I-III.

Colorectal cancer in young patients: is it a distinct clinical entity?

BACKGROUND

The incidence of colorectal cancer in young patients is increasing. It remains unclear if the disease has unique features in this age group.

METHODS

This was a single-center, retrospective cohort study which included patients diagnosed with colorectal cancer at age ≤40 years in 1997-2013 matched 1:2 by year of diagnosis with consecutive colorectal cancer patients diagnosed at age >50 years during the same period. Patients aged 41-50 years were not included in the study, to accentuate potential age-related differences. Clinicopathological characteristics, treatment, and outcome were compared between groups.

RESULTS

The cohort included 330 patients, followed for a median time of 65.9 months (range 4.7-211). Several significant differences were noted. The younger group had a different ethnic composition. They had higher rates of family history of colorectal cancer (p = 0.003), hereditary colorectal cancer syndromes (p < 0.0001), and inflammatory bowel disease (p = 0.007), and a lower rate of polyps (p < 0.0001). They were more likely to present with stage III or IV disease (p = 0.001), angiolymphatic invasion, signet cell ring adenocarcinoma, and rectal tumors (p = 0.02). Younger patients more frequently received treatment. Young patients had a worse estimated 5-year disease-free survival rate (57.6  vs. 70 %, p = 0.039), but this did not retain significance when analyzed by stage (p = 0.092). Estimated 5-year overall survival rates were 59.1 and 62.1 % in the younger and the control group, respectively (p = 0.565).

CONCLUSIONS

Colorectal cancer among young patients may constitute a distinct clinical entity. Further research is needed to validate our findings and define the optimal approach in this population.

Impact of age and comorbidity on survival in colorectal cancer

BACKGROUND

Patients with colorectal cancer are often excluded from clinical trials based on age or a poor performance score. However, 70% of colorectal cancer is diagnosed in patients over 65. Evaluation on the influence of age and comorbidity on survival and cause of death in a non-selected population.

METHODS

Included were 621 consecutive patients with colorectal cancer. An extensive chart review was performed for 392 patients with colon cancer and 143 patients with rectal cancer. Analyses were performed separately for both groups.

RESULTS

Median survival of colon cancer patients was 5.13 years, 131 patients (34.3%) died from tumour progression. Age and comorbidity were significant predictors for overall survival (P<0.001). Age was also a significant predictor of cause of death (P=0.001). In rectal cancer patients median survival was 4.67 years, 51 (35.7%) of patients died from tumour progression. Neither age nor comorbidity was significant predictors of survival. Age was a significant predictor of cause of death (P<0.001).

CONCLUSIONS

In colon cancer patient age and comorbidity predict survival. This represents possible bias or a reduced survival benefit of treatment, and is an indication that colon cancer is not the prognosis defining illness in the majority of patients. In rectal cancer patients neither age or comorbidity significantly impacted survival.

Current estimates of the cure fraction: a feasibility study of statistical cure for breast and colorectal cancer

BACKGROUND

The probability of cure is a long-term prognostic measure of cancer survival. Estimates of the cure fraction, the proportion of patients "cured" of the disease, are based on extrapolating survival models beyond the range of data. The objective of this work is to evaluate the sensitivity of cure fraction estimates to model choice and study design.

METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER)-9 registries to construct a cohort of breast and colorectal cancer patients diagnosed from 1975 to 1985. In a sensitivity analysis, cure fraction estimates are compared from different study designs with short- and long-term follow-up. Methods tested include: cause-specific and relative survival, parametric mixture, and flexible models. In a separate analysis, estimates are projected for 2008 diagnoses using study designs including the full cohort (1975-2008 diagnoses) and restricted to recent diagnoses (1998-2008) with follow-up to 2009.

RESULTS

We show that flexible models often provide higher estimates of the cure fraction compared to parametric mixture models. Log normal models generate lower estimates than Weibull parametric models. In general, 12 years is enough follow-up time to estimate the cure fraction for regional and distant stage colorectal cancer but not for breast cancer. 2008 colorectal cure projections show a 15% increase in the cure fraction since 1985.

DISCUSSION

Estimates of the cure fraction are model and study design dependent. It is best to compare results from multiple models and examine model fit to determine the reliability of the estimate. Early-stage cancers are sensitive to survival type and follow-up time because of their longer survival. More flexible models are susceptible to slight fluctuations in the shape of the survival curve which can influence the stability of the estimate; however, stability may be improved by lengthening follow-up and restricting the cohort to reduce heterogeneity in the data.

Is there a subgroup of long-term evolution among patients with advanced lung cancer?: hints from the analysis of survival curves from cancer registry data

BACKGROUND

Recently, with the access of low toxicity biological and targeted therapies, evidence of the existence of a long-term survival subpopulation of cancer patients is appearing. We have studied an unselected population with advanced lung cancer to look for evidence of multimodality in survival distribution, and estimate the proportion of long-term survivors.

METHODS

We used survival data of 4944 patients with non-small-cell lung cancer (NSCLC) stages IIIb-IV at diagnostic, registered in the National Cancer Registry of Cuba (NCRC) between January 1998 and December 2006. We fitted one-component survival model and two-component mixture models to identify short- and long- term survivors. Bayesian information criterion was used for model selection.

RESULTS

For all of the selected parametric distributions the two components model presented the best fit. The population with short-term survival (almost 4 months median survival) represented 64% of patients. The population of long-term survival included 35% of patients, and showed a median survival around 12 months. None of the patients of short-term survival was still alive at month 24, while 10% of the patients of long-term survival died afterwards.

CONCLUSIONS

There is a subgroup showing long-term evolution among patients with advanced lung cancer. As survival rates continue to improve with the new generation of therapies, prognostic models considering short- and long-term survival subpopulations should be considered in clinical research.

Use of the Word "Cure" in the Oncology Literature

PURPOSE

"Cure" is an important word in oncology but its use in the published literature has not been examined. I investigated all oncology articles using cure in the title field and published in 2012. The definition of cure was examined, specifically whether or not authors use the word to connote some surviving subset of patients who go on to experience outcomes similar to age-matched, normal controls-a definition favored by researchers and employed in survival function analyses.

METHODS

All articles published between January 1, 2012, and December 31, 2012, with the word cure in the title field were retrieved from Thompson Reuters' Web of Science. After exclusions, articles were read in full to examine what definitions of cure was used. Additionally, for each situation (type of cancer, stage/grade) where the word cure was used, a literature search was performed to ascertain whether there existed documented cases of cure.

RESULTS

Twenty-nine oncology articles used the word cure in their title in 2012. Nearly half, 14 (48%) of 29, used the term in situations (cancer type, stage/grade) currently considered incurable. Approximately one-third (34.5%) of the articles used the word consistent with the definition that, after a set period of time, some surviving subset of patients experience survival similar to normal controls.

CONCLUSION

There is heterogeneity in the use of the word cure in the literature.

Deprivation and access to treatment for colorectal cancer in Southeast Scotland 2003-2009

AIM

Socioeconomic deprivation is associated with poorer survival from colorectal cancer. We examined the association of deprivation with access to treatment, disease stage at presentation and choice of treatment for colorectal cancer within a regional managed clinical network.

METHOD

We performed a retrospective analysis of data from the Southeast Scotland Cancer Network colorectal database for the period 2003-2009. Socioeconomic status was assigned into five categories using postcode of residence and the Scottish Index of Multiple Deprivation score. Outcomes were access to consultation and treatment, stage of disease at presentation and treatment factors (type of surgery, adjuvant radiotherapy and adjuvant chemotherapy).

RESULTS

Of 4960 colorectal cancer patients, 4016 patients (81%) underwent operative treatment. Deprivation was not associated with age, gender, tumour site, disease stage, delay in treatment pathway or permanent stoma rate. Primary tumour resection (P = 0.006) and chemotherapy treatment (P = 0.018) were higher in the least deprived compared with the most deprived quintile. Socioeconomic status was associated with both primary tumour resection [odds ratio for the most affluent compared with the most deprived quintiles (OR) 1.34, 95% confidence interval (CI) 1.05-1.72, P = 0.018] and chemotherapy treatment (OR 1.44, 95% CI 1.15-1.80, P = 0.001). However, when health board of treatment was added to the model, only chemotherapy treatment was independently associated with deprivation (OR 1.46, 95% CI 1.16-1.83, P = 0.001).

CONCLUSION

Deprivation is not associated with treatment delay or more advanced disease stage at presentation. An apparent association between deprivation and treatment choice may be explained by other differences between patients treated in different areas.