EUROCOURSE lessons learned from and for population-based cancer registries in Europe and their programme owners: Improving performance by research programming for public health and clinical evaluation

Melanoma epidemiology in Europe: what is new?

Every year in Europe over 150,000 new cases of melanoma are reported and over 25,000 lives are lost to this tumor. Incidence has been rising rapidly, faster than for any other cancer, and it is expected to continue to do so in most regions. Mortality also crept up, decades-long, with only few very recent exceptions. Thus, melanoma remains a public health problem that will not go away soon, nor easy. Some notable progress has been made in the last decade in the fight against this tumor. Registration and reporting for skin cancers improved across Europe. Incidence trends have begun to plateau or even to descend in younger age groups, in some countries, and there are encouraging signs that mortality might do the same, after the recent therapeutic breakthroughs. Survival rates are on average above 80% at 5 years for European patients, while diagnosis trends toward ever thinner tumors. Yet this progress is far from uniform across the continent, with many Southern-and Eastern European countries still struggling with sub-optimal cancer reporting, delayed access to innovative treatments, late detection and insufficient healthcare funding, that push survival rates down to harrowing 50%. This article aims to give an updated overview of the epidemiological situation of melanoma in Europe, highlighting the progress but also the persisting disparities in tumor burden, prognosis and access to quality cancer care and surveillance between European countries, as a reminder that relentless efforts must continue in order to tackle this aggressive tumor in an effective and equitable manner.

Differences in the incidence and mortality of digestive cancer between Global Cancer Observatory 2020 and Global Burden of Disease 2019

The burden of digestive cancers is increasing worldwide. The Global Cancer Observatory (GLOBOCAN) 2020 and the Global Burden of Disease (GBD) 2019 are two primary cancer databases, which have a significant impact on policy formulation and resource allocation. We aim to compare the incidence and mortality of digestive cancers between them. Digestive cancer (esophageal, stomach, colorectal, liver, gallbladder and pancreatic cancer) incidence was obtained from the Cancer Today and GBD 2019 result tool. The top five countries with the most or minor difference between GLOBOCAN 2020 and GBD 2019 in age-standardized incidence rates (ASIRs) of digestive cancers were identified. A systematic search on the incidence of specific digestive cancer in selected countries from PubMed and Embase was conducted, and 20 of 281 publications were included. The most significant differences in digestive cancers incidence were commonly found in Asian countries (70%), particularly Indonesia, Vietnam and Myanmar, located in Southeast Asia. The ASIRs for most digestive cancers, except liver cancer, in GLOBOCAN 2020 were higher than those in GBD 2019. Gallbladder cancer had the highest average ratio, followed by liver cancer. The most commonly used standard population was Segi's standard population, followed by the World Health Organization standard population. The data sources nor the processing methods of GLOBOCAN 2020 and GBD 2019 were not similar. Low- and middle-income countries without population-based cancer registries were more likely to have selection bias in data collection and amplify regional variations of etiological factors. Better judgments on the quality of cancer data can be made.

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.

Expanding the Secondary Use of Prostate Cancer Real World Data: Automated Classifiers for Clinical and Pathological Stage

Background

Explicit documentation of stage is an endorsed quality metric by the National Quality Forum. Clinical and pathological cancer staging is inconsistently recorded within clinical narratives but can be derived from text in the Electronic Health Record (EHR). To address this need, we developed a Natural Language Processing (NLP) solution for extraction of clinical and pathological TNM stages from the clinical notes in prostate cancer patients.

Methods

Data for patients diagnosed with prostate cancer between 2010 and 2018 were collected from a tertiary care academic healthcare system's EHR records in the United States. This system is linked to the California Cancer Registry, and contains data on diagnosis, histology, cancer stage, treatment and outcomes. A randomly selected sample of patients were manually annotated for stage to establish the ground truth for training and validating the NLP methods. For each patient, a vector representation of clinical text (written in English) was used to train a machine learning model alongside a rule-based model and compared with the ground truth.

Results

A total of 5,461 prostate cancer patients were identified in the clinical data warehouse and over 30% were missing stage information. Thirty-three to thirty-six percent of patients were missing a clinical stage and the models accurately imputed the stage in 21-32% of cases. Twenty-one percent had a missing pathological stage and using NLP 71% of missing T stages and 56% of missing N stages were imputed. For both clinical and pathological T and N stages, the rule-based NLP approach out-performed the ML approach with a minimum F1 score of 0.71 and 0.40, respectively. For clinical M stage the ML approach out-performed the rule-based model with a minimum F1 score of 0.79 and 0.88, respectively.

Conclusions

We developed an NLP pipeline to successfully extract clinical and pathological staging information from clinical narratives. Our results can serve as a proof of concept for using NLP to augment clinical and pathological stage reporting in cancer registries and EHRs to enhance the secondary use of these data.

Trends in Breast Cancer Mortality Between 2001 and 2017: An Observational Study in the European Union and the United Kingdom

PURPOSE

Breast cancer is the most common cancer in women worldwide, representing 25.4% of the newly diagnosed cases in 2018. The past two decades have seen advancements in screening technologies, guidelines, and newer modalities of treatment. Our study reports and compares trends in breast cancer mortality in the European Union and the United Kingdom.

MATERIALS AND METHODS

We used the WHO Mortality Database. We extracted breast cancer mortality data from 2001 to 2017 on the basis of the International Classification of Diseases, 10th revision system. Crude mortality rates were dichotomized by sex and reported by year. We computed age-standardized death rates (ASDRs) per 100,000 population using the world standard population. Breast cancer mortality trends were compared using joinpoint regression analysis.

RESULTS

We analyzed data from 24 EU countries, including the United Kingdom. For women, breast cancer mortality was observed to be downtrending in all countries except Croatia, France, and Poland. For the most recent female data, the highest ASDR for breast cancer was identified in Croatia (19.29 per 100,000), and the lowest ASDR was noted in Spain (12.8 per 100,000). Denmark had the highest change in ASDR and the highest estimated annual percentage change of -3.2%. For men, breast cancer mortality decreased in 18 countries, with the largest relative reduction observed in Denmark with an estimated annual percentage change of -27.5%. For the most recent male data, the highest ASDR for breast cancer was identified in Latvia (0.54 per 100,000).

CONCLUSION

Breast cancer mortality rates have down trended in most EU countries between 2001 and 2017 for both men and women. Given the observational nature of this study, causality to the observed trends cannot be reliably ascribed. However, possible contributing factors should be considered and subject to further study.

The European cancer burden in 2020: Incidence and mortality estimates for 40 countries and 25 major cancers

INTRODUCTION

Europe is an important focus for compiling accurate and up-to-date world cancer statistics owing to its large share of the world's total cancer burden. This article presents incidence and mortality estimates for 25 major cancers across 40 individual countries within European areas and the European Union (EU-27) for the year 2020.

METHODS

The estimated national incidence and mortality rates are based on statistical methodology previously applied and verified using the most recently collected incidence data from 151 population-based cancer registries, mortality data and 2020 population estimates.

RESULTS

Estimates reveal 4 million new cases of cancer (excluding non-melanoma skin cancer) and 1.9 million cancer-related deaths. The most common cancers are: breast in women (530,000 cases), colorectum (520,000), lung (480,000) and prostate (470,000). These four cancers account for half the overall cancer burden in Europe. The most common causes of cancer deaths are: lung (380,000), colorectal (250,000), breast (140,000) and pancreatic (130,000) cancers. In EU-27, the estimated new cancer cases are approximately 1.4 million in males and 1.2 million in females, with over 710,000 estimated cancer deaths in males and 560,000 in females.

CONCLUSION

The 2020 estimates provide a basis for establishing priorities in cancer-control measures across Europe. The long-established role of cancer registries in cancer surveillance and the evaluation of cancer control measures remain fundamental in formulating and adapting national cancer plans and pan-European health policies. Given the estimates are built on recorded data prior to the onset of coronavirus disease 2019 (COVID-19), they do not take into account the impact of the pandemic.

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.

Rapid health data repository allocation using predictive machine learning

Health-related data is stored in a number of repositories that are managed and controlled by different entities. For instance, Electronic Health Records are usually administered by governments. Electronic Medical Records are typically controlled by health care providers, whereas Personal Health Records are managed directly by patients. Recently, Blockchain-based health record systems largely regulated by technology have emerged as another type of repository. Repositories for storing health data differ from one another based on cost, level of security and quality of performance. Not only has the type of repositories increased in recent years, but the quantum of health data to be stored has increased. For instance, the advent of wearable sensors that capture physiological signs has resulted in an exponential growth in digital health data. The increase in the types of repository and amount of data has driven a need for intelligent processes to select appropriate repositories as data is collected. However, the storage allocation decision is complex and nuanced. The challenges are exacerbated when health data are continuously streamed, as is the case with wearable sensors. Although patients are not always solely responsible for determining which repository should be used, they typically have some input into this decision. Patients can be expected to have idiosyncratic preferences regarding storage decisions depending on their unique contexts. In this paper, we propose a predictive model for the storage of health data that can meet patient needs and make storage decisions rapidly, in real-time, even with data streaming from wearable sensors. The model is built with a machine learning classifier that learns the mapping between characteristics of health data and features of storage repositories from a training set generated synthetically from correlations evident from small samples of experts. Results from the evaluation demonstrate the viability of the machine learning technique used.

Use of cancer data for cancer control in the Eastern Mediterranean Region: Results of a survey among population-based cancer registries

Data from population-based cancer registries (PBCR) are critical for planning, monitoring and evaluation of cancer control programs, but are frequently underutilized by key stakeholders. As part of the ongoing partnership of the International Agency for Research on Cancer (IARC) and the WHO Eastern Mediterranean Regional Office (EMRO) in cancer surveillance, we designed a cancer registry survey to assess the level of involvement of PBCR in national cancer control planning across the region. A questionnaire on registry characteristics, their contribution to cancer control and perceived barriers, was sent to 14 countries with operational PBCR. We obtained replies from Bahrain, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Qatar, Saudi Arabia, Tunisia and the United Arab Emirates. We found a high participation of PBCR in cancer control planning (all registries involved, 46% routinely) and the evaluation of screening (92% registries involved, 46% routinely), but a much lower level of participation in palliative care and rehabilitation activities. Specified barriers included poor governance, a lack of awareness by policy makers, insufficient resources and a limited availability of data electronically, including mortality data. Appropriate planning to ensure the sustainability of PBCR (including the employment of permanent staff), increasing training, building research capacity and ensuring an efficient provision of high-quality data to policymakers, were among the proposed solutions. The results of our study reinforce the need for further tailoring of activities in support of cancer registration and enhanced networking among stakeholders, toward improving quality and use of cancer registry data for cancer control in the EMR.

Melanoma Epidemiology and Early Detection in Europe: Diversity and Disparities

Melanoma claims annually more than 20,000 lives in Europe and is an important public health burden through its continuously increasing incidence and with its high mortality, costs, and complexity of care in advanced stages. Epidemiological surveillance is indispensable for the research into its causes, new prognostic markers, and innovative therapies, as well as for the building of efficient cancer control plans. However, important differences in the sources and availability of accurate epidemiological data exist among European countries and regions, contributing to a heterogeneous picture with 20-fold differences in the reported national melanoma incidence rates, divergent mortality trends, and solid disparities in survival across the Continent. Countries in the eastern half of Europe report the lowest incidence rates, but high case fatality, persisting and increasing mortality, a higher proportion of thicker tumors and late diagnosis, and lower survival rates. They are the least well equipped with quality cancer registration and reporting, and they lag behind in efficient cancer control plans implementation. This review highlights the main differences in melanoma epidemiology across Europe, together with an insight into their underlying causes in the areas of melanoma registration, early diagnosis, and prevention. These differences should be acknowledged and understood by physicians, researchers, and all stakeholders involved in improving melanoma care and outcomes, as no one-size-fits-all solution can tackle the melanoma problem in Europe. Instead, there is a need for nuanced strategies, adapted to the heterogeneous national and regional contexts, that would build on European diversity to eliminate the outcome disparities.

The fall and rise of cancer registration in Estonia: The dangers of overzealous application of data protection

BACKGROUND

The population-based Estonian Cancer Registry (ECR) has maintained a database of cancer cases since 1968. Between 2001 and 2007 the ECR was prohibited from linking cancer records to death certificates. In January 2008, the prohibition was lifted, and two years later the ECR was able to begin tracing back unmatched deaths. This paper estimates the effect of the linkage ban on reported cancer incidence and survival.

METHODS

Incident cancers in 2001-2007 were extracted from the ECR database in May 2018 to allow for late registrations. Two datasets were created: one with all incident cases and another without death-certificate-initiated (DCI) cases. Using both datasets, age-standardised incidence rates (ASIR) and their ratios; age-standardised five-year relative survival ratios (ARSR) and excess mortality rate ratios were calculated.

RESULTS

In 2001-2007, 46,535 incident cancers were registered in the ECR. Of them, 2299 (4.9 %) were DCI cases. The inclusion of DCI cases increased the ASIR for overall cancer by 6 % in men and 3 % in women. An increase ≥10 % in ASIR for lung, liver and pancreatic cancer was observed. The effect of accrued DCI cases to the ARSR was minor. Excess mortality in the dataset without DCI cases was 4 % underestimated in men and 3 % in women.

CONCLUSION

Biases in cancer incidence and survival measures generated by the temporary record linkage ban were largely correctable by using trace-back procedures when this became possible. Nevertheless, this type of ban and the arguments put forward to justify it, harm disease registration and register-based research.

Current status of site-specific cancer registry system for the clinical researches: aiming for future contribution by the assessment of present medical care

BACKGROUND

The current status of site-specific cancer registry has not been elucidated, but sufficient system is found in some societies. The purpose of this study was to clear the present condition of site-specific cancer registries in Japan and to suggest for the improvement.

METHODS

The questionnaire was conducted by the study group of the Ministry of Health, Labor, and Welfare. It consisted of 38 questions, conflicts of interest, clinical research method, informed consent and funding for registry. We distributed this questionnaire to 28 academic societies, which had published the clinical practice guideline(s) assessed under Medical Information Network Distribution Service (MINDS).

RESULTS

The concept of the importance in assessment for medical quality by the data of the site-specific cancer registry was in good consensus. But the number of the society with the mature registry was limited. The whole-year registry with the scientific researches in the National Clinical Database (NCD) and in the Translational Research Informatics Center (TRI) might seem to be in success, because assured enhancement may be estimated. Now, academic societies have the structural factors, i.e., the financial limitation in the registry maintenance and the data analysis, and in the difficulty of employment of the researchers with skill and talent.

CONCLUSIONS

To manage the site-specific cancer registry effectively, the scientific registry system will be essentially important. Each academic society had much experienced highly qualified clinical researches in past. Accordingly, the scientific suggestion and co-operation should be of great importance for the improvement.

Key indicators of organized cancer screening programs: Results from a Delphi study

Objective

To maximize benefits and reduce potential harms of organized cancer screening programs in Europe, monitoring, quality assurance, and evaluation of long-term impact are required. We aimed to identify the most important indicators to be collected and reported. The study was designed to establish a consensus within a European-level working group and suggest a manageable list of key indicators.

Methods

We conducted a Delphi study among policymakers, researchers, and program coordinators who were experts in breast, cervical, or colorectal cancer screening. Study participants evaluated the importance of screening indicators on a 5-point Likert scale.

Results

The top 10 indicators by study participants were interval cancer rate, detection rate, screening attendance, screening coverage, cancer incidence, cause-specific mortality, proportion of persons attending further assessment after a positive screen test result, proportion of persons attending a treatment after diagnosis, invitation coverage, and distribution of cancers by mode of detection. Performance indicators were generally considered more important than outcome indicators. Subgroup analyses by cancer types showed similar results, and only cervical cancer screening experts had slightly different preferences. Subgroup analyses by experts’ roles indicated that policymakers found different indicators important compared with researchers or program coordinators, probably because of their different point of view on screening.

Conclusion

The implication of our priority ranking is twofold: it serves as an initial guidance for countries that have not yet established a system to collect data, and as a checklist for those where data collection is already established, to assess the comprehensiveness of their system.

Low proportion of unreported cervical treatments in the cancer registry of Norway between 1998 and 2013

BACKGROUND

Accurate information about treatment is needed to evaluate cervical cancer prevention efforts. We studied completeness and validity of reporting cervical treatments in the Cancer Registry of Norway (CRN).

MATERIAL AND METHODS

We identified 47,423 (92%) high-grade cervical dysplasia patients with and 3983 (8%) without recorded treatment in the CRN in 1998-2013. We linked the latter group to the nationwide registry of hospital discharges in 1998-2015. Of patients still without treatment records, we randomly selected 375 for review of their medical history. Factors predicting incomplete treatment records were assessed by multiple imputation and logistic regression.

RESULTS

Registry linkage revealed that 10% (401/3983) of patients received treatment, usually conization, within one year of their initial high-grade dysplasia diagnosis. Of those, 11% (n = 44) were missing due to unreporting and 89% (n = 357) due to misclassification at the CRN. Of all cases in medical review, patients under active surveillance contributed almost 60% (223/375). Other reasons of being without recorded treatment were uncertain dysplasia diagnosis, invasive cancer or death. Coding error occurred in 19% (73/375) of randomly selected cases. CRN undercounted receipt of treatment by 38% (n = 1526) among patients without recorded treatment which translates into 97% overall completeness of treatment data. Incomplete treatment records were particularly associated with public laboratories, patients aged 40-54 years, and the latest study years.

CONCLUSIONS

CRN holds accurate information on cervical treatments. Completeness and particularly validity can be further improved through the establishment of new internal routines and regular linkage to hospital discharges.

Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018

INTRODUCTION

Europe contains 9% of the world population but has a 25% share of the global cancer burden. Up-to-date cancer statistics in Europe are key to cancer planning. Cancer incidence and mortality estimates for 25 major cancers are presented for the 40 countries in the four United Nations-defined areas of Europe and for Europe and the European Union (EU-28) for 2018.

METHODS

Estimates of national incidence and mortality rates for 2018 were based on statistical models applied to the most recently published data, with predictions obtained from recent trends, where possible. The estimated rates in 2018 were applied to the 2018 population estimates to obtain the estimated numbers of new cancer cases and deaths in Europe in 2018.

RESULTS

There were an estimated 3.91 million new cases of cancer (excluding non-melanoma skin cancer) and 1.93 million deaths from cancer in Europe in 2018. The most common cancer sites were cancers of the female breast (523,000 cases), followed by colorectal (500,000), lung (470,000) and prostate cancer (450,000). These four cancers represent half of the overall burden of cancer in Europe. The most common causes of death from cancer were cancers of the lung (388,000 deaths), colorectal (243,000), breast (138,000) and pancreatic cancer (128,000). In the EU-28, the estimated number of new cases of cancer was approximately 1.6 million in males and 1.4 million in females, with 790,000 men and 620,000 women dying from the disease in the same year.

CONCLUSION

The present estimates of the cancer burden in Europe alongside a description of the profiles of common cancers at the national and regional level provide a basis for establishing priorities for cancer control actions across Europe. The estimates presented here are based on the recorded data from 145 population-based cancer registries in Europe. Their long established role in planning and evaluating national cancer plans on the continent should not be undervalued.

Observational health research in Europe: understanding the General Data Protection Regulation and underlying debate

Insights into the incidence and survival of cancer, the influence of lifestyle and environmental factors and the interaction of treatment regimens with outcomes are hugely dependent on observational research, patient data derived from the healthcare system and from volunteers participating in cohort studies, often non-selective. Since 25th May 2018, the European General Data Protection Regulation (GDPR) applies to such data. The GDPR focusses on more individual control for data subjects of 'their' data. Yet, the GDPR was preceded by a long debate. The research community participated actively in that debate, and as a result, the GDPR has research exemptions as well. Some of those apply directly; other exemptions need to be implemented into national law. Those exemptions will be discussed together with a general outline of the GDPR. I propose a substantive definition of research-absent in the GDPR-which can warrant its special status in the GDPR. The debate is not over yet. Most legal texts exhibit ambiguity and are interpreted against a background of values. In this case, those could be subsumed under informational self-determination versus solidarity and the deeper meaning of autonomy. Values will also guide national implementation and their interpretation. The value of individual control or informational self-determination should be balanced by nuanced visions about our mutual dependency in healthcare, as an ever-learning system, especially in the European solidarity-based healthcare systems. Good research governance might be a way forward to escape the consent or anonymise dichotomy.

Is low survival for cancer in Eastern Europe due principally to late stage at diagnosis?

BACKGROUND

Cancer survival has persistently been shown to be worse for Eastern European and UK/Ireland patients than those of other European regions. This is often attributed to later stage at diagnosis. However, few stage-specific survival comparisons are available, so it is unclear whether poorer quality treatment or other factors also contribute. For the first time, European cancer registries have provided stage-at-diagnosis data to EUROCARE, enabling population-based stage-specific survival estimates across Europe.

DATA AND METHODS

In this retrospective observational study, stage at diagnosis (as TNM, condensed TNM, or Extent of Disease) was analysed for patients (≥15 years) from 15 countries grouped into 4 regions (Northern Europe: Norway; Central Europe: Austria, France, Germany, Switzerland, The Netherlands; Southern Europe: Croatia, Italy, Slovenia, and Spain; and Eastern Europe: Bulgaria, Estonia, Lithuania, Poland, and Slovakia), diagnosed with 7 malignant cancers in 2000-2007, and followed to end of 2008. A new variable (reconstructed stage) was created which used all available stage information. Age-standardised 5-year relative survival (RS) by reconstructed stage was estimated and compared between regions. Excess risks of cancer death in the 5 years after diagnosis were also estimated, taking age, sex and stage into account.

RESULTS

Low proportions of Eastern European patients were diagnosed with local stage cancers and high proportions with metastatic stage cancers. Stage-specific RS (especially for non-metastatic disease) was generally lower for Eastern European patients. After adjusting for age, sex, and stage, excess risks of death remained higher for Eastern European patients than for European patients in general.

CONCLUSIONS

Late diagnosis alone does not explain worse cancer survival in Eastern Europe: greater risk of cancer death together with worse stage-specific survival suggest less effective care, probably in part because fewer resources are allocated to health care than in the rest of Europe. We recommend that Eastern European cancer registries and other involved bodies to draw attention to poor cancer survival, so as to stimulate research and inform policies to improve outcomes.

Bridging the gap between the randomised clinical trial world and the real world by combination of population-based registry and electronic health record data: A case study in haemato-oncology

Randomised clinical trials (RCTs) are considered the basis of evidence-based medicine. It is recognised more and more that application of RCT results in daily practice of clinical decision-making is limited because the RCT world does not correspond with the clinical real world. Recent strategies aiming at substitution of RCT databases by improved population-based registries (PBRs) or by improved electronic health record (EHR) systems to provide significant data for clinical science are discussed. A novel approach exemplified by the HemoBase haemato-oncology project is presented. In this approach, a PBR is combined with an advanced EHR, providing high-quality data for observational studies and support of best practice development. This PBR + EHR approach opens a perspective on randomised registry trials.

Survival trends in childhood chronic myeloid leukaemia in Southern-Eastern Europe and the United States of America

AIM

To assess trends in survival and geographic disparities among children (0-14 years) with chronic myeloid leukaemia (CML) before and after the introduction of molecular therapy, namely tyrosine kinase inhibitors (TKIs) in Southern-Eastern European (SEE) countries and the USA.

METHODS

We calculated survival among children with CML, acute lymphoblastic (ALL) and acute myeloid leukaemia (AML) in 14 SEE (1990-2014) cancer registries and the U.S. Surveillance, Epidemiology and End Results Program (SEER, 1990-2012). We used Kaplan-Meier curves and multivariate Cox regression models to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Among 369 CML cases, substantial improvements were noted in 2-year survival during the post-TKI (range: 81-89%) compared to pre-TKI period (49-66%; HR: 0.37, 95% CI: 0.23-0.60). Risk of death was three times higher for <5-year-old children versus those aged 10-14 years (HR: 3.03, 95% CI: 1.85-4.94) and 56% higher for those living in SEE versus SEER (HR: 1.56, 95% CI: 1.01-2.42). Regardless of geographic area and period of TKI administration, however, age seems to be a significant determinant of CML prognosis (pre-TKI period, HR_0-4y: 2.71, 95% CI: 1.53-4.79; post-TKI period, HR_0-4y: 3.38, 95% CI: 1.29-8.85). Noticeably, post-TKI survival in CML overall approximates that for ALL, whereas therapeutic advancements for AML remain modest.

CONCLUSION

Registry data show that introduction of molecular therapies coincides with revolutionised therapeutic outcomes in childhood CML entailing dramatically improved survival which is now similar to that in ALL. Given that age disparities in survival remain substantial, offering optimal therapy to entire populations is an urgent priority.

Cancer registries in Europe-going forward is the only option

Cancer registries (CR) are the fundamental source of objective cancer data, and thus are indispensable for the evaluation of the cancer burden and for design of effective cancer control plans. Their potential roles spread far beyond epidemiological research, from the exploration of the causes of cancer to health economics, from the evaluation of mass screening programmes to monitoring the quality and outcomes of health services, from addressing the inequalities in access to healthcare, to patients' quality of life analyses, from treatment safety to the development of biomarkers. In Europe, cancer registration is challenged by significant disparities in the quality and coverage of CRs, by insufficient harmonisation and comparability of procedures and data, by heterogeneous legislation that limits CR's abilities for networking, collaboration, and participation in research. These arise against the background of large variations in economical, regulatory, social, and cultural national contexts. Important steps have been taken at European Union (EU)-level in recent years towards mapping and understanding these challenges, identifying best practices and formulating sensible recommendations, and creating the policy frameworks and the tools for cooperation and information sharing. Yet, as cancer has now become the second cause of death in Europe, one third of the population still lacks quality cancer registration, mostly in the regions with lowest resources and health status. It is therefore imperative that the efforts to support the development of CRs continue, and that the wealth of knowledge and vision acquired in this area is transformed into action.

Registration of childhood cancer: Moving towards pan-European coverage?

Cancer is relatively rare in childhood, but it contributes considerably to childhood mortality, years of life lost per person and late effects in survivors. Large populations need to be covered to set up meaningful studies of these rare conditions. Cancer registries ensure cancer surveillance, thus providing the basis for research as well as policy decisions. In this paper we examine coverage of childhood population by cancer registries in Europe and encourage national cancer registration. Over 200 cancer registries in various stages of development were identified as collecting data on childhood cancer patients in Europe. They cover 52% of the childhood population in the World Health Organisation (WHO) European region and 83% in the European Union (EU). More than 80% of this coverage is ensured by nationwide data collection, which is ongoing in 29 European countries. Overall coverage of the childhood population could increase to around 98%, if the recently established cancer registries start producing results and others improve their quality and dissemination plans. Paediatric cancer registries are being established with increasing frequency even in the areas covered by general cancer registries, and they tend to be national. Compared with regional registration, national cancer registries are more cost-effective, record larger number of cases, they can achieve higher completeness, less biased incidence and survival estimates and they are conditioned for national and international research. National registration of childhood cancer should be the rule in Europe, so that accurate regional, nation-wide and international statistics can provide solid baselines for research, clinical practice and public health policy. Governmental support and stakeholders' involvement are indispensable to guarantee optimal data quality and completeness.