The EUROCARE-3 database: methodology of data collection, standardisation, quality control and statistical analysis

One-Year Outcome of Multiple Blood-Brain Barrier Disruptions With Temozolomide for the Treatment of Glioblastoma

Introduction: To overcome the blood-brain barrier (BBB) which interferes with the effect of chemotherapeutic agents, we performed multiple disruptions of BBB (BBBD) with magnetic resonance-guided focused ultrasound on patients with glioblastoma (GBM) during standard adjuvant temozolomide (TMZ) chemotherapy [clinical trial registration no.NCT03712293 (clinicaltrials.gov)]. We report a 1-year follow-up result of BBBD with TMZ for GBM. Methods: From September 2018 to January 2019, six patients were enrolled (four men and two women, median age: 53 years, range: 50-67 years). Of the six patients, five underwent a total of six cycles of BBBD during standard TMZ adjuvant therapy. One patient underwent three cycles of BBBD but continued with TMZ chemotherapy. The 1-year follow-up results of these six patients were reviewed. Results: The mean follow-up duration was 15.17 ± 1.72 months. Two patients showed a recurrence of tumor at 11 and 16 months, respectively. One underwent surgery, and the other patient was restarted with TMZ chemotherapy due to the tumor location with a highly possibility of surgical complications. The survival rate up to 1 year was 100%, and the other four patients are on observation without recurrence. None of the six patients had immediate or delayed BBBD-related complications. Conclusion: Multiple BBBDs can be regarded as a safe procedure without long-term complications, and it seems to have some survival benefits. However, since TMZ partially crosses the BBB, a further extended study with large numbers would be needed to evaluate the benefits of BBBD resulting in an increase of TMZ concentration. This study opened a new therapeutic strategy for GBM by combining BBBD with a larger molecular agent.

Estimates of the Incidence and Prevalence of Hepatocellular Carcinoma in Italy in 2002 and Projections for the Years 2007 and 2012

Aims and background

Data on liver cancer incidence and prevalence in Italy are not available on a national and regional level.

Methods

We provided estimates of the number of incident and prevalent cases for hepatocellular carcinoma in Italy overall and in various regions in 2002 and gave projections for the years 2007 and 2012. We obtained annual numbers of incident cases of hepatocellular carcinoma by combining mortality data provided by the World Health Organization and information on survival for liver cancer, and subsequently derived five-year prevalence for hepatocellular carcinoma by combining incidence with information on survival.

Results

In 2002, there were about 5800 incident cases and 4300 prevalent cases of hepatocellular carcinoma in Italy. The most reliable estimate of hepatocellular carcinoma incident cases in Italy in 2007 is between 5500 and 6000, and this figure is likely to decline to 5000–5500 in 2012. The best estimate of prevalence is about 4000 cases in 2007, which is likely to decline to 3700 in 2012.

Conclusions

Incidence and prevalence of hepatocellular carcinoma are likely to remain approximately stable between 2002 and 2007 and slightly decrease in the subsequent quinquennia. These projections are, however, subject to large uncertainties because of the problems in diagnosis and death certification for this neoplasm, particularly for the elderly.

Estimates of the Incidence and Prevalence of Renal Cell Carcinoma in Italy in 2002 and Projections for the Years 2007 and 2012

Aims and background

Data on kidney cancer incidence and prevalence are not available on a national and regional level. We provided estimates of the number of incident and prevalent cases of kidney and renal cell cancer in Italy overall and in various regions in 2002 and gave projections for the years 2007 and 2012.

Methods

We derived annual numbers of incident cases combining mortality data provided by the World Health Organization and information on relative survival from kidney cancer and we subsequently derived 5-year prevalence by combining incidence with information on survival. We provided different projection estimates for the years 2007 and 2012 for incidence and prevalence, on the basis of various hypothetical scenarios, i.e., stable rates over time or steady falls by 1% per year.

Results

In 2002, there were about 8000 incident cases and 26,800 prevalent cases of kidney cancer in Italy. Of these, approximately 6800 and 22,750 were incident and prevalent cases of renal cell cancer, respectively. The most reliable estimate of incident kidney cancer cases in Italy over the period 2007–2012 is likely to range between 7000 and 9000. Of these, between 6000 and 8000 are renal cell cancer cases. The best estimate of prevalence of kidney cancer is between 20,000 and 34,000 cases and that of renal cell cancer between 17,000 and 29,000 cases.

Conclusions

Incidence and prevalence of renal cell cancer are likely to remain approximately stable between 2002 and 2007. Increased diagnostic attention due to widespread use of echography and other diagnostic techniques may, however, lead to earlier detection of kidney neoplasms and consequently to an apparent increase in the incidence of renal cell cancer.

Life Tables for World-Wide Comparison of Relative Survival for Cancer (CONCORD Study)

Background

The CONCORD study compares population-based relative survival from cancer using data from cancer registries in five continents. To estimate relative survival, general mortality life tables are required. Available statistics are incomplete, so various approaches are used to construct complete life tables. This article outlines how the life tables were constructed for CONCORD; it compares life expectancy at birth between 101 populations covered by cancer registries in 31 countries and compares the impact of two approaches to the deployment of life tables in relative survival analysis.

Methods

The CONCORD approach, using specific mathematical methods, produced complete (single-year-of-age) life tables by sex, cancer registry area, calendar year (1990–1999) and race (only in the USA). In order to study the impact of different approaches, we compared relative survival in the USA using the US national life table, centered on the relevant census years, and the CONCORD approach. We estimated relative survival in each American participating cancer registry for patients diagnosed with breast (women), colorectal or prostate cancer during 1990–1994 and followed up to 1999.

Results

Average life expectancy at birth during 1990–1999 varied in CONCORD cancer registry areas from 64 to 78 years in males and from 71 to 84 years in females. It increased during the 1990s more in men than in women. In the USA, it was lower in blacks than in whites. Relative survival in American populations was lower with the CONCORD approach, which incorporates trends and geographic variation in background mortality, than with the USA census life tables.

Conclusions

International variation in background mortality by geographic area, calendar time, race, age and sex is wide. We suggest that in international comparisons of cancer relative survival, complete life tables that are specific for cancer registry area, calendar year and race should be used.

Use of socio-economic factors and healthcare resources to estimate cancer survival in European countries with partial national cancer registration

Background and aims

Cancer is a chronic disease whose clinical history has a strong relationship with socio-economic indicators, and it could be defined as a real “social disease”. For this reason, socio-economic factors can be used to project survival rates by means of ecological models. The present study had two main aims: to generalize to all adult patients study of the association between survival and socio-economic and healthcare technologies and related medical resources factors; to provide insights on the possible bias in giving national meaning to survival rates based on pools of regional cancer registries where national coverage is not available.

Material and methods

The EUROCARE 3 Study provided age-standardized survival rates at 5 years from the diagnosis for 10 major cancer sites collected by 52 cancer registries from 21 European countries for the period 1990–1994. For each area and country, socio-economic and health-related variables were collected for the period 1993–1995. Multiple linear regression models were used to compute predicted survival rates in countries totally covered by registration, starting from the correlation between socio-economic and health-related variables and observed survival rates. For those areas not totally covered by cancer registry activity, a correctional parameter coming from the previous linear regression models was computed in order to estimate survival at a national level also in these countries.

Results

Predicted survival rates were very close to the observed rates for countries totally covered by cancer registries. The estimates were also good for nations with partial national cancer registration, with less convergence in results for countries where socio-economic differences between the whole territory and the covered area were relevant.

Conclusions

In the light of these findings, evaluation of the role of socio-economic and health-related factors and the estimation of survival is of utmost importance in order to evaluate healthcare outcomes and to support planners in allocating resources in a more effective and egalitarian way.

Temozolomide with or without Radiotherapy in Patients with Newly Diagnosed Glioblastoma Multiforme: A Meta-Analysis

BACKGROUND/AIM

The current meta-analysis evaluated the survival outcomes of newly diagnosed glioblastoma patients treated with radiotherapy (RT) alone and with RT + temozolomide (TMZ).

METHODS

Relevant studies were identified by an extensive literature search in Medline, Current Contents and Cochrane databases by 2 independent reviewers using the terms "glioblastoma multiforme/glioblastoma, TMZ, radiation therapy/RT and survival."

RESULTS

Results revealed a median survival of 13.41-19 months in the combined treatment group, as opposed to 7.7-17.1 months in the RT-alone group. Progression-free survival (PFS) was also significantly different between the 2 groups (RT + TMZ, 6.3-13 months; RT-alone, 5-7.6 months). While there was no significant difference in the 6-month survival and 6-month PFS rates between the RT + TMZ and RT groups (pooled OR 0.690; p = 0.057 and OR 0.429, p = 0.052, respectively), the 1-year survival and 1-year PFS rates showed significant difference (OR 0.469; p = 0.030 and OR 0.245, p < 0.001, respectively).

CONCLUSIONS

Concomitant RT + TMZ is more effective and improves the overall survival and PFS in patients with newly diagnosed glioblastoma.

Age-specific cancer survival in Estonia: recent trends and data quality

Background

A number of population-based studies have demonstrated lower cancer survival in elderly patients than among middle-aged or younger patients. Also, data quality in cancer registries has been shown to be associated with age. The objective of this study was to examine the recent age-specific cancer survival trends and age-specific quality of cancer data in Estonia.

Methods

Using Estonian Cancer Registry data, we calculated relative survival ratios (RSRs) for eight common cancers in Estonia in 1995–1999 (cohort method) and 2005–2009 (period method) for four major age groups (15–54, 55–64, 65–74, and 75–84 years at diagnosis). The main data quality indicators were calculated, and the age-specific effect of missing death certificate initiated (DCI) cases on survival was estimated comparing 5-year RSRs computed from the complete data set with those from data set without DCI cases.

Results

We observed overall rise in 5-year RSR for all eight cancers over the study period, with a considerable variation by age, with the lowest survival among the oldest patients. The widest age gradient in 5-year RSR was seen for bladder cancer (20% units in 2005–2009), followed by cancers of lung (16% units), kidney (15% units), breast and prostate (13% units), stomach and rectum (11% units), and colon (5% units). All data quality indicators, including proportion of cases with unknown stage showed a similar age-related pattern with the lowest quality in the oldest age group. The effect of missing DCI cases on survival estimates increased by age and was around 3% units for prostate and kidney cancers among the oldest patients.

Conclusion

Young or middle-aged patients in Estonia experienced larger survival gain since the late 1990s than elderly patients. Decreasing quality of cancer registry data along with increasing patient age suggests less thorough clinical investigations in older age groups.

Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2)

BACKGROUND

Worldwide data for cancer survival are scarce. We aimed to initiate worldwide surveillance of cancer survival by central analysis of population-based registry data, as a metric of the effectiveness of health systems, and to inform global policy on cancer control.

METHODS

Individual tumour records were submitted by 279 population-based cancer registries in 67 countries for 25·7 million adults (age 15-99 years) and 75,000 children (age 0-14 years) diagnosed with cancer during 1995-2009 and followed up to Dec 31, 2009, or later. We looked at cancers of the stomach, colon, rectum, liver, lung, breast (women), cervix, ovary, and prostate in adults, and adult and childhood leukaemia. Standardised quality control procedures were applied; errors were corrected by the registry concerned. We estimated 5-year net survival, adjusted for background mortality in every country or region by age (single year), sex, and calendar year, and by race or ethnic origin in some countries. Estimates were age-standardised with the International Cancer Survival Standard weights.

FINDINGS

5-year survival from colon, rectal, and breast cancers has increased steadily in most developed countries. For patients diagnosed during 2005-09, survival for colon and rectal cancer reached 60% or more in 22 countries around the world; for breast cancer, 5-year survival rose to 85% or higher in 17 countries worldwide. Liver and lung cancer remain lethal in all nations: for both cancers, 5-year survival is below 20% everywhere in Europe, in the range 15-19% in North America, and as low as 7-9% in Mongolia and Thailand. Striking rises in 5-year survival from prostate cancer have occurred in many countries: survival rose by 10-20% between 1995-99 and 2005-09 in 22 countries in South America, Asia, and Europe, but survival still varies widely around the world, from less than 60% in Bulgaria and Thailand to 95% or more in Brazil, Puerto Rico, and the USA. For cervical cancer, national estimates of 5-year survival range from less than 50% to more than 70%; regional variations are much wider, and improvements between 1995-99 and 2005-09 have generally been slight. For women diagnosed with ovarian cancer in 2005-09, 5-year survival was 40% or higher only in Ecuador, the USA, and 17 countries in Asia and Europe. 5-year survival for stomach cancer in 2005-09 was high (54-58%) in Japan and South Korea, compared with less than 40% in other countries. By contrast, 5-year survival from adult leukaemia in Japan and South Korea (18-23%) is lower than in most other countries. 5-year survival from childhood acute lymphoblastic leukaemia is less than 60% in several countries, but as high as 90% in Canada and four European countries, which suggests major deficiencies in the management of a largely curable disease.

INTERPRETATION

International comparison of survival trends reveals very wide differences that are likely to be attributable to differences in access to early diagnosis and optimum treatment. Continuous worldwide surveillance of cancer survival should become an indispensable source of information for cancer patients and researchers and a stimulus for politicians to improve health policy and health-care systems.

FUNDING

Canadian Partnership Against Cancer (Toronto, Canada), Cancer Focus Northern Ireland (Belfast, UK), Cancer Institute New South Wales (Sydney, Australia), Cancer Research UK (London, UK), Centers for Disease Control and Prevention (Atlanta, GA, USA), Swiss Re (London, UK), Swiss Cancer Research foundation (Bern, Switzerland), Swiss Cancer League (Bern, Switzerland), and University of Kentucky (Lexington, KY, USA).

Reconciliation of international administrative coding systems for comparison of colorectal surgery outcome

AIM

Significant variation in colorectal surgery outcomes exists between different countries. Better understanding of the sources of variable outcomes using administrative data requires alignment of differing clinical coding systems. We aimed to map similar diagnoses and procedures across administrative coding systems used in different countries.

METHOD

Administrative data were collected in a central database as part of the Global Comparators (GC) Project. In order to unify these data, a systematic translation of diagnostic and procedural codes was undertaken. Codes for colorectal diagnoses, resections, operative complications and reoperative interventions were mapped across the respective national healthcare administrative coding systems. Discharge data from January 2006 to June 2011 for patients who had undergone colorectal surgical resections were analysed to generate risk-adjusted models for mortality, length of stay, readmissions and reoperations.

RESULTS

In all, 52 544 case records were collated from 31 institutions in five countries. Mapping of all the coding systems was achieved so that diagnosis and procedures from the participant countries could be compared. Using the aligned coding systems to develop risk-adjusted models, the 30-day mortality rate for colorectal surgery was 3.95% (95% CI 0.86-7.54), the 30-day readmission rate was 11.05% (5.67-17.61), the 28-day reoperation rate was 6.13% (3.68-9.66) and the mean length of stay was 14 (7.65-46.76) days.

CONCLUSION

The linkage of international hospital administrative data that we developed enabled comparison of documented surgical outcomes between countries. This methodology may facilitate international benchmarking.

Control of data quality for population-based cancer survival analysis

BACKGROUND

Population-based cancer survival is an important measure of the overall effectiveness of cancer care in a population. Population-based cancer registries collect data that enable the estimation of cancer survival. To ensure accurate, consistent and comparable survival estimates, strict control of data quality is required before the survival analyses are carried out. In this paper, we present a basis for data quality control for cancer survival.

METHODS

We propose three distinct phases for the quality control. Firstly, each individual variable within a given record is examined to identify departures from the study protocol; secondly, each record is checked and excluded if it is ineligible or logically incoherent for analysis; lastly, the distributions of key characteristics in the whole dataset are examined for their plausibility.

RESULTS

Data for patients diagnosed with bladder cancer in England between 1991 and 2010 are used as an example to aid the interpretation of the differences in data quality. The effect of different aspects of data quality on survival estimates is discussed.

CONCLUSIONS

We recommend that the results of data quality procedures should be reported together with the findings from survival analysis, to facilitate their interpretation.

Key determinants of short-term and long-term glioblastoma survival: a 14-year retrospective study of patients from the Hermelin Brain Tumor Center at Henry Ford Hospital

OBJECTIVE

Glioblastoma (GBM) is a heterogeneous neoplasm with a small percentage of long-term survivors. Despite aggressive surgical resection and advances in radiotherapy and chemotherapy, the median survival for patients with GBM is 12-14 months. Factors associated with a favorable prognosis include young age, high performance status, gross resection >98%, non-eloquent tumor location and O6-methylguanine methyltransferase (MGMT) promoter methylation. We retrospectively analyzed the relationship of clinical, epidemiologic, genetic and molecular characteristics with survival in patients with GBM.

METHODS

This retrospective analysis of overall survival looked at the outcomes of 480 patients diagnosed with GBM over 14 years at a single institution. Multivariate analysis was performed examining multiple patient characteristics.

RESULTS

Median survival time improved from 11.8 months in patients diagnosed from 1995 to 1999 to 15.9 months in those diagnosed from 2005 to 2008. Factors associated with survivor groups were age, KPS, tumor resection, treatment received and early progression. 18 cancer-related genes were upregulated in short-term survivors and five genes were downregulated in short-term survivors.

CONCLUSIONS

Epidemiologic, clinical, and molecular characteristics all contribute to GBM prognosis. Identifying factors associated with survival is important for treatment strategies as well as research for novel therapeutics and technologies. This study demonstrated improved survival for patients over time as well as significant differences among survivor groups.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Survival of patients with oral cavity cancer in Germany

The purpose of the present study was to describe the survival of patients diagnosed with oral cavity cancer in Germany. The analyses relied on data from eleven population-based cancer registries in Germany covering a population of 33 million inhabitants. Patients with a diagnosis of oral cavity cancer (ICD-10: C00-06) between 1997 and 2006 are included. Period analysis for 2002-2006 was applied to estimate five-year age-standardized relative survival, taking into account patients' sex as well as grade and tumor stage. Overall five-year relative survival for oral cavity cancer patients was 54.6%. According to tumor localization, five-year survival was 86.5% for lip cancer, 48.1% for tongue cancer and 51.7% for other regions of the oral cavity. Differences in survival were identified with respect to age, sex, tumor grade and stage. The present study is the first to provide a comprehensive overview on survival of oral cavity cancer patients in Germany.

Valid comparisons and decisions based on clinical registers and population based cohort studies: assessing the accuracy, completeness and epidemiological relevance of a breast cancer query database

Background

Data accuracy and completeness are crucial for ensuring both the correctness and epidemiological relevance of a given data set. In this study we evaluated a clinical register in the administrative district of Marburg-Biedenkopf, Germany, for these criteria.

Methods

The register contained data gathered from a comprehensive integrated breast-cancer network from three hospitals that treated all included incident cases of malignant breast cancer in two distinct time periods from 1996–97 (N=389) and 2003–04 (N=488). To assess the accuracy of this data, we compared distributions of risk, prognostic, and predictive factors with distributions from established secondary databases to detect any deviations from these “true” population parameters. To evaluate data completeness, we calculated epidemiological standard measures as well as incidence-mortality-ratios (IMRs).

Results

In total, 12% (13 of 109) of the variables exhibited inaccuracies: 9% (5 out of 56) in 1996–97 and 15% (8 out of 53) in 2003–04. In contrast to raw, unstandardized incidence rates, (in-) directly age-standardized incidence rates showed no systematic deviations. Our final completeness estimates were IMR=36% (1996–97) and IMR=43% (2003–04).

Conclusion

Overall, the register contained accurate, complete, and correct data. Regional differences accounted for detected inaccuracies. Demographic shifts occurred. Age-standardized measures indicate an acceptable degree of completeness. The IMR method of measuring completeness was inappropriate for incidence-based data registers. For the rising number of population-based health-care networks, further methodological advancements are necessary. Correct and epidemiologically relevant data are crucial for clinical and health-policy decision-making.

Survival from common and rare cancers in Germany in the early 21st century

BACKGROUND

Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States.

PATIENTS AND METHODS

Cancer patients diagnosed in 1997-2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002-2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database.

RESULTS

Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin's lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin's lymphoma.

CONCLUSIONS

German cancer survival estimates are mostly higher than the 2000-2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

Patient and tumour characteristics, management, and age-specific survival in women with breast cancer in the East of England

BACKGROUND

Breast cancer relative survival (BCRS), which compares the observed survival of women with breast cancer with the expected survival of women for the whole population of the same age, time period, and geographical region, tends to be poorer in older women, but the reasons for this are not clear. We examined the influence of patient and tumour characteristics, and treatment on BCRS to see whether these could explain the age-specific effect.

METHODS

Data for 14,048 female breast cancer patients diagnosed from 1999 to 2007, aged 50 years or over were obtained from the Eastern Cancer Registration and Information Centre. We estimated relative 5- and 10-year survival for patients in four age groups (50-69, 70-74, 75-79, and 80+ years). We also modelled relative excess mortality (REM) rate using Poisson regression adjusting for patient characteristics and treatment. The REMs derived from these models quantify the extent to which the hazard of death differs from the hazard in the reference category, after taking into account the background risk of death in the general population. We compared the results with those obtained for breast cancer-specific mortality, analysed using multivariate Cox regression.

RESULTS

Median follow-up time was 4.7 years. Relative 5-year survival was 89, 81, 76, and 70% for patients aged 50-69, 70-74, 75-79, and 80+ years, respectively. Corresponding relative 10-year survival was 84, 77, 67, and 66%. Unadjusted REM was 1.93, 2.74, and 3.88 for patients aged 70-74, 75-79, and 80+ years, respectively, (50-69 years as reference). The equivalent hazard ratios from the Cox model were 1.88, 2.45, and 3.81. These were attenuated after adjusting for confounders (REM - 1.49, 1.36, and 1.23; Cox - 1.47, 1.50, and 1.76).

CONCLUSION

We confirmed poorer BCRS in older women in our region. This was partially explained by known prognostic factors. Further research is needed to determine whether biological differences or suboptimal management can explain the residual excess mortality.

European disparities in malignant digestive endocrine tumours survival

The aim of this study was to report on malignant digestive endocrine tumours (MDET) prognosis in several European countries. We analysed survival data from 19 cancer registries in 12 European countries on 3,715 MDET diagnosed between 1985 and 1994. The overall 5-year survival rate was 47.5%. It was 58.1% for differentiated MDET and 8.1% for small-cell MDET (p < 0.001), 55.9% for patients under 65 and 37.0% for older patients. Survival rates for small intestinal and colorectal were higher than for the other sites. The 5-year relative survival rates were 60.3% in Northern Europe, 53.6% in Western Continental Europe, 42.5% in the UK, 37.6% in Eastern Europe (p < 0.001). Among well-differentiated pancreatic tumours, 5-year relative survival was 55.6% for insulinoma, 48.4% for gastrinoma, 33.4% for glucagonoma, 28.8% for carcinoid tumours and 49.9% for non-functioning tumours. The relative excess risk of death was significantly lower in Western Continental Europe and Northern Europe and significantly higher in Easter European compared to the UK. MDET differentiation, site, geographic area, age and sex, were independent prognostic factors. Overall, in Europe approximately half of the patients with MDET survive 5 years after the initial diagnosis. Prognosis varies with tumour differentiation, anatomic site and histological type. There are significant differences in survival from MDET among European countries, independently of other prognostic factors.

Survival for ethmoid sinus adenocarcinoma in European populations

BACKGROUND

Adenocarcinoma of the ethmoid sinus is rare. EUROCARE data provide a good opportunity to study the survival of this rare disease in a population of continental size.

PATIENTS AND METHODS

A total of 204 cases, age 15 to 99 years, diagnosed with primary ethmoid sinus adenocarcinoma between 1983 and 1994, were analyzed. The data were contributed by 22 population-based cancer registries from the nine countries participating in EUROCARE. Relative survival by sex, age, period of diagnosis, region and stage, and adjusted relative excess risk (RER) of death, were estimated.

RESULTS

Survival was 83%, 58% and 46%, 1, 3 and 5 years, respectively after diagnosis. Five-year survival was best (60%) in patients of 55-64 years and worst (33%) in the oldest age group (> or =65 years). Five-year survival differ between European population: in Norway (55%, 95% confidence interval 26.4-80.9) and western Europe that includes populations from Eindhoven, Saarland, Geneva, Italy and France (56%, 95%CI 41.3-68.9) was higher than in the UK (41%, 95% CI 30.8-51.8) and eastern Europe which includes Slovakia and Slovenia, (22%, 95% CI 3.5-54.4). Five-year survival did not improve over time. Due to the rarity of the disease, all the survival differences did not reach the statistical significance.

CONCLUSIONS

Since no survival improvement with time was evident from this study, efforts should be made to improve early diagnosis. GPs and ENT specialists should be alerted to the disease and encouraged to take occupational histories in people with persistent nasal symptoms, which may lead to a reasonable suspicion of malignancy. Monitoring of exposed workers may also improve early diagnosis. Patients with suspected ethmoid cancer should be referred immediately a specialized diagnosis and treatment centre.

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.

Glioblastoma multiforme: a review of therapeutic targets

Glioblastoma is the commonest primary brain tumor, as well as the deadliest. Malignant gliomas such as glioblastoma multiforme (GBM) present some of the greatest challenges in the management of cancer patients worldwide, despite notable recent achievements in oncology. Even with aggressive surgical resections using state-of-the-art preoperative and intraoperative neuroimaging, along with recent advances in radiotherapy and chemotherapy, the prognosis for GBM patients remains dismal: survival after diagnosis is about 1 year. Established prognostic factors are limited, but include age, Karnofsky performance status, mini-mental status examination score, O6-methylguanine methyltransferase promoter methylation and extent of surgery. Standard treatment includes resection of > 95% of the tumor, followed by concurrent chemotherapy and radiotherapy. Nevertheless, GBM research is being conducted worldwide at a remarkable pace, in the laboratory and at the bedside, with some of the more recent promising studies focused on identification of aberrant genetic events and signaling pathways to develop molecular-based targeted therapies, tumor stem cell identification and characterization, modulation of tumor immunological responses and understanding of the rare long-term survivors. With this universally fatal disease, any small breakthrough will have a significant impact on survival and provide hope to the thousands of patients who receive this diagnosis annually. This review describes the epidemiology, clinical presentation, pathology and tumor immunology, with a focus on understanding the molecular biology that underlies the current targeted therapeutics being tested.

Cancer survival analysis in Hamburg 1995-2003: assessing the data quality within a population-based registry

INTRODUCTION

Population-based cancer survival analysis constitutes valuable reference material for the clinical field of oncology. The objectives of this study were to assess the quality of the Hamburg Cancer Registry's (HCR) database in this respect, to perform survival analyses by means of selected sites, and to evaluate the results in relation to prevalent opinions and external estimates.

METHODS

Data quality was assessed by the proportion of cases documented as diagnosed at death, external estimates of completeness, reliability of follow-up, histological verification and information on stage. Included were first primary malignancies of the colon (ICD10 C18, n=4,544), female breast (C50, n=9,259), prostate (C61, n=5,707) and urinary bladder (C67, D09.0, n=3,148), diagnosed in Hamburg residents 1995-2003. Observed and relative survival (OS, RS) were estimated by site, sex, time, age and stage.

RESULTS

Regarding female breast cancer in Hamburg, high levels of data quality and completeness exist while the explanatory power concerning malignancies of the colon, prostate and urinary bladder is limited. Age-standardised 5-year relative cancer survival estimates amounted for female breast to 81%, for colon to 49% (male) and 52% (female), for prostate to 81% and for urinary bladder to 71% (male) and 62% (female).

CONCLUSION

The study demonstrates the capacities and limitations of an epidemiological cancer registry to produce convincing survival estimates for clinical use, under the terms of a voluntary case reporting system.

The EUROCARE-4 database on cancer survival in Europe: data standardisation, quality control and methods of statistical analysis

This paper describes the collection, standardisation and checking of cancer survival data included in the EUROCARE-4 database. Methods for estimating relative survival are also described. Incidence and vital status data on newly diagnosed European cancer cases were received from 93 cancer registries in 23 countries, covering 151,400,000 people (35% of the participating country population). The third revision of the International Classification of Diseases for Oncology was used to specify tumour topography and morphology. Records were extensively checked for consistency and compatibility using multiple routines; flagged records were sent back for correction. An algorithm assigned standardised sequence numbers to multiple cancers. Only first malignant cancers were used to estimate relative survival from registry, year, sex and age-specific life tables. Age-adjusted and Europe-wide survival were also estimated. The database contains 13,814,573 cases diagnosed in 1978-2002; 92% malignant. A negligible proportion of records was excluded for major errors. Of 5,753,934 malignant adult cases diagnosed in 1995-2002, 5.3% were second or later cancers, 2.7% were known from death certificates only and 0.4% were discovered at autopsy. The remaining 5,278,670 cases entered the survival analyses, 90% of these had microscopic confirmation and 1.3% were censored alive after less than five years' follow-up. These indicators suggest satisfactory data quality that has improved since EUROCARE-3.

Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis

We examined socioeconomic inequalities in cancer survival in New Zealand among 132,006 people ages 15 to 99 years who had a cancer registered (1994-2003) and were followed up to 2004. Relative survival rates (RSR) were calculated using deprivation-specific life tables. A census-based measure of socioeconomic position (New Zealand deprivation based on the 1996 census) based on residence at the time of cancer registration was used. All RSRs were age-standardized, and further standardization was used to investigate the effect of extent of disease at diagnosis on survival. Weighted linear regression was used to estimate the deprivation gap (slope index of inequality) between the most and least deprived cases. Socioeconomic inequalities in cancer survival were evident for all of the major cancer sites, with the deprivation gap being particularly high for prostate (-0.15), kidney and uterus (both -0.14), bladder (-0.12), colorectum (-0.10), and brain (+0.10). Accounting for extent of disease explained some of the inequalities in survival from breast and colorectal cancer and melanoma and all of the deprivation gaps in survival of cervical cancer; however, it did not affect RSRs for cancers of the kidney, uterus, and brain. No substantial differences between the total compared with the non-Māori population were found, indicating that the findings were not due to confounding by ethnicity. In summary, socioeconomic disparities in survival were consistent for nearly all cancer sites, persisted in ethnic-specific analyses, and were only partially explained by differential extent of disease at diagnosis. Further investigation of reasons for persisting inequalities is required.

EUROCARE-4. Survival of cancer patients diagnosed in 1995-1999. Results and commentary

EUROCARE-4 analysed about three million adult cancer cases from 82 cancer registries in 23 European countries, diagnosed in 1995-1999 and followed to December 2003. For each cancer site, the mean European area-weighted observed and relative survival at 1-, 3-, and 5-years by age and sex are presented. Country-specific 1- and 5-year relative survival is also shown, together with 5-year relative survival conditional to surviving 1-year. Within-country variation in survival is analysed for selected cancers. Survival for most solid cancers, whose prognosis depends largely on stage at diagnosis (breast, colorectum, stomach, skin melanoma), was highest in Finland, Sweden, Norway and Iceland, lower in the UK and Denmark, and lowest in the Czech Republic, Poland and Slovenia. France, Switzerland and Italy generally had high survival, slightly below that in the northern countries. There were between-region differences in the survival for haematologic malignancies, possibly due to differences in the availability of effective treatments. Survival of elderly patients was low probably due to advanced stage at diagnosis, comorbidities, difficult access or lack of availability of appropriate care. For all cancers, 5-year survival conditional to surviving 1-year was higher and varied less with region, than the overall relative survival.

Survival from salivary glands adenoid cystic carcinoma in European populations

Adenoid cystic carcinoma (ACC) of salivary gland origin is rare. The EUROCARE data provide a good opportunity to study the survival of this uncommon cancer in a large population. A total of 2611 cases, aged 15 to 99 years, diagnosed between 1983 and 1994 with primary salivary gland ACC were analyzed. Thirty-two population based cancer registries from seventeen countries participating in EUROCARE contributed the data. Relative survival by sex, age, period of diagnosis, region, site and stage, and the adjusted relative excess risk (RER) of death were estimated. Survival since diagnosis was 94%, 78% and 65% at 1, 5 and ten years, respectively. Ten-year survival was best (69%) in patients of the youngest age group (15-54 years) and from Northern Europe (69%). In the UK was higher (65%) than in Western (62%) and Eastern (56%) Europe. ACCs in nasal cavity (RER 2.6), pharynx (RER 3.5) and larynx and bronchus (RER 3.9) had a worse prognosis compared to those of oral cavity. A strong effect of stage at diagnosis on RERs and some worsening of survival at five years over time (80% in 1983-1985, 76% in 1992-1994) were also evident. The findings of the present study, as those from clinical studies, confirm the important impact of primary site and stage at diagnosis on survival. Furthermore, we could demonstrate that survival for ACC did not improve over time and that cases from Eastern countries had a significant worse prognosis. Improvements in the disease detection in its early stage and international collaborative research should be encouraged.

Incidence, clinical characteristics and survival of malignant lymphomas: a population-based study from a cancer registry in northern Italy

We conducted a population-based study of peripheral lymphomas (PL) that had been diagnosed between 1997 and 2003 in the province of Modena, Italy, with the aim of providing updated incidence, clinical and survival data for these cancers. We evaluated the incidence patterns and time trends of 1582 cases of PL that had been reclassified according to the WHO classification of hematological malignancies. Data regarding clinical characteristics, treatment and outcome were also collected for each case. The World Age-Standardized Rate (ASR) was calculated as 13.4, 2.2 and 3.4 per 100,000 people for B-cell non-Hodgkin's lymphoma (NHL), T-cell NHL and Hodgkin's Lymphoma (HL), respectively, with an increase of 1.62% per year during the study period. The lymphoma subtype showing the highest incidence was found to be diffuse large B-cell lymphoma (DLBCL) with an ASR of 4.8. Compared with reports from other western countries, our series is characterized by a higher incidence of HL and indolent B-NHL in general, and of CLL/SLL (ASR = 3.3) and marginal zone NHL (ASR = 1.5), in particular, and also by a lower incidence of FL (ASR = 2). After a median follow-up of 54 months, the 5-year relative survival for the whole series was found to be 70% with a statistically significant improvement for cases diagnosed during 2002-2003 (from 66 to 74%; p = 0.03). Survival improvement within the study period was also evident for patients with DLBCL, HL and T-NHL. Our study provides a comprehensive description of both the epidemiological and clinical features of PL cases in Modena and our data also reflect the major advances in the curability of some histological subtypes of this disease. The usefulness of a population-based approach to better characterizing different lymphoma subtypes is also demonstrated.

Ethnic differences in prostate cancer survival in New Zealand: a national study

OBJECTIVE

To examine disease-specific survival from prostate cancer by ethnic group in New Zealand.

METHODS

Analyses were based on the 7,733 men with histologically confirmed prostate cancer diagnosed from the start of 1996 to the end of 1999 in New Zealand. Five-year adjusted prostate-specific mortality rates and hazard ratios were calculated for Maori, Pacific, and European men.

RESULTS

In univariate analyses, Maori and Pacific men had higher mortality particularly in the first year after a diagnosis of prostate cancer than did European men. The strongest prognostic factors for prostate cancer were Gleason score and age. When survival analyses by ethnic group were adjusted for age and Gleason score the disparities in survival for Maori men and Pacific men with low-grade prostate cancers remained, with European men having the best survival.

CONCLUSIONS

Several possible explanations have been proposed to explain the survival disparities by ethnicity in New Zealand. Differentials in Gleason grade of disease by ethnic group explain a lot of these disparities. Further data on stage of disease at diagnosis, co-morbidity, treatment, access to health services, and behavioral and environmental factors are needed to resolve these issues.

Incidence and clinicopathologic features of gastrointestinal stromal tumors. A population-based study

Background

Although the diagnostic criteria and pathogenesis of gastrointestinal stromal tumors (GIST) have recently been elucidated, knowledge of the epidemiology of this malignancy is still limited. This study examined the incidence of GIST in the province of Modena, including pathologic features and clinical outcome.

Methods

Gastrointestinal mesenchymal tumors identified by the Modena Cancer Registry between 1991 and 2004 were analyzed with an immunohistochemical panel that included staining for CD-117 and PDGFRα. Size, mitotic rate, and other pathologic parameters were recorded. Each tumor was categorized into National Institutes of Health risk categories (very low, low, intermediate, and high risk).

Results

One hundred twenty-four cases were classified as GIST. The age-adjusted incidence rate was 6.6 per million. Seventy-five percent of patients were symptomatic; 34% had a previous or concomitant history of cancer. High-risk features were present in 47% of cases. Seventy-eight percent were submitted to radical surgery. After complete resection, the 5-year disease-free survival rates were 94%, 92%, 100%, and 40% for patients at very low, low, intermediate, and high risk, respectively. In multivariate analysis, high risk was the main predictor of recurrence.

Conclusion

This population-based study shows that the incidence of GIST in Northern Italy is comparable to that reported in other European countries. Survival was favorable in lower risk categories and in most of the resected cases. In our study, resected patients at very low, low, and intermediate risk had a similar outcome. Our data support the need to consider high-risk patients after complete surgical resection for treatment with the best available approach.

Patients with previous cancer should not be excluded in international comparative cancer survival studies

In international comparisons or time trend analyses of cancer survival, it is common practice to restrict analyses to patients with a first cancer, i.e., to exclude patients with previous cancer diagnoses. However, the proportion of cancer patients with known previous cancer depends on the time cancer registries have been running, which results in varying proportions of excluded patients across registries. If prognosis of patients with second cancers differs from prognosis of patients with first cancers, varying exclusions may bias survival comparisons. We empirically evaluate the dependence of proportions of patients recorded as having a first cancer on time since initiation of cancer registration and the impact of excluding patients with known previous cancer on cancer survival estimates using the data of the nationwide Finnish Cancer Registry. Among 20 common cancer sites investigated, the proportion of "first cancers" varied between 97.4 and 99.7% in 1953-1957, the first 5-years of cancer registration, and decreased continuously to levels between 83.9 and 92.7% in 1993-1997. Excluding patients with a previous cancer diagnosis had little impact on estimates of survival of cancer patients diagnosed in 1953-1957, but increased 5-year relative survival estimates among patients diagnosed in 1993-1997 for each of the 20 cancers. The extent of the increase varied by cancer site and age. The increase ranged up to 2.9% points for crude and up to 1.7% points for age adjusted 5-year relative survival. These results caution against exclusion of patients with previous cancer diagnosis in comparative analyses of cancer survival.

International comparisons of survival from lung cancer: pitfalls and warnings

Population-based survival data can provide valuable comparative data on outcome but should be interpreted with caution. Differences in data collection and analysis, patient and tumor characteristics and treatment options can have an impact on reported results. Ideally, data from the whole population, including clinical-only diagnoses, should be reported and the methods of case identification described. The relative survival rates should preferably be given. Data on patient characteristics such as age, sex, ethnicity and socioeconomic deprivation should be described, together with tumor details such as pathology and clinical stage. Whenever possible, details on the use of treatments should be reported.

A wide difference in cancer survival between middle aged and elderly patients in Europe

Nowadays the burden of cancer in elderly people has reached an alarming extent. The purpose of this study is comparing cumulative and conditional relative survival in elderly patients between 65 and 84 years and younger adults aged from 55 to 64. Fifty-three cancer registries of 22 European countries, participating in the EUROCARE-3 programme, collected information on the cases diagnosed over the period 1990-1994. We computed cumulative and conditional relative survival for 16 cancer sites. Middle aged patients experienced a better prognosis than the elderly for all cancer sites, in both sexes and the differences were more marked at 1 than 5 years since diagnosis. The very large differences noted in the first period after cancer detection declined in the subsequent years and, when 5-years conditional survival was considered, for several cancers the elderly and younger adults had the same probabilities of surviving. The death relative excess risks (RERs) in the elderly with respect younger individuals were really very high and markedly larger at 1 than 5 years, and in women than men. Genitourinary and gynaecological cancers showed the highest RERs, around 2.0 and between 1.5 and 2.5 respectively. This very high early mortality could be due not only to clinical aspects: the barriers to health care access and a consequent late diagnosis might represent for elderly patients the main determinant of this very large prognostic disadvantage. In conclusion, clinical management of cancer in the elderly remains a major issue to be faced with complex social and health care policies.

Incidence of uveal melanoma in Europe

PURPOSE

To estimate incidence rates of uveal melanoma in Europe from 1983 to 1994.

DESIGN

Incidence analysis of data from cancer registries adhering to the European Cancer Registry-based study on survival and care of cancer patients (EUROCARE) (cases diagnosed from 1983 to 1994).

PARTICIPANTS

Data of 6673 patients with ocular melanoma (as defined by International Classification of Diseases for Oncology morphology codes 8720 to 8780 [melanoma] and International Classification of Diseases 9 (ICD9) codes 190.0 [iris and ciliary body], 190.5 [retina], 190.6 [choroid], and 190.9 [unspecified ocular location]) from 33 cancer registries of 16 European countries.

METHODS

Incidence rate ratios (IRRs) were obtained from a multilevel Poisson regression model.

MAIN OUTCOME MEASURES

Incidence rates and IRRs associated with demographic and geographic variables.

RESULTS

Standardized incidence rates increased from south to north across registries, from a minimum of <2 per million in registries of Spain and southern Italy up to >8 per million in Norway and Denmark. The inclusion of tumors with unspecified ocular location (code 190.9) increased incidence rates in most United Kingdom registries, but not in the other geographic areas, where this code was seldom used for uveal melanomas. Incidence increased noticeably up to age 55 (IRR, 1.46 per 5 years; 95% confidence interval [CI], 1.36-1.57) but leveled off after age 75 (IRR, 0.99 per 5 years; 95% CI, 0.93-1.05), with intermediate levels midway (IRR, 1.18 per 5 years; 95% CI, 1.12-1.23). It was also higher in males (IRR, 1.22; 95% CI, 1.16-1.28). Rates were stable during the study period, but a cohort effect was evidenced, accounting for higher incidence rates in people born during the period 1910 to 1935 (P = 0.005). Incidence increased with latitude (P = 0.008), which explained most differences in rates among areas.

CONCLUSIONS

In this large series of uveal melanomas, we found stable incidence during the years 1983 to 1994. The north-to-south decreasing gradient supports the protective role of ocular pigmentation. European ophthalmologists should develop guidelines to standardize the coding of tumors treated conservatively using the ICD classification to improve the registration and surveillance of uveal melanoma by cancer registries.

Quantitative exploration of possible reasons for the recent improvement in breast cancer survival

OBJECTIVE

Breast cancer mortality has been declining in many countries including Canada because of improvements in survival. This study attempts to explain observed trends in breast cancer survival with special attention given to the role of improvements in early detection and treatment.

METHODS

This study is based on 4,312 women diagnosed with primary invasive breast carcinoma treated in a Canadian breast center between 1976 and 2000 and followed to the end of 2001. Observed and relative survival rates were calculated. Multivariate relative survival regression models were used to assess trends in breast cancer survival over the study period.

RESULTS

The proportion of women with small tumors (< or = 10 mm) was higher in late 1990s, while that of women with regional involvement was lower compared to earlier periods. Adjuvant chemotherapy or endocrine therapy use increased steadily from 6.6% to 84.0% during the study period. Five-year relative survival rates ranged between 82.1% and 83.7% between 1976 and 1990, and increased thereafter to reach 87.6% in 1991-95, and 92.1% in 1996-2000. During the first five years after diagnosis, women diagnosed in 1991-95 and 1996-2000 experienced a reduction in breast cancer mortality of 28% (Relative Risk (RR)= 0.72; 95% CI: 0.59-0.89) and 49% (RR = 0.51; 95% CI: 0.39-0.68) respectively compared to women diagnosed in 1976-90. Improvement in breast cancer survival in 1990's could not be explained by characteristics of women, biology of the tumor, advancements in early detection and type of initial treatments.

CONCLUSION

A substantial increase in breast cancer survival was observed in the 1990s but the reasons for this improvement remain elusive. Better knowledge of these reasons could help not only to further reduce the burden related to breast cancer but also the burden related to other major cancer sites.

Survival of cancer patients in France: a population-based study from The Association of the French Cancer Registries (FRANCIM)

We present the main results of the first population-based cancers survival study gathering all French registry data. Survival data on 205,562 cancer cases diagnosed between 01/01/1989 and 31/12/1997 were analysed. Relative survival was estimated using an excess rate model. The evolution of the excess mortality rate over the follow-up period was graphed. The analysis emphasised the effect of age at diagnosis and its variation with time after diagnosis. For breast and prostate cancers, the age-standardised five-year relative survivals were 84% and 77%, respectively. The corresponding results in men and women were 56% versus 58% for colorectal cancer and 12% versus 16% for lung cancer. For some cancer sites, the excess mortality rate decreased to low values by five years after diagnosis. For most cancer sites, age at diagnosis was a negative prognostic factor but this effect was often limited to the first year after diagnosis.

Variation in relative survival of thyroid cancers in Europe: Results from the analysis on 21 countries over the period 1983–1994 (EUROCARE-3 study)

We described the relative survival of thyroid cancer cases diagnosed in Europe during the period 1990-1994 and analysed time trends in relative survival during the period 1983-1994 using the EUROCARE-3 database. Relative survival of thyroid cancers is one of the highest amongst cancer sites, with age-standardised relative survival rates of 74% in men and 82% in women over the period 1990-1994, with marked differences between countries. The higher relative survival rates are observed in Scandinavian countries and the lower rates are observed in the UK and the countries of Eastern Europe. Relative survival is higher in women than in men, and decreases with age whatever the histological group. There are significant differences in relative survival according to histological type. Relative survival has slightly increased over the period 1983-1994 only when all histological types have been considered together. Time trend was, however, non-existent when the different histological groups were taken into account except during the most recent period of observation. One possible explanation for the differences in relative survival between countries and sex may probably be found in the changes in thyroid classification and diagnosis techniques. When these changes are not homogeneous, the distribution of thyroid cancers by histology and by stage at diagnosis may be very different. The only way to understand these differences is to conduct specific studies including a description of stage at diagnosis, diagnosis procedures used for staging and details of treatment.

Variation in lung cancer survival rates between countries: Do differences in data reporting contribute?

BACKGROUND

Mortality rates from lung cancer are known to vary considerably between countries. Differences in patients, disease, investigation and treatment are thought to account for some survival shortfalls but it is not known whether differences in collection or processing of data also contribute.

METHODOLOGY

We searched recognised sources where information regarding mortality rates have been published for the United Kingdom, Europe and United States (US). Data regarding patient selection, demographics and mortality rates were extracted.

RESULTS

Published international 5-year survival for patients with lung cancer varies from 5% to 16%. The survival figures quoted in the literature are based on data which varies widely in its collection and statistical analysis and this information is not always in the public domain. Data from the US suggests an overall 5-year survival rate of up to 16% although this figure covers only a quarter of the general population and excludes patients without histological confirmation. Many European countries report higher mortality rates although in most, data includes patients without proven histology. European datasets have variable population coverage.

CONCLUSION

Selective data collection and variable population coverage may account for some of the differences in lung cancer survival between countries. More transparent description of data collection and analysis would be helpful but ideally a uniform method of reporting data is required in order to make valid comparisons in mortality rates.

Incidence of and survival from Wilms' tumour in adults in Europe: data from the EUROCARE study

Wilms' tumour, or nephroblastoma, is an embryonal cancer of the kidney that occurs mainly in young children. This is a very rare tumour among adults, with an incidence rate of less than 0.2 per million per year. The aims of this study were to report the survival of adults diagnosed with nephroblastoma in Europe and to analyse time trends and geographic variations in survival. All the adults (age range 15-99 years) diagnosed with a Wilms' tumour during 1983-1994 and registered by one of the 22 cancer registries in 16 countries contributing to the EUROCARE (European cancer registries study on cancer patients' survival and care) database were analysed. Relative survival at 1 and 5 years after diagnosis was estimated by age, sex, geographic area, period of diagnosis and tumour stage. A total of 143 patients, with a median age of 34 years, were included in the analysis. Crude annual incidence rates varied geographically between 0.17 and 0.27 per million. Overall relative survival was 69.9% (95% confidence interval (CI) 61.8-78.0%) at 1 year and 47.3% (38.2-56.4%) at 5 years. Survival was 2.1-fold higher for women than for men (95% CI 1.3-3.5). There was a non-significant trend for better survival for younger patients and localised tumours, but no improvement in survival by period of diagnosis. Survival was not different between geographic areas. Our results suggest a poorer outcome of nephroblastoma in adults compared with published results in children. This may, at least partly, be explained by the rarity of this diagnosis. Prognosis may be improved by the use of specific treatment guidelines for nephroblastoma in adults.

Calculating age-adjusted cancer survival estimates when age-specific data are sparse: an empirical evaluation of various methods

We evaluated empirically the performance of various methods of calculating age-adjusted survival estimates when age-specific data are sparse. We have illustrated that a recently proposed alternative method of age adjustment involving the use of balanced age groups or age truncation may be useful for enhancing calculability and reliability of adjusted survival estimates.

Radiation and chemoradiation therapy for esophageal adenocarcinoma

The aims of preoperative chemoradiation therapy (preop-CRT) for esophageal adenocarcinoma are to reduce incomplete local resection (R1,R2), local and systemic recurrences that are reported in up to 30% of patients who undergo surgery alone. Phase II studies of preop-CRT, with radiation doses in the 40-50 Gy range, and concurrent chemotherapy with 5-fluorouracil (5-FU)-cisplatin +/- paclitaxel, or cisplatin-paclitaxel, have reported subsequent RO resection rates of 80%-100%, with tumor sterilization achieved in 8%-49% of cases, and consequently improved local control. New chemotherapy regimens omitting 5-FU have reduced the incidence of severe esophagitis, unplanned hospitalization, with comparable efficacy. Among three randomised trials that compared preop-CRT to surgery alone, one shown a debatable survival advantage. Reducing local recurrence rates lead to a switch to more distant failures, and increasing the radiation dose beyond 45 Gy appears to be of little value. However, it should be remembered that preop-CRT has associated toxicity, and may increase postoperative mortality. Novel strategies, which include induction with chemotherapy followed by preop-CRT, and for radiation therapy, three dimensional conformation techniques, image fusioning, and improved definition of treatment volumes, are still considered experimental and should be tested in specialized centers.