Characteristics of patients with missing information on stage: a population-based study of patients diagnosed with colon, lung or breast cancer in England in 2013

Emergency presentation of colorectal cancer in older adults: A retrospective cohort analysis

INTRODUCTION

Adults aged 70 years and over account for almost 60% of colorectal cancer (CRC) diagnoses in the United Kingdom. Whilst emergency presentation of CRC is known to be associated with poorer outcomes across all ages, older adults are less likely to be treated with curative intent and have poorer overall survival (OS). We aimed to investigate whether presentation, management, or outcome differed in older (≥70 years) versus younger (<70 years) adults in our population.

MATERIALS AND METHODS

The electronic records of patients diagnosed with CRC within the period 2016 to 2019 in National Health Service (NHS) Tayside, Scotland were retrospectively analysed. Patients were grouped by age (<70 years and ≥70 years). Demographics were compared by Chi-squared or t-test, and Kaplan-Meier and Cox proportional hazard regression were used for survival analyses.

RESULTS

In total, 1245 patients were diagnosed with CRC (median age 71 years, range 20-98). Of these, 215 patients (17.3%) presented emergently and were included in the analysis. Older adults accounted for 65.1% (n = 140) of emergency presentations. Older adults were less likely to present with classical symptoms of CRC (80.0% vs 90.7%, p = 0.04) and more likely to present via the medical assessment unit (46.4% vs 30.7%, p = 0.03). Additionally, older adults were less likely to receive a histological diagnosis of CRC (71.4% vs 97.3%, p < 0.001) or have complete staging investigations performed (78.6% vs 96.0%, p < 0.001). Fewer older adults underwent surgical management (55.0% vs 86.7%, p < 0.001) and fewer were treated with chemotherapy (14.3% vs 69.3%, p < 0.001). Whilst older adults had poorer median OS than those aged <70 years (12.0 vs 34.4 months, p < 0.001), multivariate Cox proportional hazards regression demonstrated that higher stage (stage III hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.6-4.7, stage IV HR 16.7, 95% CI 9.7-28.8, incomplete HR 8.2, 95% CI 4.6-14.7) and not receiving chemotherapy (HR 2.6, 95% CI 1.7-4.0) were associated with poorer survival, whereas age and sex were not.

DISCUSSION

Emergency presentation of colorectal cancer was more common in older adults. Older adults were more likely to present atypically, less likely to have completed staging, and had lower rates of intervention, which were associated with poorer survival outcome.

Risks of second primary cancers among 584,965 female and male breast cancer survivors in England: a 25-year retrospective cohort study

Background

Second primary cancers (SPCs) after breast cancer (BC) present an increasing public health burden, with little existing research on socio-demographic, tumour, and treatment effects. We addressed this in the largest BC survivor cohort to date, using a novel linkage of National Disease Registration Service datasets.

Methods

The cohort included 581,403 female and 3562 male BC survivors diagnosed between 1995 and 2019. We estimated standardized incidence ratios (SIRs) for combined and site-specific SPCs using incidences for England, overall and by age at BC and socioeconomic status. We estimated incidences and Kaplan-Meier cumulative risks stratified by age at BC, and assessed risk variation by socio-demographic, tumour, and treatment characteristics using Cox regression.

Findings

Both genders were at elevated contralateral breast (SIR: 2.02 (95% CI: 1.99-2.06) females; 55.4 (35.5-82.4) males) and non-breast (1.10 (1.09-1.11) females, 1.10 (1.00-1.20) males) SPC risks. Non-breast SPC risks were higher for females younger at BC diagnosis (SIR: 1.34 (1.31-1.38) <50 y, 1.07 (1.06-1.09) ≥50 y) and more socioeconomically deprived (SIR: 1.00 (0.98-1.02) least deprived quintile, 1.34 (1.30-1.37) most).

Interpretation

Enhanced SPC surveillance may benefit BC survivors, although specific recommendations require more detailed multifactorial risk and cost-benefit analyses. The associations between deprivation and SPC risks could provide clinical management insights.

Funding

CRUK Catalyst Award CanGene-CanVar (C61296/A27223). Cancer Research UK grant: PPRPGM-Nov 20∖100,002. This work was supported by core funding from the NIHR Cambridge Biomedical Research Centre (NIHR203312)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Socio-demographic inequalities in stage at diagnosis of lung cancer: A French population-based study

BACKGROUND

Diagnosing patients at a non-advanced stage has become a mainstay of lung cancer prevention and control strategies. Understanding socio-demographic inequalities in stage at diagnosis may improve the targeting of interventions on patients at higher risk. This study aimed to identify these socio-demographic determinants in a large-scale French population-based cancer registry.

METHODS

All incident lung cancers diagnosed between 2008 and 2019 identified from the Poitou-Charentes Cancer Registry (south-west France) were included. Stage at diagnosis was categorised as advanced/non-advanced (TNM III/IV vs I/II) according to the 8th TNM edition, the objective being to ensure a consistent level of prognosis over time. Socio-demographic variables included age, sex, the French European Deprivation Index (EDI) and patient's place of residence. Their impact on stage at diagnosis was quantified by multivariate logistic regression models with subgroup analyses by histological subtype.

RESULTS

Out of the 15,487 included patients, 75% were diagnosed at an advanced stage (66% to 95% depending on the histological subtype), 17% at a non-advanced stage and 10% at a non-specified stage. Multivariate analysis showed different patterns according to histological subtypes. In patients with adenocarcinoma, a higher risk of advanced stage was found for younger and older patients (u-shape), those most deprived, and those living in rural areas. The same effect of age was reported for squamous cell carcinomas, while no association was found for small-cell lung carcinomas.

CONCLUSIONS

This study highlighted substantial socio-demographic inequalities in stage at diagnosis, specifically for adenocarcinoma patients. Diagnosis strategies could be refined and strengthened in the non-smoker population, in which adenocarcinomas are mainly reported.

Development of a monoclonal antibody to ITPRIPL1 for immunohistochemical diagnosis of non-small cell lung cancers: accuracy and correlation with CD8+ T cell infiltration

Introduction: Cancer biomarkers are substances or processes highly associated with the presence and progression of cancer, which are applicable for cancer screening, progression surveillance, and prognosis prediction in clinical practice. In our previous studies, we discovered that cancer cells upregulate inositol 1,4,5-triphosphate receptor-interacting protein-like 1 (ITPRIPL1), a natural CD3 ligand, to evade immune surveillance and promote tumor growth. We also developed a monoclonal ITPRIPL1 antibody with high sensitivity and specificity. Here, we explored the application of anti-ITPRIPL1 antibody for auxiliary diagnosis of non-small cell lung cancer (NSCLC). Methods: NSCLC patient tissue samples (n = 75) were collected and stained by anti-ITPRIPL1 or anti-CD8 antibodies. After excluding the flaked samples (n = 15), we evaluated the expression by intensity (0-3) and extent (0-100%) of staining to generate an h-score for each sample. The expression status was classified into negative (h-score < 20), low-positive (20-99), and high-positive (≥ 100). We compared the h-scores between the solid cancer tissue and stroma and analyzed the correlation between the h-scores of the ITPRIPL1 and CD8 expression in situ in adjacent tissue slices. Results: The data suggested ITPRIPL1 is widely overexpressed in NSCLC and positively correlates with tumor stages. We also found that ITPRIPL1 expression is negatively correlated with CD8 staining, which demonstrates that ITPRIPL1 overexpression is indicative of poorer immune infiltration and clinical prognosis. Therefore, we set 50 as the cutoff point of ITPRIPL1 expression H scores to differentiate normal and lung cancer tissues, which is of an excellent sensitivity and specificity score (100% within our sample collection). Discussion: These results highlight the potential of ITPRIPL1 as a proteomic immunohistochemical NSCLC biomarker with possible advantages over the existing NSCLC biomarkers, and the ITPRIPL1 antibody can be applied for accurate diagnosis and prognosis prediction.

Correctness and Completeness of Breast Cancer Diagnoses Recorded in UK CPRD Aurum and CPRD GOLD Databases: Comparison to Hospital Episode Statistics and Cancer Registry (Companion Paper 2)

Purpose

To evaluate the new Clinical Practice Research Datalink (CPRD) Aurum database, we estimated 'correctness' (ie accuracy, validity) and 'completeness' (ie presence, missingness) of malignant breast cancer diagnoses recorded in CPRD Aurum compared to external linked data sources: Hospital Episode Statistics (HES) Admitted Patient Care (APC), HES Outpatient (OP), and Cancer Registry (CR), and to the previously validated CPRD GOLD.

Methods

Linkage-eligible, female patients with incident malignant breast cancer diagnosis recorded in at least one study data source were selected. Correctness was the proportion of malignant breast cancer cases recorded in CPRD Aurum or GOLD who also had a diagnosis recorded in HES APC/OP (2004-2019) or CR (2004-2016). Completeness was estimated by identifying all malignant breast cancer diagnoses in HES APC/OP or CR and calculating the proportion with a concordant diagnosis in CPRD Aurum or GOLD.

Results

Compared to HES APC/OP, there were 85,659 and 31,452 eligible patients in CPRD Aurum and GOLD, respectively. Correctness estimates were high (CPRD Aurum 83.5%, GOLD 81.7%). Compared to CR, there were 70,190 and 29,597 eligible patients in CPRD Aurum and GOLD, respectively: correctness was 89.1% for CPRD Aurum and 88.2% for GOLD. Completeness estimates for CPRD Aurum and GOLD were high (>90%). Diagnoses were recorded in CPRD Aurum within -7 to 74 days of those in the linked sources. Reasons for discordant diagnostic coding included presence of treatment or other clinical codes only, diagnosis coded after end of follow-up, non-malignant breast cancer in linked data, and administrative codes in lieu of diagnostic codes.

Conclusion

These results indicate that correctness and completeness of malignant breast cancer diagnoses in CPRD Aurum were high and similar to CPRD GOLD. This provides confidence in use of CPRD Aurum for research purposes. Where complete case capture is important, researchers should consider linkage to HES APC or CR.

Novel methods to define invasive procedures at the end of life were developed to improve quality of end of life care research: a population-based cohort study in colorectal cancer

BACKGROUND

Understanding the use of invasive procedures (IPs) at the end of life (EoL) is important to avoid undertreatment and overtreatment, but epidemiologic analysis is hampered by limited methods to define treatment intent and EoL phase. This study applied novel methods to report IPs at the EoL using a colorectal cancer case study.

METHODS

An English population-based cohort of adult patients diagnosed between 2013 and 2015 was used with follow-up to 2018. Procedure intent (curative, noncurative, diagnostic) by cancer site and stage at diagnosis was classified by two surgeons independently. Joinpoint regression modeled weekly rates of IPs for 36 subcohorts of patients with incremental survival of 0-36 months. EoL phase was defined by a significant IP rate change before death. Zero-inflated Poisson regression explored associations between IP rates and clinical/sociodemographic variables.

RESULTS

Of 87,731 patients included, 41,972 (48%) died. Nine thousand four hundred ninety two procedures were classified by intent (inter-rater agreement 99.8%). Patients received 502,895 IPs (1.39 and 3.36 per person year for survivors and decedents). Joinpoint regression identified significant increases in IPs 4 weeks before death in those living 3-6 months and 8 weeks before death in those living 7-36 months from diagnosis. Seven thousand nine hundred eight (18.8%) patients underwent IPs at the EoL, with stoma formation the most common major procedure. Younger age, early-stage disease, men, lower comorbidity, those receiving chemotherapy, and living longer from diagnosis were associated with IPs.

CONCLUSION

Methods to identify and classify IPs at the EoL were developed and tested within a colorectal cancer population. This approach can be now extended and validated to identify potential undertreatment and overtreatment.

Non-Surgical Site Pain in Women following Breast Cancer Surgery: A Systematic Review and Meta-Analysis

Background

Chronic pain after breast cancer surgery affects up to 60% of patients. Evidence supports the fact that pain outwith the surgical site is a significant issue. This systematic review and meta-analysis sought to evaluate the prevalence of non-surgical site pain (NSSP) in women after breast cancer surgery at 6 months post-operatively.

Methods

Adult women with a confirmed breast cancer diagnosis who had undergone breast cancer surgery were identified. The outcome pursued was pain outwith the surgical site measured on either NRS/VRS or VAS rating scale. CENTRAL, Embase, PubMed, MEDLINE, CINAHL, PsycInfo, Web of Science, and Scopus were searched to identify studies that examined NSSP after breast cancer surgery at 6 months. Data were gathered via pre-piloted Excel forms and analysed both quantitively and qualitatively. Meta-analysis was carried out using a random-effects model to assess risk difference with 95% confidence interval (CI).

Results

A total of sixteen studies were identified for inclusion. Eleven studies failed to provide sufficient data and consequently were analysed qualitatively. Five studies were adequate for quantitative analysis, including a total of 995 patients. Meta-analysis identified a risk difference of 18% (95% CI: 5-31%) between patients who had breast cancer surgery and a reference, however, this is low-quality evidence.

Conclusion

This review has highlighted that breast cancer surgery increases the risk of pain outwith the surgical site postoperatively. It was additionally identified that NSSP data are often gathered in research yet rarely presented in results or highlighted as a primary outcome. As the quality of evidence was low, research specifying NSSP as a primary outcome is required to provide more certainty.

Age-related differences in colon and rectal cancer survival by stage, histology, and tumour site: An analysis of United States SEER-18 data

Age-related differences in colon and rectal cancer survival have been observed, even after accounting for differences in background mortality. To determine how stage, tumour site, and histology contribute to these differences, we extracted age-specific one-year relative survival ratio (RS) stratified by these factors. We used colon and rectal cancer cases diagnosed between 2012 and 2016 from 18 United States Surveillance Epidemiology and End Results cancer registries. For colon cancer, 1-year RS ranged from 87.8 % [95 % Confidence Interval: 87.5-88.2] in the 50-64-year-olds to 62.3 % [61.3-63.3] in 85-99-year-olds and for rectal cancer ranged from 92.3 % [91.8-92.7] to 65.0 % [62.3-67.5]. With respect to stage, absolute differences in RS between 50-64-year-olds and 75-84-year-olds increased with increasing stage (from 6 [5-7] %-points in localised disease to 27 [25-29] %-points in distant disease) and were the highest for cancers of unknown stage (> 28 %-points). Age-related differences in survival were smallest for persons with tumours in the right-sided colon (8 [7-9] %-points) and largest for tumours of the colon without tumour site further specified (25 [21-29] %-points). With respect to histology, differences ranged from 7.4 % to 10.6 %-points for cancers with one of the three primary histologies (adenocarcinoma, mucinous adenocarcinoma, signet ring cell carcinoma) and were several-fold higher (42 %-points) for those with unknown/other histology (< 6 % of cases). Because age-related differences in survival were observed for all histologies and tumour sites, RS differences are unlikely to be driven by differences in the distribution of these factors by age. Differences in stage distribution by age are likely to contribute toward age-related differences in survival. Within stage groups, age differences in survival could be explained by frailty and/or therapy. Future studies incorporating data on treatment and geriatric conditions including frailty and comorbidity would support further understanding of the age gap in colon and rectal cancer survival.

Immortal-time bias in older vs younger age groups: a simulation study with application to a population-based cohort of patients with colon cancer

BACKGROUND

In observational studies, the risk of immortal-time bias (ITB) increases with the likelihood of early death, itself increasing with age. We investigated how age impacts the magnitude of ITB when estimating the effect of surgery on 1-year overall survival (OS) in patients with Stage IV colon cancer aged 50-74 and 75-84 in England.

METHODS

Using simulations, we compared estimates from a time-fixed exposure model to three statistical methods addressing ITB: time-varying exposure, delayed entry and landmark methods. We then estimated the effect of surgery on OS using a population-based cohort of patients from the CORECT-R resource and conducted the analysis using the emulated target trial framework.

RESULTS

In simulations, the magnitude of ITB was larger among older patients when their probability of early death increased or treatment was delayed. The bias was corrected using the methods addressing ITB. When applied to CORECT-R data, these methods yielded a smaller effect of surgery than the time-fixed exposure approach but effects were similar in both age groups.

CONCLUSION

ITB must be addressed in all longitudinal studies, particularly, when investigating the effect of exposure on an outcome in different groups of people (e.g., age groups) with different distributions of exposure and outcomes.

Impute-then-exclude versus exclude-then-impute: Lessons when imputing a variable used both in cohort creation and as an independent variable in the analysis model

We examined the setting in which a variable that is subject to missingness is used both as an inclusion/exclusion criterion for creating the analytic sample and subsequently as the primary exposure in the analysis model that is of scientific interest. An example is cancer stage, where patients with stage IV cancer are often excluded from the analytic sample, and cancer stage (I to III) is an exposure variable in the analysis model. We considered two analytic strategies. The first strategy, referred to as "exclude-then-impute," excludes subjects for whom the observed value of the target variable is equal to the specified value and then uses multiple imputation to complete the data in the resultant sample. The second strategy, referred to as "impute-then-exclude," first uses multiple imputation to complete the data and then excludes subjects based on the observed or filled-in values in the completed samples. Monte Carlo simulations were used to compare five methods (one based on "exclude-then-impute" and four based on "impute-then-exclude") along with the use of a complete case analysis. We considered both missing completely at random and missing at random missing data mechanisms. We found that an impute-then-exclude strategy using substantive model compatible fully conditional specification tended to have superior performance across 72 different scenarios. We illustrated the application of these methods using empirical data on patients hospitalized with heart failure when heart failure subtype was used for cohort creation (excluding subjects with heart failure with preserved ejection fraction) and was also an exposure in the analysis model.

Age-related differences in cancer relative survival in the United States: A SEER-18 analysis

Cancer survival has improved since the 1990s, but to different extents across age groups, with a disadvantage for older adults. We aimed to quantify age-related differences in relative survival (RS-1-year and 1-year conditioning on surviving 1 year) for 10 common cancer types by stage at diagnosis. We used data from 18 United States Surveillance Epidemiology and End Results cancer registries and included cancers diagnosed in 2012 to 2016 followed until December 31, 2017. We estimated absolute differences in RS between the 50 to 64 age group and the 75 to 84 age group. The smallest differences were observed for prostate and breast cancers (1.8%-points [95% confidence interval (CI): 1.5-2.1] and 1.9%-points [95% CI: 1.5-2.3], respectively). The largest was for ovarian cancer (27%-points, 95% CI: 24-29). For other cancers, differences ranged between 7 (95% CI: 5-9, esophagus) and 18%-points (95% CI: 17-19, pancreas). Except for pancreatic cancer, cancer type and stage combinations with very high (>95%) or very low (<40%) 1-year RS tended to have smaller age-related differences in survival than those with mid-range prognoses. Age-related differences in 1-year survival conditioning on having survived 1-year were small for most cancer and stage combinations. The broad variation in survival differences by age across cancer types and stages, especially in the first year, age-related differences in survival are likely influenced by amenability to treatment. Future work to measure the extent of age-related differences that are avoidable, and identify how to narrow the survival gap, may have most benefit by prioritizing cancers with relatively large age-related differences in survival (eg, stomach, esophagus, liver and pancreas).

Relationship between ethnicity and stage at diagnosis in England: a national analysis of six cancer sites

OBJECTIVES

Cancer stage at diagnosis is a determinant of treatment options and survival. Previous research has shown differences in barriers to presentation with cancer between ethnic groups. The completeness and quality of cancer stage and ethnicity data has improved markedly over recent years in England, allowing for comparison of stage distributions at diagnosis between ethnic groups. This study aimed to assess relationships between ethnic group and two outcomes: unknown stage cancer and late stage (stages 3 and 4) cancer, after adjustment for confounders.

DESIGN AND SETTING

A retrospective secondary data analysis using data from NHS Digital's National Cancer Registration and Analysis Service and Hospital Episode Statistics records from 2012 to 2016.

PARTICIPANTS

This study analysed newly diagnosed breast, colon, non-small cell lung cancer (NSCLC), ovary, prostate and uterine cancers in white British, Caribbean, African, Chinese and Asian patients aged 15-99 in England.

RESULTS

Caribbean, African and Asian women with breast or ovarian cancer, Caribbean and African women with uterine or colon cancer, Caribbean women with NSCLC and Caribbean men with colon cancer had increased odds of late-stage disease at diagnosis compared with the white British cohort. In contrast, Caribbean and African men with prostate cancer had decreased odds of late-stage cancer. Where stage was known, there were variations in late-stage cancer by ethnic group.

CONCLUSIONS

Low symptom awareness and barriers to presentation can cause delays, resulting in later stage diagnosis. Targeted intervention campaigns to help raise awareness of cancer signs and symptoms and the benefits of early diagnosis, along with removing barriers to appropriate referrals, could help to improve these inequalities.

Head and neck cancer in the UK: what was the stage before COVID-19? UK cancer registries analysis (2011-2018)

Introduction People who present with more advanced stage head and neck cancer (HNC) are associated with poorer outcomes and survival. The burden and trends of advanced stage HNC are not fully known at the population level. The UK national cancer registries routinely collect data on HNC diagnoses.Aims To describe trends in stage of diagnosis of HNCs across the UK before the COVID-19 pandemic.Methods Aggregated HNC incidence data were requested from the national cancer registries of the four UK countries for the ten most recent years of available data by subsite and American Joint Commission on Cancer stage at diagnosis classification. Additionally, data for Scotland were available by age group, sex and area-based socioeconomic deprivation category.Results Across the UK, rates of advanced stage HNC had increased, with 59% of patients having advanced disease at diagnosis from 2016-2018. England had a lower proportion of advanced disease (58%) than Scotland, Wales or Northern Ireland (65-69%) where stage data were available. The completeness of stage data had improved over recent years (87% by 2018).Conclusion Prior to the COVID-19 pandemic, diagnoses of HNC at an advanced stage comprised the majority of HNCs in the UK, representing the major challenge for the cancer healthcare system.

Distance to highway and factory density related to lung cancer death and associated spatial heterogeneity in effects in Jiading District, Shanghai

This study aimed to determine the spatial effects of traffic- and industrial-related pollution on the mortality for lung cancer (LC). We conducted a retrospective cohort study by using the data from LC registry in Jiading District for the period from 2002 to 2012. Standard parametric model with Weibull distribution was used for spatial survival analysis. Shorter distance to highway (adjusted odds ratio (aOR) = 1.15, 95% confidence interval (CI): 1.03-1.30) and higher factory density (aOR = 1.20, 95% CI: 1.05-1.37) were significantly associated with an increased risk of LC death, and there was a spatial difference in the associations between northern and southern areas of Jiading District. The risk was high in suburbs as compared with urban areas. Traffic- and industrial-related pollution were significantly associated with an increased risk of LC death, which showed a spatial variation. Further studies are needed to better understand the current LC status in the suburbs and to reduce health disparities.

Quantifying the impact of pre-existing conditions on the stage of oesophagogastric cancer at diagnosis: a primary care cohort study using electronic medical records

BACKGROUND

Pre-existing conditions interfere with cancer diagnosis by offering diagnostic alternatives, competing for clinical attention or through patient surveillance.

OBJECTIVE

To investigate associations between oesophagogastric cancer stage and pre-existing conditions.

METHODS

Retrospective cohort study using Clinical Practice Research Datalink (CPRD) data, with English cancer registry linkage. Participants aged ≥40 years had consulted primary care in the year before their incident diagnosis of oesophagogastric cancer in 01/01/2010-31/12/2015. CPRD records pre-diagnosis were searched for codes denoting clinical features of oesophagogastric cancer and for pre-existing conditions, including those providing plausible diagnostic alternatives for those features. Logistic regression analysed associations between stage and multimorbidity (≥2 conditions; reference category: no multimorbidity) and having 'diagnostic alternative(s)', controlling for age, sex, deprivation and cancer site.

RESULTS

Of 2444 participants provided, 695 (28%) were excluded for missing stage, leaving 1749 for analysis (1265/1749, 72.3% had advanced-stage disease). Multimorbidity was associated with stage [odds ratio 0.63, 95% confidence interval (CI) 0.47-0.85, P = 0.002], with moderate evidence of an interaction term with sex (1.76, 1.08-2.86, P = 0.024). There was no association between alternative explanations and stage (odds ratio 1.18, 95% CI 0.87-1.60, P = 0.278).

CONCLUSIONS

In men, multimorbidity is associated with a reduced chance of advanced-stage oesophagogastric cancer, to levels seen collectively for women.

Socio-Economic Position, Cancer Incidence and Stage at Diagnosis: A Nationwide Cohort Study in Belgium

Background: Socio-economic position is associated with cancer incidence, but the direction and magnitude of this relationship differs across cancer types, geographical regions, and socio-economic parameters. In this nationwide cohort study, we evaluated the association between different individual-level socio-economic and -demographic factors, cancer incidence, and stage at diagnosis in Belgium. Methods: The 2001 census was linked to the nationwide Belgian Cancer Registry for cancer diagnoses between 2004 and 2013. Socio-economic parameters included education level, household composition, and housing conditions. Incidence rate ratios were assessed through Poisson regression models. Stage-specific analyses were conducted through logistic regression models. Results: Deprived groups showed higher risks for lung cancer and head and neck cancers, whereas an inverse relation was observed for malignant melanoma and female breast cancer. Typically, associations were more pronounced in men than in women. A lower socio-economic position was associated with reduced chances of being diagnosed with known or early stage at diagnosis; the strongest disparities were found for male lung cancer and female breast cancer. Conclusions: This study identified population groups at increased risk of cancer and unknown or advanced stage at diagnosis in Belgium. Further investigation is needed to build a comprehensive picture of socio-economic inequality in cancer incidence.

What are the implications of using individual and combined sources of routinely collected data to identify and characterise incident site-specific cancers? a concordance and validation study using linked English electronic health records data

OBJECTIVES

To describe the benefits and limitations of using individual and combinations of linked English electronic health data to identify incident cancers.

DESIGN AND SETTING

Our descriptive study uses linked English Clinical Practice Research Datalink primary care; cancer registration; hospitalisation and death registration data.

PARTICIPANTS AND MEASURES

We implemented case definitions to identify first site-specific cancers at the 20 most common sites, based on the first ever cancer diagnosis recorded in each individual or commonly used combination of data sources between 2000 and 2014. We calculated positive predictive values and sensitivities of each definition, compared with a gold standard algorithm that used information from all linked data sets to identify first cancers. We described completeness of grade and stage information in the cancer registration data set.

RESULTS

165 953 gold standard cancers were identified. Positive predictive values of all case definitions were ≥80% and ≥94% for the four most common cancers (breast, lung, colorectal and prostate). Sensitivity for case definitions that used cancer registration alone or in combination was ≥92% for the four most common cancers and ≥80% across all cancer sites except bladder cancer (65% using cancer registration alone). For case definitions using linked primary care, hospitalisation and death registration data, sensitivity was ≥89% for the four most common cancers, and ≥80% for all cancer sites except kidney (69%), oral cavity (76%) and ovarian cancer (78%). When primary care or hospitalisation data were used alone, sensitivities were generally lower and diagnosis dates were delayed. Completeness of staging data in cancer registration data was high from 2012 (minimum 76.0% in 2012 and 86.4% in 2014 for the four most common cancers).

CONCLUSIONS

Ascertainment of incident cancers was good when using cancer registration data alone or in combination with other data sets, and for the majority of cancers when using a combination of primary care, hospitalisation and death registration data.

Temporal and geographic changes in stage at diagnosis in England during 2008-2013: A population-based study of colorectal, lung and ovarian cancers

BACKGROUND

Increasing diagnosis of cancer when the disease is still at early stages is a priority of cancer policy internationally. In England, reducing geographical inequalities in early diagnosis is also a key objective. Stage at diagnosis is not recorded for many patients, which may bias assessments of progress. We evaluate temporal and geographical changes in stage at diagnosis during 2008-2013 for colorectal, non-small cell lung, and ovarian cancers, using multiple imputation to minimise bias from missing data.

METHODS

Population-based data from cancer registrations, routes to diagnosis, secondary care, and clinical audits were individually linked. Patient characteristics and recorded stage were summarised. Stage was imputed where missing using auxiliary information (including patient's survival time). Logistic regression was used to estimate temporal and geographical changes in early diagnosis adjusted for case mix using a multilevel model.

RESULTS

We analysed 196,511 colorectal, 180,048 non-small cell lung, and 29,076 ovarian cancer patients. We estimate that there were very large increases in the percentage of patients diagnosed at stages I or II between 2008-09 and 2012-13: from 32% to 44% for colorectal cancer, 19% to 25% for non-small cell lung cancer, and 28% to 31% for ovarian cancer. Geographical inequalities reduced for colorectal and ovarian cancer.

INTERPRETATION

Multiple imputation is an optimal approach to reduce bias from missing data, but residual bias may be present in these estimates. Increases in early-stage diagnosis coincided with increased diagnosis through the "two week wait" pathway and colorectal screening. Epidemiological analyses from 2013 are needed to evaluate continued progress.

Breast cancer survival in sub-Saharan Africa by age, stage at diagnosis and human development index: A population-based registry study

Breast cancer is the leading cancer diagnosis and second most common cause of cancer deaths in sub-Saharan Africa (SSA). Yet, there are few population-level survival data from Africa and none on the survival differences by stage at diagnosis. Here, we estimate breast cancer survival within SSA by area, stage and country-level human development index (HDI). We obtained data on a random sample of 2,588 breast cancer incident cases, diagnosed in 2008-2015 from 14 population-based cancer registries in 12 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2,311 were included for survival analyses. The 1-, 3- and 5-year observed and relative survival (RS) were estimated by registry, stage and country-level HDI. We equally estimated the excess hazards adjusting for potential confounders. Among patients with known stage, 64.9% were diagnosed in late stages, with 18.4% being metastatic at diagnosis. The RS varied by registry, ranging from 21.6%(8.2-39.8) at Year 3 in Bulawayo to 84.5% (70.6-93.5) in Namibia. Patients diagnosed at early stages had a 3-year RS of 78% (71.6-83.3) in contrast to 40.3% (34.9-45.7) at advanced stages (III and IV). The overall RS at Year 1 was 86.1% (84.4-87.6), 65.8% (63.5-68.1) at Year 3 and 59.0% (56.3-61.6) at Year 5. Age at diagnosis was not independently associated with increased mortality risk after adjusting for the effect of stage and country-level HDI. In conclusion, downstaging breast cancer at diagnosis and improving access to quality care could be pivotal in improving breast cancer survival outcomes in Africa.

Assessing a modified-AJCC TNM staging system in the New South Wales Cancer Registry, Australia

Background

In 2017, the New South Wales Cancer Registry (NSWCR) participated in a project, supported by Cancer Australia, aiming to provide national stage data for melanoma, prostate, colorectal, breast, and lung cancers diagnosed in 2011. Simplified business rules based on the American Joint Committee for Cancer (AJCC) Tumour-Node-Metastasis (TNM) stage were applied to obtain Registry-Derived (RD) stage, defined as the best estimate of TNM stage at diagnosis using routine notifications available within cancer registries. RD-stage was compared with Degree of Spread (DoS), which has been recorded for all applicable cancers in NSWCR at a population-based level since 1972, and a summary AJCC-TNM stage group, which has been collected variably since 2006. For each of the five high incidence cancers, we compared the level of improvements RD-staging provided in terms of completeness and accuracy (alignment to more clinically relevant AJCC-TNM) over DoS.

Methods

For each of the five cancers, stage data were extracted from NSWCR pre- and post- RD-staging to compare data completeness across all three staging systems. The alignment between DoS/RD-stage and AJCC-TNM was compared, as were the expected and observed cross-tabulated frequency distributions using a subset of NSWCR data. To determine differences between use of DoS, RD-stage, and AJCC-TNM in an epidemiological analysis, we compared survival models developed from each of the three stage variables.

Results

We found RD-staging provided greatest stage data completeness and alignment to AJCC-TNM for prostate cancers, followed by breast, then melanoma and lung cancers. For colorectal cancer, summary stage from DoS was confirmed as an equivalent surrogate staging system to both AJCC-TNM and RD-stage.

Conclusions

This analysis provides an evidence-based approach that can be used to inform decision-making for resource planning and potential implementation of a new stage data field in population-based cancer registries.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-6062-x) contains supplementary material, which is available to authorized users.