Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Cancer Prevention with Resistant Starch in Lynch Syndrome Patients in the CAPP2-Randomized Placebo Controlled Trial: Planned 10-Year Follow-up

ABSTRACT

The CAPP2 trial investigated the long-term effects of aspirin and resistant starch on cancer incidence in patients with Lynch syndrome (LS). Participants with LS were randomized double-blind to 30 g resistant starch (RS) daily or placebo for up to 4 years. We present long-term cancer outcomes based on the planned 10-year follow-up from recruitment, supplemented by National Cancer Registry data to 20 years in England, Wales, and Finland. Overall, 463 participants received RS and 455 participants received placebo. After up to 20 years follow-up, there was no difference in colorectal cancer incidence (n = 52 diagnosed with colorectal cancer among those randomized to RS against n = 53 on placebo) but fewer participants had non-colorectal LS cancers in those randomized to RS (n = 27) compared with placebo (n = 48); intention-to-treat (ITT) analysis [HR, 0.54; 95% confidence interval (CI), 0.33-0.86; P = 0.010]. In ITT analysis, allowing for multiple primary cancer diagnoses among participants by calculating incidence rate ratios (IRR) confirmed the protective effect of RS against non-colorectal cancer LS cancers (IRR, 0.52; 95% CI, 0.32-0.84; P = 0.0075). These effects are particularly pronounced for cancers of the upper GI tract; 5 diagnoses in those on RS versus 21 diagnoses on placebo. The reduction in non-colorectal cancer LS cancers was detectable in the first 10 years and continued in the next decade. For colorectal cancer, ITT analysis showed no effect of RS on colorectal cancer risk (HR, 0.92; 95% CI, 0.62-1.34; P = 0.63). There was no interaction between aspirin and RS treatments. In conclusion, 30 g daily RS appears to have a substantial protective effect against non-colorectal cancer cancers for patients with LS.

PREVENTION RELEVANCE

Regular bowel screening and aspirin reduce colorectal cancer among patients with LS but extracolonic cancers are difficult to detect and manage. This study suggests that RS reduces morbidity associated with extracolonic cancers. See related Spotlight, p. 557.

Outcome-Oriented Deep Temporal Phenotyping of Disease Progression

Chronic diseases evolve slowly throughout a patient's lifetime creating heterogeneous progression patterns that make clinical outcomes remarkably varied across individual patients. A tool capable of identifying temporal phenotypes based on the patients different progression patterns and clinical outcomes would allow clinicians to better forecast disease progression by recognizing a group of similar past patients, and to better design treatment guidelines that are tailored to specific phenotypes. To build such a tool, we propose a deep learning approach, which we refer to as outcome-oriented deep temporal phenotyping (ODTP), to identify temporal phenotypes of disease progression considering what type of clinical outcomes will occur and when based on the longitudinal observations. More specifically, we model clinical outcomes throughout a patient's longitudinal observations via time-to-event (TTE) processes whose conditional intensity functions are estimated as non-linear functions using a recurrent neural network. Temporal phenotyping of disease progression is carried out by our novel loss function that is specifically designed to learn discrete latent representations that best characterize the underlying TTE processes. The key insight here is that learning such discrete representations groups progression patterns considering the similarity in expected clinical outcomes, and thus naturally provides outcome-oriented temporal phenotypes. We demonstrate the power of ODTP by applying it to a real-world heterogeneous cohort of 11 779 stage III breast cancer patients from the U.K. National Cancer Registration and Analysis Service. The experiments show that ODTP identifies temporal phenotypes that are strongly associated with the future clinical outcomes and achieves significant gain on the homogeneity and heterogeneity measures over existing methods. Furthermore, we are able to identify the key driving factors that lead to transitions between phenotypes which can be translated into actionable information to support better clinical decision-making.

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study

BACKGROUND

There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England.

METHODS

Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated.

FINDINGS

As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53-71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89-95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020.

INTERPRETATION

The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England.

FUNDING

Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

Retrospective cohort study of admission timing and mortality following COVID-19 infection in England

OBJECTIVES

We investigated whether the timing of hospital admission is associated with the risk of mortality for patients with COVID-19 in England, and the factors associated with a longer interval between symptom onset and hospital admission.

DESIGN

Retrospective observational cohort study of data collected by the COVID-19 Hospitalisation in England Surveillance System (CHESS). Data were analysed using multivariate regression analysis.

SETTING

Acute hospital trusts in England that submit data to CHESS routinely.

PARTICIPANTS

Of 14 150 patients included in CHESS until 13 May 2020, 401 lacked a confirmed diagnosis of COVID-19 and 7666 lacked a recorded date of symptom onset. This left 6083 individuals, of whom 15 were excluded because the time between symptom onset and hospital admission exceeded 3 months. The study cohort therefore comprised 6068 unique individuals.

MAIN OUTCOME MEASURES

All-cause mortality during the study period.

RESULTS

Timing of hospital admission was an independent predictor of mortality following adjustment for age, sex, comorbidities, ethnicity and obesity. Each additional day between symptom onset and hospital admission was associated with a 1% increase in mortality risk (HR 1.01; p<0.005). Healthcare workers were most likely to have an increased interval between symptom onset and hospital admission, as were people from Black, Asian and minority ethnic (BAME) backgrounds, and patients with obesity.

CONCLUSION

The timing of hospital admission is associated with mortality in patients with COVID-19. Healthcare workers and individuals from a BAME background are at greater risk of later admission, which may contribute to reports of poorer outcomes in these groups. Strategies to identify and admit patients with high-risk and those showing signs of deterioration in a timely way may reduce the consequent mortality from COVID-19, and should be explored.

Cancer prevention with aspirin in hereditary colorectal cancer (Lynch syndrome), 10-year follow-up and registry-based 20-year data in the CAPP2 study: a double-blind, randomised, placebo-controlled trial

BACKGROUND

Lynch syndrome is associated with an increased risk of colorectal cancer and with a broader spectrum of cancers, especially endometrial cancer. In 2011, our group reported long-term cancer outcomes (mean follow-up 55·7 months [SD 31·4]) for participants with Lynch syndrome enrolled into a randomised trial of daily aspirin versus placebo. This report completes the planned 10-year follow-up to allow a longer-term assessment of the effect of taking regular aspirin in this high-risk population.

METHODS

In the double-blind, randomised CAPP2 trial, 861 patients from 43 international centres worldwide (707 [82%] from Europe, 112 [13%] from Australasia, 38 [4%] from Africa, and four [<1%] from The Americas) with Lynch syndrome were randomly assigned to receive 600 mg aspirin daily or placebo. Cancer outcomes were monitored for at least 10 years from recruitment with English, Finnish, and Welsh participants being monitored for up to 20 years. The primary endpoint was development of colorectal cancer. Analysis was by intention to treat and per protocol. The trial is registered with the ISRCTN registry, number ISRCTN59521990.

FINDINGS

Between January, 1999, and March, 2005, 937 eligible patients with Lynch syndrome, mean age 45 years, commenced treatment, of whom 861 agreed to be randomly assigned to the aspirin group or placebo; 427 (50%) participants received aspirin and 434 (50%) placebo. Participants were followed for a mean of 10 years approximating 8500 person-years. 40 (9%) of 427 participants who received aspirin developed colorectal cancer compared with 58 (13%) of 434 who received placebo. Intention-to-treat Cox proportional hazards analysis revealed a significantly reduced hazard ratio (HR) of 0·65 (95% CI 0·43-0·97; p=0·035) for aspirin versus placebo. Negative binomial regression to account for multiple primary events gave an incidence rate ratio of 0·58 (0·39-0·87; p=0·0085). Per-protocol analyses restricted to 509 who achieved 2 years' intervention gave an HR of 0·56 (0·34-0·91; p=0·019) and an incidence rate ratio of 0·50 (0·31-0·82; p=0·0057). Non-colorectal Lynch syndrome cancers were reported in 36 participants who received aspirin and 36 participants who received placebo. Intention-to-treat and per-protocol analyses showed no effect. For all Lynch syndrome cancers combined, the intention-to-treat analysis did not reach significance but per-protocol analysis showed significantly reduced overall risk for the aspirin group (HR=0·63, 0·43-0·92; p=0·018). Adverse events during the intervention phase between aspirin and placebo groups were similar, and no significant difference in compliance between intervention groups was observed for participants with complete intervention phase data; details reported previously.

INTERPRETATION

The case for prevention of colorectal cancer with aspirin in Lynch syndrome is supported by our results.

FUNDING

Cancer Research UK, European Union, MRC, NIHR, Bayer Pharma AG, Barbour Foundation.

Nationwide Incidence of Metastatic Cutaneous Squamous Cell Carcinoma in England

Importance

Cutaneous squamous cell carcinoma (cSCC) is the most common skin cancer with metastatic potential, but epidemiologic data are poor. Changes to the National Cancer Registration and Analysis Service (NCRAS) in England have allowed more accurate data analysis of primary and metastatic cSCC since 2013.

Objective

To assess the national incidence of cSCC and metastatic cSCC (mcSCC) in England from 2013 through 2015.

Design, Setting, and Participants

This national population-based study identified a cohort of patients with cSCC and mcSCC in England from January 1, 2013, through December 31, 2015. Patients were identified using diagnostic codes derived from pathology reports in the NCRAS. Data were analyzed from March 1, 2017, through March 1, 2018.

Main Outcomes and Measures

Incidence rates across sex and risk factors for cSCC were derived from the NCRAS data. Risk of occurrence of mcSCC among the population with cSCC was assessed with Cox proportional hazards regression analysis to determine indicators of mcSCC.

Results

Among the 76 977 patients with first primary cSCC in 2013 through 2015 (62.7% male; median age, 80 years [interquartile range, 72-86 years]), the age-standardized rates for the first registered cSCC in England from 2013 through 2015 were 77.3 per 100 000 person-years (PY) (95% CI, 76.6-78.0) in male patients and 34.1 per 100 000 PY (95% CI, 33.7-34.5) in female patients. Increased primary cSCC tumor count was observed in older, white male patients in lower deprivation quintiles. After a maximum follow-up of 36 months, cumulative incidence of mcSCC developed in 1.1% of women and 2.4% of men with a primary cSCC. Significant increases in the risk of metastasis with adjusted hazard rates of approximately 2.00 were observed in patients who were aged 80 to 89 years (hazard ratio [HR], 1.23; 95% CI, 1.07-1.43), 90 years or older (HR, 1.35; 95% CI, 1.09-1.66), male (HR, 1.79; 95% CI, 1.52-2.10), immunosuppressed (HR, 1.99; 95% CI, 1.64-2.42), and in higher deprivation quintiles (HR for highest quintile, 1.64; 95% CI, 1.35-2.00). Primary cSCC located on the ear (HR, 1.70; 95% CI, 1.42-2.03) and lip (HR, 1.85; 95% CI, 1.29-2.63) were at highest risk of metastasis.

Conclusions and Relevance

This study presents the first national study of the incidence of mcSCC. With limited health care resources and an aging population, accurate epidemiologic data are essential for informing future health care planning, identifying high-risk patients, and evaluating skin cancer prevention policies.

Data resource description: Systemic Anti-Cancer Therapy (SACT) Dataset

Background The Systemic Anti-Cancer Therapy (SACT) dataset is a unique source of national, real-world data reporting chemotherapy activity delivered by NHS treatment providers in England. SACT data are collected with the intent of improving disease-free or progression-free survival. Main Aim The SACT dataset aims to provide a detailed resource on systemic treatments delivered in secondary and tertiary settings in England for patients with cancer. Approach The SACT dataset is collected and curated by the National Cancer Registration and Analysis Service (NCRAS) at Public Health England. The dataset was launched in a phased implementation from April 2012. From April 2014 submission of SACT data became mandatory for all NHS treatment providers. Data are collected on the patient, tumour, regimen, treatment cycle, drug details, and treatment outcomes. The SACT dataset can be linked to other data held by NCRAS, for example the cancer registry1, Hospital Episodes Statistics2, and the national Radiotherapy Dataset to provide a complete picture of the cancer patient pathway. Results The SACT dataset is being used: for the appraisal of drugs funded through the Cancer Drugs Fund; to review the quality of cancer care as part of the National Cancer Audits; and for observational research purposes, including investigating 30-day mortality following chemotherapy3, and sociodemographic variation in the use of chemotherapy in patients with stage IV lung, oesophageal, stomach and pancreatic cancer4. The data are also released to external researchers via the Office for Data Release. Conclusion The SACT dataset is a unique resource in terms of the breadth and depth of information on chemotherapy prescribed to cancer patients. The key strengths are: the national coverage; real-world data; detailed clinical information beyond cancer registration data; and the ability to link to other cancer datasets. References Henson KE, Elliss-Brookes L, Coupland VH, Payne E, Vernon S, Rous B et al. Data Resource Profile: National Cancer Registration Dataset in England. Int J Epidemiol 2019; doi 10.1093/ije/dyz076. Herbert A, Wijlaars L, Zylbersztejn A, Cromwell D, Hardelid P. Data Resource Profile: Hospital Episode Statistics Admitted Patient Care (HES APC). Int J Epidemiol 2017; 46(4): 1093-1093i; e-pub ahead of print 2017/03/25; doi 10.1093/ije/dyx015. Wallington M, Saxon EB, Bomb M, Smittenaar R, Wickenden M, McPhail S et al. 30-day mortality after systemic anticancer treatment for breast and lung cancer in England: a population-based, observational study. The Lancet Oncology 2016; 17(9): 1203-1216; doi 10.1016/s1470-2045(16)30383-7. Henson KE, Fry A, Lyratzopoulos G, Peake M, Roberts KJ, McPhail S. Sociodemographic variation in the use of chemotherapy and radiotherapy in patients with stage IV lung, oesophageal, stomach and pancreatic cancer: evidence from population-based data in England during 2013-2014. Br J Cancer 2018; doi 10.1038/s41416-018-0028-7.

Data resource description: National Cancer Registration Dataset in England

Background The National Cancer Registration and Analysis Service (NCRAS), in Public Health England (PHE), collects and quality assures clinical information on all cases of cancer that occur in people living in England. The data collected supports the delivery of effective NHS cancer services. Aim NCRAS aims to curate a clinically rich data resource, which this abstract describes. Approach The data collected by NCRAS comes from several sources including Multi-Disciplinary Team (MDT) meetings and pathology reports. Data is reviewed by Cancer Registration Officers with the assistance of automated tools for data linkage and de-duplication of identical data sources. The data collected includes: patient identifiers; patient characteristics (e.g. sex, ethnicity); cancer specific fields (e.g. diagnosis date, cancer site, morphology, laterality, stage at diagnosis); cancer treatment fields; death information (e.g. date and cause of death); health care system information (e.g. hospital of diagnosis); and geography at diagnosis (based on patient’s postcode of residence). Results Data is submitted by 162 healthcare providers, covering over 1,700 MDTs. Population-based official statistics are available for cancers diagnosed since 1971. The data is routinely used to inform and allow evidence-based decisions about NHS service provision and patient care and to longitudinally track cancer incidence rates and survival statistics. In recent years, completeness of specific items such as stage has greatly improved. However, non-death outcomes, such as quality of life assessments and recurrence, are currently difficult to identify. Conclusion Detailed clinical information on cancer across the patient pathway enables the measurement of the diagnosis, treatment and survival outcome of all patients diagnosed with cancer. This population-based national data resource is critical to support service provision, clinical audit, commissioning, planning of services, public health and epidemiological research; all of which contribute to improved outcomes for people diagnosed with cancer.

Epidemiology of basal and cutaneous squamous cell carcinoma in the U.K. 2013-15: a cohort study

BACKGROUND

Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC), together known as keratinocyte cancers (KCs), are the commonest cancer in white ethnic populations. Recent improvements to registry data collection in England has allowed more accurate analysis of the epidemiology of BCC and cSCC and for the first time we are able to provide an accurate (representative) tumour burden for KC in the U.K.

OBJECTIVES

To estimate the incidence of BCC and cSCC in the U.K.

METHODS

A cohort of patients with KCs between 2013 and 2015 were identified using linkage to diagnostic codes derived from pathology reports collected into the national cancer registry. Data from England's cancer registry were combined with data from Scotland, Northern Ireland and Wales. European age-standardized incidence rates (EASRs) of the first BCC and cSCC per patient per annum (PPPA) were calculated.

RESULTS

In the U.K, the EASR of the first BCC and cSCC PPPA in 2013-15 were 285 and 77 per 100 000 person years, respectively (211 120 KCs total in 2015). The mean annual percentage increase was 5% between 2013 and 2015 for both BCC and cSCC. By counting the first KC PPPA, we include an additional 51% KCs compared with the previous reporting technique which counts only the first BCC and cSCC in a patient's lifetime, yet it represents a probable underestimation of 5-11% of the true tumour count.

CONCLUSIONS

Based on an improved methodology, a more representative incidence of KC is presented, which is essential to healthcare planning and will lead to improved understanding of the epidemiology of KC. What's already known about this topic? Keratinocyte cancers (KCs) are the most common cancers affecting white ethnic populations. The incidence of basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) is increasing worldwide including the U.K., most commonly in elderly male Caucasian patients. These cancers are traditionally substantially underreported and frequently excluded from national cancer statistics. What does this study add? Using improved data collection methods in England and validated tumour-reporting techniques, we report the most accurate BCC and cSCC incidence data for the U.K. ever published. Identifying the first BCC and cSCC per patient per annum, the incidence of BCC and cSCC in the U.K. (excluding Wales) was 285 and 77 per 100 000 person years, respectively, between 2013 and 2015, with more than 210 000 KCs in the U.K. in 2015.

Impact of variation in cancer registration practice on observed international cancer survival differences between International Cancer Benchmarking Partnership (ICBP) jurisdictions

BACKGROUND

International cancer survival comparisons use cancer registration data to report cancer survival, which informs the development of cancer policy and practice. Studies like the International Cancer Benchmarking Partnership (ICBP) have a duty to understand how registration differences impact on survival prior to drawing conclusions.

METHODS

Key informants reported differences in registration practice for capturing incidence date, death certificate case handling and registration of multiple primary tumours. Sensitivity analyses estimated their impact on one-year survival using baseline and supplementary cancer registration data from England and Sweden.

RESULTS

Variations in registration practice accounted for up to a 7.3 percentage point difference between unadjusted (estimates from previous ICBP survival data) and adjusted (estimates recalculated accounting for registration differences) one-year survival, depending on tumour site and jurisdiction. One-year survival estimates for four jurisdictions were affected by adjustment: New South Wales, Norway, Ontario, Sweden. Sweden and Ontario's survival reduced after adjustment, yet they remained the jurisdictions with the highest survival for breast and ovarian cancer respectively. Sweden had the highest unadjusted lung cancer survival of 43.6% which was adjusted to 39.0% leaving Victoria and Manitoba with the highest estimate at 42.7%. For colorectal cancer, Victoria's highest survival of 85.1% remained unchanged after adjustment.

CONCLUSION

Population-based cancer survival comparisons can be subject to registration biases that may impact the reported 'survival gap' between populations. Efforts should be made to apply consistent registration practices internationally. In the meantime, survival comparison studies should provide acknowledgement of or adjustment for the registration biases that may affect their conclusions.

BRCA Challenge: BRCA Exchange as a global resource for variants in BRCA1 and BRCA2

The BRCA Challenge is a long-term data-sharing project initiated within the Global Alliance for Genomics and Health (GA4GH) to aggregate BRCA1 and BRCA2 data to support highly collaborative research activities. Its goal is to generate an informed and current understanding of the impact of genetic variation on cancer risk across the iconic cancer predisposition genes, BRCA1 and BRCA2. Initially, reported variants in BRCA1 and BRCA2 available from public databases were integrated into a single, newly created site, www.brcaexchange.org. The purpose of the BRCA Exchange is to provide the community with a reliable and easily accessible record of variants interpreted for a high-penetrance phenotype. More than 20,000 variants have been aggregated, three times the number found in the next-largest public database at the project’s outset, of which approximately 7,250 have expert classifications. The data set is based on shared information from existing clinical databases—Breast Cancer Information Core (BIC), ClinVar, and the Leiden Open Variation Database (LOVD)—as well as population databases, all linked to a single point of access. The BRCA Challenge has brought together the existing international Evidence-based Network for the Interpretation of Germline Mutant Alleles (ENIGMA) consortium expert panel, along with expert clinicians, diagnosticians, researchers, and database providers, all with a common goal of advancing our understanding of BRCA1 and BRCA2 variation. Ongoing work includes direct contact with national centers with access to BRCA1 and BRCA2 diagnostic data to encourage data sharing, development of methods suitable for extraction of genetic variation at the level of individual laboratory reports, and engagement with participant communities to enable a more comprehensive understanding of the clinical significance of genetic variation in BRCA1 and BRCA2.

The goal of this study and paper has been to develop an international resource to generate an informed and current understanding of the impact of genetic variation on cancer risk across the cancer predisposition genes, BRCA1 and BRCA2. Reported variants in BRCA1 and BRCA2 available from public databases were integrated into a single, newly created site, www.brcaexchange.org, to provide a reliable and easily accessible record of variants interpreted for a high-penetrance phenotype.

Cohort profile: prescriptions dispensed in the community linked to the national cancer registry in England

PURPOSE

The linked prescriptions cancer registry data resource was set up to extend our understanding of the pathway for patients with cancer past secondary care into the community, to ultimately improve patient outcomes.

PARTICIPANTS

The linked prescriptions cancer registry data resource is currently available for April to July 2015, for all patients diagnosed with cancer in England with a dispensed prescription in that time frame.The dispensed prescriptions data are collected by National Health Service (NHS) Prescription Services, and the cancer registry data are processed by Public Health England. All data are routine healthcare data, used for secondary purposes, linked using a pseudonymised version of the patient's NHS number and date of birth.Detailed demographic and clinical information on the type of cancer diagnosed and treatment is collected by the cancer registry. The dispensed prescriptions data contain basic demographic information, geography measures of the dispensed prescription, drug information (quantity, strength and presentation), cost of the drug and the date that the dispensed prescription was submitted to NHS Business Services Authority.

FINDINGS TO DATE

Findings include a study of end of life prescribing in the community among patients with cancer, an investigation of repeat prescriptions to derive measures of prior morbidity status in patients with cancer and studies of prescription activity surrounding the date of cancer diagnosis.

FUTURE PLANS

This English linked resource could be used for cancer epidemiological studies of diagnostic pathways, health outcomes and inequalities; to establish primary care comorbidity indices and for guideline concordance studies of treatment, particularly hormonal therapy, as a major treatment modality for breast and prostate cancer which has been largely delivered in the community setting for a number of years.

Investigation of the international comparability of population-based routine hospital data set derived comorbidity scores for patients with lung cancer

INTRODUCTION

The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome.

METHODS

Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4-36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons.

RESULTS

It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable.

CONCLUSION

The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required.

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit

BACKGROUND

Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this.

AIM

To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit.

DESIGN AND SETTING

Clinical audit of cancer diagnosis in general practices in England.

METHOD

Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management.

RESULTS

Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more.

CONCLUSION

The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer.

An updated PREDICT breast cancer prognostication and treatment benefit prediction model with independent validation

BACKGROUND

PREDICT is a breast cancer prognostic and treatment benefit model implemented online. The overall fit of the model has been good in multiple independent case series, but PREDICT has been shown to underestimate breast cancer specific mortality in women diagnosed under the age of 40. Another limitation is the use of discrete categories for tumour size and node status resulting in 'step' changes in risk estimates on moving between categories. We have refitted the PREDICT prognostic model using the original cohort of cases from East Anglia with updated survival time in order to take into account age at diagnosis and to smooth out the survival function for tumour size and node status.

METHODS

Multivariable Cox regression models were used to fit separate models for ER negative and ER positive disease. Continuous variables were fitted using fractional polynomials and a smoothed baseline hazard was obtained by regressing the baseline cumulative hazard for each patients against time using fractional polynomials. The fit of the prognostic models were then tested in three independent data sets that had also been used to validate the original version of PREDICT.

RESULTS

In the model fitting data, after adjusting for other prognostic variables, there is an increase in risk of breast cancer specific mortality in younger and older patients with ER positive disease, with a substantial increase in risk for women diagnosed before the age of 35. In ER negative disease the risk increases slightly with age. The association between breast cancer specific mortality and both tumour size and number of positive nodes was non-linear with a more marked increase in risk with increasing size and increasing number of nodes in ER positive disease. The overall calibration and discrimination of the new version of PREDICT (v2) was good and comparable to that of the previous version in both model development and validation data sets. However, the calibration of v2 improved over v1 in patients diagnosed under the age of 40.

CONCLUSIONS

The PREDICT v2 is an improved prognostication and treatment benefit model compared with v1. The online version should continue to aid clinical decision making in women with early breast cancer.

30-day mortality after systemic anticancer treatment for breast and lung cancer in England: a population-based, observational study

Background

30-day mortality might be a useful indicator of avoidable harm to patients from systemic anticancer treatments, but data for this indicator are limited. The Systemic Anti-Cancer Therapy (SACT) dataset collated by Public Health England allows the assessment of factors affecting 30-day mortality in a national patient population. The aim of this first study based on the SACT dataset was to establish national 30-day mortality benchmarks for breast and lung cancer patients receiving SACT in England, and to start to identify where patient care could be improved.

Methods

In this population-based study, we included all women with breast cancer and all men and women with lung cancer residing in England, who were 24 years or older and who started a cycle of SACT in 2014 irrespective of the number of previous treatment cycles or programmes, and irrespective of their position within the disease trajectory. We calculated 30-day mortality after the most recent cycle of SACT for those patients. We did logistic regression analyses, adjusting for relevant factors, to examine whether patient, tumour, or treatment-related factors were associated with the risk of 30-day mortality. For each cancer type and intent, we calculated 30-day mortality rates and patient volume at the hospital trust level, and contrasted these in a funnel plot.

Findings

Between Jan 1, and Dec, 31, 2014, we included 23 228 patients with breast cancer and 9634 patients with non-small cell lung cancer (NSCLC) in our regression and trust-level analyses. 30-day mortality increased with age for both patients with breast cancer and patients with NSCLC treated with curative intent, and decreased with age for patients receiving palliative SACT (breast curative: odds ratio [OR] 1·085, 99% CI 1·040–1·132; p<0·0001; NSCLC curative: 1·045, 1·013–1·079; p=0·00033; breast palliative: 0·987, 0·977–0·996; p=0·00034; NSCLC palliative: 0·987, 0·976–0·998; p=0·0015). 30-day mortality was also significantly higher for patients receiving their first reported curative or palliative SACT versus those who received SACT previously (breast palliative: OR 2·326 99% CI 1·634–3·312; p<0·0001; NSCLC curative: 3·371, 1·554–7·316; p<0·0001; NSCLC palliative: 2·667, 2·109–3·373; p<0·0001), and for patients with worse general wellbeing (performance status 2–4) versus those who were generally well (breast curative: 6·057, 1·333–27·513; p=0·0021; breast palliative: 6·241, 4·180–9·319; p<0·0001; NSCLC palliative: 3·384, 2·276–5·032; p<0·0001). We identified trusts with mortality rates in excess of the 95% control limits; this included seven for curative breast cancer, four for palliative breast cancer, five for curative NSCLC, and seven for palliative NSCLC.

Interpretation

Our findings show that several factors affect the risk of early mortality of breast and lung cancer patients in England and that some groups are at a substantially increased risk of 30-day mortality. The identification of hospitals with significantly higher 30-day mortality rates should promote review of clinical decision making in these hospitals. Furthermore, our results highlight the importance of collecting routine data beyond clinical trials to better understand the factors placing patients at higher risk of 30-day mortality, and ultimately improve clinical decision making. Our insights into the factors affecting risk of 30-day mortality will help treating clinicians and their patients predict the balance of harms and benefits associated with SACT.

Funding

Public Health England.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

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

OBJECTIVES

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

DESIGN

Simulation study.

SETTING

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

A population-based validation of the prognostic model PREDICT for early breast cancer

INTRODUCTION

Predict (www.predict.nhs.uk) is a prognostication and treatment benefit tool developed using UK cancer registry data. The aim of this study was to compare the 10-year survival estimates from Predict with observed 10-year outcome from a British Columbia dataset and to compare the estimates with those generated by Adjuvant! (www.adjuvantonline.com).

METHOD

The analysis was based on data from 3140 patients with early invasive breast cancer diagnosed in British Columbia, Canada, from 1989-1993. Demographic, pathologic, staging and treatment data were used to predict 10-year overall survival (OS) and breast cancer specific survival (BCSS) using Adjuvant! and Predict models. Predicted outcomes from both models were then compared with observed outcomes.

RESULTS

Calibration of both models was excellent. The difference in total number of deaths estimated by Predict was 4.1 percent of observed compared to 0.7 percent for Adjuvant!. The total number of breast cancer specific deaths estimated by Predict was 3.4 percent of observed compared to 6.7 percent for Adjuvant! Both models also discriminate well with similar AUC for Predict and Adjuvant! respectively for both OS (0.709 vs 0.712) and BCSS (0.723 vs 0.727). Neither model performed well in women aged 20-35.

CONCLUSION

In summary Predict provided accurate overall and breast cancer specific survival estimates in the British Columbia dataset that are comparable with outcome estimates from Adjuvant! Both models appear well calibrated with similar model discrimination. This study provides further validation of Predict as an effective predictive tool following surgery for invasive breast cancer.

PREDICT: a new UK prognostic model that predicts survival following surgery for invasive breast cancer

Introduction

The aim of this study was to develop and validate a prognostication model to predict overall and breast cancer specific survival for women treated for early breast cancer in the UK.

Methods

Using the Eastern Cancer Registration and Information Centre (ECRIC) dataset, information was collated for 5,694 women who had surgery for invasive breast cancer in East Anglia from 1999 to 2003. Breast cancer mortality models for oestrogen receptor (ER) positive and ER negative tumours were derived from these data using Cox proportional hazards, adjusting for prognostic factors and mode of cancer detection (symptomatic versus screen-detected). An external dataset of 5,468 patients from the West Midlands Cancer Intelligence Unit (WMCIU) was used for validation.

Results

Differences in overall actual and predicted mortality were <1% at eight years for ECRIC (18.9% vs. 19.0%) and WMCIU (17.5% vs. 18.3%) with area under receiver-operator-characteristic curves (AUC) of 0.81 and 0.79 respectively. Differences in breast cancer specific actual and predicted mortality were <1% at eight years for ECRIC (12.9% vs. 13.5%) and <1.5% at eight years for WMCIU (12.2% vs. 13.6%) with AUC of 0.84 and 0.82 respectively. Model calibration was good for both ER positive and negative models although the ER positive model provided better discrimination (AUC 0.82) than ER negative (AUC 0.75).

Conclusions

We have developed a prognostication model for early breast cancer based on UK cancer registry data that predicts breast cancer survival following surgery for invasive breast cancer and includes mode of detection for the first time. The model is well calibrated, provides a high degree of discrimination and has been validated in a second UK patient cohort.

Adjuvant UK: A UK Prognostic Model for Early Breast Cancer That Includes Mode of Detection

AIM: To develop and validate a prognostication model to predict overall survival for women treated for early breast cancer in the UK based on cancer registry data. Unlike SEER, this dataset includes accurate information on mode of detection as well as systemic therapy.METHOD: Using the Eastern Cancer Registration & Information Centre (ECRIC) dataset, information was collated for 5818 women diagnosed with invasive breast cancer in East Anglia from 1999-2003. All patients underwent surgery, had records of pathological staging (tumour size, grade, lymph node status, ER status), systemic treatment (chemotherapy, hormone therapy, both), mode of detection (screen-detected, symptomatic) and follow up, censored on 31 December 2007. A model was derived from these data using Cox proportional hazards, with ER positive and ER negative tumours modelled separately, and this was subsequently validated in an external dataset of 5468 patients from the West Midlands Cancer Intelligence Unit (WMCIU). Validation was performed by comparing (a) observed and expected mortality (overall & breast cancer specific) at 5 & 8 years and (b) receiver operating characteristic (ROC) curves in both ECRIC & WMCIU datasets.RESULTS:ECRIC datasetDifference in overall observed/expected mortality &lt;1% at 5 years (14.8% vs 14.9%) and 8 years (18.9% vs 18.9%). Area under ROC curve (AUC) was 0.81.Difference in breast cancer specific observed/expected mortality &lt;1% at 5 years (10.6% vs 11.0%) and 8 years (12.9% vs 13.5%). AUC was 0.84.WMCIU dataset:Difference in overall observed/expected mortality &lt; 1% at 5 years (15.8% vs 16.5%) and 8 years (17.5% vs 17.8%). AUC was 0.79.Difference in breast cancer specific observed/expected mortality &lt;2% at 5 years (11.0% vs 12.6%) and 8 years (12.2% vs 13.6%). AUC was 0.82.Overall model fit was good across all subgroups although the ER positive model provided better discrimination (AUC 0.82) than ER negative (AUC 0.75). There was no significant difference between the ROC curves generated with ECRIC and WMCIU data (ER positive X2 = 0.17, p=0.68; ER negative X2 =0.00, P=0.95).CONCLUSION: We have developed a prognostication model for early breast cancer based on data from a UK cancer registry that has included mode of detection for the first time. The model is well calibrated, provides a high degree of discrimination and has been validated in a second patient cohort. This model will underpin a new web-based prognostication and treatment benefit tool for early breast cancer based on UK data (Adjuvant UK).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4033.

Primary and isolated anaplastic large cell lymphoma of the bone marrow

Anaplastic large cell lymphoma (ALCL) is a T-cell lymphoma in which the majority of patients present with advanced stage III or IV disease. Here we report a case of ALCL where bone marrow was the only site of disease, in a 60-year-old man with pyrexia and pancytopenia. The diagnosis of ALCL was made on detection of CD30-positive anaplastic cells in the bone marrow, together with prominent hemophagocytosis. Genetics confirmed the clonal nature of the disease and showed it to be anaplastic lymphoma kinase (ALK) negative. Primary isolated bone marrow ALCL should be considered in the diagnosis of pancytopenia associated with hemophagocytosis.

Adjuvant UK: Validation of a UK prognostic model for early breast cancer

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Background: To develop and validate a prognostication model to predict overall survival for women treated for early breast cancer in the UK based on cancer registry data. The main advantages are that unlike SEER, this dataset includes accurate information on mode of detection as well as systemic therapy. Methods: Using the Eastern Cancer Registration & Information Centre (ECRIC) dataset, information was collated for 5,818 women diagnosed with invasive breast cancer in East Anglia from 1999–2003. All patients underwent surgery, had records of pathological staging (tumour size, grade, lymph node status, ER status) and systemic treatment (chemotherapy, hormone therapy, both), mode of detection (screen-detected, symptomatic) and were followed up to December 2007. A model was derived from these data using Cox proportional hazards and this was subsequently validated in an external dataset of 5,468 patients from the West Midlands Cancer Intelligence Unit (WMCIU). Validation was performed by comparing (a) observed and predicted mortality - overall and by risk group decile - and (b) receiver operating characteristic (ROC) curves in both ECRIC & WMCIU datasets. Results: ECRIC dataset: Observed/predicted deaths were: 2 years (262/267), 5 years (868/867), 8 years (1108/1093). Area under ROC curve was 0.800WMCIU dataset: Observed/predicted deaths were: 2 years (317/298), 5 years (862/919), 8 years (955/999). Area under ROC curve was 0.783. The model and validation worked equally well at all time points (2, 5, 8 years) and in all risk group deciles. In the validation dataset the observed and predicted 8-year OS was within 1% (17.5% versus 18.3%). There was no significant statistical difference between the ROC curves (X2 = 2.35, P=.12) for prediction at 8 years in ECRIC and WMCIU data. Conclusions: We have developed a prognostication model for early breast cancer based on data from a UK cancer registry and validated the model using data from another UK registry. The model was well calibrated and provides a high degree of discrimination. This model will underpin the first web-based prognostication and treatment benefit tool for early breast cancer in the UK (Adjuvant UK).

No significant financial relationships to disclose.

IT innovation in histopathology recruitment, training and research

The introduction of national recruitment and cohort training in histopathology in England has produced significant challenges and highlighted opportunities for development. Innovative information technology solutions have been deployed to facilitate recruitment and enhance education provision and research.