Elsevier

European Journal of Cancer

Volume 51, Issue 15, October 2015, Pages 2120-2129
European Journal of Cancer

Age and case mix-standardised survival for all cancer patients in Europe 1999–2007: Results of EUROCARE-5, a population-based study

https://doi.org/10.1016/j.ejca.2015.07.025Get rights and content

Abstract

Background

Overall survival after cancer is frequently used when assessing a health care service’s performance as a whole. It is mainly used by the public, politicians and the media, and is often dismissed by clinicians because of the heterogeneous mix of different cancers, risk factors and treatment modalities. Here we give survival details for all cancers combined in Europe, correlating it with economic variables to suggest reasons for differences.

Methods

We computed age and cancer site case-mix standardised relative survival for all cancers combined (ACRS) for 29 countries participating in the EUROCARE-5 project with data on more than 7.5 million cancer cases from 87 population-based cancer registries, using complete and period approach.

Results

Denmark, United Kingdom (UK) and Eastern European countries had lower survival than neighbouring countries. Five-year ACRS has been increasing throughout Europe, and substantial increases, between 1999–2001 and 2005–2007, have been achieved in countries where survival was lower in the past. Five-year ACRS for men and women are positively correlated with macro-economic variables like the Gross Domestic Product (GDP) and Total National Expenditure on Health (TNEH) (R2 about 70%). Countries with recent larger increases in GDP and TNEH had greater increases in cancer survival.

Conclusions

ACRS serves to compare all cancer survival in Europe taking account of the geographical variability in case-mixes. The EUROCARE-5 data on ACRS confirm previous EUROCARE findings. Survival appears to correlate with macro-economic determinants, particularly with investments in the health care system.

Introduction

Population-based cancer registries (CRs) began to operate in Europe from the 1940s onwards, mainly providing indicators of risk, prognosis and burden of cancer [1]. Over the years increasing numbers of CRs have run studies on survival, in evaluation service of clinical practice and of mass screening programmes, aetiological research [1] and survivorship studies [2], [3], [4]. The role of cancer registration is strongly recognised, and CRs are considered a pillar of cancer control by the World Cancer Declaration of the Union for International Cancer Control (UICC) [5] and European Commission [6], [7].

In general, clinicians tend to underuse the findings of population-based survival studies and rely more on studies of selected patient groups in randomised clinical trials or outcome studies from hospitals (or groups of hospitals) [8]. However, population-based survival data can provide essential information for administrators and policy makers. For instance, in 2000, cancer action plans were implemented in Denmark and the United Kingdom (UK) with the aim of improving cancer treatment and outcomes, following the discovery of unexpectedly poor cancer survival in these countries by the EUROCARE [8]. Cancer registry data have also been widely used for evaluations and monitoring the impact of action plans [9]. Although some countries have used cancer survival statistics to set priorities for the provision of cancer care, the economic and social implications of changes in cancer survival are not widely appreciated [8].

These considerations are especially appropriate if we consider the measure of survival for all cancers combined. Epidemiologists and clinicians acknowledge that the complex mixture of different cancer types and subtypes with different risk factors, diagnostic methods, therapies and prognosis makes it problematic to base conclusions on overall measures (incidence, survival and mortality) [10]. However, the general public, journalists, politicians and administrators often prefer summary measures (such as survival for all cancers combined) as they offer a broad picture of cancer burden and serve to evaluate the impact of cancer control plans [10]. Population-based relative survival for all cancers has been proposed as a useful indicator for monitoring cancer control across countries [11].

The present paper illustrates the results of survival analyses for all cancers combined for each country participating in EUROCARE-5 [12]. Survival data must be comparable, in order to deliver a correct benchmark across administrative borders (e.g. among countries). Cancer survival statistics are usually considered comparable if the original data are: (a) collected in a standardised way (EUROCARE-5 data originate from CRs working to standardised data collection and coding rules), (b) estimated by the same methods (the EUROCARE-5 methods are described elsewhere [12]) and (c) if the results presented are age-standardised [13]. In presenting data for all cancers combined, it is also essential to consider the differing case-mixes of cancers in different countries, and to eliminate the confounding effect if, for example, the incidence of highly lethal cancers is higher in one country than in another. Here, therefore, we present the population-based age-standardised and cancer site-standardised relative survival for all cancers combined correlating it with economic variables so to interpret any differences [11].

Section snippets

Materials and methods

EUROCARE-5 materials and methods are fully described elsewhere [12]. We shall just summarise the features used in estimating survival for all cancers combined.

Ninety-nine CRs, collecting data for adult (⩾15 years) cancer patients, contributed to the EUROCARE-5 study. For analyses of all cancers combined, 12 registries were excluded as they only gathered data for specific cancer sites [12].

We present analyses of three different datasets: (a) analysis on cancer patients diagnosed in 2000–2007 in

Results

Table 1 shows the case-mix weights applied for ACRS estimates by sex, and the range of different weights across Europe (weights are associated with the frequency with which each cancer appears in a given country cancer site distribution). Several sites showed a four-fold ratio between max and minimum. Large ranges were for male lung cancer (8% points in Sweden to 26% points in Poland), female lung cancer (3% in Malta to 15% in Scotland), female breast cancer (21% in Lithuania to 37% in

Discussion

We analysed over 7.5 million cancer cases from the European CRs participating in the EUROCARE-5 project, and conducted a comprehensive survival analysis on all cancer cases, in 29 European countries. Most of the CRs had participated in the European Network of Cancer Registries survey in 2010–2012 [1]. We focused on survival for all cancers combined and in this general indicator we did not analyse the role of different cancer sites, as survival for specific cancer sites is dealt with in other

Conclusion

The EUROCARE-5 data suggest that on a clinical level cancer survival depends on the widespread application of effective diagnosis and treatment modalities, and can be correlated with macro-economic determinants, in particular investment in the health care system. Our data, together with those of clinical registries [48], could be used by clinicians too, to engage local governments in discussions on the relevance of ACRS differences across Europe and to seek long-term effects of treatments and

Role of funding sources

The study was funded by the Compagnia di San Paolo, Fondazione Cariplo Italy, Italian Ministry of Health (Ricerca Finalizzata 2009, RF-2009-1529710) and the European Commission (European Action Against Cancer, EPAAC, Joint Action No. 20102202). The funding sources had no role in study design, data collection, analysis or interpretation, the writing of the report or the decision to submit the article for publication.

Conflict of interest statement

None declared.

Acknowledgements

Thanks to Chiara Margutti, Simone Bonfarnuzzo and Camilla Amati for their assistance.

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