Elsevier

European Journal of Cancer

Volume 93, April 2018, Pages 127-137
European Journal of Cancer

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

https://doi.org/10.1016/j.ejca.2018.01.084Get rights and content

Highlights

  • Patients were diagnosed at more advanced stage in Eastern Europe (EE) than elsewhere.

  • EE had lowest stage-specific survival and highest risk of cancer death.

  • Less effective care may be the major cause of poor cancer outcomes in EE.

  • More resources should be made available to improve cancer outcomes in EE.

Abstract

Background

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

Data and methods

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

Results

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

Conclusions

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

Introduction

EUROCARE, the continuing population-based investigation of European cancer survival, found that the well-known between-country differences in 5-year relative survival (RS) persisted for patients diagnosed in 2000–2007 [1], [2], latest period for which data are available. Survival was confirmed as low for Eastern European and UK/Ireland patients and high for Northern and Central European patients. Differences in cancer biology, intensity of screening, extent of diagnostic workup, quality of care, and organisation of care delivery contribute to these inequalities [1], but stage at diagnosis is also important [3], as shown by analyses of the influence of diagnostic work-up, stage, and treatments on survival in random samples of cancer registry (CR) cases (collecting clinical data on all cases is too resource-intensive) [4], [5], [6].

The present retrospective observational study provides the first Europe-wide population-based estimates of stage distribution at diagnosis and stage-specific RS for selected cancers and CRs, for which the stage information sent to EUROCARE-5 was considered to be of sufficiently high quality.

Section snippets

Materials and methods

The EUROCARE-5 protocol [7] asked CRs to send data—specifically including stage at diagnosis, on adult (≥15 years) patients diagnosed with 15 types of cancer in 2000–2007 and followed to the end of 2008.

Although stage is an essential element of CR data [8], not all European CRs collect it, and many experience difficulties in accessing and coding it [9], [10]. The protocol therefore requested stage be provided in one or more of 3 forms [7]: TNM (most detailed), condensed TNM, and (summary)

Results

Over 900,000 primary invasive cancers were analysed (Table 1): 39% breast, 22% colon, 18% lung, 11% rectum, 5% stomach, and 2% each for thyroid and melanoma. Patients with lung, colon, rectum and stomach cancers were generally older than those with the other cancers (26–40% versus 9–20% ≥ 75 years; 10–15% versus 33–55% < 55 years). Age distribution varied somewhere between regions, with Eastern European patients tending to be younger. For cancers of rectum, stomach, and lung, >55% of cases were

Discussion

Our main findings are that Eastern European cancer patients were not only diagnosed at a more advanced stage than patients in other parts of Europe but also had worse stage-specific RS, and a greater RER of cancer death (except lung cancer death) than European cancer patients in general, even after adjusting for age, sex and stage. Worse stage-specific RS combined with greater risk of cancer death strongly suggests less effective care as a major cause of poorer outcomes in Eastern Europe.

‘Less

Funding

This work was supported by the Compagnia di San Paolo, the Cariplo Foundation, the European Commission [grant number 20102202, European Action Against Cancer, EPAAC Joint Action], and the Italian Ministry of Health [grant number 1529710, Ricerca Finalizzata 2009, RF-2009].

Role of funding sources

The funding sources had no role in study design, the collection, analysis or interpretation of data, the writing of the report or the decision to submit the article for publication.

Conflict of interest statement

None declared.

Acknowledgements

The authors thank Chiara Margutti and Simone Bonfarnuzzo for their assistance, and Don Ward for help with the English.

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