Cancer Relative Survival Research Articles

Equity in cancer patient survival in Finland

To study temporal, regional and education-related differences in cancer patient survival in Finland by site and sex. Population-based relative and cause-specific cancer survival analysis using the complete and period methods....

Oropharyngeal Cancer, Race, and the Human Papillomavirus

This perspective on Settle et al. (beginning on p. 776 in this issue of the journal) discusses the racial disparity in oropharyngeal cancer survival in relation to the biological factor human papillomavirus and its association with sexual behavior. This discussion is expanded to a more general consideration of biological and nonbiological (e.g., socioeconomic and cultural) factors affecting racial disparities in disease.

Dietary folate and vitamin B12 intake before diagnosis decreases gastric cancer mortality risk among susceptible MTHFR 677TT carriers

Objective To assess gastric cancer survival in relation to dietary intake of methyl donors and the methylenetetrahydrofolate reductase 677C > T ( MTHFR 677C > T ) polymorphism. Methods A prospective cohort of 257 incidental, histologically confirmed gastric cancer cases was assembled in January 2004 and followed until June 2006. Patients were recruited from the main oncology and/or gastroenterology units in Mexico City and were queried regarding their sociodemographic information, clinical history, and dietary habits 3 y before the onset of their symptoms. The intake of methyl donors was estimated with a food-frequency questionnaire and the MTHFR 677C > T polymorphisms were determined by polymerase chain reaction/restriction fragment length polymorphism analysis. Cox's multivariate regression models were used to estimate the mortality risk of gastric cancer. Results MTHFR 677TT carriers with low folate and vitamin B12 intakes had the lowest survival rate in cases of gastric cancer. High intakes of folate and vitamin B12 before diagnosis was associated with decreased gastric cancer mortality risk in susceptible MTHFR 677TT carriers (mortality risk for folate 0.14, 95% confidence interval 0.04–0.46, P for trend = 0.001; mortality risk for vitamin B12 0.23, 95% confidence interval 0.08–0.66, P for trend = 0.008). Conclusion Folate and related B vitamins may be used as an intervention strategy to improve the survival outcome of gastric cancer.

Temporal trends in the incidence and survival of cancers of the upper aerodigestive tract in Ontario and the United States

The Ontario Cancer Registry (OCR) and the Surveillance, Epidemiology and End Results (SEER) databases were used to describe temporal trends in the incidence and survival of squamous cancers of the upper aerodigestive tract (UADT) in Ontario and the US between 1984 and 2001. Between the 1984-86 and 1999-01 periods, the age-adjusted incidence rate of all first primary cancers of the UADT decreased from 11.6 (11.2-12.0) to 8.8 (8.5-9.1) in Ontario and 13.0 (12.7-13.3) to 10.2 (10.0-10.4) in the US. Significant decreases in incidence were observed in many UADT sites but there was no significant change in the incidence of cancer of the oropharynx in either the US or Canada. Over the same period, the 5-year relative survival for all UADT cancers increased from 49.2% (47.2-51.2%) to 57.1%(55.0-59.1%) in Ontario and from 48.1% (46.9-49.3%) to 52.4% (51.2-53.6%) in the US. This significant improvement in the outcome of UADT cancer was largely due to a dramatic increase in the 5-year relative survival for cancers of the oropharynx from 31.1% (27.1-35.1%) to 53.6% (49.3-57.9%) in Ontario and from 35.3% (32.9-37.8%) to 51.0% (48.7-53.3%) in the US. Smaller increases in survival were observed in cancers of the oral cavity, nasopharynx, and hypopharynx, but there was no evidence of any increase in survival for cancer of the larynx. These results are consistent with the hypothesis that there has been a major change in the etiology of cancer of the oropharynx in Canada and the US and a concomitant change in its response to therapy.

Body mass index and breast cancer survival in relation to the introduction of mammographic screening

Aims Mammographic screening reduces mortality in breast cancer. It is not known if this reduction is more pronounced in certain groups. Obesity has been associated with worse survival following breast cancer diagnosis. This study investigates BMI in relation to breast cancer mortality, and if this association is affected by invitation to mammographic screening. Methods In 1976, a randomised mammographic screening trial, inviting 50% of all women aged 45–69 years ( n = 42 283), was set up in Malmö, Sweden. BMI in relation to breast cancer mortality was examined separately in women invited or not invited to screening in the trial. The analyses also included a historical control-group diagnosed before the screening trial. The study included 2974 women diagnosed in 1961–1991. Relative risks (RR) with a 95% confidence interval was obtained from a Cox proportional hazard analysis and in the analysis of all women, follow-up was limited to 10 years. Results Obese women (BMI ≥ 30) not invited to mammographic screening had a higher adjusted RR of dying of breast cancer as compared to normal weight women (2.08:1.13–3.81) in the 10-year follow-up. In women invited to screening there was no association between BMI and breast cancer mortality. In the historical control group, mortality was increased in overweight women (BMI: 25–30), RR = 1.27:0.99–1.62, and obese women, RR = 1.32:0.94–1.84, but these associations totally disappeared in the multivariate analysis, following adjustment for tumour size and stage. Conclusions Overweight and obese women may be a group that profit from mammographic screening to more than normal weight women.

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

Introduction. Population-based cancer survival analysis constitutes valuable reference material for the clinical field of oncology. The objectives of this study were to assess the quality of the Hamburg Cancer Registry's (HCR) database in this respect, to perform survival analyses by means of selected sites, and to evaluate the results in relation to prevalent opinions and external estimates. Methods. Data quality was assessed by the proportion of cases documented as diagnosed at death, external estimates of completeness, reliability of follow-up, histological verification and information on stage. Included were first primary malignancies of the colon (ICD10 C18, n=4 544), female breast (C50, n=9 259), prostate (C61, n=5 707) and urinary bladder (C67, D09.0, n=3 148), diagnosed in Hamburg residents 1995–2003. Observed and relative survival (OS, RS) were estimated by site, sex, time, age and stage. Results. Regarding female breast cancer in Hamburg, high levels of data quality and completeness exist while the explanatory power concerning malignancies of the colon, prostate and urinary bladder is limited. Age-standardised 5-year relative cancer survival estimates amounted for female breast to 81%, for colon to 49% (male) and 52% (female), for prostate to 81% and for urinary bladder to 71% (male) and 62% (female). Conclusion. The study demonstrates the capacities and limitations of an epidemiological cancer registry to produce convincing survival estimates for clinical use, under the terms of a voluntary case reporting system.

Social differences in breast cancer survival in relation to patient management within a National Health Care System (Sweden)

Epidemiologic studies have shown that cancer survival is poorer in low compared with high socioeconomic groups. We investigated whether these differences were associated with disparities in tumour characteristics and management. This cohort study was based on 9,908 women aged 20-79 years at diagnosis with primary breast cancer identified in a Swedish population-based clinical register. Information on socioeconomic standing was obtained from a social database. The 5-year cause-specific survival (CSS) and mortality hazard ratios (HR) were estimated by Cox proportional hazard models to assess differences in survival between socioeconomic groups while adjusting for diagnostic intensity, tumour characteristics and treatment. Following adjustment for age, year and stage at diagnosis, the risk of dying of breast cancer was 35% lower among women with high education compared with that of low education (HR = 0.65, 95% CI 0.53-0.80). When compared with women with high education, a lower percentage of women with low education had been investigated for proliferation (84 vs. 76%) or hormone receptor status (89 vs. 81%), had tumours <or=20 mm (68 vs. 64%), were treated at a main hospital (75 vs. 68%) and had received radiation treatment (80 vs. 67%) or chemotherapy (31 vs. 18%). However, these proportional differences could not explain the observed social gradient in survival. To minimize social differences in breast cancer survival, further research should address not only factors leading to inequities in management but also focus on patient factors such as health awareness, comorbidity burden and compliance to adjuvant treatment.

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

The CONCORD study compares population-based relative survival from cancer using data from cancer registries in five continents. To estimate relative survival, general mortality life tables are required. Available statistics are incomplete, so various approaches are used to construct complete life tables. This article outlines how the life tables were constructed for CONCORD; it compares life expectancy at birth between 101 populations covered by cancer registries in 31 countries and compares the impact of two approaches to the deployment of life tables in relative survival analysis. The CONCORD approach, using specific mathematical methods, produced complete (single-year-of-age) life tables by sex, cancer registry area, calendar year (1990-1999) and race (only in the USA). In order to study the impact of different approaches, we compared relative survival in the USA using the US national life table, centered on the relevant census years, and the CONCORD approach. We estimated relative survival in each American participating cancer registry for patients diagnosed with breast (women), colorectal or prostate cancer during 1990-1994 and followed up to 1999. Average life expectancy at birth during 1990-1999 varied in CONCORD cancer registry areas from 64 to 78 years in males and from 71 to 84 years in females. It increased during the 1990s more in men than in women. In the USA, it was lower in blacks than in whites. Relative survival in American populations was lower with the CONCORD approach, which incorporates trends and geographic variation in background mortality, than with the USA census life tables. International variation in background mortality by geographic area, calendar time, race, age and sex is wide. We suggest that in international comparisons of cancer relative survival, complete life tables that are specific for cancer registry area, calendar year and race should be used.

A Bayesian analysis of relative cancer survival with geoadditive models

In this paper, we develop a so-called relative survival analysis that is used to model the excess risk of a certain sub-population relative to the natural mortality risk which is present in the whole population. Such models are typically used in population-based studies that aim at identifying prognostic factors for disease-specific mortality, with data on specific causes of death not being available. This paper combines relative survival with Bayesian geoadditive regression allowing for a flexible semiparametric analysis. Our work has been motivated by continuous-time spatially referenced survival data on breast cancer where causes of death are not known. A detailed analysis of these data is given. The usefulness of the approach is further illustrated by means of a simulated data set.

Would compliance with cancer care standards improve survival for breast, colorectal and lung cancers?

Objective:To investigate whether cancer service standards are associated with survival for breast, colorectal and lung cancers at population level.Methods:Standards of hospital cancer services in England, measured in 2001, were aggregated...

Lung cancer (LC) survival in relation to histologic subtype: Implications for LC prevention and early detection

1530 Background: We previously demonstrated in 307,797 LC pts entered on the SEER (Surveillance Epidemiology and End Results) database from 1975–2003 that adenocarcinoma (AD) is now the most common form of LC in the US (JTO, 2:S305, 2007). AD is most common in women and men, blacks and whites, and in all age groups. The epidemic of smoking-related AD relates to the introduction of low tar/light cigarettes by the Tobacco Industry (TI), which led smokers to compensate for low yields by inhaling more deeply and smoking more intensely. Objectives of this analysis is to examine 5-yr survival (5YrS) in relation to LC histology, and to explore whether improvements in 5YrS in recent decades (5% in 1950–1954, 8% in 1965–1969, 16% in 1995–2002) may reflect changes in histology. Methods: SEER data on 171,261 LC pts diagnosed from1980–2002 were analyzed to determine 5YrS of AD, squamous cell (SQ), small cell (SmC), and large-cell (LgC). Comparisons were drawn based upon stage (local disease [LD], regional [RD], and distant [DD]), gender, race, age, and yr of diagnosis. Results: 5YrS for all stages and histologies was15.3%, with only modest improvements over time. While disease stage was the most powerful predictor of 5YrS, histology was also a major predictor. For all stages, 5YrS was 20% in AD, 15% in SQ, 12% in LgC, and 6% in SmC. Nonetheless, stage distribution was most favorable in SQ. Improved 5YrS for AD relates to superior outcome in LD: AD-58%, SQ- 41%, LgC-40%, SmC-13%. In RD, 5YrS was only slightly better for AD; in DD, 5YrS was most favorable for SQ. When adjusted for stage and histology, 5YrS was better in females than males, whites than blacks, and was inversely related to age. Conclusions: 5YrS for lung AD is significantly superior to other histologies. Improved survival in AD primarily reflects differences in biologic behavior of localized AD, rather than improved stage distribution. The 5YrS difference for localized AD is particularly striking in women. The rise of AD appears to have contributed to modest improvement in 5YrS in recent decades. Dramatically improved 5YrS for localized AD underscores the importance of early detection for lung AD. More importantly, this project underscores the urgent need for comprehensive TI regulation to reduce the epidemic of smoking-related lung AD. No significant financial relationships to disclose.

Hazard regression model and cure rate model in colon cancer relative survival trends: are they telling the same story?

Hazard regression models and cure rate models can be advantageously used in cancer relative survival analysis. We explored the advantages and limits of these two models in colon cancer and focused on the prognostic impact of the year of diagnosis on survival according to the TNM stage at diagnosis. The analysis concerned 9,998 patients from three French registries. In the hazard regression model, the baseline excess death hazard and the time-dependent effects of covariates were modelled using regression splines. The cure rate model estimated the proportion of 'cured' patients and the excess death hazard in 'non-cured' patients. The effects of year of diagnosis on these parameters were estimated for each TNM cancer stage. With the hazard regression model, the excess death hazard decreased significantly with more recent years of diagnoses (hazard ratio, HR 0.97 in stage III and 0.98 in stage IV, P < 0.001). In these advanced stages, this favourable effect was limited to the first years of follow-up. With the cure rate model, recent years of diagnoses were significantly associated with longer survivals in 'non-cured' patients with advanced stages (HR 0.95 in stage III and 0.97 in stage IV, P < 0.001) but had no significant effect on cure (odds ratio, OR 0.99 in stages III and IV, P > 0.5). The two models were complementary and concordant in estimating colon cancer survival and the effects of covariates. They provided two different points of view of the same phenomenon: recent years of diagnosis had a favourable effect on survival, but not on cure.

B4-06: Lung Cancer Survival in Relation to Histologic Subtype: An Analysis based upon Surveillance Epidemiology and End Results (SEER) Data

B4-06: Lung Cancer Survival in Relation to Histologic Subtype: An Analysis based upon Surveillance Epidemiology and End Results (SEER) Data

Trends in rectal cancer survival in relation to the local control strategy

13536 Background: The Swedish Rectal Cancer Trial showed improved survival with improved local control due to adjuvant radiotherapy. Improved survival in several population-based studies, credited to improved local control due to quality assurance programs involving surgery, ± radiotherapy, has also been reported. In Manitoba (Canada) local control in rectal cancer was suboptimal in the mid 1990’s (local recurrence &gt;18% in stage I-III) despite adopting the 1991 NIH chemo-radiotherapy guidelines. There continues to be no quality assurance program. We were interested in exploring trends in survival in Manitoba, particularly in the subset of patients where local control is an issue. Methods: All patients diagnosed with rectum and rectosigmoid adenocarcinoma from 1985 to 1999 were identified from the Manitoba Cancer Registry. Demographic, peri-operative and operative treatment information, and death dates were abstracted from the Registry. Manitoba population and death counts used in the calculation of age-specific relative survival probabilities were obtained from Statistics Canada. Survival was examined for all patients for the time periods of 1985–89, 1990–94 and 1995–99 and subsequently limited to those that underwent major rectal cancer surgery (Hartmann’s, anterior, and abdominal perineal resection). The Ederer II method was used in the estimation of survival probabilities. Results: A total of 3021 rectal cancer patients were identified with 1723 (57.0%) having major surgery. Five-year relative survival for all patients was 48.7%, 49.6% and 56.2% for the three periods respectively. The major surgery group results were 56.9%, 58.1% and 59.7%. Peri-operative radiotherapy was used in 38% of the 1995–99 major surgery group, twice the rate of 1985–89; peri-operative chemotherapy 41%, a ten-fold increase. Conclusions: Consistent with other studies, overall rectal cancer five-year survival in Manitoba has improved since 1985. Smaller survival improvements in the major surgery subgroup, despite increased radiotherapy use (as well as chemotherapy), suggests that better local control was not the major factor in the overall survival improvement, as has been suggested in other studies. Future work should include review of the local control strategy and factors to explain the improved survival. No significant financial relationships to disclose.

Decline in Cervical Cancer Incidence and Mortality in New South Wales in Relation to Control Activities (Australia)

To examine time trends in cervical cancer incidence and mortality in NSW women aged yen20 years in relation to important health service initiatives and programs. Data on cervical cancer incidence and mortality were obtained from the NSW Central Cancer Registry for 1972-2001, and corresponding annual populations obtained from the Australian Bureau of Statistics. Direct age-standardised rates in the yen20 year population were calculated using the 2001 NSW census population as standard. Proportional reductions in incidence and mortality since 1972-1974 were also calculated and related to key health service factors and to published NSW 5-year cervical cancer relative survival for similar periods. Declines in cervical cancer incidence (-10%) and mortality (-20%), and increased degree-of-spread specific survival following the introduction of universal health care in 1975 suggest effects of greater access to Pap screening, earlier access to diagnosis and treatment services, and improved effectiveness of treatment. Incidence plateaued during the 1980s, but mortality fell further (-7%) due to an increased proportion of localised cancers (without change to degree-of-spread specific survival). The 1980s mortality reduction was a consequence of earlier diagnosis and/or secondary prevention, not improved treatment effectiveness or reduced incidence. A marked and sustained incidence decline to 2001 (-35%) occurred after the introduction of the NSW Cervical Screening Program in 1992. This was followed 3 years later by a sustained mortality decline (-20%). During the 1990s survival across all degrees of spread remained unchanged and the mortality reduction was due entirely to reduction in incidence. The substantial reduction of cervical cancer incidence and mortality in NSW over the last 3 decades is associated with important health service interventions that relate to control of cervical cancer, particularly the implementation of a population-based organised cervical screening program.

Analysis of clinical characteristics, management and survival of patients with Ta T1 bladder tumours in Sweden between 1997 and 2001

To analyse the management and outcome of patients with Ta T1 urinary bladder cancer in a population-based national database. Between 1997 and 2001, 94% of all newly diagnosed cases of urinary bladder cancer were registered in the Swedish National Bladder Cancer Register. Data were analysed regarding gender, healthcare region, stage and grade for patients with Ta T1 tumours. The choice of initial treatment in different regions was reviewed. Survival was analysed by calculating relative survival. Out of 9859 registered patients, there were 4442 Ta tumours and 2139 T1 tumours. The median age at diagnosis was 72 and 73 years for patients with Ta and T1 tumours, respectively. Seventy-six percent of the patients were men. The choice of treatment varied between different healthcare regions. A significant trend towards an increased use of intravesical therapy was seen over time. Significantly fewer older than younger patients received such therapy. There was also a tendency towards more intensive therapy in men. The bladder cancer relative 5-year survival rate was 93% for Ta and 75% for T1 tumours. Survival was similar for men and women. Our analysis revealed a regional variation in the treatment of bladder cancer. A large group of patients, even those at high risk, were still undertreated. However, the recent publication of guidelines may have contributed to an increased use of intravesical treatment. Urologists tended to treat TaG3 and T1G3 tumours more aggressively than T1G2 tumours. Therapeutic aggressiveness decreased as the age of the patients increased. The survival rate of patients with bladder cancer in Sweden seems to remain at the levels previously reported for the 1980s.

Regional Differences in Breast Cancer Survival Despite Common Guidelines

Despite a uniform regional breast cancer care program, breast cancer survival differs within regions. We therefore examined breast cancer survival in relation to differences in diagnostic activity, tumor characteristics, and treatment in seven Swedish counties within a single health care region. We conducted a population-based observational study using a clinical breast cancer register in one Swedish health care region. Eligible women (n = 7,656) ages 40 to 69 years diagnosed with primary breast cancer between 1992 and 2002 were followed up until 2003. The 7-year relative survival ratio was used to estimate breast cancer survival. Excess mortality was modeled using Poisson regression to study differences in survival between counties. The 7-year relative survival for breast cancer patients was significantly lower (up to 7% in absolute risk difference) in one county (county A) compared with the others. This difference existed only among women diagnosed before 1998, ages 50 to 59 years, and was strongest among stage II breast cancer patients. Adjustment for amount of diagnostic activity eliminated the survival differences among the counties. The amount of diagnostic activity was also lower in county A during the same time period. After county A, during 1997-1998, began to adhere strictly to the regional breast cancer care program, neither any survival differences nor diagnostic activity differences were observed. Markers of diagnostic activity explained survival differences within our region, and the underlying mechanisms may be several. Low diagnostic activity may entail later diagnosis or inadequate characterization of the tumor and thereby missed treatment opportunities. Strengthening of multidisciplinary management of breast cancer can improve survival.

Prostate cancer incidence and survival in relation to education (United States)

There are few data on prostate cancer incidence and survival in relation to socioeconomic status in the 1990s, after the introduction of prostate specific Antigen (PSA) testing. We studied the relation of education to prostate cancer incidence and survival in the Cancer Prevention Study II (CPS-II) Nutrition Cohort. Participants provided questionnaire data on diet, medical history, education, and PSA testing. We followed 72,449 men from 1992-1999 for cancer incidence (4279 incident cases), and through 2000 for survival (158 prostate cancer deaths among incident cases). Multivariate-adjusted rate ratios (RRs) were calculated using Cox proportional hazards models. Self-reported (PSA) tests were more common among the more highly educated. Men with at least a college education had a 15-19% higher prostate cancer incidence than those with a high school education or less, but this association was limited to localized cancers and was attenuated by adjustment for PSA testing. Survival analysis among incident prostate cancer cases adjusted for stage and grade at diagnosis showed much lower prostate cancer mortality for men with at least a high school education compared to those with less than a high school education (RR = 0.49, 95% CI = 0.32-0.76). This study suggests that higher education is associated with slightly increased incidence of prostate cancer, at least partly due to greater use of PSA screening and a greater detection of localized tumors among more highly educated men. The much lower survival rates from prostate cancer among those with less than a high school education cannot be explained by available data and may reflect disparities in treatment. In 1999, 27% of US males over age 55 and older had less than a high school education.

Cancer disparities by race/ethnicity and socioeconomic status.

This article highlights disparities in cancer incidence, mortality, and survival in relation to race/ethnicity, and census data on poverty in the county or census tract of residence. The incidence and survival data derive from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program; mortality data are from the National Center for Health Statistics (NCHS); data on the prevalence of major cancer risk factors and cancer screening are from the National Health Interview Survey (NHIS) conducted by NCHS. For all cancer sites combined, residents of poorer counties (those with greater than or equal to 20% of the population below the poverty line) have 13% higher death rates from cancer in men and 3% higher rates in women compared with more affluent counties (less than 10% below the poverty line). Differences in cancer survival account for part of this disparity. Among both men and women, five-year survival for all cancers combined is 10 percentage points lower among persons who live in poorer than in more affluent census tracts. Even when census tract poverty rate is accounted for, however, African American, American Indian/Alaskan Native, and Asian/Pacific Islander men and African American and American Indian/Alaskan Native women have lower five-year survival than non-Hispanic Whites. More detailed analyses of selected cancers show large variations in cancer survival by race and ethnicity. Opportunities to reduce cancer disparities exist in prevention (reductions in tobacco use, physical inactivity, and obesity), early detection (mammography, colorectal screening, Pap tests), treatment, and palliative care.

Explaining gastric cancer survival differences among European countries.

Wide geographic variability in incidence and mortality rates for gastric cancer exists throughout the world despite persistent decreases over several decades. Variability in survival from gastric cancer is also evident and countries with higher incidence rates of gastric cancer show better survival rates than countries with lower incidence. The aim of this study was to identify reasons for the association between incidence and survival and to obtain survival estimates and differences corrected for this variation, thus facilitating further interpretation by clinical factors such as stage and treatment. Relative survival rates for gastric cancer derived from the EUROCARE-2 database for 47 cancer registries in 17 European countries were analyzed with regression methods to adjust differences by age, sex, period of diagnosis, subsite of the stomach, histologic type and stage at diagnosis. Overall, nearly 60% of the variability in gastric cancer relative survival was explained by differences in these variables. Factors are related to treatment and general management of patients is expected to explain the residual variability in gastric cancer survival between European countries. There is a need to improve completeness and standardization of detailed information collected on gastric cancer patients to allow detailed comparative analyses and interpretation.