Excess Mortality Ratio Research Articles

US State Restrictions and Excess COVID-19 Pandemic Deaths

Despite considerable prior research, it remains unclear whether and by how much state COVID-19-related restrictions affected the number of pandemic deaths in the US. To determine how state restrictions were associated with excess COVID-19 deaths over a 2-year analysis period. This was a cross-sectional study using state-level mortality and population data from the US Centers for Disease Control and Prevention for 2020 to 2022 compared with baseline data for 2017 to 2019. Data included the total US population, with separate estimates for younger than 45 years, 45 to 64 years, 65 to 84 years, and 85 years or older used to construct age-standardized measures. Age-standardized excess mortality rates and ratios for July 2020 to June 2022 were calculated and compared with prepandemic baseline rates. Excess death rates and ratios were then regressed on single or multiple restrictions, while controlling for excess death rates or ratios, from March 2020 to June 2020. Estimated values of the dependent variables were calculated for packages of weak vs strong state restrictions. Behavioral changes were investigated as a potential mechanism for the overall effects. Data analyses were performed from October 1, 2023, to June 13, 2024. Age and cause of death. Excess deaths, age-standardized excess death rates per 100 000, and excess death ratios. Mask requirements and vaccine mandates were negatively associated with excess deaths, prohibitions on vaccine or mask mandates were positively associated with death rates, and activity limitations were mostly not associated with death rates. If all states had imposed restrictions similar to those used in the 10 most restrictive states, excess deaths would have been an estimated 10% to 21% lower than the 1.18 million that actually occurred during the 2-year analysis period; conversely, the estimates suggest counterfactual increases of 13% to 17% if all states had restrictions similar to those in the 10 least-restrictive states. The estimated strong vs weak state restriction difference was 271 000 to 447 000 deaths, with behavior changes associated with 49% to 79% of the overall disparity. This cross-sectional study indicates that stringent COVID-19 restrictions, as a group, were associated with substantial decreases in pandemic mortality, with behavior changes plausibly serving as an important explanatory mechanism. These findings do not support the views that COVID-19 restrictions were ineffective. However, not all restrictions were equally effective; some, such as school closings, likely provided minimal benefit while imposing substantial cost.

Relative survival in patients with cancer and kidney failure.

The population with kidney failure is at increased risk of cancer and associated mortality. Relative survival can provide insight into the excess mortality, directly or indirectly, attributed to cancer in the population with kidney failure. We estimated relative survival for people all ages receiving dialysis (n=4089) and kidney transplant recipients (n=3253) with de novo cancer, and for the general population with cancer in Australia and New Zealand (n=3043166) over the years 1980-2019. The entire general population was the reference group for background mortality, adjusted for sex, age, calendar year and country. We used Poisson regression to quantify excess mortality ratios. Five-year relative survival for all-site cancer was markedly lower than that for the general population for people receiving dialysis [0.25, 95% confidence interval (CI) 0.23-0.26] and kidney transplant recipients (0.55, 95% CI 0.53-0.57). In dialysis, excess mortality was more than double (2.16, 95% CI 2.08-2.25) that of the general population with cancer and for kidney transplant recipients 1.34 times higher (95% CI 1.27-2.41). There was no difference in excess mortality from lung cancer between people with kidney failure and the general population with cancer. Comparatively, there was a significant survival deficit for people with kidney failure, compared with the general population with cancer, for melanoma, breast cancer and prostate cancers. Decreased cancer survival in kidney failure may reflect differences in multi-morbidity burden, reduced access to treatment, or greater harm from or reduced efficacy of treatments. Our findings support research aimed at investigating these hypotheses.

Examining Excess Mortality Associated With the COVID-19 Pandemic for Renters Threatened With Eviction

Residential evictions may have increased excess mortality associated with the COVID-19 pandemic. To estimate excess mortality associated with the COVID-19 pandemic for renters who received eviction filings (threatened renters). This retrospective cohort study used an excess mortality framework. Mortality based on linked eviction and death records from 2020 through 2021 was compared with projected mortality estimated from similar records from 2010 through 2016. Data from court records between January 1, 2020, and August 31, 2021, were collected via the Eviction Lab's Eviction Tracking System. Similar data from court records between January 1, 2010, and December 31, 2016, also collected by the Eviction Lab, were used to estimate projected mortality during the pandemic. We also constructed 2 comparison groups: all individuals living in the study area and a subsample of those individuals living in high-poverty, high-filing tracts. Eviction filing. All-cause mortality in a given month. The difference between observed mortality and projected mortality was used as a measure of excess mortality associated with the pandemic. The cohort of threatened renters during the pandemic period consisted of 282 000 individuals (median age, 36 years [IQR, 28-47]). Eviction filings were 44.7% lower than expected during the study period. The composition of threatened renters by race, ethnicity, sex, and socioeconomic characteristics during the pandemic was comparable with the prepandemic composition. Expected cumulative age-standardized mortality among threatened renters during this 20-month period of the pandemic was 116.5 (95% CI, 104.0-130.3) per 100 000 person-months, and observed mortality was 238.6 (95% CI, 230.8-246.3) per 100 000 person-months or 106% higher than expected. In contrast, expected mortality for the population living in similar neighborhoods was 114.6 (95% CI, 112.1-116.8) per 100 000 person-months, and observed mortality was 142.8 (95% CI, 140.2-145.3) per 100 000 person-months or 25% higher than expected. In the general population across the study area, expected mortality was 83.5 (95% CI, 83.3-83.8) per 100 000 person-months, and observed mortality was 91.6 (95% CI, 91.4-91.8) per 100 000 person-months or 9% higher than expected. The pandemic produced positive excess mortality ratios across all age groups among threatened renters. Renters who received eviction filings experienced substantial excess mortality associated with the COVID-19 pandemic.

Lymphoid blood cancers, incidence and survival 2005-2023: A report from the UK’s Haematological Malignancy Research Network

BackgroundPopulation-based information on cancer incidence and outcome are required to inform clinical practice and research; but contemporary data are lacking for many lymphoid cancer subtypes. MethodsSet within a socio-demographically representative UK population of ∼4 million, data are from an established UK patient cohort (N = 22,414 diagnoses). Information on incidence (crude and age-standardised) and survival (overall and net) is presented for > 40 subtypes. ResultsThe median diagnostic age was 69.9 years (interquartile range 59.1–78.3), but unlike many other cancers, lymphoid malignancies can be diagnosed at any age; different subtypes dominating at different ages. Males were more likely to be diagnosed than females (age-standardised sex rate ratio: 1.55 (95% Confidence Interval: 1.50,1.59)), and most subtypes had a male predominance, some more than three-fold (e.g. Burkitt lymphoma 3.26 (2.42, 4.40)). Five-year net survival estimates varied hugely, ranging from 97.4% (95% CI: 56.5, 99.9) in patients with hairy cell leukaemia to 31.6% (95% CI: 2.5, 69.8) in those with T-cell prolymphocytic leukaemia. No significant sex difference in survival were observed for the majority of diagnoses; one exception being classical Hodgkin lymphoma, where males had a higher mortality (Excess Mortality Ratio: 1.44 (95% CI: 1.11, 1.87)). An improvement in survival over time was observed for some, but not all, of the major diagnostic groups. ConclusionsMarked incidence and survival variations by subtype, sex and age confirm the heterogeneity of lymphoid neoplasms and highlight the importance of accurately characterising disease entities. Despite recent improvements, routine cancer registration of lymphoid neoplasms remains challenging and new issues continue to emerge; including the lack of an international consensus on classification and the recording of progressions and transformations. Furthermore, the increasing need for additional molecular and genomic information required for accurate classification is likely to impact negatively on the quality of cancer registration data, especially in low income countries.

Incidence trends and survival in early-onset esophagogastric adenocarcinoma: A Swedish population-based cohort study.

Early-onset adenocarcinomas of different sites are increasing in high-income countries, data on esophagogastric adenocarcinoma are sparse. We performed a Swedish population-based cohort study over 1993-2019 to delineate differences in incidence and survival in early-onset (age 20-54 years) compared to later-onset (55-99 years) esophageal, cardia, and non-cardia gastric adenocarcinoma. Temporal incidence trends were quantified as annual percentage changes (APC) and survival differences as excess mortality rate ratios (EMRR) using Poisson regression and including 95% confidence intervals (CI). Among 27,854 esophagogastric adenocarcinoma patients, 2576 were early-onset whereof 470 were esophageal, 645 were cardia, and 1461 were non-cardia gastric. Except non-cardia gastric, the male predominance was larger in early- compared to later-onset disease. Advanced stage and signet ring cell morphology were more common among early-onset patients. Early- and later-onset APC estimates were comparable and esophageal adenocarcinoma incidence increased, cardia remained stable, and non-cardia gastric decreased. Early-onset patients had better survival than later-onset, which was amplified when adjusting for prognostic factors including stage (adjusted EMRR 0.73 [95% CI 0.63-0.85] in esophageal, 0.75 [95% CI 0.65-0.86] in cardia, and 0.67 [95% CI 0.61-0.74] in non-cardia gastric adenocarcinoma). The early-onset survival advantage was more pronounced in localized stages 0-II (all sites) and women (esophageal and non-cardia gastric). We found no major differences in incidence trends comparing early- and later-onset esophagogastric adenocarcinoma. Despite unfavorable prognostic features, early-onset esophagogastric adenocarcinoma survival was better than later-onset, particularly in localized stages and women. Our findings suggest delayed diagnosis in younger individuals and especially men.

Seasonal effects on cancer incidence and prognosis

Background It is unknown if the reduction in the expected number of cancer cases diagnosed during Swedish holidays are due to diagnostic delays, how different cancers are affected, and if the season of diagnosis influences long-term cancer survival. We aimed to quantify seasonal trends in incidence and excess mortality for a wide range of malignancies, requiring more or less urgent clinical management. Material and methods This nationwide cohort study included all Swedish residents aged 20–84 in 1990–2019. Incidence and relative survival in pancreatic, colorectal, lung, urothelial, breast, and prostate cancer, together with malignant melanoma, non-Hodgkin lymphoma, and acute leukemia diagnosed during holiday and post-holiday were compared to working (reference) season. Incidence rate ratios (IRR) were estimated using Poisson regression and excess (cancer) mortality rate ratios using flexible parametric models. Results We identified 882,980 cancer cases. Incidence declined during holiday season for all malignancies and the IRR ranged from 0.58 (95% CI 0.57–0.59 in breast to 0.92 (95% CI 0.89–0.94) in pancreatic cancer. A post-holiday increase was noted for acute leukemia, pancreatic, and lung cancer. For all malignancies except lung cancer, non-Hodgkin lymphoma, and acute leukemia, the excess mortality at 2 years from diagnosis was higher among those diagnosed during the holiday season. A tendency toward elevated short-term (0.5 years) excess mortality was noted in the post-holiday group, but long-term effects only persisted in breast cancer. Conclusion This study demonstrates lower holiday detection rates and higher mortality rates in various cancer types diagnosed during holiday season. Healthcare systems should offer a uniform level of cancer care independent of calendar season.

Sex differences in lymphoma incidence and mortality by subtype: A population-based study.

It is well established that the male sex is associated with increased risk for, as well as poorer survival of, most cancers. A similar pattern has been described in lymphomas but has not yet been comprehensively assessed. In this nationwide population-based cohort study, we used the Swedish Lymphoma Register to investigate sex differences in lymphoma subtype incidence and excess mortality in adults (age 18-99) diagnosed in 2000-2019. Male-to-female incidence rate ratios (IRRs) and excess mortality ratios (EMRs) adjusted for age and calendar year were predicted using Poisson regression. We identified 36 795 lymphoma cases, 20 738 (56.4%) in men and 16 057 (43.6%) in women. Men were at significantly higher risk of 14 out of 16 lymphoma subtypes with IRRs ranging from 1.15 (95% confidence interval [CI] 1.09-1.22) in follicular lymphoma to 5.95 (95% CI 4.89-7.24) in hairy cell leukemia. EMRs >1 were seen in 13 out of 16 lymphoma subtypes indicating higher mortality in men, although only statistically significant for classical Hodgkin lymphoma 1.26 (95% CI 1.04-1.54), aggressive lymphoma not otherwise specified 1.29 (95% CI 1.08-1.55), and small lymphocytic lymphoma 1.52 (95% CI 1.11-2.07). A corresponding analysis using data from the Danish Lymphoma Register was performed with comparable results. In conclusion, we demonstrate a significantly higher incidence and trend toward higher mortality in men for most lymphoma subtypes. Future studies with large patient material that include detailed clinicopathological prognostic factors are warranted to further delineate and explain sex differences in lymphoma survival to enable optimal management of lymphoma patients regardless of sex.

Effect of sex on survival after resection of oesophageal cancer: nationwide cohort study.

BackgroundAccumulating evidence suggests a survival benefit after curative oesophageal cancer surgery in women compared with men. The aim of this study was to explore sex disparities in survival after surgery with curative intent in patients with oesophageal cancer.MethodsThis was a population-based cohort study, including all patients with oesophageal or gastric cancer who underwent surgery with a curative intent between 2006 and 2017 in Sweden. Female versus male mortality rate ratio (MRR) and excess mortality rate ratio (EMRR) were used as measures of survival. Two different parametric models were designed to account for potential confounders. Patients with gastric cancer were used as a comparison group as no differences in survival between sexes were expected among these patients.ResultsA total of 1301 patients underwent resection for oesophageal adenocarcinoma and 305 patients for oesophageal squamous cell carcinoma. Women had a lower EMRR (0.76, 95 per cent c.i. 0.58 to 1.01, P = 0.056; 0.52, 95 per cent c.i. 0.32 to 0.84, P = 0.007 respectively) in both histological subtypes. The effect was more profound in early clinical stages, in patients receiving neoadjuvant treatment, and without postoperative complications. No sex-related difference was observed in survival of patients with gastric cancer.ConclusionsWomen undergoing resection for oesophageal carcinoma have better survival compared with men.

Risk factors for excess all-cause mortality during the first wave of the COVID-19 pandemic in England: A retrospective cohort study of primary care data.

The COVID-19 pandemic's first wave in England during spring 2020 resulted in an approximate 50% increase in all-cause mortality. Previously, risk factors such as age and ethnicity, were identified by studying COVID-related deaths only, but these were under-recorded during this period. To use a large electronic primary care database to estimate the impact of risk factors (RFs) on excess mortality in England during the first wave, compared with the impact on total mortality during 2015-19. Medical history, ethnicity, area-based deprivation and vital status data were extracted for an average of 4.8 million patients aged 30-104 years, for each year between 18-March and 19-May over a 6-year period (2015-2020). We used Poisson regression to model total mortality adjusting for age and sex, with interactions between each RF and period (pandemic vs. 2015-19). Total mortality during the pandemic was partitioned into "usual" and "excess" components, assuming 2015-19 rates represented "usual" mortality. The association of each RF with the 2020 "excess" component was derived as the excess mortality ratio (EMR), and compared with the usual mortality ratio (UMR). RFs where excess mortality was greatest and notably higher than usual were age >80, non-white ethnicity (e.g., black vs. white EMR = 2.50, 95%CI 1.97-3.18; compared to UMR = 0.92, 95%CI 0.85-1.00), BMI>40, dementia, learning disability, severe mental illness, place of residence (London, care-home, most deprived). By contrast, EMRs were comparable to UMRs for sex. Although some co-morbidities such as cancer produced EMRs significantly below their UMRs, the EMRs were still >1. In contrast current smoking has an EMR below 1 (EMR = 0.80, 95%CI 0.65-0.98) compared to its UMR = 1.64. Studying risk factors for excess mortality during the pandemic highlighted differences from studying cause-specific mortality. Our approach illustrates a novel methodology for evaluating a pandemic's impact by individual risk factor without requiring cause-specific mortality data.

Survival, causes of death, and the prognostic role of comorbidities in chronic lymphocytic leukemia in the pre-ibrutinib era: A population-based study.

To evaluate temporal trends in survival and causes of death in patients with chronic lymphocytic leukemia (CLL) in a nationwide study. The cohort consisted of 13,009 Swedish CLL patients diagnosed 1982-2013. Relative survival (RS) and excess mortality rate ratios (EMRR) with 95% confidence intervals (95% CIs) were estimated using flexible parametric survival models. Cause-specific hazard ratios (HRs) were estimated for the linear effect of 10-year increase in year of diagnosis. The excess mortality decreased comparing 2003-2013 to 1982-1992 (EMRR=0.53, 95% CI 0.48-0.58). The 5-year RS increased between 1982 and 2012 for patients >51years at diagnosis and improved for patients ≤51years after 2002. The rate of CLL-specific deaths decreased over time (HR=0.78, 95% CI 0.75-0.81). Compared to patients with no comorbidity, patients with 1 and 2+ Charlson Comorbidity Index points had HR=1.35 (95% CI 1.25-1.45) and HR=1.47 (95% CI 1.37-1.57) for CLL-related mortality, respectively. Survival in CLL patients improved in the era of chemoimmunotherapy, and this was largely explained by reduced CLL-related mortality. The increased rate of CLL-related mortality in patients with comorbidities emphasizes the importance of the newer and better tolerated targeted therapy.

Trends in survival of epithelial ovarian/tubal cancer by histology and socioeconomic status in Denmark 1996–2017

ObjectivesTo examine time trends in ovarian/tubal cancer relative survival, excess mortality, and all-cause mortality for different histological types and levels of socioeconomic position. MethodsWomen with ovarian/tubal cancer diagnosed 1996–2017 were identified in the Danish Cancer Registry (n = 11,755). Age-standardized 5-year relative survival over time was estimated by histology, socioeconomic status, and stage. Furthermore, 5-year excess mortality rate ratios (EMRR) according to calendar time for all categories of histology and socioeconomic status were calculated using a Poisson regression model. Finally, all-cause mortality by histology and socioeconomic status was estimated in multivariate Cox proportional hazards regression models. ResultsStatistically significant improvements in 5-year relative survival occurred for all histological types over time except mucinous tumors (5-year EMRR, localized: 0.92 (95% CI: 0.71–1.16); advanced: 0.96 (95% CI: 0.85–1.08). Increase in relative survival over time and corresponding decrease in excess mortality was observed for all categories of socioeconomic status except for women with localized disease in the lowest income group (5-year EMRR = 0.91 (95% CI:0.76–1.10)). The impact of histology and socioeconomic status on all-cause mortality depended on time since diagnosis. Among the socioeconomic factors, especially low educational level and living alone were associated with increased all-cause mortality, particularly in the first year after diagnosis. ConclusionsOvarian/tubal cancer survival generally increased over time across histological types and socioeconomic factors. However, the lack of improvement for mucinous tumors needs further research. Additionally, the results for women with low income and education shows that continued focus on social equality in survival is necessary.

Sex Differences in Lymphoma Incidence and Excess Mortality By Subtype: A Comprehensive National Study

IntroductionFor most cancer types, cancer incidence as well as cancer-specific mortality is higher in men compared to women. The underlying reasons for this remain unclear but hypotheses include sex differences in environmental exposure to carcinogens, health-seeking behavior and biology, such as hormonal, anatomical, and molecular disparities. For lymphomas, the impact of sex seems to differ by subtype, treatment, and calendar time. For example, in Hodgkin lymphoma (HL), male sex has historically been considered an established negative prognostic factor but in contemporary studies, therapeutic advances appear to have attenuated the prognostic value of sex. In contrast, a negative impact of male sex on prognosis has become manifest during the last decades in patients with diffuse large B-cell lymphoma and follicular lymphoma, with sex differences in rituximab clearance in elderly proposed as one explanation. Previous studies have not considered the longer life expectancy of women when predicting incidence and prognosis, and comprehensive studies on the impact of sex on incidence and excess mortality in lymphomas are lacking. Therefore, we aimed to quantify and outline sex differences in lymphoma incidence and lymphoma excess mortality by subtype in a large, population-based cohort.MethodsAdult patients diagnosed with lymphoma 2000-2019 were identified via the Swedish lymphoma register (>95% national coverage). Sex-specific incidence rates were computed as the number of new cancer cases per 100,000 person-years/year and age-standardized to the Swedish population in 2019 (using population counts from Statistics Sweden). Male-to-female incidence rate ratios (IRRs) with 95% confidence intervals (CIs), adjusted for age and year of diagnosis, were estimated using Poisson regression models. Sex-specific 5-year relative survival was calculated as the ratio of the observed lymphoma patient and the matched (sex, age, and calendar year) population 5-year survival and age-standardized according to the International Cancer Survival Standards. Male-to-female 5-year excess mortality rate ratios (EMRR) including 95% CIs were estimated including age and calendar year in the Poisson regression models.ResultsA total of 36 859 patients with lymphoma were identified during the study period. Median age for all patients was 69 (range 16-99) years. In the whole cohort there was a male predominance of 56%. Distribution of patients by sex, and male-to-female IRR and EMRR adjusted for age and year of diagnosis by major lymphoma subtype are presented in Table 1, and graphically in Figure 1. Overall, significantly higher incidence rates among men were observed for all lymphoma subtypes except marginal zone lymphoma and primary mediastinal B-cell lymphoma. The higher male-to-female IRRs remained largely stable over calendar time. For some subtypes, male-to-female IRR differed by age. For example, in HL, male and female IRs were similar up to 35 years, whereafter the male-to-female IRR increased. For both Burkitt lymphoma and Nodular lymphocyte predominant Hodgkin lymphoma the higher male-to-female IRR was most pronounced among patients under the age of 50, although incidence was higher among men of all ages for both subtypes. Regarding survival, there was a trend for higher excess mortality among men for several subtypes (Table 1, Fig 1). Significantly higher EMRRs among male patients were seen in HL, aggressive lymphomas not otherwise specified, and small lymphocytic lymphoma.ConclusionIn this large population-based study we observe a significantly higher incidence rate among men for all but two lymphoma subtypes. Further, there was a trend for worse survival among male lymphoma patients for most lymphomas although only significantly worse for three subtypes, potentially due to small numbers for rare subtypes and limited adjustment. As of yet, reasons for sex differences in incidence and excess mortality of lymphoma are unknown. Better understanding of underlying factors to these differences may improve management of lymphomas and increase knowledge of lymphoma biology and etiology. Thus, further studies on sex differences in lymphoma with detailed data regarding disease-specific patient characteristics, treatment and patient-related factors such as comorbidity and socioeconomic status are warranted. [Display omitted] DisclosuresWeibull: Jansen-Cilag: Other: part of a research collaboration between Karolinska Institutet and Janssen Pharmaceutica NV for which Karolinska Institutet has received grant support. El-Galaly: Abbvie: Other: Speakers fee; ROCHE Ltd: Ended employment in the past 24 months. Smedby: Jansen-Cilag: Other: part of a research collaboration between Karolinska Institutet and Janssen Pharmaceutica NV for which Karolinska Institutet has received grant support.

The wait time to primary surgery in endometrial cancer – impact on survival and predictive factors: a population-based SweGCG study

Background Poor survival rates in different cancer types are sometimes blamed on diagnostic and treatment delays, and it has been suggested that such delays might be related to sociodemographic factors such as education and ethnicity. We examined associations of the wait time from diagnosis to surgery and survival in endometrial cancer (EC) and explored patient and tumour factors influencing the wait time. Material and methods In this historical population-based cohort study, The Swedish Quality Registry for Gynaecologic Cancer (SQRGC) was used to identify EC patients who underwent primary surgery between 2010 and 2018. Factors associated with a wait time > 32 d were analysed with logistic regression. The 32-d time point was defined in accordance with the Swedish Standardisation Cancer Care programme. Adjusted Poisson regression analyses were used to analyse excess mortality rate ratio (EMRR). Results Out of 7366 women, 5535 waited > 32 d for surgery and 1098 > 70 d. The overall median wait time was 44 d. The factors most strongly associated with a wait time > 32 d were surgery at a university hospital (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 1.08–1.66) followed by country of birth (OR 1.31, 95% CI 1.10–1.55) and year of diagnosis. There were no associations between wait time and histology or age. A wait time < 15 d was associated with higher mortality (adjusted EMRR 2.29,95% CI 1.36–3.84) whereas no negative survival impact was seen with a wait time of 70 d. Age, tumour stage, histology and risk group were highly associated with survival, whereas education, country of origin and hospital level did not have any impact on survival. Conclusions Surgery within the first two weeks after EC diagnosis was associated with worsened survival. A prolonged wait time did not seem to have any significant adverse effect on prognosis. Highlights Surgery within the first two weeks after diagnosis of endometrial cancer (EC) was associated with poorer survival. A prolonged wait time to surgery did not worsen prognosis. Delay in time to surgery was associated with sociodemographic factors.

Mortality in patients with Crohn’s disease in Örebro, Sweden 1963–2010

Background Some studies have suggested a reduced life expectancy in patients with Crohn’s disease (CD) compared with the general population. The evidence, however, is inconsistent. Aims Prompted by such studies, we studied survival of CD patients in Örebro county, Sweden. Methods From the medical records, we identified all patients diagnosed with CD during 1963–2010 with follow-up to the end of 2011. We estimated: overall survival, net and crude probabilities of dying from CD, relative survival ratio (RSR), and excess mortality rate ratios (EMRR) at 10-year follow-up. Results The study included 492 patients (226 males, 266 females). Median age at diagnosis was 32 years (3–87). Net and crude probabilities of dying from CD increased with increasing age and were higher for women. Net survival of patients aged ≥60 at diagnosis was worse for patients diagnosed during 1963–1985 (54%) than for patients diagnosed during 1986–1999 (88%) or 2000–2010 (93%). Overall, CD patients’ survival was comparable to that in the general population [RSR = 0.98; 95% CI: (0.95–1.00)]. However, significantly lower than expected survival was suggested for female patients aged ≥60 diagnosed during the 1963–1985 [RSR = 0.47 (0.07–0.95)]. The adjusted model suggested that, compared with diagnostic period 1963–1985, disease-related excess mortality declined during 2000–2010 [EMRR = 0.36 (0.07–1.96)]; and age ≥60 at diagnosis [EMRR = 7.99 (1.64–39.00), reference: age 40–59], female sex [EMRR = 4.16 (0.62–27.85)], colonic localization [EMRR = 4.20 (0.81–21.88), reference: ileal localization], and stricturing/penetrating disease [EMRR = 2.56 (0.52–12.58), reference: inflammatory disease behaviour] were associated with poorer survival. Conclusion CD-related excess mortality may vary with diagnostic period, age, sex and disease phenotype. Key summary There is inconsistent evidence on life expectancy of patients with Crohn’s disease Crohn’s disease-specific survival improved over time. Earlier diagnosis period, older age at diagnosis, female sex, colonic disease and complicated disease behaviour seems to be associated with excess Crohn’s disease-related mortality.

658 BETTER SURVIVAL IN FEMALES THAN MALES AFTER RESECTION OF OESOPHAGEAL OR GASTROESOPHAGEAL JUNCTION CANCER: A COHORT STUDY IN SWEDEN

Abstract Accumulating evidence points to a better survival in female patients after a curative oesophageal cancer surgery. However, there is a need for more well-designed and sufficiently powered studies for limitations in previous studies. Better understanding of sex differences in the postoperative survival may be helpful for a sex-specific treatment. Methods This is a population-based cohort study including all patients in Sweden with oesophageal cancer that underwent a curative surgical treatment between 2006 and 2017. Sex difference in postoperative survival was explored with excess mortality rate ratio (EMRR) and absolute difference of excess mortality rate along the whole follow-up time, using flexible parametric model. Age at the time of surgery, Charlson comorbidity index, ASA score, tumor stage, post-operative complications, marital status, education level and hospital volume were considered as covariates in the analysis model. Stratification analysis by clinical stages, perioperative neoadjuvant treatment and post-operative complications was also performed. Results In all, there were 1301 patients resected for oesophageal adenocarcinoma and 305 patients for oesophageal squamous cell carcinoma. For both oesophageal adenocarcinoma and oesophageal squamous cell carcinoma, female patients had a lower excess mortality rate than males (adjusted EMRR: 0.77, 95% CI: 0.58–1.01, P = 0.059; 0.53, 95% CI: 0.33–0.85, P = 0.009, respectively). This sex difference was particularly strong shortly after surgery then gradually decreased over the ensuing years (Figure) and was more profound in the early clinical stages, and in patients receiving neoadjuvant treatment and without post-operative complications. Conclusion Female patients seem to have a better survival shortly after esophagectomy for patients with oesophageal adenocarcinoma and oesophageal squamous cell carcinoma, and the sex difference thereafter weakened. Our results may imply a different response to oesophageal cancer surgery between the sexes, and associated pre- and post-operative treatment, thus a sex-specific strategy may be considered in further work.

Long-term Survival of Treated Tuberculosis Patients in Comparison to a General Population In South India: A Matched Cohort Study

ObjectivesThis study aimed to measure the mortality rate, potential years of life lost, and excess general mortality among individuals treated for pulmonary tuberculosis (TB) in a TB endemic country. MethodsA retrospective analysis was conducted on a population-based cohort study of 4022 TB patients and 12,243 gender-matched and age-matched controls from prevalence surveys conducted between 2000 and 2004 in the Thiruvallur district of Tamil Nadu, South India. ResultsThe mortality rate among TB patients was 59/1000 person-years. The excess standardized mortality ratio was 2.3 (95% CI: 1.7–3.1). The rate of potential years of life lost was 6.15/1000 (95% CI: 5.97–6.33) in the TB cohort compared to the general population of 1.52/1000 (95% CI: 1.46–1.60). Individuals aged >50 years, those underweight (<40 kg), with treatment failures, or lost to follow-up had higher mortality rates when compared with the rest of the TB cohort. The risk of death was significantly higher in the TB cohort until the end of the fourth year when compared with later years. ConclusionMortality in the TB cohort was 2.3 times higher than in the age-matched general population. Most deaths occurred in the first year after completing treatment. Post-treatment follow-ups and interventions for reducing comorbid conditions are necessary to prevent deaths.

Survival patterns of invasive lobular and invasive ductal breast cancer in a large population-based cohort with two decades of follow up

BackgroundInvasive lobular carcinoma (ILC) comprises 8–15 % of all invasive breast cancers and large population-based studies with >10 years of follow-up are rare. Whether ILC has a long-time prognosis different from that of invasive ductal carcinoma, (IDC) remains controversial. PurposeTo investigate the excess mortality rate ratio (EMRR) of patients with ILC and IDC and to correlate survival with clinical parameters in a large population-based cohort. Material and methodsFrom 1989 through 2006, we identified 17,481 patients diagnosed with IDC (n = 14,583) or ILC (n = 2898), younger than 76 years from two Swedish Regional Cancer Registries. Relative survival (RS) during 20 years of follow up was analysed. ResultsILC was significantly associated with older age, larger tumours, ER positivity and well differentiated tumours. We noticed an improved survival for patients with ILC during the first five years, excess mortality rate ratio (EMRR) 0.64 (CI 95 % 0.53–0.77). This was shifted to a significant decreased survival 10–15 years after diagnosis (EMRR 1.49, CI 95 % 1.16–1.93). After 20 years the relative survival rates were similar, 0.72 for ILC and 0.73 for IDC. ConclusionsDuring the first five years after surgery, the EMRR was lower for patients with ILC as compared to patients with IDC, but during the years 10–15 after surgery, we observed an increased EMRR for patients with ILC as compared to IDC. These EMRR between ILC and IDC were statistically significant but the absolute difference in excess mortality between the two groups was small.

Survival in Primary Myelofibrosis: A Population-based Analysis in the Netherlands

Survival in Primary Myelofibrosis: A Population-based Analysis in the Netherlands

Characterizing all-cause excess mortality patterns during COVID-19 pandemic in Mexico

BackgroundLow testing rates and delays in reporting hinder the estimation of the mortality burden associated with the COVID-19 pandemic. During a public health emergency, estimating all cause excess deaths above an expected level of death can provide a more reliable picture of the mortality burden. Here, we aim to estimate the absolute and relative mortality impact of COVID-19 pandemic in Mexico.MethodsWe obtained weekly mortality time series due to all causes for Mexico, and by gender, and geographic region from 2015 to 2020. We also compiled surveillance data on COVID-19 cases and deaths to assess the timing and intensity of the pandemic and assembled weekly series of the proportion of tweets about ‘death’ from Mexico to assess the correlation between people’s media interaction about ‘death’ and the rise in pandemic deaths. We estimated all-cause excess mortality rates and mortality rate ratio increase over baseline by fitting Serfling regression models and forecasted the total excess deaths for Mexico for the first 4 weeks of 2021 using the generalized logistic growth model.ResultsWe estimated the all-cause excess mortality rate associated with the COVID-19 pandemic in Mexico in 2020 at 26.10 per 10,000 population, which corresponds to 333,538 excess deaths. Males had about 2-fold higher excess mortality rate (33.99) compared to females (18.53). Mexico City reported the highest excess death rate (63.54) and RR (2.09) compared to rest of the country (excess rate = 23.25, RR = 1.62). While COVID-19 deaths accounted for only 38.64% of total excess deaths in Mexico, our forecast estimate that Mexico has accumulated a total of ~ 61,610 [95% PI: 60,003, 63,216] excess deaths in the first 4 weeks of 2021. Proportion of tweets was significantly correlated with the excess mortality (ρ = 0.508 [95% CI: 0.245, 0.701], p-value = 0.0004).ConclusionThe COVID-19 pandemic has heavily affected Mexico. The lab-confirmed COVID-19 deaths accounted for only 38.64% of total all cause excess deaths (333,538) in Mexico in 2020. This reflects either the effect of low testing rates in Mexico, or the surge in number of deaths due to other causes during the pandemic. A model-based forecast indicates that an average of 61,610 excess deaths have occurred in January 2021.

Implementation of National Guidelines increased survival in advanced ovarian cancer - A population-based nationwide SweGCG study

AimThe first Swedish National Guidelines for Ovarian Cancer (NGOC) were published in 2012. We aimed to evaluate surgical outcomes and survival in patients with stage IIIC-IV disease, before and after the NGOC implementation. MethodWomen with primary epithelial ovarian cancer, FIGO stage IIIC–IV, registered in the Swedish Quality Registry for Gynecologic Cancer 2008–2011 and 2013–2016 were included. Surgical outcomes were analyzed, including frequency of complete cytoreduction (R0). Relative survival (RS) and excess mortality rate ratios (EMRRs) were computed as measures of survival. Univariable and multivariable regression (Poisson) were calculated. ResultsIn total, 3728 women were identified, 1746 before and 1982 after NGOC. After adjusting for age and stage, survival was improved 2013–2016 vs. 2008–2011 (EMRR 0.89; 95%CI:0.82–0.96, p < 0.05). For women undergoing primary debulking surgery (PDS), R0 frequency (28.9% vs. 53.3%; p < 0.001) and 5-year RS (29.6% (95%CI:26.8–32.8) vs. 37.4% (95%CI:33.6–41.7)) were increased, but fewer patients (58% vs. 44%, p < 0.001) underwent PDS after NGOC implementation. Median survival for the PDS cohort increased from 35 months (95%CI,32.8–39.2) to 43 months (95%CI,40.9–46.4). In the neoadjuvant chemotherapy (NACT) + interval debulking surgery (IDS) cohort, R0 increased (36.8% to 50.1%, p < 0.001), but not 5-year RS (17.5% vs. 20.7%, ns). Compared to PDS, the EMRR was 1.32 (95%CI,1.19–1.47, p < 0.001) for NACT+IDS and 3.00 (95%CI,2.66–3.38, p < 0.001) for chemotherapy alone. In multivariable analyses, PDS, R0, age ≤ 70 years, and stage IIIC were found to be independent factors for improved RS. ConclusionImplementation of the first National Guidelines for Ovarian Cancer improved relative survival in advanced ovarian cancer.