The prevalence of cancer: a review of the available data

AIMS AND BACKGROUND: Cancer prevalence in a population, defined as the proportion - or the number - of people who were diagnosed with a cancer during their lives and are still alive at a given date, is a crucial indicator for heath care planning and resource allocation. Long-term population-based cancer registries (CR) are the appropriate tools to produce prevalence figures, which, however, are scarcely available. This paper contains a review up to 1999 of the published data world-wide (reports and articles) on cancer prevalence: including measured and estimated figures. MATERIALS AND METHODS: Data on cancer prevalence from CRs are available for the Nordic countries, Connecticut, and Italy. In addition, electronic data are available for the European Union (EU). Data for the Nordic countries were first published in the mid-seventies, reporting the prevalence for 1970. The first data from Connecticut were available 10 years later. Estimates for all EU countries were published by the International Agency for Research on Cancer (IARC) in 1997. In Italy, observed and estimated data on the prevalence of respiratory and digestive tract cancer and breast cancer have been published during the nineties, followed by a systematic analysis for all cancers in 1999. By using information obtained from CRs, cancer prevalence data were calculated directly (observed prevalence) by means of incidence and follow-up information on individual cancer patients, or indirectly (estimated prevalence) by means of mathematical models, which generally use epidemiological information at the aggregate level. RESULTS: Cancer prevalence for all cancers combined (proportions per 100,000 inhabitants) showed values of less than 700 in males and less than 800 in females in 1970 (Finland) to over 2,300 in males and over 3,000 in females in 1992 (Italian registries). With few exceptions, in each country and period considered the cancer sites contributing most to cancer prevalence are lung, colon-rectum, prostate and bladder in males, colon-rectum, breast, uterus (both cervix and corpus) and ovary in females. At present, comparison of measurements from different areas is difficult because there exists no standardized mode of presentation. CONCLUSIONS: In spite of their being potentially useful for health care planning, prevalence data have been produced inconsistently and late by cancer registries, at least in comparison with the systematic availability of incidence and survival statistics. The available data can be compared only to a limited extent due to differences in completeness, in the choice of indicators, in the standard populations, and in the frequency of publication. It would be desirable that in the future data will be produced systematically, with a higher level of standardization compared to the past, and, most importantly, on the same geographic and administrative scale as health-care decision-making.     

Cancer prevalence in Italian regions with local cancer registries

OBJECTIVE: To provide estimates and projections of cancer incidence and prevalence for those Italian regions whose population is partially covered by a cancer registry (CR) and to determine to what extent local CRs can be considered representative of the region, thus improving the potential of the information provided by CRs. METHODS: A statistical method, MIAMOD (mortality-incidence analysis model), was used to estimate regional cancer incidence and prevalence from regional cancer mortality data and patient survival data recorded by the cancer registries. Estimates of the cancer incidence and prevalence in the various regions have thus been obtained for a number of major cancer sitas. A first and important step in validating the regional estimates has been the comparison of the MIAMOD estimates in the areas covered by the cancer registries with empirical incidence and prevalence observed by CRs, in order to assess the consistency in data, methods and assumptions. Empirical prevalence has been calculated by counting patients with a diagnosis of cancer who were alive on the reference date by PREVAL method. A correction factor has been applied to include patients diagnosed before the period of activity of the registry. RESULTS: General consistency was found between empirical and estimated (by MIAMOD) incidence and prevalence in the registry areas, which is indicative of the quality and the completeness of all data involved as well as the appropriateness of model choices. The prevalence of all cancers combined for Italian regions with CRs was estimated and projected to the year 2000 as ranging between 1,240 per 100,000 in Sicilia and 2,781 in Emilia-Romagna for men, while for women these figures were 1,765 in Sicilia and 4,019 in Liguria. Comparison of cancer prevalence in CR areas with regional estimates shows quite good consistency for Piemonte, Liguria and Lombardia, which means that the local CRs (of Torino, Genova and Varese, respectively) are representative of their respective regions. Prevalence in Emilia-Romagna appears to be rather well represented by only one, the Parma CR, of the three local CRs. The southern Italian registries of Latina and Ragusa recorded a lower cancer prevalence than was actually estimated in their respective regions. DISCUSSION: Cancer registries with a longer period of activity showed better agreement between empirical and estimated figures due to the more precise information provided, particularly regarding survival and incidence trends. In conclusion, this work shows the potential of the cancer registries not only to represent their population with respect to cancer morbidity but also as an invaluable tool to extrapolate this information to the larger areas they represent.     

Trends in mortality from primary liver cancer in Europe

Upward trends in incidence and mortality from primary liver cancer have been reported from Japan, the USA and a few European countries. Thus, we systematically reviewed trends in age-standardised death certification rates from primary liver cancer between 1970 and 1996 in 20 European countries providing data for the World Health Organisation database. Overall age-standardised (world population) mortality rates were approximately stable or showed no consistent trends in seven countries, including Bulgaria and Hungary (with exceedingly high rates), Finland, The Netherlands and the UK. Moderate rises were observed in Austria, Germany and Switzerland, and much larger upward trends in France and Italy, particularly for males. Downward trends were observed in both sexes in Belgium, Spain, Ireland, Greece and several Scandinavian countries. The per cent change in rates per year ranged, for males, from -7.4% for Ireland and -5.1% for Spain to +4.4% for Italy and +8.6% for France. Trends were more favourable in women, with 15 out of 20 countries showing downward trends in rates, and moderately more favourable in middle age (45-64 years) and, in major European countries, in young adults (20-44 years of age). In conclusion, trends in liver cancer mortality in Europe are heterogeneous. The fall in mortality in countries like Spain may be largely explained by improvements in the distinction between primary and secondary liver neoplasms, whereas upward trends in Central Europe and Italy are likely to be, at least in part, real. Increases in infection with the hepatitis C virus, and improved and increased searches for liver cancer in cirrhotic patients are two of the likeliest explanations for these observations.     

Variations in survival from breast cancer in Europe by age and country, 1978–1989

The objective of this study, part of the wider EUROCARE II collaborative project, was to examine variations by age and country in the relative survival of women from breast cancer in Europe, based on data for 145 000 cases in 1985–1989 and trends based on (245 000) cases for 1978–1989. Data were supplied by 42 cancer registries in 17 countries to a common protocol. Results for some countries where the participating registries covered only small proportions of the total population may not be representative of the whole country. In 1985–1989 there were wide differences among the 17 countries: survival was above the European average in Iceland, Finland, Sweden, Switzerland, France and Italy; around average in Denmark, The Netherlands, Germany and Spain; below average in Scotland, England and Slovenia; and well below average in Slovakia, Poland and Estonia. In France, Spain and Italy, but not in the U.K., there were wide differences in survival among the participating registries. Survival generally declined with age, particularly in the elderly (75 years and over)—this was most marked in Denmark, Scotland and England. Over the period 1978–1989, 1-year survival improved by 2% overall and 5-year survival by 6%. There were improvements in 5-year survival in all countries except Iceland, Germany, Switzerland and Estonia, and in all age groups except the youngest (15–44 years). It is likely that differences in the access to and quality of care in the various countries played a large part in explaining the differences in survival.     

Differences in the epidemic rise and decrease of prostate cancer among geographical areas in Southern Europe. an analysis of differential trends in incidence and mortality in France,Italy and Spain

This is a population-based study aimed at evaluating incidence and mortality trends for prostate cancer in France, Italy and Spain, during the prostate-specific antigen (PSA) era, considering elderly people aged 70 years and over and younger adults aged between 40 and 69 years. Trends were estimated by a log-linear Poisson regression model and expressed as an Estimated Annual Percent Change (EAPC). Incidence increased sharply in almost all areas. Spain showed the lowest increases. Incidence started to rise around 1985 in France and after 1990 in Italy and Spain. Mortality increased until the late 1980s in all countries, then declined in France and Italy (-2.5% in 40-69 year age group), but not in Spain. Younger people showed a much higher rise in incidence than the elderly, while mortality decreased mainly in the younger adults. The decrease in mortality was more marked in those areas and the younger age group where the rise in incidence was higher and started earlier, i.e. in France and in younger people, suggesting that the PSA test may have had a positive effect on mortality, although other clinical advances also have to be taken into account.     

Time trends of breast cancer survival in Europe in relation to incidence and mortality

Increasing breast cancer survival, observed in most western countries, is not easily interpreted: it could be due to better treatment, more effective treatment due to earlier diagnosis or simply lead-time bias. Increased diagnostic activity (e.g., screening) can inflate both incidence and survival. To understand interrelations between incidence, mortality and survival trends and their consequences, we analyzed survival trends in relation to mortality and incidence. Starting with observed survival from EUROCARE, mortality from WHO and using the MIAMOD method, we estimated breast cancer incidence trends from 1970 to 2005 in 10 European countries. To smooth out peaks in incidence and survival due to early diagnosis activity, survival trends were assumed similar to those observed by EUROCARE in 1983-1994. The following patterns emerged: (1) increasing survival with increasing incidence and declining or stable mortality (Sweden, Finland); (2) slight survival increase, marked incidence increase and slight mortality decrease (Denmark, the Netherlands and France); (3) increasing survival, marked decrease in mortality and tendency to incidence stabilization (UK); (4) marked survival increase, steady or decreasing mortality and moderate increases in incidence (Spain, Italy); (5) stable survival, increasing incidence and mortality (Estonia). In most countries survival increased, indicating a real advantage for patients when accompanied by decreasing or stable mortality, and attributable to improved cancer care (Sweden, UK, France, Italy and Spain). In Finland (with high survival), the Netherlands and Denmark, increasing mortality and incidence indicate increasing breast cancer risk, probably related to life-style factors. In Estonia, low and stable survival in the context of increasing incidence and mortality suggests inadequate care.     

International trends and patterns of prostate cancer incidence and mortality

Prostate cancer is the most commonly diagnosed cancer in western men, and incidence is rising rapidly in most countries, including low-risk populations. Age-adjusted incidence and mortality rates from 15 and 13 countries between 1973-77 and 1988-92, respectively, were compared to provide leads for future analytic studies. Large increases in both incidence and mortality rates of prostate cancer were seen for all countries. For incidence, increases were more pronounced in the United States, Canada, Australia, France and the Asian countries, while the increases in medium-risk countries were moderate. Increases in incidence ranged from 25%-114%, 24%-55% and 15%-104% in high-, medium- and low-risk countries, respectively. Mortality rates rose more rapidly in Asian countries than in high-risk countries. Substantial differences in incidence and mortality across countries were evident, with U.S. blacks having rates that were 50-60 times higher than the rates in Shanghai, China. Increasing incidence rates in the United States and Canada are likely to be due in part to the widespread use of transurethral resection of the prostate and prostate-specific antigen testing, while increases in the Asian countries are probably related to westernization in these low-risk populations. The large disparities in incidence between high- and low-risk countries may be due to a combination of genetic and environmental factors. Future studies are needed to examine gene-gene and gene-environment interactions in various countries concurrently to shed light on the etiology of prostate cancer and to help elucidate reasons for the large differences in risk between populations.     

Differences in stage and therapy for breast cancer across Europe

We examined variations in stage, diagnostic workup and therapy for breast cancer across Europe. Seventeen cancer registries in six European countries contributed 4,480 cases diagnosed in 1990-91. The clinical records of these cases were examined, and the distribution of stage, diagnostic examinations and therapy were analyzed. Stage was earliest in the French registries, followed by those of Italy and Eindhoven (Netherlands). The proportion of stage I cancers was highest in the French areas with screening in place. Estonia, the English registries and Granada (Spain) had the most advanced stage at diagnosis. Use of liver ultrasonography varied from 84% (Italian registries) to 18% (Granada). Bone scan use varied from 81% (Italian registries) to 15% (Mersey, UK). The highest proportions treated by breast-conserving surgery were in the French (57%) and English registries (63%); the lowest were in Estonia (6%) and Granada (11%). The highest proportions of Halsted mastectomies were in Italy (19%) and Granada (8%). In all countries except England, 90% of operations included axillary lymphadenectomy. Medical treatment only was given to 8% of (mostly advanced) cases overall. Estonia (21%) and the English registries (14%) had the highest proportions of patients given medication only. Chemotherapy was given to low proportions of node-positive cases in the Italian (76%) and English (74%) areas; breast-conserving surgery for stage I tumors varied from 24% in Granada to 84% in England. These wide differences in breast cancer care across Europe in the early 1990s indicate a need for continual monitoring of past treatments to help ensure application of the most effective protocols.     

Geographic and temporal variations in cancer of the corpus uteri: incidence and mortality in pre- and postmenopausal women in Europe

Corpus uteri cancer is the fourth most common neoplasm in women in Europe and the tenth most common cause of cancer death. We examined geographic and temporal variations in corpus uteri cancer incidence and mortality rates in the age groups 25-49 and 50-74 in 22 European countries. The disease is considerably less common in premenopausal women, with incidence and mortality rates decreasing throughout Europe and mortality declines more marked in western and southern European countries. Incidence rates among postmenopausal women are highest in the Czech Republic, Slovakia, Sweden and Slovenia and lowest in France and the United Kingdom. Increasing incidence trends in this age group are observed in the Nordic countries (except Denmark) and in the United Kingdom. Some increases are also seen in eastern (Slovakia) and southern Europe (Spain and Slovenia), while relatively stable or modestly decreasing trends are observed in Italy and most western European countries. Postmenopausal mortality rates are systematically higher in eastern Europe, with death rates in the Ukraine, Latvia, Czech Republic, Russia and Belarus 2-3 times those seen in western Europe. Declining mortality trends are seen in most populations, though in certain Eastern European countries, the declines began rather recently, during the 1980s. In Belarus and Russia, recent postmenopausal death rates are stable or increasing. The rates are adjusted for misclassification of uterine cancer deaths but remain unadjusted for hysterectomy, and where there is an apparent levelling off of incidence or mortality rates recently, rising prevalence of hysterectomy cannot be discounted as an explanation. However, the trends by age group can be viewed in light of several established risk factors for endometrial cancer that are highly prevalent and most likely changing with time. These are discussed, as are the prospects for preventing the disease.     

National cancer prevalence estimation in France

In France, as in several other European countries, prevalence has to be estimated from the modelling of 2 of the 3 basic epidemiological measures of incidence, mortality, and survival. Since, in these countries, follow-up of cancer patients is only made in a few registries, we explored the feasibility of estimating prevalence in the absence of follow-up data. The method, which used only incidence and mortality, was validated on Danish data and applied to France. For this latter country, the estimation procedure is based on the recorded mortality data and an estimate of incidence for the entire country. It is applied to selected sites of cancer, which account for 80% of the estimated incidence. In 1992, the prevalence of patients who had such a diagnosis amounts to 538,000 women and 424, 000 men. The most frequent cancer sites are head and neck, breast, and large bowel. Most of the cancer sites present an increase in prevalence proportion between 1987 and 1992. The larger increases concern breast and prostate cancer.     

Cancer prevalence in United States,Nordic Countries,Italy, Australia,and France: an analysis of geographic variability

Background:

The objectives of this study were to quantitatively assess the geographic heterogeneity of cancer prevalence in selected Western Countries and to explore the associations between its determinants.

Methods:

For 20 cancer sites, 5-year cancer prevalence, incidence, and survival were observed and age standardised for the mid 2000s in the United States, Nordic European Countries, Italy, Australia, and France.

Results:

In Italy, 5-year crude prevalence for all cancers was 1.9% in men and 1.7% in women, while it was ∼1.5% in all other countries and sexes. After adjustment for the different age distribution of the populations, cancer prevalence in the United States was higher (20% in men and 10% in women) than elsewhere. For all cancers combined, the geographic heterogeneities were limited, though relevant for specific cancers (e.g., prostate, showing >30% higher prevalence in the United States, or lung, showing >50% higher prevalence in USA women than in other countries). For all countries, the correlations between differences of prevalence and differences of incidence were >0.9, while prevalence and survival were less consistently correlated.

Conclusion:

Geographic differences and magnitude of crude cancer prevalence were more strongly associated with incidence rates, influenced by population ageing, than with survival rates. These estimates will be helpful in allocating appropriate resources.     

Colon cancer prevalence and estimation of differing care needs of colon cancer patients.

BACKGROUND: Cancer prevalence-the proportion of people in a population with a diagnosis of cancer-includes groups with widely differing cancer care needs. We estimated the proportions of the prevalent colon cancer cases requiring initial care, terminal care and follow-up. PATIENTS AND METHODS: Prevalence by year since diagnosis was estimated from incidence and vital status data on 243,471 colon cancer cases collected by EUROPREVAL from 36 European population-based cancer registries. The proportions of cured and fatal cases were estimated by applying 'cure' survival models to the dataset. The proportion of recurrence-free cases was estimated by analysis of a representative sample of 278 colon cancer patients from the Lombardy Cancer Registry (LCR), northern Italy. RESULTS: The proportions of total prevalence requiring initial care was estimated at 12% in the LCR and 10% in Italy and Europe. Recurrence-free patients formed 89% of the total prevalence in the LCR and 91% in Italy and Europe. Eleven per cent (LCR) and 9% (Italy, Europe) of the total prevalence had recurred and consisted of patients in the terminal phase of their illness. CONCLUSIONS: In 1992, 660,000 people were living with a diagnosis of colon cancer in Europe. We have estimated the proportions of this prevalence requiring particular types health care in the years following diagnosis, providing data useful for planning the allocation of health-care resources.     

EUROCOURSE recipe for cancer surveillance by visible population-based cancer RegisTrees® in Europe: From roots to fruits

Currently about 160 population-based cancer registries (CRs) in Europe have extensive experience in generating valid information on variation in cancer risk and survival with time and place. Most CRs cover all cancers, but some are confined to specific cancers or to children. They cover 15–55% of the populations in all of the larger member states of the European Union (EU), except the United Kingdom (UK), and 100% coverage in 80% of those with populations below 20 million. The EU FP 7 EUROCOURSE project, which operated in 2009–2013, explored the essential role of CRs in cancer research and public health, and also focused attention on their programme owners (POs) and stakeholders (e.g. cancer societies, oncological professionals, cancer patient groups, and planners, providers and evaluators of cancer care and mass screening). Generally, all CRs depended on their regional and/or national oncological context and were increasingly involved in population-based studies of quality of cancer care, long-term prognosis and quality of life, one third being very active. Within the public health domain, CRs, in addition to describing the variety of environmental and lifestyle-related cancer epidemics, have also contributed actively to aetiologic research by a European databases that showed wide discrepancies in cancer risk and survival across the EU, and in more depth by follow-up of cohorts and recruitment for case-control studies. CRs were also actively contributing to independent evaluation of mass screening as an intervention which affects quality of care and cancer mortality. The potential of CRs for clinical evaluation has grown substantially through interaction with clinical stakeholders and more incidentally biobanks, also with greater involvement of patient groups – with a special focus on elderly patients who generally do not take part in clinical trials. Whereas 25–35% of CRs are active in a range of cancer research areas, the rest have a low profile and usually provide only incidence and survival data. If they are unable to do so because POs and stakeholders do not demand it, they might also be inhibited by data protection restrictions, especially in German and French speaking countries. The value of population-based studies of quality of oncologic care and mass screening and the flawless reputation with regard to data protection of intensively used CRs in the northwest of Europe offered a sharp contrast, although they also follow the 1995 EU guideline on data protection. CRs thus offer a perfect example of what can be done with sensitive and minimal data, also when enriched by linkages to other databases. Intensive use of the data has allowed CR research departments to take on a visible expertise-based profile but a neutral in many public controversies in preventive oncology. Their management and fundability also appeared to benefit from externally classifying the wide array of tumour- or tract-specific intelligence and research activities for the various users in oncology and public health and also patients – who are the source of the data – are better informed. Transparency on what CRs enable may also improve through programmes of research have been deemed essential to our funding POs (ministries, cancer charities, cancer centres or public health institutes) who might benefit from some guidance to – often suboptimal –governance. Therefore, a metaphoric RegisTree® has been developed for self-assessment and to clarify CR working methods and domain-specific performance to stakeholders and funding agencies, showing much room for development in many CRs. All in all, CRs are likely to remain unique sources of independent expert information on the burden of cancer, indispensable for cancer surveillance, with increased attention to cancer survivors, up to 4% of the population. Investments in the expanding CR network across Europe offer an excellent way forward for comparative future cancer surveillance with so many epidemiologic and clinical changes ahead.     

International trends in incidence of cervical cancer: II. Squamous-cell carcinoma

Time trends in the incidence of squamous-cell carcinomas of the cervix during the period 1973-1991 were examined using data provided by 60 population-based cancer registries from 32 defined populations in 25 countries. Three components of the incidence trend were studied: age, calendar period of diagnosis and birth cohort. Cumulative incidence rates per 1,000 person-years for 2 groups, age ranges 25-49 and 50-74 years, were calculated from the model that best described the incidence data. A significant decline in incidence was noted in the American populations (except for US Hispanic), Australia, the non-Maori women of New Zealand, northern and western Europe (except Italy and Spain, where the rates remain stable) and Asian populations (except Malay women of Singapore, who have stable rates). These trends were of similar magnitude for the whole age range studied (25-74 years). An increasing trend, mainly restricted to younger women, was found for Slovakia, Jewish women born in Israel and the United Kingdom. In Slovenia, the increasing trend was observed for all age groups. The predominant pattern shown by cancer registries in developed countries is of a reduction in the incidence of squamous cervical cancer. This could be, at least partially, attributed to the widespread practice of screening for cervical lesions. The major exception to the pattern is observed in the United Kingdom, though the increasing incidence in young women has changed to a decrease in recent years. There are only a few series covering a long period of time in developing countries, but there is little evidence for a major impact of screening.     

Contrasts in cancer prevalence in Connecticut,Iowa, and Utah

BACKGROUND: Cancer prevalence--the proportion of a population with cancer, including those recently diagnosed, those in treatment, and survivors--is an important indicator of future health care requirements. Only limited information on cancer prevalence is available for the United States. In particular, comparative interstate studies are not available. In this study, we estimate and analyze the prevalence of seven major cancers in Connecticut, lowa, and Utah using the tried and tested PREVAL method applied to National Cancer Institute registry data. METHODS: We analyzed data on 242,851 carcinomas of the stomach, colorectum, pancreas, breast, uterus (corpus), ovary, and non-Hodgkin lymphoma (NHL), diagnosed in white Americans from 1973 through 1992. Observed prevalence was estimated by applying the PREVAL method to incidence and life status data from the cancer registries. Complete prevalence was estimated by applying correction factors obtained by modeling incidence and survival rates. RESULTS: The ratio of the highest to the lowest prevalence (as proportions) ranged from 1.69 for uterine carcinoma to 2.73 for stomach carcinoma, showing that marked differences in cancer prevalence exist within the United States. Utah had the lowest prevalence for each carcinoma. Connecticut and lowa had similar prevalence levels for carcinomas of the colorectum, pancreas, and ovary and for NHL. Breast carcinoma was the most prevalent, with 826 cases per 100,000 of population in Utah, 1518 per 100,000 in lowa, and 1619 per 100,000 in Connecticut. Cancer survival did not differ greatly among the three registry populations. The major determinants of prevalence differences were incidence and the population age distribution. CONCLUSIONS: PREVAL provides reliable estimates of the numbers of living people in a population who have had a cancer diagnosis. Prevalence depends on incidence and survival and on the age structure of population. All these factors have changed markedly in recent years and will continue to do so in the future. Cancer prevalence should be monitored over time to evaluate changes by area, sex, age, and cancer site. The prevalence figures presented are directly comparable with those from European cancer registries.     

The prevalence of colorectal cancer in Italy

AIMS: To analyze the prevalence of colorectal cancer (CRC) in different areas of Italy by age, interval since diagnosis and disease stage at diagnosis, and to estimate the prevalence of CRC. These data provide estimates of patient demand on health resources. PATIENTS AND METHODS: Eleven Italian cancer registries (CRs) provided data on 33,740 patients observed for up to 15 years. For the 1,829 cases from the specialized colorectal cancer registry of Modena we analyzed prevalence by Dukes' stage and family history. PREVAL software produced observed prevalence figures by time from diagnosis; to determine the total prevalence, correction factors were applied to the observed data. RESULTS: At the end of 1992, five-year CRC prevalence was high (close to 200 per 100,000) in Genova, Parma, Romagna and Firenze, and low (around 75 per 100,000) in the southern areas of Latina and Ragusa. For all CRs, 86 patients per 100,000 population were alive up to 2 years from diagnosis and 77 per 100,000 between 2 and 5 years from diagnosis. The 5-year prevalence of patients diagnosed with Dukes' B or C (high risk of recurrence and requiring postoperative surveillance) was 152 per 100,000; that of Dukes' A patients 36 per 100,000 (considered cured after surgery and not requiring intensive follow-up or care); that of unstaged patients plus those with distant metastasis at diagnosis was 28 per 100,000 at 5 years (requiring palliative care but not follow-up). The 12-year prevalence of HNPCC was 23 per 100,000, or about 7% of the total; for such patients knowledge of the long-term prevalence is important because they are diagnosed young and are at high risk of multiple tumor development. CONCLUSIONS: 70% of the prevalent patients diagnosed within 5 years prior to the prevalence date were likely to require care for cancer recurrence, while 13% of the prevalent cases required care for distant metastases.     

Estimating regional cancer burden in countries with partial registration coverage: an application to all malignant neoplasms in Italy over the period 1970-2010

Regional epidemiological indicators of cancer burden are essential information for cancer surveillance and health resources planning, especially in countries with partial registration coverage and geographically variable risk patterns, such as Italy.This paper presents a methodology to derive cancer incidence and prevalence at the regional and national scale and illustrates its application to all malignant neoplasms in Italy for the period 1970–2010.The method, denoted as MIAMOD, is based on a back-calculation approach and derives cancer-specific morbidity measures by using official mortality data and model-based relative survival from local Cancer Registries data. The output includes time-trends and projections of a complete set of epidemiological indicators, i.e. mortality, incidence and prevalence.Results for all cancers in Italy show different incidence patterns by gender and a pronounced regional variability among men: male incidence is estimated to decrease in almost all northern-central regions, while more stable or even rising trends are estimated in the southern regions. No incidence reduction is expected for women. Prevalence increases country-wide in both sexes.The proposed approach can be applied to derive regional up-to-date time trends of cancer burden indicators in countries with local and sparse cancer registration systems. These estimates are useful for planning health services on a national and regional basis and for highlighting regional differences.     

Quality analysis of population-based information on cancer stage at diagnosis across Europe,with presentation of stage-specific cancer survival estimates: A EUROCARE-5 study

BackgroundCancer registries (CRs) are fundamental for estimating cancer burden, evaluating screening and monitoring health service performance. Stage at diagnosis—an essential information item collected by CRs—has been made available, for the first time, by CRs participating in EUROCARE-5. We analysed the quality of this information and estimated stage-specific survival across Europe for CRs with good data quality.Data and methodsSixty-two CRs sent stage (as TNM, condensed TNM or extent of disease) for 15 cancers diagnosed in 2000–2007. We assessed the quality, partly by comparing stage according to the three systems. We also developed procedures to reconstruct stage (categories: local, regional, metastatic and unknown) using information from all three systems, thus minimising the amount of missing information.ResultsModerate-to-excellent stage concordance was found for practically all 24 CRs, for which it was possible to compare at least two staging systems. However, since stage was often incorrectly assigned, and information on the presence/absence of metastases was often lacking, data on only 7/15 cancers from 34/62 CRs (15 countries) were of sufficient quality for further analysis. Cases diagnosed ≥70 years had more advanced (or lacking) stage– and worse stage-specific survival than those <70 years.ConclusionsMany European CRs collect and record reasonably accurate stage information. Others have difficulties. Both the completeness of primary data and the accuracy of stage coding need to be improved in order for CRs to fulfil their expanding roles in cancer control. We propose our stage reconstruction/checking procedures as a means of fully exploiting the stage information provided by EUROCARE CRs. More advanced (or lacking) stage at diagnosis plus poorer stage-specific survival in the elderly are worrying.     

Comparison of treatment costs of grade 3/4 adverse events associated with erlotinib or pemetrexed maintenance therapy for patients with advanced non-small-cell lung cancer (NSCLC) in Germany, France, Italy, and Spain

Objective of this indirect economic comparison was to estimate and compare management costs of grade 3/4 adverse events (AEs) reported for first-line erlotinib or pemetrexed maintenance therapy in patients with advanced non-small cell lung cancer (NSCLC). The economic analysis was performed for Germany, France, Italy and Spain.Types and incidences of reported grade 3/4 AEs observed with erlotinib or pemetrexed maintenance therapy were retrieved from two recently published placebo-controlled trials. Country-specific estimates on standard treatment algorithms and incremental medical resource utilization associated with each of the reported grade 3/4 AEs have been obtained from clinical oncologists practicing in the four countries and co-authoring this article. The resource use items were subsequently assigned country-specific tariffs to estimate total per-patients costs associated with the AE profiles of the two compared maintenance regimens. For the economic analysis a customized economic spreadsheet model was employed.Our comparison shows lower total average per-patient AE management costs for erlotinib than for pemetrexed maintenance therapy in all four studied countries. Total estimated cost savings per patient in favour of erlotinib amount to € 121, € 237, € 106, and € 119 for Germany, France, Italy and Spain, respectively. These AE cost savings for erlotinib when compared to pemetrexed represent a decrease by 80%, 71%, 94%, and 82%, respectively. The study also discovered considerable differences in AE management costs across countries which are primarily due to differences in clinician's estimates of hospitalization referral rates.Erlotinib maintenance therapy in patients with advanced NSCLC causes lower AE management costs than pemetrexed maintenance therapy indicating a potentially superior tolerability profile.     

Stage at diagnosis is a key explanation of differences in breast cancer survival across Europe

We used multiple regression models to assess the influence of disease stage at diagnosis on the 5‐year relative survival of 4,478 patients diagnosed with breast cancer in 1990–1992. The cases were representative samples from 17 population‐based cancer registries in 6 European countries (Estonia, France, Italy, Netherlands, Spain and UK) that were combined into 9 regional groups based on similar survival. Five‐year relative survival was 79% overall, varying from 98% for early, node‐negative (T1N0M0) tumours; 87% for large, node‐negative (T2‐3N0M0) tumours; 76% for node‐positive (T1‐3N+M0) tumours and 55% for locally advanced (T4NxM0) tumours to 18% for metastatic (M1) tumours and 69% for tumours of unspecified stage. There was considerable variation across Europe in relative survival within each disease stage, but this was least marked for early node‐negative tumours. Overall 5‐year relative survival was highest in the French group of Bas‐Rhin, Côte d'Or, Hérault and Isère (86%), and lowest in Estonia (66%). These geographic groups were characterised by the highest and lowest percentages of women with early stage disease (T1N0M0: 39% and 9%, respectively). The French, Dutch and Italian groups had the highest percentage of operated cases. The number of axillary nodes examined, a factor influencing nodal status, was highest in Italy and Spain. After adjusting for TNM stage and the number of nodes examined, survival differences were greatly reduced, indicating that for these women, diagnosed with breast cancer in Europe during 1990–1992, the survival differences were mainly due to differences in stage at diagnosis. However, in 3 regional groups, the relative risks of death remained high even after these adjustments, suggesting less than optimal treatment. Screening for breast cancer did not seem to affect the survival patterns once stage had been taken into account. © 2003 Wiley‐Liss, Inc.