Transcript Colorectal cancer survival

Risk of skin cancer following phototherapy for
neonatal jaundice: retrospective cohort study
Does late presentation explain the
David H Brewster, Janet S Tucker, Michael
apparent
survival
deficit
for
cancer
Fleming, Carole Morris, Diane L Stockton,
David J Lloyd,
Bhattacharya,
in Sohinee
Scotland?
1,2
1
3,4
1
3,4
1
3,4
James WT Chalmers1,2
1Information Services
Division,
NHS National
Services
Scottish
Cancer
Taskforce
Workshop:
Scotland
Better
Awareness of Cancer Symptoms
2University of Edinburgh
3University
4Aberdeen
of Aberdeen
22 January 2010
Maternity Hospital
Outline
• Background – selected results from the
EUROCARE-4 study
• Potential explanations for survival variations
• Evidence for more advanced disease at
diagnosis in the UK
• Potential explanations for this
• England’s National Awareness and Early
Diagnosis Initiative (NAEDI)
• Conclusions
Breast cancer and colorectal cancer diagnosed 1995-99.
Five year relative survival by country
90
80
70
% surviving
60
Denmark
England
Scotland
Finland
Norway
Sweden
50
40
30
20
10
0
Breast
Colorectal
Some factors to consider in population-based
survival comparisons
Data quality factors
Tumour-related factors
Population coverage
Completeness of ascertainment
Accuracy of registration
Completeness of follow-up
‘Death certificate only’ registrations
Extent of disease
Site (and sub-site) of tumour
Tumour morphology
Tumour biology
Host factors
Health care-related factors
Age
Sex
Socio-economic status
Race/Ethnicity
Co-morbidity
Mortality from other causes
Behaviour
Screening
Diagnostic facilities
Treatment facilities
Quality of treatment
Follow-up care
Colorectal cancer diagnosed 1995-99. Five year relative survival vs survival
conditional on surviving at least one year
80
70
60
% surviving
50
Denmark
England
Scotland
Finland
Norway
Sweden
40
30
20
10
0
5-year Relative survival
Conditional survival
Absolute excess death rates (breast cancer)
text
Important observation
•The survival deficit (the excess mortality) in England is
mainly in the older patients
•... and mainly in the short term after diagnosis
Source (last three slides): Professor Henrik Møller, Kings College London
and Thames Cancer Registry.
See also: Møller H, Sandin F, Bray F, Klint A, Linklater KM, Purushotham
A, Robinson D, Holmberg L. Breast cancer survival in England, Norway
and Sweden: A population-based comparison. Int J Cancer 2010 (in
press).
EUROCARE high resolution study of colorectal cancer:
Relative risk of death within 3 years of diagnosis
Registry
(No of
cases)
Model 1 (sex Model 2
+ age + site) (model 1 +
stage)
Model 3
(model 2 +
surgery –
resected
cases only)
Model 4
(model 3 +
staging
procedures†
– resected
cases only)
Mersey
(207)
1.15
1.10
1.01
0.99
Thames
(176)
1.41*
1.37*
1.25
1.19
*P<0.05 †Staging procedures = no of LNs examined and liver imaging
Source: Gatta et al. Gut 2000;47:533-8.
England’s response to these observations
The National Awareness and Early Diagnosis
Initiative (NAEDI)
• Announced in the English Cancer Reform Strategy (2007)
• Co-led by CR-UK and DoH
• Aim is to coordinate a programme of activity to support local
interventions to raise public awareness of symptoms and
signs of cancer, and to encourage people to present sooner
• Also encompasses a programme of research
• Much of the evidence underpinning NAEDI was published in
a supplement to the British Journal of Cancer (3 December
2009).
Certainly there is some evidence that..
• Public awareness of warning signs is low (esp. among
males, younger people, lower SES, and ethnic minorities).
• Some patients present long after the onset of symptoms.
• GPs are sometimes slow to refer.
• Some reasons for pre-hospital delays have been identified.
• Sometimes, there are some perceived barriers to consulting.
• There are delays in hospital.
• Individual and community interventions may promote
awareness and early presentation.
BUT
• Delay is not synonymous with advanced stage – don’t forget
tumour biology
Colorectal cancer diagnosed 2002: the delay-survival paradox
Some outstanding questions…
• Is awareness of cancer symptoms lower in the UK than in
some other European countries?
• What will be the impact on patients with cancer of more
patients without cancer coming forward?
• Do UK GPs perform any better or worse than their
European counter-parts?
• Are delays longer in the UK, and if so, do they account for
any of the survival deficit?
• What is the role of lifestyle factors in relation to stage and
outcome?
• Can GPs really improve their referral performance? – the
prevalence of cancer is relatively low among GP attendees,
which inevitably means that the positive predictive value of
symptoms is lower than in hospital.
Effect of prevalence on positive predictive value
(PPV) with constant sensitivity and specificity
Prevalence (%)
PPV (%)
Sensitivity (%)
Specificity (%)
0.1
1.8
90
95
1.0
15.4
90
95
5.0
48.6
90
95
50.0
94.7
90
95
Positive predictive value of rectal
bleeding for colorectal cancer
Setting
PPV (%)
Single episode in
the community
0.1
Reported to GP
2-3
Referred to
hospital
5-7
Conclusions
• Survival from major epithelial cancers seems to be lower
in Scotland (and the UK) compared to all of the Nordic
countries except Denmark
• The excess risk of death seems to occur early on and is
more apparent in oldest age groups
• Other evidence suggests that, on average, UK patients
may be presenting with more advanced disease at
diagnosis
• But we don’t know for sure whether this is due to later
presentation, later referral, delays in diagnosis or
staging, or more aggressive disease
• We know that lifestyle factors can influence survival, but
we don’t really know to what extent, if any, this
contributes to European survival variations
• The reasons for reported survival differences seem most
likely to be multifactorial