Anjali Shah

Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England

BACKGROUND The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. METHODS We analysed population-based survival in 2.2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996-2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996-2000 (before the cancer plan), 2001-03 (initialisation), and 2004-06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. FINDINGS 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996-2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996-2000 and 2001-03, but higher in England than in Wales during 2004-06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North-South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001-03 and 2004-06. INTERPRETATION The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004-06, whereas the opposite was true during 2001-03. This reversal of survival trends in 2001-03 and 2004-06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan.

Socioeconomic inequalities in cancer survival in England after the NHS cancer plan

Background:Socioeconomic inequalities in survival were observed for many cancers in England during 1981–1999. The NHS Cancer Plan (2000) aimed to improve survival and reduce these inequalities. This study examines trends in the deprivation gap in cancer survival after implementation of the Plan.Materials and method:We examined relative survival among adults diagnosed with 1 of 21 common cancers in England during 1996–2006, followed up to 31 December 2007. Three periods were defined: 1996–2000 (before the Cancer Plan), 2001–2003 (initialisation) and 2004–2006 (implementation). We estimated the difference in survival between the most deprived and most affluent groups (deprivation gap) at 1 and 3 years after diagnosis, and the change in the deprivation gap both within and between these periods.Results:Survival improved for most cancers, but inequalities in survival were still wide for many cancers in 2006. Only the deprivation gap in 1-year survival narrowed slightly over time. A majority of the socioeconomic disparities in survival occurred soon after a cancer diagnosis, regardless of the cancer prognosis.Conclusion:The recently observed reduction in the deprivation gap was minor and limited to 1-year survival, suggesting that, so far, the Cancer Plan has little effect on those inequalities. Our findings highlight that earlier diagnosis and rapid access to optimal treatment should be ensured for all socioeconomic groups.

Geographical variation in life expectancy at birth in England and Wales is largely explained by deprivation

Study objective: To describe the population mortality profile of England and Wales by deprivation and in each government office region (GOR) during 1998, and to quantify the influence of geography and deprivation in determining life expectancy. Design: Construction of life tables describing age specific mortality rates and life expectancy at birth from death registrations and estimated population counts. Life tables were created for (a) quintiles of income deprivation based on the income domain score of the index of multiple deprivation 2000, (b) each GOR and Wales, and (c) every combination of deprivation and geography. Setting: England and Wales. Patients/participants: Residents of England and Wales, 1998. Main results: Life expectancy at birth varies with deprivation quintile and is highest in the most affluent groups. The differences are mainly attributable to differences in mortality rates under 75 years of age. Regional life expectancies display a clear north-south gradient. Linear regression analysis shows that deprivation explains most of the geographical variation in life expectancy. Conclusions: Geographical patterns of life expectancy identified within these data for England and Wales in 1998 are mainly attributable to variations in deprivation status as defined by the IMD 2000 income domain score.

Survival and cure of acute myeloid leukaemia in England, 1971-2006: a population-based study.

The 5‐year relative survival of adults diagnosed with acute myeloid leukaemia (AML) was less than 10% during the 1970s and 1980s in England. This population‐based study estimated the 5‐year relative survival and ‘cure’ for 48 380 adult patients diagnosed with AML in England during 1971–2006. Relative survival and cure mixture models were used to produce estimates of 5‐year relative survival and the percentage ‘cured’. ‘Cure’ was defined as the proportion of a group of survivors for whom there is no excess mortality compared with the general population. The 5‐year relative survival and the percentage ‘cured’ increased for patients aged under 70 years at diagnosis during 1971–2006, but advancing age was associated with poorer outcome. During the study period a dramatic increase in 5‐year relative survival occurred in those aged 15–24 years, from 7% to 53%. The percentage ‘cured’ was less than 10% for all ages in 1975, but increased to 45% for those aged 15–24 years in 2000. Cure could not be estimated for patients over 70 years, because survival was consistently low (<5%). The long‐term outcome of patients with AML has improved substantially, particularly in younger patients. The potential exists for further increasing levels of ‘cure’.

Increasing incidence of childhood leukaemia: a controversy re-examined

We provide evidence of a gradual increase in the incidence of childhood leukaemia over the twentieth century from examination of trends in both incidence and mortality in England and Wales. We conclude that much of the recorded increase is likely to be real.

Childhood leukaemia: long-term excess mortality and the proportion ‘cured’

Survival from childhood leukaemia has increased, but the proportion of children cured is unknown. The proportion ‘cured’ is defined as the proportion of survivors for whom, as a group, there is no longer excess mortality compared to the general population. Average time to cure is defined as the time since diagnosis at which the excess mortality rate has declined to or below a predetermined small value. Data on children diagnosed with leukaemia during 1971–2000 in Great Britain were used to estimate trends in survival, the proportion cured and the average time to cure. Five-year survival for all types of leukaemia combined rose from 33 to 79% by 2000. The percentage cured rose from 25 to 68% by 1995; it is predicted to increase to 73% for those diagnosed more recently. Average time to cure increased from 12 years (95% confidence interval (CI): 11–14) to 19 years (95% CI: 14–26) for lymphoid leukaemia (average annual increase of 0.3 years; P<0.001), but remained at about 5 years for acute nonlymphoblastic leukaemia. The proportion of children cured of leukaemia has risen dramatically, but the period of excess mortality associated with lymphoid leukaemia has also increased, possibly because of late relapse, secondary malignancy and toxicity from treatment.

Place of death and hospital care for children who died of cancer in England, 1999-2006.

AIM To describe patterns of hospital care and to evaluate factors influencing place of death for children who died after a diagnosis of cancer in England during 1999-2006. MATERIALS AND METHODS Registrations of children on the National Registry of Childhood Tumours (NRCT) who were diagnosed with cancer and died during 1999-2006 in England were linked to the Hospital Episode Statistics (HES) and to death certificates. Multivariable logistic modelling was used to assess factors that influence dying at home or in hospital. RESULTS 1864 (96%) of children with cancer registrations were linked to HES records. The validation of hospital as a place of death and ethnicity between data sources was good, although anomalies within HES data exist. Similar proportions of children are dying at home (45%) and in hospital (47%), and the percentage dying in a hospice or care home increased from 2% to 10%. Of the children who died in hospital, 74% were admitted as emergencies or as a transfer from another hospital. Greater proportions of children were diagnosed with a leukaemia or lymphoma, those dying within six months of diagnosis, Asian and Black children, those from a deprived background and those not treated in a CCLG centre died in a hospital. CONCLUSIONS Patterns of hospital care varied considerably by type of cancer, death within six months of diagnosis, ethnicity and deprivation. Further research is required to elucidate explanations for these patterns and to evaluate methods to increase the proportion of children dying at home who wish to do so.

Pattern of symptoms and signs of primary intracranial tumours in children and young adults: a record linkage study

Objective To describe the age pattern and temporal evolution of symptoms and signs of intracranial tumours in children and young adults before diagnosis. Design and setting A record linkage study using population-based data from the National Cancer Registry, linked to Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). Patient cohort Patients aged 0–24 years when diagnosed with a primary intracranial tumour between 1989 and 2006 in England. Methods Linked records of relevant symptoms and signs in primary care and hospitals were extracted from CPRD (1989–2006, 181 patients) and HES (1997–2006, 3959 patients). Temporal and age-specific changes in presentation rates before diagnosis of an intracranial tumour, for each of eight symptom groups, were estimated in generalised additive models. Results All symptoms presented with increasing frequency until eventual diagnosis. The frequency of presentation of raised intracranial pressure (ICP) to hospitals rose rapidly to 36.4 per 100 person-months (95% CI 34.6 to 38.4) in the final month before diagnosis in the entire cohort. Clinical features in primary care were less specific: the main features were visual disturbance (rate: 0.49 per 100 person-months; 95% CI 0.33 to 0.72) in newborns to 4-year-olds, headache in 5-year-olds to 11-year-olds (0.64; 0.47 to 0.88), 12-year-olds to 18-year-olds (1.59; 1.21 to 2.08) and 19-year-olds to 24-year-olds (2.44; 1.71 to 3.49). The predominant features at hospital admission were those of raised ICP: between 1.17 per 100 person-months (95% CI 1.08 to 1.26) in newborns to 4-year-olds and 0.77 (0.67 to 0.88) in 19-year-olds to 24-year-olds. Conclusions Non-localising symptoms and signs were more than twice as common as focal neurological signs. An intracranial tumour should be considered in patients with relevant symptoms that do not resolve or that progress rapidly.

Survival from multiple myeloma in England and Wales up to 2001

Multiple myeloma is an uncommon neoplasm of plasma cells affecting mainly the elderly; it is rare under the age of 50 years. Each year in England and Wales, approximately 1800 cases are registered in men (1.5% of all malignancies) and 1500 in women (1.2% of all malignancies). Incidence has increased steadily since the 1980s in both sexes in many countries, including England and Wales (Coleman et al, 1993; Quinn et al, 2001). Incidence is slightly higher in men, and it has risen by approximately 12% in both sexes since the mid-1980s to reach 6.1 per 100 000 per year in men and 5.5 in women by 1999. No marked socioeconomic gradient in incidence has previously been reported in England and Wales, but the most deprived fifth of the population provides a striking exception to the overall trend in the 1990s: incidence rates in this group increased very little in either sex, and by 1999, annual incidence was 20–25% lower than in the other four deprivation groups (4.5 and 4 per 100 000 in men and women, respectively).

Survival from non-Hodgkin lymphoma in England and Wales up to 2001

Non-Hodgkin lymphoma comprises a disparate set of malignancies of lymphoid tissue, other than Hodgkins disease, with a wide variety of biological, clinical and prognostic features. The clinical classification of lymphomas has changed considerably in response to advances in medical knowledge, but it has been difficult to assimilate these changes into the International Classification of Diseases (ICD) for Oncology, used by population-based cancer registries for coding cases for international comparison of cancer incidence (Percy et al, 1984). The tenth revision of the ICD provided more rubrics for non-Hodgkin lymphoma (C82–C85, C91.4, C96) than the two available in ICD-9 (200, 202), but cancer registry data were only coded to ICD-10 from 1995 or later. As a result, it is not yet possible to provide long-term comparisons of incidence and survival trends for specific types of non-Hodgkin lymphoma with population-based data. This is also true of mortality data, which were only coded to ICD-10 from 2000 or later, and which are derived from the limited diagnostic information on death certificates, as opposed to the medical records used to register newly diagnosed cases. Mortality data are generally reported for all the non-Hodgkin lymphomas combined. We present survival trends for the same broad category of all the non-Hodgkin lymphomas combined. Non-Hodgkin lymphoma is the most common lympho-haemopoietic malignancy in adults. It ranks as the eighth most common malignancy with almost 8000 new cases diagnosed each year. The male–female ratio is approximately 1.5. Non-Hodgkin lymphoma has tripled in frequency in both sexes since the early 1970s (Quinn et al, 2001), an increase echoed in many countries (Coleman et al, 1993). More than 60% of cases arise in persons aged 60 years or more, and the increase in incidence has been up to five-fold in older men and women, with little change in young adults. Incidence is slightly higher in affluent than deprived men, but there is no difference for women. The causes of NHL are not well established, although solvents, pesticides and other chemicals have been implicated (Blair and Kazerouni, 1997; Lynge et al, 1997; Stellman, 1998). Certain viruses, such as Epstein–Barr virus, HIV and HTLV are known to be potentially lymphoma-inducing (IARC, 1996, 1998), whereas oncogenic viruses have recently been suspected (Metayer et al, 1998). We analysed the data for 78 894 patients registered with non-Hodgkin lymphoma as a first primary malignancy in England and Wales during the period 1986–1999, some 86% of those eligible. Nine per cent of cases were excluded from survival analysis because their recorded survival was zero (date of diagnosis same as date of death): most of these will have been registered from a death certificate only (DCO); hence, their date of diagnosis and their duration of survival were both unknown. These cases could not be reliably distinguished from cases with true zero survival in the national data. The proportion of cases excluded from analysis as DCO was similar in all deprivation groups, and this is unlikely to have had a material impact on estimates of trend or socioeconomic gradient in survival. A further 3% of patients were excluded because the lymphoma was not their first primary malignancy, along with 1.8% whose vital status was unknown at 5 November 2002, when the data were extracted for analysis.