Evelyn Williams

Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study

BACKGROUND Marked differences in population based survival across Europe were found for colorectal cancers diagnosed in 1985–1989. AIMS To understand the reasons for these differences in survival in a new analysis of colorectal cancers diagnosed between 1988 and 1991. SUBJECTS A total of 2720 patients with adenocarcinoma of the large bowel from 11 European cancer registries (CRs). METHODS We obtained information on stage at diagnosis, diagnostic determinants, and surgical treatment (not routinely collected by CRs) and analysed the data in relation to three year observed survival, calculating relative risks (RRs) of death and adjusting for age, sex, site, stage, and determinants of stage. RESULTS Three year observed survival rates ranged from 25% (Cracow) to 59% (Modena), and were low in the Thames area (UK) (38%). Survival rates between registries for “resected” patients varied less than those for all patients. When age, sex, and site were considered, RRs ranged from 0.7 (95% confidence intervals (CI) 0.6–0.9) (Modena) to 2.3 (95% CI 1.9–2.9) (Cracow). After further adjustment by stage, between registry RR variation was between 0.8 (95% CI 0.6–0.9) and 1.8 (95% CI 1.5-2.2). Inter-registry RR differences were slightly reduced when the determinants of stage (number of nodes examined and liver imaging) were included in the model. The reduction was marked for the UK registries. CONCLUSIONS The wide differences across Europe in colorectal cancer survival depend to a large extent on differences in stage at diagnosis. There are wide variations in diagnostic and surgical practices. There was a twofold range in the risk of death from colorectal cancer even after adjustment for surgery and disease stage.

Breast Carcinoma Survival in Europe and the United States: A Population-Based Study

Breast carcinoma survival rates were found to be higher in the U.S. than in Europe.

Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis and surgery

Background: Population based colorectal cancer survival among patients diagnosed in 1985–89 was lower in Europe than in the USA (45% v 59% five year relative survival). Aims: To explain this difference in survival using a new analytic approach for patients diagnosed between 1990 and 1991. Subjects: A total of 2492 European and 11 191 US colorectal adenocarcinoma patients registered by 10 European and nine US cancer registries. Methods: We obtained clinical information on disease stage, number of lymph nodes examined, and surgical treatment. We analysed three year relative survival, calculating relative excess risks of death (RERs, referent category US patients) adjusted for age, sex, site, surgery, stage, and number of nodes examined, using a new multivariable approach. Results: We found that 85% of European patients and 92% of US patients underwent surgical resection. Three year relative survival was 69% for US patients and 57% for European patients. After adjustment for age, sex, and site, the RER was significantly high in all 10 European populations, ranging from 1.07 (95% confidence interval 0.86–1.32) (Modena, Italy) to 2.22 (1.79–2.76) (Thames, UK). After further adjustment for stage, surgical resection, and number of nodes examined (a determinant of stage), RERs ranged from 0.77 (0.62–0.96) to 1.59 (1.28–1.97). For some European registries the excess risk was small and not statistically significant. Conclusions: US-Europe survival differences in colorectal cancer are large but seem to be mostly attributable to differences in stage at diagnosis. There are wide variations in diagnostic and surgical practice between Europe and the USA.

Prognostic value of morphology and hormone receptor status in breast cancer: a population-based study

We analysed the 5-year relative survival among 4473 breast cancer cases diagnosed in 1990–1992 from cancer registries in Estonia, France, Italy, Spain, the Netherlands and the UK. Among eight categories based on ICD-O codes (infiltrating ductal carcinoma, lobular plus mixed carcinoma, comedocarcinoma, ‘special types’, medullary carcinoma, not otherwise specified (NOS) carcinoma, other carcinoma and cancer without microscopic confirmation), the 5-year relative survival ranged from 66% (95% CI 61–71) for NOS carcinoma to 95% (95% CI 90–100) for special types (tubular, apocrine, cribriform, papillary, mucinous and signet ring cell); 27% (95% CI 18–36) for cases without microscopic confirmation. Differences in 5-year relative survival by tumor morphology and hormone receptor status were modelled using a multiple regression approach based on generalised linear models. Morphology and hormone receptor status were confirmed as significant survival predictors in this population-based study, even after adjusting for age and stage at diagnosis.

Does the ‘Liverpool Care Pathway' facilitate an improvement in quality of care for dying cancer patients?

Background:The Liverpool Care Pathway for the Dying Patient (LCP) aims to transfer hospice principles of care for dying patients to other health-care sectors. This post-bereavement survey explored the LCP’s effectiveness in improving quality of care for cancer patients.Methods:Postal self-completion questionnaires were sent to 778 next-of-kin to consecutive deceased patients who had died an ‘expected’ cancer death in a hospice and acute tertiary hospital.Results:Following exclusions (n=53), 255 of the 725 next-of-kin agreed to participate (35.2% response rate). Overall hospice participants reported the best quality of care, and hospital participants, for whom care was not supported by the LCP, reported the worst quality of care. Multivariate analysis showed the hospice was an independent predictor for patients being treated with dignity (OR 8.46) and receiving adequate family support (OR 7.18) (P<0.0001). Care supported by the LCP and the hospital specialist palliative care team were both associated with good family support, but neither was an independent predictor.Conclusions:From the bereaved relatives’ perspective, within the hospital, the LCP is effective in improving specific aspects of care, such as symptom control for dying patients. Further improvement is required, however, to attain the hospice standard of care.

Assessing quality of care for the dying: The development and initial validation of a postal self-completion questionnaire for bereaved relatives

Background: Evaluating ‘quality of care for the dying’ from the patients’ perspective has practical and ethical difficulties: an alternative is to use bereaved relatives’ views as ‘proxy’ measures. Currently, within the United Kingdom, there is no validated instrument which specifically examines quality of care in the last days of life or the impact of the Liverpool Care Pathway (LCP) for the Dying Patient. Aim: To develop and validate a questionnaire for use with bereaved relatives assessing the quality of care for patients and families in the last days of life and the immediate period after the bereavement. Design: The instrument, ‘Evaluating Care and Health Outcomes – for the Dying’ (ECHO-D), was developed in four distinct phases: 1. Question formulation, 2. Expert panel review (n = 6), 3. Wider audience review (n = 25), 4. Pilot, including cognitive pre-testing interviews and preliminary test–retest reliability assessment with bereaved relatives (n = 80) Setting: The study was conducted within a hospice and an acute hospital involving healthcare professionals, lay members and bereaved relatives. Results: The systematic and robust process of questionnaire development generated evidence for ECHO-D’s face and content validity. Response rate for the pilot stage with bereaved relatives, however, was comparatively low (23.4%). Test–retest analysis from the pilot showed moderate or good stability for 13 out of 17 key questions, although small sample numbers limited the interpretation. Conclusions: ECHO-D is the first instrument specifically to assess ‘quality of care for the dying’, focussing on the last days of life, and has direct links with the use of the LCP Programme.

Does the timing of comorbidity affect colorectal cancer survival? A population based study

Objectives Comorbid conditions in colorectal cancer patients can influence both clinical eligibility for treatment and survival. We aimed to evaluate the effect of comorbidity on 1 year survival from colorectal cancer, and to assess whether this effect varied with the timing of the comorbidity in relation to the cancer diagnosis. Study design and setting A population based cohort of 29 563 colorectal cancer patients diagnosed between 1997 and 2004 in the North West of England was evaluated. The excess hazard of death up to 1 year after diagnosis was estimated using deprivation and region specific life tables to adjust for background mortality. Results were adjusted for age and stage at diagnosis. Results Comorbid conditions diagnosed during the period 18 to 6 months before the diagnosis of colorectal cancer were strongly associated with lower survival at 1 year. Stage and age remained the strongest predictors of cancer related mortality even after adjustment for comorbidity. Conclusions Administrative data provide a good estimate of the prevalence of most comorbid conditions but may be biased for some comorbid conditions that can be contra-indicators for cancer treatment. The time window in which a comorbid condition occurs in relation to the cancer diagnosis should be taken into account. Adjustment should be carried out, where possible, to provide more robust and clinically appropriate comparisons of population based cancer patient survival.

Control sample design using a geodemographic discriminator : An application of Super Profiles

Abstract. The development and application of an innovative sampling framework for use in a British study of the early detection of gastric cancer are described. The Super Profiles geodemographic discriminator is used in the identification of geographically distinct control and contrast areas from which samples of cancer registry case records may be drawn for comparison with the records of patients participating in the gastric cancer intervention project. Preliminary results of the application of the framework are presented and confirm its effectiveness in satisfactorily reflecting known patterns of variation in cancer occurrence by age, gender and social class. The method works well for cancers with a known and clear social gradient, such as lung and breast cancer, moderately well for gastric cancer and somewhat less well for oesophageal cancer, where the social class gradient is less clear.