Matthew Soeberg

Global surveillance of cancer survival 1995–2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2)

BACKGROUND Worldwide data for cancer survival are scarce. We aimed to initiate worldwide surveillance of cancer survival by central analysis of population-based registry data, as a metric of the effectiveness of health systems, and to inform global policy on cancer control. METHODS Individual tumour records were submitted by 279 population-based cancer registries in 67 countries for 25·7 million adults (age 15-99 years) and 75,000 children (age 0-14 years) diagnosed with cancer during 1995-2009 and followed up to Dec 31, 2009, or later. We looked at cancers of the stomach, colon, rectum, liver, lung, breast (women), cervix, ovary, and prostate in adults, and adult and childhood leukaemia. Standardised quality control procedures were applied; errors were corrected by the registry concerned. We estimated 5-year net survival, adjusted for background mortality in every country or region by age (single year), sex, and calendar year, and by race or ethnic origin in some countries. Estimates were age-standardised with the International Cancer Survival Standard weights. FINDINGS 5-year survival from colon, rectal, and breast cancers has increased steadily in most developed countries. For patients diagnosed during 2005-09, survival for colon and rectal cancer reached 60% or more in 22 countries around the world; for breast cancer, 5-year survival rose to 85% or higher in 17 countries worldwide. Liver and lung cancer remain lethal in all nations: for both cancers, 5-year survival is below 20% everywhere in Europe, in the range 15-19% in North America, and as low as 7-9% in Mongolia and Thailand. Striking rises in 5-year survival from prostate cancer have occurred in many countries: survival rose by 10-20% between 1995-99 and 2005-09 in 22 countries in South America, Asia, and Europe, but survival still varies widely around the world, from less than 60% in Bulgaria and Thailand to 95% or more in Brazil, Puerto Rico, and the USA. For cervical cancer, national estimates of 5-year survival range from less than 50% to more than 70%; regional variations are much wider, and improvements between 1995-99 and 2005-09 have generally been slight. For women diagnosed with ovarian cancer in 2005-09, 5-year survival was 40% or higher only in Ecuador, the USA, and 17 countries in Asia and Europe. 5-year survival for stomach cancer in 2005-09 was high (54-58%) in Japan and South Korea, compared with less than 40% in other countries. By contrast, 5-year survival from adult leukaemia in Japan and South Korea (18-23%) is lower than in most other countries. 5-year survival from childhood acute lymphoblastic leukaemia is less than 60% in several countries, but as high as 90% in Canada and four European countries, which suggests major deficiencies in the management of a largely curable disease. INTERPRETATION International comparison of survival trends reveals very wide differences that are likely to be attributable to differences in access to early diagnosis and optimum treatment. Continuous worldwide surveillance of cancer survival should become an indispensable source of information for cancer patients and researchers and a stimulus for politicians to improve health policy and health-care systems. FUNDING Canadian Partnership Against Cancer (Toronto, Canada), Cancer Focus Northern Ireland (Belfast, UK), Cancer Institute New South Wales (Sydney, Australia), Cancer Research UK (London, UK), Centers for Disease Control and Prevention (Atlanta, GA, USA), Swiss Re (London, UK), Swiss Cancer Research foundation (Bern, Switzerland), Swiss Cancer League (Bern, Switzerland), and University of Kentucky (Lexington, KY, USA).

Health impact assessment: the state of the art

Health impact assessment (HIA) has matured as a form of impact assessment over the past two decades. The use of HIA methods and approaches has expanded rapidly, and it now has applications in both the public and private sectors and in an increasing number of countries around the world. This paper presents an overview of the historical and recent international developments in HIA, before detailing the existing strengths, weaknesses, opportunities and threats to practice. It draws upon the HIA literature, five workshops on ‘Current issues in HIA practice’ held at International Association for Impact Assessment (IAIA) conferences between 2006 and 2011, and the experience of the authors.

Factors associated with survival in a large series of patients with malignant pleural mesothelioma in New South Wales.

Background:Although the prognosis of most patients presenting with malignant pleural mesothelioma (MPM) is poor, a small proportion survives long term. We investigated factors associated with survival in a large patient series.Methods:All patients registered with the NSW Dust Diseases Board (2002–2009) were included in an analysis of prognostic factors using Kaplan–Meier and Cox regression analysis. On the basis of these analyses, we developed a risk score (Prognostic Index (PI)).Results:We identified 910 patients: 90% male; histology (epithelioid 60%; biphasic 13%; sarcomatoid 17%); stage (Tx-I-II 48%; III-IV 52%); and calretinin expression (91%). Treatment: chemotherapy(CT) 44%, and extrapleural-pneumonectomy (EPP) 6%. Median overall survival (OS) was 10.0 months. Longer OS was associated with: age <70 (13.5 vs 8.5 months; P<0.001); female gender (12.0 vs 9.9 months; P<0.001); epithelioid subtype (13.3 vs 6.2 months; P<0.001); ECOG status 0 (27.4 vs 9.7 months; P=0.015), calretinin expression (10.9 vs 5.5 months; P<0.001); neutrophil–lymphocyte ratio (NLR) <5 (11.9 vs 7.5 months; P<0.001); platelet count <400 (11.5 vs 7.2 months; P<0.001); and normal haemoglobin (16.4 vs 8.8 months; P<0.001). On time-dependent analysis, patients receiving pemetrexed-based chemotherapy (HR=0.83; P=0.048) or EPP (HR=0.41; P<0.001) had improved survival. Age, gender, histology, calretinin and haematological factors remained significant on multivariate analysis. In all, 24% of patients survived >20 months: 16% of these receiving EPP, and 66% CT. The PI offered improved prognostic discrimination over one of the existing prognostic models (EORTC).Conclusions:We identified calretinin expression, age, gender, histological subtype, platelet count and haemoglobin level as independent prognostic factors. Patients undergoing EPP or pemetrexed-based chemotherapy demonstrated better survival, but 84% and 34% of long survivors, respectively, did not receive radical surgery or chemotherapy.

Bias in relative survival methods when using incorrect life‐tables: Lung and bladder cancer by smoking status and ethnicity in New Zealand

Relative survival and excess mortality approaches are commonly used to estimate and compare net survival from cancer. These approaches are based on the assumption that the underlying (non‐cancer) mortality rate of cancer patients is the same as that of the general population. This assumption is likely to be violated particularly in the context of smoking‐related cancers. The magnitude of this bias has not been estimated. The objective of this article is to estimate the bias in relative survival ratios (RSRs) and excess mortality rate ratios (EMRRs) from using total population compared to correct subpopulation specific life‐tables. Analyses were conducted on 1996–2001 linked census–cancer data (including smoking status) for people with lung and bladder cancer, using sex‐specific (standard practice), sex‐ and ethnic‐specific, sex‐ and smoking‐specific and sex‐, ethnic‐ and smoking‐specific life‐tables. Five‐year RSRs using sex‐specific life‐tables, compared to fully stratified life‐tables, were underestimated by 10–25% for current smoking and Maori populations. For example, the current smoker male bladder cancer RSR was 0.700 for sex‐specific life‐tables, compared to 0.838 for fully stratified life‐tables. Similarly, EMRRs comparing current to never smokers and Maori to non‐Maori were overestimated using sex‐specific life‐tables only: modestly only for lung cancer, but markedly for bladder cancer. For example, the EMRR comparing current to never smokers with bladder cancer in a fully adjusted regression model was 1.475 when using sex‐specific life‐tables only, but reduced to 1.098 when using fully stratified life‐tables. Substantial bias can occur when estimating relative cancer survival across subpopulations if non‐matching life‐tables are used.

Incidence and survival trends for malignant pleural and peritoneal mesothelioma, Australia, 1982–2009

Background Australia is known to have had one of the highest per-capita asbestos consumption rates, yet there are few contemporary reports on malignant mesothelioma trends. Methods Data on 10 930 people with malignant pleural mesothelioma (MPM) and 640 people with malignant peritoneal mesothelioma diagnosed in Australia during 1982–2009 were analysed. Observed incidence rate trends were quantified. Incidence rates were projected up to 2030 using observed incident cases during 1982–2012. The relative per-decade change in excess mortality during 1999–2009 was estimated. Results During 1982–2009, acceleration in MPM age-standardised incidence rates were highest for women and those aged 75 years and above, with average annual percentage changes of +4.9 (95% CI 3.6 to 6.2) and +7.2 (95% CI 5.4 to 9.0), respectively. Age-standardised incidence rates for men with MPM aged 0–64 years decelerated rapidly during 2003–2009, an average annual percentage change of −5.1% (95% CI −7.6% to −2.5%). Overall, male age-specific MPM incidence rates in the age group of 65–74 year during 2010–2030 are projected to decline with rates projected to increase for older men and women with MPM. There was a statistically significant 16% relative reduction in the excess mortality rate (EMR) up to 5 years postdiagnosis for people diagnosed with malignant pleural and peritoneal mesothelioma combined in 2009 compared with those diagnosed in 1999, an EMR ratio of 0.84 (95% CI 0.77 to 0.92). Conclusions Australias malignant mesothelioma incidence rates appear to have reached maximum levels but with differences over time by age, gender and tumour location. Improvements over time in survival provide a glimpse of hope for this almost invariably fatal disease.

Trends in incidence and survival for anal cancer in New South Wales, Australia, 1972–2009

INTRODUCTION Little is known about the incidence and survival of anal cancer in New South Wales (NSW), Australia, as anal cancer cases are often grouped together with other colorectal cancers in descriptive epidemiological analyses. METHODS We studied patterns and trends in the incidence and survival of people diagnosed with anal cancer in NSW, Australia, 1972-2009 (n=2724). We also predicted anal cancer incidence in NSW during 2010-2032. Given the human papilloma virus-associated aetiology for most anal cancers, we quantified these changes over time in incidence and survival by histological subtype: anal squamous cell carcinoma (ASCC); and anal adenocarcinoma (AAC). RESULTS There was a linear increase in incident anal cancer cases in NSW with an average annual percentage change (AAPC) of 1.6 (95% CI 1.1-2.0) such that, in combination with age-period-cohort modelling, we predict there will be 198 cases of anal cancer in the 2032 calendar year (95% CI 169-236). Almost all of these anal cancer cases are projected to be ASCC (94%). Survival improved over time regardless of histological subtype. However, five-year relative survival was substantially higher for people with ASCC (70% (95% CI 66-74%)) compared to AAC (51% (95% CI 43-59%)), a 37% difference. Survival was also greater for women (69% (95% CI 64-73%)) with ASCC compared to men (55% (95% CI 50-60%)). It was not possible to estimate survival by stage at diagnosis particularly given that 8% of all cases were recorded as having distant stage and 22% had missing stage data. INTERPRETATION Aetiological explanations, namely exposure to oncogenic types of human papillomavirus, along with demographic changes most likely explain the actual and projected increase in ASCC case numbers. Survival differences by gender and histological subtype point to areas where further research is warranted to improve treatment and outcomes for all anal cancer patients.

Trends in ethnic and socioeconomic inequalities in cancer survival, New Zealand, 1991-2004

Improvements in cancer survival may be distributed inequitably throughout populations and across time. We assessed trends in cancer survival inequalities in New Zealand by ethnic and income group. 126,477 people diagnosed with cancer between 1991 and 2004, followed-up to 2006, were included. First, inequalities pooled over time were measured with excess mortality rate ratios (EMRRs). Second, interpretation of changes in inequalities over time can differ depending on whether one uses EMRRs, excess mortality rate differences (EMRD) or absolute differences in relative survival risks (RSRD); we estimated all three by cancer-site and (for EMRRs only) pooled across all sites. We found that pooled over time and all sites, Māori had an EMRR of 1.29 (95% CI, 1.24-1.34) compared to non-Māori. The low compared to high-income EMRR was 1.12 (95% CI, 1.09-1.15). Pooled over cancers, there was no change in the ethnic EMRR over time but the income EMRR increased by 9% per decade (1-17%). Changes over time in site-specific inequalities were imprecisely measured, but the direction of change was usually consistent across EMRRs, EMRDs and RSRDs. There were persistent ethnic inequalities in cancer survival over time, and slower improvements for low-income people.

Malignant mesothelioma in Australia 2015: Current incidence and asbestos exposure trends

ABSTRACT Australia is known to have had the highest per-capita asbestos consumption level of any nation, reaching a peak in the 1970s. Although crocidolite was effectively banned in the late 1960s, and amosite use ceased in the mid 1980s, a complete asbestos ban was not implemented until 2003. This resulted in an epidemic of asbestos-related disease, which has only now reached its peak. Between 1982 and 2011, 13,036 individuals were newly diagnosed with malignant mesothelioma, with 690 diagnosed in 2011. A further 778 cases were identified between 1945 and 1981 from retrospective searches and the first 2 years of the Australian Mesothelioma Program. The age-standardized malignant mesothelioma incidence rate has leveled off in the last 10 years (2.8 per 100,000 in 2011). There has been a marked increase over time in the age-specific incidence rates for individuals aged 75 years or older. Data from the current Australian Mesothelioma Registry on asbestos exposure history in Australia is available for 449 subjects diagnosed between July 1, 2010, and April 1, 2015. This asbestos exposure history data show that 60% (n = 268) of cases had probable or possible occupational asbestos exposure, with trade-based jobs being the most frequent sources of occupational asbestos exposure. In addition, out of the 449 cases, 377 were recorded as having probable or possible nonoccupational asbestos exposure. Continuous vigilance toward changes over time in the settings in which people are exposed to asbestos and in the descriptive epidemiology of malignant mesothelioma is recommended to enable a comprehensive understanding of the current and future impact of asbestos-related diseases in Australia.

Patterns in the incidence, mortality and survival of malignant pleural and peritoneal mesothelioma, New South Wales, 1972–2009

Introduction: Malignant pleural mesothelioma (MPM) and malignant peritoneal mesothelioma (MPeM) are often grouped together in descriptive epidemiological analyses, resulting in limited understanding of epidemiological patterns for these tumour types.

Investigating changes over time in socioeconomic gaps in cancer survival: using differences in relative survival versus differences in excess mortality rates can give different answers

We read with interest the paper by Lyratzopoulos et al. [1], examining changing socioeconomic gaps in relative survival from breast and rectal cancer from 1973 to 2004 in England. They find widening inequalities in 5-year relative survival for rectal cancer and narrowing inequalities for breast cancer. They then interpret these trends in light of Victora’s inverse equity hypothesis [2]; namely, bigger improvements in the efficacy of breast cancer treatment occurred in the 1970s than in the 1990s, meaning that deprived women’s breast cancer survival caught up with non-deprived women in recent times as they too gained (albeit delayed) full access and benefit from the major innovations in the 1970s. Conversely, the big improvements in rectal cancer treatment have only occurred more recently, consistent with currently widening socioeconomic gaps in survival. We think this is a reasonable deduction and interpretation. However, we think the authors may have dismissed too lightly the issue of scale of measurement. Lyratzopoulos et al. [1] chose to present 5-year relative survival ratios (RSRs) and interpret the absolute gap in relative survival between deprivation groups. They state that a similar interpretation was made if ratios of RSRs were used, rather than absolute gaps. However, survival is alternatively (and perhaps more coherently) thought of as a result of mortality rates—or excess mortality rates (akin to hazard ratios) in case of relative survival methodologies [3]. Table 1 shows what the excess mortality rates would have been to produce the RSRs shown by Lyratzopoulos et al. [1], assuming that they were constant over the 5 years, and using the formula 2ln([RSR]/100)/5. In contrast to a narrowing of the absolute gap in relative survival between deprived and non-deprived over time for breast cancer, one sees a widening in the ratio of excess mortality rates over time. (For rectal cancer, the rate ratio increases over time, just as does the absolute gap in relative survival.) The reason for this different conclusion for breast cancer when using excess mortality rates, and their ratios, is that survival is bound between 0 and 1.0. Consider a constant excess mortality rate ratio of 1.5 comparing deprived and nondeprived. When the non-deprived group’s excess mortality rate is 0.03 per person per year, the five RSRs are 0.86 and 0.80 for non-deprived and deprived, respectively, a gap of 0.06. However, when the non-deprived group’s excess mortality rate is 0.10 per person per year, the five RSRs are 0.61 and 0.47, a wider gap in RSRs of 0.13 (using non-rounded data). That is, the patterns in gaps between RSRs (be it on an absolute or relative scale) and the patterns in gaps in excess mortality rates vary notably with background variation in the average or reference groups excess mortality rate. We suggest that not only do absolute and relative gaps in relative survival need presenting in inequality analyses for cancer survival but so too do the gaps in excess mortality rates.