Z. Uhry

Are breast cancer screening practices associated with sociodemographic status and healthcare access? Analysis of a French cross-sectional study.

The aim of this study was to analyse the role of womens sociodemographic and healthcare access characteristics according to breast cancer screening practices (organized, individual or no screening). A cross-sectional study was set up in seven French districts using a self-administered postal questionnaire. Randomization was stratified proportionally on age and urban/rural status in each district separately among attendees and nonattendees to the organized breast cancer screening programme (OS). A total of 5638 women aged 50–74 years returned their questionnaires: 1480 in the attendee OS group and 4158 in the nonattendee group. Among them, 3537 declared having undergone a recent mammography outside the organized programme (individual, IS group) and 621 declared never having undergone a mammography or having done so more than 2 years ago (NS group). Analyses showed a gradient between the three groups (IS, OS and NS, respectively) in their association with breast cancer screening practices considering three factors: an increasing gradient was observed for renunciation of basic healthcare for financial reasons, a decreasing gradient in the regular visit to a medical gynaecologist and having had a Pap smear in the last 3 years. Three other variables that showed a decreasing gradient are: living with a partner, current use of hormone replacement therapy and having had a check-up in the last 5 years. In conclusion, the main differences between breast cancer screening practices were largely associated with difficulties in healthcare access, considering regular gynaecological visits in particular.

Multi-state Markov models in cancer screening evaluation: a brief review and case study

This work presents a brief overview of Markov models in cancer screening evaluation and focuses on two specific models. A three-state model was first proposed to estimate jointly the sensitivity of the screening procedure and the average duration in the preclinical phase, i.e. the period when the cancer is asymptomatic but detectable by screening. A five-state model, incorporating lymph node involvement as a prognostic factor, was later proposed combined with a survival analysis to predict the mortality reduction associated with screening. The strengths and limitations of these two models are illustrated using data from French breast cancer service screening programmes. The three-state model is a useful frame but parameter estimates should be interpreted with caution. They are highly correlated and depend heavily on the parametric assumptions of the model. Our results pointed out a serious limitation to the five-state model, due to implicit assumptions which are not always verified. Although it may still be useful, there is a need for more flexible models. Over-diagnosis is an important issue for both models and induces bias in parameter estimates. It can be addressed by adding a non-progressive state, but this may provide an uncertain estimation of over-diagnosis. When the primary goal is to avoid bias, rather than to estimate over-diagnosis, it may be more appropriate to correct for over-diagnosis assuming different levels in a sensitivity analysis. This would be particularly relevant in a perspective of mortality reduction estimation.

Estimating infra-national and national thyroid cancer incidence in France from cancer registries data and national hospital discharge database

ObjectiveAs in many countries, cancer registries cover only part of the population in France. Incidence/mortality ratio observed in registries is usually extrapolated to produce national estimates of cancer incidence. District-level estimates are not currently available. For cancer sites such as thyroid, the incidence/mortality ratio widely varies between districts, and alternative indicators must be explored. This study aims to produce national and district-level estimations of thyroid cancer incidence in France, using the ratio between incidence and hospital-based incidence.MethodsAnalyses concerned population living in France and aged over 20, for the period 1998–2000. For each sex, number of incident cases were analysed according to number of surgery admissions for thyroid cancer (Poisson model) in the districts covered by a registry. Age was included in the model as fixed effect and district as random effect. The model’s ability to predict incidence was tested through cross-validation. The model was then extrapolated to produce national incidence estimations, and for women, district-level estimations.ResultsThe national estimations of incidence rate age-standardised on the world population were 3.1 [95% prediction interval: 2.8–3.4] for men and 10.6 [9.8–11.4] for women, corresponding respectively to 1,148 [1,042–1,264] and 4,104 [3,817–4,413] annual new cases. For women, district-level incidence rates presented wide geographical variations, ranging broadly from 5 to 20 per 100,000. These estimations were quite imprecise, but their imprecision was smaller than the extent of geographical disparities.ConclusionNational incidence estimations obtained are relatively precise. District-level estimations in women are imprecise and should be treated carefully. They are informative though regarding the extent of geographical disparities. The approach can be useful to improve national incidence estimates and to produce district-level estimates for cancer sites presenting a high variability of the incidence/mortality ratio.

A Suitable Approach to Estimate Cancer Incidence in Area without Cancer Registry

Objective. Use of cancer cases from registries and PMSI claims database to estimate Département-specific incidence of four major cancers. Methods. Case extraction used principal diagnosis then surgery codes. PMSI cases/registry cases ratios for 2004 were modelled then Département-specific incidence for 2007 estimated using these ratios and 2007 PMSI cases. Results. For 2007, only colon-rectum and breast cancer estimations were satisfactorily validated for infranational incidence not ovary and kidney cancers. For breast, the estimated national incidence was 50,578 cases and the incidence rate 98.6 cases per 100,000 person per year. For colon-rectum, incidence was 21,172 in men versus 18,327 in women and the incidence rate 38 per 100,000 versus 24.8. For ovary, the estimated incidence was 4,637 and the rate 8.6 per 100,000. For kidney, incidence was 6,775 in men versus 3,273 in women and the rate 13.3 per 100.000 versus 5.2. Conclusion. Incidence estimation using PMSI patient identifiers proved encouraging though still dependent on the assumption of uniform cancer treatments and coding.

Valeur prédictive et sensibilité du programme de médicalisation des systèmes d'information (PMSI) par rapport aux registres des cancers : application au cancer de la thyroïde (1999-2000)

BACKGROUND Cancer registries have a complete recording of new cancer cases occurring among residents of a specific geographic area. In France, they cover only 13% of the population. For thyroid cancer, where incidence rate is highly variable according to the district conversely to mortality, national incidence estimates are not accurate. A nationwide database, such as hospital discharge system, could improve this estimate but its positive predictive value and sensibility should be evaluated. METHODS The positive predictive value and the sensitivity for thyroid cancer case ascertainment (ICD-10) of the national hospital discharge system in 1999 and 2000 were estimated using the cancer registries database of 10 French districts as gold standard. The linkage of the two databases required transmission of nominative information from the health facilities of the study. From the registries database, a logistic regression analysis was carried out to identify factors related to being missed by the hospital discharge system. RESULTS Among the 973 standardized discharge charts selected from the hospital discharge system, 866 were considered as true positive cases, and 107 as false positive. Forty five of the latter group were prevalent cases. The predictive positive value was 89% (95% confidence interval (CI): 87-91%) and did not differ according to the district (p=0,80). According to the cancer registries, 322 thyroid cancer cases diagnosed in 1999 or 2000 were missed by the hospital discharge system. Thus, the sensitivity of this latter system was 73% (70-76%) and varied significantly from 62% to 85% across districts (p<0.001) and according to the type of health facility (p<0.01). CONCLUSION Predictive positive value of the French hospital discharge system for ascertainment of thyroid cancer cases is high and stable across districts. Sensitivity is lower and varies significantly according to the type of health facility and across districts, which limits the interest of this database for a national estimate of thyroid cancer incidence rate.

Trends of incidence and survival in squamous-cell carcinoma of the anal canal in France: a population-based study.

Data on anal cancer epidemiology are rare. The aim of this study was to report on trends of incidence and survival for anal cancer in France before the implementation of the human papilloma virus vaccine. This analysis was carried out on 1150 squamous-cell carcinomas of the anal canal diagnosed from 1989 to 2004 in a population of 5.7 million people covered by eight population-based cancer registries. Time trends in incidence were modeled using an age–period–cohort model. Net survival rates were obtained using the recently validated unbiased Pohar-Perme estimator. The incidence of squamous-cell carcinoma of the anal canal increased from 0.2 to 0.5/100 000 person-years among men and from 0.7 to 1.3/100 000 person-years among women from 1982 to 2012. Among women, the increase peaked after 2005, with an annual percentage change of +3.4% between 2005 and 2012, as compared with +2.6% among men. The net survival was 56% (95% confidence interval, 49–64) at 5 years and 48% (33–70) at 10 years among men. It was higher among women, at 65% (61–69) and 56% (50–63) at 5 and 10 years, respectively. The prognosis improved between 1989–1997 and 1998–2004. This improvement was slightly greater for men than for women, thus progressively reducing the gap between sexes. The incidence of squamous-cell anal canal cancer increased slightly among both sexes, but the increase was more marked among women than among men. The potential benefit of prophylactic female human papilloma virus vaccination against cervical cancer in France should be further evaluated.

Deaths with Asthma in France, 2000–2005: A Multiple-Cause Analysis

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000–2005. In 2004–2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (−12% and −11%/year in the 1–44 and 45–64 age groups, respectively). The decline for all deaths with asthma was less pronounced (−9%/year in the 1–44 age group and −8%/year in the 45–64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (−12%/year for underlying cause, −9% for multiple-cause) than women (−5% and −3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1–44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.

Focus on an unusual rise in pancreatic cancer incidence in France

Background Pancreatic cancer is one of the most lethal. Most countries have exhibited a stable or decreasing incidence over time. The aim of this study was to provide updated French temporal trends in pancreatic cancer incidence and mortality over the past three decades. Methods Incidence was estimated using the French National Network of Cancer Registries (FRANCIM) and mortality using the French Mortality Statistics Office. World age-standardized incidence and mortality were modelled by age-period-cohort models. The net cumulative risk of developing pancreatic cancer by birth cohort was calculated, as were annual percentage changes (APCs) in incidence and mortality. Results Between 1982 and 2012, age-standardized incidence increased from 4.8 in 1980 to 9.6 per 100 000 in men and from 2.3 to 6.8 in women. The mean APC was 2.3% (2.1-2.6) and 3.6% (3.3-3.9), respectively. The cumulative risk of developing pancreatic cancer before age 75 rose from 0.62% for males born around 1920 to 1.17% for those born around 1950. It was respectively 0.31% and 0.86% for women. Mortality did not vary in men (8.1 per 100 000). It slightly increased in women from 4.0 in 1982 to 5.4 in 2012. Conclusion Pancreatic cancer incidence and mortality exhibited diverging trends. Incidence increased over the last 30 years in France whereas mortality did not vary in men and moderately increased in women. Incidence remained lower than mortality up to 2002. One cannot exclude the possibility that a similar trend may appear in other countries. Etiological studies are required to further explain this increase.

Ovarian cancer in France: Trends in incidence, mortality and survival, 1980–2012

OBJECTIVE The aim of this epidemiological study was to describe the incidence, mortality and survival of ovarian cancer (OC) in France, according to age, period of diagnosis, and histological type. METHODS Incidence and mortality were estimated from 1980 to 2012 based on data in French cancer registries and from the Centre for Epidemiology of Causes of Death (CépiDc-Inserm) up to 2009. Net survival was estimated from registry data using the Pohar-Perme method, on cases diagnosed between 1989 and 2010, with date of last follow-up set at 30 June 2013. RESULTS In 2012, 4615 cases of OC were diagnosed in France, and 3140 women died from OC. World population age-standardized incidence and mortality rates declined by respectively 0.6% and 1.2% per year between 1980 and 2012. Net survival at 5years increased slightly, from 40% for the period 1989-1993 to 45% for the period 2005-2010. Net survival varied considerably according to histological type. Germ cell tumors had better net survival at 10years (81%) compared to epithelial tumors (32%), sex cord-stromal tumors (40%) and tumors without biopsy (8%). CONCLUSIONS Our study shows a decline in incidence and mortality rates from ovarian cancer in France between 1980 and 2012, but net survival remains poor overall, and improved only slightly over the whole study period.

National cancer incidence is estimated using the incidence/mortality ratio in countries with local incidence data: is this estimation correct?

BACKGROUND In countries with local cancer registration, the national cancer incidence is usually estimated by multiplying the national mortality by the incidence/mortality (I/M) ratio from pooled registries. This study aims at validating this I/M estimation in France, by a comparison with estimation obtained using the ratio of incidence over hospital discharge (I/HD) or the ratio of incidence over health insurance data (long-duration diseases, I/LDD). METHODS This comparison was performed for 22 cancer sites over the period 2004-2006. In France, a longitudinal I/M approach was developed relying on incidence and mortality trend analyses; here, the corresponding estimations of national incidence were extracted for 2004-2006. The I/HD and I/LDD estimations were performed using a common cross-sectional methodology. RESULTS The three estimations were found similar for most cancers. The relative differences in incidence rates (vs. I/M) were below 5% for numerous cancers and below 10% for all cancers but three. The highest differences were observed for thyroid cancer (up to +21% in women and +8% in men), skin melanoma (up to +13% in women and +8% in men), and Hodgkin disease in men (up to +15%). Differences were also observed in women aged over 60 for cervical cancer. Except for thyroid cancer, differences were mainly due to the smoothing performed in the I/M approach. CONCLUSION Our results support the validity of I/M approaches for national estimations, except for thyroid cancer. The longitudinal version of this approach has, furthermore, the advantage of providing smoothed estimations and trend analyses, including useful birth-cohort indicators, and should thus be preferred.