“Cancer survival in Britain the worst in Europe,” The Daily Telegraph reports.
This and many other similar headlines are prompted by a major new study on cancer survival rates in Europe from 1997 to 2007.
While survival rates have tended to improve, cancer survival still varies widely between European countries. The lowest survival rates for most cancers were found in eastern Europe.
The study also found that the UK and Ireland has lower survival rates than the European average for many cancers, particularly of the colon, ovary, kidney, stomach and lung. The lung cancer survival rate in particular was far lower than for other regions. The UK has about average survival rates for cancer of the rectum, breast, prostate, melanoma of the skin and lymphomas.
Researchers say the main reason for low survival rates in the UK seems to be delayed diagnosis, underuse of successful treatments and unequal access to treatment, particularly among elderly people.
However, patient factors are not accounted for, such as the level of smoking, alcohol misuse and poor diet in the UK.
It could be the case that poor cancer care in the UK is not solely to blame for the below average cancer survival rates, but may also be related to the factors listed above.
Where did the story come from?
The study was carried out by researchers from a number of centres across Europe including the London School of Hygiene and Tropical Medicine in the UK. It was funded by the European Commission, Italian Ministry of Health and the Cariplo Foundation.
The study was published in the peer-reviewed medical journal Lancet Oncology.
Unsurprisingly, the research got wide coverage in the UK press, with the Mail Online pointing out that cancer survival rates in the UK were often on a par with former states of the eastern bloc and below comparable countries such as France and Germany. The Mail also included comments from NHS England as well as cancer charities, while The Guardian linked the study to a story about reported moves to raise awareness of cancer among older people.
The good news about the improvements in childhood cancer rates appears to have been ignored.
What kind of research was this?
The findings on both adult and childhood cancer survival rates come from an ongoing population based study called EUROCARE which provides regular updates of cancer survival in Europe.
EUROCARE’s findings are important since they can be used to improve national cancer plans and organise better cancer care.
The researchers point out that cancer diagnosis and treatment have changed greatly in recent decades, with screening for breast cancer and cervical cancer, and to a lesser extent colorectal cancer, being widely adopted. They also say there have been advances in diagnostic imaging, genetic profiling, and cancer treatments.
The latter includes the introduction of targeted drugs, multidisciplinary care and a growing concentration of treatment in specialist centres.
The EUROCARE-5 database contains about 22 million records of patients diagnosed from 1978 to 2007 and followed up to Dec 31, 2008. The participation of additional countries, especially from eastern Europe, has increased coverage.
What did the research involve?
The researchers analysed data for more than 10 million adult patients (aged 15 and over) who had been diagnosed with cancer up to 2007 and followed up to 2008.
The data came from 107 population-based cancer registries from 29 countries, grouped into five regions:
- Denmark, Finland, Iceland, Norway, Sweden (northern Europe)
- England, Ireland, Northern Ireland, Scotland, Wales (UK and Ireland)
- Austria, Belgium, France, Germany, Netherlands, Switzerland (central Europe)
- Croatia, Italy, Malta, Portugal, Slovenia, Spain (southern Europe)
- Bulgaria, Czech Republic, Estonia, Latvia, Lithuania, Poland, Slovakia (eastern Europe)
All invasive, primary cancers, except non-melanoma skin cancer (which is rarely lethal), were eligible for inclusion and were defined according to international guidelines. Patients who had more than one type of cancer were included in each of the counts.
The researchers used anonymised cancer registration records, which had to contain information about each patient’s:
- date of birth
- whether they were dead or alive at the last record
- the site and characteristics of the cancer
- the basis for diagnosis
Cases diagnosed at autopsy or registered only from a death certificate were excluded.
The researchers applied standard quality control procedures to detect missing or invalid information and possible errors in patients’ records. About 68,000 records with major or probable errors were returned to registries for correction or confirmation. From this information they calculated the five year survival rate for 46 cancers, weighted by age and country.
They also calculated country-specific and age-specific survival for 10 common cancers, together with survival differences between the time periods 1999-2001, 2002-4, and 2005-7.
What were the basic results?
The researchers found that overall, the five year survival rates increased steadily over time for all European regions. Cancers with the largest increases in survival rates were:
- Prostate cancer – 81.7% in 2005-7, compared to 73.4% in 1999 to 2001
- Non-Hodgkin lymphoma – 60.4% in 2005-7, compared to 53.8% in 1999-2001
- Rectal cancer – 57.6% in 2005-7 compared to 52.1% in 1999-2001
They say that survival rates in eastern Europe were generally low and below the European average, with survival rates highest for northern, central, and southern Europe.
In the UK and Ireland survival rates were:
- Around the European average for rectal cancer, breast cancer, prostate cancer, skin melanoma, and non-Hodgkin lymphoma.
- Low for kidney, stomach, ovarian, colon, and lung cancers.
- Much lower for lung cancer than for other regions for all periods, although results for lung cancer in some regions (central and eastern Europe) may be affected by overestimation.
Generally survival usually decreased with age, although to different degrees depending on region and cancer type.
Looking specifically at the UK and Ireland compared to neighbouring countries, the study found that:
- For breast cancer, survival rate in the UK was 79.2%, slightly below the European average (81.8%) and lower than France (86.1%), Germany (83.6%) and Austria (82.1%).
- For colon cancer, survival rate was 51.8%, lower than the European average (57%) and lower than Germany (62.2%), Austria (61.2%) and France (59.7%).
- For lung cancer survival was 9%, below the European average (13%) and Austria (16.7%), Germany (15.6%) and France (13.8%).
- For prostate cancer survival was 80.6%, below the European average and below Austria (90.4%), Germany (89.4%) and France (88.9%).
- For ovarian cancer, survival was 31%, below the European average (37.6%) and below Austria (41.4%), Germany (40.3%) and France (40.1%).
- For melanoma, survival was 85.6%, higher than the European average (83.2%) and Austria (83.1%) but below Germany (89.4%) and France (87.2%).
How did the researchers interpret the results?
The researchers say that the major advances in cancer management that occurred up to 2007 seem to have resulted in improved survival in Europe. The differences in survival between countries are probably explained by differences in stage at diagnosis and accessibility to good care, different diagnostic and screening approaches, and differences in cancer biology.
Variations in socioeconomic, lifestyle, and general health between populations might also have a role. Further studies are needed to fully interpret these findings and how to remedy disparities, they say.
The results of this large study on cancer survival are likely to be reliable. There may be some errors or omissions in the information obtained from cancer registries but the researchers took steps to minimise these and they are unlikely to have affected the overall results.
Findings of slightly lower survival rates of some cancers in the UK compared to similar countries are likely to raise concerns.
The findings have already provoked a media debate in the UK, with one charity executive reportedly calling them “truly depressing” and Sean Duffy, National Clinical Director for Cancer at NHS England saying that “real inroads” have been made into improving cancer survival in England.
However, writing in a linked commentary article in the same journal, Professor Alastair Munro from the University of Dundee School of Medicine, points out that to understand the patterns that emerge we need more detailed information.
"Registries should record more sociodemographic information and more details about investigation, staging, treatment, recurrences, and second-line treatment,” he argues. “Until more is known about the individual attributes of patients, the interpretation of the EUROCARE studies will be far from straightforward."
As Prof Munro says, there are no details about the rates of risk taking behaviour for the UK compared to the European studies in terms of smoking, alcohol use, diet and sun exposure.
And the UK may have more in common with countries such as Poland, Bulgaria and the Czech Republic, rather than France, Germany and Sweden, when it comes to our smoking, eating, drinking and exercising habits.
It would be premature and unjust to purely attribute the difference to the level of care received in the UK.