New data and analyses from a long-running study of cancer survival in Europe have shown that the number of people actually cured of cancer – rather than just surviving for at least five years after diagnosis – is rising steadily.
A special issue of the European Journal of Cancer  containing reports from the EUROCARE-4 Working Group, includes, for the first time, an estimate of the proportions of patients who are cured of their cancer in Europe and who, therefore, have a life expectancy equal to that of the rest of the population. The analysis divides patients into two groups – the proportion who may be considered cured of their disease and who are likely to die of something else, and those who will die of their cancer.
The study compared two periods – 1988-1990 and 1997-1999 – and found the proportion of patients estimated to be cured of lung, stomach and colorectal cancers increased from 6% to 8%, from 15% to 18% and from 42% to 49%, respectively.
Dr Riccardo Capocaccia of the National Centre for Epidemiology, Surveillance and Health Promotion (Rome, Italy), who is the guest editor of the EUROCARE-4 special issue, said: "Increases between 1988-1990 and 1997-1999 in the estimated proportion of European patients cured of lung, stomach and colorectal cancers are noteworthy. The proportion cured is not affected by 'lead time' (earlier diagnosis without improvement in life expectancy), so these trends suggest genuine progress in cancer control."
However, as with many other papers in the EJC special issue, the paper on the proportion of cured patients showed there were significant differences between countries in Europe.
For all cancers combined, most men (47%) were cured in Iceland and most women (59%) were cured in France and Finland, while in Poland the least men (21%) and women (38%) were cured.
Dr Capocaccia said: "For all cancers combined, the very wide range in the proportion of patients cured in the contributing countries, ranging from 21% to 47% in men and 38% to 59% in women, also depends on the varying frequency across Europe of the different cancers. This proportion is, therefore, also an indicator of Europe-wide variations in cancer control, because it reflects progress in diagnosis and treatment, as well as success in the prevention of the most fatal cancers.
"Geographic variation in the estimated proportion of patients diagnosed in 1988-1999 who were cured ranged from about 4% to 10% for lung cancer, from 9% to 27% for stomach cancer, from 25% to 49% for colon and rectum cancer, and from 55% to 73% for breast cancer."
For instance, Denmark, Czech Republic and Poland had the lowest proportion of cured lung cancer patients (less than 5%), while France and Spain had the highest (more than 10%). For colorectal cancer, less than 30% were cured in Poland, Czech Republic and Slovenia but 49% were cured in France. In Finland, France, Spain and Sweden, about 73% of breast cancer patients were cured, while the proportion was less than 60% in Czech Republic, Poland and Slovenia.
For prostate cancer, the proportion of men cured was associated more with the intensity of PSA testing activity than with the efficacy of treatments. France led the way with more than 60% of men cured, while only 14% were cured in Denmark. This difference was largely due to cases diagnosed earlier through the PSA test, and many of these prostate cancers would not have killed and might not even have given rise to any symptoms. Indeed, prostate cancer mortality was no higher in Denmark than elsewhere in Northern Europe.
For breast cancer, results showed a gap between Poland, the Czech Republic and Slovenia and more western European countries of about 10%. "Part of this difference has been attributed to the introduction of breast cancer screening from the mid-1990s in several western European countries. If this is true, the implication is that early diagnosis saves the lives of women with breast cancer by rendering their disease more curable," said Dr Capocaccia.
The EUROCARE study has been running since 1990 and is the widest epidemiological study on the survival of cancer patients in Europe. This most recent report, EUROCARE-4, includes data from 93 population-based cancer registries in 23 European countries, covering a total population of about 151,400,000, which represents 35% of the total population in those countries. The EUROCARE-4 database contains the anonymised records for more than 13,500,000 cancer patients diagnosed during the period 1978-2002, with information on their vital status up to 31 December 2003 or later. Preliminary data on survival from EUROCARE-4 were published in 2007.
In addition to the estimates of the proportion of patients cured, data in the EJC special issue that are new since 2007 include comparisons of survival between the elderly and the middle-aged, between men and women and the survival of children.
Survival of the elderly (70-99 years) was lower than for middle-aged patients (55-69 years). Dr Capocaccia said: "This is probably due to more advanced stage of disease at diagnosis, other serious conditions, and more difficult access to, or lack of availability of, appropriate care. The difference was particularly evident for women. During the period 1995-2002 covered by EUROCARE-4, five-year survival improved less for patients aged 70-84 than for those aged 55-69, widening the gap in survival between these two age bands. Survival differences between the oldest and middle-aged patients were mainly concentrated in the first year after diagnosis: five-year survival conditional on survival for the first year after diagnosis varied much less with age than unconditional five-year survival, suggesting that older patients are often diagnosed too late to be efficiently treated."
Women have longer life expectancy than men and better survival from chronic diseases like cardiovascular disease and cancer. Age-adjusted five-year relative survival was higher in women than men for 21 out of 26 types of cancer for which survival was estimated in both sexes. Particularly marked differences were found for cancers of the head and neck, bone, thyroid and stomach, and for melanoma of the skin. Women had significantly lower survival only for cancers of the biliary tract, bladder and larynx. For all cancers combined, and after adjustment for age and for the different patterns of cancer in each sex, women had a two per cent overall advantage in five-year survival (52% vs. 50%). The survival advantage for women younger than 64 was four per cent; this difference decreased with increasing age, becoming negligible in the elderly.
"This suggests that sex hormone patterns may play a role in the consistently higher survival seen for women," said Dr Capocaccia.
In children, adolescents and young adults, five-year survival for all cancers combined was 81% in children (0-14 years) and 87% in adolescents and young adults (15-24 years). From 1995-1999 to 2000-2002, the risk of death within five years of diagnosis fell significantly for young patients, by 8% in children and 13% in adolescents and young adults. International differences in survival also narrowed for children and young adults. Survival improved over time for all the main cancer types affecting the young. The improvement was statistically significant for acute lymphoid leukaemia and central nervous system tumours in children and for non-Hodgkin lymphoma in adolescents and young adults.
"Cancer survival in patients aged less than 25 years is poorly documented in Eastern European countries. Complete cancer registration should be a priority for these countries, as an essential part of a policy for effective cancer control in Europe," said Dr Capocaccia.
Professor Alexander M.M. Eggermont, president of ECCO – the European CanCer Organisation, welcomed the latest data from EUROCARE-4. "EUROCARE-4 provides essential information on the pattern of survival of cancer patients across Europe. Without this information it would be impossible to assess whether improvements in cancer diagnosis, treatment and care are actually having an effect on the outcome for patients. It also tells us what cancers and which areas of Europe need to be targeted for further research and investment.
"The good news is that, for most cancers, survival has increased during the 1980s and 1990s. There were big differences between countries; however, most of the largest increases in survival have occurred in countries where survival was low at first, and this has contributed to a reduction in the disparities in survival across Europe.
"Europe is changing, with more countries joining the EU, and cancer medicine is also changing and improving. This means that more people have higher expectations of the medical profession. We must do our best to meet these expectations and help both patients and colleagues by disseminating information about better diagnostics, treatments and cures as widely as possible across the whole of Europe, and, indeed, the world. This will be achieved by collaboration and communication, and future EUROCARE studies will, no doubt, chart how successful we have been. Cancer registries play a vital role here, and I would urge all countries to protect and develop them so that information on cancer incidence and survival becomes ever more accurate."
 European Journal of Cancer, Vol 45, issue 6 (April 2009), pages 901-1094. "Survival of cancer patients in Europe, 1995-2002: The EUROCARE 4 Study."
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