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EBU TRAINING 18 June 2012 Ministry of Health, Rome, Italy. The best and the worst in Europe: what are they doing that we are not?. Silvia Francisci ISS Roma, Italy. Comparisons: why?.

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18 June 2012 Ministry of Health, Rome, Italy

The best and the worst in Europe: what are they doing that we are not?

Silvia Francisci

ISS Roma, Italy

comparisons why
Comparisons: why?

Comparing the major cancer burden indicators in different countries for the various cancer types can give you an idea of where improvements could be made, and help to learn from the successes of other countries – What are they doing right that we are not?

Comparing within a single country over time can show whether and how fast things are improving, which is important to evaluate how well cancer plans and policies are working

cancer burden indicators incidence mortality
Cancer burden indicators: Incidence, Mortality
  • Incidence rate is the number of new cancers of a specific site/type occurring in a specified population during a year, it is usually expressed as the number of cancers per 100,000 population at risk  represents a measure of risk in a population and depends on the distribution of risk factors
  • Mortality rate is the number of deaths, with cancer as the underlying cause of death, occurring in a specified population during a year. Cancer mortality is usually expressed as the number of deaths due to cancer per 100,000 population represents measure of final outcome and depends on timeliness of diagnosis/care and effectiveness of treatment

Incidence and Mortality by country:

Colorectal cancer

Crude rates

STD rates

The effect of age structure adjustement on geographical ranking




Risk increase or PSA effect?

c ancer burden indicators survival
Cancer burden indicators: Survival
  • Cause of death known Cancer Specific Survival probability of surviving cancer after x years from diagnosis in a cohort of patients diagnosed in a period of time t
  • Cause of death unknown Relative Survival (RS)

ratio of the observed survival in the patients group to the expected survival in a similar group in the population (same age, sex, year, area, socio-economic class etc…)

  • RS measures the extra-risk of dyingof cancer patients by removing the competitive mortality due to causes other than cancer. It approximates a NET SURVIVAL measure.


104 adult + 9 ChildhoodCRs

About 21 milioncases in the DB

National coverage in 20 countries: 140 millionpopulation


Italy, France, Spain, Portugal, Germany, Switzerland, Belgium, Poland, Romania: 113 millionpopulation (34% of the total)

EUROCARE-5 Increased number of countries/registries, expecially eastern European countries

population based cancer registry data quality issues
Population-based cancer registry: data quality issues
  • Completeness of incidence
  • Completeness and quality of follow-up
  • Standard quality indicators (Death Certificate Only cases, Microscopically Verified, morphology NOS)

 ensure comparability of results

  • Additional variables: stage at diagnosis, treatments

 facilitate interpretation of results


5-year Relative Survival cohort 1995-99 all cancers

Berrino F, Lancet Oncology (2007) – EUROCARE 4 STUDY


5-year RS Trend 1989-1998, all cancers, by country

Verdecchia A, European Journal of Cancer (2009) – EUROCARE-4 STUDY

Cancer burden indicators: PrevalenceThe number of surviving cancer patients in a population at a defined index date.

Population Ageing




cancer burden indicators prevalence
Cancer burden indicators: Prevalence
  • Total (or complete) prevalence involves all survivors irrespectively of the date of diagnosis.
  • Partial (or Limited Duration)prevalence by years from diagnosis represents the number of survivors by limited disease duration.
    • 1-2 years LD patients under main treatment and rehabilitation
    • 3-5 years LD patients under clinical follow-up for recurrences and metastasis
    • 5-10 years LD patients that are possibly cured

Prevalence in Italy (2006), Nordic countries (2006) and UK (2008)

  • Data sources:
  • Italy: PIO 7 project and ItalianAssociationofCancerRegistries. Prevalence date: 1-1-2006
  • Nordiccountries: Engholm G, Ferlay J, Christensen N, Bray F, GjerstorffML, Klint A, Køtlum JE, Olafsdóttir E, Pukkala E, Storm HH (2010). NORDCAN-aNordictoolforcancer information, planning, qualitycontrol and research. ActaOncol. 2010 Jun;49(5):725-36.
  • UK: Maddams J, Brewster D, Gavin A, Steward J, Elliott J,Utley M, and Møller H. Cancer prevalence in the United Kingdom. Br J Cancer 2009 Aug 4;101(3):541-7
cancer burden indicators cure fraction
Cancer burden indicators: cure fraction
  • Modelling survival allows to estimate another important indicator of cancer burden: the fraction of patients cured from the disease
  • Cure fraction P measures the proportion of patients which do not show an extra-risk of death with respect to a comparable groups in the general population (statistical definition of cure)
  • P is an indicator not influenced by lead time bias (diagnostic anticipation without real survival improvement)

As cancer diagnostic procedures and treatments improve, the possibility of cure for many cancers becomes a reality.

  • The cure fraction (P), is the survival level as the curve (CRS) flattens
  • Higher survival levels correspond to wider cured fractions

55% cured

45% cured

35% cured


Cure fraction colorectal cancer patients

Colorectal cancer cure fraction is increasing over time

On average 45% of patients are cured

There is large variability across European countries

Francisci et al. EJC (2009)

avoidable deaths
Avoidable deaths

Ellis, European Journal of Cancer 2012

avoidable deaths in england
Avoidable deaths in England
  • Improvement in survival overall
  • Narrowing of the deficit between socio-economic groups (only 2% of reduction)

Ellis, European Journal of Cancer 2012

  • The overall set of descriptive indicators provide a
  • comprehensive picture of cancer burden
  • The comprehensive description of cancer burden is important in order to inform health policy and to properly address cancer plans
  • Comparisons across Europe are needed in order to
    • validate national data
    • identify opportunities to improve health care
    • revise guidelines and practice patterns
    • increase our understanding of patient outcomes and economic consequences of different policies related to cancer screening, treatment, and programs of care