INCREASE IN CANCER SURVIVAL IN EUROPE BUT STILL SURVIVAL IS BETTER IN USA

European Data Show Increase in Proportion of "Cured" Cancer Patients

April 1, 2009 — Although large differences in cancer survival remain among individual European countries, the overall data for Europe show that the number of patients who are considered "cured" is rising steadily.

This trend emerges from 1 of the latest analyses carried out by the EUROCARE (European Cancer Registry-Based Study of Cancer Patients' Survival and Care)-4 Working Group, and detailed in a paper appearing in the special April issue of the European Journal of Cancer. In an accompanying commentary, the working group also suggests that cancer care in Europe is comparable to that in the United States, despite statistics showing lower survival rates.

EUROCARE began in the early 1990s, and has published results on cancer survival periodically since 1995. Initially funded by the European Community, the project is now funded by the Italian Compagnia di San Paolo Foundation.

This latest version of the study, EUROCARE-4, is based on records of more than 13,500,000 cancer patients diagnosed from 1978 to 2002. Preliminary cancer survival data were published in 2007, but like the conclusions from the earlier EUROCARE studies, these survival statistics were based on cancer patients who were still alive 5 years after diagnosis.

However, these classic survival indicators do not distinguish between patients who are cured (and thus have a life expectancy close to the rest of the population) and those who will die of their disease, the authors of the new analysis explain. Another shortcoming is that this classic approach does not account for so-called lead-time bias, where there is an earlier diagnosis of the disease but no improvement in life expectancy.

To overcome these drawbacks, the authors performed a new analysis, based on a parametric-cure model. Cancer patients were divided into 2 groups: those who were expected to die from their disease, and those who were considered "cured" and likely to die from another cause.

This new analysis compared data for the periods 1988 to 1990 and 1997 to 1999, and shows increases in the proportion of patients who were considered cured. For lung cancer, this proportion rose from 6% to 8%, for stomach cancer the jump was from 15% to 18%, and for colorectal cancer, the increase was from 42% to 49%.

These increases are "noteworthy," says Richard Capocaccia, MD, from the National Center for Epidemiology, Surveillance and Health Promotion, in Rome, Italy. Dr. Capocaccia was a key member of the EUROCARE-4 working group, and is a guest editor of the special issue of the Journal.

The proportion of patients cured is not affected by the lead time, so "these trends suggest genuine progress in cancer control," he said in a statement.

However, there was a wide variation in the proportion of patients cured in individual European countries. For instance, the figures for 1988 to 1999 show that for lung cancer less than 5% of patients were cured in Denmark, the Czech Republic, and Poland, whereas more than 10% of patients were cured in Spain. For colorectal cancer, the best cure rate (49%) was seen in France, whereas the worst cure rates (<30%)>

The very wide range in the proportion of patients cured in the contributing countries depends, to some extent, on the varying frequencies across Europe of these different cancers, Dr. Capocaccia commented. "This proportion is, therefore, also an indicator of Europe-wide variations in cancer control, because it reflects the progress in diagnosis and treatment, as well as success in the prevention of the most fatal cancers," he said.

Wide Variation Across European Countries

This wide variation across the individual countries of Europe has been a recurring theme of all of the EUROCARE reports, and these statistics have been used as ammunition by critics of healthcare systems.

Such criticism has been particularly fierce in the United Kingdom, which comes out badly in these studies, showing cancer survival rates that are among the worst in Europe. Highly vocal critics, including a leading medical oncologist, have said these statistics show that the UK National Health System is inefficient at managing cancer, and that the National Cancer Plan has not improved matters much, as recently reported by Medscape Oncology.

New data in these latest reports from EUROCARE-4 will add fuel to this fire. In 1 of the new analyses, the authors consider cancer survival rates alongside each country's per capita total national expenditure on health, and found that there was "moderate correlation" between these 2 factors.

However, there were notable exceptions; Denmark and the United Kingdom had lower survival rates than countries with similar spending on healthcare, the authors note. In addition, it is noteworthy that Switzerland has very similar rates to Sweden, but at a much higher cost, suggesting that cost-effectiveness could be improved in Switzerland, the authors note.

Denmark is an anomaly among the Nordic countries. The authors note that Iceland, Norway, Sweden, and Finland are characterized by "excellent overall cancer survival, while Denmark has much worse survival, and the difference can only be partly explained by differences in case mix."

Finland had better survival than expected from its moderate health expenditure, suggesting effective health management, the authors comment. Spain, Italy, and Portugal also had better survival than countries with comparable spending, but the authors caution that the cancer registries in these countries were incomplete, and survival in the areas covered may not reflect those of the whole country. In particular, in Italy, survival is significantly better in the wealthy north than in the poorer south — a finding that was reported by the Italian newspaper L'Espresso as "only miracles can save cancer patients in southern Italy," they note.

Eastern European countries have the lowest healthcare expenditure and also the lowest cancer survival rates. The relative excess risk for death is 28% higher in eastern Europe than in central Europe, the authors note.

New Data Show "Reduction in Disparities"

In an editorial comment, Franco Berrino, MD, from the Istituto Nazionale die Tumori, in Milan Italy, and colleagues from the EUROCARE-4 working group provide some context for the new findings.

The first of the reports, EUROCARE-1 (published in 1995), revealed dramatic between-country differences, with low rates in eastern Europe, intermediate rates in Denmark and the United Kingdom, and high rates in the other western European populations. The 2 subsequent studies broadly confirmed these findings, but also suggested that, across Europe, the survival differences may be widening, the group notes. "However, time-trend analyses presented in the current EUROCARE-4 monograph, which includes cases diagnosed up to 1999, clearly indicate a narrowing of survival differences, with absolute improvements greater for countries with low survival in the past than for countries where survival was already high," they write.

This point was emphasized by Alexander Eggermont, MD, PhD, president of the European Cancer Organization, who commented on the latest report in a statement.

"The good news is that, for most cancers, survival increased during the 1980s and 1990s," Dr. Eggermont said. "Most of the largest increases in survival occurred in countries where survival was low at first, and this has contributed to a reduction in the disparities in survival across Europe."

How Does Europe Compare With United States?

"European patients need to know that there is no particular reason to think that cancer treatment in the United States is better than can be obtained in Europe," say Dr. Berrino and colleagues. Although the statistics show better cancer survival rates in the United States than in Europe, the group analyzes and dissects the data, and suggests that the differences may be smaller than they at first appear.

For all cancers combined, 5-year survival estimates for 2000 to 2002 were much higher for the American patients monitored by the 14 cancer registries in the SEER program than in the 47 cancer registries included in the EUROCARE survival analysis, the group notes. The figures were 66.3% vs 47.3% for men and 62.9% vs 55.8% for women.

However, the huge difference for men was largely due to the lower incidence of rapidly fatal cancers (mainly lung and stomach), and the exceptionally high incidence and survival for prostate cancers in the United States were largely attributable to overdiagnosis, Dr. Berrino and colleagues state. After excluding prostate cancer, the difference between the United States and Europe for men is halved (46.9% vs 38.1%), although the survival rate remains better in the United States.

In addition, the authors note that although breast cancer survival has been reported as being significantly higher in the United States than in Europe, a comparative study found that differences in age, stage at diagnosis, and number of lymph nodes evaluated explained most of the excess risk for European patients, indicating that the problem is later diagnosis, rather than less effective treatments (Cancer. 2004;100:715-722).

When cancer was considered by specific site, nearly all of the sites showed a higher average survival rate in the United States than in Europe, the authors comment. The exceptions were cancers of the stomach and testes, Hodgkin's disease, and acute myeloid leukemia, for which survival rates were better in Europe. Nonetheless, for most cancer sites — but not prostate or colon — American "survival was within the range of European countries," the group comments.

"It is also important to stress than in both Europe and the Untied States, there are large survival differences between the rich and the poor," Dr. Berrino and colleagues note.