Cancer survival has improved throughout Europe in the past decade, but large disparities in survival among individual countries remain, according to 2 new reports.
The disparities hold true for both adults and children diagnosed with cancer from 2000 to 2007, researchers report in studies onadult cancer survival and childhood cancer survival published in the January issue of the Lancet Oncology.
The EUROCARE-5 studies are the latest in a series comparing European countries. They are large retrospective observational studies of population-based cancer survival in Europe and, over the past 20 years, have shown large, sometimes unexpected, differences in survival among European populations.
The studies in their totality have also shown improvement in survival over the years in some but not all European countries.
"The good news is that the number of adults surviving for at least 5 years after diagnosis has risen steadily over time in all European regions, reflecting major advances in cancer management, such as organized cancer screening programs and improved treatments. But there continues to be big disparities between countries," study coleader Roberta De Angelis, MD, from the Istituto Superiore di Sanità in Rome, said in a statement.
But an accompanying comment cautions that the limited datasets used in EUROCARE-5 make it difficult to accurately interpret the results.
"If the past is any guide, the results will be interpreted as indicators of the quality of cancer services," writes editorialist J. Alastair Munro, MD, from the University of Dundee School of Medicine, Ninewells Hospital, Scotland. A "league table mentality" is then applied, he says. "This approach might be perfectly satisfactory for competitive sport but often generates more heat than insight when applied to health or education."
Dr. Munro notes that survival after a cancer diagnosis clearly correlates with the general health of a country's citizens, and if patients are unfit for surgery, radiotherapy, or chemotherapy, no amount of investment in cancer services will improve outcomes. "Poor cancer survival can be a result of injustices embedded deeply within an unhealthy society."
Five-Year Cancer Survival in Adults
The adult EUROCARE-5 study analyzed data from 107 population-based cancer registries from 29 countries grouped into 5 regions:
- Northern Europe (Denmark, Finland, Iceland, Norway, Sweden)
- the United Kingdom and Ireland (England, Ireland, Northern Ireland, Scotland, Wales)
- Central Europe (Austria, Belgium, France, Germany, the Netherlands, Switzerland)
- Southern Europe (Croatia, Italy, Malta, Portugal, Slovenia, Spain)
- Eastern Europe (Bulgaria, the Czech Republic, Estonia, Latvia, Lithuania, Poland, Slovakia)
The analysis yielded myriad findings on survival for 46 cancers.
Approximately one third of all cancers had 5-year survival greater than 80%, and about one quarter had survival below 30%.
Table. Cancers With the Highest 5-Year Survival Rates
| Cancer | % | 95% Confidence Interval |
| Testicular cancer | 88.6 | 87.4–89.7 |
| Lip cancer | 88.1 | 86.6–89.4 |
| Thyroid cancer | 86.5 | 86.1–87.0 |
| Prostate cancer | 83.4 | 83.1–83.6 |
| Cutaneous melanoma | 83.2 | 82.9–83.6 |
| Breast cancer | 81.8 | 81.6–82.0 |
| Hodgkin's lymphoma | 80.8 | 80.2–81.4 |
For colon cancer, mean 5-year survival was 57.0%, and Northern, Central, and Southern Europe had similar survival (60.0%). Survival was lower for Eastern Europe and the United Kingdom and Ireland.
For rectal cancer, mean survival was 55.8%, and was better for women then for men. Central and Northern Europe had highest survival, Southern Europe and the United Kingdom and Ireland had intermediate survival, and Eastern Europe had much lower survival.
Lung cancer had the lowest mean survival (13.0%), and women did better than men. Age was a strong determinant of survival, ranging from 24.3% for patients 15 to 44 years of age to 7.9% for those older than 75 years.
Cutaneous melanoma had a good mean survival (83.2%), and women had much better survival than men. Survival was good in most regions (80% to 90%), but for Eastern Europe it was generally 50% to 75%. Exceptions were Croatia, with survival similar to Western Europe, and the Czech Republic, with survival above the regional mean.
For breast cancer, the 5-year survival in most European countries was close to the European mean (81.8%). However, in Eastern Europe, breast cancer survival was 10% to 15% lower.
The analysis also showed that for women 75 years and older with breast cancer, survival was particularly low in the United Kingdom and Ireland.
Importantly, however, survival after breast cancer increased the most in Eastern Europe and the United Kingdom.
For ovarian cancer, mean survival was low (37.6%), and decreased with age. Survival ranged from 31.0% in the United Kingdom and Ireland to 41.1% in Northern Europe. Here again, the largest gains were in Eastern Europe.
For prostate cancer, survival was high (83.4%), although it was much lower in Eastern Europe, except in the Czech Republic and Lithuania.
For kidney cancer, mean 5-year survival was 60.6%, and was better for women than for men. Southern and Central Europe had the best survival (above 60%). In most other countries, survival was 50% to 60%, but was below 50% in Bulgaria, Denmark, and the United Kingdom and Ireland.
For non-Hodgkin's lymphoma, mean 5-year survival was 59.4%, and was higher for women than for men. Eastern Europe had lower survival than Northern Europe (49.7% vs 63.3%).
Survival Increasing and Gap Closing
The researchers note that, overall, 5-year relative survival has increased steadily over time for all European regions.
The gulf in survival between east and west is closing, and there is evidence that some Eastern European countries with previously poorer survival are catching up.
For example, improvements in breast cancer survival in Eastern Europe from 1999 to 2007 have gone from 70% to 75%. This has reduced the gap between Eastern Europe and the best-performing countries (82% to 85%), which are in Northern Europe, over the same time period.
Also, adults in the United Kingdom and Ireland continue to have shorter survival than the European average for many common cancers, particularly colon (52% vs 57%), ovary (31% vs 38%), and kidney (48% vs 61%), but have about-average survival rates for rectal, breast, and prostate cancer and for cutaneous melanoma and lymphomas.
The best survival for most cancers are in the Nordic countries, with the exception of Denmark, and in Central Europe and some countries in Southern Europe — particularly Italy, Portugal, and Spain.
Table. Cancers With Particularly Large Increases in Survival Throughout Europe
| Cancer | 1999, % | 2007, % |
| Prostate cancer | 73 | 82 |
| Rectal cancer | 52 | 58 |
| Non-Hodgkin's lymphoma | 54 | 60 |
"The most likely reasons for improved survival for non-Hodgkin's lymphoma and rectal cancer are more effective drugs and better surgical techniques," Dr. De Angelis said in a statement. "Earlier diagnosis, as well as detection of indolent cancers and overdiagnosis, owing to the increasing use of prostate-specific antigen testing, explains the dramatic increase in numbers of patients surviving prostate cancer," she added.
Five-Year Cancer Survival in Children
The EUROCARE-5 study that analyzed 59,579 children showed that inequalities in childhood cancer survival persist, although 5-year survival in children 0 to 14 years of age for all cancers combined is generally good.
For 1999 to 2001, the 5-year survival rate for all cancers was 76.1% (95% confidence interval [CI], 74.4 - 77.7); for 2005 to 2007, that rose to 79.1% (95% CI, 77.3 - 80.7; hazard ratio, 0.973; 95% CI, 0.965 - 0.982; P < .0001).
The greatest improvements were in Eastern Europe, where 5-year survival rose from 65.2% (95% CI, 63.1 - 67.3) in 1999 to 2001 to 70.2% (95% CI, 67.9 - 72.3) in 2005 to 2007.
"But we still found large survival differences within European areas, ranging from a low of 70% in Eastern Europe to 80% or more in Northern, Central, and Southern Europe," study coleader Gemma Gatta, MD, from the Istituto Nazionale Tumori in Milan, Italy, said in a statement
For the leukemias, which account for more than one third of childhood cancers, the risk for death within 5 years of diagnosis fell by an average of 4% to 6% each year.
However, mortality for all of Europe did not change significantly for Hodgkin's lymphoma, Burkitt's lymphoma, central nervous system tumors, neuroblastoma, Wilms' tumor, Ewing's sarcoma, osteosarcoma, or rhabdomyosarcoma.
Why These Disparities Exist
In their discussions, the EUROCARE-5 researchers note that the differences in survival among the 5 European regions represent differences in resources allocated to healthcare; countries that spent more on healthcare generally had better survival.
But health spending is not the only factor affecting cancer outcome, they add. "Differences in cancer survival can be affected by factors other than the provision and organization of healthcare, such as socioeconomic status, lifestyle, and general health status differences between populations."
The researchers offer possible reasons for the poorer survival in Eastern Europe in a statement.
"The main factors influencing poorer survival in Eastern Europe include a shortage of public funding for cancer control, lack of national cancer plans, and inadequate access to screening programs and up-to-date treatment protocols," they note.
"The main cause of suboptimum survival for UK and Danish adult patients seems to be delayed diagnosis," they explain.
They suggest that "developing and extending twinning programs and pairing medical institutions in high-income countries with those in low-income and middle-income countries could help narrow the survival gaps across Europe for childhood cancers."
The researchers conclude that interpreting cancer survival differences is complex. Longer survival may be due to better treatments or earlier diagnosis that improves the efficacy of existing treatments."
Interpretation of EUROCARE Studies Difficult
In his editorial, Dr. Munro points out that 21 of the countries analyzed in EUROCARE-5 have cancer registries but 8 do not. This makes it very difficult to compare cancer care among the 29 countries.
"In view of the adverse effects of socioeconomic deprivation on cancer survival, any comparisons excluding the banlieues défavorisées of Paris but including impoverished areas of Glasgow are likely to mislead," Dr. Munro writes.
To make sense of the patterns that emerge from large population-based studies such as EUROCARE, registries "should record more sociodemographic information and more details about investigation, staging, treatment, recurrences, and second-line treatment," he concludes.
The researchers involved in such studies should also "actively seek information about long-term consequences of treatment and precise information about causes of death."
More needs to be known about the individual attributes of patients. Until then, "the interpretation of the EUROCARE studies will be far from straightforward," Dr. Munro writes.
The EUROCARE-5 studies were funded by the Italian Ministry of Health, European Commission, Compagnia di San Paolo Foundation, and Cariplo Foundation. Dr. De Angelis and Dr. Munro have disclosed no relevant financial relationships.
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