Patients diagnosed with breast, lung, colorectal, or ovarian cancer in the United Kingdom and Denmark had significantly worse one- and five-year survival rates compared with patients diagnosed in Australia, Canada, and Sweden, while those in Norway had intermediate survival, according to a report by the International Cancer Benchmarking Partnership, now available online in The Lancet (doi:10.1016/S0140-673662231-3). The study, however, showed improvements in all countries over the study time period, from 1995 to 2007.
“Broadly speaking survival is improving for all of these cancers in all six countries,” Michel Coleman, MD, Professor at the London School of Hygiene & Tropical Medicine, said during a news conference in London.
“Survival has improved more or less in parallel in each of the six countries for colorectal cancer, lung cancer, and ovarian cancer. For breast cancer there has been a narrowing of the international range. What I mean by that is the difference in survival between the highest and lowest countries for patients diagnosed in the late ‘90s was larger than the corresponding difference for patients diagnosed in 2005 to 2007.
“Once we've adjusted for age the difference between the highest and lowest fell from 14% to 8% at five years after diagnosis, he continued. In other words, even though survival is improving in all countries for breast cancer, it has improved more or more rapidly in the countries where survival was initially the lowest—namely the UK and Denmark.”
Represent Large Number of Avoidable Premature Deaths
Dr. Coleman emphasized that while the percentage differences may not seem very large, they represent a large number of avoidable premature deaths. “The overall goal of the study is to study these differences in survival in such a way that we understand what causes them and can generate an evidence base for policy to reduce them,” he said.
In fact, Lancet Editor Richard Horton, MD, who chaired the news conference, said that it is only when such independent data are available that researchers and the public can know whether health policy changes improve patient outcomes.
“I think what this work shows beautifully is the contribution that independently commissioned research can bring to policy making,” he said.
“This work does provide the most reliable report card we have right now on the effectiveness of cancer services in the United Kingdom and with the new government's very dramatic health reform over the next few years, there is an urgent requirement for that kind of independently commissioned reports on services.
“Without that kind of evidence, we are not going to be able to see whether that wholesale revolution in National Health Service care is actually going to deliver benefit to patients.”
Reasons for the Difference
Dr. Coleman and his coauthors based their analysis on population-based cancer registries, which included data from 2.4 million adult cancer patients, and all of the countries in the analysis have similar wealth and national health services.
The team says the current publication is only the first analysis of the data and more in-depth analyses will follow in the coming year.
In the meantime, however, they say the differences in survival are likely due to late diagnosis and differences in treatment, particularly in the United Kingdom—represented by England, Wales, and Northern Ireland—and Denmark, as well as in patients aged 65 and older.
Access to Medication a Factor?
When asked whether access to drugs was likely to contribute to the differences in survival, both Dr. Coleman and Professor Sir Michael Richards, MD, National Cancer Director at the Department of Health in England, said they did not think it was a major factor. Dr. Coleman said that the only study he knew of that addressed this issue directly was done in Australia and found only a two to three percent difference in five-year survival.
Prof Sir Mike Richards elaborated on the point, saying, “For adjuvant therapy for breast cancer, we have access to all of the same drugs as anybody else would, and I think it is extremely unlikely that any issues of access to drugs really makes a very significant part in these results.
“The reason for that is the drugs where there have been issues about access in this country are drugs that, by and large, have very modest impact on survival. Typically they are the ones that might prolong average survival by three months or so. So I think it is most unlikely that they account for a significant part of this.”
Rather he said that while more complete staging data, from the UK and other countries, would improve the analysis, the particularly poor one-year survival rate in the UK suggested that late diagnosis contributed significantly to poorer survival.
For example, the study reported that one-year survival for patients diagnosed with colorectal cancer between 2005 and 2007 was 83.5% to 84.9% in Australia, Canada, and Sweden, 82.4% in Norway, compared with 77.7% in Denmark and 74.7% in the UK.
Similarly, one-year survival for lung cancer patients during the same period was 42.8% to 43.6% in Australia, Canada, and Sweden, 39.2% in Norway, and 34.9% in Denmark, and just 29.7% in the UK.
Making Future Gains
When asked about why the gap in survival had declined in breast cancer but not other cancers, he said that many changes in cancer care start in the breast cancer population and then move into other cancers.
For example, the National Health Service mandated that patients with breast cancer symptoms be seen within two weeks, and that program was subsequently applied to other types of cancer.
Additionally, breast cancer screening not only helps detect cancers but also raises public awareness, which leads to women contacting their health care provider sooner than they might otherwise. He predicts that a similar increase in awareness will occur for colorectal cancer now that screening programs are in place for that malignancy.
Additionally he noted that over the course of the current study period, the UK has had several programs aimed at improving cancer care. The initial efforts were focused on secondary and tertiary care centers, which needed increased capacity in both facilities and clinical staff.
More recently, the government has put a bigger emphasis on earlier diagnosis in collaboration with Cancer Research UK. And moving forward, the Department of Health plans a three-pronged effort to improve patient outcome, including raising public awareness of the signs and symptoms of cancer, working with general practitioners to reduce delays in the primary care setting, and giving general practitioners better access to diagnostic tests.
“I can assure people that the findings that are being reported today are being acted on immediately, and our absolute aim is to narrow that gap so that over time this country has outcomes that are amongst the best in the world,” he concluded.
The study was funded by the Department of Health, England, and Cancer Research UK.