The impact of National Death Index linkages on population-based cancer survival rates in the United States

Background: In order to ensure accurate survival estimates, population-based cancer registries must ascertain all, or nearly all, patients diagnosed with cancer in their catchment area, and obtain complete follow-up information on all deaths that occurred among registered cancer patients. In the US, linkage with state death records may not be sufficient to ascertain all deaths. Since 1979, all state vital statistics offices have reported their death certificate information to the National Death Index (NDI). Objective: This study was designed to measure the impact of linkage with the NDI on population-based relative and cancer cause-specific survival rates in the US. Methods: Central cancer registry records for patients diagnosed 1993–1995 from California, Colorado, and Idaho were linked with death certificate information (deaths 1993–2004) from their individual state vital statistics offices and with the NDI. Two databases were created: one contained incident records with deceased patients linked only to state death records and the second database contained incident records with deceased patients linked to both state death records and the NDI. Survival estimates and 95% confidence intervals from each database were compared by state and primary site category. Results: At 60 months follow-up, 42.1–48.1% of incident records linked with state death records and an additional 0.7–3.4% of records linked with the NDI. Survival point estimates from the analysis without NDI were not contained within the corresponding 95% CIs from the NDI augmented analysis for all sites combined and colorectal, pancreas, lung and bronchus, breast, prostate, non-Hodgkin lymphoma, and Kaposi sarcoma cases in all 3 states using relative survival methods. Additional combinations of state and primary site had significant survival estimate differences, which differed by method (relative versus cause-specific survival). Conclusion: To ensure accurate population-based cancer survival rates, linkage with the National Death Index to ascertain out of state and late registered deaths is a necessary process for US central cancer registries.     

The validity of cancer information on death certificates in Norway and the impact of death certificate initiated cases on cancer incidence and survival

BackgroundDeath certificates are an important source of information for cancer registries. The aim of this study was to validate the cancer information on death certificates, and to investigate the effect of including death certificate initiated (DCI) cases in the Cancer Registry of Norway when estimating cancer incidence and survival.MethodsAll deaths in Norway in the period 2011–2015 with cancer mentioned on the death certificates were linked to the cancer registry. Notifications not registered from other sources were labelled death certificate notifications (DCNs), and considered as either cancer or not, based on available information in the registry or from trace-back to another source.ResultsFrom the total of 65 091 cancers mentioned on death certificates in the period 2011–2015, 58,425 (89.8%) were already in the registry. Of the remaining 6 666 notifications, 2 636 (2 129 with cancer as underlying cause) were not regarded to be new cancers, which constitutes 4.0% of all cancers mentioned on death certificates and 39.5% of the DCNs. Inclusion of the DCI cases increased the incidence of all cancers combined by 2.6%, with largest differences for cancers with poorer prognosis and for older age groups. Without validation, including the 2 129 disregarded death certificates would over-estimate the incidence by 1.3%. Including DCI cases decreased the five-year relative survival estimate for all cancer sites combined with 0.5% points.ConclusionIn this study, almost 40% of the DCNs were regarded not to be a new cancer case, indicating unreliability of death certificate information for cancers that are not already registered from other sources. The majority of the DCNs where, however, registered as new cases that would have been missed without death certificates. Both including and excluding the DCI cases will potentially bias the survival estimates, but in different directions. This biases were shown to be small in the Cancer Registry of Norway.     

The completeness and timeliness of cancer registration and the implications for measuring cancer burden

BackgroundPopulation based cancer registration provides a critical role in disease surveillance in terms of incidence, survival, cancer cluster investigations and prevalence trends, and therefore high levels of completeness and timeliness are required. This study estimates completeness and variation between early and late registrations in the N. Ireland Cancer Registry (NICR) and assesses the implications for reporting cancer incidence and for registry-based research.MethodsTwo main approaches assessed completeness. For the period 2010–2012, incidence reported in the first year of data publication was compared to incidence reported in subsequent years until 2015. Demographic characteristics and survival of incident cases ascertained before the first publication year were compared to those ascertained in subsequent years. The flow method approach was used to estimate completeness annually after the incident year.ResultsOverall incidence for all cancers increased between the first year of data publication and subsequent years up to 2015, irrespective of year of diagnosis. Late registrations had poorer survival. The flow method approach estimated the completeness of case ascertainment of NICR data to be 96% complete at five years for all cancers combined.ConclusionThe estimated completeness levels for the NICR are comparable to other high quality cancer registries internationally. While data timeliness has little impact on incidence estimates, delays in registration may have implications for specific research studies into incidence and survival. This means that improvements in the timeliness of reporting should be a target for all registries but not at the expense of completeness.     

Bias in survival estimates created by a requirement for consent to enter a clinical breast cancer registry

BackgroundA requirement for consent for inclusion may bias the results from a clinical registry. This study gives a direct measure of this bias, based on a population-based clinical breast cancer registry where the requirement for consent was removed after further ethical review and data could be re-analysed.MethodsIn Auckland, New Zealand, the population-based clinical breast cancer registry required written patient consent for inclusion from 2000-2012. A subsequent ethical review removed this requirement and allowed an analysis of consented and non-consented patients. Kaplan-Meier survival to 10 years (mean follow-up 5.1 years, maximum 13.9 years), demographic and clinical characteristics were compared. Of 9244 women with invasive cancer, 926 (10.4%) were not consented, and of 1642 women with ductal carcinoma in situ, 245 (14.9%) were not consented.ResultsSurvival was much higher for consenting patients; invasive cancer, 5 year survival 83.2% (95% confidence limits 82.2–84.1%) for consenting patients, 57.1% (53.0–60.9%) for non-consenting, and 80.8% in all patients. Analyses based only on consenting patients overestimate survival in all patients by around 2% at 2, 5, and 10 years. Non-consented patients were older, more often of Pacific ethnicity, had fewer screen-detected cancers, and more often had metastatic disease; they less frequently had primary surgery or systemic treatments.ConclusionData from a registry requiring active consent gives an upward bias in survival results, as non-consenting patients have more extensive disease, less treatment, and lower survival. To give unbiased results active consent should be not required in a clinical cancer registry.     

Staging practices and breast cancer stage among population-based registries in the MENA region

BackgroundAvailability of stage information by population-based cancer registries (PBCR) remains scarce for diverse reasons. Nevertheless, stage is critical cancer control information particularly for cancers amenable to early detection. In the framework of the Global Initiative for Cancer Registry Development (GICR), we present the status of stage data collection and dissemination among registries in the Middle East and Northern Africa (MENA) region as well as the stage distribution of breast cancer patients.MethodsA web-based survey exploring staging practices and breast cancer stage was developed and sent to 30 PBCR in 18 countries of the MENA region.ResultsAmong 23 respondent PBCR, 21 collected stage data, the majority (80%) for all cancers. Fourteen registries used a single classification (9 TNM and 5 SEER), 7 used both staging systems in parallel. Out of 12,888 breast cancer patients (seven registries) 27.7% had unknown TNM stage (11.1% in Oman, 46% in Annaba). When considering only cases with known stage, 65.3% were early cancers (TNM I+II), ranging from 57.9% in Oman to 83.3% in Batna (Algeria), and 9.9% were stage IV cancers. Among the nine registries providing SEER Summary stage for breast cancer cases, stage was unknown in 19% of the cases, (0 in Bahrain, 39% in Kuwait). Stage data were largely absent from the published registry reports.ConclusionDespite wide stage data collection by cancer registries, missing information and low dissemination clearly limit informing efforts on early detection. The use of two classification systems in parallel implies additional workload and might undermine completeness. The favourable results of early cancer (TNM I+II) in two thirds of breast cancer patients needs to be interpreted with caution and followed up in time. Although efforts to improve quality of stage data are needed, our findings are particularly relevant to the WHO Global Breast Cancer Initiative.     

Effects of the length of central cancer registry operations on identification of subsequent cancers and on survival estimates

BackgroundPopulation-based cancer survival analyses have traditionally been based on the first primary cancer. Recent studies have brought this practice into question, arguing that varying registry reference dates affect the ability to identify earlier cancers, resulting in selection bias. We used a theoretical approach to evaluate the extent to which the length of registry operations affects the classification of first versus subsequent cancers and consequently survival estimates.MethodsSequence number central was used to classify tumors from the New York State Cancer Registry, diagnosed 2001–2010, as either first primaries (value = 0 or 1) or subsequent primaries (≥2). A set of three sequence numbers, each based on an assumed reference year (1976, 1986 or 1996), was assigned to each tumor. Percent of subsequent cancers was evaluated by reference year, cancer site and age. 5-year relative survival estimates were compared under four different selection scenarios.ResultsThe percent of cancer cases classified as subsequent primaries was 15.3%, 14.3% and 11.2% for reference years 1976, 1986 and 1996, respectively; and varied by cancer site and age. When only the first primary was included, shorter registry operation time was associated with slightly lower 5-year survival estimates. When all primary cancers were included, survival estimates decreased, with the largest decreases seen for the earliest reference year.ConclusionsRegistry operation length affected the identification of subsequent cancers, but the overall effect of this misclassification on survival estimates was small. Survival estimates based on all primary cancers were slightly lower, but might be more comparable across registries.     

Neuroblastoma in Spain: Linking the national clinical database and epidemiological registries – A study by the Joint Action on Rare Cancers

PurposeLinkage between clinical databases and population-based cancer registries may serve to evaluate European Reference Networks’ (ERNs) activity, by monitoring the proportion of patients benefiting from these and their impact on survival at a population level. To test this, a study targeting neuroblastoma (Nb) was conducted in Spain by the European Joint Action on Rare Cancers.Material and methodsSubjects: Nb cases, incident 1999–2017, aged < 15 years. Linkage included: Spanish Neuroblastoma Clinical Database (NbCDB) (1217 cases); Spanish Registry of Childhood Tumours (RETI) (1514 cases); and 10 regional population-based registries (RPBCRs) which cover 33% of the childhood population (332 cases). Linkage was semiautomatic. We estimated completeness, incidence, contribution, deficit, and 5-year survival in the databases and specific subsets.ResultsNational completeness estimates for RETI and NbCDB were 91% and 72% respectively, using the Spanish RPBCRs on International Incidence of Childhood Cancer (https://iicc.iarc.fr/) as reference. RPBCRs’ specific contribution was 1.6%. Linkage required manual crossover in 54% of the semiautomatic matches. Five-year survival was 74% (0–14 years) and 90% (0–18 months).ConclusionsAll three databases were incomplete as regards Spain as a whole and should therefore be combined to achieve full childhood cancer registration. A unique personal patient identifier could facilitate such linkage. Most children have access to Nb clinical trials. Consolidated interconnections between the national registry and clinical registries (including ERNs and paediatric oncology clinical groups) should be established to evaluate outcomes.     

Randomization to Screening for Prostate,Lung, Colorectal and Ovarian Cancers and Thyroid Cancer Incidence in Two Large Cancer Screening Trials

Background

Thyroid cancer incidence has increased significantly over the past three decades due, in part, to incidental detection. We examined the association between randomization to screening for lung, prostate, colorectal and/or ovarian cancers and thyroid cancer incidence in two large prospective randomized screening trials.

Methods

We assessed the association between randomization to low-dose helical CT scan versus chest x-ray for lung cancer screening and risk of thyroid cancer in the National Lung Screening Trial (NLST). In the Prostate Lung Colorectal and Ovarian Cancer Screening Trial (PLCO), we assessed the association between randomization to regular screening for said cancers versus usual medical care and thyroid cancer risk. Over a median 6 and 11 years of follow-up in NLST and PLCO, respectively, we identified 60 incident and 234 incident thyroid cancer cases. Cox proportional hazards regression was used to calculate the cause specific hazard ratios (HR) and 95% confidence intervals (CI) for thyroid cancer.

Results

In NLST, randomization to lung CT scan was associated with a non-significant increase in thyroid cancer risk (HR  = 1.61; 95% CI: 0.96–2.71). This association was stronger during the first 3 years of follow-up, during which participants were actively screened (HR  = 2.19; 95% CI: 1.07–4.47), but not subsequently (HR  = 1.08; 95% CI: 0.49–2.37). In PLCO, randomization to cancer screening compared with usual care was associated with a significant decrease in thyroid cancer risk for men (HR  = 0.61; 95% CI: 0.49–0.95) but not women (HR  = 0.91; 95% CI: 0.66–1.26). Similar results were observed when restricting to papillary thyroid cancer in both NLST and PLCO.

Conclusion

Our study suggests that certain medical encounters, such as those using low-dose helical CT scan for lung cancer screening, may increase the detection of incidental thyroid cancer.     

Cancer incidence in Nigeria: A report from population-based cancer registries

Introduction: Cancer has become a major source of morbidity and mortality globally. Despite the threat that cancer poses to public health in sub-Saharan Africa (SSA), few countries in this region have data on cancer incidence. In this paper, we present estimates of cancer incidence in Nigeria based on data from 2 population-based cancer registries (PBCR) that are part of the Nigerian national cancer registry program. Materials and methods: We analyzed data from 2 population based cancer registries in Nigeria, the Ibadan Population Based Cancer Registry (IBCR) and the Abuja Population Based Cancer Registry (ABCR) covering a 2 year period 2009-2010. Data are reported by registry, gender and in age groups. We present data on the age specific incidence rates of all invasive cancers and report age standardized rates of the most common cancers stratified by gender in both registries. Results: The age standardized incidence rate for all invasive cancers from the IBCR was 66.4 per 100000 men and 130.6 per 100000 women. In ABCR it was 58.3 per 100000 for men and 138.6 per 100000 for women. A total of 3393 cancer cases were reported by the IBCR. Of these cases, 34% (1155) were seen among males and 66% (2238) in females. In Abuja over the same period, 1128 invasive cancers were reported. 33.6% (389) of these cases were in males and 66.4% (768) in females. Mean age of diagnosis of all cancers in men for Ibadan and Abuja were 51.1 and 49.9 years respectively. For women, mean age of diagnosis of all cancers in Ibadan and Abuja were 49.1 and 45.4 respectively. Breast and cervical cancer were the commonest cancers among women and prostate cancer the most common among men. Breast cancer age standardized incidence rate (ASR) at the IBCR was 52.0 per 100000 in IBCR and 64.6 per 100000 in ABCR. Cervical cancer ASR at the IBCR was 36.0 per 100000 and 30.3 per 100000 at the ABCR. The observed differences in incidence rates of breast, cervical and prostate cancer between Ibadan and Abuja, were not statistically significant. Conclusion: Cancer incidence data from two population based cancer registries in Nigeria suggests substantial increase in incidence of breast cancer in recent times. This paper highlights the need for high quality regional cancer registries in Nigeria and other SSA countries.     

Women cancers in India: Incidence,trends and their clinical extent from the National Cancer Registry Programme

BackgroundTo provide a comprehensive assessment of women cancer in India utilizing the systematically collected data on all cancers by the National Cancer Registry Programme (NCRP).MethodsThe study examined 10,2287 cancer cases among women cancers providing cancer burden for major anatomical sites. Aggregated data of 28 PBCRs and 58 HBCRs under NCRP for 2012–16 was analysed for incidence rates, trends, cumulative risk of developing cancer, stage at detection and treatments offered.ResultsStudy results have found region –wide variation of women cancers by indicating highest proportions in western followed by southern region of India. North-Eastern region had lowest proportion. It was observed that breast is highest ranking cancer in most registry areas of urban agglomerations of country while cancer cervix was leading site in registries of rural areas like Barshi (15.3) and Osmanabad &Beed (13.1). States of Mizoram (23.2) and Tripura (9.5) along with Pasighat, Cachar and Nagaland. Median age of occurrence for women for these anatomical sites ranged from 45 to 60 years of age. For cancer breast, cervix and ovary –most cases were detected with regional spread. These findings were different for cancer corpus uteri where registries have reported higher proportions (49.3 %) of localized stage at detection. Loco regional cancers had higher proportions of multimodality treatments.ConclusionStudy provides a foundation for assessing the status of women cancers in the country. Variations between geographies would guide appropriate support for action to strengthen efforts to improve cancer prevention and control in underserved areas of the country. This would facilitate advocacy for better investments and research on women cancers.     

Cancer risk in childhood-onset systemic lupus

Introduction

The aim of this study was to assess cancer incidence in childhood-onset systemic lupus erythematosus (SLE).

Methods

We ascertained cancers within SLE registries at 10 pediatric centers. Subjects were linked to cancer registries for the observational interval, spanning 1974 to 2009. The ratio of observed to expected cancers represents the standardized incidence ratio (SIR) or relative cancer risk in childhood-onset SLE, versus the general population.

Results

There were 1020 patients aged <18 at cohort entry. Most (82%) were female and Caucasian; mean age at cohort entry was 12.6 years (standard deviation (SD) = 3.6). Subjects were observed for a total of 7,986 (average 7.8) patient-years. Within this interval, only three invasive cancers were expected. However, 14 invasive cancers occurred with an SIR of 4.7, 95% confidence interval (CI) 2.6 to 7.8. Three hematologic cancers were found (two non-Hodgkin’s lymphoma, one leukemia), for an SIR of 5.2 (95% CI 1.1 to 15.2). The SIRs stratified by age group and sex, were similar across these strata. There was a trend for highest cancer occurrence 10 to 19 years after SLE diagnosis.

Conclusions

These results suggest an increased cancer risk in pediatric onset SLE versus the general population. In absolute terms, this represents relatively few events. Of note, risk may be highest only after patients have transferred to adult care.     

Cancer incidence in ethnic German migrants from the Former Soviet Union in comparison to the host population

AimTo investigate cancer incidence patterns among ethnic German migrants (Aussiedler) from the Former Soviet Union, a large migrant group in Germany, in comparison to autochthonous Saarland population over a 20 year observation period.MethodsData were obtained from a cohort of Aussiedler residing in the federal state of Saarland (n = 18,619). Cancer incidence and vital status were ascertained through record linkage with the Saarland Cancer Registry and local population registries.ResultsDuring the follow up period from 1990 to 2009 we observed 638 incident diagnoses of malignant neoplasms (except non-melanoma skin cancer). The overall standardized incidence ratio (SIR) was 0.98 (95% confidence interval 0.92, 1.04). However, site-specific SIRs revealed great variation. Stomach cancer incidence was significantly higher among Aussiedler. Lung cancer was elevated for males, but lower among females. Additionally, diagnoses for colorectal cancer among males were significantly lower. Age-standardized rates (ASRs) over time show not all cancer rates of Aussiedler attenuate as expected to Saarland rates. For example, lung and prostate cancer incidence rates show increasing disparity from Saarland rates and female breast cancer incidence develops in parallel. Furthermore, ASR for overall cancer incidence of Aussiedler shows a yearly decrease (p = 0.06) whereas Saarland rates remain stable.DiscussionAussiedler incidence rates reflect incidence pattern observed in their countries of origin.     

Accuracy and completeness of the New Zealand Cancer Registry for staging of invasive breast cancer

PurposePopulation based cancer registries are an invaluable resource for monitoring incidence and mortality for many types of cancer. Research and healthcare decisions based on cancer registry data rely on the case completeness and accuracy of recorded data. This study was aimed at assessing completeness and accuracy of breast cancer staging data in the New Zealand Cancer Registry (NZCR) against a regional breast cancer register.MethodologyData from 2562 women diagnosed with invasive primary breast cancer between 1999 and 2011 included in the Waikato Breast Cancer Register (WBCR) were used to audit data held on the same individuals by the NZCR. WBCR data were treated as the benchmark.ResultsOf 2562 cancers, 315(12.3%) were unstaged in the NZCR. For cancers with a known stage in the NZCR, staging accuracy was 94.4%. Lower staging accuracies of 74% and 84% were noted for metastatic and locally invasive (involving skin or chest wall) cancers, respectively, compared with localized (97%) and lymph node positive (94%) cancers. Older age (>80 years), not undergoing therapeutic surgery and higher comorbidity score were significantly (p < 0.01) associated with unstaged cancer. The high proportion of unstaged cancer in the NZCR was noted to have led to an underestimation of the true incidence of metastatic breast cancer by 21%. Underestimation of metastatic cancer was greater for Māori (29.5%) than for NZ European (20.6%) women. Overall 5-year survival rate for unstaged cancer (NZCR) was 55.9%, which was worse than the 5-year survival rate for regional (77.3%), but better than metastatic (12.9%) disease.ConclusionsUnstaged cancer and accuracy of cancer staging in the NZCR are major sources of bias for the NZCR based research. Improving completeness and accuracy of staging data and increasing the rate of TNM cancer stage recording are identified as priorities for strengthening the usefulness of the NZCR.     

Risk of primary haematologic cancers following incident non-metastatic breast cancer: A Danish population-based cohort study

BackgroundBreast cancer survivors may have increased risk of subsequent haematologic cancer. We compared their risk of haematologic cancers with the general population during 38 years of follow-up.MethodsUsing population-based Danish medical registries, we assembled a nationwide cohort of women diagnosed with incident non-metastatic breast cancer during 1980–2017, with follow-up through 2018. We compared breast cancer survivors with the general population by computing standardised incidence ratios (SIR) and 95% confidence intervals (CI).ResultsAmong 101,117 breast cancer survivors, we observed 815 incident haematologic cancers (median follow-up: 7.9 years). We observed excess risk of acute myeloid leukaemia (AML) (SIR: 1.65, 95%CI: 1.33–2.01), particularly in women who received chemotherapy (SIR: 3.33, 95%CI: 2.24–4.75) and premenopausal women (SIR: 3.23, 95%CI: 2.41–4.25). The risk of acute lymphoid leukaemia (ALL) was increased (SIR: 2.25, 95%CI: 1.29–3.66), whereas the risk of chronic lymphoid leukaemia (CLL) was decreased (SIR: 0.66, 95%CI: 0.53–0.82). An additional analysis showed elevated risk of CLL 0–6 months after breast cancer diagnosis (SIR: 3.00 95%CI: 1.75–4.80).ConclusionCompared to the general population, breast cancer survivors had elevated risk of AML, particularly when treated with chemotherapy. The risk of ALL was elevated, whereas the risk of CLL was lower. The higher risk of CLL in the first six months after diagnosis likely reflects surveillance bias—due to intensified diagnostic efforts at breast cancer diagnosis and treatment—prompting earlier detection. This has likely reduced the long-term risk of CLL in breast cancer survivors.     

Population-based cancer survival in the Golestan province in the northeastern part of Iran 2007–2012

ObjectiveWe studied 5-year relative survival (RS) for 14 leading cancer sites in the population-based cancer registry (PBCR) of Golestan province in the northeastern part of Iran.MethodologyWe followed patients diagnosed in 2007–2012 through data linkage with different databases, including the national causes of death registry and vital statistics office. We also followed the remaining patients through active contact. We used relative survival (RS) analysis to estimate 5-year age-standardized net survival for each cancer site. Multiple Imputation (MI) method was performed to obtain vital status for loss to follow-up (LTFU) cases.ResultsWe followed 6910 cancer patients from Golestan PBCR. However, 2162 patients were loss to follow-up. We found a higher RS in women (29.5%, 95% CI, 27.5, 31.7) than men (21.0%, 95% CI, 19.5, 22.5). The highest RS was observed for breast cancer in women (RS=49.8%, 95% CI, 42.2, 56.9) and colon cancer in men (RS=37.9%, 95% CI, 31.2, 44.6). Pancreatic cancer had the lowest RS both in men (RS= 8.7%, 95% CI, 4.1, 13.5) and women (RS= 7.9%, 95% CI, 5.0, 10.8)ConclusionAlthough the 5-year cancer survival rates were relatively low in the Golestan province, there were distinct variations by cancer site. Further studies are required to evaluate the survival trends in Golestan province over time and compare them with the rates in the neighboring provinces and other countries in the region.     

Regional inequalities in cancer care persist in Italy and can influence survival

BackgroundPopulation-based cancer registry studies of care patterns can help elucidate reasons for the marked geographic variation in cancer survival across Italy. The article provides a snapshot of the care delivered to cancer patients in Italy.MethodsRandom samples of adult patients with skin melanoma, breast, colon and non-small cell lung cancers diagnosed in 2003–2005 were selected from 14 Italian cancer registries. Logistic models estimated odds of receiving standard care (conservative surgery plus radiotherapy for early breast cancer; surgery plus chemotherapy for Dukes C colon cancer; surgery for lung cancer; sentinel node biopsy for >1 mm melanoma, vs. other treatment) in each registry compared to the entire sample (reference).ResultsStage at diagnosis for breast, colon and melanoma was earlier in north/central than southern registries. Odds of receiving standard care were lower than reference in Sassari (0.68, 95%CI 0.51–0.90) and Napoli (0.48, 95%CI 0.35–0.67) for breast cancer; did not differ across registries for Dukes C colon cancer; were higher in Romagna (3.77, 95%CI 1.67–8.50) and lower in Biella (0.38, 95%CI 0.18–0.82) for lung cancer; and were higher in Reggio Emilia (2.37, 95%CI 1.12–5.02) and lower in Ragusa (0.27, 95%CI 0.14–0.54) for melanoma.ConclusionsNotwithstanding limitations due to variations in the availability of clinical information and differences in stage distribution between north/central and southern registries, our study shows that important disparities in cancer care persist across Italy. Thus the public health priority of reducing cancer survival disparities will not be achieved in the immediate future.     

Transition of cancer in populations in India

Background & objectivesAn assessment of transition of cancer in India during the past 30 years, according to changes in demographic and epidemiologic risk factors was undertaken.Materials & methodsCancer registry data (http://www.ncdirindia.org), (population coverage <10%), was compared with transition in life-expectancy and prevalence on smoking, alcohol and obesity. We fitted linear regression to the natural logarithm of the estimated incidence rates of various cancer registries in India.ResultsBurden of cancer in India increased from 0.6 million in 1991 to 1.4 million in 2015. Among males, common cancers are lung (12.0%), mouth (11.4%), prostate (7.0%), and tongue (7.0%) and among females, they are breast (21.0%), cervix-uteri (12.1%), ovary (6.9%), and lung (4.9%) in 2012. Increased life-expectancy and population growth as well as increased use of alcohol and increased prevalence of overweight/obesity reflected an increase in all cancers in both genders except a reduction in infection-related cancers such as cervix-uteri and tobacco-related cancers such as pharynx (excludes nasopharynx) and oesophagus.Interpretation & conclusionTransition in demographics and epidemiologic risk factors, reflected an increase in all cancers in both genders except a reduction in a few cancers. The increasing incidence of cancer and its associated factors demands a planned approach to reduce its burden. The burden assessment needs to be strengthened by increasing the population coverage of cancer registries. Continued effort for tobacco prevention and public health efforts for reducing obesity and alcohol consumption are needed to reduce the cancer burden.     

Prevalence and characteristics of cancer patients receiving care from single vs. multiple institutions

IntroductionPatients may receive cancer care from multiple institutions. However, at the population level, such patterns of cancer care are poorly described, complicating clinical research. To determine the population-based prevalence and characteristics of patients seen by multiple institutions, we used operations data from a state-mandated cancer registry.Methods and materials59,672 invasive cancers diagnosed in 1/1/2010-12/31/2011 in the Greater Bay Area of northern California were categorized as having been reported to the cancer registry within 365 days of diagnosis by: 1) ≥1 institution within an integrated health system (IHS); 2) IHS institution(s) and ≥1 non-IHS institution (e.g., private hospital); 3) 1 non-IHS institution; or 4) ≥2 non-IHS institutions. Multivariable logistic regression was used to characterize patients reported by multiple vs. single institutions.ResultsOverall in this region, 17% of cancers were reported by multiple institutions. Of the 33% reported by an IHS, 8% were also reported by a non-IHS. Of non-IHS patients, 21% were reported by multiple institutions, with 28% for breast and 27% for pancreatic cancer, but 19%% for lung and 18% for prostate cancer. Generally, patients more likely to be seen by multiple institutions were younger or had more severe disease at diagnosis.ConclusionsPopulation-based data show that one in six newly diagnosed cancer patients received care from multiple institutions, and differed from patients seen only at a single institution. Cancer care data from single institutions may be incomplete and possibly biased.     

Measuring the effect of including multiple cancers in survival analyses using data from the Canadian Cancer Registry

Background: In survival analyses using cancer registry data, second and subsequent primary cancers diagnosed in individuals are typically excluded. However, this approach may lead to biased comparisons of survival between cancer registries, or over time within a single registry. Purpose: To examine the impact of including multiple primary cancers in the derivation of survival estimates using data from a population-based national cancer registry. Methods: Five-year relative survival estimates for persons aged 15–99 years at diagnosis were derived using all eligible primary cases from the Canadian Cancer Registry (CCR)—a population-based registry containing information on cases diagnosed from 1992 onward—and then again using first primary cases only. Any pre-1992 cancer history of persons on the CCR was obtained by using auxiliary information. Results: The inclusion of multiple cancers resulted in lower estimates of 5-year relative survival for virtually all cancers studied. The effect was somewhat attenuated by age-standardization (e.g., from 1.3% to 1.0% for all cancers combined), and was greatest for bladder cancer (?2.4%) followed by oral cancer (?1.9%)—cancers that had the first and third lowest proportions of first cancers, respectively. For the majority of cancers the difference was less than 1.0%. Cancers for which there was virtually no difference (e.g., lung, pancreatic, ovarian and liver) tended to be those with a poor prognosis. Conclusion: Inclusion of second and subsequent primary cancers in the analysis tended to lower estimates of relative survival, the extent of which varied by cancer and age and depended in part on the proportion of first primary cancers.     

Cancer pattern and survival in a rural district in South India

Background: Cancer pattern data are rare and survival data are none from rural districts of India. Methods: The Dindigul Ambilikkai Cancer Registry (DACR) covering rural population of 2 millions in Dindigul district, Tamil Nadu state, South India, registered 4516 incident cancers during 2003–2006 by active case finding from 102 data sources for studying incidence pattern, of which, 1045 incident cancers registered in 2003 were followed up for estimating survival. House visits were undertaken annually for each registered case for data completion. Cancer pattern was described using average annual incidence rates and survival experience was expressed by computing observed survival by actuarial method and age-standardized relative survival (ASRS). Results: The average annual age-standardized rate per 100,000 of all cancers together was higher among women (62.6) than men (51.9) in DACR. The most common cancers among men were stomach (5.6), mouth (4.2) and esophagus (3.7). Cervical cancer (22.1) was ranked at the top among women followed by breast (10.9) and ovary (3.3). DACR incidence rates were lesser by at least two folds and 5-year survival were on par or lower than Chennai metropolitan registry for most cancers. Five-year age-standardized relative survival (%) in DACR was as follows: all cancers (29%), larynx (48), mouth (42), breast/tongue (38) and cervix (37). Conclusion: Cancer incidence was significantly lower, cancer patterns were markedly different and population-based cancer survival was lower in rural areas than urban areas thus providing valuable leads in estimating realistic cancer burden and instituting cancer control programs in India.