Implementing and monitoring the right to health in breast cancer: selection of indicators using a Delphi process.

BACKGROUND: Women with breast cancer have different chances of surviving their disease, depending on where they live. Variations in survival may stem from unequal access to prompt diagnosis, treatment and care. Implementation of the right to health may help remedy such inequalities. The right to health is enshrined in international human rights law, notably Article 12 of the International Covenant on Economic, Social and Cultural Rights. A human rights-based approach to health requires a robust, just and efficient health system, with access to adequate health services and medicines on a non-discriminatory basis. However, it may prove challenging for health policymakers and cancer management specialists to implement and monitor this right in national health systems. METHOD: This article presents the results of a Delphi study designed to select indicators of implementation of the right to health to inform breast cancer care and management. In a systematic process, 13 experts examined an initial list of 151 indicators. RESULTS: After two rounds, 54 indicators were selected by consensus, three were rejected, three were added, and 97 remained open for debate. For breast cancer, right-to-health features selected as worth implementing and monitoring included the formal recognition of the right to health in breast cancer strategies; a population-based screening programme, prompt diagnosis, strong referral systems and limited waiting times; the provision of palliative, survivorship and end-of-life care; the availability, accessibility, acceptability and quality (AAAQ) of breast cancer services and medicines; the provision of a system of accountability; and the collection of anonymised individual data to target patterns of discrimination. CONCLUSION: We propose a set of indicators as a guide for health policy experts seeking to design national cancer plans that are based on a human rights-based approach to health, and for cancer specialists aiming to implement principles of the right to health in their practice. The 54 indicators selected may be used in High-Income Countries, or member states of the OECD who also have signed the International Covenant on Economic, Social and Cultural Rights to monitor progress towards implementation of the right to health for women with breast cancer.

How should implementation of the human right to health be assessed? A scoping review of the public health literature from 2000 to 2021.

The human right to health is a critical legal tool to achieve health justice, and universal health coverage is included among the Sustainable Development Goals. However, the content and meaning of the right to health may not be used adequately in public health research. We conducted a scoping review of the literature to discover the extent to which the legal principles underlying the right to health are used in public health. We mapped the various attempts to assess implementation of this right since its legal content was clarified in 2000.The first studies emerged in 2006, with an increase and a wider variety of investigations since 2015. We observe that some key principles do form the basis of right-to-health assessments, but some concepts remain unfamiliar. Critically, public health academics may have limited access to human rights research on health, which creates a gap in knowledge between the two disciplines.

Population-Based Cancer Survival in Canada and the United States by Socioeconomic Status: Findings from the CONCORD-2 Study.

Background: Population-based cancer survival provides insight into the effectiveness of health systems to care for all residents with cancer, including those in marginalized groups. Methods: Using CONCORD-2 data, we estimated 5-year net survival among patients diagnosed 2004-2009 with one of 10 common cancers, and children diagnosed with acute lymphoblastic leukemia (ALL), by socioeconomic status (SES) quintile, age (0-14, 15-64, ≥65 years), and country (Canada or United States). Results: In the lowest SES quintile, survival was higher among younger Canadian adults diagnosed with liver (23% vs 15%) and cervical (78% vs 68%) cancers and with leukemia (62% vs 56%), including children diagnosed with ALL (92% vs 86%); and higher among older Americans diagnosed with colon (62% vs 56%), female breast (87% vs 80%), and prostate (97% vs 85%) cancers. In the highest SES quintile, survival was higher among younger Americans diagnosed with stomach cancer (33% vs 27%) and younger Canadians diagnosed with liver cancer (31% vs 23%); and higher among older Americans diagnosed with stomach (27% vs 22%) and prostate (99% vs 92%) cancers. Conclusions: Among younger Canadian cancer patients in the lowest SES group, greater access to health care may have resulted in higher cancer survival, while higher screening prevalence and access to health insurance (Medicare) among older Americans during the period of this study may have resulted in higher survival for some screen-detected cancers. Higher survival in the highest SES group for stomach and liver may relate to treatment differences. Survival differences by age and SES between Canada and the United States may help inform cancer control strategies.

Ethnic, racial and socioeconomic disparities in breast cancer survival in two Brazilian capitals between 1996 and 2012.

OBJECTIVE: To study the impact of socio-economic status and ethno-racial strata on excess mortality hazard and net survival of women with breast cancer in two Brazilian state capitals. METHOD: We conducted a survival analysis with individual data from population-based cancer registries including women with breast cancer diagnosed between 1996 and 2012 in Aracaju and Curitiba. The main outcomes were the excess mortality hazard (EMH) and net survival. The associations of age, year of diagnosis, disease stage, race/skin colour and socioeconomic status (SES) with the excess mortality hazard and net survival were analysed using multi-level spline regression models, modelled as cubic splines with knots at 1 and 5 years of follow-up. RESULTS: A total of 2045 women in Aracaju and 7872 in Curitiba were included in the analyses. The EMH was higher for women with lower SES and for black and brown women in both municipalities. The greatest difference in excess mortality was seen between the most deprived women and the most affluent women in Curitiba, hazard ratio (HR) 1.93 (95%CI 1.63-2.28). For race/skin colour, the greatest ratio was found in Curitiba (HR 1.35, 95%CI 1.09-1.66) for black women compared with white women. The most important socio-economic difference in net survival was seen in Aracaju. Age-standardised net survival at five years was 55.7% for the most deprived women and 67.2% for the most affluent. Net survival at eight years was 48.3% and 61.0%, respectively. Net survival in Curitiba was higher than in Aracaju in all SES groups." CONCLUSION: Our findings suggest the presence of contrasting breast cancer survival expectancy in Aracaju and Curitiba, highlighting regional inequalities in access to health care. Lower survival among brown and black women, and those in lower SES groups indicates that early detection, early diagnosis and timely access to treatment must be prioritized to reduce inequalities in outcome among Brazilian women.

Disparities in cervical cancer survival in the United States by race and stage at diagnosis: An analysis of 138,883 women diagnosed between 2001 and 2014 (CONCORD-3).

OBJECTIVE: During 2000-2014, age-standardized five-year net survival for cervical cancer was 63-64% in the United States. Using data from CONCORD-3, we analyzed cervical cancer survival trends by race, stage and period of diagnosis. METHODS: Data from 41 state-wide population-based cancer registries on 138,883 women diagnosed with cervical cancer during 2001-2014 were available. Vital status was followed up until December 31, 2014. We estimated age-standardized five-year net survival, by race (Black or White), stage and calendar period of diagnosis (2001-2003, 2004-2008, 2009-2014) in each state, and for all participating states combined. RESULTS: White women were most commonly diagnosed with localized tumors (45-50%). However, for Black women, localized tumors were the most common stage (43.0%) only during 2001-2003. A smaller proportion of Black women received cancer-directed surgery than White women. For all stages combined, five-year survival decreased between 2001-2003 and 2009-2014 for both White (64.7% to 63.0%) and Black (56.7% to 55.8%) women. For localized and regional tumors, survival increased over the same period for both White (by 2-3%) and Black women (by 5%). Survival did not change for Black women diagnosed with distant tumors but increased by around 2% for White women. CONCLUSIONS: Despite similar screening coverage for both Black and White women and improvements in stage-specific survival, Black women still have poorer survival than White women. This may be partially explained by inequities in access to optimal treatment. The results from this study highlight the continuing need to address the disparity in cervical cancer survival between White and Black women in the United States.

The economic burden of colorectal cancer across Europe: a population-based cost-of-illness study.

BACKGROUND: Colorectal cancer is one of the leading causes of cancer morbidity and mortality in Europe. We aimed to ascertain the economic burden of colorectal cancer across Europe using a population-based cost-of-illness approach. METHODS: In this population-based cost-of-illness study, we obtained 2015 activity and costing data for colorectal cancer in 33 European countries (EUR-33) from global and national sources. Country-specific aggregate data were acquired for health-care, mortality, morbidity, and informal care costs. We calculated primary, outpatient, emergency, and hospital care, and systemic anti-cancer therapy (SACT) costs, as well as the costs of premature death, temporary and permanent absence from work, and unpaid informal care due to colorectal cancer. Colorectal cancer health-care costs per case were compared with colorectal cancer survival and colorectal cancer personnel, equipment, and resources across EUR-33 using univariable and multivariable regression. We also compared hospital care and SACT costs against 2009 data for the 27 EU countries. FINDINGS: The economic burden of colorectal cancer across Europe in 2015 was €19·1 billion. The total non-health-care cost of €11·6 billion (60·6% of total economic burden) consisted of loss of productivity due to disability (€6·3 billion [33·0%]), premature death (€3·0 billion [15·9%]), and opportunity costs for informal carers (€2·2 billion [11·6%]). The €7·5 billion (39·4% of total economic burden) of direct health-care costs consisted of hospital care (€3·3 billion [43·4%] of health-care costs), SACT (€1·9 billion [25·6%]), and outpatient care (€1·3 billion [17·7%]), primary care (€0·7 billion [9·3%]), and emergency care (€0·3 billion [3·9%]). The mean cost for managing a patient with colorectal cancer varied widely between countries (€259-36 295). Hospital-care costs as a proportion of health-care costs varied considerably (24·1-84·8%), with a decrease of 21·2% from 2009 to 2015 in the EU. Overall, hospital care was the largest proportion (43·4%) of health-care expenditure, but pharmaceutical expenditure was far higher than hospital-care expenditure in some countries. Countries with similar gross domestic product per capita had widely varying health-care costs. In the EU, overall expenditure on pharmaceuticals increased by 213·7% from 2009 to 2015. INTERPRETATION: Although the data analysed include non-homogenous sources from some countries and should be interpreted with caution, this study is the most comprehensive analysis to date of the economic burden of colorectal cancer in Europe. Overall spend on health care in some countries did not seem to correspond with patient outcomes. Spending on improving outcomes must be appropriately matched to the challenges in each country, to ensure tangible benefits. Our results have major implications for guiding policy and improving outcomes for this common malignancy. FUNDING: Department for Employment and Learning of Northern Ireland, Medical Research Council, Cancer Research UK, Health Data Research UK, and DATA-CAN.

Are socio-economic inequalities in breast cancer survival explained by peri-diagnostic factors?

BACKGROUND: Patients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered. We set out to evaluate whether pre-existing individual health status at diagnosis and primary care consultation history (peri-diagnostic factors) could explain socio-economic differentials in survival amongst women diagnosed with breast cancer. METHODS: We conducted a retrospective cohort study of women aged 15-99 years diagnosed in England using linked routine data. Ecologically-derived measures of income deprivation were combined with individually-linked data from the English National Cancer Registry, Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. Smoking status, alcohol consumption, BMI, comorbidity, and consultation histories were derived for all patients. Time to breast surgery was derived for women diagnosed after 2005. We estimated net survival and modelled the excess hazard ratio of breast cancer death using flexible parametric models. We accounted for missing data using multiple imputation. RESULTS: Net survival was lower amongst more deprived women, with a single unit increase in deprivation quintile inferring a 4.4% (95% CI 1.4-8.8) increase in excess mortality. Peri-diagnostic co-variables varied by deprivation but did not explain the differentials in multivariable analyses. CONCLUSIONS: These data show that socio-economic inequalities in survival cannot be explained by consultation history or by pre-existing individual health status, as measured in primary care. Differentials in the effectiveness of treatment, beyond those measuring the inclusion of breast surgery and the timing of surgery, should be considered as part of the wider effort to reduce inequalities in premature mortality.

Global Trends in Survival From Astrocytic Tumors in Adolescents and Young Adults: A Systematic Review.

BACKGROUND: Brain tumors represent an important cause of cancer-related death in adolescents and young adults. Most are diagnosed in low-income and middle-income countries. We aimed to conduct the first, to our knowledge, systematic review of time trends and geographical variation in survival in this age group. METHODS: We included observational studies describing population-based survival from astrocytic tumors in patients aged 15-39 years. We queried 6 electronic databases from database inception to December 31, 2019. This review is registered with PROSPERO, number CRD42018111981. RESULTS: Among 5640 retrieved records, 20 studies fulfilled the inclusion criteria. All but 1 study focused on high-income countries. Five-year survival from astrocytoma (broad morphology group) mostly varied between 48.0% and 71.0% (1973-2004) without clear trends or geographic differences. Adolescents with astrocytoma had better outcomes than young adults, but survival values were similar when nonmalignant tumors were excluded. During 2002-2007, 5-year survival for World Health Organization grade I-II tumors was in the range of 72.6%-89.1% in England, Germany, and the United States but lower in Southeastern Europe (59.0%). Five-year survival for anaplastic astrocytoma varied between 39.6% and 55.4% (2002-2007). Five-year survival from glioblastoma was in the range of 14.2%-23.1% (1991-2009). CONCLUSIONS: Survival from astrocytic tumors remained somewhat steady over time, with little change between 1973 and 2009. Survival disparities were difficult to examine, because nearly all the studies were conducted in affluent countries. Studies often adopted the International Classification of Childhood Cancer, which, however, did not allow to accurately describe variation in survival. Larger studies are warranted, including underrepresented populations and providing more recent survival estimates.

Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

The Right to Health in Times of Pandemic: What Can We Learn from the UK's Response to the COVID-19 Outbreak?

The UK's response to COVID-19 has been widely criticized by scientists and the public. According to EuroMOMO, a European mortality monitoring initiative, the excess mortality that may be attributable to COVID-19 in England is one of the highest in Europe, second only to Spain. While critiqued from a public health perspective, much less attention is given to the implications of the pandemic outbreak for the right to health as defined under international human rights law and ratified by member states. Using the UK as a case study, we examine critically the extent to which the government's response to COVID-19 complied with the legal framework of the right to health. We review further key states' obligations on the right to health and assess its suitability in times of pandemic. Finally, we offer some recommendations for an update of the right to health. This paper adds to the body of literature on the right to health and human rights based-approaches to health.

Worldwide Trends in Survival From Common Childhood Brain Tumors: A Systematic Review.

PURPOSE: The histology of brain tumors determines treatment and predicts outcome. Population-based survival reflects the effectiveness of a health care system in managing cancer. No systematic review of worldwide variation and time trends in survival from brain tumors in children is currently available. PATIENTS AND METHODS: We considered longitudinal, observational studies comprising children diagnosed with intracranial astrocytic or embryonal tumors. We searched six electronic databases from database inception to September 30, 2018, using complex search strategies. The outcome measure was 5-year survival, estimated through a time-to-event analysis. This study is registered with PROSPERO, number CRD42018111981. RESULTS: Among 5,244 studies, we identified 47 eligible articles that provided 228 survival estimates. Only five studies were entirely or partially conducted in low-income or middle-income countries. Five-year survival from embryonal tumors increased from 37% in 1980 to approximately 60% in 2009. Although survival for medulloblastoma improved substantially (from 29% to 73% during 1959-2009), survival for primitive neuroectodermal tumors wavered over time (1973-2009) and between countries. Five-year survival from astrocytoma changed very little over the 27 years between 1982 and 2009 (from 78% to 89%). Interpretation of the literature was made difficult by the heterogeneity of study designs. CONCLUSION: Survival has improved for embryonal tumors, but little change has been observed for astrocytic tumors. We found a striking gap in knowledge about survival from childhood brain tumor subtypes in middle-income and low-income countries, where half of these tumors are diagnosed. Larger studies are needed, including in under-represented countries and based on standardized data collection, to provide up-to-date survival estimates.

Childhood cancer burden: a review of global estimates.

5-year net survival of children and adolescents diagnosed with cancer is approximately 80% in many high-income countries. This estimate is encouraging as it shows the substantial progress that has been made in the diagnosis and treatment of childhood cancer. Unfortunately, scarce data are available for low-income and middle-income countries (LMICs), where nearly 90% of children with cancer reside, suggesting that global survival estimates are substantially worse in these regions. As LMICs are undergoing a rapid epidemiological transition, with a shifting burden from infectious diseases to non-communicable diseases, cancer care for all ages has become a global focus. To improve outcomes for children and adolescents diagnosed with cancer worldwide, an accurate appraisal of the global burden of childhood cancer is a necessary first step. In this Review, we analyse four studies of the global cancer burden that included data for children and adolescents. Each study used various overlapping and non-overlapping statistical approaches and outcome metrics. Moreover, to provide guidance on improving future estimates of the childhood global cancer burden, we propose several recommendations to strengthen data collection and standardise analyses. Ultimately, these data could help stakeholders to develop plans for national and institutional cancer programmes, with the overall aim of helping to reduce the global burden of cancer in children and adolescents.

Impact of national cancer policies on cancer survival trends and socioeconomic inequalities in England, 1996-2013: population based study.

OBJECTIVE: To assess the effectiveness of the NHS Cancer Plan (2000) and subsequent national cancer policy initiatives in improving cancer survival and reducing socioeconomic inequalities in survival in England. DESIGN: Population based cohort study. SETTING: England. POPULATION: More than 3.5 million registered patients aged 15-99 with a diagnosis of one of the 24 most common primary, malignant, invasive neoplasms between 1996 and 2013. MAIN OUTCOME MEASURES: Age standardised net survival estimates by cancer, sex, year, and deprivation group. These estimates were modelled using regression model with splines to explore changes in the cancer survival trends and in the socioeconomic inequalities in survival. RESULTS: One year net survival improved steadily from 1996 for 26 of 41 sex-cancer combinations studied, and only from 2001 or 2006 for four cancers. Trends in survival accelerated after 2006 for five cancers. The deprivation gap observed for all 41 sex-cancer combinations among patients with a diagnosis in 1996 persisted until 2013. However, the gap slightly decreased for six cancers among men for which one year survival was more than 65% in 1996, and for cervical and uterine cancers, for which survival was more than 75% in 1996. The deprivation gap widened notably for brain tumours in men and for lung cancer in women. CONCLUSIONS: Little evidence was found of a direct impact of national cancer strategies on one year survival, and no evidence for a reduction in socioeconomic inequalities in cancer survival. These findings emphasise that socioeconomic inequalities in survival remain a major public health problem for a healthcare system founded on equity.

Public health surveillance of cancer survival in the United States and worldwide: The contribution of the CONCORD programme.

CONCORD is a programme for the global surveillance of cancer survival. In 2015, the second cycle of the program (CONCORD-2) established long-term surveillance of cancer survival worldwide, for the first time, in the largest cancer survival study published to date. CONCORD-2 provided cancer survival trends for 25,676,887 patients diagnosed during the 15-year period between 1995 and 2009 with 1 of 10 common cancers that collectively represented 63% of the global cancer burden in 2009. Herein, the authors summarize the past, describe the present, and outline the future of the CONCORD programme. They discuss the difference between population-based studies and clinical trials, and review the importance of international comparisons of population-based cancer survival. This study will focus on the United States. The authors explain why population-based survival estimates are crucial for driving effective cancer control strategies to reduce the wide and persistent disparities in cancer survival between white and black patients, which are likely to be attributable to differences in access to early diagnosis and optimal treatment. Cancer 2017;123:4977-81. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

The global burden of women's cancers: a grand challenge in global health.

Every year, more than 2 million women worldwide are diagnosed with breast or cervical cancer, yet where a woman lives, her socioeconomic status, and agency largely determines whether she will develop one of these cancers and will ultimately survive. In regions with scarce resources, fragile or fragmented health systems, cancer contributes to the cycle of poverty. Proven and cost-effective interventions are available for both these common cancers, yet for so many women access to these is beyond reach. These inequities highlight the urgent need in low-income and middle-income countries for sustainable investments in the entire continuum of cancer control, from prevention to palliative care, and in the development of high-quality population-based cancer registries. In this first paper of the Series on health, equity, and women's cancers, we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality, and survival, and the consequences, especially in socioeconomically disadvantaged women in different settings.

The impact of age at diagnosis on socioeconomic inequalities in adult cancer survival in England.

BACKGROUND: Understanding the age at which persistent socioeconomic inequalities in cancer survival become apparent may help motivate and support targeting of cancer site-specific interventions, and tailoring guidelines to patients at higher risk. PATIENTS AND METHODS: We analysed data on more than 40,000 patients diagnosed in England with one of three common cancers in men and women, breast, colon and lung, 2001-2005 with follow-up to the end of 2011. We estimated net survival for each of the five deprivation categories (affluent, 2, 3, 4, deprived), cancer site, sex and age group (15-44, 45-54, 55-64, and 65-74 and 75-99 years). RESULTS: The magnitude and pattern of the age specific socioeconomic inequalities in survival was different for breast, colon and lung. For breast cancer the deprivation gap in 1-year survival widened with increasing age at diagnosis, whereas the opposite was true for lung cancer, with colon cancer having an intermediate pattern. The 'deprivation gap' in 1-year breast cancer survival widened steadily from -0.8% for women diagnosed at 15-44 years to -4.8% for women diagnosed at 75-99 years, and was the widest for women diagnosed at 65-74 years for 5- and 10-year survival. For colon cancer in men, the gap was widest in patients diagnosed aged 55-64 for 1-, 5- and 10-year survival. For lung cancer, the 'deprivation gap' in survival in patients diagnoses aged 15-44 years was more than 10% for 1-year survival in men and for 1- and 5-year survival in women. CONCLUSION: Our findings suggest that reduction of socioeconomic inequalities in survival will require updating of current guidelines to ensure the availability of optimal treatment and appropriate management of lung cancer patients in all age groups and older patients in deprived groups with breast or colon cancer.

Cancer survival: global surveillance will stimulate health policy and improve equity.

Millions of people will continue to be diagnosed with cancer every year for the foreseeable future. These patients all need access to optimum health care. Population-based cancer survival is a key measure of the overall effectiveness of health systems in management of cancer. Survival varies very widely around the world. Global surveillance of cancer survival is needed, because unless these avoidable inequalities are measured, and reported on regularly, nothing will be done explicitly to reduce them.

Health systems performance and cancer outcomes.

Do the characteristics of health systems influence cancer outcomes? Although caveats are required when undertaking international comparisons of both health systems and cancer outcomes, observed differences cannot solely be explained by data problems or economic development. Health systems can influence cancer outcomes through three mechanisms: coverage, innovation, and quality of care. First, in countries where population coverage is incomplete, patients may find certain services excluded or face substantial copayments or deductibles. Second, there are variations in the rate at which innovative treatments are introduced, reflecting in particular the need for publicly funded health systems to compare costs and benefits of increasingly expensive treatments given demands for other treatments. Third, systematic differences in quality of care (early diagnosis, timely and equitable access to specialist care, and existence of systematic coordination between these activities) may lead to variations in cancer outcomes.

Stage at diagnosis and colorectal cancer survival in six high-income countries: a population-based study of patients diagnosed during 2000-2007.

BACKGROUND: Large international differences in colorectal cancer survival exist, even between countries with similar healthcare. We investigate the extent to which stage at diagnosis explains these differences. METHODS: Data from population-based cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK were analysed for 313 852 patients diagnosed with colon or rectal cancer during 2000-2007. We compared the distributions of stage at diagnosis. We estimated both stage-specific net survival and the excess hazard of death up to three years after diagnosis, using flexible parametric models on the log-cumulative excess hazard scale. RESULTS: International differences in colon and rectal cancer stage distributions were wide: Denmark showed a distribution skewed towards later-stage disease, while Australia, Norway and the UK showed high proportions of 'regional' disease. One-year colon cancer survival was 67% in the UK and ranged between 71% (Denmark) and 80% (Australia and Sweden) elsewhere. For rectal cancer, one-year survival was also low in the UK (75%), compared to 79% in Denmark and 82-84% elsewhere. International survival differences were also evident for each stage of disease, with the UK showing consistently lowest survival at one and three years. CONCLUSION: Differences in stage at diagnosis partly explain international differences in colorectal cancer survival, with a more adverse stage distribution contributing to comparatively low survival in Denmark. Differences in stage distribution could arise because of differences in diagnostic delay and awareness of symptoms, or in the thoroughness of staging procedures. Nevertheless, survival differences also exist for each stage of disease, suggesting unequal access to optimal treatment, particularly in the UK.

Cancer incidence in South Asian migrants to England, 1986-2004: unraveling ethnic from socioeconomic differentials.

Studies on cancer in migrants are informative about the relative influence of environmental and genetic factors on cancer risk. This study investigates trends in incidence from colorectal, lung, breast and prostate cancer in England among South Asians and examines the influence of deprivation, a key environmental exposure. South Asian ethnicity was assigned to patients recorded in the population-based National Cancer Registry of England during 1986-2004, using the computerized algorithm SANGRA: South Asian Names and Groups Recognition Algorithm. Population denominators were derived from population censuses. Multivariable flexible (splines) Poisson models were used to estimate trends and socioeconomic differentials in incidence in South Asians compared to non-South Asians. Overall, age-adjusted cancer incidence in South Asians was half that in non-South Asians but rose over time. Cancer-specific incidence trends and patterns by age and deprivation differed widely between the two ethnic groups. In contrast to non-South Asians, lung cancer incidence in South Asians did not fall. Colorectal and breast cancer incidence rose in both groups, more steeply in South Asians though remaining less common than in non-South Asians. The deprivation gaps in cancer-specific incidence were much less marked among South Asians, explaining some of the ethnic differences in overall incidence. Although still lower than in non-South Asians, cancer incidence is rising in South Asians, supporting the concept of transition in cancer incidence among South Asians living in England. Although these trends vary by cancer, they have important implications for both prevention and anticipating health-care demand.