The LungPath study: variation in the diagnostic and staging pathway for patients with lung cancer in England.

The LungPath project investigated differences in lung cancer diagnostic practice by following the diagnostic pathways of 1507 patients from 19 representative English lung cancer centres. We found large variation in the proportion of patients receiving positron emission tomography-CT scan (range 13%-64%) and endobronchial ultrasound (range 2%-31%). There was also wide variation in the proportion of patients with good performance status who had their tumours histologically confirmed (range 61%-100%). The variation is discussed with reference to current national guidelines and implications for patient care.

Morphological and genetic classification of lung cancer: variation in practice and implications for tailored treatment.

AIMS: Tailored therapy of lung cancer requires high-quality pathology. Tumours must be subtyped accurately and material preserved for genetic analysis upon which treatment is increasingly based. There is a presumption that pathologists have risen to this challenge, but the nature and degree of variation in practice and quality are unknown. METHODS AND RESULTS: We collected detailed information on 1507 consecutive, newly diagnosed patients referred to 19 UK lung cancer units, ranging from district general hospitals to specialist cardiothoracic units. In only four centres were pathologists handling thoracic biopsies enrolled in the thoracic external quality assessment (EQA) scheme. Achievement of a positive diagnosis of malignancy ranged from 53 to 88%. Variation in tumour subtypes was wide, and the proportion of biopsies classified as merely 'non-small-cell lung cancer, not otherwise specified' varied from 3 to 20%, despite almost universal use of immunochemistry. The proportion of tumours tested for epidermal growth factor receptor (EGFR) gene mutation ranged from 12 to 92%. CONCLUSIONS: There is considerable variation in practice among UK pathologists and arguably in the quality of pathology, raising questions about expertise, adherence to guidelines, rigour of EQA and, ultimately, the reliability of the pathology that underpins the management of lung cancer.

Recent childbirth is an adverse prognostic factor in breast cancer and melanoma, but not in Hodgkin lymphoma.

BACKGROUND: The relationship between gestation, childbirth and cancer prognosis is unknown for most cancers (e.g. Hodgkin lymphoma), whereas a body of evidence exists for melanoma and breast cancer. METHODS: The national cancer registration and hospital discharge data for women in England (1998-2007) were linked, and the records for Hodgkin lymphoma, melanoma and breast cancer were indexed as to whether women had delivered a child in separate time periods prior to their cancer diagnosis. Survival analyses were conducted in order to characterise prognosis in relation to childbirth, with statistical adjustment for age and (where possible) stage. FINDINGS: For melanoma and breast cancer, survival was strongly reduced in women who gave birth in the year prior to cancer diagnosis. The age-adjusted hazard ratios (HR) with 95% confidence intervals (CI) were 2.06 (1.42-3.01) for melanoma and 1.84 (1.64-2.06) for breast cancer. The associations were only slightly attenuated by further adjustment for tumour stage. For breast cancer, the excess death rate in women with a recent childbirth peaked at 2 years and remained elevated for 6 to 8 years. Previous childbirth had no overall effect on the outcome of Hodgkin lymphoma. INTERPRETATION: Melanoma and breast cancer prognosis are adversely affected by recent gestation and childbirth in a way that is not due to stage of the cancer, but rather to inherent biological properties of the tumours. Possible biological mechanisms include immunosuppression (melanoma), the hormonal milieu in gestation and a tumour promoting microenvironment post-partum (breast cancer).

Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007.

BACKGROUND: The authors consider whether differences in stage at diagnosis could explain the variation in lung cancer survival between six developed countries in 2004-2007. METHODS: Routinely collected population-based data were obtained on all adults (15-99 years) diagnosed with lung cancer in 2004-2007 and registered in regional and national cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Stage data for 57 352 patients were consolidated from various classification systems. Flexible parametric hazard models on the log cumulative scale were used to estimate net survival at 1 year and the excess hazard up to 18 months after diagnosis. RESULTS: Age-standardised 1-year net survival from non-small cell lung cancer ranged from 30% (UK) to 46% (Sweden). Patients in the UK and Denmark had lower survival than elsewhere, partly because of a more adverse stage distribution. However, there were also wide international differences in stage-specific survival. Net survival from TNM stage I non-small cell lung cancer was 16% lower in the UK than in Sweden, and for TNM stage IV disease survival was 10% lower. Similar patterns were found for small cell lung cancer. CONCLUSIONS: There are comparability issues when using population-based data but, even given these constraints, this study shows that, while differences in stage at diagnosis explain some of the international variation in overall lung cancer survival, wide disparities in stage-specific survival exist, suggesting that other factors are also important such as differences in treatment. Stage should be included in international cancer survival studies and the comparability of population-based data should be improved.

Primary liver cancer incidence and survival in ethnic groups in England, 2001-2007.

BACKGROUND: The patterns of primary liver cancer incidence and survival are not known for detailed ethnic groups within the UK. METHODS: Data on patients resident in England diagnosed with primary liver cancer (ICD-10 C22) between 2001 and 2007 were extracted from the National Cancer Data Repository. Age-standardised incidence rate ratios (IRRs) were calculated for different ethnic groups separately for males and females, using the White ethnic groups as baselines. Overall survival was analysed using Cox regression, adjusting sequentially for age, socioeconomic deprivation and co-morbidity. RESULTS: Ethnicity data were available for 75% (13,139/17,458) of primary liver cancer patients. Compared with the White male baseline, Chinese males had the highest IRR. Black African, Bangladeshi, Pakistani and Indian men also had statistically significant high IRRs. Black Caribbean men had a marginally elevated incidence rate compared with White men. In comparison with White women, Pakistani women had the highest IRR. Bangladeshi, Chinese, Black African and Indian women also had high IRRs. As observed in men, Black Caribbean women had an incidence rate closer to that of White women. Pakistani men and women, Black African women and Chinese men had statistically significantly better survival compared with their White counterparts. CONCLUSION: The variation found in the incidence of primary liver cancer, could be due to established risk factors such as hepatitis B and C infection being more prevalent among certain ethnic groups. Country of birth, age at migration and length of stay in England are likely to be important factors in this disease, and future research should examine these where possible.

The effect of comorbidity on stage-specific survival in resected non-small cell lung cancer patients.

AIM: To quantify the effect of comorbidity on stage-specific survival in resected non-small cell lung cancer (NSCLC) patients. METHODS: From the Danish Lung Cancer Registry, 20,461 patients diagnosed with lung cancer between 1st January 2005 and 31st December 2010 were identified. Among 3152 NSCLC patients who underwent surgical resection, mortality hazard ratios were calculated during three consecutive time periods following surgery (0-1 month, 1 month-1 year and >1 year) according to Charlson comorbidity score (CCS 0, 1, 2, 3+), Eastern Cooperative Oncology Group (ECOG) performance status, lung function, age, sex, pathological T (pT) and N (pN) stage using Cox proportional hazard modelling. The Kaplan Meier method was used to describe stage-specific survival according to the CCS. RESULTS: Severe comorbidity (CCS 3+) was independently associated with significantly higher death rates throughout the three periods of follow-up [Hazard ratio (HR) 2.06 (1.13-3.75) for CCS 3+ in 0-1 month, 1.57 (1.17-2.12) 3+ during1 month-1 year and 1.84 (1.42-2.37) after 1 year]. Stage-specific 5-year survival in patients with severe comorbidity was significantly lower than in patients without comorbid disease [e.g. 38% (95% confidence interval (CI) 23-53%) for pT1 and CCS 3+ versus 69% (62-75%) for pT1 and CCS 0]. CONCLUSION: Severe comorbidity affects survival of NSCLC patients who undergo surgical resection by as much as a single stage increment and this effect persists throughout follow-up. Further research may be necessary to help identify which patients are most likely to benefit from surgery.

Recent trends in resection rates among non-small cell lung cancer patients in England.

BACKGROUND: Lung cancer resection rates are low in England, but reports have indicated an increase in recent years. We analysed the recent trends in surgical resection by age, sex, socioeconomic deprivation and surgical procedure in England. METHODS: Data on 286 217 patients with non-small cell lung cancer diagnosed between 1998 and 2008 were extracted from the English Cancer Repository Dataset and information on surgical resection for these patients was retrieved from linked Hospital Episode Statistics records. We calculated the OR of undergoing surgery per 1-year increment by age, sex, socioeconomic deprivation and surgical procedure. A multinomial logistic regression model was used to assess the association between age and type of surgery. RESULTS: The proportion of patients with non-small cell lung cancer undergoing surgery increased from 8.8% in 1998 to 10.6% in 2008. The increase was similar between levels of socioeconomic deprivation, slightly more pronounced among women (OR=1.023 per 1-year calendar increment, 95% CI 1.016 to 1.029) than men (OR=1.010, 95% CI 1.005 to 1.015) and most prominent with increasing age (75-79 age group: OR 1.051, 95% CI 1.041 to 1.062; 80-84 age group: OR 1.102, 95% CI 1.080 to 1.124; and 85+ age group: OR 1.130, 95% CI 1.069 to 1.193). Increasing age was associated with a decreased likelihood of undergoing pneumonectomy (OR 0.88, 95% CI 0.87 to 0.89 per 5-year age increment) or sleeve resection (OR 0.75, 95% CI 0.71 to 0.79) compared with lobectomy, and a slightly increased likelihood of undergoing a wedge resection (OR 1.08, 95% CI 1.06 to 1.10). CONCLUSION: Resection rates have increased in England in recent years and most markedly so in the older age groups.

Social differences in lung cancer management and survival in South East England: a cohort study.

OBJECTIVE: To examine possible social variations in lung cancer survival and assess if any such gradients can be attributed to social differences in comorbidity, stage at diagnosis or treatment. DESIGN: Population-based cohort identified in the Thames Cancer Registry. SETTING: South East England. PARTICIPANTS: 15 582 lung cancer patients diagnosed between 2006 and 2008. MAIN OUTCOME MEASURES: Stage at diagnosis, surgery, radiotherapy, chemotherapy and survival. RESULTS: The likelihood of being diagnosed as having early-stage disease did not vary by socioeconomic quintiles (p=0.58). In early-stage non-small-cell lung cancer, the likelihood of undergoing surgery was lowest in the most deprived group. There were no socioeconomic differences in the likelihood of receiving radiotherapy in stage III disease, while in advanced disease and in small-cell lung cancer, receipt of chemotherapy differed over socioeconomic quintiles (p<0.01). In early-stage disease and following adjustment for confounders, the HR between the most deprived and the most affluent group was 1.24 (95% CI 0.98 to 1.56). Corresponding estimates in stage III and advanced disease or small-cell lung cancer were 1.16 (95% CI 1.01 to 1.34) and 1.12 (95% CI 1.05 to 1.20), respectively. In early-stage disease, the crude HR between the most deprived and the most affluent group was approximately 1.4 and constant through follow-up, while in patients with advanced disease or small-cell lung cancer, no difference was detectable after 3 months. CONCLUSION: We observed socioeconomic variations in management and survival in patients diagnosed as having lung cancer in South East England between 2006 and 2008, differences which could not fully be explained by social differences in stage at diagnosis, co-morbidity and treatment. The survival observed in the most affluent group should set the target for what is achievable for all lung cancer patients, managed in the same healthcare system.

Incidence and survival for hepatic, pancreatic and biliary cancers in England between 1998 and 2007.

INTRODUCTION: Hepatic, pancreatic and biliary (HPB) cancers are a group of diverse malignancies managed ideally in specialist centres. This study describes recent patterns in the incidence and survival of HPB cancers in England over a ten year period (1998-2007). METHODS: Data on 99,379 English patients (50,656 males; 48,723 females) diagnosed with HPB cancers between 1998 and 2007 were extracted from the National Cancer Data Repository. Data were divided into six site-specific cancer groups; pancreas, ampulla of Vater, biliary tract, primary liver, gallbladder and duodenum. Age-standardised incidence rates (per 100,000 European standard population, (ASR(E))) were calculated for each of the six groups by year of diagnosis and by socioeconomic deprivation. Survival was estimated using the Kaplan-Meier method. RESULTS: The largest group was pancreatic cancers (63%), followed by primary liver (14%) and biliary cancers (13%). ASR(E) were highest for pancreatic and primary liver cancers whereas cancers of the gallbladder, duodenum and ampulla of Vater had a very low incidence. Over time the incidence of all six groups remained relatively stable, although primary liver cancer increased slightly in males. Incidence rates were higher in males than in females in all groups except gallbladder cancer, and all six groups had a higher incidence in the more deprived quintiles. Overall survival was poor in each of the HPB cancer groups. CONCLUSIONS: HPB tumours are uncommon and are associated with poor long term survival reflecting the late stage at presentation. Incidence patterns suggest variable rates linked to socioeconomic deprivation and highlight a male predominance in all sites except the gallbladder. Identification of high risk populations should be emphasised in initiatives to raise awareness and facilitate earlier diagnosis.

Incidence and survival of oesophageal and gastric cancer in England between 1998 and 2007, a population-based study.

BACKGROUND: Major changes in the incidence of oesophageal and gastric cancers have been reported internationally. This study describes recent trends in incidence and survival of subgroups of oesophageal and gastric cancer in England between 1998 and 2007 and considers the implications for cancer services and policy. METHODS: Data on 133,804 English patients diagnosed with oesophageal and gastric cancer between 1998 and 2007 were extracted from the National Cancer Data Repository. Using information on anatomical site and tumour morphology, data were divided into six groups; upper and middle oesophagus, lower oesophagus, oesophagus with an unspecified anatomical site, cardia, non-cardia stomach, and stomach with an unspecified anatomical site. Age-standardised incidence rates (per 100,000 European standard population) were calculated for each group by year of diagnosis and by socioeconomic deprivation. Survival was estimated using the Kaplan-Meier method. RESULTS: The majority of oesophageal cancers were in the lower third of the oesophagus (58%). Stomach with an unspecified anatomical site was the largest gastric cancer group (53%). The incidence of lower oesophageal cancer increased between 1998 and 2002 and remained stable thereafter. The incidence of cancer of the cardia, non-cardia stomach, and stomach with an unspecified anatomical site declined over the 10 year period. Both lower oesophageal and cardia cancers had a much higher incidence in males compared with females (M:F 4:1). The incidence was also higher in the most deprived quintiles for all six cancer groups. Survival was poor in all sub-groups with 1 year survival ranging from 14.8-40.8% and 5 year survival ranging from 3.7-15.6%. CONCLUSIONS: An increased focus on prevention and early diagnosis, especially in deprived areas and in males, is required to improve outcomes for these cancers. Improved recording of tumour site, stage and morphology and the evaluation of focused early diagnosis programmes are also needed. The poor long-term survival reinforces the need for early detection and multidisciplinary care.

Colorectal cancer survival in socioeconomic groups in England: variation is mainly in the short term after diagnosis.

UNLABELLED: The objective of this study was to examine differences in cancer survival between socioeconomic groups in England, with particular attention to survival in the short term of follow-up. PATIENTS AND METHODS: Individuals diagnosed with colorectal cancer between 1996 and 2004 in England were identified from cancer registry records. Five-year cumulative relative survival and excess death rates were computed. RESULTS: For colon cancer there was a very high excess death rate in the first month of follow-up, and the excess death rate was highest in the socioeconomically deprived groups. In subsequent periods, excess mortality rates were much lower and there was less socioeconomic variation. The pattern of variation in excess death rates was generally similar in rectal cancer but the socioeconomic difference in death rates persisted several years longer. If the excess death rates in the entire colorectal cancer patient population were the same as those observed in the most affluent socioeconomic quintile, the annual reduction would be 360 deaths in colon cancer and 336 deaths in rectal cancer patients. These deaths occurred almost entirely in the first month and the first year after diagnosis. CONCLUSION: Recent developments in the national cancer control agenda have included an increasing emphasis on outcome measures, with short-term cancer survival an operational measure of variation and progress in cancer control. In providing clues to the nature of the survival differences between socioeconomic groups, the results presented here give strong support for this strategy.

Variation in surgical resection for lung cancer in relation to survival: population-based study in England 2004-2006.

BACKGROUND: Compared with some European countries, England has low lung cancer survival and low use of surgical resection for lung cancer. The use of surgical resection varies within England. We assessed the relationship between surgical resection rate and the survival of lung cancer patients in England. METHODS: We extracted data on 77,349 non-small cell lung cancer (NSCLC) patients diagnosed between 2004 and 2006 from the English National Cancer Repository Dataset. We calculated the frequency of surgical resection by age, socio-economic deprivation and geographical area. We used Cox regression to compute mortality hazard ratios according to quintiles of frequency of surgical resection amongst all 77,349 lung cancer patients, and separately for the 6900 patients who underwent surgical resection. RESULTS: We found large geographical variation in the surgical resection rate for NSCLC in PCT areas (3-18%). A high frequency of resection was strongly inversely associated with overall mortality (HR 0.88, 95% CI 0.86-0.91 for the highest compared to the lowest resection quintile) and only moderately associated with mortality amongst the resected patients (HR 1.15, 95% CI 0.98-1.36). Compared to the highest resection quintile, 5420 deaths could be delayed in the overall NSCLC group, whereas about 146 more deaths could be expected amongst the resected patients. CONCLUSION: The differences in the magnitudes of both the hazard ratios and the absolute excess deaths within resected patients and all NSCLC patients suggests that lung cancer survival in England could plausibly increase if a larger proportion of patients underwent surgical resection. Carefully designed research into the possible benefit of increasing resection rates is indicated.

Quantifying differences in breast cancer survival between England and Norway.

BACKGROUND: Survival from breast cancer is lower in the UK than in some other European countries. We compared survival in England and Norway by age and time from diagnosis. METHODS: We included 303,648 English and 24,919 Norwegian cases of breast cancer diagnosed 1996-2004 using flexible parametric relative survival models, enabling improved quantification of differences in survival. Crude probabilities were estimated to partition the probability of death due to all causes into that due to cancer and other causes and to estimate the number of "avoidable" deaths. RESULTS: England had lower relative survival for all ages with the difference increasing with age. Much of the difference was due to higher excess mortality in England in the first few months after diagnosis. Older patients had a higher proportion of deaths due to other causes. At 5 years post diagnosis, a woman aged 85 in England had probabilities of 0.35 of dying of cancer and 0.32 of dying of other causes, whilst in Norway they were 0.26 and 0.35. By eight years the number of "avoidable" all-cause deaths in England was 1020 with the number of "avoidable" breast cancer related deaths 1488. CONCLUSION: Lower breast cancer survival in England is mainly due to higher mortality in the first year after diagnosis. Crude probabilities aid our understanding of the impact of disease on individual patients and help assess different treatment options.

A population-based comparison of the survival of patients with colorectal cancer in England, Norway and Sweden between 1996 and 2004.

OBJECTIVE: To examine differences in the relative survival and excess death rates of patients with colorectal cancer in Norway, Sweden and England. METHODS: All individuals diagnosed with colorectal cancer (ICD10 (International Classification of Diseases, 10th revision) C18-C20) between 1996 and 2004 in England, Norway and Sweden were included in this population-based study of patients with colorectal cancer. The main outcome measures were 5-year cumulative relative period of survival and excess death rates stratified by age and period of follow-up. RESULTS: The survival of English patients with colorectal cancer was significantly lower than was observed in both Norway and Sweden. Five-year age-standardised colon cancer relative survival was 51.1% (95% CI 50.1% to 52.0%) in England compared with 57.9% (95% CI 55.2% to 60.5%) in Norway and 59.9% (95% CI 57.7% to 62.0%) in Sweden. Five-year rectal cancer survival was 52.3% (95% CI 51.1% to 53.5%) in England compared with 60.7% (95% CI 57.0% to 64.2%) and 59.8% (95% CI 56.9% to 62.6%) in Norway and Sweden, respectively. The lower survival for colon cancer in England was primarily due to a high number of excess deaths among older patients in the first 3 months after diagnosis. In patients with rectal cancer, excess deaths remained elevated until 2 years of follow-up. If the lower excess death rate in Norway applied in the English population, then 890 (13.6%) and 654 (16.8%) of the excess deaths in the colon and rectal cancer populations, respectively, could have been prevented at 5 years follow-up. Most of these avoidable deaths occurred shortly after diagnosis. CONCLUSIONS: There was significant variation in survival between the countries, with the English population experiencing a poorer outcome, primarily due to a relatively higher number of excess deaths in older patients in the short term after diagnosis. It seems likely, therefore, that in England a greater proportion of the population present with more rapidly fatal disease (especially in the older age groups) than in Norway or Sweden.

National comparisons of lung cancer survival in England, Norway and Sweden 2001-2004: differences occur early in follow-up.

BACKGROUND Countries with a similar expenditure on healthcare within Europe exhibit differences in lung cancer survival. Survival in lung cancer was studied in 2001-2004 in England, Norway and Sweden. METHODS Nationwide cancer registries in England, Norway and Sweden were used to identify 250 828 patients with lung cancer from England, 18 386 from Norway and 24 886 from Sweden diagnosed between 1996 and 2004, after exclusion of patients registered through death certificate only or with missing, zero or negative survival times. 5-Year relative survival was calculated by application of the period approach. The excess mortality between the countries was compared using a Poisson regression model. RESULTS In all subcategories of age, sex and follow-up period, the 5-year survival was lower in England than in Norway and Sweden. The age-standardised survival estimates were 6.5%, 9.3% and 11.3% for men and 8.4%, 13.5% and 15.9% for women in the respective countries in 2001-2004. The difference in excess risk of dying between the countries was predominantly confined to the first year of follow-up. The relative excess risk ratio during the first 3 months of follow-up comparing England with Norway 2001-2004 varied between 1.23 and 1.46, depending on sex and age, and between 1.56 and 1.91 comparing England with Sweden. CONCLUSION Access to healthcare and population awareness are likely to be major reasons for the differences, but it cannot be excluded that diagnostic and therapeutic activity play a role. Future improvements in lung cancer management may be seen early in follow-up.

Cancer in the London prison population, 1986-2005.

BACKGROUND: Little research has investigated cancer care in UK prisons. We wished to identify the number of new cases and the most common cancer diagnoses occurring each year in London prisoners, and the place of death for those who died from their disease. METHODS: Using the database of the Thames Cancer Registry, we identified cancer diagnoses in residents of seven London prisons from 1986 to 2005 and the place of death of patients dying from their disease between 1996 and 2005. RESULTS: On average, 31 patients were recorded as diagnosed with cancer while in prison within each 5-year period. In women, 83% (85/102) of diagnoses were in situ carcinoma of the cervix, and in men, 19% (11/57) were of lung cancer. None of the 25 patients recorded as dying from their disease died in prison. Most died in hospitals (48%, 12/25) or in hospices (28%, 7/25). CONCLUSIONS: London prisons contribute a small number of patients each year who require NHS cancer care, including those with advanced cancer who are released before death. Future studies should investigate cancer incidence for the national prison population, methods for improving screening coverage and follow-up, the timeliness of access to cancer treatments and end-of-life care, and prisoners' and health professionals' experiences of care.

Breast cancer survival in England, Norway and Sweden: a population-based comparison.

Several international studies have found that survival from breast cancer is lower in the United Kingdom than in some other European countries. We have compared breast cancer survival between the national populations of England, Norway and Sweden, with a view to identifying subsets of patients with particularly good or adverse survival outcomes. We extracted cases of breast cancer in women diagnosed 1996-2004 from the national cancer registries of the 3 countries. The study comprised 303,657 English cases, 24,919 Norwegian cases and 57,512 cases from Sweden. Follow-up was in 2001-2004. The main outcome measures were 5-year cumulative relative survival and excess death rates, stratified by age and period of follow-up. In comparison with Norway and Sweden, the excess mortality in England was particularly pronounced in the first month and in the first year after diagnosis, and generally more marked in the oldest age groups. Compared with Norwegian patients, 81% of the excess deaths in the English patients occurred in the first 2 years after diagnosis. Our findings emphasise the importance of awareness of symptoms and early detection as the main strategy to improve breast cancer survival in the United Kingdom.

Head and neck cancer in South East England between 1995-1999 and 2000-2004: An estimation of incidence and distribution by site, stage and histological type.

Population-based data on head and neck cancer (HNC) stage and histological type are poorly described for England; these data are essential for clinical management and research. The aim of this study was to describe the distribution and incidence of all HNC and selected anatomical sites by sex, age, stage and histological type using a population-based cancer registry in South East England, and determine if the incidence changed between 1995-1999 and 2000-2004. We identified all HNC cancer cases registered by the Thames Cancer Registry for 1995-1999 and 2000-2004. Frequency distributions and age-standardised incidence rates were calculated by sex, age, stage and histological type and trends in incidence between the two time periods were described using incidence rate ratios and 95% confidence intervals. A total of 8700 HNC cases were reported in 2000-2004, representing an age-standardised incidence rate of 8.59 per 100000, which did not change significantly from 1995-1999. The three commonest HNC sites were intra-oral cavity, larynx and tonsil. Males were two to six times as likely as females to be diagnosed with HNC and there was a trend toward younger age at diagnosis over time. Significant increases in the incidence rate of intra-oral cavity cancer for both sexes and tonsillar cancer among males were observed. Conversely, laryngeal cancer incidence decreased over time. Staging data was only available for about 40% of HNC cases. Seventy six percent of HNC cases were squamous cell carcinomas. Trends in incidence varied between HNC sites, highlighting the importance of presenting data for individual HNC sites. The high proportion of unstaged cancers may result from incomplete recording in medical records; thus, the reporting of staging data should be made a priority.

Inequalities in the incidence of cervical cancer in South East England 2001-2005: an investigation of population risk factors.

BACKGROUND: The incidence of cervical cancer varies dramatically, both globally and within individual countries. The age-standardised incidence of cervical cancer was compared across primary care trusts (PCTs) in South East England, taking into account the prevalence of known behavioural risk factors, screening coverage and the deprivation of the area. METHODS: Data on 2,231 cases diagnosed between 2001 and 2005 were extracted from the Thames Cancer Registry, and data on risk factors and screening coverage were collated from publicly available sources. Age-standardised incidence rates were calculated for each PCT using cases of squamous cell carcinoma in the screening age group (25-64 years). RESULTS: The age-standardised incidence rate for cervical cancer in South East England was 6.7 per 100,000 population (European standard) but varied 3.1 fold between individual PCTs. Correlations between the age-standardised incidence rate and smoking prevalence, teenage conception rates, and deprivation were highly significant at the PCT level (p < 0.001). However, screening coverage was not associated with the incidence of cervical cancer at the PCT level. Poisson regression indicated that these variables were all highly correlated and could not determine the level of independent contribution at a population level. CONCLUSION: There is excess disease burden within South East England. Significant public health gains can be made by reducing exposure to known risk factors at a population level.

Ethnicity coding in a regional cancer registry and in Hospital Episode Statistics.

BACKGROUND: The collection of ethnicity information as part of cancer datasets is important for planning services and ensuring equal access, and for epidemiological studies. However, ethnicity has generally not been well recorded in cancer registries in the UK. The aim of this study was to determine the completeness of ethnicity coding in the Thames Cancer Registry (TCR) database and within the Hospital Episode Statistics (HES) data as held by the London Health Observatory, and to investigate factors associated with ethnicity being recorded. METHODS: Records for 111821 hospital admissions of London residents with a malignant cancer as a primary diagnosis between April 2002 and March 2003 and records for 25581 London residents diagnosed with cancer in 2002 were examined. Data on sex, age, cancer network of residence, deprivation, proportion of non-whites in the local authority population, and site of cancer were available. The proportion of patients in each group with a valid ethnicity code was calculated. In the TCR data proportions were also calculated adjusted for all other variables. RESULTS: Ethnicity was recorded for 90661 (81.1%) of the hospital admissions in the HES data and 5796 (22.7%) patients on the TCR database. Patients resident in areas with a higher proportion of non-white residents and the most deprived populations were more likely to have an ethnic code on the TCR database, though this pattern was not seen in the HES data. Adjustment did not materially affect the association between deprivation and ethnicity being recorded in the TCR data. CONCLUSION: There was a large difference in completeness of ethnicity between the data sources. In order to improve the level of recording in TCR data there needs to be better recording of ethnicity in sources TCR data collection staff have access to, or use of information from other sources e.g. electronic data feeds from hospitals or pathology laboratories, or HES data itself supplied directly to TCR. Efforts to collect ethnicity data should be encouraged in all healthcare settings. Future research should explore where the difficulties collecting ethnicity information lie, whether with patients, healthcare professionals or the recording procedure, and how such problems can be overcome.