Resection rate, hospital procedure volume and survival in pancreatic cancer patients in England: Population-based study, 2005-2009.

OBJECTIVE: We assessed the association between population resection rates, hospital procedure volume and death rates in pancreatic cancer patients in England. DESIGN: Patients diagnosed with pancreatic cancer were identified from a linked cancer registration and Hospital Episode Statistics dataset. Cox regression analyses were used to assess all-cause mortality according to resection quintile and hospital volume, adjusting for sex, age, deprivation and comorbidity. RESULTS: There were 31,973 pancreatic cancer patients studied, 2580 had surgery. Increasing resection rates were associated with lower mortality among all patients (χ(2)(1df) = 176.18, ptrend < 0.001), with an unadjusted hazard ratio (HR) of 0.78 95%CI [0.75 to 0.81] in the highest versus the lowest resection quintile. Adjustment changed the estimate slightly (HR 0.82, 95%CI [0.79 to 0.85], (χ(2)(1df) = 99.44, ptrend < 0.001)). Among patients that underwent surgery, higher procedure volume was associated with lower mortality (HR = 0.88 95%CI [0.75-1.03] in hospitals carrying out 30+ versus <15 operations a year, shared frailty model, χ(2)(1df) = 1.82, ptrend = 0.177). CONCLUSION: Higher population resection rates were associated with lower mortality. The association with hospital procedure volume was less clear possibly due to small number of patients who underwent surgery. Nevertheless these results suggest survival is higher in hospitals that carry out a greater number of operations a year, particularly those doing 30+ operations, supporting the benefit of centralising perioperative expertise in specialist centres. Ensuring people are increasingly diagnosed when they are suitable candidates for surgery, and have access to these specialist centres may lead to an increase in the proportion of patients that undergo surgical resection which could plausibly increase survival of pancreatic cancer patients.

Differences in outcomes of oesophageal and gastric cancer surgery across Europe.

BACKGROUND: In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes. METHODS: National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors. RESULTS: Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year). CONCLUSION: Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted.

Ethnicity in relation to incidence of oesophageal and gastric cancer in England.

BACKGROUND: This study investigated the variation in incidence of all, and six subgroups of, oesophageal and gastric cancer between ethnic groups. METHODS: Data on all oesophageal and gastric cancer patients diagnosed between 2001 and 2007 in England were analysed. Self-assigned ethnicity from the Hospital Episode Statistics dataset was used. Male and female age-standardised incidence rate ratios (IRRs) were calculated for each ethnic group, using White groups as the references. RESULTS: Ethnicity information was available for 83% of patients (76 130/92 205). White men had a higher incidence of oesophageal cancer, with IRR for the other ethnic groups ranging from 0.17 95% confidence interval (CI) (0.15-0.20) (Pakistani men) to 0.58 95% CI (0.50-0.67) (Black Caribbean men). Compared with White women, Bangladeshi women (IRR 2.02 (1.24-3.29)) had a higher incidence of oesophageal cancer. For gastric cancer, Black Caribbean men (1.39 (1.22-1.60)) and women (1.57 (1.28-1.92)) had a higher incidence compared with their White counterparts. In the subgroup analysis, White men had a higher incidence of lower oesophageal and gastric cardia cancer compared with the other ethnic groups studied. Bangladeshi women (3.10 (1.60-6.00)) had a higher incidence of upper and middle oesophageal cancer compared with White women. CONCLUSION: Substantial ethnic differences in the incidence of oesophageal and gastric cancer were found. Further research into differences in exposures to risk factors between ethnic groups could elucidate why the observed variation in incidence exists.

Factors predicting malignant transformation in oral potentially malignant disorders among patients accrued over a 10-year period in South East England.

OBJECTIVE: The aims of the study were to determine how frequently oral potentially malignant disorders (OPMDs) transform to cancer and to identify clinical and histological factors determining the rates of transformation. METHODS: The study included 1357 patients with biopsy-confirmed OPMDs seen at Guy's Hospital between 1990 and 1999 and followed up until 2005. The patients' details (name, date of birth, gender and any other relevant information) were matched to the Thames Cancer Registry (TCR) database and Office for National Statistics (ONS) to identify patients who subsequently developed oral cancer (ICD-10 C00-C06). From each patient's record, we identified their highest grade of dysplasia, graded as none, mild, moderate or severe. The outcome of principal interest was transformation to oral squamous cell carcinoma. To avoid co-existing malignancies, follow-up was started 6 months after the date of the index biopsy. Kaplan-Meier estimates and Cox proportional hazard analysis were undertaken to explore the factors associated with the time to transformation to oral cancer. RESULTS: One thousand three hundred and fifty-seven patients were included in the study. The majority of patients were women (60.9%), and ∼30% were under 47 years of age. The most common OPMD was lichen planus/lichenoid reaction. Among all OPMDs, 204 (15.1%) had oral epithelial dysplasia (30 severe, 70 moderate and 104 mild). Thirty-five patients developed oral cancer over the follow-up period (2.6%). There was an association between dysplasia grade and time to transformation. Patients with severe dysplasia had a higher risk of transformation to oral cancer [HR 35.4 95% CI (14.2-88.3)] compared to those with no dysplasia. This association remained significant although attenuated [HR 21.6 95% CI (5.8-80.5)] following adjustment for sex, age, anatomical site of OPMD and diagnosis. A significant trend over dysplasia grades was evident (P < 0.0001). Transformation to oral cancer was also associated with increasing age (P = 0.0390). CONCLUSIONS: In 2.6% of cases, OPMDs transformed to invasive cancer for a total person follow-up time of 12,273 years (mean 9.04 years). The severity of dysplasia is a significant predictor for malignant transformation.

Investigation of low 5-year relative survival for breast cancer in a London cancer network.

BACKGROUND: Breast cancer 5-year relative survival is low in the North East London Cancer Network (NELCN). METHODS: We compared breast cancer that was diagnosed during 2001-2005 with that in the rest of London. RESULTS: North East London Cancer Network women more often lived in socioeconomic quintile 5 (42 vs 21%) and presented with advanced disease (11 vs 7%). Cox regression analysis showed the survival difference (hazard ratio: 1.27, 95% confidence interval (CI): 1.15-1.41) reduced to 1.00 (95% CI: 0.89-1.11) after adjustment for age, stage, socioeconomic deprivation, ethnicity and treatment. Major drivers were stage and deprivation. Excess mortality was in the first year. CONCLUSION: Late diagnosis occurs in NELCN.

Is it possible to determine use of hospice palliative care services by matching hospice and cancer registry data?

Population-based studies investigating access to palliative care often use death in a hospice as a proxy for service use. We linked data from a large South London hospice to Thames Cancer Registry (TCR) data to determine whether patients who received hospice services differed from those who did not. We matched hospice data for 2474 cancer patients dying between 2000 and 2006, while resident within a restricted catchment area, to TCR data for residents in this area. During matching 14.2% (n = 352) of hospice patients were excluded due to differing key dates or addresses. In addition, 5.6% (n= 175) of residents initially defined as not receiving hospice services were recorded as dying in a hospice in the TCR dataset. The problems of overlapping catchment areas and of defining patients receiving services meant we could not adequately determine use of hospice services. This method might be applied more successfully to non-urban hospices, primary care trusts or larger regions.

Trends in the epidemiology of larynx and lung cancer in south-east England, 1985-2004.

We analysed data on 8987 larynx and 174060 lung cancer patients diagnosed between 1985 and 2004, of which 17.3% of larynx and 35.5% of lung cancers were in females. The age-standardised rates for each cancer declined in both sexes, but since the 1990s, the rates in females over 70 years of age have been diverging.