Does Human Papillomavirus Play a Causative Role in Prostate Cancer? A Systematic Review Using Bradford Hill's Criteria.

Globally, prostate cancer is the fifth most common cause of cancer-related death among men, and metastatic castration-resistant prostate cancer has a high cancer-related mortality rate. However, the aetiology of this disease is not yet fully understood. While human papillomavirus (HPV) has been associated with several types of cancer, including cervical, anal, and oropharyngeal cancers, studies investigating the relationship between HPV and prostate cancer have shown mixed results. This systematic review aimed to evaluate the causative association between HPV and prostate cancer using Bradford Hill's criteria. A comprehensive search of PubMed was conducted, and 60 out of 482 studies were included in the review. The included studies were evaluated based on nine Bradford Hill criteria, and information on the identification and transmission of the virus and potential oncogenic mechanisms was also extracted. The strength of association criterion was not met, and other criteria, such as consistency and coherence, were not fulfilled. However, biological plausibility was supported, and potential oncogenic mechanisms were identified. While some studies have reported the presence of HPV in prostate cancer tissues, the overall quality of evidence remains low, and the association between HPV and prostate cancer is weak. Nevertheless, the prostate is a potential reservoir for the transmission of HPV, and the HPV E6 and E7 oncoproteins and inflammation are likely to be involved in any oncogenic mechanisms. Further studies with a higher level of evidence are needed to establish a definitive link between HPV and prostate cancer.

Impact of Racial/Ethnic Discrimination on Quality of Life Among Breast Cancer Survivors.

Although racial/ethnic disparities in health-care access, treatment, and cancer outcomes are well documented, the impact of racial/ethnic discrimination on cancer survivorship is unclear. We examined associations between quality of life (QoL) and self-reported discrimination among 3,991 women with breast cancer recruited during 2006-2013 from the Pathways Study in the Kaiser Permanente Northern California integrated health-care system, using linear regression models. Overall, 31% of women reported experiencing racial/ethnic discrimination, with differences by race/ethnicity (82% among non-Hispanic Black women vs. 19% among non-Hispanic White women) and nativity (40% among foreign-born Hispanic women vs. 76% among US-born Asian-American women). Experiencing racial/ethnic discrimination was associated with lower QoL in fully adjusted models. The mean QoL score was 119.6 (95% confidence interval (CI): 102.0, 137.1) for women who did not report discrimination, 115.5 (95% CI: 98.0, 133.0) for those who reported some discrimination/less than the median level, and 110.2 (95% CI: 92.7, 127.7) for those who reported more discrimination/greater than or equal to the median level. Discrimination was associated with lower QoL among women who used passive coping strategies or lived in neighborhoods with high neighborhood socioeconomic status, neighborhoods with high levels of segregation, or non-ethnic enclaves. Among breast cancer survivors, clinically meaningful differences in QoL scores were associated with racial/ethnic discrimination. Additional studies are needed to understand potential pathways through which these social factors affect survivorship outcomes.

What is the Definition of Cure in Non-small Cell Lung Cancer?

The concept of cure from cancer is important to patients, but can be difficult to communicate in terms that are meaningful. This is because there are a number of definitions of cure that are applied by clinicians, patients and the public, and by policymakers that have a different meaning and significance. In this article, we provide a narrative review of the evidence concerning cure in lung cancer and show how the different definitions may apply in different settings. A better understanding of the various concepts of cure will improve communication with patients on this important topic. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Hospital Characteristics and Breast Cancer Survival in the California Breast Cancer Survivorship Consortium.

INTRODUCTION: Racial/ethnic disparities in breast cancer survival are well documented, but the influence of health care institutions is unclear. We therefore examined the effect of hospital characteristics on survival. METHODS: Harmonized data pooled from 5 case-control and prospective cohort studies within the California Breast Cancer Survivorship Consortium were linked to the California Cancer Registry and the California Neighborhoods Data System. The study included 9,701 patients with breast cancer who were diagnosed between 1993 and 2007. First reporting hospitals were classified by hospital type-National Cancer Institute (NCI) -designated cancer center, American College of Surgeons (ACS) Cancer Program, other-and hospital composition of the neighborhood socioeconomic status and race/ethnicity of patients with cancer. Multivariable Cox proportional hazards models adjusted for clinical and patient-level prognostic factors were used to examine the influence of hospital characteristics on survival. RESULTS: Fewer than one half of women received their initial care at an NCI-designated cancer center (5%) or ACS program (38%) hospital. Receipt of initial care in ACS program hospitals varied by race/ethnicity-highest among non-Latina White patients (45%), and lowest among African Americans (21%). African-American women had superior breast cancer survival when receiving initial care in ACS hospitals versus other hospitals (non-ACS program and non-NCI-designated cancer center; hazard ratio, 0.67; 95% CI, 0.55 to 0.83). Other hospital characteristics were not associated with survival. CONCLUSION: African American women may benefit significantly from breast cancer care in ACS program hospitals; however, most did not receive initial care at such facilities. Future research should identify the aspects of ACS program hospitals that are associated with higher survival and evaluate strategies by which to enhance access to and use of high-quality hospitals, particularly among African American women.

Changes in Colorectal Cancer 5-Year Survival Disparities in California, 1997-2014.

BACKGROUND: Colorectal cancer incidence and mortality have declined with increased screening and scientific advances in treatment. However, improvement in colorectal cancer outcomes has not been equal for all groups and disparities have persisted over time. METHODS: Data from the California Cancer Registry were used to estimate changes in 5-year colorectal cancer-specific survival over three diagnostic time periods: 1997-2002, 2003-2008, and 2009-2014. Analyses included all patients in California with colorectal cancer as a first primary malignancy. Multivariable Cox proportional hazard regression models were used to evaluate the effect of race/ethnicity, insurance status, and neighborhood socioeconomic status (nSES) on 5-year colorectal cancer-specific survival. RESULTS: On the basis of a population-based sample of 197,060 colorectal cancer cases, racial/ethnic survival disparities decreased over time among non-Hispanic Blacks (NHB) compared with non-Hispanic Whites (NHW), after adjusting for demographic, clinical, and treatment characteristics. For cases diagnosed 1997-2002, colorectal cancer-specific hazard rates were higher for NHB [HR, 1.12; 95% confidence interval (CI), 1.06-1.19] and lower for Asians/Pacific Islanders (HR, 0.92; 95% CI, 0.87-0.96) and Hispanics (HR, 0.94; 95% CI, 0.90-0.99) compared with NHW. In 2009-2014, colorectal cancer-specific HR for NHB was not significantly different to the rate observed for NHW (HR, 1.03; 95% CI, 0.97-1.10). There were no changes in disparities in nSES, but increasing disparities by health insurance status. CONCLUSIONS: We found a decrease in survival disparities over time by race/ethnicity, but a persistence of disparities by neighborhood socioeconomic status and health insurance status. IMPACT: Further investigation into the drivers for these disparities can help direct policy and practice toward health equity for all groups.

Associations between breast cancer subtype and neighborhood socioeconomic and racial composition among Black and White women.

PURPOSE: Studies of Black-White differences in breast cancer subtype often emphasize potential ancestry-associated genetic or lifestyle risk factors without fully considering how the social or economic implications of race in the U.S. may influence risk. We assess whether neighborhood racial composition and/or socioeconomic status are associated with odds of triple-negative breast cancer (TNBC) diagnosis relative to the less-aggressive hormone receptor-positive/HER2-negative subtype (HR+ /HER-), and whether the observed relationships vary across women's race and age groups. METHODS: We use multilevel generalized estimating equation models to evaluate odds of TNBC vs. HR+ /HER2- subtypes in a population-based cohort of 7291 Black and 74,208 White women diagnosed with breast cancer from 2006 to 2014. Final models include both neighborhood-level variables, adjusting for individual demographics and tumor characteristics. RESULTS: Relative to the HR+ /HER- subtype, we found modestly lower odds of TNBC subtype among White women with higher neighborhood median household income (statistically significant within the 45-64 age group, OR = 0.981 per $10,000 increase). Among Black women, both higher neighborhood income and higher percentages of Black neighborhood residents were associated with lower odds of TNBC relative to HR+ /HER2-. The largest reduction was observed among Black women diagnosed at age ≥ 65 (OR = 0.938 per $10,000 increase; OR = 0.942 per 10% increase in Black residents). CONCLUSION: The relationships between neighborhood composition, neighborhood socioeconomic status, and odds of TNBC differ by race and age. Racially patterned social factors warrant further exploration in breast cancer subtype disparities research.

Comorbidity prevalence among cancer patients: a population-based cohort study of four cancers.

BACKGROUND: The presence of comorbidity affects the care of cancer patients, many of whom are living with multiple comorbidities. The prevalence of cancer comorbidity, beyond summary metrics, is not well known. This study aims to estimate the prevalence of comorbid conditions among cancer patients in England, and describe the association between cancer comorbidity and socio-economic position, using population-based electronic health records. METHODS: We linked England cancer registry records of patients diagnosed with cancer of the colon, rectum, lung or Hodgkin lymphoma between 2009 and 2013, with hospital admissions records. A comorbidity was any one of fourteen specific conditions, diagnosed during hospital admission up to 6 years prior to cancer diagnosis. We calculated the crude and age-sex adjusted prevalence of each condition, the frequency of multiple comorbidity combinations, and used logistic regression and multinomial logistic regression to estimate the adjusted odds of having each condition and the probability of having each condition as a single or one of multiple comorbidities, respectively, by cancer type. RESULTS: Comorbidity was most prevalent in patients with lung cancer and least prevalent in Hodgkin lymphoma patients. Up to two-thirds of patients within each of the four cancer patient cohorts we studied had at least one comorbidity, and around half of the comorbid patients had multiple comorbidities. Our study highlighted common comorbid conditions among the cancer patient cohorts. In all four cohorts, the odds of having a comorbidity and the probability of multiple comorbidity were consistently highest in the most deprived cancer patients. CONCLUSIONS: Cancer healthcare guidelines may need to consider prominent comorbid conditions, particularly to benefit the prognosis of the most deprived patients who carry the greater burden of comorbidity. Insight into patterns of cancer comorbidity may inform further research into the influence of specific comorbidities on socio-economic inequalities in receipt of cancer treatment and in short-term mortality.

Racial/ethnic and socioeconomic survival disparities for children and adolescents with central nervous system tumours in the United States, 2000-2015.

BACKGROUND AND OBJECTIVES: Central nervous system (CNS) malignancy is the commonest cause of cancer death in children and adolescents (0-19 years) in high-income settings. There is limited data on survival inequalities by race/ethnicity and socioeconomic position (SEP), for young patients, we aim to analyse their influence on survival from childhood CNS tumour. METHODS: 9577 children and adolescents diagnosed with primary malignant CNS tumours during 2000-2015, followed up until Dec 31 st, 2015, and reported to cancer registries (Surveillance, Epidemiology and End Results programme) were included in the analysis. Cox regression models estimated the hazard ratios for race/ethnicity, SEP, and individual insurance status, adjusting for sex, age, diagnostic period, and tumour type. Individual-level insurance status data were available from 2007. RESULTS: 62.5 % children and adolescents were non-Hispanic White, 10.6 % were non-Hispanic Black and 26.9 % were Hispanic. Race/ethnicity was strongly associated with survival (p < 0.001), even after adjusting for SEP, with Black (HR = 1.39 [95 %CI 1.23-1.58]) and Hispanic children (HR = 1.40 [95 %CI 1.28-1.54]) having higher hazards of death than White children. This association remained after adjusting for insurance status. There was an apparent positive association between SEP and survival that was largely attenuated after adjustment for insurance status (p = 0.20). Survival was comparable between those privately and Medicaid-insured. CONCLUSIONS: Non-Hispanic Black and Hispanic children had lower survival than their White counterparts. This association, not fully explained by differences in SEP, tumour subtype or health insurance, could be related to racially/ethnically-driven barriers to optimal healthcare, warranting further investigation.

The Mortality-to-Incidence Ratio Is Not a Valid Proxy for Cancer Survival.

PURPOSE: The ratio of cancer mortality and cancer incidence rates in a population has conventionally been used as an indicator of the completeness of cancer registration. More recently, the complement of the mortality-to-incidence ratio (1-M/I) has increasingly been presented as a surrogate for cancer survival. We discuss why this is mistaken in principle and misleading in practice. METHODS: We provide an empirical assessment of the extent to which trends in the 1-M/I ratio reflect trends in cancer survival. We used national cancer incidence, mortality and survival data in England to compare trends in both the 1-M/I ratio and net survival at 1, 5, and 10 years for 19 cancers in men and 20 cancers in women over the 29-year period from 1981 to 2009. RESULTS: The absolute difference between the 1-M/I ratio and 5-year net survival for 2009 was less than 5% for only 12 of the 39 cancer/sex combinations examined. For an additional 12, the 1-M/I ratio differed from 5-year net survival by at least 15%. The comparison is also unstable over time; thus, even when differences were small for 2009, the difference between 5-year net survival and the 1-M/I ratio had changed dramatically for most cancers between 1981 and 2009. CONCLUSION: The 1-M/I ratio lacks any theoretical basis as a proxy for cancer survival. It is not a valid proxy for cancer survival in practice, either, whether at 5 years or at any other time interval since diagnosis. It has none of the useful properties of a population-based survival estimate. It should not be used as a surrogate for cancer survival.

Colorectal Cancer Incidence Trends by Age, Stage, and Racial/Ethnic Group in California, 1990-2014.

Background: The incidence of colorectal cancer in the United States declined substantially over the past 20 years, but evidence suggests that among younger adults (under 50 years at diagnosis), incidence is increasing. However, data on age- and stage-specific incidence trends across racial/ethnic groups are limited.Methods: All incident cases of colorectal cancer diagnosed from 1990 through 2014 in adults aged 20 years and older were obtained from the California Cancer Registry. Incidence rates (per 100,000), incidence rate ratios, and triannual percent changes in incidence were estimated for each age group at diagnosis (20-49, 50-74, 75+ years), sex, stage, and race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and 7 Asian American groups).Results: Of 349,176 incident colorectal cancer cases diagnosed from 1990 through 2014, 9% were in adults younger than 50 years. Increases in incidence of early-onset colorectal cancer, especially in regional/distant stage disease, were observed in most racial/ethnic groups (statistically significant for non-Hispanic whites and Hispanics, ranging from 0.9% to 2.9% every 3 years). Incidence also increased in Vietnamese and other Southeast Asian groups of screening age (50-74 years). The incidence of colorectal cancer in non-Hispanic blacks aged 50+ declined over the 25-year period, but remained significantly higher than in non-Hispanic whites.Conclusions: Further research is needed to understand the causes of the increasing incidence of early-onset colorectal cancer. The rising incidence of colorectal cancer among Southeast Asians of screening age and the persistently high incidence in non-Hispanic blacks also warrant attention.Impact: Our findings may have implications for revisiting screening guidelines in the United States. Cancer Epidemiol Biomarkers Prev; 27(9); 1011-8. ©2018 AACR.

Trends in Cancer Survival by Health Insurance Status in California From 1997 to 2014.

IMPORTANCE: There have been substantial improvements in the early detection, treatment, and survival from cancer in the United States, but it is not clear to what extent patients with different types of health insurance have benefitted from these advancements. OBJECTIVE: To examine trends in cancer survival by health insurance status from January 1997 to December 2014. DESIGN, SETTING, AND PARTICIPANTS: California Cancer Registry (a statewide cancer surveillance system) data were used to estimate population-based survival by health insurance status in 3 calendar periods: January 1997 to December 2002, January 2003 to December 2008, and January 2009 to December 2014 with follow-up through 2014. Overall, 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma in California were included in the study. MAIN OUTCOMES AND MEASURES: Five-year all-cause and cancer-specific survival probabilities by insurance category and calendar period for each cancer site and sex; hazard ratios (HRs) and 95% CIs for each insurance category (none, Medicare, other public) compared with private insurance in each calendar period. RESULTS: According to data from 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma gathered from the California Cancer Registry, improvements in survival were almost exclusively limited to patients with private or Medicare insurance. For patients with other public or no insurance, survival was largely unchanged or declined. Relative to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20). CONCLUSIONS AND RELEVANCE: After accounting for patient and clinical characteristics, survival disparities for men with prostate cancer and women with lung or colorectal cancer increased significantly over time, reflecting a lack of improvement in survival for patients with other public or no insurance. To mitigate these growing disparities, all patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.

Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics.

Purpose Racial/ethnic disparities in cancer survival in the United States are well documented, but the underlying causes are not well understood. We quantified the contribution of tumor, treatment, hospital, sociodemographic, and neighborhood factors to racial/ethnic survival disparities in California. Materials and Methods California Cancer Registry data were used to estimate population-based cancer-specific survival for patients diagnosed with breast, prostate, colorectal, or lung cancer between 2000 and 2013 for each racial/ethnic group (non-Hispanic black, Hispanic, Asian American and Pacific Islander, and separately each for Chinese, Japanese, and Filipino) compared with non-Hispanic whites. The percentage contribution of factors to overall racial/ethnic survival disparities was estimated from a sequence of multivariable Cox proportional hazards models. Results In baseline models, black patients had the lowest survival for all cancer sites, and Asian American and Pacific Islander patients had the highest, compared with whites. Mediation analyses suggested that stage at diagnosis had the greatest influence on overall racial/ethnic survival disparities accounting for 24% of disparities in breast cancer, 24% in prostate cancer, and 16% to 30% in colorectal cancer. Neighborhood socioeconomic status was an important factor in all cancers, but only for black and Hispanic patients. The influence of marital status on racial/ethnic disparities was stronger in men than in women. Adjustment for all covariables explained approximately half of the overall survival disparities in breast, prostate, and colorectal cancer, but it explained only 15% to 40% of disparities in lung cancer. Conclusion Overall reductions in racial/ethnic survival disparities were driven largely by reductions for black compared with white patients. Stage at diagnosis had the largest effect on racial/ethnic survival disparities, but earlier detection would not entirely eliminate them. The influences of neighborhood socioeconomic status and marital status suggest that social determinants, support mechanisms, and access to health care are important contributing factors.

Multivariable flexible modelling for estimating complete, smoothed life tables for sub-national populations.

BACKGROUND: The methods currently available to estimate age- and sex-specific mortality rates for sub-populations are subject to a number of important limitations. We propose two alternative multivariable approaches: a relational model and a Poisson model both using restricted cubic splines. METHODS: We evaluated a flexible Poisson and flexible relational model against the Elandt-Johnson approach in a simulation study using 100 random samples of population and death counts, with different sampling proportions and data arrangements. Estimated rates were compared to the original mortality rates using goodness-of-fit measures and life expectancy. We further investigated an approach for determining optimal knot locations in the Poisson model. RESULTS: The flexible Poisson model outperformed the flexible relational and Elandt-Johnson methods with the smallest sample of data (1%). With the largest sample of data (20%), the flexible Poisson and flexible relational models performed comparably, though the flexible Poisson model displayed a slight advantage. Both approaches tended to underestimate infant mortality and thereby overestimate life expectancy at birth. The flexible Poisson model performed much better at young ages when knots were fixed a priori. For ages 30 and above, results were similar to the model with no fixed knots. CONCLUSIONS: The flexible Poisson model is recommended because it derives robust and unbiased estimates for sub-populations without making strong assumptions about age-specific mortality profiles. Fixing knots a priori in the final model greatly improves fit at the young ages.

Cancer incidence, survival and mortality: explaining the concepts.

Cancer incidence, survival and mortality are essential population-based indicators for public health and cancer control. Confusion and misunderstanding still surround the estimation and interpretation of these indicators. Recurring controversies over the use and misuse of population-based cancer statistics in health policy suggests the need for further clarification. In our article, we describe the concepts that underlie the measures of incidence, survival and mortality, and illustrate the synergy between these measures of the cancer burden. We demonstrate the relationships between trends in incidence, survival and mortality, using real data for cancers of the lung and breast from England and Sweden. Finally, we discuss the importance of using all three measures in combination when interpreting overall progress in cancer control, and we offer some recommendations for their use.

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.

Full dates (day, month, year) should be used in population-based cancer survival studies.

Accurate survival estimates are essential for monitoring cancer survival trends, for health care planning and for resource allocation. To obtain precise estimates of survival, full dates (day, month and year) rather than partial dates (month and year) are required. In some jurisdictions, however, cancer registries are constrained from providing full dates on the grounds of confidentiality. The bias resulting from the use of partial dates in the estimation and comparison of survival makes it impossible to determine precisely the differences in the risk of death from cancer between population groups or in successive calendar periods. Important operational arguments also exist against the use of incomplete dates for survival analysis, including increased workload for cancer registry staff and the introduction of avoidable complexity for quality control of survival data. Cancer survival is one of the most widely known outputs produced by population-based cancer registries, and it is a crucial metric for the comparative effectiveness of health services. The bodies that set data access guidelines must take a more balanced view of the risks and benefits of using full dates for the estimation of cancer survival.

Trends and inequalities in laryngeal cancer survival in men and women: England and Wales 1991-2006.

Laryngeal cancer in men is a relatively common malignancy, with a marked socioeconomic gradient in survival between affluent and deprived patients. Cancer of the larynx in women is rare. Survival tends to lower than for men, and little is known about the association between deprivation and survival in women with laryngeal cancer. This paper explores the trends and socio-economic inequalities in laryngeal cancer survival in women, with comparison to men. We examined relative survival among men and women diagnosed with laryngeal cancer in England and Wales during 1991-2006, followed up to 31 December 2007. We estimated the difference in survival between the most deprived and most affluent groups (the 'deprivation gap') at one and five years after diagnosis, for each sex, anatomical subsite and calendar period. Five year survival for all laryngeal cancers combined was up to 8% lower in women than in men. This difference is only partially explained by the differential distribution of anatomical subsites in men and women. Disparities in survival between men and women were also present within specific subsites. In contrast to men, there was little evidence of a consistent deprivation gap in survival for women at any of the anatomical subsites. The stark socioeconomic inequalities in laryngeal cancer survival in men do not appear to be replicated in women. The origins of the socio-economic inequalities in survival among men, and the disparities in survival between men and women at specific tumour subsites remains unclear.

How many deaths would be avoidable if socioeconomic inequalities in cancer survival in England were eliminated? A national population-based study, 1996-2006.

AIM: Inequalities in survival between rich and poor have been reported for most adult cancers in England. This study aims to quantify the public health impact of these inequalities by estimating the number of cancer-related deaths that would be avoidable if all patients were to have the same cancer survival as the most affluent patients. METHODS: National Cancer Registry data for all adults diagnosed with one of 21 common cancers in England were used to estimate relative survival. We estimated the number of excess (cancer-related) deaths that would be avoidable within three years after diagnosis if relative survival for patients in all deprivation groups was as high as the most affluent group. RESULTS: For patients diagnosed during 2004-2006, 7122 of the 64,940 excess deaths a year (11%) would have been avoidable if three-year survival for all patients had been as high as in the most affluent group. The annual number of avoidable deaths fell from 8435 (13%) a year for patients diagnosed during 1996-2000. Over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups. CONCLUSION: The downward trend in the annual number of avoidable deaths reflects more an improvement in survival in England overall, rather than a narrowing of the deficit in cancer survival between poor and rich. The lack of any substantial change in the percentage of avoidable excess deaths highlights the persistent nature of the deficit in survival between affluent and deprived groups.

Inequalities in cancer survival: Spearhead Primary Care Trusts are appropriate geographic units of analyses.

BACKGROUND: Cancer survival in Spearhead Primary Care trusts (PCTs) is lower than in the rest of England for most common cancers, but differences are smaller than the more substantial survival gradients between deprived and affluent populations using small-area measures of deprivation. The way in which Spearhead PCTs were designated may give an unduly favourable image of inequalities in cancer survival. METHODS: Five-year age-standardised relative survival for 10 common cancers was estimated separately for patients resident in Spearhead local authorities (LAs), Spearhead PCTs, and the rest of England. Differences in survival between Spearhead and other LAs and the corresponding differences between Spearhead and other PCTs were compared. RESULTS: Cancer survival was consistently lower for patients resident in Spearhead areas than in the rest of England for the majority of cancers, regardless of the geographic unit used. Survival was lower in Spearhead LAs than Spearhead PCTs for 11 of the 16 cancer-sex combinations examined. As a consequence, the survival gap between the Spearhead areas and the rest of England was slightly wider when the definition of Spearhead was based on LAs rather than PCTs, but the two contrasts provide a very similar picture. CONCLUSIONS: Small differences were found between using Spearhead LAs and Spearhead PCTs in the estimation of cancer survival, but results were inconsistent. Although the overlap between the two geographies is imperfect, Spearhead PCTs are appropriate geographic units for monitoring inequalities in cancer survival. However, given the instability of NHS geographical boundaries, Spearhead LAs could be a suitable alternative geographic unit.