Non-preventable cases of breast, prostate, lung, and colorectal cancer in 2050 in an elimination scenario of modifiable risk factors.

Most Western countries have increasing number of new cancer cases per year. Cancer incidence is primarily influenced by basically avoidable risk factors and an aging population. Through hypothetical elimination scenarios of multiple major risk factors for cancer, we estimated the number of new cancer cases that are non-preventable in 2050. We compare numbers of new postmenopausal breast, prostate, lung, and colorectal cancer cases in 2021 to projected numbers of new cases in 2050 under prevention scenarios regarding smoking, overweight and obesity, and alcohol consumption: no intervention, 50%, and 100% instant reduction. Cancer incidence data were derived from NORDCAN, and risk factor prevalence data from the Danish National Health Survey. Cancer projections were calculated with the Prevent program. Hypothetical 100% instant elimination of major risk factors for cancer in Denmark in 2022 will result in unchanged numbers of new breast and colorectal cancers in 2050. The number of new prostate cancers will increase by 25% compared to 2021. Unchanged risk factor levels will result in noticeable increase in cancer burden. Increase in life expectancy and age will entail an increase in cancer incidence, despite maximum effect of preventive actions in the population. Our results are important when planning future health care.

Have the recent advancements in cancer therapy and survival benefitted patients of all age groups across the Nordic countries? NORDCAN survival analyses 2002-2021.

BACKGROUND: Since the early 2000s, overall and site-specific cancer survival have improved substantially in the Nordic countries. We evaluated whether the improvements have been similar across countries, major cancer types, and age groups. MATERIAL AND METHODS: Using population-based data from the five Nordic cancer registries recorded in the NORDCAN database, we included a cohort of 1,525,854 men and 1,378,470 women diagnosed with cancer (except non-melanoma skin cancer) during 2002-2021, and followed for death until 2021. We estimated 5-year relative survival (RS) in 5-year calendar periods, and percentage points (pp) differences in 5-year RS from 2002-2006 until 2017-2021. Separate analyses were performed for eight cancer sites (i.e. colorectum, pancreas, lung, breast, cervix uteri, kidney, prostate, and melanoma of skin). RESULTS: Five-year RS improved across nearly all cancer sites in all countries (except Iceland), with absolute differences across age groups ranging from 1 to 21 pp (all cancer sites), 2 to 20 pp (colorectum), -1 to 36 pp (pancreas), 2 to 28 pp (lung), 0 to 9 pp (breast), -11 to 26 pp (cervix uteri), 2 to 44 pp (kidney), -2 to 23 pp (prostate) and -3 to 30 pp (skin melanoma). The oldest patients (80-89 years) exhibited lower survival across all countries and sites, although with varying improvements over time. INTERPRETATION: Nordic cancer patients have generally experienced substantial improvements in cancer survival during the last two decades, including major cancer sites and age groups. Although survival has improved over time, older patients remain at a lower cancer survival compared to younger patients.

Colorectal Cancer Survival in German-Danish Border Regions-A Registry-Based Cohort Study.

The aim of this study was (i) to update the reporting of colorectal cancer survival differences over time in the German-Danish border region (Schleswig-Holstein, Southern Denmark, and Zealand) and (ii) to assess the extent to which it can be explained by stage and primary treatment. Incident invasive colorectal cancer cases diagnosed from 2004 to 2016 with a follow-up of vital status through 31 December 2017 were extracted from cancer registries. Analyses were conducted by anatomical subsite and for four consecutive periods. Kaplan-Meier curves and log-rank tests were computed. Cox regression models using data from Schleswig-Holstein from 2004 to 2007 as the reference category were run while controlling for age, sex, stage, and treatment. The cox regression models showed decreasing hazard ratios of death for all three regions over time for both anatomical subsites. The improvement was stronger in the Danish regions, and adjustment for age, sex, stage, and treatment attenuated the results only slightly. In 2014-2016, colon cancer survival was similar across regions, while rectal cancer survival was significantly superior in the Danish regions. Regional survival differences can only partially be explained by differing stage distribution and treatment and may be linked additionally to healthcare system reforms and screening efforts.

Nordcan.R: a new tool for federated analysis and quality assurance of cancer registry data.

Aim of the article: We present our new GDPR-compliant federated analysis programme (nordcan.R), how it is used to compute statistics for the Nordic cancer statistics web platform NORDCAN, and demonstrate that it works also with non-Nordic data. Materials and methods: We chose R and Stata programming languages for writing nordcan.R. Additionally, the internationally used CRG Tools programme by International Agency for Research on Cancer (IARC/WHO) was employed. A formal assessment of (GDPR-compliant) anonymity of all nordcan.R outputs was performed. In order to demonstrate that nordcan.R also works with non-Nordic data, we used data from the Netherlands Cancer Registry. Results: nordcan.R, publicly available on Github, takes as input cancer and general population data and produces tables of statistics. Each NORDCAN participant runs nordcan.R locally and delivers its results to IARC for publication. According to our anonymity assessment the data can be shared with international organizations, including IARC. nordcan.R incidence results on Norwegian and Dutch data are highly similar to those produced by two other independent methods. Conclusion: nordcan.R produces accurate cancer statistics where all personal and sensitive data are kept within each cancer registry. In the age of strict data protection policies, we have shown that international collaboration in cancer registry research and statistics reporting is achievable with the federated analysis approach. Undertakings similar to NORDCAN should consider using nordcan.R.

Do investments in cancer registry databases and tools bring added value? NORDCAN as an example.

BACKGROUND: In the 1990s, the large-scale collaboration Kreftbildet i Norden (KIN) drew attention to the need for timely cancer statistics for cancer control planning in the Nordic countries. Supported by the Nordic Cancer Union (NCU), a web-based version of NORDCAN was continually developed by the Association of Nordic Cancer Registries (ANCR) from 2003, with website support and hosting by the International Agency for Research on Cancer (IARC). Despite empirical evidence of its global reach, the question of whether recurrent investment in NORDCAN brings added value was raised; we sought to formally assess this. METHODS: Scientific value was determined by extracting publications citing NORDCAN from PubMed. We compared the funds allocated to the KIN project and later Nordic studies on cancer predictions and survival, with those allocated to NORDCAN. RESULTS: 96 publications in 43 journals were retrieved. Two publication peaks, in 2010 and in 2016 relate to Nordic cancer survival and Danish age care projects, respectively. Papers citing NORDCAN increased substantially from 4 published in 2017 to the 24 papers in 2022. The integration of survival and prediction projects into NORDCAN reduced the costs of investment to one-quarter of the those required in earlier years, in real terms. DISCUSSION: User statistics and scientific output clearly points to NORDCAN bringing added value given resources expended, even with the additional costs imposed to ensure GDPR compliance. Research funding indicates that the databases and interactive tools are critical as both research and education resources. Nonetheless, a sustainable funding model is needed if NORDCAN is to continue to fulfill its utility in cancer control, health care planning and cancer research.

Survival of breast cancer patients in German-Danish border regions - A registry-based cohort study.

BACKGROUND AND AIM: Denmark reports slightly lower breast cancer survival before 2010 than its neighbouring country Germany. Previous research is limited by lacking stage and treatment information. This study aims to investigate differences in breast cancer survival between the bordering regions Schleswig-Holstein (Germany), Southern Denmark and Zealand (Denmark) using registry data including stage and treatment information. METHOD: Invasive female breast cancer cases diagnosed during 2004-2013 with follow up through 31st December 2014 were extracted from cancer registries. Cases notified by death certificates only and those aged 90+ years were excluded. Kaplan-Meier curves and log-rank tests were computed. Cox regression analysis was conducted with adjustment for year of diagnosis, age, stage, and treatment. RESULTS: The analytical sample included 42,966 cases. Kaplan-Meier curves and log-rank tests show significant survival differences between the regions. The Cox regression model adjusted for year of diagnosis and age shows significantly worse overall survival of breast cancer patients in both Danish regions compared to Schleswig-Holstein with hazard ratios (HR) of 1.09 (95 % CI: 1.04; 1.15) for patients from Southern Denmark (SD) and 1.25 (95 % CI: 1.18; 1.32) for residents of Zealand (ZL). This effect diminished after adjustment for stage and treatment (HR: 1.05 (SD), 1.09 (ZL) 95 % CI: 0.99; 1.10 (SD), 1.03; 1.15 (ZL)). CONCLUSION: Survival differences can be explained by differing stage distribution and treatment administration, which formerly were more favourable in Schleswig-Holstein. The survival gap will probably close due to Denmark's national screening program and increased use of adjuvant cancer therapy.

The histology of brain tumors for 67 331 children and 671 085 adults diagnosed in 60 countries during 2000-2014: a global, population-based study (CONCORD-3).

BACKGROUND: Global variations in survival for brain tumors are very wide when all histological types are considered together. Appraisal of international differences should be informed by the distribution of histology, but little is known beyond Europe and North America. METHODS: The source for the analysis was the CONCORD database, a program of global surveillance of cancer survival trends, which includes the tumor records of individual patients from more than 300 population-based cancer registries. We considered all patients aged 0-99 years who were diagnosed with a primary brain tumor during 2000-2014, whether malignant or nonmalignant. We presented the histology distribution of these tumors, for patients diagnosed during 2000-2004, 2005-2009, and 2010-2014. RESULTS: Records were submitted from 60 countries on 5 continents, 67 331 for children and 671 085 for adults. After exclusion of irrelevant morphology codes, the final study population comprised 60 783 children and 602 112 adults. Only 59 of 60 countries covered in CONCORD-3 were included because none of the Mexican records were eligible. We defined 12 histology groups for children, and 11 for adults. In children (0-14 years), the proportion of low-grade astrocytomas ranged between 6% and 50%. Medulloblastoma was the most common subtype in countries where low-grade astrocytoma was less commonly reported. In adults (15-99 years), the proportion of glioblastomas varied between 9% and 69%. International comparisons were made difficult by wide differences in the proportion of tumors with unspecified histology, which accounted for up to 52% of diagnoses in children and up to 65% in adults. CONCLUSIONS: To our knowledge, this is the first account of the global histology distribution of brain tumors, in children and adults. Our findings provide insights into the practices and the quality of cancer registration worldwide.

Tobacco-related cancers in Europe: The scale of the epidemic in 2018.

BACKGROUND: Tobacco smoking is the major preventable cause of cancer. Despite the longstanding decline in smoking prevalence, lung cancer remains one of the most frequently diagnosed cancers in both sexes. We aimed to estimate the current cancer burden attributable to smoking in Europe. METHODS: Smoking-related cancer incidence by country, cancer type, sex and age in Europe was estimated from GLOBOCAN 2018. We applied a modified version of the indirect method to estimate the population attributable fraction (PAF) for lung cancer and applied Levin's formula to estimate the PAF for other smoking-related cancer sites. RESULTS: In Europe in 2018, 572,000 and 186,000 cancer cases were attributable to tobacco smoking in males and females respectively, accounting for 28% (males) and 10% (females) of all cancer cases. By region, the largest and the lowest PAF due to smoking in males occurred in Eastern Europe (35% of all cancer cases) and Northern Europe (21%), respectively. Among women, this pattern was reversed (16% in Northern Europe and 6% in Eastern Europe). Lung cancer accounted for more than half of the total cancer burden attributable to smoking (382,000). Other major contributors to the total PAF were lip, oral cavity and pharynx, bladder and laryngeal cancers in men (27% out of total PAF) and colorectal, pancreatic, oral cavity and pharyngeal cancers (21%) in women. CONCLUSIONS: Tobacco smoking was responsible for one in five cancer cases in Europe in 2018. The introduction and robust implementation of tobacco control programmes are critical to reduce this cancer burden in the future.

Risk of primary brain tumour after breast cancer.

INTRODUCTION: Cancer registry data in the USA indicated that women diagnosed with breast cancer before the age of 40 were at increased risk of a new primary tumour within the brain and women aged 50 years or above were at lower risk than expected. Our aim was to investigate if similar results could be found in Danish population-based data, considering an explanatory role of hormonal status. METHODS: Our study cohort included all women diagnosed with breast cancer below the age of 60 between 1978 and 2013 in Denmark. A total of 47,920 women were followed up in the Danish Cancer Registry for primary brain cancer. Standardized incidence ratios (observed/expected cases (O/E)) were used to estimate the risk of getting a primary brain tumour in the breast cancer cohort. RESULTS: Data indicated an increased tendency of brain cancer following breast cancer at ages below 60 years (O/E = 1.24). For premenopausal women (age <49 at the diagnosis of breast cancer) the O/E was 1.25. Stratifying by time of breast cancer diagnosis, we observed an increased risk of being diagnosed with a brain tumour among women aged 49 years or younger at breast cancer diagnosis between 2004 and 2013. CONCLUSION: The results indicate an increased tendency of developing a primary brain tumour in women with previous breast cancer history. Whereas the finding in premenopausal women is in line with the SEER data, the finding among postmenopausal is not. Primary brain tumours in breast cancer patients call for research in genetics and hormones to establish common risk factors.

The acceptance and applicability of a patient-reported experience measurement tool in oncological care: a descriptive feasibility study in northern Germany.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are tools for assessing outcomes of and experiences with health care from the patient's perspective. In Germany, PROMs are widely used in research for evaluating patient outcomes and quality of care. However, the application of PREMs is rather scant, especially in oncology. The study aimed to assess the feasibility of patient-centred quality evaluation in oncological care in Germany using the German adaptation of the Danish National Cancer Patient Questionnaire. This questionnaire is a PREM/PROM-tool addressing patients of all cancer sites and covering the entire cancer patient pathway. METHODS: The Danish National Cancer Patient Questionnaire was translated into German via forward-backward translation. Face-validity was tested among three cancer patients in a conventional pre-test. The German adaptation contains 99 questions. A pilot test was carried out among 245 newly diagnosed breast and colorectal cancer patients in the German federal state Schleswig-Holstein. Patients were recruited via clinics participating in the Oncological Care Registry (12 specialised units in seven hospitals) and contacted six to nine months after diagnosis. Response behaviour and response patterns were compared to the Danish study population (n = 1964). RESULTS: The willingness among clinicians to support patient recruitment as well as the response rate of patients to the questionnaire was high (65%). Moreover, response behaviour and response patterns of German and Danish patients were consistent. Despite the generally good response behaviour of patients to the single items, the authors observed that questions assessing the diagnostic process did not fully capture German pathways. Only 19.3% of the German patients stated that their diagnostic process was initiated by a visit to a general practitioner (GP) in contrast to 52% in Denmark. The assessment of patient experiences in the diagnostic phase heavily focuses on experiences in general practice, which does not seem appropriate in the German health care setting. CONCLUSION: The translation was successful, and the feasibility of a future large-scale study within existing structures is given. However, some modifications of questions heavily related to the Danish health care system, especially referring to the diagnostic phase, are necessary.

Avoidable cancers in the Nordic countries-the potential impact of increased physical activity on postmenopausal breast, colon and endometrial cancer.

BACKGROUND: Physical activity has been shown to reduce the risk of colon, endometrial and postmenopausal breast cancer. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to insufficient levels of leisure time physical activity and estimate the potential for cancer prevention for these three sites by increasing physical activity levels. METHODS: Using the Prevent macrosimulation model, the number of cancer cases in the Nordic countries over a 30-year period (2016-2045) was modelled, under different scenarios of increasing physical activity levels in the population, and compared with the projected number of cases if constant physical activity prevailed. Physical activity (moderate and vigorous) was categorised according to metabolic equivalents (MET) hours in groups with sufficient physical activity (15+ MET-hours/week), low deficit (9 to <15 MET-hours/week), medium deficit (3 to <9 MET-hours/week) and high deficit (<3 MET-hours/week). RESULTS: If no one had insufficient levels of physical activity, about 11,000 colon, endometrial and postmenopausal breast cancer cases could be avoided in the Nordic countries in a 30-year period, which is 1% of the expected cases for the three cancer types. With a 50% reduction in all deficit groups by 2025 or a 100% reduction in the group of high deficit, approximately 0.5% of the expected cases for the three cancer types could be avoided. The number and percentage of avoidable cases was highest for colon cancer. CONCLUSION: 11,000 cancer cases could be avoided in the Nordic countries in a 30-year period, if deficit in physical activity was eliminated.

Cancer Prevention Europe.

The case for cancer prevention in Europe is the same as for all other parts of the world. The number of cancers is increasing, driven by demographic change and evolution in the exposure to risk factors, while the cost of treating patients is likewise spiralling. Estimations suggest that around 40% of cancers in Europe could be prevented if current understanding of risk and protective factors was translated into effective primary prevention, with further reductions in cancer incidence and mortality by screening, other approaches to early detection, and potentially medical prevention. However, the infrastructure for cancer prevention tends to be fragmented between and within different countries in Europe. This lack of a coordinated approach recently led to the foundation of Cancer Prevention Europe (Forman et al., 2018), a collaborative network with the main aims of strengthening cancer prevention in Europe by increasing awareness of the needs, the associated required resources and reducing inequalities in access to cancer prevention across Europe. This article showcases the need for strengthening cancer prevention and introduces the objectives of Cancer Prevention Europe and its foreseen future role in reducing the European cancer burden.

Cancer After Liver Transplantation in Children and Young Adults: A Population-Based Study From 4 Nordic Countries.

Cancer after liver transplantation (LT) constitutes a threat also for young recipients, but cancer risk factors are usually absent in children and large studies on the cancer risk profile in young LT recipients are scarce. Data of patients younger than 30 years who underwent LT during the period 1982-2013 in the Nordic countries were linked with respective national cancer registries to calculate standardized incidence ratios (SIRs). A total of 37 cancer cases were observed in 923 patients with 7846 person-years of follow-up. The SIR for all cancer types, compared with the matched general population, was 9.8 (12.4 for males and 7.8 for females). Cumulative incidence of cancer adjusted for the competing risk of death was 2% at 10 years, 6% at 20 years, and 22% at 25 years after LT. Non-Hodgkin lymphoma was the most common cancer type (n = 14) followed by colorectal (n = 4) and hepatocellular cancer (n = 4). Age was a significant risk factor for cancer, and the absolute risk of most cancers (except for lymphoma) increased considerably in young adults older than 20 years. The cancer risk pattern is different in pediatric and young LT patients compared with adult recipients. The striking increase in cancer incidence in young adulthood after the second decade of life deserves further consideration in transition programs.

Avoidable cancers in the Nordic countries-The impact of alcohol consumption.

BACKGROUND: Alcohol consumption is an important and preventable cause of cancer. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to alcohol and estimate the potential for cancer prevention by changes in alcohol consumption. METHODS: Using the Prevent macro-simulation model, the number of cancer cases in the Nordic countries over a 30-year period (2016-2045) was modelled for six sites, under different scenarios of changing alcohol consumption, and compared to the projected number of cases if constant alcohol consumption prevailed. The studied sites were colorectal, post-menopausal breast, oral cavity and pharynx, liver, larynx as well as oesophageal squamous cell carcinoma. The alcohol consumption was based on the categories of non-drinkers/occasional drinkers, light drinkers (<=12.5 g alcohol per day), moderate drinkers (>12.5 and ≤ 50 g/day) and heavy drinkers (>50 g/day). RESULTS: About 83,000 cancer cases could be avoided in the Nordic countries in a 30-year period if alcohol consumption was entirely eliminated, which is 5.5% of the expected number of cases for the six alcohol-related cancer types. With a 50% reduction in the proportion with moderate alcohol consumption by year 2025, 21,500 cancer cases could be avoided. The number of avoidable cases was highest for post-menopausal breast and colorectal cancer, but the percentage was highest for oesophageal squamous cell carcinoma. CONCLUSION: The results from this study can be used to understand the potential impact and significance of primary prevention programmes targeted towards reducing the alcohol consumption in the Nordic countries.

Tackling the tobacco epidemic in the Nordic countries and lower cancer incidence by 1/5 in a 30-year period-The effect of envisaged scenarios changing smoking prevalence.

BACKGROUND: Tobacco smoking is a leading cause of cancer and the most preventable cause of cancer worldwide. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to tobacco smoking and estimate the potential for cancer prevention by changes in smoking prevalence. METHODS: The Prevent macro-simulation model was used, estimating the future number of cancer cases in the Nordic countries over a 30-year period (2016-2045), for 13 cancer sites, under different scenarios of changing smoking prevalence, and compared to the projected number of cases if constant prevalence prevailed. RESULTS: A total of 430,000 cancer cases, of the 2.2 million expected for the 13 studied cancer sites, could be avoided in the Nordic countries over the 30-year period if smoking was eliminated from 2016 onwards. If prevalence of smoking is reduced to 5% by year 2030 and to 2% by 2040, 230,000 cancer cases could be avoided. The largest proportion of cancers can be avoided in Denmark, where smoking prevalence is the highest, and similar to the prevalence in many European countries. CONCLUSION: A large amount of cancers could be avoided in the Nordic countries if smoking prevalence was reduced. The results from this study can be used to understand the potential impact and significance of primary prevention programmes targeted towards reducing the prevalence of tobacco smoking in the Nordic countries.