Cancer incidence and mortality trends in France over 1990-2018 for solid tumors: the sex gap is narrowing.

OBJECTIVE: To analyze trends in cancer incidence and mortality (France, 1990-2018), with a focus on men-women disparities. METHODS: Incidence data stemmed from cancer registries (FRANCIM) and mortality data from national statistics (CépiDc). Incidence and mortality rates were modelled using bidimensional penalized splines of age and year (at diagnosis and at death, respectively). Trends in age-standardized rates were summarized by the average annual percent changes (AAPC) for all-cancers combined, 19 solid tumors, and 8 subsites. Sex gaps were indicated using male-to-female rate ratios (relative difference) and male-to-female rate differences (absolute difference) in 1990 and 2018, for incidence and mortality, respectively. RESULTS: For all-cancers, the sex gap narrowed over 1990-2018 in incidence (1.6 to 1.2) and mortality (2.3 to 1.7). The largest decreases of the male-to-female incidence rate ratio were for cancers of the lung (9.5 to 2.2), lip - oral cavity - pharynx (10.9 to 3.1), esophagus (12.6 to 4.5) and larynx (17.1 to 7.1). Mixed trends emerged in lung and oesophageal cancers, probably explained by differing risk factors for the two main histological subtypes. Sex incidence gaps narrowed due to increasing trends in men and women for skin melanoma (0.7 to 1, due to initially higher rates in women), cancers of the liver (7.4 to 4.4) and pancreas (2.0 to 1.4). Sex incidence gaps narrowed for colon-rectum (1.7 to 1.4), urinary bladder (6.9 to 6.1) and stomach (2.7 to 2.4) driven by decreasing trends among men. Other cancers showed similar increasing incidence trends in both sexes leading to stable sex gaps: thyroid gland (0.3 to 0.3), kidney (2.2 to 2.4) and central nervous system (1.4 to 1.5). CONCLUSION: In France in 2018, while men still had higher risks of developing or dying from most cancers, the sex gap was narrowing. Efforts should focus on avoiding risk factors (e.g., smoking) and developing etiological studies to understand currently unexplained increasing trends.

Cancer incidence in France over the 1980-2012 period: Hematological malignancies.

BACKGROUND: The classification of hematological malignancies (HMs) has changed in recent decades. For the first time, the French network of cancer registries (Francim) provides estimates for incidence and trends of HM in France between 1980 and 2012 for major HM subtypes. METHODS: Incidence was directly estimated by modeling the incidence rates measured in the cancer registry area. For each HM subtype, a "usable incidence period" was defined a priori, corresponding to the years for which all the registries collected them in a homogeneous way. For both sexes and each HM subtype, age-period-cohort models were used to estimate national incidence trends. RESULTS: Overall in France, there were an estimated 35,000 new HMs in 2012 (19,400 in men and 15,600 in women). Lymphoid malignancies accounted for more than two-thirds of HM incident cases (n=25,136). The incidence sex ratio (M/F) varied from 1.1 for classical Hodgkin lymphoma to 4.0 for mantle-cell lymphoma. The median age at diagnosis ranged from 62 to 81 years according to the major HM subtypes. Overall in both sexes, the top five most frequent HMs in 2012 were plasma cell neoplasm (about 4900 estimated cases), chronic lymphocytic leukemia/small lymphocytic lymphoma (4500 cases), diffuse large B-cell lymphoma and myelodysplastic syndromes (4100 cases), and acute myeloid leukemia (2800 cases). The incidence rates increased for follicular lymphoma and plasma cell neoplasm during the study period in both sexes. Classical Hodgkin lymphoma was relatively stable in men between 1980 and 2012 and increased in both sexes during the most recent period. Chronic myeloproliferative neoplasms, other than chronic myelogenous leukemia, are the only subtype that showed a slightly downward trend in incidence between 2003 and 2012 in both sexes. CONCLUSION: The striking differences in the incidence patterns by histologic subtype strongly suggest a certain level of etiologic heterogeneity among hematological malignancies and support the pursuit of epidemiologic analysis by subtype for HMs in international studies. Age-standardized incidence rates are essential to analyze trends in risk, whereas the number of incident cases is necessary to make provisions for healthcare resources and to evaluate the overall burden of HM.

Morphometric analysis of the distal femur in total knee arthroplasty and native knees.

AIMS: Analysis of the morphology of the distal femur, and by extension of the femoral components in total knee arthroplasty (TKA), has largely been related to the aspect ratio, which represents the width of the femur. Little is known about variations in trapezoidicity (i.e. whether the femur is more rectangular or more trapezoidal). This study aimed to quantify additional morphological characteristics of the distal femur and identify anatomical features associated with higher risks of over- or under-sizing of components in TKA. METHODS: We analysed the shape of 114 arthritic knees at the time of primary TKA using the pre-operative CT scans. The aspect ratio and trapezoidicity ratio were quantified, and the post-operative prosthetic overhang was calculated. We compared the morphological characteristics with those of 12 TKA models. RESULTS: There was significant variation in both the aspect ratio and trapezoidicity ratio between individuals. Femoral trapezoidicity was mostly due to an inward curve of the medial cortex. Overhang was correlated with the aspect ratio (with a greater chance of overhang in narrow femurs), trapezoidicity ratio (with a greater chance in trapezoidal femurs), and the tibio-femoral angle (with a greater chance in valgus knees). DISCUSSION: This study shows that rectangular/trapezoidal variability of the distal femur cannot be ignored. Most of the femoral components which were tested appeared to be excessively rectangular when compared with the bony contours of the distal femur. These findings suggest that the design of TKA should be more concerned with matching the trapezoidal/rectangular shape of the native femur. TAKE HOME MESSAGE: The distal femur is considerably more trapezoidal than most femoral components, and therefore, care must be taken to avoid anterior prosthetic overhang in TKA

Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty - why?

The aim of this study was to investigate the relationship between the geometry of the proximal femur and the incidence of intra-operative fracture during uncemented total hip arthroplasty (THA). We studied the pre-operative CT scans of 100 patients undergoing THA with an uncemented femoral component. We measured the anteroposterior and mediolateral dimensions at the level of division of the femoral neck to calculate the aspect ratio of the femur. Wide variations in the shape of the femur were observed, from round, to very narrow elliptic. The femurs of women were narrower than those of men (p < 0.0001) and small femurs were also narrower than large ones. Patients with an intra-operative fracture of the calcar had smaller and narrower femurs than those without a fracture (p < 0.05) and the implanted Corail stems were smaller in those with a fracture (mean size 9 vs 12, p < 0.0001). The variability of the shape of the femoral neck at the level of division contributes to the understanding of the causation of intra-operative fractures in uncemented THA.

[Prostate cancer incidence and mortality trends in France from 1980 to 2011]. / Le cancer de la prostate, évolution de l'incidence et de la mortalité en France entre 1980 et 2011.

UNLABELLED: The prostate cancer became for two decades the most frequent cancer in men. We describe the evolution of its incidence and mortality from 1980 to 2011 for France. METHODS: Incidence data were collected from registries and national incidence estimates were based on the use of mortality as a correlate of incidence. RESULTS: After a very strong increase of incidence between 1980 (24.8/100,000) and 2005 (124.5/100,000), we observe a net decline since (97.7/100,000, in 2011). The reduction began earlier for the old patients. The evolution of mortality is very different. We observe a regular reduction since the end of 1990s (from 18.0/100,000 in 1990 to 10.5/100,000 in 2011). The reduction began earlier for the young patients. CONCLUSION: This pattern of evolution is observed in all the countries where the use of the PSA had caused an important increase of the diagnosis of prostate cancer. LEVEL OF EVIDENCE: 3.

Cancer incidence and mortality in France over the 1980-2012 period: solid tumors.

BACKGROUND: Cancer incidence and mortality estimates for 19 cancers (among solid tumors) are presented for France between 1980 and 2012. METHODS: Incidence data were collected from 21 local registries and correspond to invasive cancers diagnosed between 1975 and 2009. Mortality data for the same period were provided by the Institut national de la santé et de la recherche médicale. The national incidence estimates were based on the use of mortality as a correlate of incidence. The observed incidence and mortality data were modeled using an age-period-cohort model. The numbers of incident cases and deaths for 2010-2012 are the result of short-term projections. RESULTS: In 2012, the study estimated that 355,000 new cases of cancer (excluding non-melanoma skin cancer) and 148,000 deaths from cancer occurred in France. The incidence trend was not linear over the study period. After a constant increase from 1980 onwards, the incidence of cancer in men declined between 2005 and 2012. This recent decrease is largely related to the reduction in the incidence of prostate cancer. In women, the rates stabilized, mainly due to a change in breast cancer incidence. Mortality from most cancer types declined over the study period. A combined analysis of incidence and mortality by cancer site distinguished cancers with declining incidence and mortality (e.g., stomach) and cancers with increasing incidence and mortality (e.g., lung cancer in women). Some other cancers had rising incidence but declining mortality (e.g., thyroid). CONCLUSION: This study reveals recent changes in cancer incidence trends, particularly regarding breast and prostate cancers.

Probabilities of dying from cancer and other causes in French cancer patients based on an unbiased estimator of net survival: a study of five common cancers.

BACKGROUND: Net survival is the survival that would be observed if cancer were the only possible cause of death. Although it is an important epidemiological tool allowing temporal or geographical comparisons, it cannot inform on the "crude" probability of death of cancer patients; i.e., when taking into account other possible causes of deaths. METHODS: In this work, we provide estimates of the crude probabilities of death from cancer and from other causes as well as the probability of being alive up to ten years after cancer diagnosis according to the age and year of diagnosis. Based on a flexible excess hazard model providing unbiased estimates of net survival, our methodology avoids the pitfalls associated with the use of the cause of death. We used data from FRANCIM, the French network of cancer registries, and studied five common cancer sites: head and neck, breast, prostate, lung, and colorectal cancers. RESULTS: For breast, prostate, and colorectal cancers, the impact of the other causes on the total probability of death increased with the age at diagnosis whereas it remained negligible for lung and head and neck cancers whatever the age. For breast, prostate, and colorectal cancer, the more recently was the cancer diagnosed, the less was the probability of death from cancer. CONCLUSION: The crude probability of death is an intuitive concept that may prove particularly useful in choosing an appropriate treatment, or refining the indication of a screening strategy by allowing the clinician to estimate the proportion of cancer patients who will die specifically from cancer.

National cancer incidence is estimated using the incidence/mortality ratio in countries with local incidence data: is this estimation correct?

BACKGROUND: In countries with local cancer registration, the national cancer incidence is usually estimated by multiplying the national mortality by the incidence/mortality (I/M) ratio from pooled registries. This study aims at validating this I/M estimation in France, by a comparison with estimation obtained using the ratio of incidence over hospital discharge (I/HD) or the ratio of incidence over health insurance data (long-duration diseases, I/LDD). METHODS: This comparison was performed for 22 cancer sites over the period 2004-2006. In France, a longitudinal I/M approach was developed relying on incidence and mortality trend analyses; here, the corresponding estimations of national incidence were extracted for 2004-2006. The I/HD and I/LDD estimations were performed using a common cross-sectional methodology. RESULTS: The three estimations were found similar for most cancers. The relative differences in incidence rates (vs. I/M) were below 5% for numerous cancers and below 10% for all cancers but three. The highest differences were observed for thyroid cancer (up to +21% in women and +8% in men), skin melanoma (up to +13% in women and +8% in men), and Hodgkin disease in men (up to +15%). Differences were also observed in women aged over 60 for cervical cancer. Except for thyroid cancer, differences were mainly due to the smoothing performed in the I/M approach. CONCLUSION: Our results support the validity of I/M approaches for national estimations, except for thyroid cancer. The longitudinal version of this approach has, furthermore, the advantage of providing smoothed estimations and trend analyses, including useful birth-cohort indicators, and should thus be preferred.

[Diversity of incidence trend patterns: implications for carcinogenesis?]. / Diversité des modèles d'évolution des incidences: implication en cancérogenèse?

OBJECTIVE: Cancers of the ENT, oesophagus and lungs are caused mainly by alcohol and/or tobacco consumption but have potentially heterogeneous latencies and dose-incidence relationships. The incidence of cancers having the same risk factors may vary in a similar way over time and space. The aim of the study was to identify groups of cancers with similar spatio-temporal incidence trends. METHODS: Fifty thousand nine hundred and eighty cases of ten cancer types were collected between 1982 and 2002 in six French departments. The incidence levels and trends were assessed using an age-cohort random-effect model that took into account heterogeneity of incidence levels and trends between departments. RESULTS: Three groups of cancer sites/types with similar spatio-temporal incidence trends were identified: (1) oral cavity, oropharynx, hypopharynx, larynx, oesophagus, and lung squamous cell carcinomas in which the incidence decreased similarly in time and space; (2) other types of lung cancer and lung adenocarcinomas whose incidence increased similarly; and (3) lung large- and small-cell carcinomas whose incidence trends were heterogeneous. CONCLUSION: Using the tools of descriptive epidemiology different cancer groups with different temporal and spatial incidence trends were identified. This diversity suggests different latencies and different sensitivities of those groups to the main risk factors, alcohol and tobacco.

[Critical analysis of French DRG based information system (PMSI) databases for the epidemiology of cancer: a longitudinal approach becomes possible]. / Analyse critique des données du PMSI pour l'épidémiologie des cancers : une approche longitudinale devient possible.

BACKGROUND: Use of French Diagnosis Related Groups (DRGs) program databases, apart from financial purposes, has recently been improved since a unique anonymous patient identification number has been created for each inpatient in administrative case mix database. Based on the work of the group for cancer epidemiological observation in the Rhône-Alpes area, (ONC-EPI group), we review the remaining difficulties in the use of DRG data for epidemiological purposes and we consider a longitudinal approach based on analysis of database over several years. We also discuss limitations of this approach. DIFFICULTIES: The main problems are related to a lack of quality of administrative data, especially coding of diagnoses. These errors come from missing or inappropriate codes, or not being in accordance with prioritization rules (causing an over- or under-reporting or inconsistencies in coding over time). One difficulty, partly due to the hierarchy of coding and the type of cancer, is the choice of an extraction algorithm. In two studies designed to estimate the incidence of cancer cared in hospitals (breast, colon-rectum, kidney, ovaries), a first algorithm, including a code of cancer as principal diagnosis with a selection of surgical procedures less performed than the second one including a code of cancer as principal diagnosis only, for which the number of hospitalizations per patient ratio was stable across time and space. The chaining over several years allows, by tracing the trajectory of the patient, to detect and correct inaccuracies, errors and missing values, and for incidence studies, to correct incident cases by removing prevalent cases. DISCUSSION: However, linkage, complete only since 2007, does not correct data in all cases. Ways of future improvement certainly pass through improved algorithms for case identification and especially by linking DRG data with other databases.

Identifying prevalent cases of breast cancer in the French case-mix databases.

OBJECTIVES: Little is known about cancer prevalence due to a lack of systematic recording of cancer patient follow-up data. To estimate the annual hospital prevalence of breast cancer in the general population of the Isère department (1.1 million inhabitants) in the Rhône-Alpes region, the second largest region in France (6 million inhabitants), we used the inpatient case-mix data, available in most European countries, to develop a method of cancer case identification. METHODS: A selection process was applied to the acute care hospital datasets among women aged 18 years or older, living in the Isère department and treated for breast cancer between 2004 and 2007. The first step in case selection was based on the national anonymous unique patient identifier. The second step consisted of retrieving all hospital stays for each case. The third step was designed to detect inconsistencies in the coding of the primary localization. An algorithm based on ICD-10 code for the hospital admission diagnosis was used to rule out hospitalizations unrelated to breast cancer. Five possible models for estimating prevalence were created combining selection steps with the admission diagnosis algorithm. RESULTS: Hospital prevalence over the four-year period varied from 6073 breast cancer cases for the simplest model (first selection step without the admission diagnosis algorithm) to 4951 when the first selection step was associated with the breast cancer code as admission diagnosis. The model combining the third selection step with a breast cancer-specific admission reason provided 5275 prevalent cases. CONCLUSION: The last model seems more appropriate for case-mix-data coding. Selecting admission diagnosis improved specificity. Combining all hospital stays for each patient has improved diagnostic sensitivity.

Evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005.

The evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005 was analysed using data derived from the French network of cancer registries (FRANCIM) and the French National Mesothelioma Surveillance Program (PNSM). Mesothelioma proportions in pleural cancers were calculated by diagnosis year in the 1980-2000 period. Our results suggest that the incidences of pleural cancer and mesothelioma levelled off in French men since 2000 and continued to increase in French women. A decrease of the annual pleural cancer incidence average in men was noticed (-3.4% of annual rate of change) between 2000 and 2005. The proportion of pleural cancers that were mesothelioma was unchanged between 1980 and 2003 with an average of 86%. The age standardised incidence rate of pleural mesothelioma remained relatively stable between 1998 and 2005 with a slight falling trend. For women, the age standardised incidence rate of pleural cancers and mesothelioma increased during the period 1998-2005. Additionally, the proportion of pleural cancers that were mesothelioma increased during the same period of time. Finally, the increased trend observed in the incidence of pleural mesothelioma and cancers in women is credibly due to their under diagnosis in the 1980-1997 period. The comparison between the French incidence and the American and British ones shows that the decreasing trend in incidence of mesothelioma and pleural cancers in French men since 2000 is potentially associated with a lower amphibole consumption and by the implementation of safety regulations at work from 1977.

Descriptive epidemiology of thyroid cancer in France: incidence, mortality and survival.

OBJECTIVES: Describe time trends of incidence and mortality associated with thyroid cancer and provide 1 and 5-year survivals by histological group in French areas covered by cancer registries. MATERIAL AND METHODS: Data for 1975 to 2004 were provided by one thyroid-dedicated and 11 general registries. Incidence estimates were obtained by correction of incidence from areas with registries, then projections for 2008 were derived. Overall and relative survivals by sex and age (diagnosis period 1989-1997; cut-off date 1st January 2002) were obtained from the dedicated and nine other registries. Comparisons between areas or time periods used world-standardized rates. RESULTS: Between 1980 and 2005, incidence increased but mortality decreased in men and women. Annual cases increased five times and projections for 2008 were 8,000 cases and 400 deaths. The main increasing subtype was papillary carcinoma. One-year overall and relative survivals were 92 and 94%, respectively. Five-year overall and relative survivals were 87 and 93%, respectively. The highest survival (>94%) concerned papillary carcinomas and the lowest (<15%) anaplastic carcinomas. Survivals were generally higher in women than in men; precisely, higher in women for papillary and follicular carcinomas but higher in men for medullary and anaplastic carcinomas. Survivals increased with age, but for medullary carcinomas. Survivals from anaplastic carcinomas were very low whatever the age. CONCLUSION: The increase of thyroid cancer frequency is dramatic but survivals are improving. Though the prognosis of the most increasing histological subtype is generally good, it remains very important to identify the causes of this steady increase to implement adequate preventive measures.

Analysis of the effect of age on the prognosis of breast cancer.

To explore the effect of age at diagnosis on relative survival from breast cancer at different cancer stages and grades, using appropriate statistical modeling of time-varying and non-linear effects of that prognostic covariate. Data on 4,791 female invasive breast cancers diagnosed between 1990 and 1997 were obtained from a French cancer registry. The effect of age on relative survival was studied using an approach based on excess rate modeling. Different models testing non-linear and non-proportional effects of age were explored for each grade and each stage. In the whole population, the effect of age was not linear and varied with the time elapsed since diagnosis. When analyzing the different sub-groups according to grade and stage, age did not have a significant effect on relative survival in grade 1 or stage 3 tumors. In grade 2 and stage 4 tumors, the excess mortality rate increased with age, in a linear way. In grade 3 tumors, age was a time-dependent factor: older women had higher excess rates than younger ones during the first year after diagnosis whereas the inverse phenomenon was observed 5 years after diagnosis. Our findings suggest that when taking into account grade and stage, the time-varying impact of young age at diagnosis is limited to grade 3 tumors, without evidence of worst prognosis at 5 years for the youngest women.

[Some interpretation of regional estimates of the incidence of cancer in France over the period 1980--2005]. / Eléments d'interprétation des estimations régionales de l'incidence du cancer en France sur la période 1980--2005.

Francim Network has already provided French national estimations of cancer incidence then regional estimations for Metropolitan France. The present technical note summarizes the underlying hypotheses and the limits of the method and suggests some aspects of interpretation of those regional results in terms of absolute numbers and of standardized rates. Results on "all cancers" illustrate those comments.

Is it possible to estimate the incidence of breast cancer from medico-administrative databases?

One approach to estimate cancer incidence in the French Départements is to quantify the relationship between data in cancer registries and data obtained from the PMSI (Programme de Médicalisation des Systèmes d'Information Médicale). This relationship may then be used in Départements without registries to infer the incidence from local PMSI data. We present here some methodological solutions to apply this approach. Data on invasive breast cancer for 2002 were obtained from 12 Départemental registries. The number of hospital stays was obtained from the National PMSI using two different algorithms based on the main diagnosis only (Algorithm 1) or on that diagnosis associated to a mention of "resection" (Algorithm 2). Considering registry data as gold standard, a calibration approach was used to model the ratio of the number of hospital stays to the number of incident cases. In Départements with registries, validation of the predictions was done through cross-validation. In Départements without registries, validation was done through a study of homogeneity of the mean number of hospital stays per patient. Cross-validation showed that the estimates predicted by the model were true with data extracted by Algorithm 1 but not by Algorithm 2. However, with Algorithm 1, there was an important heterogeneity between French Départements as to the mean number of hospital stays per patient, which had an important impact on the estimations. In the near future, the method will allow using medico-administrative data (after calibration with registry data) to estimate Départemental incidence of selected cancers.

Cancer incidence and mortality in France over the period 1980-2005.

BACKGROUND: The objective of this study was to provide updated estimates of national trends in cancer incidence and mortality for France for 1980-2005. METHODS: Twenty-five cancer sites were analysed. Incidence data over the 1975-2003 period were collected from 17 registries working at the department level, covering 16% of the French population. Mortality data for 1975-2004 were provided by the Inserm. National incidence estimates were based on the use of mortality as a correlate of incidence, mortality being available at both department and national levels. Observed incidence and mortality data were modelled using an age-cohort approach, including an interaction term. Short-term predictions from that model gave estimates of new cancer cases and cancer deaths in 2005 for France. RESULTS: The number of new cancer cases in 2005 was approximately 320,000. This corresponds to an 89% increase since 1980. Demographic changes were responsible for almost half of that increase. The remainder was largely explained by increases in prostate cancer incidence in men and breast cancer incidence in women. The relative increase in the world age-standardised incidence rate was 39%. The number of deaths from cancer increased from 130,000 to 146,000. This 13% increase was much lower than anticipated on the basis of demographic changes (37%). The relative decrease in the age-standardised mortality rate was 22%. This decrease was steeper over the 2000-2005 period in both men and women. Alcohol-related cancer incidence and mortality continued to decrease in men. The increasing trend of lung cancer incidence and mortality among women continued; this cancer was the second cause of cancer death among women. Breast cancer incidence increased regularly, whereas mortality has decreased slowly since the end of the 1990s. CONCLUSION: This study confirmed the divergence of cancer incidence and mortality trends in France over the 1980-2005 period. This divergence can be explained by the combined effects of a decrease in the incidence of the most aggressive cancers and an increase in the incidence of less aggressive cancers, partly due to changes in medical practices leading to earlier diagnoses.

An overall strategy based on regression models to estimate relative survival and model the effects of prognostic factors in cancer survival studies.

Relative survival provides a measure of the proportion of patients dying from the disease under study without requiring the knowledge of the cause of death. We propose an overall strategy based on regression models to estimate the relative survival and model the effects of potential prognostic factors. The baseline hazard was modelled until 10 years follow-up using parametric continuous functions. Six models including cubic regression splines were considered and the Akaike Information Criterion was used to select the final model. This approach yielded smooth and reliable estimates of mortality hazard and allowed us to deal with sparse data taking into account all the available information. Splines were also used to model simultaneously non-linear effects of continuous covariates and time-dependent hazard ratios. This led to a graphical representation of the hazard ratio that can be useful for clinical interpretation. Estimates of these models were obtained by likelihood maximization. We showed that these estimates could be also obtained using standard algorithms for Poisson regression.

Survival of cancer patients in France: a population-based study from The Association of the French Cancer Registries (FRANCIM).

We present the main results of the first population-based cancers survival study gathering all French registry data. Survival data on 205,562 cancer cases diagnosed between 01/01/1989 and 31/12/1997 were analysed. Relative survival was estimated using an excess rate model. The evolution of the excess mortality rate over the follow-up period was graphed. The analysis emphasised the effect of age at diagnosis and its variation with time after diagnosis. For breast and prostate cancers, the age-standardised five-year relative survivals were 84% and 77%, respectively. The corresponding results in men and women were 56% versus 58% for colorectal cancer and 12% versus 16% for lung cancer. For some cancer sites, the excess mortality rate decreased to low values by five years after diagnosis. For most cancer sites, age at diagnosis was a negative prognostic factor but this effect was often limited to the first year after diagnosis.