Prognostic value of lymphocyte-monocyte ratio at diagnosis in Hodgkin lymphoma: a meta-analysis.

BACKGROUND: Prognoses of most adult Hodgkin lymphoma (HL) patients are excellent; most of them can achieve permanent remission that can be considered cured. However, many are under-treated or over-treated by standard modern therapies. An accurate determination of prognosis may allow clinicians to design personalised treatment according to individual risk of disease progression and survival. Lymphocyte monocyte ratio (LMR) at diagnosis has been investigated as a prognostic biomarker in patients with HL. Our objective with this meta-analysis was to explore the prognostic value of the LMR at diagnosis in adult HL, by investigating the association between LMR and survival outcomes. METHODS: PUBMED and EMBASE were searched for relevant articles. Survival outcomes that we investigated included overall survival (OS), progression-free survival (PFS), event-free survival (EFS), lymphoma-specific survival (LSS), and time to progression (TTP). No restriction to the language, date, study country, or sample size was applied. Final search of databases was performed on 2 April 2018. We performed random-effects meta-analysis to aggregate and summarise the results from included studies, where four or more studies on a particular outcome were available. RESULTS: A total of eight studies (all retrospective cohort studies) involving 3319 HL patients were selected for analysis. All studies except one reported the effect of LMR on OS; five reported on PFS, three reported on TTP and LSS, respectively, and one reported on EFS. The pooled estimates showed low LMR was associated with poor OS (hazard ratio [HR] 2.67, 95% CI 1.67, 4.26) and PFS (HR 2.19, 95% CI 1.46, 3.29). Subgroup analyses of OS stratified by LMR cut-off values and sample sizes both indicated that low baseline LMR was associated with poorer prognosis. CONCLUSIONS: Low LMR at diagnosis was associated with poor OS and PFS in HL. LMR is easy and cheap to determine and has a potential role in daily clinical management. More studies are needed to validate this biomarker and explore its interaction with known prognostic factors.

Population-based cancer survival in the United States: Data, quality control, and statistical methods.

BACKGROUND: Robust comparisons of population-based cancer survival estimates require tight adherence to the study protocol, standardized quality control, appropriate life tables of background mortality, and centralized analysis. The CONCORD program established worldwide surveillance of population-based cancer survival in 2015, analyzing individual data on 26 million patients (including 10 million US patients) diagnosed between 1995 and 2009 with 1 of 10 common malignancies. METHODS: In this Cancer supplement, we analyzed data from 37 state cancer registries that participated in the second cycle of the CONCORD program (CONCORD-2), covering approximately 80% of the US population. Data quality checks were performed in 3 consecutive phases: protocol adherence, exclusions, and editorial checks. One-, 3-, and 5-year age-standardized net survival was estimated using the Pohar Perme estimator and state- and race-specific life tables of all-cause mortality for each year. The cohort approach was adopted for patients diagnosed between 2001 and 2003, and the complete approach for patients diagnosed between 2004 and 2009. RESULTS: Articles in this supplement report population coverage, data quality indicators, and age-standardized 5-year net survival by state, race, and stage at diagnosis. Examples of tables, bar charts, and funnel plots are provided in this article. CONCLUSIONS: Population-based cancer survival is a key measure of the overall effectiveness of services in providing equitable health care. The high quality of US cancer registry data, 80% population coverage, and use of an unbiased net survival estimator ensure that the survival trends reported in this supplement are robustly comparable by race and state. The results can be used by policymakers to identify and address inequities in cancer survival in each state and for the United States nationally. Cancer 2017;123:4982-93. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Life tables for global surveillance of cancer survival (the CONCORD programme): data sources and methods.

BACKGROUND: We set out to estimate net survival trends for 10 common cancers in 279 cancer registry populations in 67 countries around the world, as part of the CONCORD-2 study. Net survival can be interpreted as the proportion of cancer patients who survive up to a given time, after eliminating the impact of mortality from other causes (background mortality). Background mortality varies widely between populations and over time. It was therefore necessary to construct robust life tables that accurately reflected the background mortality in each of the registry populations. METHODS: Life tables of all-cause mortality rates by single year of age and sex were constructed by calendar year for each population and, when possible, by racial or ethnic sub-groups. We used three different approaches, based on the type of mortality data available from each registry. With death and population counts, we adopted a flexible multivariable modelling approach. With unsmoothed mortality rates, we used the Ewbank relational method. Where no data were available from the registry or a national statistical office, we used the abridged UN Population Division life tables and interpolated these using the Elandt-Johnson method. We also investigated the impact of using state- and race-specific life tables versus national race-specific life tables on estimates of net survival from four adult cancers in the United States (US). RESULTS: We constructed 6,514 life tables covering 327 populations. Wide variations in life expectancy at birth and mortality by age were observed, even within countries. During 1995-99, life expectancy was lowest in Nigeria and highest in Japan, ranging from 47 to 84 years among females and 46 to 78 years among males. During 2005-09, life expectancy was lowest in Lesotho and again highest in Japan, ranging from 45 to 86 years among females and 45 to 80 years among males. For the US, estimates of net survival differed by up to 4% if background mortality was fully controlled with state- and race-specific life tables, rather than with national race-specific life tables. CONCLUSIONS: Background mortality varies worldwide. This emphasises the importance of using population-specific life tables for geographic and international comparisons of net survival.

Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2).

BACKGROUND: Worldwide data for cancer survival are scarce. We aimed to initiate worldwide surveillance of cancer survival by central analysis of population-based registry data, as a metric of the effectiveness of health systems, and to inform global policy on cancer control. METHODS: Individual tumour records were submitted by 279 population-based cancer registries in 67 countries for 25·7 million adults (age 15-99 years) and 75,000 children (age 0-14 years) diagnosed with cancer during 1995-2009 and followed up to Dec 31, 2009, or later. We looked at cancers of the stomach, colon, rectum, liver, lung, breast (women), cervix, ovary, and prostate in adults, and adult and childhood leukaemia. Standardised quality control procedures were applied; errors were corrected by the registry concerned. We estimated 5-year net survival, adjusted for background mortality in every country or region by age (single year), sex, and calendar year, and by race or ethnic origin in some countries. Estimates were age-standardised with the International Cancer Survival Standard weights. FINDINGS: 5-year survival from colon, rectal, and breast cancers has increased steadily in most developed countries. For patients diagnosed during 2005-09, survival for colon and rectal cancer reached 60% or more in 22 countries around the world; for breast cancer, 5-year survival rose to 85% or higher in 17 countries worldwide. Liver and lung cancer remain lethal in all nations: for both cancers, 5-year survival is below 20% everywhere in Europe, in the range 15-19% in North America, and as low as 7-9% in Mongolia and Thailand. Striking rises in 5-year survival from prostate cancer have occurred in many countries: survival rose by 10-20% between 1995-99 and 2005-09 in 22 countries in South America, Asia, and Europe, but survival still varies widely around the world, from less than 60% in Bulgaria and Thailand to 95% or more in Brazil, Puerto Rico, and the USA. For cervical cancer, national estimates of 5-year survival range from less than 50% to more than 70%; regional variations are much wider, and improvements between 1995-99 and 2005-09 have generally been slight. For women diagnosed with ovarian cancer in 2005-09, 5-year survival was 40% or higher only in Ecuador, the USA, and 17 countries in Asia and Europe. 5-year survival for stomach cancer in 2005-09 was high (54-58%) in Japan and South Korea, compared with less than 40% in other countries. By contrast, 5-year survival from adult leukaemia in Japan and South Korea (18-23%) is lower than in most other countries. 5-year survival from childhood acute lymphoblastic leukaemia is less than 60% in several countries, but as high as 90% in Canada and four European countries, which suggests major deficiencies in the management of a largely curable disease. INTERPRETATION: International comparison of survival trends reveals very wide differences that are likely to be attributable to differences in access to early diagnosis and optimum treatment. Continuous worldwide surveillance of cancer survival should become an indispensable source of information for cancer patients and researchers and a stimulus for politicians to improve health policy and health-care systems. FUNDING: Canadian Partnership Against Cancer (Toronto, Canada), Cancer Focus Northern Ireland (Belfast, UK), Cancer Institute New South Wales (Sydney, Australia), Cancer Research UK (London, UK), Centers for Disease Control and Prevention (Atlanta, GA, USA), Swiss Re (London, UK), Swiss Cancer Research foundation (Bern, Switzerland), Swiss Cancer League (Bern, Switzerland), and University of Kentucky (Lexington, KY, USA).

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.

Population-Based Cancer Survival in Canada and the United States by Socioeconomic Status: Findings from the CONCORD-2 Study.

Background: Population-based cancer survival provides insight into the effectiveness of health systems to care for all residents with cancer, including those in marginalized groups. Methods: Using CONCORD-2 data, we estimated 5-year net survival among patients diagnosed 2004-2009 with one of 10 common cancers, and children diagnosed with acute lymphoblastic leukemia (ALL), by socioeconomic status (SES) quintile, age (0-14, 15-64, ≥65 years), and country (Canada or United States). Results: In the lowest SES quintile, survival was higher among younger Canadian adults diagnosed with liver (23% vs 15%) and cervical (78% vs 68%) cancers and with leukemia (62% vs 56%), including children diagnosed with ALL (92% vs 86%); and higher among older Americans diagnosed with colon (62% vs 56%), female breast (87% vs 80%), and prostate (97% vs 85%) cancers. In the highest SES quintile, survival was higher among younger Americans diagnosed with stomach cancer (33% vs 27%) and younger Canadians diagnosed with liver cancer (31% vs 23%); and higher among older Americans diagnosed with stomach (27% vs 22%) and prostate (99% vs 92%) cancers. Conclusions: Among younger Canadian cancer patients in the lowest SES group, greater access to health care may have resulted in higher cancer survival, while higher screening prevalence and access to health insurance (Medicare) among older Americans during the period of this study may have resulted in higher survival for some screen-detected cancers. Higher survival in the highest SES group for stomach and liver may relate to treatment differences. Survival differences by age and SES between Canada and the United States may help inform cancer control strategies.

Education, immigration and rising mental health inequality in Sweden.

Educational and income gradients in health are well established in the literature but there is need for a better understanding of how mental health inequalities change over time, and what drives the development. We aim to study how psychiatric diagnosis and its income-related inequality have changed over time in Sweden and to make a first attempt at disentangling the development by decomposing any changes in terms of changes in two important demographic characteristics: education and migration background. We use administrative patient data to study psychiatric inpatient diagnosis in the years 1994 and 2011. The study population comprises all individuals aged 31-64 years living in Sweden. Income-related inequalities are measured by the Concentration Index (CI). We decompose changes in the probability of receiving a diagnosis and changes in income-related inequality over time to understand the role of changing demographics. Our results show that over the study period the probability of receiving a psychiatric inpatient diagnosis increased by 12.6%, while the relative and absolute income-related inequalities in diagnosis increased by 48.2% and 66.7% respectively. In 2011, more than half of psychiatric inpatients were found among the poorest fifth of the population. The decomposition results suggest that changes in education and migration background have not played a substantial role in determining these increases. Education levels increased substantially over the study period which would be expected to protect against mental ill-health. Instead, we find that diagnoses have become more concentrated amongst the lowest educated individuals and the lowest income families, groups who appear to be increasingly disadvantaged. The growing proportion of individuals with foreign background in Sweden does, in fact, predict small increases in the probability of diagnosis, while the impact on diagnosis inequality varies depending on the definition of foreign background.

Worldwide comparison of survival from childhood leukaemia for 1995-2009, by subtype, age, and sex (CONCORD-2): a population-based study of individual data for 89 828 children from 198 registries in 53 countries.

BACKGROUND: Global inequalities in access to health care are reflected in differences in cancer survival. The CONCORD programme was designed to assess worldwide differences and trends in population-based cancer survival. In this population-based study, we aimed to estimate survival inequalities globally for several subtypes of childhood leukaemia. METHODS: Cancer registries participating in CONCORD were asked to submit tumour registrations for all children aged 0-14 years who were diagnosed with leukaemia between Jan 1, 1995, and Dec 31, 2009, and followed up until Dec 31, 2009. Haematological malignancies were defined by morphology codes in the International Classification of Diseases for Oncology, third revision. We excluded data from registries from which the data were judged to be less reliable, or included only lymphomas, and data from countries in which data for fewer than ten children were available for analysis. We also excluded records because of a missing date of birth, diagnosis, or last known vital status. We estimated 5-year net survival (ie, the probability of surviving at least 5 years after diagnosis, after controlling for deaths from other causes [background mortality]) for children by calendar period of diagnosis (1995-99, 2000-04, and 2005-09), sex, and age at diagnosis (<1, 1-4, 5-9, and 10-14 years, inclusive) using appropriate life tables. We estimated age-standardised net survival for international comparison of survival trends for precursor-cell acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML). FINDINGS: We analysed data from 89 828 children from 198 registries in 53 countries. During 1995-99, 5-year age-standardised net survival for all lymphoid leukaemias combined ranged from 10·6% (95% CI 3·1-18·2) in the Chinese registries to 86·8% (81·6-92·0) in Austria. International differences in 5-year survival for childhood leukaemia were still large as recently as 2005-09, when age-standardised survival for lymphoid leukaemias ranged from 52·4% (95% CI 42·8-61·9) in Cali, Colombia, to 91·6% (89·5-93·6) in the German registries, and for AML ranged from 33·3% (18·9-47·7) in Bulgaria to 78·2% (72·0-84·3) in German registries. Survival from precursor-cell ALL was very close to that of all lymphoid leukaemias combined, with similar variation. In most countries, survival from AML improved more than survival from ALL between 2000-04 and 2005-09. Survival for each type of leukaemia varied markedly with age: survival was highest for children aged 1-4 and 5-9 years, and lowest for infants (younger than 1 year). There was no systematic difference in survival between boys and girls. INTERPRETATION: Global inequalities in survival from childhood leukaemia have narrowed with time but remain very wide for both ALL and AML. These results provide useful information for health policy makers on the effectiveness of health-care systems and for cancer policy makers to reduce inequalities in childhood cancer survival. FUNDING: Canadian Partnership Against Cancer, Cancer Focus Northern Ireland, Cancer Institute New South Wales, Cancer Research UK, US Centers for Disease Control and Prevention, Swiss Re, Swiss Cancer Research foundation, Swiss Cancer League, and the University of Kentucky.

Cancer incidence, mortality, and survival in Eastern Libya: updated report from the Benghazi Cancer Registry.

PURPOSE: Despite the increasing burden of cancer occurred over recent years in the African continent, epidemiologic data from Northern Africa area have been so far sparse or absent. We present most recently available data from the Benghazi Cancer Registry concerning cancer incidence and mortality as well as the most comprehensive survival data set so far generated for cases diagnosed during 2003 to 2005 in Eastern Libya. METHODS: We collected and analyzed data on cancer incidence, mortality and survival that were obtained over a 3-year study period from January 1st 2003 to December 31st 2005 from the Benghazi Cancer Registry. RESULTS: A total of 3307 cancer patients were registered among residents during the study period. The world age-standardized incidence rate for all sites was 135.4 and 107.1 per 100,000 for males and females, respectively. The most common malignancies in men were cancers of lung (18.9%), colorectum (10.4%), bladder (10.1%), and prostate (9.4%); among women, they were breast (23.2%), colorectum (11.2%), corpus uteri (6.7%), and leukemia (5.1%). A total of 1367 deaths for cancer were recorded from 2003 to 2005; the leading causes of cancer death were cancers of the lung (29.3%), colorectum (8.2%), and brain (7.3%) in males and cancers of breast (14.8%), colorectum (10.6%), and liver (7%) in females. The 5-year relative survival for all cancer combined was 22.3%; survival was lower in men (19.8%) than in women (28.2%). CONCLUSIONS: This study provides an updated report on cancer incidence, mortality, and survival, in Eastern Libya which may represent a useful tool for planning future interventions toward a better cancer control.