Risk of skin cancer following phototherapy for neonatal jaundice: retrospective

cohort study David H Brewster,1,2 Janet S Tucker,3,4 Michael Fleming,1 Carole Morris,1 Diane L Stockton,1 David J Lloyd,3,4 Sohinee Bhattacharya,3,4 James WT Chalmers1,2

1Information Services Division, NHS National Services Scotland

2University of Edinburgh

3University of Aberdeen

4Aberdeen Maternity Hospital

Scottish Cancer Taskforce Workshop:

Better Awareness of Cancer Symptoms

22 January 2010

Does late presentation explain the apparent survival deficit for cancer

in Scotland?

Outline

• Background – selected results from the EUROCARE-4 study

• Potential explanations for survival variations• Evidence for more advanced disease at

diagnosis in the UK• Potential explanations for this• England’s National Awareness and Early

Diagnosis Initiative (NAEDI)• Conclusions

Breast cancer and colorectal cancer diagnosed 1995-99. Five year relative survival by country

0

10

20

30

40

50

60

70

80

90

Breast Colorectal

% s

urv

ivin

g

Denmark

England

Scotland

Finland

Norway

Sweden

Some factors to consider in population-based survival comparisons

Data quality factors Tumour-related factors

Population coverage Extent of diseaseCompleteness of ascertainment Site (and sub-site) of tumour Accuracy of registration Tumour morphology Completeness of follow-up Tumour biology ‘Death certificate only’ registrations

Host factors Health care-related factors

Age ScreeningSex Diagnostic facilitiesSocio-economic status Treatment facilitiesRace/Ethnicity Quality of treatmentCo-morbidity Follow-up careMortality from other causesBehaviour

Colorectal cancer diagnosed 1995-99. Five year relative survival vs survival conditional on surviving at least one year

0

10

20

30

40

50

60

70

80

5-year Relative survival Conditional survival

% s

urv

ivin

g Denmark

England

Scotland

Finland

Norway

Sweden

Absolute excess death rates (breast cancer)

text

Important observation

•The survival deficit (the excess mortality) in England is mainly in the older patients•... and mainly in the short term after diagnosis

Source (last three slides): Professor Henrik Møller, Kings College London and Thames Cancer Registry.

See also: Møller H, Sandin F, Bray F, Klint A, Linklater KM, Purushotham A, Robinson D, Holmberg L. Breast cancer survival in England, Norway and Sweden: A population-based comparison. Int J Cancer 2010 (in press).

Registry

(No of cases)

Model 1 (sex + age + site)

Model 2 (model 1 + stage)

Model 3 (model 2 + surgery – resected cases only)

Model 4 (model 3 + staging

procedures† – resected cases only)

Mersey

(207)

1.15 1.10 1.01 0.99

Thames

(176)

1.41* 1.37* 1.25 1.19

*P<0.05 †Staging procedures = no of LNs examined and liver imaging

EUROCARE high resolution study of colorectal cancer: Relative risk of death within 3 years of diagnosis

Source: Gatta et al. Gut 2000;47:533-8.

England’s response to these observations

The National Awareness and Early Diagnosis Initiative (NAEDI)

• Announced in the English Cancer Reform Strategy (2007)

• Co-led by CR-UK and DoH

• Aim is to coordinate a programme of activity to support local interventions to raise public awareness of symptoms and signs of cancer, and to encourage people to present sooner

• Also encompasses a programme of research

• Much of the evidence underpinning NAEDI was published in a supplement to the British Journal of Cancer (3 December 2009).

Certainly there is some evidence that..

• Public awareness of warning signs is low (esp. among males, younger people, lower SES, and ethnic minorities).

• Some patients present long after the onset of symptoms.

• GPs are sometimes slow to refer.

• Some reasons for pre-hospital delays have been identified.

• Sometimes, there are some perceived barriers to consulting.

• There are delays in hospital.

• Individual and community interventions may promote awareness and early presentation.

BUT

• Delay is not synonymous with advanced stage – don’t forget tumour biology

Colorectal cancer diagnosed 2002: the delay-survival paradox

Some outstanding questions…• Is awareness of cancer symptoms lower in the UK than in some other European countries?

• What will be the impact on patients with cancer of more patients without cancer coming forward?

• Do UK GPs perform any better or worse than their European counter-parts?

• Are delays longer in the UK, and if so, do they account for any of the survival deficit?

• What is the role of lifestyle factors in relation to stage and outcome?

• Can GPs really improve their referral performance? – the prevalence of cancer is relatively low among GP attendees, which inevitably means that the positive predictive value of symptoms is lower than in hospital.

Prevalence (%) PPV (%) Sensitivity (%) Specificity (%)

0.1 1.8 90 95

1.0 15.4 90 95

5.0 48.6 90 95

50.0 94.7 90 95

Effect of prevalence on positive predictive value (PPV) with constant sensitivity and specificity

Setting PPV (%)

Single episode in the community

0.1

Reported to GP 2-3

Referred to hospital

5-7

Positive predictive value of rectal bleeding for colorectal cancer

Conclusions

• Survival from major epithelial cancers seems to be lower in Scotland (and the UK) compared to all of the Nordic countries except Denmark

• The excess risk of death seems to occur early on and is more apparent in oldest age groups

• Other evidence suggests that, on average, UK patients may be presenting with more advanced disease at diagnosis

• But we don’t know for sure whether this is due to later presentation, later referral, delays in diagnosis or staging, or more aggressive disease

• We know that lifestyle factors can influence survival, but we don’t really know to what extent, if any, this contributes to European survival variations

• The reasons for reported survival differences seem most likely to be multifactorial