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The Eurocare 2 study re-evaluated: Ranking of countries according to survival with cancer may be flawed

Flemming Madsen, Lars Frolund and Bente Nørskov   (12 June 2007)

The Eurocare 2 study re-evaluated: Ranking of countries according to survival with cancer may be flawed 12 June 2007
Flemming Madsen, Respiratory Phycisian Allergy and Lung Clinic DK 3000 Ellsinore, Lars Frolund and Bente Nørskov Send response to journal: Re: The Eurocare 2 study re-evaluated: Ranking of countries according to survival with cancer may be flawed	Quality of care is in focus for selected groups of patients and priorities are changed accordingly. Patients with cancer is a large group and it has been argued that quality of care was lacking behind in England (1-3) and Denmark(4). Poor quality of cancer treatment may result in premature death and it was therefore only natural to compare survival with cancer between countries. Poor survival was assumed in some countries and “National Cancer Strategies” were developed. However quality of cancer management had not been thoroughly investigated and survival after cancer may not be an appropriate estimate of quality of care without controlling for potential confounders and flaws (5). Much of the public debate on cancer focused on simple ranking of countries (1;4) On this basis we found it of interest to revaluate one major database used to rank European countries with respect to survival after the diagnosis of cancer - the Eurocare 2 study(6). We also hypothesised that ranking of countries was dependent on age since age is reflecting time of exposure to a certain lifestyle and health system. Participants, methods, and results Eurocare 2(6) reports analyses of survival for the period 1985-1989 and survival trend analyses 1978-1985 for 18 European countries. In our analyses (1985-1989) the following number of patients was included in the period. Sweden 29518 (17% coverage), England 438832 (50%), Denmark 104312 (100%) and Poland 17128 (6%). Countries were ranked according to the age specific 5-yr survival for all cancers and for both sexes (highest = 1 and lowest survival = 18). For all age groups Sweden ranks no. 1 and Poland no. 16-18. In contrast England and Denmark displays a different pattern showing ranking at or above median for the younger and below for the elderly. Of countries with more than 50% coverage (notification) (7 countries) only Finland and Iceland ranks better than Denmark and England regarding overall survival. Age distribution of notified cases shows a higher proportion of the elderly (age>65yr) in England (0.63) and Denmark (0.60) compared to Sweden (0.52) and Poland (0.56). Comment Eurocare 2 should be interpreted with great care only. There are major problems with coverage of cancer notification and a simple ranking of countries on basis of Eurocare is not justified. E.g. Sweden report only 17 % of the cases compared to England (50%) and Denmark (100%). Relatively low registration of cancer in the elderly is possible in some countries leading to selection bias. This might explain our finding that younger English and Danish cancer patients manage better and older patients perform poorer concerning relative survival than their European counterparts. Another possible explanation for this observation might be that second-class treatment is offered to the elderly in England and Denmark. In Denmark we have experienced periods with age restriction to chemotherapy administered in trials only. The elderly may also continue a second-class lifestyle concerning risk factors for death. These factors may include patient and doctors delay resulting in advanced cancer when presenting to the secondary heath system (7,8). This may be the explanation for the poor survival with lung cancer we have observed in the deprived part of Copenhagen. Conclusion: Eurocare data should not be used for planning health care services, since the risk of both under and overestimation of survival with cancer is high. Our analyses of Eurocare 2 indicate that studies designed specifically to compare quality of cancer management is needed (5) and that focus in England and Denmark should be at the elderly. Reference List (1) Carnall D. Britain ranks poorly for cancer survival rates. BMJ 1995; 310(6991):1352a-1353. (2) Woodman R. NHS cancer patients denied supportive treatments. BMJ 1999; 319(7224):1520. (3) Pickles H. Treating lung cancer in the NHS market. BMJ 1997; 315(7121):1548a-1549. (4) Specht LK, Landberg T. [Cancer treatment in Skane and in Sjaelland. Do differences concerning examination and treatment explain reduced survival among Danish cancer patients?]. Ugeskr Læger 2001; 163(4):439-442. (5) Day M. Experts dispute claims of poor cancer survival in UK. BMJ 2007; 334(7602):1021-102a. (6) Berrino F. Survival of cancer patients in Europe : the EUROCARE-2 study. Lyon: World Health Organization; 1999. (7) Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age--is it inadequately investigated and treated? BMJ 1999; 319(7205):309-312. (8) Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review [see comments]. Lancet 1999; 353(9159):1127- 1131. Competing interests: None declared