The EUROCARE project analysed cancer survival data from 45 population-based cancer registries in 17 European countries, revealing wide international differences in cancer survival. We calculated 5-year relative survival for 1836287 patients diagnosed with one of 13 cancers during the period 1978-1989. The data, from 20 cancer registries in 13 countries, were grouped into four regions: Finland, Sweden, Iceland (Northern Europe); Denmark, England and Scotland (UK and Denmark); France, The Netherlands, Germany, Italy and Switzerland (Western Europe); Estonia and Poland (Eastern Europe), and broken down into four periods (1978-1980, 1981-1983, 1984-1986, 1987-1989). For each cancer, mean European and regional survival was estimated as the weighted mean of 5-year relative survival in each country. Survival increased with time for all tumours, particularly for cancers of testis (12% increase, i.e. from 79.9 to 91.9%), breast, large bowel, skin melanoma (approximately 9-10%), and lymphomas (approximately 7%). For most solid tumours, survival was highest in Northern Europe and lowest in Eastern Europe, and also low in the UK and Denmark. Regional variation was less marked for the lymphomas. Survival improved more in Western than Northern Europe, and the differences between these regions fell for bowel cancer (from 8.0% for those diagnosed in 1978-1980 to 2% for those diagnosed in 1987-1989), breast cancer (from 7.4% to 3.9%), skin melanoma (from 13.4% to 11.0%) and Hodgkin's disease (from 7.2 to 0.6%). For potentially curable malignancies such as Hodgkin's disease, large bowel, breast and testicular cancers, there were substantial increases in survival, suggesting an earlier diagnosis and more effective treatment. The persisting regional differences suggest there are corresponding differences in the availability of diagnostic and therapeutic facilities, and in the effectiveness of healthcare systems.
INTRODUCTION: Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s. OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS: The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal. CONCLUSIONS: Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.
The EUROCARE study is a European Union project to collect survival data from population-based cancer registries and analyse them according to standardised procedures. We investigated and compared oesophageal and gastric cancer survival in 17 countries between 1985 and 1989. Time trends in survival over the 1978-1989 period were also investigated in 13 countries. The overall European 1-year relative survival rates were 33% for oesophageal cancer and 40% for gastric cancer. The corresponding 5-year relative survival rates were 10 and 21%, respectively. Important intercountry survival differences exist within Europe for oesophageal and gastric cancer. Taking the European average as the reference, the relative risk (RR) of death at 5 years was at least 30% higher in Denmark, Poland, Estonia and Slovenia for oesophageal cancer and in Denmark, England, Scotland and Poland for gastric cancer. In the other countries survival figures were close to the European average. Gender had little influence on survival, whilst age at diagnosis was inversely related to prognosis. There was a slight improvement between 1978 and 1989 in 5-year overall relative survival rates for both oesophageal cancer (RR = 0.80, 95% confidence interval (CI) 0.72-0.90) and gastric cancer (RR = 0.88, 95% CI 0.82-0.94). Differences in quality of care and stage at diagnosis can explain in part the differences in survival found in the EUROCARE countries. Significant improvement in prognosis has still to be achieved.
The EUROCARE Study is a European Union project to assemble survival data from population-based cancer registries and analyse them according to standard procedures. We investigated and compared liver, pancreatic and biliary tract cancer survival in 17 countries from 1985 to 1989. Time trends in survival over the 1978-1989 period were also investigated in 12 countries. The overall European mean 1 year relative survival was 16% for primary liver cancer, 26% for biliary tract cancer and 15% for pancreatic cancer. The corresponding 5-year relative survival was 5, 12 and 4%, respectively. Taking the European average as the reference, the relative risk (RR) of death was at least 20% higher for the three cancers in Denmark and Estonia. Survival tended to be higher in Spain for primary liver cancer and biliary tract cancer. Gender had little influence on survival whilst age at diagnosis was inversely related to prognosis. There was an improvement in 1-year relative survival rate for primary liver cancer: relative risk (RR) of 0.68 (95% confidence interval (CI) of 0.60-0.77) for 1987-1989 versus 1978-1980 and biliary tract cancer (RR 0.77, 95% CI 0.68-0.87). There was less variation in 5-year relative survival rate over time. Some intercountry survival differences for primary liver, biliary tract and pancreatic cancers exist over Europe. Differences in quality of care, in particular treatment aggressiveness, may explain some of these differences in survival. New approaches to the management of these cancers need to be found.
Testicular cancer is a disease that predominantly affects young and middle aged men. Our data show that incidence rates have recently increased in men aged 15-54 years in all 13 populations examined, irrespective of whether the populations were at high, moderate or low underlying risk. The annual percentage increase in this age group between 1970 and 1985 varied from 1.9% in the West Midlands, UK, to 6.6% in Miyagi, Japan, with a median of 2.7%. Analysis of the data in two separate age bands, 15-34 and 35-54 years, shows that increases are occurring in both subgroups. This, together with analyses by histological category in Denmark and the West Midlands, UK, indicates that both teratomas and seminomas are increasing in incidence. In contrast to the pattern for incidence rates, testicular cancer mortality rates are now declining in all the nine national populations examined. The time from which mortality rates started to decline varies between populations, and in Poland, a reduction was not observed until the 1980-1985 period. This reflects delay in the uptake of effective chemotherapy for the treatment of teratomas. The decline in mortality, against a background of rapidly increasing incidence in most populations, emphasizes the appreciable improvements in prognosis associated with testicular cancer in recent decades. Although the epidemiology of testicular cancer strongly suggests the presence of environmental risk factors that may be controllable, our ignorance about the nature of these factors precludes any strategy of prevention. Early diagnosis and improved treatment will therefore remain a major focus for the control of this cancer. Our ability to treat testicular cancer is thus a major and necessary achievement given the increase in incidence.
In this study, we report on the variation in the prognosis for adult patients with lung cancer within Europe, by age, histology and country from 1985-1989. We considered trends in survival since 1978 for most countries. Survival analysis was carried out on 173,448 lung cancer cases diagnosed between 1985 and 1989 in 44 population-based cancer registries, participating in the EUROCARE study. Relative 1-year survival rates for patients with lung cancer varied from 24 to 40%, being highest in Finland, France, The Netherlands and Switzerland and lowest in Denmark, England, Poland and Scotland. Half of all patients under the age of 45 years died within 1 year of diagnosis, increasing to almost 80% for those aged 75 years or older. Whilst the prognosis for patients with non-small cell carcinoma remained more or less constant between 1978 and 1989 (25% in Denmark and 44% in Finland), that for patients with small cell carcinoma improved slightly, especially in The Netherlands (Eindhoven from 17 to 24%) and Switzerland (Geneva from 24 to 32%). In conclusion, a fairly large variation in lung cancer relative survival rates existed between European countries. The most likely explanation for the differences is the variation in access to specialised care. Except for a slight improvement in short-term survival for patients with small cell lung cancer, survival has remained poor since 1978.