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Background Patients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered. We set out to evaluate whether pre-existing individual health status at diagnosis and primary care consultation history (peri-diagnostic factors) could explain socio-economic differentials in survival amongst women diagnosed with breast cancer. Methods We conducted a retrospective cohort study of women aged 15–99 years diagnosed in England using linked routine data. Ecologically-derived measures of income deprivation were combined with individually-linked data from the English National Cancer Registry, Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. Smoking status, alcohol consumption, BMI, comorbidity, and consultation histories were derived for all patients. Time to breast surgery was derived for women diagnosed after 2005. We estimated net survival and modelled the excess hazard ratio of breast cancer death using flexible parametric models. We accounted for missing data using multiple imputation. Results Net survival was lower amongst more deprived women, with a single unit increase in deprivation quintile inferring a 4.4% (95% CI 1.4–8.8) increase in excess mortality. Peri-diagnostic co-variables varied by deprivation but did not explain the differentials in multivariable analyses. Conclusions These data show that socio-economic inequalities in survival cannot be explained by consultation history or by pre-existing individual health status, as measured in primary care. Differentials in the effectiveness of treatment, beyond those measuring the inclusion of breast surgery and the timing of surgery, should be considered as part of the wider effort to reduce inequalities in premature mortality.

We evaluated the applicability of a Clostridium difficile infection (CDI) risk index developed for patients at hospital discharge to identify persons at high-risk of CDI in a primary care population. This retrospective observational study used data from the UK Clinical Practice Research Datalink, linked with Hospital Episodes Statistics. The risk index was based on the following patient characteristics: age, previous hospitalizations, days in hospital, and prior antibiotics use. Individual risk scores were calculated by summing points assigned to pre-defined categories for each characteristic. We assessed the association of risk factors with CDI by multivariate logistic regression. The estimated CDI incidence rate was 4/10,000 and 2/10,000 person-years in 2008 and 2012, respectively. On an index with a maximal risk of 19, a cut-off for high risk of ≥7 had sensitivity, specificity and positive predictive values of 80%, 87% and 12%, respectively. A high-risk person had a ~ 35% higher risk of CDI than a low-risk person. Multivariate risk factor analysis indicated a need to reconsider the relative risk scores. The CDI risk index can be applied to the UK primary care population and help identify study populations for vaccine development studies. Reassessing the relative weights assigned to risk factors could improve the index performance in this setting.

Background Pancreatic cancer (PC) represents a substantial public health burden. Pancreatic cancer patients have very low survival due to the difficulty of identifying cancers early when the tumour is localised to the site of origin and treatable. Recent progress has been made in identifying biomarkers for PC in the blood and urine, but these cannot be used for population-based screening as this would be prohibitively expensive and potentially harmful. Methods We conducted a case-control study using prospectively-collected electronic health records from primary care individually-linked to cancer registrations. Our cases were comprised of 1,139 patients, aged 15–99 years, diagnosed with pancreatic cancer between January 1, 2005 and June 30, 2009. Each case was age-, sex- and diagnosis time-matched to four non-pancreatic (cancer patient) controls. Disease and prescription codes for the 24 months prior to diagnosis were used to identify 57 individual symptoms. Using a machine learning approach, we trained a logistic regression model on 75% of the data to predict patients who later developed PC and tested the model’s performance on the remaining 25%. Results We were able to identify 41.3% of patients < = 60 years at ‘high risk’ of developing pancreatic cancer up to 20 months prior to diagnosis with 72.5% sensitivity, 59% specificity and, 66% AUC. 43.2% of patients >60 years were similarly identified at 17 months, with 65% sensitivity, 57% specificity and, 61% AUC. We estimate that combining our algorithm with currently available biomarker tests could result in 30 older and 400 younger patients per cancer being identified as ‘potential patients’, and the earlier diagnosis of around 60% of tumours. Conclusion After further work this approach could be applied in the primary care setting and has the potential to be used alongside a non-invasive biomarker test to increase earlier diagnosis. This would result in a greater number of patients surviving this devastating disease.

ObjectivesMost research on health inequalities uses aggregated deprivation scores assigned to the small area where the patient lives; however, the concordance between aggregate area-level deprivation measures and personal deprivation experienced by individuals living in the area is poorly understood. Our objective was to examine the agreement between individual and ecological deprivation. We tested the concordance between metrics of income, occupation and education at individual and area levels, and assessed the reliability of area-based deprivation measures to predict individual deprivation circumstances.SettingEngland and Wales.ParticipantsA cancer patient cohort of 9547 individuals extracted from the Office for National Statistics Longitudinal Study.OutcomesWe quantified the concordance between measures of income, occupation and education at individual and area level. In addition, we used ROC (receiver operating characteristic) curves and the area under the curve (AUC) to assess the reliability of area-based deprivation measures to predict individual deprivation circumstances.ResultsWe found low concordance between individual-level and area-level indicators of deprivation (Cramer’s V statistics range between 0.07 and 0.20). The most commonly used indicator in health inequalities research, area-based income deprivation, was a poor predictor of individual income status (AUC between 0.56 and 0.59), whereas education and occupation were slightly better predictors (AUC between 0.62 and 0.65). The results were consistent across sexes and across six major cancer types.ConclusionsOur results indicate that ecological deprivation measures capture only part of the relationship between deprivation and health outcomes, especially with respect to income measurement. This has important implications for our understanding of the relationship between deprivation and health, and, as a consequence, healthcare policy. The results have a wide-reaching impact for the way in which we measure and monitor inequalities, and in turn, fund and organise current UK healthcare policy aimed at reducing them.

Background Increasing diagnosis of cancer when the disease is still at early stages is a priority of cancer policy internationally. In England, reducing geographical inequalities in early diagnosis is also a key objective. Stage at diagnosis is not recorded for many patients, which may bias assessments of progress. We evaluate temporal and geographical changes in stage at diagnosis during 2008-2013 for colorectal, non-small cell lung, and ovarian cancers, using multiple imputation to minimise bias from missing data. Methods Population-based data from cancer registrations, routes to diagnosis, secondary care, and clinical audits were individually linked. Patient characteristics and recorded stage were summarised. Stage was imputed where missing using auxiliary information (including patient's survival time). Logistic regression was used to estimate temporal and geographical changes in early diagnosis adjusted for case mix using a multilevel model. Results We analysed 196,511 colorectal, 180,048 non-small cell lung, and 29,076 ovarian cancer patients. We estimate that there were very large increases in the percentage of patients diagnosed at stages I or II between 2008-09 and 2012-13: from 32% to 44% for colorectal cancer, 19% to 25% for non-small cell lung cancer, and 28% to 31% for ovarian cancer. Geographical inequalities reduced for colorectal and ovarian cancer. Interpretation Multiple imputation is an optimal approach to reduce bias from missing data, but residual bias may be present in these estimates. Increases in early-stage diagnosis coincided with increased diagnosis through the "two week wait" pathway and colorectal screening. Epidemiological analyses from 2013 are needed to evaluate continued progress.

Background: Breast cancer prognosis has dramatically improved over 40 years. There is, however, no proof of population ‘cure'. This research aimed to examine the pattern of long-term excess mortality due to breast cancer and evaluate its determinants in the context of cancer registry data.Methods: We used data from the Geneva Cancer Registry to identify women younger than 75 years diagnosed with invasive, localised and operated breast cancer between 1995 and 2002. Flexible modelling of excess mortality hazard, including time-dependent (TD) regression parameters, was used to estimate mortality related to breast cancer. We derived a single “final” model using a backward selection procedure and evaluated its stability through sensitivity analyses using a bootstrap technique.Results: We analysed data from 1574 breast cancer women including 351 deaths (22.3%). The model building strategy retained age at diagnosis (TD), tumour size and grade (TD), chemotherapy and hormonal treatment (TD) as prognostic factors, while the sensitivity analysis on bootstrap samples identified nodes involvement and hormone receptors (TD) as additional long-term prognostic factors but did not identify chemotherapy and hormonal treatment as important prognostic factors. Conclusions: Two main issues were observed when describing the determinants of long-term survival. First, the modelling strategy presented a lack of robustness, probably due to the limited number of events observed in our study. The second was the misspecification of the model, probably due to confounding by indication. Our results highlight the need for more detailed data and the use of causal inference methods.

Highlights • Each difference in tumour stage (I–IV) predicts lower five-year survival, so prognostic information is lost in binary indicators. • Emergency presentation is associated with lower survival, independently of stage. • A high proportion of patients whose stage is not recorded die immediately after diagnosis. • Interval from first symptoms to diagnosis is not consistently associated with survival., Background A key component of recent English cancer policy is the monitoring of trends in early diagnosis of cancer. Early diagnosis can be defined by the disease stage at diagnosis or by other indicators derived from electronic health records. We evaluate the association between different early diagnosis indicators and survival, and discuss the implementation of the indicators in surveillance of early diagnosis. Methods We searched the PubMed database and grey literature to identify early diagnosis indicators and evaluate their association with survival. We analysed cancer registrations for 355,502 cancer patients diagnosed in England during the period 2009–2013, and quantified the association between each early diagnosis indicator and 30-day mortality and five-year net survival. Results Each incremental difference in stage (I–IV) predicts lower 5-year survival, so prognostic information is lost in comparisons which use binary stage indicators. Patients without a recorded stage have high risk of death shortly following diagnosis and lower 5-year survival. Emergency presentation is independently associated with lower five-year survival. Shorter intervals between first symptoms and diagnosis are not consistently associated with improved survival, potentially due to confounding from tumour characteristics. Interpretation Contrary to current practice, we recommend that all the stage information should be used in surveillance. Patients missing stage should also be included to minimise bias. Combined data on stage and emergency presentation could be used to create summary prognostic measures. More work is needed to create statistics based on the diagnostic interval that will be useful for surveillance.

Aim The aim of this study was to estimate the population-level ‘cure' of Maltese colorectal cancer patients diagnosed between 1995 and 2004, and to estimate the median survival time for the ‘uncured' patients. Methods and study population Analysis was conducted on 1470 cases registered by the Malta National Cancer Register between 1995 and 2004 and followed up to end of 2010. The mean age of the patients was 66.4 (95%CI 65.8–67.1), and the number of men and women were equal. Background mortality for 1995–2010 was extracted from publicly available life tables. A mixture model with Weibull survival distribution and identity link was used to model ‘cure'. Results The overall ‘cured' proportion for the patients diagnosed in 1995–1999 was 45.3% (95%CI 40.2–50.5) while the ‘cured' proportion for the patients diagnosed in 2000–2004 was 52.3% (95%CI 47.2–57.5). Median survival time for the ‘uncured' patients increased in the second calendar period from 1.25 years (95%CI 1.04–1.45) to 1.42 years (95%CI 1.15–1.76). Conclusion In Malta, as in the rest of Europe, improvements have been made in short- and long-term survival over the 15-year period under study. To continue this improvement, differences by age that still persist must be investigated and efforts focused to reduce any gaps between Malta and other European countries.

Cancer incidence, survival and mortality are essential population-based indicators for public health and cancer control. Confusion and misunderstanding still surround the estimation and interpretation of these indicators. Recurring controversies over the use and misuse of population-based cancer statistics in health policy suggests the need for further clarification. In our article, we describe the concepts that underlie the measures of incidence, survival and mortality, and illustrate the synergy between these measures of the cancer burden. We demonstrate the relationships between trends in incidence, survival and mortality, using real data for cancers of the lung and breast from England and Sweden. Finally, we discuss the importance of using all three measures in combination when interpreting overall progress in cancer control, and we offer some recommendations for their use.

Accurate survival estimates are essential for monitoring cancer survival trends, for health care planning and for resource allocation. To obtain precise estimates of survival, full dates (day, month and year) rather than partial dates (month and year) are required. In some jurisdictions, however, cancer registries are constrained from providing full dates on the grounds of confidentiality. The bias resulting from the use of partial dates in the estimation and comparison of survival makes it impossible to determine precisely the differences in the risk of death from cancer between population groups or in successive calendar periods. Important operational arguments also exist against the use of incomplete dates for survival analysis, including increased workload for cancer registry staff and the introduction of avoidable complexity for quality control of survival data. Cancer survival is one of the most widely known outputs produced by population-based cancer registries, and it is a crucial metric for the comparative effectiveness of health services. The bodies that set data access guidelines must take a more balanced view of the risks and benefits of using full dates for the estimation of cancer survival.

BACKGROUND: Although survival from breast cancer has greatly improved over the past three decades, there is little consensus as to whether a population of women diagnosed with breast cancer can ever be considered 'cured' of the disease. PATIENTS AND METHODS: We examined population 'cure' among women aged 15-99 years diagnosed with breast cancer from 1980 to 1995 in the West Midlands (England) and New South Wales (Australia). We calculated interval-specific excess mortality rates and fitted a number of statistical models to evaluate 'cure'. RESULTS: There was little evidence that these women could ever be considered cured of the disease because excess mortality due to breast cancer was evident among young and middle-aged women up to 23 years after their diagnosis. Older women diagnosed in New South Wales displayed some evidence of 'cure'. However, this was estimated to occur only after the women's 75th birthday. CONCLUSIONS: There is no strong evidence of the existence of a 'cured' subpopulation among young or middle-aged women diagnosed with breast cancer in either West Midlands or New South Wales during the period 1980-1995. Additional follow-up data would permit 'cure' to be assessed for women diagnosed more recently than 1995.

Survival from breast cancer in the UK is lower than in other countries in Western Europe, the USA and Australia. However, these international differences have not yet been examined in relation to tumor characteristics, treatment, screening history or other prognostic factors. We calculated relative survival by age, period of diagnosis, category of unemployment and extent of disease for women diagnosed with breast cancer during the period 1980-2002 in New South Wales (Australia) and West Midlands (England). National cancer registry data for each country for the period 1990-1994 were also examined. The excess hazard ratio was modeled as a function of prognostic covariables. Survival in Australia and New South Wales was higher than in England and West Midlands, respectively. In both regions, survival was lower for more deprived women and for the elderly. These differences were greater in West Midlands. Survival from localized and regional disease in New South Wales was higher than in West Midlands, but survival from metastatic disease was similar. Differences in breast cancer survival are unlikely to be entirely due to differences in data quality or to limitations of the analyses, although the measure of extent of disease used may not have been adequate to elucidate the effect of stage fully. One possible causal explanation is that the management of breast cancer differs between these regions. Further research should acquire better data on stage and investigate the effect of comorbidity and of patterns of care upon the difference in breast cancer survival between England and Australia.

Net survival is the survival that would be observed if the only possible underlying cause of death was the disease under study. It can be estimated with either cause-specific or relative survival data settings, if the informative censoring is properly considered. However, net survival estimators are prone to specific biases related to the data setting itself. We examined which data setting was the most robust against violation of key assumptions (erroneous cause of death and inappropriate life tables). We identified 4285 women in the Geneva Cancer Registry, diagnosed with breast, colorectal, lung cancer and melanoma between 1981 and 1991 and estimated net survival up to 20 years using cause-specific and relative survival settings. We used weights to tackle informative censoring in both settings and performed sensitivity analyses to evaluate the impact of misclassification of cause of death in the cause-specific setting or of using inappropriate life tables on net survival estimates in the relative survival setting. For all the four cancers, net survival was highest when using the cause-specific setting and the absolute difference between the two estimators increased with time since diagnosis. The sensitivity analysis showed that (i) the use of different life tables did not compromise net survival estimation in the relative survival setting, whereas (ii) a small level of misclassification for the cause of death led to a large change in the net survival estimate in the cause-specific setting. The relative survival setting was more robust to the above assumptions violations and is therefore recommended for estimation of net survival.

Objective To test the hypothesis that rural populations had lower uptake of screening mammography than urban populations in the Scottish and Australian setting. Method Scottish data are based upon information from the Scottish Breast Screening Programme Information System describing uptake among women residing within the NHS Highland Health Board area who were invited to attend for screening during the 2008 to 2010 round (N = 27,416). Australian data were drawn from the 2010 survey of the 1946–51 cohort of the Australian Longitudinal Study on Women's Health (N = 9890 women). Results Contrary to our hypothesis, results indicated that women living in rural areas were not less likely to attend for screening mammography compared to women living in urban areas in both Scotland (OR for rural = 1.17, 95% CI = 1.06–1.29) and Australia (OR for rural = 1.15, 95% CI = 1.01–1.31). Conclusions The absence of rural–urban differences in attendance at screening mammography demonstrates that rurality is not necessarily an insurmountable barrier to screening mammography., Highlights • Scotland and Australia provide free screening mammography for their populations. • Women living in rural areas can attend screening mammography via mobile units. • We examined rural–urban breast screening rates in Scotland and Australia. • Rural women were not less likely to attend screening mammography than urban women. • Rurality is not necessarily an insurmountable barrier to health service access.

Background : Both cause-specific and relative survival settings can be used to estimate net survival, the survival that would be observed if the only possible underlying cause of death was the disease under study. Both resulting net survival estimators are biased by informative censoring and prone to biases related to the data settings within which each is derived. We took into account informative censoring to derive theoretically unbiased estimators and examine which of the two data settings was the most robust against incorrect assumptions in the data. Patients and methods : We identified 2489 women in the Geneva Cancer Registry, diagnosed with breast cancer between 1981 and 1991, and estimated net survival up to 20-years using both cause-specific and relative survival settings, by tackling the informative censoring with weights. To understand the possible origins of differences between the survival estimates, we performed sensitivity analyses within each setting. We evaluated the impact of misclassification of cause of death and of using inappropriate life tables on survival estimates. Results : Net survival was highest using the cause-specific setting, by 1% at one year and by up to around 11% twenty years after diagnosis. Differences between both sets of net survival estimates were eliminated after recoding between 15% and 20% of the non-specific deaths as breast cancer deaths. By contrast, a dramatic increase in the general population mortality rates was needed to see the survival estimates based on relative survival setting become closer to those derived from cause-specific setting. Conclusion : Net survival estimates derived using the cause-specific setting are very sensitive to misclassification of cause of death. Net survival estimates derived using the relative-survival setting were robust to large changes in expected mortality. The relative survival setting is recommended for estimation of long-term net survival among patients with breast cancer.

This population-based study examines prognostic factors and survival trends among adults (15–99 years) diagnosed with small intestinal cancer in England and Wales during 1971–1990 and followed up to 1995. During this period, the 1- and 5-year age-standardised relative survival rates for small intestinal cancers combined were 42% and 23%, respectively. Duodenal tumours, adenocarcinomas, men, patients with advanced age and the most deprived patients had the poorest prognosis. For all small bowel tumours combined, the excess risk of death fell significantly by 6–9% every 4 years over the 20-year period (adjusted excess hazard ratio (EHR) 0.91 at 1 year after diagnosis, 0.94 at 5 years). For duodenal tumours, the EHR fell by about 14% (95% CI 5–22%) every 4 years between 1979 and 1990, and a similar trend for jejunal tumours was of borderline significance. Further population-based investigations linking survival data to individual data on diagnostic methods and types of treatment are needed.

Study objective: To describe the population mortality profile of England and Wales by deprivation and in each government office region (GOR) during 1998, and to quantify the influence of geography and deprivation in determining life expectancy. Design: Construction of life tables describing age specific mortality rates and life expectancy at birth from death registrations and estimated population counts. Life tables were created for (a) quintiles of income deprivation based on the income domain score of the index of multiple deprivation 2000, (b) each GOR and Wales, and (c) every combination of deprivation and geography. Setting: England and Wales. Patients/participants: Residents of England and Wales, 1998. Main results: Life expectancy at birth varies with deprivation quintile and is highest in the most affluent groups. The differences are mainly attributable to differences in mortality rates under 75 years of age. Regional life expectancies display a clear north-south gradient. Linear regression analysis shows that deprivation explains most of the geographical variation in life expectancy. Conclusions: Geographical patterns of life expectancy identified within these data for England and Wales in 1998 are mainly attributable to variations in deprivation status as defined by the IMD 2000 income domain score.

Background Population-based cancer survival is an important measure of the overall effectiveness of cancer care in a population. Population-based cancer registries collect data that enable the estimation of cancer survival. To ensure accurate, consistent and comparable survival estimates, strict control of data quality is required before the survival analyses are carried out. In this paper, we present a basis for data quality control for cancer survival. Methods We propose three distinct phases for the quality control. Firstly, each individual variable within a given record is examined to identify departures from the study protocol; secondly, each record is checked and excluded if it is ineligible or logically incoherent for analysis; lastly, the distributions of key characteristics in the whole dataset are examined for their plausibility. Results Data for patients diagnosed with bladder cancer in England between 1991 and 2010 are used as an example to aid the interpretation of the differences in data quality. The effect of different aspects of data quality on survival estimates is discussed. Conclusions We recommend that the results of data quality procedures should be reported together with the findings from survival analysis, to facilitate their interpretation.

OBJECTIVE: To compare breast cancer incidence in England and Australia by age, extent of disease and deprivation. METHODS: We analysed data for women aged 15-99 years diagnosed with breast cancer in England or Australia during the period 1990 to 1994, and in West Midlands or New South Wales during the period 1980 to 2002. We calculated three-year rolling average incidence rates and incidence rate ratios (IRR) between West Midlands and New South Wales by age, extent of disease and category of deprivation. RESULTS: Breast cancer incidence was higher in England than in Australia, and in West Midlands than in New South Wales but became more similar over time. Socio-economic differences in incidence were greater in New South Wales than in West Midlands. The most deprived women in West Midlands were diagnosed at a later stage of disease than the most deprived women in New South Wales. Incidence among elderly women was higher in West Midlands than in New South Wales. There were also high proportions of tumours with unknown stage among elderly women in West Midlands. CONCLUSIONS: Although the overall incidence of breast cancer is similar, differences by age, extent of disease and deprivation exist. IMPLICATIONS: The underlying reasons for these patterns require further examination.

BACKGROUND: Information on the underlying cause of death of cancer patients is of interest because it can be used to estimate net survival. The population-based Geneva Cancer Registry is unique because registrars are able to review the official cause of death. This study aims to describe the difference between the official and revised cause-of-death variables and the impact on cancer survival estimates. METHODS: The recording process for each cause of death variable is summarised. We describe the differences between the two cause-of-death variables for the 5,065 deceased patients out of the 10,534 women diagnosed with breast cancer between 1970 and 2009. The Kappa statistic and logistic regression are applied to evaluate the degree of concordance. The impact of discordance on cause-specific survival is examined using the Kaplan Meier method. RESULTS: The overall agreement between the two variables was high. However, several subgroups presented a lower concordance, suggesting differences in calendar time and less attention given to older patients and more advanced diseases. Similarly, the impact of discordance on cause-specific survival was small on overall survival but larger for several subgroups. CONCLUSION: Estimation of cancer-specific survival could therefore be prone to bias when using the official cause of death. Breast cancer is not the more lethal cancer and our results can certainly not be generalised to more lethal tumours.

Survival for ovarian cancer is the poorest of all gynaecological cancer sites. Our aim was to present the most up-to-date survival estimate for ovarian cancer by age and morphology and to answer the question whether survival for ovarian cancer improved in Europe during the 1990s.This analysis was performed with data from the EUROCARE database. We considered all adult women diagnosed with ovarian cancer between 1995 and 2002 and life status followed up until the end of 2003. A total of 97 691 cases were contributed by 72 European cancer registries in 24 countries. We estimated the most up-to-date relative survival for a mean of 23 661 patients followed up in 2000-2003 using the period hybrid approach and described the relative survival trends from the beginning of 1990s.Overall, the European age-standardised one-year, five-year and five-year conditional on surviving one-year relative survival were 67.2% (95% CI 66.6-67.8), 36.1% (95% CI 35.4-36.8) and 53.7% (95% CI 52.8-54.7), respectively. Five-year relative survival was 58.6% (95% CI 57.4-59.8), 37.1% (95% CI 36.1-38.1) and 20.5% (95% CI 19.1-21.9) in women aged 15-54, 55-74 and 75-99 years, respectively. The age-standardised five-year relative survival was 38.1% (95% CI 36.9-39.3) for serous tumours and 51.9% (95% CI 49.0-54.9) for mucinous cancers and the crude five-year relative survival was 85.6% (95% CI 81.2-90.0) for germ cell cancers. Overall, the age-standardised five-year relative survival increased from 32.4% (95% CI 31.7-33.2) in 1991-1993 to 36.3% (95% CI 35.5-37.0) in 2000-2003. There is a need to better understand the reasons for the wide variation in survival of ovarian cancer in Europe. Actions aiming to harmonise the protocols for therapy should contribute to narrowing the wide gap in survival and research on screening and early detection of ovarian cancer should be enforced.

This paper considers socioeconomic inequalities in self-assessed health amongst people with and without a history of cancer using representative data from Scotland.A cross-sectional analysis using the Scottish Health Survey was done. Cancer survivors were identified using linked Cancer Registry data. Bivariate and multivariate analysis was used to compare and contrast self-assessed health amongst those with a history of cancer to those without.Of the 17,505 survey participants, 432 (2.5 %) had a history of cancer. After taking into account potential confounders, those in the lowest socioeconomic group were more likely to report poor health than those in the highest group amongst those with a history of cancer [odds ratio, 2.96; confidence interval (CI), 1.82-4.80] and those with no history of cancer (odds ratio, 2.45; CI, 2.21-2.71). Those in the lowest socioeconomic group with no history of cancer had a greater propensity to report poor health than any of the highest groups that did have a history of cancer (p 0.01). Differences in propensities to indicate poor health were particularly marked amongst those 4 years or more post-cancer diagnosis.Findings underline the scale of socioeconomic gradients in health. That disparities were so wide amongst those most temporally distant from initial diagnosis is particularly a concern given improving survival after a cancer diagnosis.Socioeconomic circumstances have a considerable influence on health and well-being. Practitioners and policy makers should consider socioeconomic circumstances in considering approaches to health and social care of cancer survivors.

Objectives To simulate each of two hypothesised errors in the National Cancer Registry (recording of the date of recurrence of cancer, instead of the date of diagnosis, for registrations initiated from a death certificate; long term survivors who are never notified to the registry), to estimate their possible effect on relative survival, and to establish whether lower survival in the UK might be due to one or both of these errors. Design Simulation study. Setting National Cancer Registry of England and Wales. Population Patients diagnosed as having breast (women), lung, or colorectal cancer during 1995-2007 in England and Wales, with follow-up to 31 December 2007. Main outcome measure Mean absolute percentage change in one year and five year relative survival associated with each simulated error. Results To explain the differences in one year survival after breast cancer between England and Sweden, under the first hypothesis, date of diagnosis would have to have been incorrectly recorded by an average of more than a year for more than 70% of women known to be dead. Alternatively, under the second hypothesis, failure to register even 40% of long term survivors would explain less than half the difference in one year survival. Results were similar for lung and colorectal cancers. Conclusions Even implausibly extreme levels of the hypothesised errors in the cancer registry data could not explain the international differences in survival observed between the UK and other European countries.

BACKGROUND: International studies have shown that cancer survival was generally low in the UK and the Republic of Ireland compared to western and northern European countries, but no systematic comparative analysis has been performed between the UK countries and the Republic of Ireland. METHODS: Population-based survival for 20 adult malignancies was estimated for the UK and the Republic of Ireland. Data on adults (15-99 years) diagnosed between 1991 and 1999 in England, Scotland, Wales, Northern Ireland (1993-99) and the Republic of Ireland (1994-99) were analysed. All cases were followed up until the end of 2001. Relative survival was estimated by sex, period of diagnosis and country, and for the nine regions of England. Predicted survival was estimated using the hybrid approach. RESULTS: Overall, cancer survival in UK and Republic of Ireland improved during the 1990s, but there was geographic variation in survival across the UK and Republic of Ireland. Survival was generally highest in Ireland and Northern Ireland and lowest in England and Wales. Survival tended to be higher in Scotland for cancers for which early detection methods were in place. In England, survival tended to be lower in the north and higher in the south. CONCLUSIONS: The geographic variations in survival seen across the UK and Republic of Ireland are narrower than between these countries and comparable European countries. Artefact is likely to explain some, but not all of the differences across the UK and Republic of Ireland. Geographic differences in stage at diagnosis, co-morbidity and other clinical factors may also be relevant.

Background: Socioeconomic inequalities in survival were observed for many cancers in England during 1981–1999. The NHS Cancer Plan (2000) aimed to improve survival and reduce these inequalities. This study examines trends in the deprivation gap in cancer survival after implementation of the Plan. Materials and method: We examined relative survival among adults diagnosed with 1 of 21 common cancers in England during 1996–2006, followed up to 31 December 2007. Three periods were defined: 1996–2000 (before the Cancer Plan), 2001–2003 (initialisation) and 2004–2006 (implementation). We estimated the difference in survival between the most deprived and most affluent groups (deprivation gap) at 1 and 3 years after diagnosis, and the change in the deprivation gap both within and between these periods. Results: Survival improved for most cancers, but inequalities in survival were still wide for many cancers in 2006. Only the deprivation gap in 1-year survival narrowed slightly over time. A majority of the socioeconomic disparities in survival occurred soon after a cancer diagnosis, regardless of the cancer prognosis. Conclusion: The recently observed reduction in the deprivation gap was minor and limited to 1-year survival, suggesting that, so far, the Cancer Plan has little effect on those inequalities. Our findings highlight that earlier diagnosis and rapid access to optimal treatment should be ensured for all socioeconomic groups.

Summary Background The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. Methods We analysed population-based survival in 2·2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996–2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996–2000 (before the cancer plan), 2001–03 (initialisation), and 2004–06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. Findings 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996–2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996–2000 and 2001–03, but higher in England than in Wales during 2004–06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North–South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001–03 and 2004–06. Interpretation The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004–06, whereas the opposite was true during 2001–03. This reversal of survival trends in 2001–03 and 2004–06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan. Funding Office for National Statistics (contract NT-04/2355A); Cancer Research UK (programme grant C1336/A5735).

Cervical cancer is the third most common cancer in women worldwide, after cancers of the breast and large bowel, with approximately 470 000 new cases a year in 2000, some 10% of all cancers in women (Ferlay et al, 2001). Approximately 80% of all cases occur in developing countries, where cervical cancer is often the most common cancer in women, whereas in developed countries, cervical cancer only accounts for about 5% of all cancers in women. It has been known for 30 years from observational data that cervical cancer is likely to have an infectious component (Beral, 1974), subsequently confirmed as HPV (Bosch et al, 1994). Trials of vaccination already appear promising for primary prevention (Gravitt and Shah, 2005; Mao et al, 2006). In England and Wales, the age-standardised incidence of cervical cancer in the 1970s and 1980s remained between 14 and 16 per 100 000, although age-specific rates were influenced by strong cohort effects (those women born in the 1890s were at high risk, those born in the mid-1930s at low risk). The cervical screening programme began in the 1960s, offering cervical smear tests to detect premalignant lesions in women aged 25–64 years on a 5-yearly basis, but it was largely ineffective until the late 1980s (Murphy et al, 1988). In 1988, a national call and re-call system was established and coverage rose rapidly to approximately 85% (Quinn et al, 1999). As a result of these improvements, the incidence of invasive malignancy fell continuously after 1990 to below 9 per 100 000 in 2000 (Quinn et al, 2001; Office for National Statistics, 2003a). Mortality from cervical cancer in England and Wales had been declining steadily at approximately 1.5% each year from the early 1950s to the late 1980s. This long-term decline began before the introduction of screening. From 1990, the rate of decline in mortality increased three-fold, and by 2002 the age-standardised death rate had fallen to 29 per 100 000, barely one-third of the death rate in 1971 (83 per 100 000) (Office for National Statistics, 1999, 2003b). Only 1000 deaths were attributed to cervical cancer in 2002, and the screening programme has been credited with preventing 800 or more deaths a year (Quinn et al, 1999; Peto et al, 2004). We analysed the data for 44 090 women diagnosed with invasive cancer of the uterine cervix in England and Wales during the 14-year period 1986–1999, some 90% of those eligible for inclusion in the analyses. Approximately 4% of women otherwise eligible for analysis were excluded with zero recorded survival (date of diagnosis same as date of death). The proportion of women for whom recorded survival was zero did not vary between socioeconomic groups, however, and it was stable throughout the 1990s (data not shown). Therefore, these exclusions are unlikely to have had any substantial impact on socioeconomic gradients in survival, or on trends in the gradient. A further 3% of women with cervical cancer were excluded because it was not their first primary malignancy, and 2% because their vital status was unknown on 5 November 2002, the date when the data were extracted for analysis. Some two-thirds (67%) of cervical cancers were squamous carcinomas, and a further 16% were adenocarcinomas: both proportions were similar throughout the 1990s. Other morphological types were individually rare, but cancers with poorly specified morphology accounted for about 10%. Annual incidence rates for invasive cervical cancer in the late 1990s were 50% higher among the most deprived women (12.8 per 100 000) than among the most affluent (8.5 per 100 000), but this difference was less marked than in the early 1990s (63%). This is because incidence declined more among the most deprived women over this period (18%) than among the most affluent (11%) (Figure 1). Figure 1 Trends in the age-standardised incidence of cervical cancer in women aged 15–99 years, by deprivation group: England and Wales, 1986–1999.

Survival has risen steadily since the 1970s for most cancers in adults in England and Wales, but persistent inequalities exist between those living in affluent and deprived areas. These differences are not seen for children. For many of the common adult cancers, these inequalities in survival (the ‘deprivation gap') became more marked in the 1990s. This volume presents extended analyses of survival for adults diagnosed during the 14 years 1986–1999 and followed up to 2001, including trends in overall survival in England and Wales and trends in the deprivation gap in survival. The analyses include individual tumour data for 2.2 million cancer patients. This article outlines the structure of the supplement – an article for each of the 20 most common cancers in adults, followed by an expert commentary from one of the leading UK clinicians specialising in malignancies of that organ or system. The available data, quality control and methods of analysis are described here, rather than repeated in each of the 20 articles. We open the discussion between clinicians and epidemiologists on how to interpret the observed trends and inequalities in cancer survival, and we highlight some of the most important contrasts in these very different points of view. Survival improved substantially for adult cancer patients in England and Wales up to the end of the 20th century. Although socioeconomic inequalities in survival are remarkably persistent, the overall patterns suggest that these inequalities are largely avoidable.

Trends in long-term relative survival from breast cancer are examined for women diagnosed in England and Wales up to 2001, using both period and hybrid approaches. Large improvements in long-term survival are predicted. Women with breast cancer still experience persistent excess mortality up to at least 20 years after diagnosis.

Background: Social inequalities in breast cancer survival are smaller when the cancer is screen-detected. We examined survival from screen-detected and non screen-detected breast cancer by ethnicity and deprivation. Methods: Cancer registry data for 20 283 women aged 50–70 years, diagnosed between 1989–2011 and invited for screening, were linked with screening and ethnicity data. We examined Asian, Black and White groups, less deprived and middle/more deprived women. Net survival was estimated using ethnic- and deprivation-specific life tables. Estimates were corrected for lead-time bias and over-diagnosis. Results: Net survival varied by screening history. No significant differences in survival were found by ethnicity. Five-year net survival was 90.0% (95% CI, 89.3–90.8%) in less deprived groups and 86.7% (85.9–87.4%) among middle/more deprived women. Screening benefitted all ethnic and both deprivation groups. Whether screen-detected or not, more deprived women had significantly poorer outcomes: 5-year net survival was 78.0% (76.7–79.2%) for deprived women who were not screen-detected compared with 94.0% (93.1–95.1%) for less deprived women who were screen-detected. Conclusions: The three ethnic groups differed little in their breast cancer survival. Although screening confers a survival benefit to all, there are still wide disparities in survival by deprivation. More needs to be done to determine what underlies these differences and tackle them.

s for poster presentation at the Association of Breast Surgery Conference & AGM, 15th & 16th June 2015, Bournemouth International Centre P001. Rural-urban differences in screening mammography uptake in Australia and Scotland Janni Leung, Catriona Macleoad, Deirdre McLaughlin, Laura Woods, Robert Henderson, Angus Watson, Richard Kyle, Gill Hubbard, Russell Mullen, Iain Atherton 1 School of Population Health, The University of Queensland, Brisbane, Australia 2 NHS Highland, Inverness, UK London School of Hygiene & Tropical Medicine, London, UK 4 School of Health Sciences, The University of Stirling, Inverness, UK The Highland Breast Centre, Raigmore Hospital, Inverness, UK Introduction: Previous research has shown that the uptake of health screening programs can be influenced by various demographics, such as deprivation, gender and, more recently, rural residence. This study tested the hypothesis that rural populations had lower uptake of screening mammography in the Scottish and Australian setting. Methods: Scottish data is based upon information from the Scottish Breast Screening Programme Information System describing uptake among women residing within the NHS Highland Health Board area who were invited to attend for screening during the 2008 to 2010 round (N 1⁄4 27,416). Australian data were drawn from the 2010 survey of the 1946e51 cohort of the Australian Longitudinal Study on Women’s Health (N 1⁄4 9,890 women). Results: Contrary to our hypothesis, results indicated that women living in rural areas were not less likely to attend for screening mammography compared to women living in urban areas in both Scotland (OR for rural 1⁄4 1.17, 95% CI 1⁄4 1.06e1.29) and Australia (OR for rural 1⁄4 1.15, 95%CI 1⁄4 1.01e1.31). Conclusion: The absence of a lower attendance of screening mammography among women living in rural areas suggests that mobile breast screening units serving rural areas of both Scotland and Australia can be effective in ensuring adequate service provision and may provide a model in other international contexts. In conclusion, mobile units are useful in reducing inequalities relating to healthcare service access for the rural population. http://dx.doi.org/10.1016/j.ejso.2015.03.037 P002. Single-institution experience with an under age 40 symptomatic breast clinic Alaa Abdel-Rahman, Ambika Anand, Elham Abdelaziz, Mandy Holland, Adel Rashed United Lincolnshire Hospitals Trust, Lincolnshire, UK Background: Experienced sonographers have extended their role within the symptomatic breast service. A study was undertaken to ascertain whether they could provide the radiology support to women under 40 years who do not require mammograms. The aim is to measure the effectiveness of this breast clinic to ensure that radiology is providing a good service and to ensure that cancers are being detected within the population. Methods: Under 40 years clinics started in August 2005. These included only female patients with symptoms referred by their GP. Sample size was 613 patients. Breast diaries were reviewed to ascertain core biopsies performed and reports of histological diagnosis. Results: 64 (10%) core biopsies were taken 38 (59%) ultrasound guided by the sonographer and 26 (41%) freehand by the consultant surgeon. Three core biopsies (4.6%) were repeated. Three out of 613 patients (0.4%) showed breast cancer, one with high grade DCIS, one with grade III invasive ductal carcinoma and one with grade III invasive ductal carcinoma with metastatic lymph node which has been detected clinically and radiologically. 44 patients with fibroadenomas, five with fibrocystic changes, three with hamartomas, the rest with lipomas, phylloides tumour, inflammation, papillary lesion, fat necrosis, tubular adenoma, infarcted lymph node. Conclusions: Under 40 breast clinic led by a surgeon and supported by sonographers is able to provide a comprehensive service with accurate diagnosis within all relevant guidelines. It is effective in ensuring cancers are being detected within the target population and in providing an excellent service. http://dx.doi.org/10.1016/j.ejso.2015.03.038 P003. Oncotype DX testing: Our experience at the Royal Bolton Hospital Sarah Hassan, Jane Ooi, R. Welsh, M. Pearson Royal Bolton Hospital, Bolton, UK Introduction: Oncotype DX is NICE approved as a diagnostic tool to assess risk recurrence in women with early breast cancer. It predicts potential benefits of adjuvant chemotherapy. We looked at correlation between multidisciplinary team (MDT) decision and Oncotype DX risk recurrence score (RRS) in all intermediate risk early breast cancers treated at Royal Bolton Hospital (RBH) between February and August 2014. Methods: We requested Oncotype DX tests as per NICE Guidance. MDT decision regarding adjuvant chemotherapy was recorded in advance of the Oncotype DX report. The subsequent test result was correlated with the clinical decision. Data was collected prospectively. 6 of 32 patients were excluded for inappropriate test request. Results: MDT MDT did not recommended chemotherapy recommend chemotherapy High Risk (RRS) > 31 n 1⁄4 3 (11.5%) n 1⁄4 2 (7.68%) Intermediate or Low Risk (RRS) < 31 n 1⁄4 12 (46.2%) n 1⁄4 9 (34.6%) Patients with Intermediate RRS 18-31 are reputed to have little chemotherapy benefit however these remain the hardest group to advise. There were 4 cases in which Oncotype DX did not recommend chemotherapy but the clinical decision was to treat. In these cases, RRS was between 18e20 and the decision was made with the patient following an informed discussion. Conclusion: Our results show a reduction of adjuvant chemotherapy use in patients with intermediate risk breast cancer when utilising Oncotype DX. Over £20,000 was saved in this cohort. Further studies and long term follow up of patients is needed to convince specialists that chemotherapy can be omitted in patients with an intermediate RRS 18-31 http://dx.doi.org/10.1016/j.ejso.2015.03.039

BACKGROUND: Cancer survival is known to vary by socio-economic group. A review of studies published by 1995 showed this association to be universal and resilient to the many different ways in which socio-economic status was determined. Differences were most commonly attributed to differences in stage of disease at diagnosis. MATERIALS AND METHODS: A review of research published since 1995 examining the association of cancer survival with socio-economic variables. RESULTS: An association between socio-economic status and cancer survival has continued to be demonstrated in the last decade of research. Stage at diagnosis and differences in treatment have been cited as the most important explanatory factors. Some research has evaluated the psychosocial elements of this association. CONCLUSIONS: Socio-economic differences in cancer survival are now well documented. The explanatory power of stage at diagnosis, although great, should not detract from the evidence of differential treatment between social groups. Neither factor can completely explain the observed socio-economic differences in survival, however, and the importance of differences in tumour and patient factors should now be quantified.

Socioeconomic differences in age-standardised crude survival for women diagnosed with breast cancer during 1991-1999 in England were influenced by the population of the geographic area used to assign the deprivation index, but not by the choice of index.