A study published today, by Cancer Research UK-funded scientists, shows that cancer survival in England remains lower than in other similar countries – something first identified back in the late 1980s.
But it’s not all doom and gloom. The study also shows that – although we haven’t caught up yet – cancer survival in England has steadily increased since the mid-1990s.
This is the latest in a long line of research, going back 25 years, that’s attempted to draw comparisons between different countries’ cancer survival. It’s a tricky and at times controversial issue, fraught with complexity, and with a lot of caveats.
So, before we dig into today’s new figures, let’s look at the history of cancer survival comparisons, and what these studies can – and can’t – tell us.
Comparing like with like
Before international comparisons were carried out, people suspected that there were variations in survival between European countries, but no one could actually prove it. The published survival statistics among European countries obviously weren’t the same, but no one could say for sure whether the differences were because of the quality of treatment, differences in healthcare services, or the way the statistics were collected and analysed.
In 1989, the EUROCARE project was launched to develop a standard way of analysing this cancer survival data, so that people could finally make meaningful comparisons between European countries, and identify ways to improve things.
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US vs. UK
When they were first published, EUROCARE’s comparisons showed unexpectedly large variations between countries with similar levels of wealth and healthcare provision, with the UK consistently faring worse than other comparable European countries. And this led to a slew of headlines claiming that, at least for cancer, we were ‘the sick man of Europe’.
This spurred political action. The 1995 Calman-Hine report recommended strategic improvements to English cancer services to tackle worries about England’s relatively lower survival, and since then, there have been several political initiatives aimed at improving things.
These include the 2000 NHS Cancer Plan for England, which emphasised centralisation, specialisation and use of multidisciplinary teams, and the 2007 Cancer Reform Strategy, which aimed at improving cancer prevention, earlier diagnosis and patient management.
But there were still questions over exactly how comparable the data were, and – more importantly – what was causing the differences. This led the Department of Health to launch the International Cancer Benchmarking Partnership (ICBP) in 2009.
The ICBP is co-ordinated by Cancer Research UK and involves researchers, clinicians, data experts and policy makers from six countries with similar healthcare systems: Australia, Canada, Denmark, Norway, Sweden and the UK. The partnership is the first of its kind that seeks to understand not only how cancer survival varies between countries, but crucially, what could be driving these differences.
The ICBP focuses on data for bowel, lung, breast, and ovarian cancers. In 2011, it saw that survival for these cancers has been steadily improving in all ICBP countries, but the UK and Denmark had lower survival across all four diseases. Worse still, there was no sign that the UK was narrowing the survival gap with the other ICBP countries.
And so to today’s latest findings, which homed in on whether England is closing the now well-documented survival gap.
Published in the British Journal of Cancer, the study compares cancer survival in broadly the same countries and cancer types as the ICBP, but looking only at England rather than the whole of the UK, and including data for stomach cancer survival alongside the others.
Researchers at the London School of Hygiene & Tropical Medicine analysed cancer survival data between 1995 and 2009 for all six countries – plus an extra time period from 2009 to 2012 for England.
The English data came from the National Cancer Registry at the Office for National Statistics, and covers 1.9 million adults diagnosed with cancer between 1995 and 2012. The data for the other five countries was taken from a large, ongoing study called CONCORD-2, and also has information from 1.9 million adults, but in total rather than per country. CONCORD-2 has been monitoring trends in cancer survival from 1995 to 2009.
The number of people registered in national databases – known as ‘registry coverage’ – is high for the countries in today’s study. England, Canada, Denmark, Norway, and Sweden have nearly 100 per cent coverage and Australia’s coverage sits at 91 per cent. This means the data should be representative of all countries and less susceptible to differences in survival between different regions in each country (something that’s hampered previous similar attempts).
What does it look at?
This study used three ways of measuring whether England had closed the cancer survival gap.
Firstly, the researchers compared cancer survival in all countries among people diagnosed from 2005-2009.
Secondly, they looked at how the English cancer survival data from 2010-2012 stacked up against the 2005-2009 survival in the other countries, to see if England had caught up with where other countries had been.
And finally, the team looked at the amount of change each country had seen in its cancer survival figures between 1995 and 2009.
It should be kept in mind that comparing English survival in 2010-2012 to survival elsewhere in earlier time-periods is likely to be an underestimate of the gap right now, as it’s likely that other countries have improved too. That said, it’s still helpful to look at the most up-to-date cancer survival data for England to see if the 1995-2009 trends continue.
And it’s also worth pointing out that England had lower survival to begin with, so it’s likely that England’s change will be larger as there are more gains to be had.
What did it find?
The good news: the raw data shows an improvement in one-year and five-year cancer survival across all cancers in all countries between 1995 and 2009 (one-year and five-year survival are the proportions of people who have not died from their cancer (rather than anything else) at one year or five years from diagnosis). Broadly speaking, no matter which country you live in, things have improved.
The bad news: one-year and five-year survival was lowest for England and Denmark for all cancers, and this broadly remained the case throughout 1995 to 2009, echoing what was seen in the 2011 ICBP study. And on top of this, between 2010-2012 cancer survival in England was still generally lower than cancer survival had previously been in the other countries between 2005-2009. In other words – and as the infographic below shows – we haven’t yet caught up.
When comparing the level of improvement in England to the same change in the other countries, the story is more mixed. The amount England’s cancer survival had improved was greater for about half of the one-year survival comparisons, but only for 10 out of 30 comparisons for five-year survival. The most consistent improvement was in breast cancer survival, where England’s change was greater than all the other countries for one-year survival, and all but Denmark for five-year survival.
What can be done?
So, why is England lagging behind? We’ve already blogged about some of the reasons why this might be – principally the fact that the UK fares badly at detecting cancers early – and how initiatives like the National Awareness and Early Diagnosis Initiative and the ICBP are aiming to change the situation.
This study speculates that improvements in diagnostics and treatment, increased investment in cancer services and increased availability of data may be some of the reasons why England’s cancer survival continues to improve.
But it also says that to make progress on closing the cancer survival gap, England needs to invest more in centralised, specialised, and accountable services for cancer patients. And this is precisely the sort of investment that the Independent Cancer Taskforce’s cancer strategy for England calls for, highlighting just how timely these data are.
As we said earlier this week, we now need to see clear plans to put these recommendations into practice, and the resources from government to do so. Only by doing this will we see an improvement in the nation’s cancer survival statistics, and ultimately, for people diagnosed with cancer.
Natalie Moitt is a statistical information analyst at Cancer Research UK
Walters, et al. (2015). Is England closing the international gap in cancer survival? British Journal of Cancer. DOI: 10.1038/bjc.2015.265