Trends in Cancer Survival in Scotland

Transcription

1 Scottish Cancer Intelligence Unit Trends in Cancer Survival in Scotland - Trends in survival are presented for the half million adult cancer patients diagnosed in Scotland between and. The Results show, for each of major types of cancer : survival at, and years after diagnosis trends over time variations by age international comparisons variations by health board variations by socio-economic status The Overview of Results compares cancers and shows : trends in survival by period of diagnosis, age and sex median survival survival in Scotland compared with survival in England and Wales estimates of avoided deaths (due to improvements in survival over time), and of avoidable deaths (if all patients had the same prognosis as those living in the least areas of Scotland) Common Services Agency

2 For further information contact : The Cancer Surveillance Group Scottish Cancer Intelligence Unit Information & Statistics Division The National Health Service in Scotland Trinity Park House EDINBURGH EH SQ Scotland, UK Phone - Fax - cancerstats@isd.csa.scot.nhs.uk Publication enquiries and orders Phone - Fax - Cancer registration enquiries Phone - Fax - Suggested citation of print edition Scottish Cancer Intelligence Unit (). Trends in Cancer Survival in Scotland -. Edinburgh : Information & Statistics Division. Designed and typeset by ISD Scotland Publications. Common Services Agency First published

3 Preface Cancer remains a major cause of morbidity and mortality in Scotland, currently accounting for some per cent of all deaths in our country. At the same time, survival rates for most cancers have been increasing steadily so that for many forms of cancer, more than per cent of patients are now alive five years after their initial diagnosis. Trends in Cancer Survival in Scotland - is the latest in an important series of publications from the Information and Statistics Division of the NHS in Scotland. The publication takes full advantage of our excellent linked databases and our cancer registry. It sets out survival trends for all patients aged - diagnosed as having cancer in the period - but follow-up data is available to December. The report explores in detail the international variations in cancer survival, the variations observed within Scotland, and the effects of deprivation on survival rates. Survival in Scotland is compared to that in England and Wales, with estimation of the number of deaths avoided as survival has improved with time. Of added interest, the publication presents estimates of the numbers of deaths that might have been avoided if all patients had enjoyed the same prognosis as those living in our least areas. This publication adds significantly to our understanding of cancer in Scotland. It sheds important light on the factors that influence survival. Perhaps predictably, it is a mixture of good and bad news, but crucially it provides an important platform from which we can move effectively to address the cancer challenge. I recommend it unreservedly to all those concerned with cancer survival in Scotland. Sir David Carter Chief Medical Officer for Scotland March

4 Summary of key results Time trends Survival has increased for the majority of cancers over the last to years, which means that many people diagnosed with cancer are now living longer. For many cancers today, over % of patients are alive five years after diagnosis; for patients with cancer of the testis, the survival rate at five years is over %. Once they have survived for five years after diagnosis, the prospects for patients with most cancers are very good. The largest increases in survival were seen for malignant melanoma of the skin, cancer of the testis, leukaemia, and large bowel cancer; in addition, stomach and oesophageal cancer, with comparatively poor survival, have shown considerable proportional increases over time. Most of the improvements in survival reflect advances in treatment, although earlier diagnosis has probably also contributed to improvements seen for malignant melanoma of the skin, breast cancer and prostate cancer. Improvements in survival over time have been gradual with no sudden benefits due to the introduction of particular forms of treatment. International variation For many cancers, survival in Scotland in the late s, (the most recent period for which comparative data are available), compared unfavourably with survival in other European countries and the USA, but these s are difficult to interpret because of differences in population coverage, data quality and case-mix. Survival appears to have been worse in Scotland for cancers in which early diagnosis is the main influencing factor, and there is indirect evidence that patients in Scotland have, at least in the past, tended to present with more advanced disease than their European counterparts. Where highly effective medical treatment is available, for example for testicular cancer, survival in Scotland is similar to survival in other European countries.

5 Summary Variations within Scotland For some cancers, survival varies between health boards of residence. However these differences are mainly likely to reflect minor differences in data quality, random variation, and especially differences in casemix for example, the proportion of patients presenting with early versus advanced disease. Deprivation For many cancers, incidence and mortality tend to be higher and survival tends to be lower in patients from areas. The reasons for this are likely to be multi-factorial and may vary between different cancers, although there is little evidence for socio-economic inequity in access to cancer services in Scotland. Potentially many lives could be lengthened if the survival experience of the least group of patients could be extended to all patients. A priority for research is therefore to discover the causes of socioeconomic differences, in order to design practical interventions with the aim of reducing inequalities in survival.

6 Overview of results Overview of results This section provides a summary of the data available for analysis, highlights some of the differences in survival trends for different cancers in relation to period of diagnosis, age and sex; and includes a comparison of survival in Scotland with survival in England and Wales. Also included are estimates of the numbers of avoided deaths resulting from improvements in survival for patients diagnosed during compared to those diagnosed during ; and estimates of the numbers of deaths which might be avoidable if all patients in Scotland had survival prospects equivalent to those living in the least areas. For more detailed information and commentary about each cancer, readers should refer to the relevant part of the Results section. Data available for analysis The numbers of cases included in the analyses, by cancer and period of diagnosis, are shown in table. The highest numbers were seen for lung, large bowel, breast, prostate and bladder cancer, accounting for % of all malignancies in the period. Even with this large data set, covering the whole of Scotland, the number of cases available for analysis was small for some cancers, for example cancer of the thyroid, particularly when broken down by age, sex and health board or deprivation index. Improvements in diagnostic techniques, or the introduction of screening tests, can lead to the artificial appearance of an increase in risk, with cancers being diagnosed earlier, at a less advanced stage. It is possible that some of these cancers with a favourable prognosis would have never presented clinically during the patient s lifetime. This can impact on the assessment of trends in cancer survival over time so that significant trends in incidence should be taken into account when interpreting cancer survival trends. More detailed assessments of incidence trends in Scotland are available elsewhere (Harris et al, ; Swerdlow et al, ). table Number of patients entered into survival analysis by cancer and period of diagnosis Period of diagnosis Cancer (ICD-) - Oral Cavity (, -) Head and Neck (-,, ) Oesophagus () Stomach () Large Bowel (+) Colon () Rectum () Pancreas () Larynx () Trachea, Bronchus and Lung () Malignant Melanoma of the Skin () Breast () Cervix Uteri () Corpus Uteri () Ovary () Prostate () Testis () Bladder () Kidney () Brain and other CNS (+) Thyroid () Non-Hodgkin s Lymphoma (+) Hodgkin s Disease () Multiple Myeloma () Leukaemia (-) All Malignant Neoplasms ICD- - excluding non-melanoma skin cancer (ICD- ).

7 Overview of results Cancer survival trends In the most recent period examined, percentage survival at five years after diagnosis varied from under % for cancer of the pancreas to over % for cancer of the testis ( and table ). Percentage survival was worst in patients with cancers which often present at an advanced stage and are less amenable to treatment (examples being cancers of the pancreas, the lung and the oesophagus). Percentage survival tended to be better for cancers for which patients are more likely to present at an early stage (for example, cancers of the corpus uteri, bladder and thyroid, and malignant melanoma of the skin), for cancers which can be detected early by screening programmes (for example, breast cancer), and for cancers for which there have been major advances in treatment (for example, cancer of the testis and Hodgkin s disease). For the majority of cancers, survival at one year after diagnosis has improved over the period surveyed (table ), with the most improvement being seen in some of the lympho-haematopoietic malignancies, probably due to the development and implementation of increasingly effective therapies; in cancers of the large bowel; and in malignant melanoma of the skin and thyroid cancer in males. Broadly similar findings emerged from a recent study of cancer survival in England and Wales (Coleman et al, ). Percentage survival at one year after diagnosis has declined over the period in cancers of the head and neck in males, possibly reflecting changes over time towards a less favourable casemix, both in terms of the distribution of anatomical sub-sites of tumours, and in terms of the proportion of patients from areas (Macfarlane et al, ) who tend to have a poorer prognosis. Relative survival (%) at five years after diagnosis by cancer and sex patients diagnosed -, Males Testis Malignant Melanoma of the Skin Bladder Thyroid Hodgkin s Disease Larynx Head and Neck Prostate Non-Hodgkin s Lymphoma Colon Oral Cavity Rectum Kidney Multiple Myeloma Leukaemia Brain and other CNS Stomach Oesophagus Trachea, Bronchus and Lung Pancreas All Malignant Neoplasms Malignant Melanoma of the Skin Corpus Uteri Breast Thyroid Bladder Larynx Cervix Uteri Oral Cavity Head and Neck Hodgkin s Disease Non-Hodgkin s Lymphoma Colon Large Bowel Rectum Kidney Ovary Leukaemia Multiple Myeloma Brain and other CNS Stomach Oesophagus Trachea, Bronchus and Lung Pancreas All Malignant Neoplasms Females Survival ( % ) Survival ( % ) These rates are directly standardised to the 'World Standard Cancer Patient Population'. See Appendix. For some cancers (Testis, Brain and other CNS, Thyroid and Hodgkin's disease in males; Larynx in females) there were less than cases in the - age group in any time period. For these sites the comparison was made using standardised rates for the age group -. Source : Scottish Cancer Registry; GRO(S) deaths.

8 table Trends in survival by cancer, sex and period of diagnosis Relative survival (%) at one and five years ; patients aged -, diagnosed - to Overview of results Change in relative survival at years from - to Relative survival (%) at year Relative survival (%) at years Absolute change Rate of change whole per per year Cancer (ICD-) Sex - - period year (%) Oral Cavity Male % (, -) Female % Head and Neck Male % (-,, ) Female % Oesophagus () Male % Female % Stomach () Male % Female % Large Bowel Male % (+) Female % Colon () Male % Female % Rectum () Male % Female % Pancreas () Male % Female % Larynx () Male % Female % Trachea, Bronchus Male % and Lung () Female % Malignant Melanoma Male % of the Skin () Female % Breast () Female % Cervix Uteri () Female % Corpus Uteri () Female % Ovary () Female % Prostate () Male % Testis () Male % Bladder () Male % Female % Kidney () Male % Female % Brain and other CNS Male % (+) Female % Thyroid () Male % Female % Non-Hodgkin s Male % Lymphoma (+) Female % Hodgkin s Disease () Male % Female % Multiple Myeloma () Male % Female % Leukaemia (-) Male % Female % All Malignant Neoplasms Male % Female % These rates are directly standardised to the World Standard Cancer Patient Population. See Appendix. The absolute change over the whole period is calculated as the difference between relative survival at years in - and in, which for Oral Cavity cancer in males gave a decrease of.%. The absolute change per year is calculated as the annual change in absolute survival (by regression over the annual -year survival rates shown on a for each cancer), giving for Oral Cavity cancer in males an increase of.% per year. The rate of change per year gives the percentage change per year over the whole period, and for Oral Cavity cancer this was.%. (In this particular case the absolute difference between - and was negative, despite an overall average increase, because of high survival rate for - compared to other years). Because of small numbers of cases in older age groups these rates are standardised to the age group -, rather than -. ICD- - excluding non-melanoma skin cancer (ICD- ). Source : Scottish Cancer Registry; GRO(S) deaths.

9 Overview of results Over the period surveyed, most cancers showed some improvement in survival at five years after diagnosis (table and ), and for some cancers this improvement was large: for malignant melanoma of the skin, percentage survival at five years after diagnosis in males increased from % in the period - to % in the period -, an absolute increase of %. Over the same period the increase for females was %, from % (-) to % (). These increases may reflect an increase in diagnosis of early stage disease following health education programmes aimed at encouraging earlier presentation and referral. Large absolute increases in percentage survival at five years were also seen for testicular cancer (%), leukaemia (% for males and % for females) and large bowel cancer (% and % for males and females, respectively). The improvement observed for prostate cancer in the most recent period is likely to reflect the introduction of prostatespecific antigen (PSA) testing, resulting in the diagnosis of some less aggressive tumours (Brewster et al, a). Improvements in survival at five years were generally smaller than at one year indicating that, although survival is improving, either because of earlier diagnosis or improved treatment, the majority of cancer patients are not being cured. This is a common finding in studies of cancer survival (Clinical Outcomes Working Group, ). Cancers which were exceptions to this rule, and for which the increase over the period surveyed in percentage survival was greater at five years than at one year were malignant melanoma of the skin, Hodgkin s disease, breast cancer and testicular cancer. The improvement in survival for malignant melanoma of the skin seems to be only partly explained by an increasing proportion of thinner tumours (MacKie et al, ). In Hodgkin s disease, there have been major improvements in treatment using combination chemotherapy and radiotherapy (Boyle et al, ). The apparent improvement in survival for breast cancer may reflect the introduction and increasing use of systemic adjuvant therapy (Scottish Breast Cancer Focus Group et al, ). Likewise, survival has improved in testis cancer because of the advent of effective chemotherapy (Coleman et al, ). Absolute difference in relative survival at five years by cancer and sex : patients diagnosed in compared to those diagnosed in - (patients aged -) Males Malignant Melanoma of the Skin Testis Leukaemia Colon Large Bowel Multiple Myeloma Thyroid Hodgkin s Disease Rectum Bladder Non-Hodgkin s Lymphoma Prostate Kidney Stomach Oesophagus Brain and other CNS Larynx Trachea, Bronchus and Lung Pancreas Oral Cavity Head and Neck All Malignant Neoplasms Malignant Melanoma of the Skin Colon Large Bowel Rectum Leukaemia Breast Hodgkin s Disease Thyroid Kidney Bladder Non-Hodgkin s Lymphoma Larynx Stomach Brain and other CNS Corpus Uteri Head and Neck Ovary Oesophagus Trachea, Bronchus and Lung Cervix Uteri Oral Cavity Pancreas Multiple Myeloma All Malignant Neoplasms - Females Absolute difference in - Absolute difference in Source : Scottish Cancer Registry; GRO(S) deaths. Measured in terms of proportional rather than absolute change, other cancers showed substantial improvement (table ): survival at five years for cancer of the oesophagus in males increased by % per year compared to survival at the beginning of the period, and other cancers with large increases were stomach cancer and leukaemia in males with increases of about % and % respectively. Absolute differences in relative survival between the time periods - and have been shown : so, for example, the for malignant melanoma in males was.% (-) and.% (), which by subtraction gives a difference of.%. These rates are directly standardised to the 'World Standard Cancer Patient Population'. See Appendix. For some cancers (Testis, Brain and other CNS, Thyroid and Hodgkin's disease in males; Larynx in females) there were less than cases in the - age group in any time period. For these sites the comparison was made using standardised rates for the age group -.

10 Overview of results At the other end of the scale there was no improvement over the period surveyed in survival at five years after diagnosis for cancer of the pancreas, for larynx cancer in males, and for multiple myeloma and cancers of the head and neck in females. Survival in male patients from cancers of the head and neck declined over the period, probably, as mentioned above, because of changes over time to a less favourable case-mix. Survival for cancer of the cervix uteri declined between - and, but increased thereafter, perhaps reflecting increased opportunistic screening during the s until the introduction of computerised call-recall systems. The increase in survival in lung cancer patients was small in absolute terms, but in proportionate terms averaged.% per year (males) and.% per year (females). For most cancers, age-standardised relative survival was reasonably close to unstandardised relative survival. However, for multiple myeloma these estimates were different due to an artefact of the standardisation, in that for this particular cancer, the World Standard Cancer Patient Population gives substantial weight to the youngest age group, for whom the survival estimates for Scotland are not stable as they are based on very small numbers of cases (table. and appendix ). For all malignant neoplasms, percentage survival at one year after diagnosis for males increased from % in the period - to % in the period, an absolute increase of %. The corresponding increase for females was from % to %, an absolute increase of %. This is less than the increase in males because there was a comparatively small improvement in survival over the period for breast and gynaecological cancers, which contribute a large proportion of the cancers in females, and for which survival is already relatively high, rather than because cancer survival has improved more in males than in females for specific cancers. Meanwhile, survival at five years improved by around % for both sexes, that is, a proportional increase of.% per year in males and.% per year in females. All malignant neoplasms includes a wide mix of cancers with different survival patterns and the improvement may mask a change in the proportions of cancers as well as representing a genuine improvement in survival over time. table Median observed survival in years, by cancer and period of diagnosis patients aged - Period of diagnosis Cancer - Oral Cavity..... Head and Neck..... Oesophagus..... Stomach..... Large Bowel..... Colon..... Rectum..... Pancreas..... Larynx..... Trachea, Bronchus and Lung..... Malignant Melanoma of the Skin Breast Cervix Uteri Corpus Uteri Ovary..... Prostate..... Testis Bladder..... Kidney..... Brain and other CNS..... Thyroid Non-Hodgkin s Lymphoma..... Hodgkin s Disease Multiple Myeloma..... Leukaemia..... All Malignant Neoplasms..... The median observed survival time is the length of time after diagnosis until half the patients have died, irrespective of the cause of death. Where less than half the patients had died by the end of the period of follow-up (st December ) the median survival could not be calculated and is shown as missing ('-'). ICD- - excluding non-melanoma skin cancer (ICD- ). Source : Scottish Cancer Registry; GRO(S) deaths. The numbers of deaths due to cancer decrease exponentially as time from diagnosis increases. Thus, for example, if the median survival is two years, half the patients will have died within two years of diagnosis, but many of the remainder will survive substantially longer than a further two years. Median survival is highest in those cancers which have a good prognosis and/or are often diagnosed in younger people (for example, cancers of the testis, thyroid, corpus uteri, and Hodgkin s disease) (table ). Estimates of the median observed survival broadly support the results shown in and table. Over the period surveyed, median survival has increased by three years or more for cancers of the breast, bladder and thyroid, malignant melanoma of the skin and Hodgkin s disease, and for many cancers median survival has been extended by a year or more. For cancers with a very favourable prognosis, more than half the patients were still alive at the end of the period of follow-up for this analysis and so median survival could not be calculated. For all malignant neoplasms median survival increased from. to years.

11 Overview of results Survival was better in younger patients for all cancers (table ), even though adjustment was made for the higher general mortality in older age groups. This could be due to differences in tumour biology (for example, breast cancer in pre- and postmenopausal women), better general health, earlier diagnosis or better availability and effectiveness of treatment. Large variations between age groups were seen for many cancers, in particular cancer of the thyroid, the brain, non-hodgkin s lymphoma, Hodgkin s disease, multiple myeloma, and genitourinary cancers in females. Note that in the younger age groups some of these estimates are based on small numbers of cases (for more detail see table for individual cancers in the Results section). table Relative survival by cancer, sex and age group Relative survival (%) at five years after diagnosis : patients diagnosed - Age group Cancer (ICD-) Sex Oral Cavity (, -) Male Female Head and Neck (-,, ) Male Female Oesophagus () Male Female Stomach () Male Female Large Bowel (+) Male Female Colon () Male Female Rectum () Male Female Pancreas () Male Female Larynx () Male Female Trachea, Bronchus and Lung () Male Female Malignant Melanoma of the Skin () Male Female Breast () Female Cervix Uteri () Female Corpus Uteri () Female Ovary () Female Prostate () Male Testis () Male Bladder () Male Female Kidney () Male Female Brain and other CNS (+) Male Female Thyroid () Male Female Non-Hodgkin s Lymphoma (+) Male Female Hodgkin s Disease () Male Female Multiple Myeloma () Male Female Leukaemia (-) Male Female All Malignant Neoplasms Male Female Source : Scottish Cancer Registry; GRO(S) deaths. Because of small numbers of cases in older age groups it was not possible to calculate survival rates for some cancers. ICD- - excluding non-melanoma skin cancer (ICD- ).

12 Overview of results For many cancers, survival prospects differed between males and females ( ). Cancers where the difference was comparatively large included cancer of the thyroid, oral cavity, malignant melanoma of the skin, and brain and other CNS cancers, for all of which females had better survival than males; and bladder cancer, where males had a higher survival rate than females. The apparent higher survival for males with multiple myeloma seen in disappeared when the unstable survival estimates for the - year olds were excluded from the standardisation. Micheli et al () have shown that the overall male/female hazard ratio is. and that this difference is greatest in young patients, diminished in the middle aged, and reversed in the elderly. Survival for all malignant neoplasms was higher in females than in males, the chief reason being that lung cancer, which has low survival, is at present considerably more common in men than in women; whereas breast cancer, the most common cancer in females, has a relatively good prognosis. Absolute differences in survival between males and females have been shown : so, for example, the for thyroid cancer in females was.% and in males was.%, which by subtraction gives a difference of.%. These rates are directly standardised to the 'World Standard Cancer Patient Population'. See Appendix. For some cancers (Larynx, Brain and other CNS, Thyroid and Hodgkin's Disease) there were less than cases in the - age group for either males or females. For these sites the comparison was made using standardised rates for the age group -. Figure shows that survival at five years in Scotland for cases diagnosed during was very similar to survival in England and Wales. Survival was higher in Scotland for malignant melanoma of the skin (which may reflect higher rates of diagnosis of early stage disease). Survival appeared to be higher in Scotland for prostate cancer and leukaemia in males, but higher in England and Wales for Hodgkin s disease, and for larynx cancer in males. However, these differences may be due to statistical variation as the numbers of cases, at least in Scotland, is comparatively small. The higher survival in England and Wales for multiple myeloma in females resulted from the artefact discussed previously. These rates are directly standardised to the 'World Standard Cancer Patient Population'. See Appendix. Some cancers (Oral Cavity, Head and Neck) are not shown due to differences in definitions of ICD- site combinations between Scotland, and England and Wales. For some cancers (Testis, Brain and other CNS, Thyroid and Hodgkin's Disease in males; Larynx in females) there were less than cases in the age group - in Scotland. For these sites the comparison was made using standardised rates for the age group -. Multiple Myeloma Absolute difference in relative survival at five years by cancer males compared to females; patients aged -, diagnosed - On this side survival is better in males Trachea, Bronchus and Lung Pancreas Larynx Hodgkin s Disease Bladder Thyroid Oral Cavity Malignant Melanoma of the Skin Brain and other CNS Non-Hodgkin s Lymphoma Oesophagus Head and Neck Rectum Stomach On this side survival is better in females Large Bowel Kidney Leukaemia Colon All Malignant Neoplasms Absolute difference in Males Comparison of relative survival at five years between Scotland, and England and Wales : patients aged -, diagnosed Oesophagus Stomach Pancreas Females Trachea, Bronchus and Lung Pancreas Colon Large Bowel Rectum Prostate Larynx Malignant Melanoma of the Skin Bladder Kidney Brain and other CNS Thyroid Non-Hodgkin s Lymphoma Hodgkin's Disease Multiple Myeloma Leukaemia Oesophagus Stomach Trachea, Bronchus and Lung Colon Large Bowel Rectum Ovary Kidney Brain and other CNS Testis Multiple Myeloma Leukaemia Larynx Malignant Melanoma of the Skin Breast Cervix Uteri Corpus Uteri Bladder Thyroid Non-Hodgkin s Lymphoma Hodgkin's Disease Scotland England and Wales Scotland England and Wales Source : Scottish Cancer Registry; GRO(S) deaths. England and Wales estimates from Coleman et al, (CDROM). Source : Scottish Cancer Registry; GRO(S) deaths.

13 Overview of results Avoided and potentially avoidable deaths How many deaths were avoided through improvements in survival over time, or would be avoidable if patients in all groups of society were to have the same relative survival as that actually observed for patients in the most affluent group? The numbers of avoided or avoidable deaths is dependent both on the incidence of the cancer and on differences in survival, either over time (avoided deaths) or over deprivation quintiles (avoidable deaths). The percentage of avoided deaths depends on changes in survival over time whereas the percentage of avoidable deaths is dependent on differences in survival between deprivation quintiles. This percentage is not dependent on the underlying cancer incidence. Figure shows the estimated numbers of Avoided Deaths due to improvements in survival between the period - and, at five years after diagnosis. Most avoided deaths were seen in cancers of the breast ( deaths avoided), colon (), prostate (), bladder () and rectum (). Data for England and Wales, based on an analysis of deaths avoided by improvements in survival between and, showed the same cancers as having the largest numbers of avoided deaths (Richards et al, ). The exception was prostate cancer, but this may be explained by increases in prostate cancer survival that occurred in the s as an artefact of PSA testing. The cancers with the largest percentages of avoided deaths were testis (%), breast (%), Hodgkin s disease (%), bladder (%), corpus uteri (%), prostate (%) and malignant melanoma of the skin (%). Because of the introduction of the screening programme, calculations of avoided deaths for breast cancer are difficult to interpret, and no adjustment has been made for lead-time bias. (See the chapter on breast cancer in the Results section, and the section Interpretation of variations in survival for more detail). However, this would be expected to improve survival soon after diagnosis. The improvement in survival in breast cancer was seen throughout the first five years after diagnosis, and therefore is likely to be due both to increased use of systemic adjuvant therapy, as well as, for screened patients, diagnosis at an earlier stage in their disease. The concept Avoidable Deaths is calculated here for differences in survival between deprivation quintiles, but can also be applied to differences between geographical regions or countries. A deprivation gradient in survival was found for most cancers (see a in Results section for each cancer) and estimates of avoidable deaths are shown here in. The least group had, by definition, zero avoidable deaths, and the numbers of avoidable deaths in the other deprivation groups were calculated separately and then summed. The largest numbers of avoidable deaths were seen for cancers of the bladder (), breast () and colon (). The cancers with the largest percentages of avoidable deaths were : bladder (% of deaths would be avoidable), malignant melanoma of the skin (%), cervix (%) and testis (%). Conclusion Estimate of avoided deaths (with % of total deaths from each cancer) within five years of diagnosis, by cancer patients aged -, diagnosed compared to Colon (.%) Prostate (.%) Bladder (.%) Rectum (.%) Trachea, Bronchus and Lung (.%) Stomach (.%) Kidney (.%) Corpus Uteri (.%) Non-Hodgkin s Lymphoma (.%) Brain and other CNS (.%) Malignant Melanoma of the Skin (.%) Leukaemia (.%) Oesophagus (.%) Hodgkin s Disease (.%) Oral Cavity (.%) Cervix Uteri (.%) Ovary (.%) Testis (.%) Thyroid (.%) Larynx (.%) Multiple Myeloma (.%) Pancreas (.%) Head and Neck (-.%) Breast (.%) Large Bowel (.%) See Statistical Methods section. Estimate of avoidable deaths within five years of diagnosis (with % of total deaths from each cancer), by cancer if all patients had the same survival prognosis as the least patients aged -, diagnosed - Prostate (.%) Corpus Uteri (.%) Brain and other CNS (.%) Testis (.%) Leukaemia (-.%) Oesophagus (-.%) Ovary (-.%) Pancreas (-.%) Multiple Myeloma (-.%) Numbers of avoided deaths Trachea, Bronchus and Lung (.%) Kidney (.%) Stomach (.%) Rectum (.%) Malignant Melanoma of the Skin (.%) Cervix Uteri (.%) Non-Hodgkin s Lymphoma (.%) Colon (.%) Bladder (.%) Large Bowel (.%) Breast (.%) Numbers of avoidable deaths See Statistical Methods section. Cancers with small numbers of cases within deprivation quintiles (Oral Cavity, Head and Neck, Larynx, Hodgkin s Disease and Thyroid) were excluded from this analysis. This was a large population-based survival analysis which included all patients diagnosed with cancer in Scotland between and, about half a million patients in all. Over this period improvements in survival were seen for the majority of cancers, and for several cancers the improvements were substantial. For many cancers there were major advances in therapy over the period, but unfortunately this did not apply to all cancers. Because the mix of cancers differs between males and females, and survival prognosis is different for different cancers, overall survival was higher in females than in males, whereas the improvement in survival over the period was greater in males than in females. Younger patients had more favourable survival than older patients; and patients in the least categories of the population had better survival than those in the more categories, so that many cancer deaths would potentially be avoided if variations in cancer survival between patients in different deprivation categories could be eliminated. Source : Scottish Cancer Registry; GRO(S) deaths. Source : Scottish Cancer Registry; GRO(S) deaths. Deprivation Quintiles are derived from the Census.

14 Oral Cavity (ICD-, -) This diagnostic group consists of cancers of the tongue (ICD- ), gum (), floor of the mouth (), and other and unspecified parts of the mouth (). The majority of cancers arising at these sites are squamous cell carcinomas and they share similar epidemiological characteristics. However, it should be noted that survival comparisons can be influenced by the case-mix of anatomical sub-sites (Berrino and Gatta, ). Currently, over new cases of oral cancer are diagnosed in Scotland each year (ISD Scotland, ). Incidence rates have been increasing for many years, especially among younger age groups, and the risk of disease is higher among people (especially males) living in areas (Harris et al, ). Trends in oral cancer are likely to reflect changing patterns of tobacco and alcohol use, since these are the main recognised risk factors in Western populations. Although the prognosis of oral cancer is greatly improved by early detection of pre-cancerous and cancerous lesions during routine dental examination, many patients have advanced disease before they are referred for specialist treatment (The Scottish Office, ). International comparisons of incidence, mortality and survival are shown in.. Since comparative survival s are not available for cancer of the oral cavity as defined above, the data shown relate to cancers of the gum, floor of mouth, and other and unspecified parts of the mouth (ICD- -). In both sexes, incidence and mortality rates in Scotland were among the highest of the countries compared. In contrast, survival in Scotland fell in the middle range of international rates. The apparent inconsistency seen for France, between incidence, mortality and survival, may be due to the fact that these data are drawn from different data sources, and refer to different time periods. Compared to patients diagnosed in the early s, survival at one year appears to have increased among patients diagnosed more recently (.a, table.). However, survival at five years after diagnosis did not alter greatly during the period surveyed. Survival tended to decrease with increasing age at diagnosis and was considerably lower in patients aged over years (s.b and.c, table.). Among patients diagnosed under the age of years, females tended to have better survival prospects than males (.c, table.). Table. shows the results of analyses of cause-specific survival by health board of residence. Although the unadjusted survival s ranged from around % to almost % at five years, it should be noted that this comparison was based on small numbers of cases in some health boards and there were no statistically significant differences between the adjusted hazard ratios for each health board compared to the whole of Scotland. The prospects for patients who survive beyond the first year after diagnosis were reasonably favourable and many of those surviving to five years might be considered to be cured (s. and.). Incidence and mortality rates were inversely associated with socioeconomic status, and survival tended to be worse among patients from the most areas, although the latter was not a statistically significant trend (.).. International comparison of incidence, mortality and survival (with % CI) all ages : by sex (ICD- -) Males Incidence Mortality Survival Scotland England and Wales Sweden Spain Netherlands Italy Germany France Finland Denmark USA Rate per population Rate per population at years after diagnosis Females Incidence Mortality Survival Scotland England and Wales Sweden Spain Netherlands Italy Germany France Finland Denmark USA Rate per population Rate per population at years after diagnosis See Introduction to Tables and Figures for details of registries and data sources. Age-standardised rates per person-years at risk (World standard population) :. Relative survival at years, patients diagnosed -. Scotland : survival, ages -. England and Wales: incidence ; mortality ; survival (ages -). USA (SEER, whites) : incidence and mortality -, survival -.

15 Oral Cavity (ICD-, -). Relative survival (a) by year of diagnosis - year survival (a-c) For patients aged - These rates are directly standardised to the World Standard Cancer Patient Population (see Appendix ). Cases diagnosed in and do not have years follow-up. year survival Year of diagnosis (b) age group (c) males at year males at years females at year females at years (b) by age at diagnosis patients diagnosed - (c) by sex and age at diagnosis patients diagnosed - table. Years following diagnosis Cause-specific survival by health board Incidence, unadjusted survival at years and adjusted hazard ratio (with % CI) compared to Scotland : patients diagnosed Survival analyses Number % CI Incidence included Unadjusted Adjusted Health Board rates in analysis survival hazard ratio Lower Upper Argyll & Clyde Ayrshire & Arran Borders Dumfries & Galloway Fife Forth Valley Grampian Greater Glasgow Highland Lanarkshire Lothian Tayside Scotland The hazard ratio is the ratio of the rate of death in a health board to the rate in Scotland as a whole. Health boards with higher survival will usually have lower hazard ratios. However, this is not always the case because the hazard ratios have been adjusted for differences in age, sex and deprivation quintile between health boards. See Statistical Methods for further information Age group Cases diagnosed in and do not have years follow-up. Mainland health boards only. Age-standardised incidence rates per person-years at risk (European standard population). Adjusted for age, sex, and Census Carstairs deprivation quintile. Figures for Scotland include Orkney, Shetland and Western Isles. Sources : Scottish Cancer Registry; GRO(S) deaths and population estimates.

16 Oral Cavity (ICD-, -).. Relative survival at - years, conditional on having already survived,, or years after diagnosis Patients aged - Relative survival at year, conditional on having already survived - years after diagnosis By age group Patients who have survived years years age group Years of follow-up year All patients Years following diagnosis This shows, for patients who have already survived, or years following a diagnosis of cancer, the probability of surviving a further,,, and years. So, for instance, the ' year' curve is based only on patients who have already survived the first year, while the ' year' curve shows the survival probability for patients who have already survived years after diagnosis. Patients diagnosed -. (Cases still alive at.. were censored at that date). This shows the pattern of excess mortality (compared with the general population) following a diagnosis of cancer, by displaying year relative survival estimates for patients who have survived the first to years after diagnosis. If the survival curve reaches % that group of patients can be considered to be 'cured'. So for the first year following diagnosis the estimate gives survival at year for all patients; for the second and further years following diagnosis the estimate is restricted to those patients who have survived to the beginning of the second or subsequent years. Patients diagnosed -. (Cases still alive at.. were censored at that date).. Cause-specific survival by deprivation quintile Patients diagnosed (a) Survival at years ; incidence and mortality (b) Survival at - years Least mortality Deprivation quintile incidence survival Most Incidence / mortality per Years following diagnosis deprivation quintile least most Sources : Scottish Cancer Registry; GRO(S) deaths and population estimates. Tests for trend across deprivation categories : incidence (p=., linear regression on log rates); mortality (p=., linear regression on log rates) ; survival (p=., Cox regression). Cases diagnosed in and do not have years follow-up. Adjusted for age and sex. Age-standardised rates per person-years at risk (European standard population).

17 Oral Cavity (ICD-, -) table. Trends in survival by age group and period of diagnosis Observed and relative survival (%) at,,, and years; patients diagnosed - Number Observed survival (%) at Relative survival (%) at Age of cases group Period analysed yr yrs yrs yrs yr yrs yrs yrs Both sexes Directly standardised Cases diagnosed in and do not have years follow-up and cases diagnosed in and do not have years follow-up. These rates are directly age-standardised to the World Standard Cancer Patient Population (see Appendix ).

18 table continued. Oral Cavity (ICD-, -) Trends in survival by age group and period of diagnosis Observed and relative survival (%) at,,, and years; patients diagnosed - Number Observed survival (%) at Relative survival (%) at Age of cases group Period analysed yr yrs yrs yrs yr yrs yrs yrs Males Directly standardised Cases diagnosed in and do not have years follow-up and cases diagnosed in and do not have years follow-up. These rates are directly age-standardised to the World Standard Cancer Patient Population (see Appendix ).

19 Oral Cavity (ICD-, -) table continued. Trends in survival by age group and period of diagnosis Observed and relative survival (%) at,,, and years; patients diagnosed -, Number Observed survival (%) at Relative survival (%) at Age of cases group Period analysed yr yrs yrs yrs yr yrs yrs yrs Females Directly standardised Cases diagnosed in and do not have years follow-up and cases diagnosed in and do not have years follow-up. These survival rates are analysis directly was age-standardised not performed where to the there World were Standard less than Cancer cases. Patient Population (see Appendix ). These rates are directly age-standardised to the World Standard Cancer Patient Population (see Appendix ).

20 Head and Neck (ICD- -,, ) This diagnostic group consists of cancers of the lip (ICD- ), tongue (), major salivary glands (), gum (), floor of the mouth (), other and unspecified parts of the mouth (), oropharynx (), nasopharynx (), hypopharynx (), other and ill-defined sites within the lip, oral cavity and pharynx (), nasal cavities, middle ear and accessory sinuses (), and larynx (). The majority of cancers arising at these sites are squamous cell carcinomas, with the exception of the major salivary glands, where adenocarcinomas predominate. As for cancer of the oral cavity, it should be noted that survival comparisons can be influenced by the case-mix of anatomical subsites (Berrino and Gatta, ). Currently, around new cases of head and neck cancer are diagnosed in Scotland each year (ISD Scotland, ). Incidence rates have been increasing for many years and the risk of disease is higher among people (especially males) living in areas (Harris et al, ). Alcohol and tobacco are the main established risk factors for cancers of the upper aerodigestive tract although there are exceptions. The main known causes of lip cancer are exposure to sunlight and tobacco products. The causes of salivary gland cancers are largely unknown, although ionising radiation has been reported to increase risk. The Epstein-Barr virus has a well-documented association with nasopharyngeal cancer. International comparisons of incidence, mortality and survival are shown in.. Since comparative survival s are not available for cancer of the head and neck as defined above, the data shown relate to cancers of the lip, oral cavity and pharynx (ICD- -). In males, incidence and mortality rates in Scotland fell in the middle range of international rates, whereas survival was reported to be lower than average. In contrast, females had the highest incidence and mortality rates and one of the lowest survival rates of the countries compared. Compared to patients diagnosed in the early s, survival at one year appears to have changed little among patients diagnosed more recently (.a, table.). However, survival at five years after diagnosis appears to have declined during the period surveyed. This may reflect changes over time towards a less favourable case-mix, both in terms of the distribution of anatomical sub-sites of tumours, and in terms of the proportion of patients from areas (Macfarlane et al, ) who tend to have a poorer prognosis (see below). Survival tended to decrease with increasing age at diagnosis and was considerably lower in patients aged over years (s.b and.c, table.). Among younger patients, females tended to have better survival prospects than males (.c, table.). Table. shows the results of analyses of cause-specific survival by health board of residence. The unadjusted survival s ranged from around % to almost % at five years. The analysis with adjustments for age, sex and deprivation showed statistically significant variation between the health board hazard ratios (p<.). However, this variation may reflect differences in case-mix which have not been adjusted for in the analysis. The prospects for patients who survive beyond the first year after diagnosis were reasonably favourable and many of those surviving to five years might be considered to be cured (s. and.). Incidence and mortality rates were inversely associated with socioeconomic status and survival tended to be worse among patients from the most areas (.).. International comparison of incidence, mortality and survival (with % CI) all ages : by sex (ICD- -) Males Incidence Mortality Survival Scotland England and Wales Sweden Spain Netherlands Italy Germany France Finland Denmark USA Rate per population Rate per population at years after diagnosis Females Incidence Mortality Survival Scotland England and Wales Sweden Spain Netherlands Italy Germany France Finland Denmark USA Rate per population Rate per population at years after diagnosis See Introduction to Tables and Figures for details of registries and data sources. Age-standardised rates per person-years at risk (World standard population) :. Relative survival at years, patients diagnosed -. Scotland : survival, ages -. England and Wales: incidence ; mortality ; survival (ages -). USA (SEER, whites) : incidence and mortality -, survival -.