Trends in Cancer Survival in NSW 1980 to 1996

Transcription

1 Trends in Cancer Survival in NSW 19 to 1996 Xue Q Yu Dianne O Connell Bruce Armstrong Robert Gibberd Cancer Epidemiology Research Unit Cancer Research and Registers Division The Cancer Council NSW August 6

2 Acknowledgments The authors would like to thank Dr Anjali Shah, Dr Peter Baade and Ms Helen Moore for reviewing an earlier draft of this report and providing constructive feedback. We thank the NSW Central Cancer Registry for providing the data. The Cancer Registry is managed and operated by the Cancer Institute NSW under a memorandum of understanding with the NSW Department of Health. Bruce Armstrong s research is supported by a University of Sydney Medical Foundation Program Grant. The Cancer Epidemiology Research Unit is a unit of, and is directly funded by, The Cancer Council NSW. National Library of Australia Cataloguing-in-Publication data: Trends in Cancer Survival in NSW 19 to 1996 ISBN X Key words: trends, cancer survival, relative survival, cancer registry, stage migration, epidemiology, New South Wales, Australia Suggested citation: Yu XQ, O Connell DL, Armstrong BK, Gibberd RW. Trends in Cancer Survival in NSW 19 to Sydney: The Cancer Council NSW, 6. Published by The Cancer Council New South Wales, August 6 Also in this series: Breast Cancer Survival in NSW in 1973 to 1995 (1998) Survival from Cancer in New South Wales in 19 to 1995 (1999) Remoteness and Cancer Incidence, Mortality and Survival in New South Wales 1992 to 1996 (2) Cancer Survival, Incidence and Mortality by Area Health Service in NSW 1994 to (3) Cancer Epidemiology Research Unit Cancer Research and Registers Division The Cancer Council NSW PO Box 572 KINGS CROSS NSW 13 Telephone: (2) Facsimile: (2) crrd@nswcc.org.au Internet:

3 Table of Contents Executive Summary... 1 Main findings... 1 Conclusion... 1 Introduction... 4 Methods... 5 Data source... 5 Incidence data... 5 Survival data... 5 Population data... 5 Spread of disease at diagnosis... 5 Relative survival and relative excess risk of death... 6 Statistical modelling of excess risk of death... 6 Trends in incidence rates... 7 Guide to Interpretation of Results... 8 Results... 9 All cancers... 1 Lip cancer Head and neck cancer Oesophageal cancer Stomach cancer Colon cancer Rectal cancer Liver cancer Gallbladder cancer Pancreatic cancer Lung cancer... Melanoma of the skin Mesothelioma Cancer of the connective tissue Breast cancer (female) Cervical cancer Cancer of the body of the uterus Ovarian cancer Prostate cancer Testicular cancer Bladder cancer... 3 Kidney cancer Thyroid cancer Brain cancer Hodgkin s disease Non-Hodgkin lymphoma Multiple myeloma Leukaemia Cancer with unspecified site Discussion Appendix Statistical modelling methods References... 5

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5 Trends in Cancer Survival in NSW 19 to 1996 Executive Summary This report summarises the trends in cancer survival in New South Wales (NSW) for patients diagnosed in 19 to 1996 and followed up to the end of 1. A total of 343,34 newly diagnosed cancers and 28 different cancer types were included in the analysis. The main outcome measure was the 5-year relative survival for four consecutive time periods of diagnosis (19-84, , , ) for each major cancer and all cancers combined. To reduce the impacts of earlier detection on survival over time, we estimated excess risk, the risk of death over that expected if the population death rates had applied to the cancer patients, using a statistical model to adjust for disease spread at diagnosis along with histology, age and sex. This model quantifies the extent to which the excess risk of death in a given period differs from the excess risk of death in the reference period (19-84) after controlling for the factors included in the model. To support the interpretation of the survival statistics, this report also includes the trends in incidence over the same time periods and the distribution of spread of cancer at diagnosis. Main findings Significant improvements in survival over time were found for individual sites and for all cancers combined. In three cancers, a decline in survival was observed: for cancers of the connective tissue and unspecified sites, where survival decreased significantly from to ; for cancer of the bladder the decrease was not statistically significant. For all cancers together, the excess risk of death decreased by 25% in compared with For cancers of the prostate, liver, thyroid, breast, gallbladder, body of the uterus, rectum, cervix and ovary, the falls were over 3%. Figure i shows the relative changes in excess risk of death from to for 28 individual cancers and all cancers combined. However, the trends in survival varied significantly for different categories of spread of disease for 13 of the 23 cancers for which disease stage was available. In most sites improvement in survival was mainly confined to cancers that were localised or with regional spread (cancers of the oesophagus, stomach, gallbladder, lung and kidney). For all cancers combined and cancers of the colon, breast and prostate, the main trends in survival were increases in the localised, regional and unknown categories, with no improvement for distant cancers (Figure ii). For cancer of the rectum, the 5-year relative survival increased in all categories though much less so for cancers with distant spread. For ovarian cancer, the increase in survival was evident in cancers that were localised, regional or distant but not in cancers with unknown spread or all degrees of spread together (unadjusted for degree of spread); this strongly suggests that stage migration caused the apparent increased survival in each of the categories for spread (Figure ii). Conclusion The substantial fall in excess risk of death in people diagnosed with cancer in NSW between 19 and 1996 which is present in most of the 28 specific cancer types and is substantially independent of stage of cancer at diagnosis except for those classified as distant spread, and in most cases is not explicable by stage migration strongly suggests that newer cancer therapies introduced into practice in NSW since 19, as elsewhere, have produced important survival gains. There is no justification now, in our view, for continuing scepticism as to the population-wide benefits of these therapies. 1

6 Trends in Cancer Survival in NSW 19 to 1996 Figure i Relative change in excess risk # of death from to by cancer type NSW # adjusted for age group at diagnosis, sex, years since diagnosis, period of diagnosis, histological type and spread of cancer (where applicable) by a statistical model. * indicates a significant change for that cancer site (p<.1) from to

7 Trends in Cancer Survival in NSW 19 to 1996 Figure ii Trends in 5-year relative survival in categories of spread of cancer for all cancers combined and cancers of the colon, rectum, breast, ovary and prostate, NSW All cancers Colon Rectum 5-year relative survival % Breast Ovary Prostate Localised Regional Distant Unknown All stages 3

8 Trends in Cancer Survival in NSW 19 to 1996 Introduction Patient survival is one of the most important single measures of cancer patient care. Studies of cancer patient survival, using data from population-based cancer registries, are essential for monitoring and evaluating the effectiveness of cancer care (the diagnosis and treatment of cancer) in the population. Such studies provide a tool for assessing improvements in diagnostic and treatment processes, evaluating the effects of cancer treatments and imparting information for clinicians concerned with the prognosis of individual patients. The efficacy of cancer therapy is best evaluated through the study of patient survival in a randomised clinical trial. However, patients in most clinical trials have generally not been followed long enough to evaluate long-term survival. Population-based cancer registry studies allow much longer follow-up to be undertaken. Also results from registry data represent the experience of a general population of people with cancer, not one that has been selected by referral to a particular hospital or cancer centre. More importantly, the results from clinical trials may differ from actual treatment outcomes in everyday practice. Population-based data may provide insights into the practical effectiveness of treatments that cannot be obtained from trials. Survival from almost all cancers has improved, for some dramatically, during the last 3 years. Notable increases include childhood leukaemia, testicular cancer and Hodgkin s disease, in which survival improvement has been mainly due to the introduction of more effective treatments. 1-3 For female breast cancer and colorectal cancer, 5-year survival increased significantly since the late 197s: these improvements were attributed to both earlier detection and more effective treatment of cancer. 4 There has been debate, however, over the extent to which improved treatment has contributed to the trend in survival. 5 By extrapolating trends in cancer mortality in the USA, Bailar and Gornick argued that newer cancer therapies have produced few real benefits and concluded that recent decreases in cancer mortality were mainly due to falling incidence or earlier detection. 6 In this report we used data from the population-based NSW Central Cancer Registry to examine trends in 5-year relative survival and the relative excess risk of death (RER) up to 5 years after diagnosis in patients diagnosed with any of 28 cancers from 19 to 1996 in New South Wales. Even though we had incidence data from 1972, survival matching was incomplete for cases diagnosed before 19. We excluded cases diagnosed after 1996 so that all cancer cases had at least five years of follow-up for analysis. To exclude the impacts of earlier detection, we examined the trends in RER after adjustment for a measure of disease spread at diagnosis, along with histological type of cancer and other factors related to survival. We also assessed possible effects of stage migration, a shift over time in the stage distribution of a cancer towards higher stage disease due to more complete identification of disease spread. Stage migration produces an artificial increase in survival in each stage category because of the removal of more advanced disease from earlier stage categories and the transfer of relatively less advanced disease into later stage categories. 7 Within reason, taking confounding trends in stage of disease and the possibility of stage migration into account allows an interpretation of trends in excess risk of death in terms of changes in disease management. 4

9 Trends in Cancer Survival in NSW 19 to 1996 Methods Data source Cancer data for this report were obtained from the NSW Central Cancer Registry. This is a population-based register of all cancers diagnosed in NSW residents and has been operating since Notification is mandatory from public and private hospitals, departments of radiation oncology, nursing homes, pathology laboratories, outpatient departments, day procedure centres and the Registrar of Births, Deaths and Marriages. The Cancer Institute NSW manages the Registry, which is funded by the NSW Department of Health. 8 Incidence data People included in the summaries of cancer incidence were those diagnosed with at least one cancer in the 28 major sites (topography codes of these cancers are presented in Table A1 of the appendix) and who were resident in NSW at the time of diagnosis between 19 and Data for only the first invasive cancer diagnosed in a person aged between 15 and 89 years during this time period were included. Cases notified by death certificate only or first identified at post-mortem were excluded from the analysis of survival, but included in the calculation of age-standardised incidence rates. These cases made up 1.8% of the total and this was relatively constant over time, except for an increase to 3.3% in caused by the lack of Registry resources to investigate them. 8 Survival data Deaths from any cause in people with cancer were obtained by passive follow-up. All people with cancer who were not known to be dead were matched against death records up to 31 December 1 from the State Registrar of Births, Deaths and Marriages and the National Death Index compiled by the Australian Institute of Health and Welfare. Probabilistic matching was used with a multi-pass INTEGRITY 9 algorithm. Equivocal matches were investigated by individual examination of the details available and by active follow-up to notifying institutions or clinicians where necessary. However, no direct contact was made with people with cancer or their families. In the survival analyses reported here, it was assumed that those cases not known to be dead were alive. This passive approach to follow-up may fail to ascertain all deaths and may incorrectly link some incidence and death records. A study investigating its completeness and accuracy found loss to follow-up to be uniform from 19 to 1993 and estimated the resulting overestimation of relative survival to be a maximum of 2%. 1 Population data Population data for were derived from Australian Bureau of Statistics annual midyear estimates of the resident population by age groups, sex and calendar year. Population data for this report were obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) 11 which refers to a data access, analysis and reporting facility established and operated by the Centre for Epidemiology and Research, NSW Health Department. Spread of disease at diagnosis Classification of spread of disease at diagnosis was obtained from hospital medical record departments and radiotherapy notifiers, and classified into four broad categories: localised 5

10 Trends in Cancer Survival in NSW 19 to 1996 (confined to tissue or organ of origin), regional (including adjacent organs and regional lymph nodes), distant metastasis (spread to distant organs) and unknown to the Registry. This summary classification of stage is used by a number of major cancer registries around the world including registries in the Surveillance, Epidemiology, and End Results (SEER) program in the USA. While not as detailed as the standard TNM staging system a, it can be applied to most cancers occurring in whole populations. 12 Classification of stage was not applicable to staging for Hodgkin s disease, non-hodgkin lymphoma, multiple myeloma, leukaemia and brain cancer. Thus, these five cancers were not included in the stage-specific survival trends for all cancers combined but were included in the model with stage classified as unknown for these five cancers. Because of the importance of spread of disease in our analysis and the possibility of stage migration, we tabulated changes in the distribution of spread in for the sites for which it was available. In this report, we use spread of disease and stage interchangeably. Relative survival and relative excess risk of death This report describes five-year relative survival of people in each period of diagnosis from 19 to 1996 in NSW. Relative survival is the ratio of the observed survival rate experienced by cancer patients over a specified interval of time after diagnosis to the expected survival rate in a comparable group of people (in terms of age, sex and calendar year) from the general population. The life table for the corresponding calendar year was used to calculate the expected survival. A relative survival of % in a specific period indicates that the cancer has had no effect on survival in that period. A relative survival of % in a specific period indicates that % more people diagnosed with cancer in that period had died during the five years than in a comparable group of people from the general population. The excess risk of death is the risk of death above what would have been observed if the population death rates had applied to the cancer patients. To analyse trends in excess risk of death, four time periods were defined: 19-84, , and Patients diagnosed within a period of a few years will have had similar treatment protocols and access to screening. The period preceded compulsory reporting of cancer to the Registry by pathology laboratories, which was introduced in Statistical modelling of excess risk of death Excess risk of death across time periods was compared using a statistical model adjusted for age group, sex, years of follow-up, histological type and spread of disease (where applicable) for each of the 28 individual cancer sites and all cancers combined. The model for all cancers included cancer site as well. This model quantifies the extent to which the excess risk of death in a given period differs from the excess risk of death in the reference period (19-84) after controlling for the factors included in the model. The relative excess risk of death in the period was set to a value of one. A RER of less than one in another period indicates that the excess risk of death in that period was less than that in the reference period, and vice versa. Ninety-five per cent confidence intervals for the RERs are presented. A more detailed description of the statistical modelling methods can be found in the appendix. a Tumor-node-metastasis staging system describes the extent of the primary tumour as well as the involvement of regional lymph nodes and distant metastases. 6

11 Trends in incidence rates Trends in Cancer Survival in NSW 19 to 1996 To examine trends in incidence, we calculated age-standardised incidence rates for the resident population in NSW for each of the four periods between 19 and 1996 for each of the 28 cancers. These rates were expressed per, of the population and age adjusted by the direct method to the Australian estimated residential population of 1. We also calculated annual age-standardised incidence rates for 19 to 1996 and the annual percent change over the 17 years for each of the 28 cancers. The annual percent change was estimated by fitting a Poisson regression model to the natural logarithm of the rates with calendar year as a continuous independent variable. 7

12 Trends in Cancer Survival in NSW 19 to 1996 Guide to Interpretation of Results This report describes the survival patterns with one page each for the 28 individual sites and all cancers combined. There are two tables and one figure with a brief discussion about the incidence and survival patterns for each cancer. The data presented in the figures are tabulated in Table A2 of the appendix. rate is a measure to compare relative differences in incidence rates over time by adjusting for differences in the age distribution between different time periods and the 99% confidence intervals is a measure of the precision of the estimate. It represents the range of values where we are 99% certain that the true incidence rate lies. The average annual percent change (AAPC) is a commonly used measure of trends in incidence and a p- value less than.5 for the significance test is used to indicate a significant increase or decrease. The AAPC results are presented in Table A3 in the appendix. Distribution of disease spread at diagnosis over time is provided to examine the possibility of stage migration over time. The percentages of cases in each of the spread categories (localised, regional, distant and unknown) are shown for each time period of diagnosis. Five-year relative survival is the ratio of the observed survival rate experienced by cancer patients over five years to the expected survival rate in a comparable group of people (in terms of age, sex and calendar year) from the general population. In the figures, five-year relative survival was plotted for each period of diagnosis by sex, age group and disease stage at diagnosis. Due to the small number of cases for some cancer types, fewer categories for age or disease stage at diagnosis were used. For example regional and distant spread were combined and labelled as advanced stage for some analyses. Generally survival varied by sex, age group and disease stage unless specified otherwise for a particular cancer site. Absolute gain in survival is a measure of the difference in 5-year relative survival between and (relative survival in minus that for 19-84). Proportional change in survival is the ratio of the absolute change and 5-year relative survival in This indicates the relative change in relative survival over time. Relative excess risk of death compares the risk of excess death after a diagnosis of cancer over time while adjusting for other factors that may affect survival. The relative excess risk of death in was used as the reference and set to a value of 1. A relative excess risk of 1.2 for the time period indicates that patients from that period experienced a % higher excess risk of death (i.e. poorer survival) than those in the time period. A relative excess risk of.8 for the period of indicates that the excess risk of death was % lower (indicating better survival) than that for the period

13 Trends in Cancer Survival in NSW 19 to 1996 Results A total of 343,34 newly diagnosed cases for 28 different cancer types were included in this report, with the commonest cancers being breast (41,476), lung (39,769) and prostate (37,374). There were statistically significant falls in excess deaths for of the cancers with a 25% fall for all cancers combined. Cancers of the prostate, liver, thyroid, breast, gallbladder, body of uterus, rectum, cervix and ovary had falls of >3%. The falls varied by spread of disease; the largest being in localised and regionally spread tumours. Overall survival, when not adjusted for spread of cancer, generally fell in parallel with that in the specific categories of spread, which implies that stage migration did not contribute importantly to survival trends. There was a substantial increase in the proportion of cancers of unknown stage in and, to a much less extent in for 13 of the cancer types in which this increase in the proportion of unknown stage occurred. These increases were probably largely due to a change from paper-based to electronic notification of cancer from some hospitals, which meant that some information on stage provided through manual notification was no longer available to the Registry. In the remaining 7 cancer types, the increase was more gradual across the whole period of observation, indicating that additional factors, unknown to us, were influencing completeness of stage information reported to the Registry for these cancers. 9

14 Trends in Cancer Survival in NSW 19 to 1996 All cancers by Sex by Stage Males Localised Regional Females Distant Unknown Figure 1: Five-year relative survival for all cancers combined by sex, age group and spread of cancer at diagnosis NSW The incidence of all cancers combined in NSW increased insignificantly from to (Table 1a) with an average annual change of 1.6% (p=.1). Five-year relative survival improved from 47.8% in to 61.4% in (Table 1b) representing an absolute gain in survival of 13.6% and a proportional change of 28.4%. Five-year relative survival from all cancers combined was consistently higher for females than males, with a converging upward trend from to (Figure 1). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 1). For the youngest age group 5-year relative survival was 82% in Survival from all cancers combined varied significantly by period of diagnosis after adjustment for age, sex, histological type, spread of cancer and cancer type (Table 1b). The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients diagnosed with tumours with localised (14% absolute gain), regional (17% absolute gain) or unknown stage (15% absolute gain), and little gain in survival was found in patients diagnosed with distant tumours (Figure 1). Table 1a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, all cancers NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 1b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), all cancers NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis and cancer type p<.1 for period of diagnosis 1

15 Trends in Cancer Survival in NSW 19 to 1996 Lip cancer by Sex by Stage Males Localised Advanced Females Unknown Figure 2: Five-year relative survival for lip cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of lip cancer in NSW increased from to (Table 2a) with an average annual change of 2.7% (p=.2). There was little change in five-year relative survival (Table 2b) with an absolute gain in survival of 1.1% and a proportional change of 1.1%. Five-year relative survival from lip cancer was consistently higher for males than females, with a similar flat trend seen for both sexes from to (Figure 2). People aged years appeared to have a better prognosis than other age groups (Figure 2). For the age group 5-year relative survival was 96% in Survival from lip cancer was not different across periods of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 2b). The majority of patients (7.7%) were diagnosed with localised stage (Table 2a), for which the 5-year relative survival in was 94% (Figure 2). Table 2a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, lip cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 2b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), lip cancer NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p=.28 for period of diagnosis 11

16 Trends in Cancer Survival in NSW 19 to 1996 Head and neck cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 3: Five-year relative survival for head and neck cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of head and neck cancer in NSW was stable from to (Table 3a) with an average annual change of.1% (p=.72). Five-year relative survival improved from 51.2% in to 55.6% in (Table 3b) representing an absolute gain in survival of 4.4% and a proportional change of 8.7%. Five-year relative survival from head and neck cancer was consistently higher for females than males, with a similar upward trend seen for both sexes from to (Figure 3). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 3). For the youngest age group 5-year relative survival was 78% in Survival from head and neck cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 3b). The majority of patients (74%) were diagnosed with localised stage or regional spread (Table 3a), for which the 5-year relative survival in was 75% and 44% respectively (Figure 3). Table 3a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, head & neck cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 3b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), head & neck cancer NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis 12

17 Trends in Cancer Survival in NSW 19 to 1996 Oesophageal cancer by Sex by Stage Males Localised Advanced Females Unknown Figure 4: Five-year relative survival for oesophageal cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of oesophageal cancer in NSW increased from to (Table 4a) with an average annual change of 1.3% (p=.2). Five-year relative survival improved from 9.7% in to 15.4% in (Table 4b) representing an absolute gain in survival of 5.7% and a proportional change of 59.6%. Five-year relative survival from oesophageal cancer was consistently higher for females than males, with a similar upward trend seen for both sexes from to (Figure 4). People aged years had a better prognosis than other age groups with 5-year relative survival being 23.4% in (Figure 4). Survival from oesophageal cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 4b). The majority of patients (62%) were diagnosed with localised or unknown stage (Table 4a), for which the 5-year relative survival in was 31% and 1% respectively. The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients diagnosed with localised disease (15% absolute gain) (Figure 4). Table 4a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, oesophageal cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 4b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), oesophageal cancer NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis 13

18 Trends in Cancer Survival in NSW 19 to 1996 Stomach cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 5: Five-year relative survival for stomach cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of stomach cancer in NSW decreased from to (Table 5a) with an average annual change of -2.6% (p<.1). Five-year relative survival improved from.6% in to 23.8% in (Table 5b) representing an absolute gain in survival of 3.2% and a proportional change of 15.4%. Five-year relative survival from stomach cancer was consistently higher for females than males, with a similar upward trend seen for both sexes from to (Figure 5). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 5). For the youngest age group 5-year relative survival was 35% in Survival from stomach cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 5b). The majority of patients (%) were diagnosed with localised stage or regional spread (Table 5a), for which the 5-year relative survival in was 62% and 21% respectively. The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients diagnosed with localised disease (18% absolute gain), a moderate gain for people with regional spread, and little or no gain in survival was found in patients diagnosed with tumours with distant or unknown spread (Figure 5). 14 Table 5a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, stomach cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 5b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), stomach cancer NSW 5-year RSR (%) RER* (95% CI) (.87-1.) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis

19 Trends in Cancer Survival in NSW 19 to 1996 Colon cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 6: Five-year relative survival for colon cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of colon cancer in NSW increased from to (Table 6a) with an average annual change of.6% (p=.1). Five-year relative survival improved from 5.5% in to.% in (Table 6b) representing an absolute gain in survival of 9.6% and a proportional change of 18.9%. Five-year relative survival from colon cancer was not different between sexes, with a similar upward trend seen for both sexes from to (Figure 6). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 6). For the youngest age group 5-year relative survival was 67% in Survival from colon cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 6b). The majority of patients (73%) were diagnosed with localised stage or regional spread (Table 6a), for which the 5-year relative survival in was 91% and 62% respectively. The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients with localised stage (11% absolute gain) or regional spread (18% absolute gain), and a moderate gain was seen in patients with unknown stage (Figure 6). Table 6a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, colon cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 6b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), colon cancer NSW 5-year RSR (%) RER* (95% CI) (.-.89) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis 15

20 Trends in Cancer Survival in NSW 19 to 1996 Rectal cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 7: Five-year relative survival for rectal cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of rectal cancer in NSW increased from to (Table 7a) with an average annual change of 1.% (p<.1). Five-year relative survival improved from 49.5% in to 59.4% in (Table 7b) representing an absolute gain in survival of 9.8% and a proportional change of 19.9%. Five-year relative survival from rectal cancer was consistently higher for females than males, with a converging trend from to (Figure 7). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 7). For the youngest age group 5-year relative survival was 65% in Survival from rectal cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 7b). The majority of patients (76%) were diagnosed with localised stage or regional spread (Table 7a), for which the 5-year relative survival in was 87% and 54% respectively. The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients with localised stage (12% absolute gain), regional spread (16% absolute gain) or unknown stage (16% absolute gain) (Figure 7). 16 Table 7a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, rectal cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 7b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), rectal cancer NSW 5-year RSR (%) RER* (95% CI) (.-.92) (.7-.81) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for study period of diagnosis

21 Trends in Cancer Survival in NSW 19 to 1996 Liver cancer by Sex by Stage Males Localised Advanced Females -89 Unknown Figure 8: Five-year relative survival for liver cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of liver cancer in NSW increased more than 2.5 times from to (Table 8a) with an average annual change of 8.% (p<.1). Five-year relative survival improved from 7.8% in to 11.4% in (Table 8b) representing an absolute gain in survival of 3.6% and a proportional change of 47.%. Five-year relative survival from liver cancer was not different between the sexes from to (Figure 8). People aged years had much better prognosis than those in the other age groups with 5-year relative survival being 39% in (Figure 4). Survival from liver cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 8b). The majority of patients (77%) were diagnosed with localised or unknown stage disease (Table 8a), for which the 5-year relative survival in was 21.6% and 8.2% respectively (Figure 8). Table 8a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, liver cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) (2.-2.4) ( ) Table 8b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), liver cancer NSW 5-year RSR (%) RER* (95% CI) (.-.85) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for study period of diagnosis 17

22 Trends in Cancer Survival in NSW 19 to 1996 Gallbladder ladder cancer by Sex by Stage Males Localised Advanced Females Unknown Figure 9: Five-year relative survival for gallbladder cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of gallbladder cancer in NSW did not differ from to (Table 9a) with an average annual change of.2% (p=.62). Five-year relative survival improved from 9.5% in to 19.5% in (Table 9b) representing an absolute gain in survival of 1.% and a proportional change of 15.6%. Five-year relative survival from gallbladder cancer was not different between the sexes from to (Figure 9). People aged years had much better prognosis with a similar upward trend seen for other age groups from to (Figure 9). Survival from gallbladder cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 9b). The largest group of patients (34%) were diagnosed with regional spread (Table 9a). The increase in 5- year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients diagnosed with localised (26% absolute gain) or advanced disease (13%) (Figure 9). Table 9a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, gallbladder cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown (3.-3.5) ( ) (3.-3.5) ( ) Table 9b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), gallbladder cancer NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis 18

23 Trends in Cancer Survival in NSW 19 to 1996 Pancreatic cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 1: Five-year relative survival for pancreas cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of pancreatic cancer in NSW was stable from to (Table 1a) with an average annual change of.1% (p=.58). Five-year relative survival remained very low and stable over time (Table 1b). Five-year relative survival from pancreatic cancer was not different between the sexes, with a flat trend seen for both sexes from to (Figure 1). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 1). For the youngest age group 5-year relative survival was 22% in Survival from pancreatic cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 1b). The majority of patients (63%) were diagnosed with distant spread or unknown stage (Table 1a), for which the 5-year relative survival in was 2% and 5% respectively (Figure 1). Table 1a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, pancreatic cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 1b: Trends in 1-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), pancreatic cancer NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) (.-.92) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis 19

24 Trends in Cancer Survival in NSW 19 to 1996 Lung cancer by Sex by Stage Males Localised Regional Females Distant Unknown Figure 11: Five-year relative survival for lung cancer by sex, age group and spread of cancer at diagnosis NSW The incidence of lung cancer in NSW decreased from to (Table 11a) with an average annual change of -.3% (p=.1). Five-year relative survival increased slightly from 8.7% in to 12.5% in (Table 11b) representing an absolute gain in survival of 3.8% and a proportional change of 44.3%. Five-year relative survival from lung cancer was consistently higher for females than males, with a similar upward trend seen for both sexes from to (Figure 11). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 11). For the youngest age group 5-year relative survival was 26% in Survival from lung cancer varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, histology and spread of cancer at diagnosis (Table 11b). The majority of patients (%) were diagnosed with distant or unknown stage (Table 11a), for which the 5- year relative survival in was 2.4% and 9.3% respectively. The increase in 5-year relative survival varied significantly by spread of cancer at diagnosis. Much of the gain in survival was found in patients diagnosed with localised (14% absolute gain) or regional disease (7.8% absolute gain), and little or no gain in survival was found in patients diagnosed with distant disease or unknown spread (Figure 11). Table 11a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, lung cancer NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 11b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), lung cancer NSW 5-year RSR (%) RER* (95% CI) (.9-.96) ( ) ( ) * Adjusted for age, sex, histology and spread of cancer at diagnosis p<.1 for period of diagnosis

25 Trends in Cancer Survival in NSW 19 to 1996 Melanoma of the skin by Sex by Stage Males Localised Regional Females Distant Unknown Figure 12: Five-year relative survival for melanoma of the skin by sex, age group and spread of cancer at diagnosis NSW The incidence of melanoma in NSW increased from to (Table 12a) with an average annual change of 3.1% (p<.1). Five-year relative survival improved from 87.4% in to 9.9% in (Table 12b) representing an absolute gain in survival of 3.5% and a proportional change of 4.%. Five-year relative survival from melanoma was consistently higher for females than males, with a similar upward trend seen for both sexes from to (Figure 12). People aged years had the best prognosis and elderly people (75-89 years) had the worst (Figure 12). For the youngest age group 5-year relative survival was 94% in Survival from melanoma varied significantly by period of diagnosis after adjustment for age at diagnosis, sex, and spread of cancer at diagnosis (Table 12b). The vast majority of patients (87%) were diagnosed with localised disease (Table 12a), for which the 5-year relative survival in was 95%. Much of the gain in survival was found in patients with regional spread (12% absolute gain) and a moderate gain was seen in patients with distant spread (7%) (Figure 12). Table 12a: Trends in age-standardised incidence rates per, with 99% confidence intervals (CI), disease spread at diagnosis, melanoma NSW Disease spread at diagnosis (%) (99% CI) Localised Regional Distant Unknown ( ) ( ) ( ) ( ) Table 12b: Trends in 5-year relative survival (RSR) and relative excess risk of death (RER) with 95% confidence intervals (CI), melanoma NSW 5-year RSR (%) RER* (95% CI) ( ) ( ) ( ) * Adjusted for age, sex, and spread of cancer at diagnosis p<.1 for period of diagnosis 21