La sopravvivenza dei tumori maligni nei confronti internazionali: anticipazione della diagnosi o modifica del decorso naturale della malattia?

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1 La sopravvivenza dei tumori maligni nei confronti internazionali: anticipazione della diagnosi o modifica del decorso naturale della malattia? Paola Pisani Registro Tumori Infantili Piemonte Università di Torino

2 Disease natural history and survival diagnosis death onset 0 I II III IV In situ mammography micro-invasion lump growth clinical lymph node involvement metastases skin, lung, liver, bones brain

3 RCT screening for liver cancer China Chen JG, J Med Screen, 2003

4 RCT screening for liver cancer China- Chen JG, J Med Screen 2003

5 Breast cancer proportion of cases surviving at 5 years by stage (Pisani & Forman, 2003) Yorkshire, incident cases stage I % surviving years since diagnosis stage II stage III stage IV

6 Interpretation of population-based survival: geographic comparisons & time trends analyses Mortality Stage at presentation screening

7 Stomach cancer 5-yr relative survival JAPAN ITALY US SLOVENIA SWEDEN ENGLAND % surviving

8 Stomach cancer incidence & mortality - time trends 90 ASR Japan Italy Canada Osaka,Japan Varese,Italy Canada

9 Stomach cancer 5-yr relative survival time trends % ENGLAND ITALY SLOVENIA SWEDEN US

10 Crude rate of malignant cancers with unknown primary site by basis of diagnosis and year Male unknown totalmale unknown MVMale unknown other Female unknown total Female unknown MV Female unknown other male female

11 Taylor-Robinson et al., 2001 Increase in mortality rates from intrahepatic cholangiocarcinoma in England & Wales pancreas All liver (155) PLC (155.0) CCA NOS

12 Testicular cancer 5-yr relative survival SWEDEN ENGLAND US SLOVENIA ITALY POLAND % surviving

13 Testicular cancer 5-yr relative survival time trends % ENGLAND ITALY POLAND SLOVENIA SWEDEN US

14 Testis incidence & mortality Norway 12 ASR

15 Cancer of the Ovary 5-yr relative survival US SWEDEN ITALY SLOVENIA POLAND ENGLAND

16 Cancer of the Ovary 5-yr relative survival time trends % ENGLAND ITALY POLAND SLOVENIA SWEDEN US

17 Lung Cancer 5-yr relative survival % England M Italy M Poland M Slovenia M Sweden M England F Italy F Poland F Slovenia F Sweden F

18 Lung Cancer, males 5-yr relative survival time trends % England M Italy M Poland M Slovenia M Sweden M US M

19 Lung Cancer, females 5-yr relative survival time trends % England F Italy F Poland F Slovenia F Sweden F US F

20 Breast Cancer, females 5-yr relative survival time trends % UK England Italy Poland Slovenia Sweden US

21 Breast cancer: 5-year 5 relative survival - time trends SEER programme, National Cancer Institute, US (1998) EUROCARE 2, Berrino et al.,, (1999) 85 USA France 80 Sweden Italy % surviving 5 years Europe, average Netherlands England

22 Breast Cancer UK, Females (CR-UK, 2006) 140 incidence mortality -31%

23 CONCORD Study worldwide cancer survival, 1993 (Coleman et al. Lancet Oncol.,2008) Prostate

24 Summary Cancer sites not subject of mass screening: expect similar survival Screening: survival expected to increase and approach highest values. But monitor mortality

25 Estimation of Survival requires clear definition of: Cancer case Starting point: incidence date Outcome

26 Incidence date ENCR European Network of Cancer Registries recommendation 1. Date of first pathology report 2. Date of first consultation/admission to hospital or clinical institution for the cancer in question 3. Date of first clinical diagnosis of a cancer by a physician 4. Date of death (preceding autopsy if performed)

27 Incidence date Definition rules SEER Surveillance and End Result - USA 1. Date of first clinical diagnosis (Physical examination, instrumental investigation) 2. Date of first pathology report or date of first consultation/admission to hospital or clinical institution for the cancer in question 3. Date of death (preceding autopsy if performed)

28 Estimation of Survival effect of definition of Incidence date GP/ Primary care Hospital Admission Histology Death SEER US IACR ENCR Europe Survival time

29 Other measures Mortality by time as survivor Years of life gained Stage

30 Breast cancer (F) and prostate cancer (M) Proportion of cases by age, 1985 pre-screening

31 Hazard ratios of 3-year 3 survival in compared to age Age single years Adj. age & stage Adj. age, stage, HT & CT All 0.75 ( ).78) 0.95 ( ).99) 0.95 ( ) 1.00) < ( ).80) 0.80 ( ).91) 0.71 ( ).83) ( ).57) 0.68 ( ).76) 0.65 ( ).74) ( ).88) 1.01 ( ) 1.06 ( ) 1.13)

32 Breast cancer mortality, Yorkshire ASR by years since diagnosis 5+ yrs 3-44 yrs 0-22 yrs 30.0 ASRM/100, % - 3% * % * * p<.05

33 5-year cancer survival (%) in China, Europe and US good prognosis (cases 1980) Large intestine Leukaemia USA Europe Shanghai Qidong Cervix Breast Nasopharynx

34

35

36 Yorkshire Cancer Registry Stage - coding Size (mm) Lymph nodes positive: Yes / No / Unkn Distant metastases: Yes / No / Unkn

37 Conclusions The decline in breast cancer mortality in Yorkshire from occurred in short-term term survivors. Around 30% of the improvement in survival in cases <65 years is attributable to a more favourable stage at diagnosis, whereas this accounted for all of the 17% relative improvement in survival among older cases. Significant changes in the use of systemic therapy appear to have little impact on short-term term prognosis, consistently with clinical trials.

38 Stage of cases in control arms Two county Canadian HIP Trial Edinburgh Trial Trial(*) Size (mm) % 59% 64% 59% Axillary node + 45% 55% 55% 37% Stage II+ 51% n.a. 80% n.a. Note: unknown stage and in situ excluded. (*) Women * Shapiro et al., 1988 Tabar et al., 1992 Alexander et al., 1994 Miller et al., 2000

39 trial Garne et al., Cancer, 1997 Breast cancer Malmö,, Sweden Trends of stage (%) population population-based stage I II III

40 Proportions of cases surviving the disease by stage at diagnosis UK average developing countries stage UK developing countries I II III 60 40

41 Potential effect of down-staging Shift of the distribution from Manila to Shanghai pattern stage Manila Shanghai I 5% 60% II 50% 20% III 35% 10% expected reduction in annual number of deaths among recent cases after 5 years: 31%

42 Proportions of cases surviving the disease by stage at diagnosis UK average developing countries stage UK 1 developing 2 countries I II III EUROCARE 2 IARC

43 Potential effect of down-staging Shift of the distribution from Manila to Shanghai pattern stage Manila Shanghai I 5% 60% II 50% 20% III 35% 10% expected reduction in annual number of deaths among recent cases after 5 years: 31%

44 Mortality from breast cancer in Yorkshire ASR(world)/100, long-term survivors 5-yrs survivors

45 Breast cancer mortality England & Wales ASR by year % st round screening

46 ASR breast cancer mortality US white women, by age and year of death Age-adjusted rates/100,000 Decade of age

47 ASR breast cancer mortality US white women, by age and year of death Age-adjusted rates/100,000 Decade of age

48

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