Elsevier

The Lancet Oncology

Volume 15, Issue 9, August 2014, Pages 931-942
The Lancet Oncology

Articles
Survival for haematological malignancies in Europe between 1997 and 2008 by region and age: results of EUROCARE-5, a population-based study

https://doi.org/10.1016/S1470-2045(14)70282-7Get rights and content

Summary

Background

More effective treatments have become available for haematological malignancies from the early 2000s, but few large-scale population-based studies have investigated their effect on survival. Using EUROCARE data, and HAEMACARE morphological groupings, we aimed to estimate time trends in population-based survival for 11 lymphoid and myeloid malignancies in 20 European countries, by region and age.

Methods

In this retrospective observational study, we included patients (aged 15 years and older) diagnosed with haematological malignancies, diagnosed up to Dec 31, 2007, and followed up to Dec 31, 2008. We used data from the 30 cancer registries (across 20 countries) that provided continuous incidence and good quality data from 1992 to 2007. We used a hybrid approach to estimate age-standardised and age-specific 5-year relative survival, for each malignancy, overall and for five regions (UK, and northern, central, southern, and eastern Europe), and four 3-year periods (1997–99, 2000–02, 2003–05, 2006–08). For each malignancy, we also estimated the relative excess risk of death during the 5 years after diagnosis, by period, age, and region.

Findings

We analysed 560 444 cases. From 1997–99 to 2006–08 survival increased for most malignancies: the largest increases were for diffuse large B-cell lymphoma (42·0% [95% CI 40·7–43·4] to 55·4% [54·6–56·2], p<0·0001), follicular lymphoma (58·9% [57·3–60·6] to 74·3% [72·9–75·5], p<0·0001), chronic myeloid leukaemia (32·3% [30·6–33·9] to 54·4% [52·5–56·2], p<0·0001), and acute promyelocytic leukaemia (50·1% [43·7–56·2] to 61·9% [57·0–66·4], p=0·0038, estimate not age-standardised). Other survival increases were seen for Hodgkin's lymphoma (75·1% [74·1–76·0] to 79·3% [78·4–80·1], p<0·0001), chronic lymphocytic leukaemia/small lymphocytic lymphoma (66·1% [65·1–67·1] to 69·0% [68·1–69·8], p<0·0001), multiple myeloma/plasmacytoma (29·8% [29·0–30·6] to 39·6% [38·8–40·3], p<0·0001), precursor lymphoblastic leukaemia/lymphoma (29·8% [27·7–32·0] to 41·1% [39·0–43·1], p<0·0001), acute myeloid leukaemia (excluding acute promyelocytic leukaemia, 12·6% [11·9–13·3] to 14·8% [14·2–15·4], p<0·0001), and other myeloproliferative neoplasms (excluding chronic myeloid leukaemia, 70·3% [68·7–71·8] to 74·9% [73·8–75·9], p<0·0001). Survival increased slightly in southern Europe, more in the UK, and conspicuously in northern, central, and eastern Europe. However, eastern European survival was lower than that for other regions. Survival decreased with advancing age, and increased with time only slightly in patients aged 75 years or older, although a 10% increase in survival occurred in elderly patients with follicular lymphoma, diffuse large B-cell lymphoma, and chronic myeloid leukaemia.

Interpretation

These trends are encouraging. Widespread use of new and more effective treatment probably explains much of the increased survival. However, the persistent differences in survival across Europe suggest variations in the quality of care and availability of the new treatments. High-resolution studies that collect data about stage at diagnosis and treatments for representative samples of cases could provide further evidence of treatment effectiveness and explain geographic variations in survival.

Funding

Compagnia di San Paolo, Fondazione Cariplo, European Commission, and Italian Ministry of Health.

Introduction

New targeted drugs for treating haematological malignancies became available from the early 2000s, including anti-CD20 monoclonal antibodies for B-cell lymphomas1, 2 and acute lymphoblastic leukaemia,3 imatinib for chronic myeloid leukaemia,4 and proteasome inhibitors for myeloma.5 These treatments have greatly improved prognosis for chronic myeloid leukaemia, many lymphoid neoplasms and, to a lesser extent, multiple myeloma.2, 6, 7, 8 However these improvements were mainly documented in hospital-based series or controlled trials. Few population-based studies by cancer registries have investigated survival for haematological malignancies.8 Cancer registries include all incident cases in a registry area and thus reflect clinical practice and survival everywhere, not just in centres of excellence or selected groups of patients. Past EUROCARE studies9 have shown substantial differences in population-based survival for haematological malignancies across Europe; however, because of changes in disease classification and definitions of malignancy over recent decades, investigating changes in haematological malignancy survival over time was not possible. The HAEMACARE project10 promoted the standardisation of data registration for haematological malignancies by EUROCARE cancer registries, and encouraged adoption of the updated International Classification of Disease for Oncology.11, 12 As a result, survival time trends can now be estimated in different European populations based on comparable data.

The primary aim of the present study was to investigate changes in 5-year relative survival for adult European patients diagnosed with haematological malignancies by morphology, age at diagnosis, and European region; we were particularly interested in morphologies for which new, more effective treatments became available from the early 2000s. We aimed to corroborate our results with multivariate models to estimate relative excess risks of death in these patients by calendar period, age at diagnosis, and European region, in the 5 years after diagnosis.

Section snippets

Participants

We included adult (age ≥15 years) patients archived in the EUROCARE-5 database,13 diagnosed with haematological malignancies up to Dec 31, 2007 and followed up to Dec 31, 2008. We used standardised procedures to check data quality and data completeness, as described elsewhere.13 Cases were coded according to the International Classification of Disease for Oncology 3rd edition,11 grouped according to WHO12 and HAEMACARE10, 14 criteria, and divided into four categories according to age at

Results

560 444 haematological malignancies were diagnosed between 1996 and 2007 in the regions covered: 7% from southern Europe, 8% from northern Europe, 9% from eastern Europe, 20% from central Europe, and 56% from the UK (table 1). Only 2·8% of cases overall were recorded on death certificate only or diagnosed at autopsy, with high proportions in Wales (3·2%), Malta (3·3%), England (4·0%), Basel (6·1%), Saarland (8·4%), and Slovakia (14·0%; table 1). Excluding these cases, and grouping the remaining

Discussion

Our data suggest that survival improved for most haematological malignancies over the study period. Multivariate analysis showed a significant decrease in excess risk of death for all malignancies except myelodysplastic syndromes. However, despite this encouraging change, improvements in survival were not uniform across Europe, which could be a result of persisting inequalities in the provision of care. Even after adjustment for age, period, and year of follow-up, survival for most

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