Breast, lung, ovarian and colorectal cancer survival from 1995 to 2007: Higher in Australia, Canada and Sweden than in UK and Denmark

December 21, 2010

New research published Online First and in an upcoming Lancet shows that for four major cancers (breast, ovarian, colorectal, and lung), survival rates at both 1 and 5 years for cancers diagnosed between 1995 and 2007 are higher in Australia, Canada, and Sweden than in the UK (England, Wales and Northern Ireland) and Denmark, while in Norway survival rates are intermediate. The results are consistent with late diagnosis or differences in treatment in Denmark and the UK, and in patients aged 65 and over across all jurisdictions. The Article comes from the International Benchmarking Partnership, represented by Professor Michel Coleman, London School of Hygiene and Tropical Medicine, UK, and England's Department of Health National Director for Cancer Professor Sir Mike Richards, and more than 80 colleagues across the six nations studied. The study was funded by the Department of Health, England, and Cancer Research UK.

Previous findings have shown that for patients diagnosed with cancer from 1995 to 1999, up to 11,400 more patients died each year within 5 years of diagnosis across England, Scotland and Wales than would have been the case if 5-year cancer survival rates in these countries had matched the highest levels achieved in 13 other European countries. Breast, ovarian, lung and colorectal cancers accounted for half of those avoidable deaths.

Since the late 1990s many countries have implemented new cancer plans, including England (2000), Northern Ireland (1996), Wales (2004) and Denmark (2005). Among other aims, these plans aimed to raise cancer survival rates to the higher rates seen in other high-income countries. Even Sweden, with its already high-survival rates, has implemented a new plan in 2009 aiming to reduce regional survival discrepancies within its borders. Covering the period 1995 to 2007, this new study analyses survival rates for the four cancers above in six countries*: Australia (New South Wales and Victoria), Canada (Alberta, Manitoba, British Columbia, Ontario) Denmark, Norway, Sweden, and the UK (England, Northern Ireland [NI] and Wales). Survival at 1 year and 5 years was calculated, along with the conditional 5-year survival rate* (survival at 5 years conditional on surviving the first year).

Relative survival improved during 1995-2007 for all four cancers in all jurisdictions. Survival was persistently higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark, England, Northern Ireland, and Wales, particularly in the first year after diagnosis and for patients aged 65 years and older. International differences narrowed at all ages for breast cancer between 1995 and 2007, from about 9% to 5% (with the range for one-year survival across the six countries at 89-98% for 1995-99 and 93-98% for 2005-2007). For 5-year breast-cancer survival, the international differences narrowed from about 14% to 8% at 5 years (73-87% for 1995-99 and 81-89% for 2005-07). International ranges narrowed less or not at all for the other three cancers studied. For colorectal cancer, the international range narrowed only for patients aged 65 years and older, by 2-6% at 1 year and by 2-3% at 5 years.

For colorectal cancer, one in 11 patients (9%) diagnosed across all jurisdictions between 1995 and 2007 died within one month of diagnosis (UK: NI 8%, England 11%, Wales 11%). Colorectal cancer survival increased at similar rates across the six countries, but survival rates in the UK and Denmark were by 2007 still lagging significantly behind those of Australia, Canada and Sweden. For example, five-year colorectal cancer survival in the UK for 2005-07 was at 54%, compared to 66% in Australia.

Almost a quarter of patients (23%) diagnosed with lung cancer across all jurisdictions between 1995 and 2007 died within one month of diagnosis (UK: NI 21%, England 24%, Wales 26%) and almost all the improvement in lung cancer survival across this period was attributable to improvements in 1-year survival. For 2005-07, 1-year survival was around 30% in the UK nations, 35% in Denmark, and 39-44% in Australia (43%), Canada (42%), Norway (39%), and Sweden (44%). 5-year survival was low at 9-11% in the UK and Denmark versus 15-20% in the other four countries. The international range in conditional 5-year survival has widened, and lung cancer survival in Denmark and the UK was lower than in other jurisdictions at all ages throughout 1995-2007, especially for those aged 65 years and older.

While 1-year and 5-year breast cancer survival rates improved more in Denmark and in the UK than in the other countries from 1995 to 2007, overall, rates were still lower by 2007 (UK 5-year survival 86% versus Australia 91%). Thus the reason for this could be that the other countries have already hit (or almost hit) the maximum ceiling for survival while the UK and Denmark are playing catch-up. In contrast to the other cancers, only one in 50 (2.0%) of women across all jurisdictions died within one month of breast cancer diagnosis (UK NI 1.3%, England 2.5%, Wales 3.3%). As with colorectal cancer, one in every 11 women (9%) across all jurisdictions died within one month of a diagnosis of ovarian cancer (NI 10%, England 12%, Wales 13%). The geographical differences in survival for ovarian cancer generally resembled those for colorectal cancer, with 1-year survival during 2005-07 generally lower in the UK and Denmark than in the other countries, for example one-year ovarian cancer survival was 60% in the UK for 2005-07, compared with 72% in Canada. However, in all three UK nations, conditional 5-year survival for ovarian cancer in all three UK nations was higher than in New South Wales and Victoria (Australia), and close to the levels recorded in British Columbia and Ontario (Canada).

While more detailed analysis will be published in future papers, the authors say that the lower survival rates in Denmark and the UK suggest late diagnosis remains a problem in both countries. Sir Mike Richards says**: "These data will be crucial in helping all the partners involved improve their cancer outcomes. In England we have already started work on improving early diagnosis, including a new campaign starting next month to alert people to the early signs and symptoms of bowel, lung and breast cancer and plans to give GPs more direct access to key diagnostic tests. Full details of our future plans will follow when the Coalition Government launches its new cancer strategy in the New Year."

The authors add: "Differences in individual, health-system, and clinical factors--such as public awareness of cancer, diagnostic delay, stage [of cancer at diagnosis], comorbidity [other serious illnesses at time of cancer diagnosis], and access to optimum treatment--are all potential explanations for the overall differences in relative survival."

They discuss that in the UK, manpower (in the health service) was low in the 1990s, and that elderly people and less affluent groups were affected by late diagnosis, treatment delays, and lower survival. Also, in breast cancer treatment, previous studies have shown that that women with breast cancer in the UK were operated on less often, had axillary dissection less often, and have fewer nodes sampled than do women in other countries. (Axillary dissection is surgery that opens the armpit to identify, examine, or remove lymph nodes).

The authors conclude: "Up-to-date survival trends show increases but persistent differences between countries, which are broadly consistent with trends in cancer incidence and mortality. Data quality and changes in classification are not likely explanations. The patterns are consistent with late diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older."

The International Cancer Benchmarking Partnership is already working on examining a range of potential reasons for these persisting differences in cancer survival between the UK, Denmark and the other countries studied. These include: late presentation and more advanced stage at diagnosis, treatment variation, population awareness and beliefs about cancer, general practitioner beliefs and behaviour, and delay from first symptom to diagnosis.

Sara Hiom, Director of Health Information at Cancer Research UK, said: "It's encouraging to see that survival for breast, bowel, lung, and ovarian cancers has improved across the board and this study shows how far survival has improved for some of the most common cancers in the UK. But we still have work to do. Now we know how we currently compare to other countries, we must look at exactly why these differences in survival exist.

"When the government refreshes its cancer strategy, it's vital to retain a focus on early diagnosis and on improving equitable access to treatment. We also urge the government to continue to collect good quality information. Reliable data--which are consistent across the country--are crucial to understanding the extent of the problem and identifying the causes of the survival gap within the UK and compared to other countries."
Professor Michel Coleman, London School of Hygiene and Tropical Medicine, UK. T) +44 20 7927 2478 E)

For Professor Sir Mike Richards, please contact Department of Health (England), Press Office. T) +44 (0) 20 7210 5221 E)

Cancer Research UK press office T) +44 (0) 20 3469 8352 / +44 (0)7050 264 059 E)

For full Article, see:

For Web Appendix containing supplementary data, see:

For audio from embargoed press conference in London (Tues 21 Dec) see:

(speakers: Dr Richard Horton, Editor, The Lancet (chair)

Professor Michel Coleman, London School of Hygiene and Tropical Medicine, UK

Professor Sir Michael Richards, Department of Health, England

Sara Hiom, Cancer Research UK's director of health information. )

For a document giving background on the International Benchmarking Partnership, see:

Note to editors: A linked Comment will be published with this Article when it is allocated to a future issue of The Lancet.

*Conditional 5-year survival indicates differences in treatment strategies between countries, since the effect of late diagnoses and their resultant early deaths are removed from this calculation. However, it is important to note that optimal treatment plans also affects 1-year survival.

**A quote direct from Sir Mike Richards that cannot be found in the text of the Article



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