Albreht, T

Alexe, DM

Coleman, M

Martin-Moreno, J

McKee, M

English

LSHTM Research Online

Rowan, S; Rachet, B; Alexe, DM; Cooper, N; Coleman, MP (2008)Survival from prostate cancer in England and Wales up to 2001.British journal of cancer, 99 Suppl 1. pp. 75-77. ISSN 0007-0920Downloaded from: http://researchonline.lshtm.ac.uk/6962/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/Survival AnalysisSurvival from prostate cancer in England and Wales up to 2001S Rowan1, B Rachet2, DM Alexe2, N Cooper3 and MP Coleman*,21Office for National Statistics (Room 2000), Segensworth Road, Titchfield, Fareham, Hants PO15 5RR, UK;2Cancer Research UK Cancer Survival Group,Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, UK;3Social and Health Analysis and Reporting Division, Office for National Statistics (Room FG/114), 1 MyddeltonStreet, London EC1R 1UW, UKBritish Journal of Cancer (2008) 99, S75–S77. doi:10.1038/sj.bjc.6604595 www.bjcancer.comPublished online 23 September 2008& 2008 Cancer Research UK                      Within the last 10 years, prostate cancer has become the mostcommon malignancy among men in England and Wales. The age-standardised incidence rate exceeded that for colorectal cancer by1993, and overtook the (declining) rate for lung cancer in 1999(Quinn et al, 2001). By the early 2000s, approximately 29000 menwere diagnosed each year with prostate cancer, accounting for onein four of all new cancers in men (excluding nonmelanoma skincancer). Prostate cancer is rare under the age of 50 years, butincidence rises steeply with age, reaching nearly 1000 cases per100000 per year (1% annual risk) in men aged 85 years and more.Each year, there are some 9000 deaths from prostate cancer,approximately one in eight of all cancer deaths in men (Office forNational Statistics, 2003).The causes of prostate cancer are not well known. Family historyin first-degree relatives is a risk factor, and incidence is 60% higherin African Americans and 38% lower in Asian Americans than inUS Whites (Platz and Giovannucci, 2006), but possible risk factorsrelated to nutrition, environment, lifestyle, sexual history,occupation and ethnicity have not been conclusively identified.The natural history of prostate cancer is poorly understood,ranging from clinically indolent cancers to highly aggressive andoften fatal disease (Breslow et al, 1977). Treatment in the 1990sincluded various combinations of surgery, radiotherapy, che-motherapy and endocrine therapy, but early disease was some-times managed by ‘watchful waiting’, and other modalities, such ascryotherapy, ultrasound and laser treatment have also been usedfor local disease control (Kirby, 1996a,b).Age-standardised incidence of prostate cancer rose slowly from1971 up to the late 1980s, but tripled during the 1990s to more than90 cases per 100000 per year. This rapid increase is largelyattributable to the increasingly widespread use of prostate-specificantigen (PSA) testing, which has led to an increase in the recordedincidence of localised prostate cancer (Evans and Møller, 2003;Pashayan et al, 2006a,b).Prostate cancer is now more common among the affluent. In theearly 1980s, incidence was 35–40 cases per 100000 per year in alldeprivation groups. In the decade up to the mid-1990s, however,incidence increased more than two-fold among the most affluentmen, more rapidly than among the most deprived men, and is nowabout 40% higher in the most affluent groups (Quinn et al, 2001).Age-standardised mortality rates remained stable from 1950 to the1980s before rising gradually, reaching a peak of 31 cases per100000 per year in 1993, then declining slightly thereafter.We analysed the data for over 201000 men diagnosed with afirst, primary, malignant neoplasm of the prostate in England andWales during the 14-year period 1986–1999 and who werefollowed up to the end of 2001, some 86% of the 233000 menpotentially eligible for inclusion. Approximately 9% (19800 men)had a recorded survival of zero, most of them who were registeredsolely from a death certificate, but for a further 1.4% (3300) thevital status was unknown on 5 November 2002, when the data wereextracted for analysis, and 3.2% (7500) of men were excludedbecause the prostate cancer was not their first primary cancer.The vast majority of prostate cancers are adenocarcinoma (Rossand Schottenfeld, 1996). The proportion so described in Englandand Wales rose from just under 60% of all cases in the early 1990sto approximately 85% by the early 2000s, in parallel with a declinein the proportion coded as epithelial malignancy without furtherspecification, from 28 to approximately 10% (data not shown).This pattern suggests steady improvement in the recording ofpathological data, rather than a shift in the type of malignancy.SURVIVAL TRENDSFor men diagnosed during 1996–1999, 1-year survival rose to 89%,from 78% a decade or so earlier. This represents a rapiddeprivation-adjusted increase of some 6% every 5 years since1986–1990 (Table 1, Figure 1).Five-year survival has increased with extraordinary rapidityfrom 43% for men diagnosed during 1986–1990 to 68% for mendiagnosed during 1996–1999, an average deprivation-adjustedincrease of almost 16% (95% CI: 14.8–17.0%) every 5 years.For men diagnosed during 1991–1995 and followed up to 2001,10-year survival had risen to 41%, a similarly rapid rate of increase.Hybrid analysis (Brenner and Rachet, 2004) based on the follow-up of survivors during 2000–2001 suggests that survival willcontinue to improve, but more slowly than over the previousdecade, reaching 90% at 1 year and 70% at 5 years (Table 1).DEPRIVATIONDespite high overall survival, there is a significant deprivation gapin survival, which increased significantly during the 1990s*Correspondence: Professor MP Coleman;E-mail: michel.coleman@lshtm.ac.ukBritish Journal of Cancer (2008) 99, S75–S77& 2008 Cancer Research UK All rights reserved 0007– 0920/08 $32.00www.bjcancer.com(Figure 2). Five-year survival for men in the most deprived groupswho were diagnosed during 1996–1999 was some 7% lower thanfor men in the most affluent group (deprivation gap –7.2%). Thisrepresents a significant widening of the deprivation gap by anaverage of  3.2% every 5 years since 1986–1990 (Table 2).Hybrid analysis based on the follow-up of men who werealive during all or part of the period 2000–2001 suggests thatthe deprivation gap may not widen any further, with adeprivation gap of  4t o 7% in relative survival at 1, 5 and 10years (Table 2).COMMENTThe recent trends in prostate cancer survival are remarkable. Survivalimproved by approximately 5–6% every 5 years between 1971–1975a n d1 9 8 1–1 9 8 5 ,b u ti td i dn o tc h a n g ea ta l lb e t w e e nt h ee a r l ya n dl a t eTable 1 Trends in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, men (15–99 years) diagnosed during1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisSurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CI1 year Men 78.3 (77.9, 78.7) 82.5 (82.2, 82.8) 88.9 (88.6, 89.2) 6.2** (5.5, 6.8) 89.9 (89.5, 90.3)5 years Men 42.7 (42.1, 43.3) 55.1 (54.6, 55.6) 68.4 (67.7, 69.0) 15.9** (14.8, 17.0) 69.9 (69.2, 70.6)10 years Men 28.2 (27.5, 28.8) 41.1 (40.2, 41.9) 16.4** (13.8, 19.0) 54.0 (52.8, 55.2)CI¼confidence interval.aSurvival estimated with cohort or complete approach (see Rachet et al, 2008).bMean absolute change (%) in survival every 5 years, adjusted fordeprivation (see Rachet et al, 2008).cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.020406080100Relative survival (%)0 2 4 6 8 10Years since diagnosis2000–20011996–19991991–19951986–1990MenFigure 1 Relative survival (%) up to 10 years after diagnosis by calendarperiod of diagnosis: England and Wales, adults (15–99 years) diagnosedduring 1986–1999 and followed up to 2001. Survival estimated withcohort or complete approach (1986–1990, 1991–1995, 1996–1999) orhybrid approach (2000–2001) (see Rachet et al, 2008).40506070805-year relative survival (%)Affluent 2 3 4 DeprivedDeprivation category2000–20011996–19991991–19951986–1990MenFigure 2 Trends in the deprivation gap in 5-year relative survival (%) bycalendar period of diagnosis: England and Wales, adults (15–99 years)diagnosed during 1986–1999 and followed up to 2001.Table 2 Trends in the deprivation gap in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, men(15–99 years) diagnosed during 1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CI1 year Men  3.0** ( 4.2,  1.8)  4.2** ( 5.1,  3.3)  4.1** ( 4.9,  3.3)  0.6 ( 1.3, 0.2)  4.4** ( 5.5,  3.3)5 years Men  1.2 ( 2.9, 0.4)  6.0** ( 7.4,  4.6)  7.2** ( 9.0,  5.5)  3.2** ( 4.5,  2.0)  7.3** ( 9.2,  5.3)10 years Men 0.0 ( 1.9, 1.8)  4.9** ( 7.3,  2.5)  4.9** ( 7.9,  1.8)  6.7** ( 9.9,  3.6)CI¼confidence interval.aSurvival estimated with cohort or complete approach (see Rachet et al, 2008).bMean absolute change (%) in the deprivation gap in survival every5 years, adjusted for the underlying trend in survival (see Rachet et al, 2008).cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.Survival from prostate cancer in England and WalesS Rowan et alS76British Journal of Cancer (2008) 99(S1), S75–S77 & 2008 Cancer Research UK1980s (Coleman et al, 1999). The very rapid increase reported here,represents a sharp reacceleration of survival during the 1990s.However, the patterns and trends in prostate cancer incidenceand survival are not an artefact. They reflect a rapid and substantialshift in the biological and clinical spectrum of prostate cancer, as wenow define, diagnose, register and treat it, following the introductionof sensitive new diagnostic techniques such as the PSA test.The PSA test enables invasive prostate cancer to be identifiedearlier than it might have been diagnosed clinically on the basis ofsymptoms, but the test also enables the identification of latent tumoursthat may never have caused symptoms during the man’s lifetime(Horwich et al, 1995). Thus, the chance of a man in England and Walesbeing diagnosed with prostate cancer between his sixtieth and eightiethbirthdays rose from 4%, based on the pattern of incidence by agethroughout the 1980s, to just 5% by 1990, but it almost doubled overthe next 10 years to reach 9% by 2000 (Table 3). At a population level,therefore, prostate cancer as defined in the PSA era since the early1990s is no longer the same disease as it was in the 1980s.In the absence of widespread access to a substantially improvedtreatment for early prostate cancer in the last 15 years of the 20thcentury, it seems most likely that the extremely rapid improvementin recorded survival for men diagnosed with prostate cancerduring the period 1986–1999 reflects an increase in the diagnosis,treatment and registration of men with asymptomatic malignancyas a result of the increasingly widespread use of PSA tests duringthe 1990s (Evans and Møller, 2003).The concurrent increase in the difference in survival betweenaffluent and deprived men, taken with the increase in incidence,similarly more rapid among men in affluent groups, also suggeststhat affluent men have had greater access to PSA tests than men inthe more deprived groups.A minority of cases (8.5%) were excluded from analysis becausethe only available information was from a death certificate; hence,their duration of survival was unknown. These men probably havehad shorter survival than the average for men who were registeredduring their lifetime (Berrino et al, 1995). The proportion of suchcases differed very little among deprivation categories or overtime; however, (data not shown), so their exclusion is mostunlikely to have biased the estimates of the widening deprivationgap in survival.In Europe, the international range in 5-year survival for mendiagnosed with prostate cancer during 1990–1994 was wider thanfor any other cancer, ranging from 39% in Poland to 85% inAustria (Sant et al, 2003). Survival in the Nordic countries washigh, and rose further during the 12 years up to 1994, with theexception of Denmark, where survival was lower and barelyincreased at all (Coleman et al, 2003). As with the socioeconomicdifferences in the incidence and survival trends reported here,these patterns seem likely to be at least in part attributable tointernational differences in the intensity of diagnostic andscreening activity.The implications for asymptomatic men diagnosed with prostatecancer following a PSA test are important. The randomised trialsof mass screening for prostate cancer with the PSA test are notexpected to report mortality results until 2010 (de Koning et al,2002; Hakama et al, 2008).REFERENCESBerrino F, Este `ve J, Coleman MP (1995) Basic issues in the estimation andcomparison of cancer patient survival. In Survival of Cancer Patients inEurope: the EUROCARE Study (IARC Scientific Publications No. 132),Berrino F, Sant M, Verdecchia A, Capocaccia R, Hakulinen T, Este `ve J(eds), pp 1–14. International Agency for Research on Cancer: LyonBrenner H, Rachet B (2004) Hybrid analysis for up-to-date long-termsurvival rates in cancer registries with delayed recording of incidentcases. Eur J Cancer 40: 2494–2501Breslow N, Chan CW, Dhom G, Drury RA, Franks LM, Gellei B, Lee YS,Lundberg S, Sparke B, Sternby NH, Tulinius H (1977) Latent carcinoma ofprostate at autopsy in seven areas. The International Agency for Researchon Cancer, Lyon, France. I n tJC a n c e r20: 680–688Coleman MP, Babb P, Damiecki P, Grosclaude PC, Honjo S, Jones J, Knerer G,Pitard A, Quinn MJ, Sloggett A, De Stavola BL (1999) Cancer Survival Trendsin England and Wales 1971–1995: Deprivation and NHS Region. Studies onMedical and Population Subjects No. 61. The Stationery Office: LondonColeman MP, Gatta G, Verdecchia A, Este `ve J, Sant M, Storm HH,Allemani C, Ciccolallo L, Santaquilani M, Berrino F, EUROCAREWorking Group (2003) EUROCARE-3 summary: cancer survivalin Europe at the end of the 20th century. Ann Oncol 14(5):128–149de Koning HJ, Auvinen A, Berenguer Sanchez A, Calais da Silva F, Ciatto S,Denis L, Gohagan JK, Hakama M, Hugosson J, Kranse R, Nelen V, ProrokPC, Schro ¨der FH (2002) Large-scale randomized prostate cancerscreening trials: program performances in the European RandomizedScreening for Prostate Cancer trial and the Prostate, Lung, Colorectal andOvary cancer trial. Int J Cancer 97: 237–244Evans HS, Møller H (2003) Recent trends in prostate cancer incidence andmortality in southeast England. Eur Urol 43: 337–341Hakama M, Coleman MP, Alexe DM, Auvinen A (2008) Cancer screening.In Responding to the Challenge of Cancer in Europe, Coleman MP,Alexe DM, Albreht T, McKee CM (eds), pp 69–92. Institute of PublicHealth of the Republic of Slovenia: LjubljanaHorwich A, Waxman J, Schroder FH (1995) Tumours of the prostate. InOxford Textbook of Oncology, Peckham M, Pinedo HM, Veronesi U (eds)2 edn, pp 1498–1530. Oxford Medical Publications: New YorkKirby RS (1996a) Recent advances in the medical management of prostatecancer. Br J Clin Pract 50: 88–93Kirby RS (1996b) The future management of prostate cancer? Eur Urol29(Suppl 2): 132–133Office for National Statistics (2003) Mortality Statistics: Cause, England andWales, 2002. Series DH2 No. 29. Office for National Statistics: LondonPashayan N, Powles JW, Brown C, Duffy SW (2006a) Excess cases ofprostate cancer and estimated overdiagnosis associated with PSA testingin East Anglia. Br J Cancer 95(3): 401–405Pashayan N, Powles JW, Brown C, Duffy SW (2006b) Incidence trends ofprostate cancer in East Anglia, before and during the era of PSA testing.Br J Cancer 95(3): 398–400Platz EA, Giovannucci E (2006) Prostate cancer. In Cancer Epidemiologyand Prevention. Schottenfeld D, Fraumeni JF (eds) 3 edn, pp 1128–1150.Oxford University Press: OxfordQuinn MJ, Babb P, Brock A, Kirby L, Jones J (2001) Cancer Trends inEngland and Wales 1950–1999. Studies on Medical and PopulationSubjects No. 66. Office for National Statistics: LondonRachet B, Woods LM, Mitry E, Riga M, Cooper N, Quinn MJ, Steward J,Brenner H, Este `ve J, Sullivan R, Coleman MP (2008) Cancer survivalin England and Wales at the end of the 20th century. Br J Cancer99(Suppl 1): S2–S10Ross RK, Schottenfeld D (1996) Prostate cancer. In Cancer Epidemiologyand Prevention. Schottenfeld D, Fraumeni JF (eds) 2 edn, pp 1180–1206.Oxford University Press: OxfordSant M, Aareleid T, Berrino F, Bielska Lasota M, Carli P-M, Faivre J,Grosclaude PC, He ´delin G, Matsuda T, Møller H, Moller T, Verdecchia A,Capocaccia R, Gatta G, Micheli A, Santaquilani M, Roazzi P, Lisi D,EUROCARE Working Group (2003) EUROCARE-3: survival of cancer patientsdiagnosed 1990–94 – results and commentary. Ann Oncol 14(5): 61–118Table 3 Incidence per 100000 per year and cumulative risk (%)between sixtieth and eightieth birthdays, England and Wales, 1982–2000Year of diagnosisAge (years) 1982 1985 1990 1995 200060–64 57 65 96 129 20265–69 130 130 172 253 38470–74 226 233 292 416 53975–79 375 382 487 610 706Cumulative risk (%) 3.86 3.97 5.10 6.80 8.75Survival from prostate cancer in England and WalesS Rowan et alS77British Journal of Cancer (2008) 99(S1), S75–S77 & 2008 Cancer Research UK

Basic issues in the estimation and comparison of cancer patient survival.

Cancer 95(3): 398–400 Platz EA, Giovannucci E

Cancer Trends in England and Wales 1950–1999. Studies on Medical and Population Subjects No. 66. Office for National Statistics: London Rachet

EUROCARE Working Group (2003) EUROCARE-3: survival of cancer patients diagnosed 1990–94 – results and commentary.

In Responding to the Challenge of Cancer

Making progress against cancer

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Making progress against cancer

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