Elsevier

The Lancet

Volume 391, Issue 10125, 17–23 March 2018, Pages 1023-1075
The Lancet

Articles
Global surveillance of trends in cancer survival 2000–14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries

https://doi.org/10.1016/S0140-6736(17)33326-3Get rights and content

Summary

Background

In 2015, the second cycle of the CONCORD programme established global surveillance of cancer survival as a metric of the effectiveness of health systems and to inform global policy on cancer control. CONCORD-3 updates the worldwide surveillance of cancer survival to 2014.

Methods

CONCORD-3 includes individual records for 37·5 million patients diagnosed with cancer during the 15-year period 2000–14. Data were provided by 322 population-based cancer registries in 71 countries and territories, 47 of which provided data with 100% population coverage. The study includes 18 cancers or groups of cancers: oesophagus, stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate, and melanoma of the skin in adults, and brain tumours, leukaemias, and lymphomas in both adults and children. Standardised quality control procedures were applied; errors were rectified by the registry concerned. We estimated 5-year net survival. Estimates were age-standardised with the International Cancer Survival Standard weights.

Findings

For most cancers, 5-year net survival remains among the highest in the world in the USA and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway, and Sweden. For many cancers, Denmark is closing the survival gap with the other Nordic countries. Survival trends are generally increasing, even for some of the more lethal cancers: in some countries, survival has increased by up to 5% for cancers of the liver, pancreas, and lung. For women diagnosed during 2010–14, 5-year survival for breast cancer is now 89·5% in Australia and 90·2% in the USA, but international differences remain very wide, with levels as low as 66·1% in India. For gastrointestinal cancers, the highest levels of 5-year survival are seen in southeast Asia: in South Korea for cancers of the stomach (68·9%), colon (71·8%), and rectum (71·1%); in Japan for oesophageal cancer (36·0%); and in Taiwan for liver cancer (27·9%). By contrast, in the same world region, survival is generally lower than elsewhere for melanoma of the skin (59·9% in South Korea, 52·1% in Taiwan, and 49·6% in China), and for both lymphoid malignancies (52·5%, 50·5%, and 38·3%) and myeloid malignancies (45·9%, 33·4%, and 24·8%). For children diagnosed during 2010–14, 5-year survival for acute lymphoblastic leukaemia ranged from 49·8% in Ecuador to 95·2% in Finland. 5-year survival from brain tumours in children is higher than for adults but the global range is very wide (from 28·9% in Brazil to nearly 80% in Sweden and Denmark).

Interpretation

The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 cancers that collectively represent 75% of all cancers diagnosed worldwide every year. It contributes to the evidence base for global policy on cancer control. Since 2017, the Organisation for Economic Co-operation and Development has used findings from the CONCORD programme as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries worldwide. Governments must recognise population-based cancer registries as key policy tools that can be used to evaluate both the impact of cancer prevention strategies and the effectiveness of health systems for all patients diagnosed with cancer.

Funding

American Cancer Society; Centers for Disease Control and Prevention; Swiss Re; Swiss Cancer Research foundation; Swiss Cancer League; Institut National du Cancer; La Ligue Contre le Cancer; Rossy Family Foundation; US National Cancer Institute; and the Susan G Komen Foundation.

Introduction

The incidence of cancer continues to rise, both in high-income countries and, especially, in low-income and middle-income countries. Prevention is crucial, but implementation has been slow and incomplete, even in high-income countries. Prevention is a long-term strategy, and not all cancers can be prevented.1 To reduce cancer mortality, reduction of cancer incidence and improvement of cancer survival are both necessary.

Many patients will continue to be diagnosed with cancer every year for decades to come: an estimated 14 million patients a year worldwide around 2012,2 with a 50% projected increase to 21·6 million patients a year by 2030.3 Those patients will all need prompt diagnosis and optimal treatment to improve their survival. Monitoring the effectiveness of national and regional health systems in treating and caring for these patients becomes ever more crucial.

Research in context

Evidence before this study

In 2015, the second cycle of the CONCORD programme (CONCORD-2) established global surveillance of cancer survival as one of the key metrics of the effectiveness of health systems and to inform global policy on cancer control. This was done by analysis of individual records for 25·7 million patients diagnosed with one of ten common cancers during 1995–2009 and followed up to Dec 31, 2009. The data were provided by 279 population-based cancer registries in 67 countries. CONCORD-2 revealed wide differences in cancer survival trends that were attributed to differences in access to early diagnosis and optimal treatment.

Added value of this study

CONCORD-3 covers almost 1 billion people worldwide. It includes 15 common cancers in adults and three common cancers in children. Data quality has improved. The results are timely, published within 3 years of the end of follow-up. CONCORD-3 updates the worldwide surveillance of cancer survival to 2014. It includes data for over 37·5 million patients diagnosed with cancer during the 15-year period 2000–14. Data were provided by more than 320 population-based cancer registries in 71 countries and territories, including 27 countries of low or middle income; 47 countries provided data with 100% population coverage. The study now includes 18 cancers or groups of cancers: oesophagus, stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate, and melanoma of the skin in adults, together with brain tumours, leukaemias, and lymphomas in both adults and children. These cancers represent 75% of all cancers diagnosed worldwide every year, in both low-income and high-income countries. The use of a similar study design and the same statistical methods as in CONCORD-2 enables the evaluation of survival trends for ten cancers over the 20-year period 1995–2014. For the first time, worldwide trends in survival are also available for cancers of the oesophagus, pancreas, and brain, and lymphomas and leukaemias.

Implications of all the available evidence

The CONCORD programme enables comparative evaluation of the effectiveness of health systems in providing cancer care. It also contributes to the evidence base for global policy on cancer control. CONCORD monitors progress towards the overarching goal of the 2013 World Cancer Declaration, to achieve “major reductions in premature deaths from cancer, and improvements in quality of life and cancer survival” by 2020. It provides evidence to support WHO policy following the Cancer Resolution passed by the World Health Assembly in 2017. The International Atomic Energy Agency's Programme for Action on Cancer Therapy used CONCORD-2 results in 2015 to launch its worldwide campaign to highlight the global divide in cancer survival, and to raise awareness of persistent inequalities in access to life-saving cancer services. The results were used in a Lancet Series on women's cancers in 2016. The US Centers for Disease Control and Prevention used the results in a 2017 supplement to the journal Cancer to inform cancer control policy designed to reduce racial differences in cancer survival.

CONCORD-3 can be expected to affect cancer control policy worldwide, especially in countries with low survival. The Organisation for Economic Co-operation and Development published a subset of CONCORD-3 results in 2017 as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries worldwide. The survival estimates will also form part of the Lancet Oncology Commission on childhood cancer in 2018. Future research will include examination of the impact on international differences in cancer survival of stage at diagnosis, compliance with treatment guidelines, and the quality of health care.

In 2016, the WHO Executive Board recommended strengthening health systems to ensure early diagnosis and accessible, affordable, high-quality care for all patients with cancer.3 The World Health Assembly followed up with a resolution on cancer control in May, 2017. It included recommendations that national cancer control strategies should aim to reduce late presentation and ensure appropriate treatment and care for potentially curable malignancies such as acute leukaemia in children “to increase survival, reduce mortality and improve quality of life”.4

President Tabaré Vázquez of Uruguay and WHO Director-General Tedros Ghebreyesus have called for all countries “to provide universal health coverage, thereby ensuring all people can access needed preventive and curative health-care services, without falling into poverty”.5 Their call relates to all non-communicable diseases, including cancer. Population-based cancer survival is one metric that can help evaluate whether all people have access to effective treatment services.

In 2015, the second cycle of the CONCORD programme (CONCORD-2) established global surveillance of cancer survival for the first time,6 with publication of trends in survival over the 15-year period 1995–2009 among patients diagnosed with cancer in 67 countries, home to two thirds (4·8 billion) of the world's population. In 40 countries, the data had 100% national population coverage. CONCORD-2 incorporated centralised quality control and analysis of individual data for 25 676 887 patients diagnosed with one of the ten common cancers that represented 63% of the global cancer burden in 2009. The 279 population-based registries covered a combined total population of 896 million people.

The US National Cancer Institute, in an invited commentary7 for The Lancet, noted that the global analyses of cancer survival in CONCORD-2 provided insights from countries with successful cancer control initiatives that could be applied in other regions, and that the availability of better data “provides a clearer picture of the effect of cancer control programmes on the ultimate goal of improving survival and reducing the effect of cancer on the social and economic development of countries”.

The US Centers for Disease Control and Prevention described CONCORD-2 as the start of global surveillance of cancer survival,8 with survival estimates “that can be compared so scientists can begin to determine why survival differs among countries. This could lead to improvements in cancer control programs.” The results from CONCORD-2 influenced national cancer control strategy in the UK in July, 2015.9, 10 In September, 2015, the International Atomic Energy Agency's Programme for Action on Cancer Therapy used the results to launch a worldwide campaign11 to highlight the global divide in cancer survival, and to raise awareness of persistent inequalities in access to life-saving cancer services.12 Further analyses of survival trends and disparities by race and stage at diagnosis in 37 US states have been included in a supplement to Cancer,13, 14 designed to improve cancer control in the USA.

CONCORD-3 updates worldwide surveillance of cancer survival trends to include patients diagnosed up to 2014, with follow-up to Dec 31, 2014. In countries that were already involved, more registries are participating, and eight more countries have joined the programme. Follow-up for patients diagnosed during 2000–09 with one of the ten cancers included in CONCORD-2 has been updated. CONCORD-3 includes data for patients diagnosed during 2000–14 with one of 18 malignancies that represent 75% of the global cancer burden (table 1). In addition to information on stage at diagnosis, we have collected data on tumour grade and the first course of treatment. Findings are published within 3 years of the end of follow-up.

Section snippets

Cancer registries

We contacted 412 cancer registries in 85 countries: 20 in Africa (13 countries), 45 in Central and South America (15 countries), 68 in North America (two countries), 80 in Asia (20 countries), 189 in Europe (33 countries), and ten in Oceania (two countries).

When the data call for CONCORD-3 was issued in May, 2016, 12 of the 279 cancer registries that had participated in CONCORD-2 were no longer operational. The registry in Benghazi (Libya) had been disrupted by war, the registry in Macerata

The CONCORD database 2000–14

We analysed data for 322 cancer registries in 71 countries in Africa (eight registries, six countries), Central and South America (33 registries, 13 countries), North America (57 registries, two countries), Asia (66 registries, 17 countries), Europe (149 registries, 31 countries), and Oceania (nine registries, two countries; figure 1).

For 47 countries, data were provided with 100% coverage of the national population: 41 countries for both adults and children, and six for children only

Discussion

CONCORD-3 updates the worldwide surveillance of cancer survival to 2014. It is the largest and most up-to-date study of international cancer survival trends. It includes individual data for more than 37·5 million patients diagnosed with cancer during the 15-year period 2000–14. Data were provided by more than 320 population-based cancer registries in 71 countries and territories, in 47 of which the data covered 100% of the population. The participating countries were home to 67% of the world's

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