Dr Felipe Ades:

Survival after cancer diagnosis in Europe is strongly associated with how much governments spend on health care (Video at the bottom of text)

Amsterdam, The Netherlands (ECCO PRESS RELEASE): The more an EU (European Union) national government spends on health, the fewer the deaths after a cancer diagnosis in that country, according to new research to be presented to the 2013 European Cancer Congress (ECC2013) [1] today (Sunday) and published simultaneously in the leading cancer journal Annals of Oncology [2].

Researchers will tell the meeting that higher wealth and higher health expenditure are strongly associated both with increased cancer incidence and decreased cancer mortality. In the case of breast cancer, increased health expenditure appears to be even more strongly associated with better outcomes.

Dr Felipe Ades, MD, a medical oncologist at the Breast European Adjuvant Studies Team (BrEAST), a clinical trials unit and data centre in Belgium, will say: “We have observed that the more spent on health, the fewer the deaths after a cancer diagnosis and this is specially marked in breast cancer. We have also noticed that, despite all the initiatives to standardise public health policies, there is significant variation between health expenditure and cancer incidence and mortality in the 27 EU member states. This disparity is more glaring between the Western and Eastern European countries.” [3]

Dr Ades and his colleagues obtained information on populations, cancer incidence, and mortality from the World Health Organization, the International Monetary Fund and the World Bank [4]. They looked at factors such as countries’ gross domestic product (GDP), the percentage of GDP invested in healthcare and health expenditure per person per year, and compared these wealth and health expenditure indicators with their own estimates of the proportion of patients dying after a cancer diagnosis.

While the population of Western Europe – approximately 400 million inhabitants – is around four times larger than that of Eastern Europe, Western countries’ total GDP is more than 10-fold higher than that of Eastern Europe [5]. The researchers also found a significant difference between the health expenditure of these countries.

“Not surprisingly, health expenditure per capita is strongly correlated with the GDP per capita and with the percentage of GDP spent on heath,” Dr Ades will say. “The cut-off point between Eastern and Western European countries for health expenditure per person per year is around 2,600 US dollars. For instance, among the Western European countries Portugal has the lowest per capita expenditure at 2,690 dollars, while among the Eastern European countries, Slovenia has the highest per capita expenditure at 2,551 dollars. In the West, Luxembourg spent the most per person per year – 6,592 dollars – while in the East, Romania spent the least – 818 dollars.”

The researchers found that, proportionally, Eastern Europe had lower cancer incidence and higher cancer mortality, while the opposite was the case in Western Europe. Dr Ades will tell the congress: “From our results it is evident that Eastern European countries, except Cyprus, have higher mortality rates than the Western European countries for approximately the same range of incidence. This indicates that proportionally more patients die after a diagnosis of cancer in Eastern Europe than in Western Europe. This pattern is strongly associated with health expenditure; the more a country spends on health, the fewer patients die after a cancer diagnosis.

“In countries spending less than 2,000 dollars per capita in health care, like Romania, Poland and Hungary, around 60% of the patients die after a diagnosis of cancer; in countries spending between 2,500-3,500 dollars this figure is around 40% and 50%, as in the case of Portugal, Spain and the United Kingdom; moving up to around 4,000 dollars, less than 40% of the patients die, as in the case of France, Belgium and Germany.”

The research does not analyse the reasons for the higher incidence of cancer in Western European countries. However, it suggests that, as cancer deaths do not increase in the same proportion to incidence in these countries, it may be due partly to the existence of greater numbers of Western screening programmes, which detect more cancers at their early, more treatable stages, and to the availability of effective treatments in these countries. 

Dr Ades and his colleagues also looked specifically at breast cancer. “We did this because breast cancer is the best example of an oncologic disease with effective screening methods. Also, in European populations it has been shown that breast cancer screening reduces mortality in comparison to non-screening,” he will say. “We found that the association between greater wealth and higher health expenditure and the incidence of breast cancer was even stronger than in other cancers, a fact possibly linked to the inherent higher incidence of breast cancer in Western countries but also to the increased detection due to screening availability, although this was not the case for deaths from the disease as breast cancer mortality is similar across the European Union. However, when we divided the number of new cases of breast cancer by the number of deaths from breast cancer to establish the ratio of deaths to incidence, we found that a smaller fraction of patients died after diagnosis in Western Europe than in Eastern Europe, and this was also strongly associated with higher wealth and health expenditure.”

Dr Ades will also say: “Although financing health systems is a responsibility of national governments, the European Union has enacted a Charter of Fundamental Rights to standardise public health policies. Our research demonstrates that despite the initiatives to render more uniform the health policy across the EU member states, there are still marked differences between Eastern and Western Europe in regards to cancer indicators. More research is needed to investigate these issues further.”

ECCO president, Professor Cornelis van de Velde, commented: “This is an interesting study confirming that, just as overall life expectancy is higher in countries that spend proportionately more on health, so cancer patients’ survival is also higher in these countries. It is interesting to see that this association is even stronger for patients with breast cancer as compared to other cancers, and that, despite the initiatives to standardise health care across Europe, disparities are still present.

“Factors such as the proportion of GDP spent on health, levels of employment and numbers of hospital beds are associated with a favourable prognosis for cancer patients, and previous studies have shown that these appear to be responsible for over 65% of the variations between countries in survival for breast cancer in Western Europe.”

ESMO spokesperson, Professor José Martin-Moreno, Professor of Public Health at the Medical School at the Universidad de Valencia (Spain), commented: “Cancer is a leading cause of mortality in Europe, and yet there is an important deficit between the resources needed to control it and those deployed to do so. In this context, Dr Ades and colleagues have produced an important study, confirming that funding for health systems is crucial to ensuring good patient outcomes and warning over health inequalities across the EU countries. Given the ongoing economic recession, this is a message that European governments and citizens need to know. Public health expenditure, along with adequate governance and accountability mechanisms, evidence-based guidelines, and proper capacity-building, are all essential ingredients for a strong health system and for a better society.”

Abstract no: 1400, “Discrepancies in cancer incidence and mortality and its relation to health expenditure among the 27 European Union member states”. Public Health and Epidemiology proffered papers session, Sunday 29 September 2013.



Dr Kirstin De Bruijn:

Diabetes increases the risk of developing and dying from breast and colon cancer (Video at the bottom of text)

Amsterdam, The Netherlands (ECCO PRESS RELEASE): Diabetes is linked to an increased risk of developing cancer, and now researchers have performed a unique meta-analysis that excludes all other causes of death and found that diabetic patients not only have an increased risk of developing breast and colon cancer but an even higher risk of dying from them.

Dr Kirstin De Bruijn will tell the 2013 European Cancer Congress (ECC2013) [1], today (Sunday), that previous studies have examined the association between diabetes and dying from cancer but death from specific types of cancer has not been well-studied. “Our meta-analysis is the first to combine incidence and death from breast and colon cancer, while excluding all other causes of death. We have investigated the link between diabetes and the risk of developing as well as the risk of dying from these cancers,” she will say.

Dr De Bruijn, a PhD student in the Surgery Department at the Erasmus University Medical Center in Rotterdam (The Netherlands), and colleagues analysed results from 20 trials that had taken place between 2007 and 2012, involving more than 1.9 million patients with breast or colon cancer, with or without diabetes.

They found that patients with diabetes had a 23% increased risk of developing breast cancer and a 38% increased risk of dying from the disease compared to non-diabetic patients. Diabetic patients had a 26% increased risk of developing colon cancer and a 30% increased risk of dying from it compared to non-diabetic patients.

Dr De Bruijn will say: “The results for breast and colon cancer incidence in patients with diabetes are consistent with other meta-analyses. Furthermore, this meta-analysis shows a higher risk and a stronger association between diabetes and death from breast and colon cancer than previously reported.

“Cancer patients who are obese and diabetic are an already more vulnerable group of individuals when it comes to surgery, as they have an increased risk of developing complications both during and after surgery. If more obese and diabetic patients have to have an operation because of cancer, healthcare costs will increase.

“Worldwide, the numbers of obese and subsequent diabetic patients are still increasing and it is a cause for concern that these individuals are at a higher risk of developing cancer and dying from it. Studies have already highlighted the increased risk of developing cancer for diabetics. Our meta-analysis, which is unique since it looks at the risks for breast and colon cancer while excluding all other causes of death, provides stronger evidence for the association between diabetes and the risk of developing and dying from these cancers. We want to make people more aware of this problem and we hope that prevention campaigns regarding obese and diabetic patients will focus on highlighting this increased risk.”

Dr De Bruijn and her colleagues intend to follow up their work by investigating what effect other factors associated with diabetes have on cancer risk and death, such as the anti-diabetic medication, metformin, as well as insulin and the duration of diabetes.

“It is extremely important that prevention campaigns on obesity and diabetes are intensified and that they also focus on children, to prevent them from becoming obese and developing cancer later in life,” she will conclude.

Professor Cornelis van de Velde, President of ECCO, said: “With the increase in incidence of both diabetes and breast cancer, this is an important update of the meta-analyses on this subject and an interesting addition to the literature as this study excluded other causes of death. As the results are consistent with earlier meta-analyses, the substantial increased risk of breast cancer should be part of prevention campaigns. For further research, it would be important to study how other, competing risk factors might affect survival, as elderly cancer patients with diabetes are usually diagnosed with other conditions as well. Additionally, the potential role of metformin in relation to improved survival and cancer recurrence needs to be studied.”

Professor Hans-Joerg Senn, scientific director at the Tumor and Breast Centre ZeTuP, St Gallen, Switzerland, said: “The message from the Erasmus Medical Center is disturbing and highly important, for the medical community, as well as for the public and politicians. It highlights once more the importance of the negative interactions between lifestyle, metabolism, overweight and certain frequent types of cancers, such as here between diabetes, obesity and breast cancer as well as colon cancer. It is time for increased and more effective information and prevention campaigns, especially in the economically developed world, where caloric abundance is prevalent.”

Abstract no: 1402, “A meta-analysis on breast and colorectal cancer in diabetic patients: higher incidences and mortality rates”. Public Health and Epidemiology, proffered papers session, Sunday 29 September



Professor Philippe Autier:

Colorectal cancer screening works; ‘irrefutable’ evidence that fall in death rates is attributable to screening programmes (Video at the bottom of text)

Amsterdam, The Netherlands (ECCO PRESS RELEASE): Screening for colorectal cancer (CRC) in European countries is highly effective in reducing mortality from the disease. Some of the resources currently being devoted to breast and prostate screening programmes, where the evidence of effectiveness is much less clear-cut, should be reallocated to the early detection of CRC, the 2013 European Cancer Congress (ECC2013) [1] will hear today (Sunday).

Professor Philippe Autier, Vice President, Population Studies, at the International PreventionResearch Institute, Lyon, France, will report on results extracted from data on CRC collected as partof the Survey of Health, Ageing, and Retirement in Europe (SHARE) project on exposure to screeningin men and women aged 50 and over in 11 European countries between 1989 and 2010. Using theWorld Health Organisation cause of death database, the researchers calculated changes in deathrates from CRC in the different countries, and related them to the scope and take-up of CRCscreening activities.

Screening involves either a faecal occult blood test (FOBT), which checks a sample of faeces forhidden blood, or endoscopy, where a tiny camera is introduced into the large bowel to look for thepolyps that can be a precursor of cancer. Screening activities were either part of nationalprogrammes, for example FOBT screening in France and in the UK, FOBT or endoscopy in Germanyand some Italian regions, or the result of decisions made by individuals and their doctors. Endoscopicscreening is often carried out without a prior FOBT examination.

“We saw quite clearly that the greater proportions of men and women who were screened, the greaterthe reductions in mortality,” Prof Autier will say. “Reduced death rates from CRC were not noticeablein countries where screening was low, even though healthcare services in those countries weresimilar to those in countries where screening was more widespread.”

In Austria, where 61% of all those studied reported having undertaken a FOBT, deaths from CRCdropped by 39% for men and 47% for women during the period. In Greece, however, where only 8%of males had had an endoscopic examination as opposed to 35% in Austria, death rates from CRCrose during the period by 30% for men and 2% for women.

Overall, in all the European countries studied, 73% of the decrease in CRC mortality over ten years inmales, and 82% in females, could be explained by their having had one or more endoscopicexamination of the large bowel over the last ten years. “The evidence could not be clearer,” ProfAutier says, “and it is therefore very disappointing that national differences in the availability of CRCscreening programmes are still so pronounced.”

The researchers believe that the large differences in screening rates between different Europeancountries are due to a number of factors. “First, many countries still do not have a national CRCscreening programme. Second, the acceptability of screening methods is often low, sometimes due tocultural differences between countries. There is also the question of the availability of qualifiedpersonnel. In some countries, there are insufficient gastroenterologists available to perform endoscopy. Even with FOBT screening, an endoscopy is needed if the test is positive,” says Prof Autier.

”Since the main goal of CRC screening is to remove polyps in the bowel, the risk of over-diagnosis islow, unlike that seen in breast and prostate cancer screening. “The risk of bowel perforation withendoscopy, while not non-existent, is very low and so far no trial has reported rates of perforation thatcould compromise the feasibility of screening on either practical or ethical grounds,” Prof Autier says.The researchers now intend to gather further data on screening and to include those from the USA,Canada, and Australia. “There are signs that CRC screening can reduce the incidence of this canceras well as mortality from it, in exactly the same way as is happening with cervical cancer screening.We would also like to investigate the cost-effectiveness of CRC screening, since we believe that ithas the potential to bring about economic gains associated with averted CRC cases and deaths, andhence to more than pay for its initial cost,” says Prof Autier.

“If two-thirds of eligible people in each country attend screening, we believe that we could see aconsiderable reduction in CRC mortality in a minimum of ten years. National healthcare services needto put more effort into organising screening programmes based on FOBT or endoscopy, and intoinforming people aged 50 and over about the availability of these tests so that they can make achoice.”

The evidence for the reduction in mortality from CRC screening programmes is just as strong as it isfor cervical cancer, the researchers say. It is strengthened by the fact that there are major differencesbetween countries where health care is of similar quality, which can only be attributed to thedifferences in screening rates. For example, 34% of men in France aged 50 or more and 12% of menin the same age group in The Netherlands had an endoscopic screening during the period studied.Between 1996 and 2009, CRC mortality decreased by 31% in men in France but the decrease in menin The Netherlands was only 4% over the same period. A similar pattern was seen in women from thetwo countries.

“There is a clear relationship between randomised trials showing the ability of any type of CRCscreening to reduce the risk of death from the disease, data from cancer registries showing declinesin the incidence of advanced CRC, and declines in CRC mortality over time. In breast cancer, there isno such smooth logical sequence between randomised trials and these population statistics. It seemsto us that there is now an irrefutable case for devoting some of the resources from breast andprostate cancer screening to the early detection of CRC,” Professor Autier will conclude.Professor Cornelis van de Velde, President of ECCO, said: “Colorectal cancer screening works, butthis study shows major differences in Europe in its use and structure. It is very disappointing thatthere are so many differences in outcome due to limitations in the use of screening. People over 50should be informed of the availability of the test, and pressure should be put on national healthservices to put more effort into organising screening programmes. Now there is an initiative tocompare data, not only within Europe but also from USA, Canada and Australia. It is certainly anECCO priority to harmonise colorectal cancer screening throughout Europe so that every futurecolorectal cancer patient will get the best chance of early detection.”

ESMO spokesperson, Professor Eric Van Cutsem, from the University Hospitals Leuven, Leuven,Belgium, said: “These interesting data underline the utility of systematic colorectal cancer screening,as currently recommended by the European Council. The findings also support the need to sensitisepoliticians and the public on the need for well-organised screening programmes, incorporating goodquality assurance, in order to raise public awareness and achieve high rates of participation.”

Abstract no: 1405, “Trends in colorectal cancer mortality and screening activities in Europeancountries.” Public Health and Epidemiology proffered papers session, Sunday 29 September.