Harry Comber

The aim of this study was to investigate inequalities in survival for non-Hodgkin’s lymphoma (NHL), distinguishing between direct and indirect effects of patient, social and process-of-care factors. All cases of NHL diagnosed in Ireland in 2004–2008 were included. Variables describing patient, cancer, stage and process of care were included in a discrete-time model of survival using Structural Equation Modelling software. Emergency admissions were more common in patients with co-morbid conditions or with more aggressive cancers, and less frequent for patients from more affluent areas. Aggressive morphology, female sex, emergency admission, increasing age, comorbidity, treatment in a high caseload hospital and late stage were associated with increased hazard of mortality. Private patients had a reduced hazard of mortality, mediated by systemic therapy, admission to high caseload hospitals and fewer emergency admissions. The higher rate of emergency presentation, and consequent poorer survival, of uninsured patients, suggests they face barriers to early presentation. Social, educational and cultural factors may also discourage disadvantaged patients from consulting with early symptoms of NHL. Non-insured patients, who present later and have more emergency admissions would benefit from better access to diagnostic services. Older patients remain disadvantaged by sub-optimal treatment, treatment in non-specialist centres and emergency admission.

Emergency presentation of rectal cancer carries a relatively poor prognosis, but the roles and interactions of causative factors remain unclear. We describe an innovative statistical approach which distinguishes between direct and indirect effects of a number of contextual, patient and tumour factors on emergency presentation and outcome of rectal cancer. All patients diagnosed with rectal cancer in Ireland 2004–2008 were included. Registry information, linked to hospital discharge data, provided data on patient demographics, comorbidity and health insurance; population density and deprivation of area of residence; tumour type, site, grade and stage; treatment type and optimality; and emergency presentation and hospital caseload. Data were modelled using a structural equation model with a discrete‐time survival outcome, allowing us to estimate direct and mediated effects of the above factors on hazard, and their inter‐relationships. Two thousand seven hundred and fifty patients were included in the analysis. Around 12% had emergency presentations, which increased hazard by 80%. Affluence, private patient status and being married reduced hazard indirectly by reducing emergency presentation. Older patients had more emergency presentations, while married patients, private patients or those living in less deprived areas had fewer than expected. Patients presenting as an emergency were less likely to receive optimal treatment or to have this in a high caseload hospital. Apart from stage, emergency admission was the strongest determinant of poor survival. The factors contributing to emergency admission in this study are similar to those associated with diagnostic delay. The socio‐economic gradient found suggests that patient education and earlier access to endoscopic investigation for public patients could reduce emergency presentation.

Rising cancer incidence and survival mean that the number of cancer survivors is growing. Accumulating evidence suggests many survivors have long-term medical and supportive care needs, and that these needs vary by survivors’ socio-demographic and clinical characteristics. To illustrate how cancer registry data may be useful in survivorship care service planning, we generated population-based estimates of cancer prevalence in Ireland and described socio-demographic and clinical characteristics of the survivor population. Details of people diagnosed with invasive cancer (ICD10 C00-C96) during 1994–2011, and who were still alive on 31/12/2011, were abstracted from the National Cancer Registry, and tabulated by cancer site, sex, current age, marital status, initial treatment, and time since diagnosis. Associations were investigated using chi-square tests. After excluding non-melanoma skin cancers, 17-year cancer prevalence in Ireland was 112,610 (females: 58,054 (52%) males: 54,556 (48%)). The four most prevalent cancers among females were breast (26,066), colorectum (6,598), melanoma (4,593) and uterus (3,505) and among males were prostate (23,966), colorectum (8,207), lymphoma (3,236) and melanoma (2,774). At the end of 2011, 39% of female survivors were aged <60 and 35% were ≥70 compared to 25% and 46% of males (p < 0.001). More than half of survivors of bladder, colorectal and prostate cancer were ≥70. Cancers with the highest percentages of younger (<40) survivors were: testis (50%); leukaemia (females: 28%; males: 22%); cervix (20%); and lymphoma (females: 19%; males: 20%). Fewer female (57%) than male (64%) survivors were married but the percentage single was similar (17-18%). More female (25%) than male survivors (18%; p < 0.001) were ≥10 years from diagnosis. Overall, 69% of survivors had undergone cancer-directed surgery, and 39%, 32% and 18% had received radiotherapy, chemotherapy and hormone therapy, respectively. These frequencies were higher among females than males (surgery: 82%, 54%; radiotherapy: 42%, 35%; chemotherapy: 40%, 22%; hormone therapy: 23%, 13%). These results reveal the socio-demographic and clinical heterogeneity of the survivor population, and highlight groups which may have specific medical and supportive care needs. These types of population-based estimates may help decision-makers, planners and service providers to develop follow-up and after-care services to effectively meet survivors’ needs.

Nonmelanoma skin cancer (NMSC) is the most common cancer in white people, but is registered inconsistently by population-based registries. To analyse the changing profile of NMSC in a national population, to interpret evolving patterns of sun exposure and to recommend measures to reduce risk. We analysed trends in the demographic, clinical and socioeconomic profile of > 50 000 cases of NMSC registered between 1994 and 2011 by the Irish National Cancer Registry, which aims to register all episodes of NMSC in the Irish population to a high degree of completeness. The incidence of cutaneous basal cell (BCC) and squamous cell carcinoma (SCC) was stable from 1994 to 2002, but increased significantly (BCC more than SCC) in the subsequent decade. The largest relative increases in the incidence of BCC were in younger populations and in clothed body sites. The incidence of both cancers was lower in rural areas. Incidence of BCC and, to a lesser extent, of SCC, increased with increasing affluence in urban, but not in rural, areas. Recent increases in skin cancers on the trunk and limbs in younger people appear to be related to increasing affluence and consequent leisure-related, episodic sun exposure. This population is at high risk of subsequent skin cancers throughout life and will need active surveillance. As preventive programmes are cost-effective in lowering the incidence of NMSC, they should be targeted at leisure exposure in young people. The recording of consistent international data on NMSC should also be a priority.

Background.Cancer incidence rates vary considerably between countries and by socioeconomic status (SES). We investigate the impact of SES upon the relative cancer risk in two neighbouring countries.Methods.Data on 229,824 cases for 16 cancers diagnosed in 1995–2007 were extracted from the cancer registries in Northern Ireland (NI) and Republic of Ireland (RoI). Cancers in the two countries were compared using incidence rate ratios (IRRs) adjusted for age and age plus area-based SES.Results.Adjusting for SES in addition to age had a considerable impact on NI/RoI comparisons for cancers strongly related to SES. Before SES adjustment, lung cancer incidence rates were 11% higher for males and 7% higher for females in NI, while after adjustment, the IRR was not statistically significant. Cervical cancer rates were lower in NI than in RoI after adjustment for age (IRR: 0.90 (0.84–0.97)), with this difference increasing after adjustment for SES (IRR: 0.85 (0.79–0.92)). For cancers with a weak or nonexistent relationship to SES, adjustment for SES made little difference to the IRR.Conclusion.Socioeconomic factors explain some international variations but also obscure other crucial differences; thus, adjustment for these factors should not become part of international comparisons.