European Multidisciplinary Cancer Congress (EMCC) 2011, 23-27 September, Stockholm

Heterogeneity in European cancer treatment standards

Professor David Forman – St James’s Hospital, Leeds, UK


David Forman, thank you very much indeed for telling us a little bit about your talk. You’re giving an overview of cancer in Europe from an IARC Lyons point of view, tell us about it.

At the International Agency for Cancer Research we have responsibility for bringing together the statistics on cancer throughout the world and in this particular context within continental Europe. What I’m going to present at this meeting is an overview of where we are in terms of the position of cancer in Europe and, importantly I think, the quite marked variation that exists within Europe in terms of the burden of the disease in different parts of the continent.

So that’s incidence?

That’s incidence but we also do cover mortality statistics as well and try and look at the overlap, if you like, between incidence and mortality because the two sources of statistics reinforce each other.

So you’re producing league tables or how is this going to be discussed?

Well we look at the pattern, I prefer to call it, rather than a league table of cancer in Europe as a whole, in each individual country within Europe and in regions of Europe. Different countries, different regions give you different patterns and they tell you much about the risk factors for those types of cancer and indeed they often act as a springboard for future research studies.

For instance?

Just to give one example, very few people know that the Czech Republic has got the highest rates of cancer of the kidney, not just in Europe but in the world.

Wow.

And they are something like threefold higher than the average European rates. Now kidney cancer is a relatively under-researched form of the disease in terms of its etiology, why should its etiology be particularly different in the Czech Republic than elsewhere?

And it’s different from what it used to be, Czechoslovakia, the Slovak end?

As far as the figures allow us to tell us, it has been increasing over time. But if you look back now, with this knowledge, at what the figures were like in the past, then it does seem as though this has been a particular European hot spot for kidney cancer for quite some time.

What are the other worrying things, David, that you want to alarm us about?

One worrying feature is the importance, the relative importance, of cervical cancer, particularly in Central and Eastern Europe in comparison to Northern and Western Europe. It’s worrying because we know a lot about how we can prevent this disease and diagnose it in a pre-malignant form, and clearly the prevention story and the screening strategy is not penetrating evenly within Europe. Consequently, there are communities, one example is in Romania, where cervix cancer is only exceeded in women by the instance of breast cancer. Now in most Northern, Western European countries cervix cancer remains of importance but it is usually outside the top five or six cancers amongst women.

That’s reflected by what, economic status in the country or absence of a cancer plan or what?

For whatever reason I think it is most likely due to the ineffective implementation or lack of a fully effective implementation of population- based screening programmes. And by and large the instance figures for cervical cancers are remarkably sensitive to the implementation of screening programmes; in the Nordic countries one can see quite distinctly a downturn in the incidence of this disease subsequent to the introduction of population-based screening.

The politicians use the survival league tables to bandy slang around at one another, do you think this is appropriate?

They do.

Are the survival data reliable enough, because there has been considerable criticism of some of the European studies on survival?

There has indeed. I would defend the use of survival data as another metric alongside instance and mortality and it depends a little on the cancer that you’re talking about and, if you like, the current state of play in terms of where we are in terms of prevention, in terms of treatment and so on, as to what is the most reliable, the most meaningful, indicator of what is happening to the disease.

And where are the worrying signs in Europe in terms of survival data?

Again, I’m not specifically talking about survival at the meeting here.

But you know more about it than I do.

But, by and large, one sees an east-west dichotomy in the data that are available and as you move east in the continent, to some extent, the survival figures get worse but then of course there are specific concerns, the UK has long been concerned about its relative poor standing in survival league tables in comparison with countries in mainland Europe.

Yes, that’s been used as a political football with absolutely no effect, as far as I can see, and not a great deal of improvement, however, that’s a UK issue. Any other European trends? Obviously the aging trend is a big concern and the burden of care is going to have to be created.

Absolutely and one of the sets of figures that I will present at the meeting looks at what is going to happen to the overall burden of cancer in Europe just as a result of the demographic shifts that are happening in the population: population is expanding and, more importantly, it’s getting older. There is a cancer burden, a cancer price that is paid for that unless one can develop more effective prevention strategies and more effective screening implementation for those cancers that are susceptible to it.

I will make one specific comment which concerns me a great deal and that is what is happening in terms of lung cancer rates in young women in many European countries.

Spain, Portugal…

Well the country where the international agency is based, in France, shows rather depressing figures in terms of what’s happening to lung cancer trends in women under the age of 50. And, indeed, one can see quite visibly on the streets the lack of awareness of the damage that can be caused by cigarette smoking and you do see it particularly amongst women now rather than men.

I think that we’re not as good at communicating that risk as the tobacco companies are in targeting that very susceptible group of women. They’ve given up on advertising to men, I think, and they’re outsmarting us and outperforming us, outpointing us all the way, David, and I really do believe that we’d better give ourselves a very big shake. It is, as you say, absolutely awful to see these young women strutting around with cigarettes in their mouths.

No, that’s absolutely true but, at the same time, and the lung cancer figures in young women do tell you this, there’s heterogeneity, it’s not an even pattern in different European countries.

It isn’t, no.

And there are obviously places which are doing a lot worse and places which are doing somewhat better in getting that health prevention message out there.

David Forman, thank you very much indeed, I really appreciate you giving us ten minutes.

It’s a pleasure.