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Colorectal cancer survival in the USA and Europe: a CONCORD high-resolution study
  1. Claudia Allemani1,
  2. Bernard Rachet1,
  3. Hannah K Weir2,
  4. Lisa C Richardson2,
  5. Côme Lepage3,
  6. Jean Faivre3,
  7. Gemma Gatta4,
  8. Riccardo Capocaccia5,
  9. Milena Sant6,
  10. Paolo Baili6,
  11. Claudio Lombardo7,
  12. Tiiu Aareleid8,
  13. Eva Ardanaz9,10,
  14. Magdalena Bielska-Lasota11,
  15. Susan Bolick12,
  16. Rosemary Cress13,
  17. Marloes Elferink14,
  18. John P Fulton15,
  19. Jaume Galceran16,
  20. Stanisław Góźdź17,18,
  21. Timo Hakulinen19,
  22. Maja Primic-Žakelj20,
  23. Jadwiga Rachtan21,
  24. Chakameh Safaei Diba22,
  25. Maria-José Sánchez23,24,
  26. Maria J Schymura25,
  27. Tiefu Shen26,
  28. Giovanna Tagliabue27,
  29. Rosario Tumino28,
  30. Marina Vercelli29,30,
  31. Holly J Wolf31,
  32. Xiao-Cheng Wu32,
  33. Michel P Coleman1
  1. 1Cancer Research UK Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  3. 3Côte-d'Or Digestive Cancer Registry, Faculté de Médecine, Dijon Cédex, France
  4. 4Evaluative Epidemiology Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  5. 5National Center of Epidemiology, Surveillance and Promotion of Health, National Institute of Health, Rome, Italy
  6. 6Descriptive Studies and Health Planning Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  7. 7Alleanza Contro il Cancro, Rome, Italy
  8. 8Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
  9. 9Navarra Cancer Registry, Navarra Public Health Institute, Navarra, Spain
  10. 10CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
  11. 11National Institute of Public Health, National Institute of Hygiene, Warszawa, Poland
  12. 12SC Department of Health and Environmental Control, South Carolina Central Cancer Registry, Office of Public Health Statistics and Information Systems, Columbia, South Carolina, USA
  13. 13Public Health Institute, Cancer Registry of Greater California, Sacramento, California, USA
  14. 14Comprehensive Cancer Centre the Netherlands, Utrecht, The Netherlands
  15. 15Rhode Island Department of Health, Rhode Island Cancer Registry, Providence, Rhode Island, USA
  16. 16Tarragona Cancer Registry, Foundation Society for Cancer Research and Prevention, Pere Virgili Health Research Institute, Tarragona, Spain
  17. 17Świętokrzyskie Centrum Onkologii (Holycross Cancer Centre), Kielce, Poland
  18. 18Faculty of Health Sciences, Jan Kochanowski University of Humanities and Sciences in Kielce, Kielce, Poland
  19. 19Finnish Cancer Registry, Helsinki, Finland
  20. 20Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
  21. 21Cracow Cancer Registry, Centre of Oncology, M Skłodowska-Curie Memorial Cancer Institute, Krakow, Poland
  22. 22National Cancer Registry of Slovakia, National Health Information Center, Bratislava, Slovakia
  23. 23Andalusian School of Public Health, Granada, Spain
  24. 24CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  25. 25New York State Department of Health, New York State Cancer Registry, Albany, New York, USA
  26. 26Illinois Department of Public Health, Illinois State Cancer Registry, Springfield, Illinois, USA
  27. 27Cancer Registry and Environmental Epidemiology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  28. 28Cancer Registry and Histopathology Unit, Civile-MP Arezzo Hospital, ASP Ragusa, Ragusa, Italy
  29. 29UOS Epidemiologia Descrittiva, USM-IST (IRCCS Azienda Ospedaliera Universitaria San Martino—IST Istituto Nazionale per la Ricerca sul Cancro), Largo R Benzi, Genova, Italy
  30. 30Sez. Epidemiologia Descrittiva, Dipartimento di Scienze della Salute, Università di Genova, Genova, Italy
  31. 31Cancer Prevention and Control Division, University of Colorado Cancer Center, Colorado School of Public Health, Aurora, Colorado, USA
  32. 32Louisiana Tumor Registry, LSU Health Sciences Center School of Public Health, New Orleans, Louisiana, USA
  1. Correspondence to Dr Claudia Allemani; claudia.allemani{at}


Objectives To assess the extent to which stage at diagnosis and adherence to treatment guidelines may explain the persistent differences in colorectal cancer survival between the USA and Europe.

Design A high-resolution study using detailed clinical data on Dukes’ stage, diagnostic procedures, treatment and follow-up, collected directly from medical records by trained abstractors under a single protocol, with standardised quality control and central statistical analysis.

Setting and participants 21 population-based registries in seven US states and nine European countries provided data for random samples comprising 12 523 adults (15–99 years) diagnosed with colorectal cancer during 1996–1998.

Outcome measures Logistic regression models were used to compare adherence to ‘standard care’ in the USA and Europe. Net survival and excess risk of death were estimated with flexible parametric models.

Results The proportion of Dukes’ A and B tumours was similar in the USA and Europe, while that of Dukes’ C was more frequent in the USA (38% vs 21%) and of Dukes’ D more frequent in Europe (22% vs 10%). Resection with curative intent was more frequent in the USA (85% vs 75%). Elderly patients (75–99 years) were 70–90% less likely to receive radiotherapy and chemotherapy. Age-standardised 5-year net survival was similar in the USA (58%) and Northern and Western Europe (54–56%) and lowest in Eastern Europe (42%). The mean excess hazard up to 5 years after diagnosis was highest in Eastern Europe, especially among elderly patients and those with Dukes’ D tumours.

Conclusions The wide differences in colorectal cancer survival between Europe and the USA in the late 1990s are probably attributable to earlier stage and more extensive use of surgery and adjuvant treatment in the USA.

Elderly patients with colorectal cancer received surgery, chemotherapy or radiotherapy less often than younger patients, despite evidence that they could also have benefited.

  • Epidemiology
  • Public Health
  • Statistics & Research Methods

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