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We analysed 1.6 million population-based EUROCARE-4 cancer cases (26 cancer sites, excluding sex-specific sites, and breast) from 23 countries to investigate the role of sex in cancer survival according to age at diagnosis, site, and European region. For 15 sites (salivary glands, head and neck, oesophagus, stomach, colon and rectum, pancreas, lung, pleura, bone, melanoma of skin, kidney, brain, thyroid, Hodgkin disease and non-Hodgkin's lymphoma) age- and region-adjusted relative survival was significantly higher in women than men. By multivariable analysis, women had significantly lower relative excess risk (RER) of death for the sites listed above plus multiple myeloma. Women significantly had higher RER of death for biliary tract, bladder and leukaemia. For all cancers combined women had a significant 5% lower RER of death. Age at diagnosis was the main determinant of the women's advantage, which, however, decreased with increasing age, becoming negligible in the elderly, suggesting that sex hormone patterns may have a role in women's superior ability to cope with cancer. (C) 2008 Elsevier Ltd. All rights reserved.

BACKGROUND: EUROCARE-3 collected data from 45 population-based cancer registries in 20 countries on 24 620 European children aged from 0 to 14 years diagnosed with malignancy in the period 1990-1994. METHODS: Five-year survival between countries was compared for all malignancies and for the major diagnostic categories, adjusting for age, and estimated average European survival weighting for differences in childhood populations. RESULTS: For all cancers combined, survival variation was large (45% in Estonia to 90% in Iceland), and was generally low (60-70%) in eastern Europe and high (> or =75%) in Switzerland, Germany and the Nordic countries (except Denmark). The Nordic countries had the highest survival for four of the seven major tumour types: nephroblastoma (92%), acute lymphoid leukaemia (85%), CNS tumours (73%) and acute non-lymphocytic leukaemia (62%). The eastern countries had lowest survival: 89% for Hodgkin's disease, 71% for nephroblastoma, 68% for acute lymphoid leukaemia, 61% for non-Hodgkin's lymphoma, 57% for central nervous system (CNS) tumours and 29% for acute non-lymphocytic leukaemia. CONCLUSIONS: The Nordic countries represent a survival gold standard to which other countries can aspire. Since most childhood cancers respond well to treatment, survival differences are attributable to differences in access (including referral and timely diagnosis) and use of modern treatments; however, the obstacles to access and application of standard treatments probably vary markedly with country.

EUROCARE-3 analysed the survival of 1815584 adult cancer patients diagnosed from 1990 to 1994 in 22 European countries. The results are reported in tables, one per cancer site, coded according to the International Classification of Diseases (ICD)-9 classification. The main findings of the tables are summarised and commented on in this article. For most solid cancers, wide differences in survival between different European populations were found, as also reported by EUROCARE-1 and EUROCARE-2, despite a remarkable (10%) overall increase in cancer survival from 1985 to 1994. Survival was highest in northern Europe (Sweden, Norway, Finland and Iceland), and fairly good in central-southern Europe (France, Switzerland, Austria and Spain). Survival was particularly low in eastern Europe, low in Denmark and the UK, and fairly low in Portugal and Malta. The mix of tumour stage at diagnosis explains much of the survival differences for cancers of the digestive tract, female reproductive system, breast, thyroid, and also skin melanoma. For tumours of the urinary tract and prostate, the differences were explained mainly by differences in diagnostic criteria and procedures. The case mix by anatomic subsite largely explains differences in survival for head and neck cancers. For oesophagus, pancreas, liver and brain cancer, with poor prognoses, survival differences were limited. Tumours, for which highly effective treatments are available, such as testicular cancer, Hodgkin's lymphoma and some haematological malignancies, had fairly uniform survival across Europe. Survival for all tumours combined (an indicator of the overall cancer care performance of a nation's health system) was better in young than old patients, and better in women than men. The affluence of countries influenced overall cancer survival through the availability of adequate diagnostic and treatment procedures, and screening programmes.

Summary International differences and trends in cancer survival withinEurope are larger than can reasonably be accounted for by arte-fact, bias or chance. The geographical patterns and trends in sur-vival are often broadly consistent with geographical differences ortrends in the type of cancer, diagnostic investigations or overallinvestment in health care, and for several major cancers, support-ing evidence is available from population-based studies of clinicalinformation. Incomplete ascertainment of cancer cases, particu-larly of long-term survivors, may contribute to some regional andinternational differences in survival, however, and more system-atic information on completeness is required. We may concludethat large international differences in survival do exist for manycancers, but we should be cautious in drawing quantitative orcausal conclusions from observational survival data.We do not yet have a fully satisfactory interpretation of thesedifferences, but we have few alternatives to this type of study if weare to understand the determinants of improved outcome for allcancer patients, and to enable better planning of their health care.The EUROCARE Working Group has developed several strategiesto disentangle the various possible explanations [73]. These includefurther development of high-resolution studies to examine theimpact on survival differences of disease stage, staging techniquesand treatment; and further development of mathematical modelsof cure. Extension of systematic international survival compari-sons to other regions of the world, such as Australia, Canada, Japanand the USA, is also in progress (the CONCORD study) [22].Oncologists and epidemiologists may provide insight into thegeographic differences and trends in survival reported by thisstudy, and may suggest further lines of enquiry. Do we need morerefined studies of survival to monitor progress against cancer andto plan future cancer care? Will such analyses help us quantify theeffect of new treatments arising from recent progress in the basicsciences and genomics on population cancer survival rates? Sub-stantial human and financial resources are required to improve theoutcome of cancer treatment. Will future investments in cancerservices include matching investment to monitor their impact onsurvival and mortality?Earlier diagnosis and prompt, universal access to optimal treat-ment would be expected to reduce international differences incancer survival in Europe. To achieve this, oncologists and healthcare planners will need better information on the comparativeperformance of their health systems. Population-based cancer reg-istries provide some of the information for such comparisons, buttheir traditional output may no longer be sufficient to evaluate theeffectiveness of health systems, and especially to explain geo-graphical differences in survival. In some countries, their role isalso under threat. Confidentiality constraints recently inhibitedthe collection of cancer registration data in the UK [90], and thelinkage of cancer registrations and deaths is currently illegal inEstonia [91]. Both activities are essential for internationally com-parable survival rates. Legal protection for cancer registrationacross Europe will be required.The mission of cancer registries should be reconsidered, and thepriority shifted from classical descriptive epidemiology and geo-graphical pathology toward more analytical monitoring ofprogress against cancer, including the probability of survival andcure, the burden of cancer prevalence, and the late effects oftherapy. Several European studies of this type have been reportedrecently [3, 36, 9294] and others are in progress. Many cancer–registries are developing closer relationships with cancer clini-cians and general practitioners, and some now systematicallycollect detailed clinical information that was collected eitherirregularly or not at all in the past. These developments willimprove the power of population-based cancer data to explain dif-ferences in cancer survival, and should enhance their relevance toclinical practice.European average survival rates are useful for comparativepurposes, but they should not become the goal for cancer controlprogrammes: the benchmark should always be the highest achiev-able survival rates.The aim of exploring geographic differences in cancer survivalis not to establish international league tables or to excite nationalrivalries, but to estimate the range of survival rates, and to identifyregions or countries in which survival could be improved.