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Introduction For stage III colon cancer (CC), surgery followed by chemotherapy is the main curative approach, although optimum times between diagnosis and surgery, and surgery and chemotherapy, have not been established. Materials and methods We analysed a population-based sample of 1912 stage III CC cases diagnosed in eight European countries in 2009–2013 aiming to estimate: (i) odds of receiving postoperative chemotherapy, overall and within eight weeks of surgery; (ii) risks of death/relapse, according to treatment, Charlson Comorbidity Index, time from diagnosis to surgery for emergency and elective cases, and time from surgery to chemotherapy; and (iii) time-trends in chemotherapy use. Results Overall, 97% of cases received surgery and 65% postoperative chemotherapy, with 71% of these receiving chemotherapy within eight weeks of surgery. Risks of death and relapse were higher for cases starting chemotherapy with delay, but better than for cases not given chemotherapy. Fewer patients with high comorbidities received chemotherapy than those with low (P

List of ACCIS contributors = Monika Hackl, Anna Zborovskaya, Nadya Dimitrova, Zdravka Valerianova, Ladislav Dušek, Margit Mägi, Alain Monnereau, Jacqueline Clavel, Michel Velten, Anne-Valérie Guizard, Véronique Bouvier, Xavier Troussard, Anne-Sophie Woronoff, Emilie Marrer, Brigitte Trétarre, Marc Colonna, Olivier Ganry, Pascale Grosclaude, Berndt Holleczek, Zsuzsanna Jakab, Laufey Tryggvadóttir, Lucia Mangone, Franco Merletti, Stefano Ferretti, Bianca Caruso, Maria Michiara, Rosario Tumino, Fabio Falcini, Roberto Zanetti, Giovanna Tagliabue, Otto Visser, Giske Ursin, Ryszard Mężyk, Kamila Kepska, José Laranja Pontes, Maja Primic Žakelj, Rafael Fernández-Delgado, Marisa L Vicente Raneda, Enrique Almar Marqués, José Ramón Quirós Garcia, Arantza Lopez de Munain, Rafael Marcos-Gragera, Maria-Jose Sanchez-Perez, Maria Ramos Monserrat, Eva Ardanaz, Jaume Galceran, Staffan Khan, Claudia E Kuehni Christine Bouchardy, Fabio Levi, Isabelle Konzelmann, Sabine Rohrmann Sally Vernon, David H Brewster, Ceri White, Anastasia Dolya Background A deceleration in the increase in cancer incidence in children and adolescents has been reported in several national and regional studies in Europe. Based on a large database representing 1∙3 billion person-years over the period 1991–2010, we provide a consolidated report on cancer incidence trends at ages 0–19 years. Methods We invited all population-based cancer registries operating in European countries to participate in this population-based registry study. We requested a listing of individual records of cancer cases, including sex, age, date of birth, date of cancer diagnosis, tumour sequence number, primary site, morphology, behaviour, and the most valid basis of diagnosis. We also requested population counts in each calendar year by sex and age for the registration area, from official national sources, and specific information about the covered area and registration practices. An eligible registry could become a contributor if it provided quality data for all complete calendar years in the period 1991–2010. Incidence rates and the average annual percentage change with 95% CIs were reported for all cancers and major diagnostic groups, by region and overall, separately for children (age 0–14 years) and adolescents (age 15–19 years). We examined and quantified the stability of the trends with joinpoint analyses. Findings For the years 1991–2010, 53 registries in 19 countries contributed a total of 180335 unique cases. We excluded 15162 (8·4%) of 180335 cases due to differing practices of registration, and considered the quality indicators for the 165173 cases included to be satisfactory. The average annual age-standardised incidence was 137∙5 (95% CI 136∙7–138∙3) per million person-years and incidence increased significantly by 0∙54% (0∙44–0∙65) per year in children (age 0–14 years) with no change in trend. In adolescents, the combined European incidence was 176∙2 (174∙4–178∙0) per million person-years based on all 35138 eligible cases and increased significantly by 0·96% (0∙73–1∙19) per year, although recent changes in rates among adolescents suggest a deceleration in this increasing trend. We observed temporal variations in trends by age group, geographical region, and diagnostic group. The combined age-standardised incidence of leukaemia based on 48458 cases in children was 46∙9 (46∙5–47∙3) per million person-years and increased significantly by 0∙66% (0∙48–0∙84) per year. The average overall incidence of leukaemia in adolescents was 23∙6 (22∙9–24∙3) per million person-years, based on 4702 cases, and the average annual change was 0∙93% (0∙49–1∙37). We also observed increasing incidence of lymphoma in adolescents (average annual change 1·04% [0·65–1·44], malignant CNS tumours in children (average annual change 0·49% [0·20–0·77]), and other tumours in both children (average annual change 0·56 [0·40–0·72]) and adolescents (average annual change 1∙17 [0∙82–1∙53]). Interpretation Improvements in the diagnosis and registration of cancers over time could partly explain the observed increase in incidence, although some changes in underlying putative risk factors cannot be excluded. Cancer incidence trends in this young population require continued monitoring at an international level. Funding Federal Ministry of Health of the Federal German Government, the European Union’s Seventh Framework Programme, and International Agency for Research on Cancer

Background: Rare cancers pose challenges for diagnosis, treatments, and clinical decision making. Information about rare cancers is scant. The RARECARE project defined rare cancers as those with an annual incidence of less than six per 100 000 people in European Union (EU). We updated the estimates of the burden of rare cancers in Europe, their time trends in incidence and survival, and provide information about centralisation of treatments in seven European countries. Methods: We analysed data from 94 cancer registries for more than 2 million rare cancer diagnoses, to estimate European incidence and survival in 2000–07 and the corresponding time trends during 1995–2007. Incidence was calculated as the number of new cases divided by the corresponding total person-years in the population. 5-year relative survival was calculated by the Ederer-2 method. Seven registries (Belgium, Bulgaria, Finland, Ireland, the Netherlands, Slovenia, and the Navarra region in Spain) provided additional data for hospitals treating about 220 000 cases diagnosed in 2000–07. We also calculated hospital volume admission as the number of treatments provided by each hospital rare cancer group sharing the same referral pattern. Findings: Rare cancers accounted for 24% of all cancers diagnosed in the EU during 2000–07. The overall incidence rose annually by 0.5% (99·8% CI 0·3–0·8). 5-year relative survival for all rare cancers was 48·5% (95% CI 48·4 to 48·6), compared with 63·4% (95% CI 63·3 to 63·4) for all common cancers. 5-year relative survival increased (overall 2·9%, 95% CI 2·7 to 3·2), from 1999–2001 to 2007–09, and for most rare cancers, with the largest increases for haematological tumours and sarcomas. The amount of centralisation of rare cancer treatment varied widely between cancers and between countries. The Netherlands and Slovenia had the highest treatment volumes. Interpretation: Our study benefits from the largest pool of population-based registries to estimate incidence and survival of about 200 rare cancers. Incidence trends can be explained by changes in known risk factors, improved diagnosis, and registration problems. Survival could be improved by early diagnosis, new treatments, and improved case management. The centralisation of treatment could be improved in the seven European countries we studied., peer-reviewed

In most developed countries, incidence of cervical cancer declined likely due to well-established cervical cancer screening programs. However, such decline has not been identified in Eastern Europe, where such programs are not well established.This study utilized data of the Bulgarian Cancer Registry for the period 1993-2013. Age-standardized incidence and mortality trends were analyzed using Joinpoint regression. Maps were created to illustrate spatial distributions of rates.The northern region of Bulgaria showed a larger cervical cancer burden than the southern region and rural women tended to be diagnosed at older ages (p0.0001) and later stages (p0.0001) than urban women. The distribution of disease stages changed over the 21 years, with most common stages of diagnosis being stage II in 1993 (39.2%) to stage I in 2013 (44.7%; p0.0001). While age-standardized mortality slightly increased over the 21 years (from 4.8 to 5.2 per 100,000; p=0.009), age-standardized incidence increased from 14.0 to 21.4 per 100,000 up until 2006 (p0.001), after which it plateaued.The lack of a similar plateau in mortality may be because the second most prevalent stage of diagnosis in recent years was stage III, indicating diagnosis at advanced symptomatic stages. Cervical cancer incidence is expected to continue to decrease if screening programs are strengthened and human papillomavirus vaccines are widely utilized. As Bulgaria has shared cervical cancer trends with other Eastern European countries in the past, it may be beneficial to develop future prevention interventions based on a regional, rather than a country-specific level.

The burden of cervical cancer varies considerably in the European Union (EU). In this article, we describe trends in incidence of and mortality from this cancer in the two most affected areas: the Baltic countries (Estonia, Latvia and Lithuania) and Southeast Europe (Bulgaria and Romania). Incidence data were obtained from the national cancer registries. Data on population and number of deaths from uterine cancers were extracted from the World Health Organization mortality database. Mortality rates were corrected for inaccuracies in the death certification of not otherwise specified uterine cancer. Joinpoint regression was used to study the annual variation of corrected and standardized incidence and mortality rates. Changes were assessed by calendar period and age group, whereas the evolution by birth cohort was synthesized by computing standardized cohort incidence/mortality ratios. Joinpoint regression revealed rising trends of incidence (in Lithuania, Bulgaria and Romania) and of mortality (in Latvia, Lithuania, Bulgaria and Romania). In Estonia, rates were rather stable. Women born between 1940 and 1960 were at continuously increasing risk of both incidence of and mortality from cervical cancer. Although some quality issues in the registration of cancer and causes of death cannot be ignored, the trends indicate increased exposure to human papillomavirus infection and absence of effective screening programs. Rising trends of cervical cancer in the most affected EU member states reveal a worrying pattern that warrants urgent preventive actions.

The aim of the study was to compare current policy, Organisation and coverage of cervical cancer screening programmes in the European Union (EU) member states with European and other international recommendations. According to the questionnaire-based survey, there are large variations in cervical cancer screening policies and inadequacies in the key organisational elements of the programme such as registration and monitoring required for quality-assurance and fail-safe mechanisms. Based on data from available screening registers, coverage of the screening test taken within the population-based programme was below 80% in all programmes, ranging from 10% to 79%. The screening capacity is satisfactory in most EU member states, however, and there is even over-capacity in several countries. There are also countries which do not have an acceptable capacity yet. Control of proper capacity along with education, training and communication among women, medical professionals and authorities are required, accordingly The study indicates that, despite substantial efforts, the recommendations of the Council of the EU on organised population-based screening for cervical cancer are not yet fulfilled. Decision-makers and health service providers should consider stronger measures or incentives in order to improve cervical cancer control in Europe. (C) 2009 Elsevier Ltd. All rights reserved.

BACKGROUND Bulgaria has undergone considerable social changes in the last 40 years, including a transition from a 75% rural to a 75% urban population. These changes might be expected to be reflected in disease rates. The Bulgarian cancer registry has computerized data on cancer incidence throughout the country from 1981 onwards. METHODS Incidence rates in Bulgaria from 1981 to 1990 of cancers of the lung, stomach, large bowel, prostate and bladder in males and of cancers of the breast, lung, stomach, large bowel, cervix and corpus uteri in females were analysed with particular attention to time trends, age-specific changes in rates and urban/rural differences. Poisson regression was used for statistical analysis. RESULTS Male rates of cancers of the lung, large bowel, prostate and bladder increased significantly over the period, with average annual increases of 0.4%, 2.9%, 1.3% and 2.3% respectively. In females, rates of cancers of the breast, cervix and corpus uteri increased significantly, with average annual increases of 1.3%, 1.9%, and 2.9%. In both sexes, stomach cancer incidence declined significantly, by 3.0% per year for males and 3.6% per year for females. Rural rates were lower than urban rates for most cancers, particularly in the higher age groups. The decline in male stomach cancer rates was confined to rural areas. The increases in rates of lung cancer and prostate cancer in males and of colorectal cancer and breast cancer in females were most rapid in urban areas. CONCLUSIONS Substantial changes in rates of various cancers have taken place from 1981 to 1990, in particular increases in rates of breast cancer and large bowel cancer in women resident in urban areas. It is suggested that dietary changes may be responsible for some of these changes.

Background In Bulgaria the previously (1970–1985) existing population based cervical cancer screening was replaced in the early 1990s with an opportunistic model due to political and socioeconomic reasons. As a result, in the last 20 years, cervical cancer incidence and mortality rates steady increased. The objective of the EUROCHIP project in Bulgaria was to evaluate the readiness of the health system as well as health providers' attitudes to implementation in the country of a population based screening program for cervical cancer. Methods Using a structured questionnaire, a convenience sample of medical specialists representing different actors involved in cervical cancer prevention, treatment, financing and policy were interviewed. Results The majority of interviewed practitioners worried that organization and implementation of an effective population-based cervical cancer screening program is not possible in the current unstable health system. A nostalgic attitude to the cervical cancer screening, performed in the past and pessimistic view on the capability of the current health system to cope are strong. As main barriers to implementation of an effective program were pointed financial and organizational ones. Motivation for gynecologists to perform smear test should include better information, organization and payment. Discussion Medical specialists in Bulgaria are aware of the alarming rates of cervical cancer incidence and mortality in the country. However, due to the insufficient communication and interaction between policy makers and front-line health care staff, they do not have enough information on the ongoing programs. Absence of health policy regarding screening is considered as main barrier for implementation of an effective screening program.

Objective The burden of cervical cancer varies considerably in the European Union. In this paper, we describe trends in incidence of and mortality from this cancer in the five most affected member states. Methods Data on number of deaths from uterine cancers and the size of the female population of Estonia, Latvia, Lithuania, Bulgaria and Romania were extracted from the WHO mortality database. Mortality rates were corrected for inaccuracies in the death certification of not otherwise specified uterine cancer. Incidence data were obtained from the national cancer registries. Joinpoint regression was used to study the annual variation of corrected and standardized incidence and mortality rates. Changes by birth cohort were assessed for specific age groups and subsequently synthesized by computing standardized cohort incidence/mortality ratios. Results Joinpoint regression revealed rising trends of incidence (in Lithuania, Bulgaria and Romania) and of mortality (in Latvia, Lithuania, Bulgaria and Romania). In Estonia, rates were rather stable. Women born between 1940 and 1960 were at continuously increasing risk of both incidence of and mortality from cervical cancer. Conclusions Rising trends of cervical cancer in the most affected EU member states reveal a worrying pattern that warrants urgent introduction of effective preventive actions as described in the European guidelines.

qualityscreeningprogramsforcervicalcancercanbeplannedandimplemented. Itis essential to reach high level of information about screening and acceptance of it ‐ both in the population , among medical professions, and decision-makers ‐ and ad herencetostrictquality-assuredprotocols.Alsocontinuousmonitoringandscientif ic evaluation of the activity showing the benefits and potential harms is an integral part of the activity . Within the Health Information framework of the European Commission, the EUROCHIP project performed a number of descriptive studies on cancer indicators in order to identify specific cancer control priorities and problems in various Euro pean countries 5 . The current reports , referring to cervical cancer screening in the Eastern European member states with highest burden of cervical cancer in the EU (i.e. Bulgaria, Estonia, Lithuania, Latvia and Romania ) 6,7 , show unanimously that screening does not yet work well across the EU 8-11 . It emerges that among the gener al public, but also among the professionals as well as decision makers, information on what is screening and on what principles it is based on, is yet not good enough to trigger adequate participation (in the case of the public), adequate collaboration (in thecaseofprofessionals)andnecessarychangesoflegislation(inthecaseofdecision makers).Very low compliance to population-based screening as documented in the reports , included in this issue ofTumori, is one consequence. One important conse quenceofinsufficientawarenessisverylowcompliancetopopulation-basedscreen ing,asdocumentedinthereportsincludedinthisissueofTumori.Itislikely thatthis has also impact on the validity and quality assurance of the screening programs, which are not consistent everywhere.