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In studies of cancer survival, Population-Based Cancer Registries PBCRs can provide an overview of the disease for places that have this source of information available. In Brazil, PBCR is officially available in 22 state capitals and 8 cities in the interior of the country.

Five-year survival rate was estimated by the unbiased and consistent net survival estimator, which is used in the country estimates of the global surveillance of cancer survival programme CONCORD Group, for all cases, and also by sex, age group, diagnosis period and place of residence.

The probability of death and the of years of life lost to illness were also estimated. The estimated standardised 5-year survival rate for colorectal cancer was There was no difference between the curves when the survival rate was assessed by diagnostic period — and — , sex, age group or city of residence. The gross 5-year probability of death from the disease was The may reflect late diagnosis, difficult access and delays in starting treatment. Keywords : colorectal cancer, survival analysis, Brazil. Publication costs for this article were supported by e cancer UK Charity Recent data show that cancer incidence and mortality are increasing worldwide [ 1 ].

These measures, along with survival, are common indicators in epidemiology and, when reliable, can provide an overview of the impact of this disease on the geographic region of interest. They can also be used to evaluate disease control strategies [ 2 ]. The efficient and effective planning of cancer control programmes depends on the creation of indicators.

In Brazil, where neoplasms were the second leading cause of death in , second only to diseases of the circulatory system [ 3 ], these indicators are created by using information from Cancer Registries and the Mortality Information System MIS [ 3 , 4 ]. The country has two types of Cancer Registries — the Hospital-Based Registry, which has a mainly clinical role, i.

The Population-Based Registry is found in 22 state capitals and 8 cities in the interior of the country [ 4 ]. Colorectal cancer is a known important disease which may be related to hereditary syndromes or family history [ 5 , 6 ]. However, in most cases, it occurs sporadically and is associated with inappropriate lifestyle and behaviour [ 7 , 8 ].

Increased mortality and incidence of this disease have been observed in Brazil [ 9 — 13 ]. For , the state has an estimated adjusted colorectal cancer incidence rate of Registries such as those that provide data for the CONCORD Programme often obtain information on the cause of death only through death certificates [ 14 ]. Therefore, knowing the cause of death would not be required. Relative survival would be a ratio for the survival seen in the cohort of cancer patients and the expected survival for a comparable group, but without the disease [ 16 ].

The methods that have been generally used to calculate the relative survival rate are Ederer I, Ederer II and Hakulinen. These three methods differ in terms of the time during which the matched individuals are considered at risk to calculate the expected survival rate [ 16 ]. In this method, a hypothetical situation is estimated in which the study disease would be the only possible cause of death. The relevant risk is broken down into risk from the disease and risk from other causes [ 17 ].

Risk breakdown is possible when the times to death from the disease and from any other cause are independent conditions. The survival rate derived from the excess risk is the net survival — an important estimator in comparing populations, as it is independent of the population risk [ 17 ]. Using a unique code in the R software [ 20 ], the database was standardised, i.

The same programmes were used to compare the registry data with those of the identified MIS obtained from the State Health Department of the state of Mato Grosso for — At this stage, potential updates on the death registers were sought so as to estimate the 5-year net survival for all cases included.

The 5-year net survival was calculated for all cases and also by sex, age group, diagnosis period — and — , city of residence and also for the combined information of sex and age group, city and age group. As a preliminary exploratory analysis, the total of cases was used to compare the relative survival methodologies known as Ederer I and Ederer II.

Corazziari et al [ 22 ] also determine that the weight ased to the 15—year-old age group can be safely ased to the 0—year-old age group, since colorectal cancer is among those for which the portion of childhood cancer would be inificant [ 22 ]. The use of a life table from another nearby location with similar characteristics is not expected to have any major impact on the result [ 25 , 26 ]. The relsurv [ 27 ] package of the R software [ 20 ] was used to compare the relative survival and net survival estimation techniques, to apply the chosen methodology and also to estimate the gross probability of death from the study disease and death from other causes, also estimating the of years of life lost to illness.

As for other log-rank tests, this test was only performed when the risks were proportional, as this is where the most reliable are seen [ 28 ]. A ificance level of 0. The original file contained records, but duplicates were found after the deterministic and probabilistic search, with cases remaining. When reviewing these cases, four of them were coded as D These five cases were also excluded, with cases then remaining in the base. Cases identified only through the death check service, corresponding to 60 cases in the relevant base, were also excluded, as the survival time of these patients is not known, and its use might affect the estimates.

Therefore, cases were used for the survival study Figure 1. The description of the main features in the reviewed database for the survival rate study can be seen in absolute s and percentages in Table 1. The comparison of methods using all cases showed that the estimated 5-year net survival was After standardisation by age group, the resulting net survival was When assessing net survival by diagnostic period — — being the first period, and — the second period — despite the numerical difference between point estimates, i.

Figure 1. Figure 2. Table 1. Considering sex, women had a higher survival point estimate of When standardised, the estimated net survival for women was The standardised survival rate was As for the age group, the highest point survival rates were seen in the 45—year-old The lowest survival rates were seen in the oldest age groups of 65—74 years old When stratified by sex and age group, the highest point estimates for the 5-year survival rate were found in the 45—year-old age group, both for women — After 5 years since diagnosis, the probability of death from the study disease was It is possible to see that the gross probability of death from the disease increases initially and becomes more stable over time Figure 4.

The standardised estimated colorectal cancer net survival rate in the study population was This result reflects the need of improvement in the Brazilian health system to achieve similar survival rates. On the other hand, these findings are compatible with what was observed for Brazil in the aforementioned study, with survival estimates of As seen in the CONCORD Group study for Brazil, a potential improvement in the survival rate, even if not statistically ificant, is suggested for the study cities between the first and second study periods — Sex appears to be an independent prognostic predictor in colorectal cancer, with women having a longer survival rate; this could be attributed to genetic, hormonal, immune or environmental factors [ 29 ].

The study consistently indicated a higher net survival rate for women in the point estimate, although this difference was not statistically ificant. In addition to adopting healthy habits — which is up to the individual — in order to reduce the risk of a of pathologies, including colorectal cancer [ 7 , 8 ], health care systems should be able to offer and enable primary prevention by screening for precursor lesion resection polyps , enable early diagnosis, if possible, and also effective treatment.

The relatively low survival rate observed shows that there is a need for improvement in health education and in the screening and treatment system. As for screening, it is known that, if well indicated, it can reduce mortality and increase survival [ 30 ]. There are several types of screening, including colonoscopy, rectosigmoidoscopy and faecal occult blood test. Brazil does not have an organised cancer screening programme. The implementation of population screening was not considered feasible and cost-effective; however, the importance of sending warning s to the population and health care providers was recognised, as well as providing immediate access to diagnostic means when the disease is suspected [ 32 ].

A recent study showed that population screening based on quantitative faecal immunochemical test may be an opportunity in Brazil for early diagnosis [ 33 ], but a major barrier would still be how to deal with increased demand for definitive diagnosis [ 34 ]. The Unified Health System has as principles the universality of access, equal care and equity. Actions should be organised in an integrated, regionalised and hierarchical manner [ 36 ].

Its creation represented an increase in the supply of services, but regional differences, underfunding, changes in the age structure of the population and changes in its health conditions compromise its effectiveness [ 37 ]. Silva et al [ 38 ] showed that the provision of specialised services for cancer is still deficient in the country. The low survival rate in the study region may reflect the difficulty in accessing health services, when existent, due to social, economical, cultural and information barriers.

Figure 3. Figure 4. On the other hand, there was a decrease in physical inactivity in the city. For the consumption of alcoholic beverages, there was a slight increase in the total population from However, the result was due to increased consumption by women, since for men there was a decrease in the intake of alcoholic beverages [ 39 , 40 ]. As for the state of Mato Grosso, there is a high consumption of red meat and a high proportion of adults classified as insufficiently active [ 41 ].

These are risk factors unrelated to survival, but it is important to recognise the profile of the population involved in this study. Other studies involving colon cancer found similar only [ 43 , 44 ]. Specifically for patients with stage III colon cancer, impaired survival was observed in delays longer than 8 weeks after surgery.

Difficulties in the course between surgical treatment and adjuvant treatment, when required, may be associated with the found in this study. In addition, the lowest net survival rate were estimated for patients aged 65—74 This result may be partly related to treatment delays, as well as the administration of less intense treatments than indicated for individuals over 70 years of age [ 45 ], even when there are benefits from the treatment [ 46 ]. This study showed an improvement, albeit not statistically ificant, for the estimated of cases in the second study period — There have been many developments in the field of colorectal cancer treatment in recent years, including the incorporation of new drugs [ 47 , 48 ].

However, it is not possible to say whether there was any influence and how extensive it was in a population-based study [ 43 ]. Regarding the methodology, the use of data from this study to compare three methods Ederer I, Ederer II and net survival showed similar when the observation is made for a short period 5 years , but the Pohar Perme method would be considered an unbiased estimator when censoring is non-informative and the calculation uses continuous time [ 18 ].

Even though there are limitations to the use of PBCR data, such as a lack of detailed information on the therapeutic course, surgical procedure, staging and complementary treatment, these are considered to be key measurements to assess the health care system effectiveness in the management of cancer patients, as it can give an overview that does not depend on age, social condition, comorbidities and stage of the disease at diagnosis [ 49 ]. Relative survival methodologies, and in particular the net survival estimation methodology, were developed precisely for this type of data [ 14 , 16 , 17 ].

Some data, which were incomplete in the studied PBCR, such as education, race, occupation and extent of the disease, if complete, could enrich the analysis and indicate groups that might need more attention. Data such as time between symptoms and diagnosis, time between diagnosis and treatment, laterality, histology, extension, type of treatment, possible complications, associated pathologies could contribute to a better understanding of the , but should be the subject of other studies. In any case, the existence of a PBCR shows an interest in serving the population, since the data produced by the registry can be a source of information for epidemiological studies in an attempt to identify populations at risk and measure the effectiveness of cancer prevention and control programmes [ 4 ].

The development of awareness and warning campaigns about the disease and risk factors can somehow impact the survival rate by determining earlier diagnoses and a consequent increase in survival.

Women sex Juiz de fora

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Net survival for colorectal cancer in Cuiabá and Várzea Grande (state of Mato Grosso), Brazil