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Introduction Lung cancer is the most common cause of cancer-related death in the United States (US). Tobacco smoking is a well-recognized cause of lung cancer. About 2% of the United States (US) population lives in Tennessee (TN). Nearly 21 % of TN adults are current smokers as per 2019 data, compared to 14% across the US. The percentage of smokers has historically been high in TN and its surroundings. This can be attributed to the area's socio-economic and cultural characteristics, along with large areas of tobacco farming in the region. This increases the risk of lung cancer in the TN population. Surveillance Epidemiology and End Results Program (SEER) is a collection of cancer registries across the US, covering about 35% of the US population (TN cancer registry is not a part of SEER). Our study compares lung cancer incidence and characteristics in the TN cancer registry with the SEER 18 registry. Materials and Methods Data were collected from the TN cancer registry and SEER separately for lung and bronchial cancer. Data was analyzed for different histological subtypes, age groups, gender, stage at diagnosis, and rural/urban residence. Stata and Microsoft Excel were used in data analysis. A Chi-square test was used to calculate the statistical significance. Results From 2008 to 2017, 58644 cases of lung cancer were reported in the Tennessee cancer registry. During the same period, 519112 cases were reported in the SEER registry. The most frequent histological subtype of lung cancer in TN and SEER was adenocarcinoma (frequency of 17,503 Vs. 182346), followed by squamous cell carcinoma and small cell carcinoma. Most cancers in TN and SEER were diagnosed at stage of distant metastasis (46% vs. 52% ), followed by regional metastasis, localized, and in situ (Image1). The frequency of lung cancer diagnosis was high among those older than 65 in TN and SEER (64% vs. 69%). Males had a higher incidence of lung cancer in both registries. Most lung cancers were reported in the urban area in both registries. Chronic obstructive pulmonary disease was the most commonly reported secondary diagnosis (3,099), followed by pleural effusion in the TN database; the comparable data were not available in SEER. Relative survival at 12 months and five years for lung cancer in TN were 46.6 % and 19.5 % (Vs. 46.4% and 19.9% in SEER) Discussion and Conclusion If both registries were perfect, then lung and bronchial cancer incidence will be 9241 and 6048 per million in ten years in TN and SEER, respectively. But after careful analysis, we conclude that such analysis will be erroneous. The proportion of different histological types, stage at diagnosis, age groups, and gender were in the same order in both groups. Although chi-square test values are significant for all the variables, we infer no conclusion considering the data's inherent bias. Further in-depth analysis of the data is required.

Registros de Câncer são sistemas padronizados, flexíveis e multicêntricos para coleta de dados de pacientes com neoplasias, permitindo a obtenção de dados epidemiológicos de alta qualidade a um baixo custo. Eles podem ser de base populacional, abrangendo todos os casos de uma área geográfica delimitada, possibilitando calcular sua incidência e sobrevida, quanto de base hospitalar, coletando dados sobre o paciente para uso em pesquisa, educação continuada e melhoria dos atendimentos. Essas abordagens, na Medicina Veterinária, tiveram início na década de 60 com o Kansas Animal Tumor Registry (1961) e com o California Animal Tumor Registry (1963). Desde então, outras iniciativas similares surgiram nos Estados Unidos, Canadá, Noruega, Dinamarca, Suécia e Reino Unido. Esses registros, concentrados no Hemisfério Norte, não existem ainda na América Latina. Este trabalho teve como objetivo avaliar a viabilidade de implantação de um Registro de Câncer Animal na cidade de São Paulo, SP, Brasil. Elaborou-se um registro piloto para permitir entender a sua viabilidade em larga escala quanto Sistema de Informação em Saúde. Foram desenvolvidos identidade, logotipo, formulários de admissão e seguimento, e um software especializado, o SIRCA-SP, para o funcionamento do Registro de Câncer Animal de São Paulo (RCA-SP). O fluxo de informação foi planejado para que a coleta pudesse ser realizada de forma multicêntrica, padronizada e sigilosa. A análise preliminar dos dados permite entender as características da distribuição local do câncer e o potencial do RCA-SP. O estudo de viabilidade foi realizado através de parâmetros definidos pelo Center for Diseases Control, Atlanta, EUA. O RCA-SP foi criado, em 2013, como um registro de base hospitalar que coleta informações sobre cães e gatos diagnosticados com câncer a partir de janeiro de 2012 em hospitais, clínicas e serviços autônomos veterinários sediados na cidade de São Paulo. O software SIRCA-SP foi desenvolvido para otimizar e garantir a qualidade dos dados coletados, consolidados e armazenados pelo RCA-SP. O sistema possui interface amigável e pode ser acessado via internet. Os formulários foram padronizados e geram dados comparáveis aos outros Registros de Câncer em animais e humanos. Avaliação preliminar dos dados demonstra predomínio, nos 645 casos registrados de cães (96,58%) e de fêmeas (80,15%). As localizações de câncer mais comuns foram em glândula mamária (63,88%), pele (17,98%) e em órgãos genitais (5,43%). O sistema demonstrou ser simples, flexível, bem aceito, oportuno e útil. A sua representatividade, por ser projeto piloto, é pequena, mas tenderá a aumentar com adesão de novas fontes notificadoras. O sistema não possui mecanismos de garantia de sua exaustividade. Algumas soluções como o sistema de pré-verificação de inclusão, projetado para evitar entrada duplicada de dados, e a integração entre prontuário eletrônico e os campos de interesse epidemiológico auxiliam na distribuição de responsabilidades do registro aos usuários e, consequente, diminuição de custos operacionais. A implantação de um Registro de Câncer Animal na cidade de São Paulo mostrou-se viável e a coleta multicêntrica é realizada de forma contínua e ininterrupta / Cancer Registries are flexible, multicentric and standardized systems to collect data from patients with neoplasia, allowing the epidemiological registry of high quality data, at low cost. They can be classified as population-based, covering all cases in a defined geographical area, allowing incidence and survival calculation, or, hospital-based, collecting data about the patient for research, continuing education and improvement of care. Those approaches started in Veterinary Medicine in the 60’s, with the Kansas Animal Tumor Registry (1961) and the California Animal Tumor Registry (1963). Since then, other similar initiatives have emerged in United States, Canada, Norway, Denmark, Sweden, Italy and United Kingdom. Those registries, concentrated in North Hemisphere, were absent in Latin America up to now. This study aimed to assess the feasibility of implementing an Animal Cancer Registry in Sao Paulo, SP, Brazil. A pilot cancer registry system was developed to allow understanding its feasibility, in large scale, as a Health Information System. An identity, logo, admission and follow-up forms were developed, and a specialized software, the SIRCA-SP, for Sao Paulo Animal Cancer Registry (RCA-SP) operation was standardized. An information flow was planned, so that the collection could be performed in a multicentric, standardized and confidential way. Preliminary analysis of the data allowed the understanding of local cancer distribution characteristics and the RCA-SP potential. The feasibility study was perform using parameters defined by the Centers for Disease Control, Atlanta, USA. The RCA-SP, created in 2013, is a hospital-based cancer registry, which collects information about dogs and cats diagnosed with cancer since January 2012 in hospitals, clinics and veterinary autonomous services in Sao Paulo, SP, Brazil. The SIRCA-SP was designed to optimize and ensure the quality of data collection, consolidation and storing by RCA-SP. The system has a friendly interface and can be access via Internet. The forms were standardized and generate data comparable to other cancer registries in animals and humans. Preliminary survey data shows predominance, in the 645 cases, of dogs (96.58%) and females (80.15%). The most common cancer location were mammary gland (63.88%), skin (17.98%) and genitals (5.43%). The system proved to be simple, flexible, well accepted, timely and useful. As a pilot study, its representativeness is still small, but tends to increase with the accession of new reporting sources. The system has no assurance mechanisms of their completeness. Some solutions such, as the pre-verification tool, designed to avoid duplicated entries, and the electronic medical records integration with the standard epidemiological fields, share the fields to assist in the distribution of registry responsibilities to users and, consequently, decrease operating costs. The implementation of an Animal Cancer Registry in São Paulo proved to be feasible, and the multicentric collection is ready to be carried out continuously and uninterruptedly

Registros de Câncer são sistemas padronizados, flexíveis e multicêntricos para coleta de dados de pacientes com neoplasias, permitindo a obtenção de dados epidemiológicos de alta qualidade a um baixo custo. Eles podem ser de base populacional, abrangendo todos os casos de uma área geográfica delimitada, possibilitando calcular sua incidência e sobrevida, quanto de base hospitalar, coletando dados sobre o paciente para uso em pesquisa, educação continuada e melhoria dos atendimentos. Essas abordagens, na Medicina Veterinária, tiveram início na década de 60 com o Kansas Animal Tumor Registry (1961) e com o California Animal Tumor Registry (1963). Desde então, outras iniciativas similares surgiram nos Estados Unidos, Canadá, Noruega, Dinamarca, Suécia e Reino Unido. Esses registros, concentrados no Hemisfério Norte, não existem ainda na América Latina. Este trabalho teve como objetivo avaliar a viabilidade de implantação de um Registro de Câncer Animal na cidade de São Paulo, SP, Brasil. Elaborou-se um registro piloto para permitir entender a sua viabilidade em larga escala quanto Sistema de Informação em Saúde. Foram desenvolvidos identidade, logotipo, formulários de admissão e seguimento, e um software especializado, o SIRCA-SP, para o funcionamento do Registro de Câncer Animal de São Paulo (RCA-SP). O fluxo de informação foi planejado para que a coleta pudesse ser realizada de forma multicêntrica, padronizada e sigilosa. A análise preliminar dos dados permite entender as características da distribuição local do câncer e o potencial do RCA-SP. O estudo de viabilidade foi realizado através de parâmetros definidos pelo Center for Diseases Control, Atlanta, EUA. O RCA-SP foi criado, em 2013, como um registro de base hospitalar que coleta informações sobre cães e gatos diagnosticados com câncer a partir de janeiro de 2012 em hospitais, clínicas e serviços autônomos veterinários sediados na cidade de São Paulo. O software SIRCA-SP foi desenvolvido para otimizar e garantir a qualidade dos dados coletados, consolidados e armazenados pelo RCA-SP. O sistema possui interface amigável e pode ser acessado via internet. Os formulários foram padronizados e geram dados comparáveis aos outros Registros de Câncer em animais e humanos. Avaliação preliminar dos dados demonstra predomínio, nos 645 casos registrados de cães (96,58%) e de fêmeas (80,15%). As localizações de câncer mais comuns foram em glândula mamária (63,88%), pele (17,98%) e em órgãos genitais (5,43%). O sistema demonstrou ser simples, flexível, bem aceito, oportuno e útil. A sua representatividade, por ser projeto piloto, é pequena, mas tenderá a aumentar com adesão de novas fontes notificadoras. O sistema não possui mecanismos de garantia de sua exaustividade. Algumas soluções como o sistema de pré-verificação de inclusão, projetado para evitar entrada duplicada de dados, e a integração entre prontuário eletrônico e os campos de interesse epidemiológico auxiliam na distribuição de responsabilidades do registro aos usuários e, consequente, diminuição de custos operacionais. A implantação de um Registro de Câncer Animal na cidade de São Paulo mostrou-se viável e a coleta multicêntrica é realizada de forma contínua e ininterrupta / Cancer Registries are flexible, multicentric and standardized systems to collect data from patients with neoplasia, allowing the epidemiological registry of high quality data, at low cost. They can be classified as population-based, covering all cases in a defined geographical area, allowing incidence and survival calculation, or, hospital-based, collecting data about the patient for research, continuing education and improvement of care. Those approaches started in Veterinary Medicine in the 60’s, with the Kansas Animal Tumor Registry (1961) and the California Animal Tumor Registry (1963). Since then, other similar initiatives have emerged in United States, Canada, Norway, Denmark, Sweden, Italy and United Kingdom. Those registries, concentrated in North Hemisphere, were absent in Latin America up to now. This study aimed to assess the feasibility of implementing an Animal Cancer Registry in Sao Paulo, SP, Brazil. A pilot cancer registry system was developed to allow understanding its feasibility, in large scale, as a Health Information System. An identity, logo, admission and follow-up forms were developed, and a specialized software, the SIRCA-SP, for Sao Paulo Animal Cancer Registry (RCA-SP) operation was standardized. An information flow was planned, so that the collection could be performed in a multicentric, standardized and confidential way. Preliminary analysis of the data allowed the understanding of local cancer distribution characteristics and the RCA-SP potential. The feasibility study was perform using parameters defined by the Centers for Disease Control, Atlanta, USA. The RCA-SP, created in 2013, is a hospital-based cancer registry, which collects information about dogs and cats diagnosed with cancer since January 2012 in hospitals, clinics and veterinary autonomous services in Sao Paulo, SP, Brazil. The SIRCA-SP was designed to optimize and ensure the quality of data collection, consolidation and storing by RCA-SP. The system has a friendly interface and can be access via Internet. The forms were standardized and generate data comparable to other cancer registries in animals and humans. Preliminary survey data shows predominance, in the 645 cases, of dogs (96.58%) and females (80.15%). The most common cancer location were mammary gland (63.88%), skin (17.98%) and genitals (5.43%). The system proved to be simple, flexible, well accepted, timely and useful. As a pilot study, its representativeness is still small, but tends to increase with the accession of new reporting sources. The system has no assurance mechanisms of their completeness. Some solutions such, as the pre-verification tool, designed to avoid duplicated entries, and the electronic medical records integration with the standard epidemiological fields, share the fields to assist in the distribution of registry responsibilities to users and, consequently, decrease operating costs. The implementation of an Animal Cancer Registry in São Paulo proved to be feasible, and the multicentric collection is ready to be carried out continuously and uninterruptedly

L'objectif du registre des cancers de Guyane est de collecter l ensemble des tumeurs invasives et/ou in situ survenues depuis le 1er janvier 2003 chez des patients vivant en Guyane, quels que soient la localisation de la tumeur, le lieu de diagnostic et de traitement. Cette thèse a pour but de décrire la population atteinte d un cancer afin d améliorer les connaissances sur cette maladie et ainsi de permettre aux actions de santé publique d être plus efficaces.De 2003 à 2009, le taux d incidence des cancers standardisé sur l âge était, dans les deux sexes, 30% inférieur en Guyane par rapport à la France métropolitaine et n était pas différent de celui d Amérique du Sud.Nous avons comparé l incidence, la mortalité et la survie relative des patientes atteintes d un cancer invasif du sein (CIS) et des patientes atteintes d un cancer invasif du col de l utérus (CIC) entre la Guyane et la métropole.Le ratio incidence/mortalité indiquait que les cancers du sein étaient de plus mauvais pronostic en Guyane par rapport à la métropole.La survie relative des femmes atteintes d un CIS était inférieure en Guyane par rapport à la France métropolitaine.En Guyane, le taux standardisé d incidence du cancer du col de l utérus était 4 fois plus élevé qu en métropole. Les femmes vivant dans l intérieur de la Guyane semblaient être diagnostiquées à un stade plus tardif et plus souvent sur symptômes que les femmes du littoral. L accès aux soins des migrants est un challenge et une source d inégalité de santé. La détection précoce des cancers à travers des programmes de prévention est cruciale pour améliorer la survie par cancer et notamment chez les patients étrangers. / The objective of the cancer registry of French Guiana is to compile all patients living in French Guiana with malignant invasive pathology and/or in situ lesions starting January 1st 2003 in persons living in French Guiana, whatever the tumoral location and the place of diagnosis and care. This study aimed to describe the population with invasive cancer to improve the knowledge about this disease in order to target public health interventions more effectively.The age standardised incidence rate was 30% times lower than in France in both sexes and the same than in South America.We compared incidence and relative survival of patients with invasive breast cancer (IBC) and patients with invasive cervical cancer (ICC) between women from French Guiana and metropolitan France.The ratio between incidence and mortality showed that the prognosis of IBC in French Guiana was worse than in metropolitan France.The relative survival rate among women with IBC in French Guiana was lower than among women in metropolitan France.In French Guiana, the age-standardized incidence rate of cervical cancer was four times higher than in France. Women living in remote areas seemed to be diagnosed later and more often following symptoms.Access to care for migrants is challenging and sustains health inequalities. Early detection through prevention programs is crucial for increasing cancer survival notably for foreign-born patients. Further studies with more patients and other variables could improve the knowledge about these diseases

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第18907号 / 社医博第65号 / 新制||社医||9(附属図書館) / 31858 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 富樫 かおり, 教授 武藤 学 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Radical prostatectomy is the main surgical treatment for prostate cancer and is associated with various short-term complications. Racial and ethnic minority patients have worse postoperative outcomes than White patients following prostate cancer surgery. One of the factors that may contribute to the racial differences in postoperative outcomes is the differential use of new medical technology of robot-assisted surgery (RAS) across racial and ethnic groups. Patients undergoing robot-assisted radical prostatectomy (RARP) have been shown to have reduced short-term complications, length of stay (LOS), and readmissions and comparable long-term survival compared with patients undergoing open radical prostatectomy (ORP). Previous studies demonstrated that racial and ethnic minority patients with prostate cancer were less likely to receive RARP than White patients. However, critical gaps remain in 1) understanding current evidence on racial and ethnic disparities related to RAS in pelvic cancer surgery thoroughly; 2) determining the impact of RARP on racial and ethnic disparities in postoperative outcomes among prostate cancer patients, and; 3) investigating the role of surgeons on the differential use of RARP across racial and ethnic groups. To address these gaps, this dissertation conducted a systematic review to comprehensively understand racial and ethnic disparities in the use of RAS in four major pelvic cancer treatments (prostate, uterine, bladder, and rectal cancers). Following the systematic review, empirical analyses were performed using linked New York State Cancer Registry and statewide discharge records to determine the contribution of RARP to racial and ethnic disparities in the short-term outcomes after prostate cancer surgery, including determining the presence and pattern of interaction between race/ethnicity and RARP use. Based on a multilevel framework, two important hypotheses were also tested to assess surgeons’ influence on the use of RARP across racial and ethnic groups through access to care and the process of care. The systematic review found consistent evidence that Black and Hispanic patients were less likely to receive RAS than White patients in all four pelvic cancer surgeries. There is a lack of formal assessment to determine the impact of RAS use on racial and ethnic disparities in postoperative outcomes. The systematic review also found that racial and ethnic minorities were less likely to receive treatment at RAS-performing or high-technology centers than White patients. But there is a paucity of research examining physician-level factors that may be related to differential use of RAS across racial and ethnic groups. The first empirical analysis detected a statistical interaction between race/ethnicity and procedure approach that was present on the additive scale but not on the multiplicative scale. Specifically, when undergoing RARP rather than ORP, non-Hispanic Black (NHB) and Hispanic men with prostate cancer, as compared to non-Hispanic White (NHW) men, experienced a greater reduction in the risk of adverse short-term outcomes of major events (NHB vs. NHW: RERI -0.32, 95% CI (-0.70,-0.01); Hispanic vs. NHW: RERI -0.28, 95% CI (-0.74,0.09)) and prolonged LOS (NHB vs. NHW: RERI -0.32, 95% CI (-0.70,-0.01); Hispanic vs. NHW: RERI -0.28, 95% CI(-0.74,0.09)) on the absolute risk (additive) scale. The second empirical analysis confirmed the two hypotheses related to surgeons’ role in the racial and ethnic disparities related to RARP use. First, NHB and Hispanic patients were more likely to be treated by surgeons who were low-RARP users (NHB vs. NHW: OR 1.73, 95% CI 1.58-1.90; Hispanic vs. NHW: OR 2.14, 95% CI 1.90-2.41) or by surgeons at non-RARP facilities (NHB vs. NHW: OR 4.26, 95% CI 3.45-5.27; Hispanic vs. NHW: OR 4.01, 95% CI 3.44-4.67) than NHW patients, supporting racial and ethnic disparities in access to care. Second, when treated by the same surgeon and having similar conditions, NHB and Hispanic patients were less likely to receive RARP than NHW patients (NHB vs. NHW: OR 0.73, 95% CI 0.59-0.91; Hispanic vs. NHW: OR 0.72, 95% CI 0.55-0.96), supporting racial and ethnic disparities in the process of care. In summary, this dissertation identified gaps in current literature and showed that NHB and Hispanic patients with prostate cancer were less likely to receive but benefitted more from RARP than NHW patients. Increasing equitable penetration of robot-assisted technology may help reduce racial disparities in patient outcomes after radical prostatectomy. This dissertation also revealed that NHB and Hispanic patients were less likely to be treated by high-RARP-use surgeons and less likely to receive RAPR when treated for similar conditions by the same surgeons than NHW patients. Addressing structural barriers faced by racial and ethnic minority patients during care-seeking and the process of care can help reduce disparities in RAS use.

Introduction: Les études populationnelles sur le cancer nécessitent un recensement de référence fiable et exhaustif, en théorie possible à partir d'un recueil histologique. Méthode: Depuis 2005, toutes les structures d'anatomopathologie des Alpes-Maritimes adressent les codes ADICAP des tumeurs malignes et invasives et identifiants patients. L'exhaustivité pour les cancers du sein et colorectaux des 50-75 ans a été évalué par méthode de capture recapture en modélisation log-linéaire et en Bayesien à partir des cas communs ou non dépistés et vus en Réunion de Concertation Pluridisciplinaire. RésultatUn programme d'assurance qualité a permis de s'assurer de la fiabilité des données recueillies.L'estimation de l'exhaustivité était de plus de 90 % pour les cancers du sein et colorectaux des 50-75 ans. Les taux observés sur le département des Alpes-Maritimes, comparés aux taux estimés en France, se sont révélés cohérents.Enfin, la base a été utilisée pour déterminer l'existant les lésions prénéoplasiques du col de l'utérus avant la vaccination anti-HPV. ConclusionCe travail conclut à l'intérêt d'un recueil histologique des cas de cancers incidents. / Introduction Cancer population studies require reliable and complete baseline data, which should theoretically be available by collecting histopathology records.Method Since 2005, all histopathology laboratories from Alpes-Maritimes address ADICAP codes for invasive cancer and patient identifiers. The completeness of such a collection was evaluated using capture-recapture analysis based on three data sources concerning breast and colorectal cancers with the number of cases which were common or not between sources recording screened, diagnosed and treated cancers in the French Alpes Maritimes districtResult Data quality for the ADICAP code database may be considered satisfactoryThe estimated completeness of cancer records collected from histopathology laboratories was higher than 90%.Rates observed in the Alpes-Maritimes, compared with estimated rates in France have proven consistent. Rates of CIN for the entire female population of the Alpes-Maritimes in 2006 has been established.Conclusion A verified and validated histopathology data collection may be useful for cancer population studies.

Doctor of Philosophy / Over the past decade, population-based cancer registry data have been used increasingly worldwide to evaluate and improve the quality of cancer care. The utility of the conclusions from such studies relies heavily on the data quality and the methods used to analyse the data. Interpretation of comparative survival from such data, examining either temporal trends or geographical differences, is generally not easy. The observed differences could be due to methodological and statistical approaches or to real effects. For example, geographical differences in cancer survival could be due to a number of real factors, including access to primary health care, the availability of diagnostic and treatment facilities and the treatment actually given, or to artefact, such as lead-time bias, stage migration, sampling error or measurement error. Likewise, a temporal increase in survival could be the result of earlier diagnosis and improved treatment of cancer; it could also be due to artefact after the introduction of screening programs (adding lead time), changes in the definition of cancer, stage migration or several of these factors, producing both real and artefactual trends. In this thesis, I report methods that I modified and applied, some technical issues in the use of such data, and an analysis of data from the State of New South Wales (NSW), Australia, illustrating their use in evaluating and potentially improving the quality of cancer care, showing how data quality might affect the conclusions of such analyses. This thesis describes studies of comparative survival based on population-based cancer registry data, with three published papers and one accepted manuscript (subject to minor revision). In the first paper, I describe a modified method for estimating spatial variation in cancer survival using empirical Bayes methods (which was published in Cancer Causes and Control 2004). I demonstrate in this paper that the empirical Bayes method is preferable to standard approaches and show how it can be used to identify cancer types where a focus on reducing area differentials in survival might lead to important gains in survival. In the second paper (published in the European Journal of Cancer 2005), I apply this method to a more complete analysis of spatial variation in survival from colorectal cancer in NSW and show that estimates of spatial variation in colorectal cancer can help to identify subgroups of patients for whom better application of treatment guidelines could improve outcome. I also show how estimates of the numbers of lives that could be extended might assist in setting priorities for treatment improvement. In the third paper, I examine time trends in survival from 28 cancers in NSW between 1980 and 1996 (published in the International Journal of Cancer 2006) and conclude that for many cancers, falls in excess deaths in NSW from 1980 to 1996 are unlikely to be attributable to earlier diagnosis or stage migration; thus, advances in cancer treatment have probably contributed to them. In the accepted manuscript, I described an extension of the work reported in the second paper, investigating the accuracy of staging information recorded in the registry database and assessing the impact of error in its measurement on estimates of spatial variation in survival from colorectal cancer. The results indicate that misclassified registry stage can have an important impact on estimates of spatial variation in stage-specific survival from colorectal cancer. Thus, if cancer registry data are to be used effectively in evaluating and improving cancer care, the quality of stage data might have to be improved. Taken together, the four papers show that creative, informed use of population-based cancer registry data, with appropriate statistical methods and acknowledgement of the limitations of the data, can be a valuable tool for evaluating and possibly improving cancer care. Use of these findings to stimulate evaluation of the quality of cancer care should enhance the value of the investment in cancer registries. They should also stimulate improvement in the quality of cancer registry data, particularly that on stage at diagnosis. The methods developed in this thesis may also be used to improve estimation of geographical variation in other count-based health measures when the available data are sparse.

Doctor of Philosophy / Over the past decade, population-based cancer registry data have been used increasingly worldwide to evaluate and improve the quality of cancer care. The utility of the conclusions from such studies relies heavily on the data quality and the methods used to analyse the data. Interpretation of comparative survival from such data, examining either temporal trends or geographical differences, is generally not easy. The observed differences could be due to methodological and statistical approaches or to real effects. For example, geographical differences in cancer survival could be due to a number of real factors, including access to primary health care, the availability of diagnostic and treatment facilities and the treatment actually given, or to artefact, such as lead-time bias, stage migration, sampling error or measurement error. Likewise, a temporal increase in survival could be the result of earlier diagnosis and improved treatment of cancer; it could also be due to artefact after the introduction of screening programs (adding lead time), changes in the definition of cancer, stage migration or several of these factors, producing both real and artefactual trends. In this thesis, I report methods that I modified and applied, some technical issues in the use of such data, and an analysis of data from the State of New South Wales (NSW), Australia, illustrating their use in evaluating and potentially improving the quality of cancer care, showing how data quality might affect the conclusions of such analyses. This thesis describes studies of comparative survival based on population-based cancer registry data, with three published papers and one accepted manuscript (subject to minor revision). In the first paper, I describe a modified method for estimating spatial variation in cancer survival using empirical Bayes methods (which was published in Cancer Causes and Control 2004). I demonstrate in this paper that the empirical Bayes method is preferable to standard approaches and show how it can be used to identify cancer types where a focus on reducing area differentials in survival might lead to important gains in survival. In the second paper (published in the European Journal of Cancer 2005), I apply this method to a more complete analysis of spatial variation in survival from colorectal cancer in NSW and show that estimates of spatial variation in colorectal cancer can help to identify subgroups of patients for whom better application of treatment guidelines could improve outcome. I also show how estimates of the numbers of lives that could be extended might assist in setting priorities for treatment improvement. In the third paper, I examine time trends in survival from 28 cancers in NSW between 1980 and 1996 (published in the International Journal of Cancer 2006) and conclude that for many cancers, falls in excess deaths in NSW from 1980 to 1996 are unlikely to be attributable to earlier diagnosis or stage migration; thus, advances in cancer treatment have probably contributed to them. In the accepted manuscript, I described an extension of the work reported in the second paper, investigating the accuracy of staging information recorded in the registry database and assessing the impact of error in its measurement on estimates of spatial variation in survival from colorectal cancer. The results indicate that misclassified registry stage can have an important impact on estimates of spatial variation in stage-specific survival from colorectal cancer. Thus, if cancer registry data are to be used effectively in evaluating and improving cancer care, the quality of stage data might have to be improved. Taken together, the four papers show that creative, informed use of population-based cancer registry data, with appropriate statistical methods and acknowledgement of the limitations of the data, can be a valuable tool for evaluating and possibly improving cancer care. Use of these findings to stimulate evaluation of the quality of cancer care should enhance the value of the investment in cancer registries. They should also stimulate improvement in the quality of cancer registry data, particularly that on stage at diagnosis. The methods developed in this thesis may also be used to improve estimation of geographical variation in other count-based health measures when the available data are sparse.