http://bmj.com/cgi/content/full/325/7357/182/a
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Janice Hopkins Tanne New York
Cancer mortality in the United States may be underestimated, because deaths within a month of surgery for solid tumours are recorded as deaths related to treatment, according to researchers.
Dr H Gilbert Welch and Dr William Black of Dartmouth Medical School in New Hampshire argue that cancer mortality should include not only deaths from cancer but also deaths caused by treatment for cancer. In the Journal of the National Cancer Institute (2002;94:1066-70) they report that 41% of deaths within a month of treatment for cancer were attributed to another cause, and thus cancer mortality was underestimated by 0.9%, and that many deaths after a month were also not counted as deaths from cancer. Their study has implications for cancer statistics, success in treating cancer, and early screening. However, their study did not go unchallenged—an accompanying editorial says that Welch and Black’s proposals may be impractical.
The authors say there are no guidelines for classifying deaths related to cancer treatment, and all deaths within the first month after surgery should be considered as deaths from cancer.
Using data from the National Cancer Institute’s surveillance, epidemiology, and end results programme for 1994 to 1998, they determined the proportion of deaths not attributed to cancer for 19 common solid tumours. They found that cancer was not named (coded on the death certificate) as the cause of death for 42% of 1695 colorectal cancer patients, 34% of 525 lung cancer patients, 54% of 256 bladder cancer patients, 24% of 242 ovarian cancer patients, and 75% of 106 prostate cancer patients.
Had those deaths been reported as cancer deaths, recent decreases in cancer mortality would have been less. They say that misclassification of cancer deaths has increased over the last 20 years.
Finding cancer through screening may also lead to an undercount, as surgery becomes more common for early cancer. The authors ask whether, for instance, a patient who has an apparently curative lobectomy for lung cancer but dies of pneumonia six months later should be counted as a death from cancer treatment.
Dr Colin Begg, chairman of the department of epidemiology at the Memorial
Sloan-Kettering Cancer Center in New York, said, "Reporting deaths is not an
exact science, as we’ve known for many years." He said that men aged over 65 who
had a radical prostatectomy had only about double the risk of dying as other men
in their age group in any given month (0.49% versus 0.28%). If all deaths after
cancer surgery were recorded as cancer deaths, he said, "That would screw up the
statistics for other diseases—for example, for people who died of myocardial
infarctions."
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