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      Worldwide comparison of survival from childhood leukaemia for 1995–2009, by subtype, age, and sex (CONCORD-2): a population-based study of individual data for 89 828 children from 198 registries in 53 countries


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          Global inequalities in access to health care are reflected in differences in cancer survival. The CONCORD programme was designed to assess worldwide differences and trends in population-based cancer survival. In this population-based study, we aimed to estimate survival inequalities globally for several subtypes of childhood leukaemia.


          Cancer registries participating in CONCORD were asked to submit tumour registrations for all children aged 0–14 years who were diagnosed with leukaemia between Jan 1, 1995, and Dec 31, 2009, and followed up until Dec 31, 2009. Haematological malignancies were defined by morphology codes in the International Classification of Diseases for Oncology, third revision. We excluded data from registries from which the data were judged to be less reliable, or included only lymphomas, and data from countries in which data for fewer than ten children were available for analysis. We also excluded records because of a missing date of birth, diagnosis, or last known vital status. We estimated 5-year net survival (ie, the probability of surviving at least 5 years after diagnosis, after controlling for deaths from other causes [background mortality]) for children by calendar period of diagnosis (1995–99, 2000–04, and 2005–09), sex, and age at diagnosis (<1, 1–4, 5–9, and 10–14 years, inclusive) using appropriate life tables. We estimated age-standardised net survival for international comparison of survival trends for precursor-cell acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML).


          We analysed data from 89 828 children from 198 registries in 53 countries. During 1995–99, 5-year age-standardised net survival for all lymphoid leukaemias combined ranged from 10·6% (95% CI 3·1–18·2) in the Chinese registries to 86·8% (81·6–92·0) in Austria. International differences in 5-year survival for childhood leukaemia were still large as recently as 2005–09, when age-standardised survival for lymphoid leukaemias ranged from 52·4% (95% CI 42·8–61·9) in Cali, Colombia, to 91·6% (89·5–93·6) in the German registries, and for AML ranged from 33·3% (18·9–47·7) in Bulgaria to 78·2% (72·0–84·3) in German registries. Survival from precursor-cell ALL was very close to that of all lymphoid leukaemias combined, with similar variation. In most countries, survival from AML improved more than survival from ALL between 2000–04 and 2005–09. Survival for each type of leukaemia varied markedly with age: survival was highest for children aged 1–4 and 5–9 years, and lowest for infants (younger than 1 year). There was no systematic difference in survival between boys and girls.


          Global inequalities in survival from childhood leukaemia have narrowed with time but remain very wide for both ALL and AML. These results provide useful information for health policy makers on the effectiveness of health-care systems and for cancer policy makers to reduce inequalities in childhood cancer survival.


          Canadian Partnership Against Cancer, Cancer Focus Northern Ireland, Cancer Institute New South Wales, Cancer Research UK, US Centers for Disease Control and Prevention, Swiss Re, Swiss Cancer Research foundation, Swiss Cancer League, and the University of Kentucky.

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          Most cited references23

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          Childhood Acute Lymphoblastic Leukemia: Progress Through Collaboration.

          To review the impact of collaborative studies on advances in the biology and treatment of acute lymphoblastic leukemia (ALL) in children and adolescents.
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            Paediatric cancer in low-income and middle-income countries.

            Patterns of cancer incidence across the world have undergone substantial changes as a result of industrialisation and economic development. However, the economies of most countries remain at an early or intermediate stage of development-these stages are characterised by poverty, too few health-care providers, weak health systems, and poor access to education, modern technology, and health care because of scattered rural populations. Low-income and middle-income countries also have younger populations and therefore a larger proportion of children with cancer than high-income countries. Most of these children die from the disease. Chronic infections, which remain the most common causes of disease-related death in all except high-income countries, can also be major risk factors for childhood cancer in poorer regions. We discuss childhood cancer in relation to global development and propose strategies that could result in improved survival. Education of the public, more and better-trained health professionals, strengthened cancer services, locally relevant research, regional hospital networks, international collaboration, and health insurance are all essential components of an enhanced model of care. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              New policies to address the global burden of childhood cancers

              Childhood cancer is a major global health issue. Every year, almost 100 000 children die from cancer before the age of 15 years, more than 90% of them in resource-limited countries. Here, we review the key policy issues for the delivery of better care, research, and education of professionals and patients. We present a key list of time-limited proposals focusing on change to health systems and research and development. These include sector and system reforms to make care affordable to all, policies to promote growth of civil society around both cancer and Millennium Development Goals, major improvements to public health services (particularly the introduction of national cancer plans), improved career development, and increased remuneration of specialist health-care workers and government support for childhood cancer registries. Research and development proposals focus on sustainable funding, the establishment of more research networks, and clinical research specifically targeted at the needs of low-income and middle-income countries. Finally, we present proposals to address the need for clinical trial innovation, the complex dichotomy of regulations, and the threats to the availability of data for childhood cancers. Copyright © 2013 Elsevier Ltd. All rights reserved.

                Author and article information

                Lancet Haematol
                Lancet Haematol
                The Lancet. Haematology
                Elsevier Ltd
                11 April 2017
                May 2017
                11 April 2017
                : 4
                : 5
                : e202-e217
                [a ]Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [b ]National Cancer Registration and Analysis Service, Public Health England, Oxford, UK
                [c ]Evaluative Epidemiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
                [d ]National Registry of Childhood Haematopoietic Malignancies, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des Cancers de l'Enfant et de l'Adolescent, Paris, France
                [e ]Umtata University, Mthatha, South Africa
                [f ]Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Catalan Institute of Oncology-Girona, Girona, Spain
                [g ]Registro Español de Tumores Infantiles, UVEG, Valencia, Spain
                [h ]Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
                [i ]Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
                [j ]Swiss Childhood Cancer Registry, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
                [k ]Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
                Author notes
                [* ]Correspondence to: Dr Audrey Bonaventure, Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UKCorrespondence to: Dr Audrey BonaventureCancer Survival GroupDepartment of Non-Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonWC1E7HTUK concord@ 123456lshtm.ac.uk

                The members of the CONCORD Working Group are listed in the appendix

                © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).



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