SummaryBackgroundCancer survival is a key measure of the effectiveness of health-care systems. Persistent regional and international differences in survival represent many avoidable deaths. Differences in survival have prompted or guided cancer control strategies. This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival.MethodsData from population-based cancer registries in 12 jurisdictions in six countries were provided for 2·4 million adults diagnosed with primary colorectal, lung, breast (women), or ovarian cancer during 1995–2007, with follow-up to Dec 31, 2007. Data quality control and analyses were done centrally with a common protocol, overseen by external experts. We estimated 1-year and 5-year relative survival, constructing 252 complete life tables to control for background mortality by age, sex, and calendar year. We report age-specific and age-standardised relative survival at 1 and 5 years, and 5-year survival conditional on survival to the first anniversary of diagnosis. We also examined incidence and mortality trends during 1985–2005.FindingsRelative survival improved during 1995–2007 for all four cancers in all jurisdictions. Survival was persistently higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark, England, Northern Ireland, and Wales, particularly in the first year after diagnosis and for patients aged 65 years and older. International differences narrowed at all ages for breast cancer, from about 9% to 5% at 1 year and from about 14% to 8% at 5 years, but less or not at all for the other cancers. For colorectal cancer, the international range narrowed only for patients aged 65 years and older, by 2–6% at 1 year and by 2–3% at 5 years.InterpretationUp-to-date survival trends show increases but persistent differences between countries. Trends in cancer incidence and mortality are broadly consistent with these trends in survival. Data quality and changes in classification are not likely explanations. The patterns are consistent with later diagnosis or differences in treatment, particularly in Denmark and the UK, and in patients aged 65 years and older.FundingDepartment of Health, England; and Cancer Research UK.

Obesity is a risk factor for the development of new cases of breast cancer and also affects survival in women who have already been diagnosed with breast cancer. Early studies of obesity and breast cancer survival have been summarised in two meta-analyses, but the latest of these only included studies that recruited women diagnosed as recently as 1991. The primary aim of this study was to conduct a meta-analysis that included the more recent studies. A systematic search of MEDLINE, EMBASE and CINAHL was conducted to identify original data evaluating the effects of obesity on survival in newly diagnosed breast cancer patients. Adjusted hazard ratios (HR) from individual studies were pooled using a random effects model. A series of pre-specified sensitivity analyses were conducted on factors such as overall versus breast cancer survival and treatment versus observational cohort. The meta-analysis included 43 studies that enrolled women diagnosed with breast cancer between 1963 and 2005. Sample size ranged from 100 to 424168 (median 1192). The meta-analysis showed poorer survival among obese compared with non-obese women with breast cancer, which was similar for overall (HR = 1.33; 95% confidence interval (CI): 1.21, 1.47) and breast cancer specific survival (HR = 1.33; 95% CI: 1.19, 1.50). The survival differential varied only slightly, depending on whether body mass index (1.33; 1.21, 1.47) or waist-hip ratio (1.31; 1.08, 1.58) was used as the measure of obesity. There were larger differences by whether the woman was pre-menopausal (1.47) or post-menopausal (1.22); whether the cohort included women diagnosed before (1.31) or after 1995 (1.49); or whether the women were in a treatment (1.22) or observational cohort (1.36), but none of the differences were statistically significant. Women with breast cancer, who are obese, have poorer survival than women with breast cancer, who are not obese. However, no study has elucidated the causal mechanism and there is currently no evidence that weight loss after diagnosis improves survival. Consequently, there is currently no reason to place the additional burden of weight loss on women already burdened with a diagnosis of cancer. Further research should concentrate on assessing whether factors such as diabetes or type of chemotherapy modify the obesity effect and on understanding the causal mechanism, in particular the role of relative under-dosing.

It has been suggested that malnutrition during fetal life and early childhood may lead to increased risk of cardiovascular mortality and metabolic syndrome in adults. One way to study this has been to examine pregnancies that are a result of exposure to maternal famine and their association with subsequent development of the metabolic syndrome in adulthood. Varying findings have been demonstrated in this literature. In a famine study that examined the association between fetal famine exposure and the metabolic syndrome, no statistically significant associations were found. However, the failure to show an association could be due to the relatively short Dutch winter, limiting exposure to famine during gestation. The risk of adverse long-term consequences of famine exposure during early life may be exacerbated in later life among adults who are exposed to a nutritionally rich environment represented by a Western dietary pattern or are overweight.The aim of this study was to investigate the association between famine exposure in China during fetal life and early childhood with the risk of metabolic syndrome during adulthood and to determine whether exposure in later life to nutritional rich environments affects this association. Data were obtained from the 2002 China National Nutrition and Health Survey administered on 7874 adults born between 1954 and 1964. The risk of the metabolic syndrome was assessed among adults from 5 exposure cohorts: nonexposed, and fetal, early childhood, mid-childhood, and late childhood exposed.The severity of the famine was determined using the excess death rate in the geographical region during exposure. The metabolic syndrome defined by adenosine triphosphate (ATP) III criteria included 3 or more of the following: elevated fasting plasma triglyceride, lower plasma high-density lipoprotein (HDL) cholesterol, elevated fasting glucose levels, higher waist circumference, and hypertension.The risk of the metabolic syndrome was higher among adults born in severely affected famine areas, who had been exposed to the famine during fetal life compared with nonexposed adults (odds ratio, 3.13, 95% confidence interval, 1.24 to 7.89, P ϭ 0.016). There were similar associations among adults who were exposed to the famine during early childhood, but not among adults exposed to famine during mid or late childhood. The risk of the metabolic syndrome was especially high in later life for participants born in severely affected famine areas and had Western dietary habits or were overweight in adulthood.These findings show that exposure to famine in China during fetal life and early childhood is associated with a higher risk of metabolic syndrome in adulthood. ABSTRACTStudies examining the possible association of birth order, presentation, and mode of delivery with adverse neonatal outcomes after twin delivery have had conflicting results. The contribution of each to adverse outcomes of twin delivery is unclear.This literature review investigated whether differences in birth order, presentation, and deliv...