December 19, 2014

Moving the goalposts

A century ago there was no useful treatment for cancer, nothing that would postpone death. A century ago, there wasn’t any point in screening for cancer; you might as well just wait for it to turn up. A century ago, it would still have been true that early diagnosis would improve 1-year survival.

Cancer survival is defined as time from diagnosis to death. That’s not a very good definition, but there isn’t a better one available since the start of a tumour is not observable and not even very well defined.  If you diagnose someone earlier, and do nothing else helpful, the time from diagnosis to death will increase. In particular, 1-year survival is likely to increase a lot, because you don’t have to move diagnosis much earlier to get over the 1-year threshold.  Epidemiologists call this “lead-time bias.”

The Herald has a story today on cancer survival in NZ and Australia that completely misses this issue. It’s based on an article in the New Zealand Medical Journal that also doesn’t discuss the issue, though the editorial commentary in the journal does, and also digs deeper:

If the average delay from presentation to diagnosis was 4 weeks longer in New Zealand due to delay in presentation by the patient, experimentation with alternative therapy, or difficulty in diagnosis by the doctor, the 1-year relative survival would be about 7% poorer compared to Australia. The range of delay among patients is even more important and if even relatively few patients have considerable delay this can greatly influence overall relative survival due to a lower chance of cure. Conversely, where treatment is seldom effective, 1-year survival may be affected by delay but it may have little influence on long-term survival differences. This was apparent for trans-Tasman differences in relative survival for cancers of the pancreas, brain and stomach.  However, relative survival for non-Hodgkin lymphoma was uniformly poorer in New Zealand suggesting features other than delay in diagnosis are important.

That is, part of the difference between NZ and Australian cancer survival rates is likely to be lead-time bias — Australians find out they have incurable cancer earlier than New Zealanders do — but part of it looks to be real advantages in treatment in Australia.

Digging deeper like this is important. You can always increase time from diagnosis to death by earlier diagnosis. That isn’t as useful as increasing it by better treatment.

[update: the commentary seems to have become available only to subscribers while I was writing this]


Thomas Lumley (@tslumley) is Professor of Biostatistics at the University of Auckland. His research interests include semiparametric models, survey sampling, statistical computing, foundations of statistics, and whatever methodological problems his medical collaborators come up with. He also blogs at Biased and Inefficient See all posts by Thomas Lumley »