Abstract

Population-based cancer registries (PBCRs) are a key element for cancer control. They measure cancer incidence and trends, provide indicators for planning and evaluating cancer control activities, and undertake research. The first two PBCRs in Spain were established in Zaragoza in 1960 and Navarre in 1970, but it was from 1980 to 1995 when most of the existing registries went into operation. Today, 26.5% of the Spanish population is served by a cancer registry. All registries’ quality-control indicators meet the inclusion criteria for comparability and quality of data required by the International Agency for Research on Cancer, and indeed some fulfil most of the excellence criteria for gold standard certification. After their initiation into recording accurate and complete information targeted at ascertaining cancer incidence in their catchment areas, PBCRs are progressively broadening their scope and becoming increasingly involved in collecting and analysing additional data on patient care, diagnosis, disease stage, treatment and follow-up. Spanish registries have become actively engaged in research projects, domestic and international, at a rate that has risen remarkably in the past decade. The creation of a network of Spanish cancer registries is being considered, with the aim of its becoming a key player in developing standards for cancer registration, providing training and technical assistance, undertaking quality audits and promoting the use of cancer surveillance data to reduce the burden of cancer in Spain.

background

Cancer control requires indicators for planning and evaluating its activities. Cancer registration has been defined as the process of ongoing systematic collection of data on the occurrence and characteristics of reportable neoplasms, with the purpose of helping to assess and control the impact of malignancies on the community. The cancer registry is an information system which attempts to collect, store, analyse and interpret data on persons with cancer [1, 2]. A population-based cancer registry (PBCR) records all new cases in a geographically defined area, and is thus unique for monitoring cancer incidence. PBCRs were initially concerned with describing cancer patterns and trends. Subsequently, many of them developed the necessary capability to follow up registered patients and calculate survival and prevalence. Over the past 20 years, the role of registries has expanded further to encompass the planning and assessment of cancer control activities, and the care of individual cancer patients [3, 4].

A hospital-based cancer registry records all cases at a given hospital, usually without knowledge of the background population. While hospital-based registries are mostly involved in improving the quality of patient care, they also serve the needs of the hospital's administration and in-house cancer programme [5]. For many years, PBCRs collected basic information targeted at ascertaining the incidence of different tumours, while hospital-based registries recorded many variables (relating to diagnosis, prognostic factors and treatment) on a more limited number of cases. Nowadays, however, the development of electronic clinical records and powerful linkage facilities means that this distinction is becoming increasingly old-fashioned. Moreover, as Parkin [3] has pointed out, PBCRs are an essential component of cancer surveillance around which cancer surveillance programmes are built.

A central cancer registry is a facility which co-ordinates co-operating hospital registries in a specific geographical area, and which collects, combines, compares and assesses uniformly defined information on cancer patients [6]. It may or may not cover a geographically defined population.

history of population-based cancer registries in Spain

The pioneers in cancer registration in Spain were the Zaragoza and Navarre registries, which came into operation in 1960 and 1970 [7, 8]. Two highly motivated physicians in the field of cancer control, Dr Zubiri in Zaragoza and Dr Viñes [9] in Navarre, led a process that was supported by the cancer leagues and health authorities. In 1977, Spain's first democratically elected government after the Franco dictatorship created the present-day Ministry of Health which, 1 year later, proceeded to launch a National Cancer Registration Plan. This plan sought to set up cancer registries in several regions, which, together with the established registries, would lead to registration that would be a true reflection of variability in cancer incidence across Spain. The new registries were established in Castile (Valladolid), Andalusia (Seville), the Canary Islands (Santa Cruz de Tenerife) and Asturias. Nevertheless, owing to lack of local support and sufficient funding, this initiative failed and, after a short period, three of the registries were closed [10]. Indeed, only the Asturias Cancer Registry is still operational [11]. Over the next decade, several registries were initiated, e.g. Tarragona (1980) [12], Murcia (1981) [13], Granada (1985) [14] and the Basque Country (1986) [15]. The Basque Country registry incorporated an existing hospital tumour registry in Guipúzcoa. In the following years, two monographic registries broadened their scope to cover all cancer sites, namely, the Mallorca Colorectal and Girona Female Breast and Gynaecological Cancer registries [16]. Currently, there are 12 registries that have contributed to the Cancer Incidence in Five Continents (CI5) series edited by the International Agency for Research on Cancer (IARC) (Table 1). The CI5 series of books provides incidence data that have been peer-reviewed, and are deemed to meet the quality criteria for unbiased registration [4]. If the La Rioja registry is included (data from which are included in several articles featured in this supplement), the combined population covered by these 13 registries is ∼12 million (26.5% of the Spanish population) (Figure 1) (Table 2). The situation in Spain is similar to that in other Mediterranean countries, such as France or Italy. Currently, 15 of the 27 European Union Member States have national cancer registration coverage, and eight have regional coverage [17].

Table 1.

Contribution of Spanish population-based cancer registries to the successive volumes of Cancer Incidence in Five Continentsa

Volume Period (approx.) No. registries No. Spanish registries Spanish registries 
III 1968–72 61 Zaragoza 
IV 1973–77 79 Zaragoza, Navarre 
1978–82 105 Zaragoza, Navarre, Tarragona 
VI 1983–87 138 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country 
VII 1988–92 150 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias 
VIII 1993–97 186 11 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias, Canary Islands, Cuenca, Girona 
IX 1998–2002 225 11 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias, Canary Islands, Cuenca, Girona 
Volume Period (approx.) No. registries No. Spanish registries Spanish registries 
III 1968–72 61 Zaragoza 
IV 1973–77 79 Zaragoza, Navarre 
1978–82 105 Zaragoza, Navarre, Tarragona 
VI 1983–87 138 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country 
VII 1988–92 150 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias 
VIII 1993–97 186 11 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias, Canary Islands, Cuenca, Girona 
IX 1998–2002 225 11 Zaragoza, Navarre, Tarragona, Murcia, Granada, Basque Country, Mallorca, Albacete, Asturias, Canary Islands, Cuenca, Girona 

aVolume III was published in 1976 and volume IX n 2007.

Table 2.

Population-based cancer registries in Spain: 2009

      Quality indicators for all sites: 1998–2002a Contribution of registry to articles of this supplement
 
      Men
 
Women
 
   
 First year of operationb Population in 2008 % of spanish population covered by the registry Founding statute (yes/no) CI5c %MV %DCO Mortality/incidence (%) % of unknown age %MV %DCO Mortality/incidence (%) % of unknown age Trends Childhood tumours Survival 
All sites 
Albacete 1990 400 836 0.9 Yes Yes 85.7 4.2 53.1 0.1 86.1 4.7 50.7 0.1 Yes Yes Yes 
Asturias 1982 1 085 110 2.3 No Yes 89.2 3.6 62.8 0.4 88.0 3.8 53.9 0.9 Yes Yes No 
Basque Country 1986 2 171 243 4.7 Yes Yes 88.7 2.6 52.3 0.0 87.8 3.8 48.0 0.0 Yes Yes Yes 
Canary Islands 1993 1 835 533 3.9 Yes Yes 87.9 4.0 56.4 0.1 89.2 3.9 49.6 0.0 Yes No No 
Cuenca 1993 216 899 0.5 Yes Yes 77.8 7.9 57.1 0.0 79.4 8.1 51.0 0.0 Yes No No 
Girona 1995 746 840 1.6 No Yes 88.5 3.7 50.8 0.2 87.7 4.4 45.1 0.2 Yes Yes Yes 
Granada 1985 905 285 1.9 Yes Yes 86.0 0.7 62.1 0.0 88.0 1.0 52.2 0.0 Yes Yes Yes 
La Rioja 1993 321 025 0.7 Yes No 81.5 4.6 56.3 0.0 81.2 6.0 51.6 0.0 Yes No No 
Mallorca 1988 846 210 1.8 No Yes 89.7 4.0 57.0 0.3 89.8 4.7 50.5 0.3 Yes Yes No 
Murcia 1981 1 445 410 3.1 Yes Yes 87.8 3.4 52.5 0.0 89.0 3.3 43.9 0.0 Yes Yes Yes 
Navarre 1970 629 569 1.3 No Yes 90.1 1.8 51.8 0.0 89.1 2.2 47.1 0.0 Yes Yes Yes 
Tarragona 1980 802 336 1.7 No Yes 87.3 4.6 48.9 0.5 87.1 5.4 48.0 0.5 Yes Yes Yes 
Zaragoza 1960 968 831 2.1 Yes Yes 91.4 4.3 69.2 0.1 90.0 5.0 62.2 0.1 Yes Yes No 
All  12 375 127 26.5              
Monographic                 
Castellón 1995 298 462 0.6 Yes No     95.0 4.5 29.4 0.0 Yes No Yes 
Valencian region (childhood) 2000 747 133 1.6 Yes No 91.84 0.4 16.3 0.0 93.88 0.0 20.0 0.0 No Yes No 
Spain  46 661 950 100.0              
      Quality indicators for all sites: 1998–2002a Contribution of registry to articles of this supplement
 
      Men
 
Women
 
   
 First year of operationb Population in 2008 % of spanish population covered by the registry Founding statute (yes/no) CI5c %MV %DCO Mortality/incidence (%) % of unknown age %MV %DCO Mortality/incidence (%) % of unknown age Trends Childhood tumours Survival 
All sites 
Albacete 1990 400 836 0.9 Yes Yes 85.7 4.2 53.1 0.1 86.1 4.7 50.7 0.1 Yes Yes Yes 
Asturias 1982 1 085 110 2.3 No Yes 89.2 3.6 62.8 0.4 88.0 3.8 53.9 0.9 Yes Yes No 
Basque Country 1986 2 171 243 4.7 Yes Yes 88.7 2.6 52.3 0.0 87.8 3.8 48.0 0.0 Yes Yes Yes 
Canary Islands 1993 1 835 533 3.9 Yes Yes 87.9 4.0 56.4 0.1 89.2 3.9 49.6 0.0 Yes No No 
Cuenca 1993 216 899 0.5 Yes Yes 77.8 7.9 57.1 0.0 79.4 8.1 51.0 0.0 Yes No No 
Girona 1995 746 840 1.6 No Yes 88.5 3.7 50.8 0.2 87.7 4.4 45.1 0.2 Yes Yes Yes 
Granada 1985 905 285 1.9 Yes Yes 86.0 0.7 62.1 0.0 88.0 1.0 52.2 0.0 Yes Yes Yes 
La Rioja 1993 321 025 0.7 Yes No 81.5 4.6 56.3 0.0 81.2 6.0 51.6 0.0 Yes No No 
Mallorca 1988 846 210 1.8 No Yes 89.7 4.0 57.0 0.3 89.8 4.7 50.5 0.3 Yes Yes No 
Murcia 1981 1 445 410 3.1 Yes Yes 87.8 3.4 52.5 0.0 89.0 3.3 43.9 0.0 Yes Yes Yes 
Navarre 1970 629 569 1.3 No Yes 90.1 1.8 51.8 0.0 89.1 2.2 47.1 0.0 Yes Yes Yes 
Tarragona 1980 802 336 1.7 No Yes 87.3 4.6 48.9 0.5 87.1 5.4 48.0 0.5 Yes Yes Yes 
Zaragoza 1960 968 831 2.1 Yes Yes 91.4 4.3 69.2 0.1 90.0 5.0 62.2 0.1 Yes Yes No 
All  12 375 127 26.5              
Monographic                 
Castellón 1995 298 462 0.6 Yes No     95.0 4.5 29.4 0.0 Yes No Yes 
Valencian region (childhood) 2000 747 133 1.6 Yes No 91.84 0.4 16.3 0.0 93.88 0.0 20.0 0.0 No Yes No 
Spain  46 661 950 100.0              
a

These indicators are for all sites excluding non-melanoma skin cancer.

b

Year when activities began or first year with incidence data.

c

Registries that have published in Cancer Incidence in Five Continents.

%DCO, percentage death certificate only; %MV, percentage microscopic verification.

Figure 1.

Population-based cancer registries in Spain 2009.

Figure 1.

Population-based cancer registries in Spain 2009.

Monographic cancer registries, albeit population based, solely collect cases representing a particular age range or cancer type. There are two such monographic registries in Spain, i.e. the Comunitat Valenciana Childhood Cancer Registry and Castellón Provincial Breast Cancer Registry. The latter is currently widening its scope to identify all cancers.

In addition, recent years have witnessed other initiatives to set up PBCRs in provinces or autonomous regions (Comunidades Autónomas) (Andalusia, Catalonia, Cantabria, Galicia, Castile–León, Castile–La Mancha and Extremadura). These PBCRs, data from which have not yet been included in international publications, are still at different stages of development [18].

Insofar as central cancer registries are concerned, the National Childhood Cancer Registry (Registro Nacional de Tumores Infantiles—Sociedad Española de Hematología Pediátrica/RNTI-SEHOP) is a specialised central cancer registry based in a nationwide network of collaborating centres, which includes all the paediatric oncology units in Spanish hospitals. Being a hospital-based scheme, the RNTI-SEHOP covers the entire country, with an estimated average completeness of expected incidence of >80% since 2000: in the geographical areas of Aragon, Catalonia, the Basque Country and Navarre, however, completeness comes close to being population based [19].

All registries belong to institutions that are funded by their respective regional authorities, except for Tarragona, which belongs to the Foundation Society for Cancer Research and Prevention, an institution that is likewise funded by its regional authority. Nevertheless, additional funds from research projects are an important supplementary source of revenue, since in several registries the official income is for basic operations. Legal support is to be found in the regulations of the pertinent institution and, in some cases, in a specific Founding Statute (Table 2). In addition to their adherence to both national and international confidentiality guidelines, all cancer registry databases are registered with the Spanish Data Protection Authority as required by law [20].

quality indicators

The role of cancer registries can be summarised by classifying it into five areas, namely: cancer control; research; informing the public; health education; and teaching. Cancer registries must have quality-control procedures in place so as to produce reliable data and achieve their designated aims. The three components of quality in cancer registration are: completeness (the proportion of all incident cancer cases in a registry population that is included in the registry database); validity (the proportion of cases in the database with a given characteristic, such as site or age, that truly has the attribute); and timeliness [21, 22]. A comprehensive set of indicators routinely measured by cancer registries is scrutinised to assess the quality of the data submitted for publication in CI5. These are fully described in Chapter 5 of Volume IX [23], and some are shown in Table 2 for Spanish cancer registries, e.g. the proportion of microscopically verified cases (MV%), the proportion of death-certificate-only registrations (DCO%), the mortality:incidence ratio (M:I) and the proportion of cases for which age was unknown. All registries’ quality-control indicators meet the IARC inclusion criteria for comparability and quality of data, and indeed some fulfil most of the excellence criteria, such as those required by the North American Association of Central Cancer Registries, for gold standard certification (e.g. DCO% ≤3%) [24] (Table 2). Some registries are also able to monitor death-certificate-initiated (DCI) cases to assess completeness. A DCI registration is one for which the initial information comes via the death certificate, without which the case would never have been detected. DCI cases represent a failure to identify cases during life, and the proportion of such cases can therefore be used to provide a quantitative estimate of completeness. All Spanish registries endeavour to trace DCI cases, while DCO cases represent those cases for which no information other than a death certificate mentioning cancer could be obtained [22]. Figure 2 depicts the trend in DCOs and DCIs for four registries: DCIs were high at the inception of case registration, with a sharp decline in the initial years and a subsequent stabilisation as case-ascertainment procedures became consolidated. As 100% completeness is almost impossible to attain, completeness is deemed acceptable where it is ≥90%, and very good where it is ≥95% [24]. Quantitative methods for evaluating completeness based on death certificate notification and M:I, and applied to these registries for the most recent period resulted in coverage of close to 95% in three instances. Overall, therefore, Spanish registries can be said to record and produce good quality data.

Figure 2.

Death Certificate Notification (DCN) and Death Certificate Only (DCO) cases as a percentage of total registrations for all sites, except non-melanoma skin cancer: Tarragona, Murcia, Mallorca and Cuenca registries, 1982–2004.

Figure 2.

Death Certificate Notification (DCN) and Death Certificate Only (DCO) cases as a percentage of total registrations for all sites, except non-melanoma skin cancer: Tarragona, Murcia, Mallorca and Cuenca registries, 1982–2004.

cancer incidence and trends

The most basic function of PBCRs in relation to cancer control is to assess the magnitude of the cancer burden and its probable future trend. Measurement of incidence (new cases), trends and projections by cancer site are the main goals of cancer registries. More recently, population-based survival and prevalence have also been included among their usual activities. As is standard practice for cancer registries worldwide, Spanish PBCRs produce data on cancer incidence by age, cancer site and residence, as part of their regular activities in aid of cancer control in the areas in which they are located. Reports and monographs with these data are available on their websites.

In 1998–2002, age-standardised incidence rates (standardised to the world population) for all cancers, except non-melanoma skin cancer, ranged from 150.3 per 100 000 women in Cuenca to 207.2 in Girona, and from 221.1 per 100 000 men in Cuenca to 350.6 in the Basque Country. Registries in the north of Spain displayed moderate rates in comparison with other European areas but southern registries showed low rates. Whereas breast, colon and corpus uteri were the most common sites for cancers in women, prostate, lung and bladder were the leading sites for cancer in men (Figure 3). Spain has one of the highest incidences in the world of lip, laryngeal and urinary bladder cancer in men, and very low rates of cervical cancer in women [23].

Figure 3.

Age-standardised (world) incidence rates for all cancers, except non-melanoma skin cancer, and for the three leading sites for men and women: Spanish regions covered by population-based cancer registries, 1998–2002. Data published in Cancer Incidence in Five Continents, Vol IX (reference 23).

Figure 3.

Age-standardised (world) incidence rates for all cancers, except non-melanoma skin cancer, and for the three leading sites for men and women: Spanish regions covered by population-based cancer registries, 1998–2002. Data published in Cancer Incidence in Five Continents, Vol IX (reference 23).

survival

Information on population-based survival is a key indicator in assessing accessibility to and performance of health care. It is also required for estimating how many cancer survivors are alive at any one time, in order to plan health services (prevalence). These data can only be sourced from population-based cancer registries. EUROCARE (European Cancer Registry-based Study on Survival and Care) project was set up in 1989 to measure and explain international differences in cancer survival in Europe [25]. The latest report (EUROCARE-4) presented survival data drawn from 83 cancer registries in 23 European countries on adult European patients diagnosed in the period 1995–99 and followed up until the end of 2003 [26]. Since the first study was published, a steadily increasing number of Spanish registries have contributed to EUROCARE, with 10 registries contributing to EUROCARE-4 (Table 3). Until very recently, follow-up has not been an easy task in Spain because the National Death Index, a database that includes all deaths that have occurred since 1987, was not accessible prior to 2005 [27]. Apart from EUROCARE, individual registries have published survival analyses, mostly focused on a specific cancer [28–33]. In the 1990s, an initiative was sponsored by the European Network of Cancer Registries to establish the Automated Childhood Cancer Information System (ACCIS), with the aim of collecting, presenting, interpreting and disseminating data on childhood cancer in Europe and, primarily, furnishing valid incidence and survival indicators. The ACCIS database contains childhood and adolescent cancer cases registered over the last 30 years in 78 European PBCRs based in 27 European countries [34]. Ten Spanish PBCRs contributed data to this project [31, 35, 36].

Table 3.

Main international and national research projects in which Spanish registries have been or are currently involved

Project National (N) or International (I) Year Design/aims Co-ordinating centre Registriesa No. of countries 
Cancer of the larynx/hypopharynx, tobacco and alcohol: IARC international case–control study in Turin and Varese (Italy), Zaragoza and Navarre (Spain), Geneva (Switzerland) and Calvados (France) 1980 Population-based case–control International Agency for Research on Cancer (IARC), France Na, Za 
Cervical cancer, human papillomavirus and sex behaviour in Spain and Colombia 1985 Population-based case–control IARC, France Gi, BC, Mu, Na, Za 
SEARCH Childhood Brain Tumours Study 1985 Population-based case–control IARC, France RTICVb 
HELIOS I: Risk factors of non-melanoma skin cancer 1989 Population-based case–control Piedmont Cancer Registry, Turin, Italy Gr, Mu 
HELIOS II: Prevention of melanoma and non-melanocytic skin cancers: development of a new method for high-risk group detection (HELIOS-2) 2001 Hospital-based case–control Piedmont Cancer Registry, Turin, Italy Gr, Mu 
EUROCARE: European Cancer Registry-based Study on Survival and Care 1990 Population-based survival National Tumour Institute, Milan, Italy Gi, Gr, Ma, Ta 12 
EUROCARE-2 1993 Population-based survival National Tumour Institute, Milan, Italy Gi, BC, Gr, Ma, Na, Ta 17 
EUROCARE-3 1997 Population-based survival National Tumour Institute, Milan, Italy BC, Ca, Gr, Ma, Na, Ta, RTICVb, RNTIc 20 
EUROCARE High Resolution Study: understanding the reasons for cancer patients’ survival differences in Europe 1999 Population-based, patterns of care and survival National Tumour Institute, Milan, Italy Ca, Gr, Na, Ta 
EUROCARE-4 2000 Population-based survival National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Na, Ta, RNTIc, RTICVb 23 
EPIC: European Prospective Investigation into Cancer and nutrition 1990 Prospective cohort IARC, France As, BC (Gui), Gr, Mu, Na 10 
EUROCLUS Clustering of Childhood Leukaemia in Europe 1993 Clustering and trends University of Edinburgh, Scotland, UK RTICV 11 
EPIC-Elderly: The role of diet on the longevity of elderly Europeans 2002 Prospective cohort University of Athens, Greece As, BC (Gui), Gr, Mu, Na 10 
EUROCIM: Cancer Incidence and Mortality in Spain – Patterns and Trends 1990 Incidence and trends IARC, France Ab, As, Gr, Ca, Ma, Mu, Na, Ta, Za, BC 
The ECP calcium fibre polyp prevention study 1990 Clinical trial Digestive Cancer Registry of Burgundy (Registre Bourguignon des Tumeurs Digestives), Dijon, France Ma 
EUROPREVAL 1996 Prevalence National Tumour Institute, Milan, Italy BC, Ma, Na, Ta 17 
International multicentre case–control study of cancer of the oral cavity and oropharynx and human papillomavirus (HPV) 1997 Hospital-based case–control IARC, France Gr 
Assessment of feasibility of workplace health promotion (PREWORK) 1997 Health promotion Finnish Institute of Occupational Health, Helsinki, Finland Ma 
ACCIS: Automated Childhood Cancer Information System 1999 Incidence and population-based survival IARC, France Ab, As, BC, Gi, Gr, CI, Ma, Na, Ta, Za, RNTIb 27 
CONCORD Study: cancer survival worldwide 1999 Population-based survival London School of Hygiene and Tropical Medicine, London, UK BC, Gr, Ma, Mu, Na, Ta 28 
EUROCHIP: European Cancer Health Indicator Project 2001 Health indicators National Tumour Institute, Milan, Italy BC, Gr, Mu, Ma, Na 15 
EUROCHIP-2 – The Action 2004 Health indicators National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Mu, Na, Za 27 
EUROCHIP-3 – Inequalities 2008 Health indicators National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Mu, Na 27 
Second primary multiple tumours 2001 Descriptive IARC, France Za 10 
HAEMACARE- Cancer Registry Based project on Haematological malignancies 2005 Incidence, prevalence and population-based survival National Tumour Institute, Milan, Italy BC, Gr, Gi, Ma, Na, Za, 15 
RARECARE: Surveillance of Rare Cancers in Europe 2007 Incidence, prevalence and population-based survival National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Na, Mu, Ta, RTICV 22 
REDEPICAN: Red Iberoamericana de Sistemas de Información y Epidemiología del Cáncer (Latin American Cancer Epidemiology and Informations Systems Network) 2007 Network Cuban Cancer Registry BC, Gr, Mu 
Collaborative Group on Observational Studies of Breast Cancer Survivors (COBS) 2007 Prospective cohort University of Oxford, UK Gi, Na 29 
EUROCOURSE 2008 Network European Network of Cancer Registries BC, Na, Ta 12 
Rare tumours in Spain 2003 Incidence and population-based survival Andalusian School of Public Health, Granada, Spain Ab, As, BC, Ca, Cu, Gi, Gr, CI, Ma, Mu, Na, Ri, Ta, Za NAd 
Aromatic DNA adducts, genetic susceptibility and risk of cancers of lung, stomach, breast, and colon and rectum. 2005 Case–cohort Catalonian Oncology Institute, Barcelona, Spain As, BC(Gui), Gr, Mu, Na NA 
Accuracy of the hospital administrative databases in identifying incident cases of different cancers: strategies to evaluate health care providers using administrative data 2006 Validation study Aragon Health Sciences Institute, Zaragoza, Spain BC, Gr, Mu, Za NA 
Incidence of and trends in childhood tumours in Spain: a collaboration of 11 registries 2007 Incidence and trends National Childhood Cancer Registry (Registro Nacional Tumores InfantilesRNTI). University of Valencia, Spain Ab, As, BC, RTICV, Gi, Gr, Ma, Mu, Na, Ta, Za, NA 
Female breast cancer survival, variations in clinical practices and other associated factors: study in eight Spanish population-based cancer registries 2008 Retrospective cohort Aragon Health Sciences Institute, Zaragoza, Spain Ab, BC, Ca, Cu, Gi, Gr, Mu, Na, Ri NA 
New epidemiological methods and health information systems in cancer 2008 Incidence, trends and population-based survival Regional Health Authority, Murcia, Spain All NA 
MEDEA: cancer incidence, socio-economic inequalities and industrial pollution 2009 Geocoding and small areas analysis Public Health Agency, Barcelona, Spain As, Gi, Mu, Za NA 
Project National (N) or International (I) Year Design/aims Co-ordinating centre Registriesa No. of countries 
Cancer of the larynx/hypopharynx, tobacco and alcohol: IARC international case–control study in Turin and Varese (Italy), Zaragoza and Navarre (Spain), Geneva (Switzerland) and Calvados (France) 1980 Population-based case–control International Agency for Research on Cancer (IARC), France Na, Za 
Cervical cancer, human papillomavirus and sex behaviour in Spain and Colombia 1985 Population-based case–control IARC, France Gi, BC, Mu, Na, Za 
SEARCH Childhood Brain Tumours Study 1985 Population-based case–control IARC, France RTICVb 
HELIOS I: Risk factors of non-melanoma skin cancer 1989 Population-based case–control Piedmont Cancer Registry, Turin, Italy Gr, Mu 
HELIOS II: Prevention of melanoma and non-melanocytic skin cancers: development of a new method for high-risk group detection (HELIOS-2) 2001 Hospital-based case–control Piedmont Cancer Registry, Turin, Italy Gr, Mu 
EUROCARE: European Cancer Registry-based Study on Survival and Care 1990 Population-based survival National Tumour Institute, Milan, Italy Gi, Gr, Ma, Ta 12 
EUROCARE-2 1993 Population-based survival National Tumour Institute, Milan, Italy Gi, BC, Gr, Ma, Na, Ta 17 
EUROCARE-3 1997 Population-based survival National Tumour Institute, Milan, Italy BC, Ca, Gr, Ma, Na, Ta, RTICVb, RNTIc 20 
EUROCARE High Resolution Study: understanding the reasons for cancer patients’ survival differences in Europe 1999 Population-based, patterns of care and survival National Tumour Institute, Milan, Italy Ca, Gr, Na, Ta 
EUROCARE-4 2000 Population-based survival National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Na, Ta, RNTIc, RTICVb 23 
EPIC: European Prospective Investigation into Cancer and nutrition 1990 Prospective cohort IARC, France As, BC (Gui), Gr, Mu, Na 10 
EUROCLUS Clustering of Childhood Leukaemia in Europe 1993 Clustering and trends University of Edinburgh, Scotland, UK RTICV 11 
EPIC-Elderly: The role of diet on the longevity of elderly Europeans 2002 Prospective cohort University of Athens, Greece As, BC (Gui), Gr, Mu, Na 10 
EUROCIM: Cancer Incidence and Mortality in Spain – Patterns and Trends 1990 Incidence and trends IARC, France Ab, As, Gr, Ca, Ma, Mu, Na, Ta, Za, BC 
The ECP calcium fibre polyp prevention study 1990 Clinical trial Digestive Cancer Registry of Burgundy (Registre Bourguignon des Tumeurs Digestives), Dijon, France Ma 
EUROPREVAL 1996 Prevalence National Tumour Institute, Milan, Italy BC, Ma, Na, Ta 17 
International multicentre case–control study of cancer of the oral cavity and oropharynx and human papillomavirus (HPV) 1997 Hospital-based case–control IARC, France Gr 
Assessment of feasibility of workplace health promotion (PREWORK) 1997 Health promotion Finnish Institute of Occupational Health, Helsinki, Finland Ma 
ACCIS: Automated Childhood Cancer Information System 1999 Incidence and population-based survival IARC, France Ab, As, BC, Gi, Gr, CI, Ma, Na, Ta, Za, RNTIb 27 
CONCORD Study: cancer survival worldwide 1999 Population-based survival London School of Hygiene and Tropical Medicine, London, UK BC, Gr, Ma, Mu, Na, Ta 28 
EUROCHIP: European Cancer Health Indicator Project 2001 Health indicators National Tumour Institute, Milan, Italy BC, Gr, Mu, Ma, Na 15 
EUROCHIP-2 – The Action 2004 Health indicators National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Mu, Na, Za 27 
EUROCHIP-3 – Inequalities 2008 Health indicators National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Mu, Na 27 
Second primary multiple tumours 2001 Descriptive IARC, France Za 10 
HAEMACARE- Cancer Registry Based project on Haematological malignancies 2005 Incidence, prevalence and population-based survival National Tumour Institute, Milan, Italy BC, Gr, Gi, Ma, Na, Za, 15 
RARECARE: Surveillance of Rare Cancers in Europe 2007 Incidence, prevalence and population-based survival National Tumour Institute, Milan, Italy Ab, BC, Ca, Gi, Gr, Na, Mu, Ta, RTICV 22 
REDEPICAN: Red Iberoamericana de Sistemas de Información y Epidemiología del Cáncer (Latin American Cancer Epidemiology and Informations Systems Network) 2007 Network Cuban Cancer Registry BC, Gr, Mu 
Collaborative Group on Observational Studies of Breast Cancer Survivors (COBS) 2007 Prospective cohort University of Oxford, UK Gi, Na 29 
EUROCOURSE 2008 Network European Network of Cancer Registries BC, Na, Ta 12 
Rare tumours in Spain 2003 Incidence and population-based survival Andalusian School of Public Health, Granada, Spain Ab, As, BC, Ca, Cu, Gi, Gr, CI, Ma, Mu, Na, Ri, Ta, Za NAd 
Aromatic DNA adducts, genetic susceptibility and risk of cancers of lung, stomach, breast, and colon and rectum. 2005 Case–cohort Catalonian Oncology Institute, Barcelona, Spain As, BC(Gui), Gr, Mu, Na NA 
Accuracy of the hospital administrative databases in identifying incident cases of different cancers: strategies to evaluate health care providers using administrative data 2006 Validation study Aragon Health Sciences Institute, Zaragoza, Spain BC, Gr, Mu, Za NA 
Incidence of and trends in childhood tumours in Spain: a collaboration of 11 registries 2007 Incidence and trends National Childhood Cancer Registry (Registro Nacional Tumores InfantilesRNTI). University of Valencia, Spain Ab, As, BC, RTICV, Gi, Gr, Ma, Mu, Na, Ta, Za, NA 
Female breast cancer survival, variations in clinical practices and other associated factors: study in eight Spanish population-based cancer registries 2008 Retrospective cohort Aragon Health Sciences Institute, Zaragoza, Spain Ab, BC, Ca, Cu, Gi, Gr, Mu, Na, Ri NA 
New epidemiological methods and health information systems in cancer 2008 Incidence, trends and population-based survival Regional Health Authority, Murcia, Spain All NA 
MEDEA: cancer incidence, socio-economic inequalities and industrial pollution 2009 Geocoding and small areas analysis Public Health Agency, Barcelona, Spain As, Gi, Mu, Za NA 
a

Ab, Albacete; As, Asturias; BC, Basque Country; BC(Gui), Guipúzkoa; Ca, Castellón; Cu, Cuenca; Gi, Girona; Gr, Granada; CI, Canary Islands; Ma, Mallorca; Mu, Murcia; Na, Navarre; Ta, Tarragona; Ri, Rioja; Za, Zaragoza; RTICV, Valencian Regional Childhood Cancer Registry; RNTI, Spanish National Childhood Cancer Registry (Registro Nacional de Tumores Infantiles).

b

Prior to 2000, coverage limited to the Province of Valencia since 1983.

c

RNTI participated with data from two areas (Aragon, Catalonia) without overlapping with the PBCRs in the same regions.

d

Not applicable.

patient care

After their initiation into recording accurate and complete information targeted at ascertaining cancer incidence in their catchment areas, PBCRs are progressively broadening their scope and becoming increasingly involved in collecting and analysing additional data on patient care, diagnosis, disease stage, treatment and follow-up. Hence, rather than being confined to cancer incidence alone, PBCRs can also monitor some aspects of clinical cancer care practice, thus providing a population-based focus.

In this context, PBCRs could contribute to the management of cancer patient care programmes established in their designated catchment area, by ensuring that all cancer patients have access to the same resources for diagnosis and treatment, and are managed according to the recommended guidelines. Variations in patterns of care can make a difference in terms of outcome, and comparative studies can provide interesting observations concerning the impact of such variations, principally in terms of survival and/or quality of life. EUROCARE is an example of a collaborative study in which variations in cancer patient survival among different European areas have been observed, in that collection of additional data has highlighted just how important stage at diagnosis and treatment can be in terms of outcome [37].

planning and evaluation

Cancer registries are playing a relevant role in establishing and evaluating cancer control programmes in Spain at both national and regional level. As most of them belong to the Regional Health Authorities, registry staff often participate in different stages of the cancer planning process, e.g. by furnishing data for setting priorities and action plans, analysing data before implementing breast and colorectal screening programmes, and providing interval cases for assessing such programmes. No less important is their involvement in numerous task forces and working groups. Although this work is time consuming and partly invisible, it is nevertheless of great value because it is a means of transferring the results of research to public health practice.

research

PBCRs play an important role in cancer research. Cancer registries produce descriptive epidemiology results, including time trends and geographical patterns of incidence rates, which are useful, not only for planning and evaluation, but also for the generation of hypotheses. Among recent publications on time trends are the article on breast cancer by Pollán et al. [38] and those included in this issue [39–46]. While a detailed description of the research undertaken by Spanish PBCRs goes beyond the scope of this article, a brief outline is nonetheless warranted. Table 3 summarises the main international and national research projects in which Spanish registries have been or are currently involved. These were chosen on the basis of the following criteria: (i) international where more than one country participated, or national where at least four registries were included; (ii) funding coming from a public agency, with competitive calls and peer review; (iii) with publications, where the project had concluded; (iv) IARC-funded projects. Several characteristics can be highlighted, namely: (a) the high degree of collaboration with the IARC, with PBCRs having been involved in aetiological research projects co-ordinated by the IARC for almost 30 years, starting as far back as 1980 with the case–control study on cancer of the larynx/hypopharynx, tobacco and alcohol conducted in Italy, Spain (Zaragoza and Navarre), Switzerland and France [47]; (b) the mean number of projects per registry is 11 (range 2–24) with four registries (Basque Country, Granada, Murcia and Navarre) participating in ≥18; (c) the diversity of design, including large multicentre prospective cohort studies, such as the European Prospective Investigation on Cancer and Nutrition (EPIC) [48, 49], population-based case–control studies [50, 51], clinical trials [52], validity studies [53] and studies on survival and patterns of care [37, 54]; (d) during the past decade, several collaborative projects among cancer registries have been launched in the framework of the Networks of Excellence in Epidemiology and Public Health, and promoted by the Carlos III Institute of Health (Instituto de Salud Carlos IIIISCIII), the agency that funds health research in Spain; and consequently, (e) there are several new projects featuring leaders belonging to a cancer registry.

final comments

Although >26% of the Spanish population is covered by cancer registries (28% in the case of childhood cancer), the distribution of these registries is not random. Estimates based on pooling the results from existing registries may not be as accurate as a nationwide cancer registry but could provide a reasonable approximation to the position in Spain as a whole. Furthermore, PBCR-based indices, such as the M:I ratio, are used to calculate cancer incidence for the entire country or autonomous region, as has indeed been done both in Spain and in other countries without national coverage by applying statistical methods of a lesser or greater degree of sophistication [55–57]. In the USA, the Surveillance, Epidemiology and End Results (SEER) programme, set up in 1973 by the National Cancer Institute, comprises 18 cancer registries that also cover a non-random sample of the population. Some 20 years later a National Cancer Registry Programme was established with the aim of having a PBCR in every State [4, 58]. In Spain, 11 out of 17 Autonomous Regions have PBCRs and a minimum of another five are in the process of establishing or consolidating one.

The successful collaboration between Spanish registries in both international and national projects, as well as the booster effect of more recent networking in public health and epidemiology promoted by the Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), should serve as encouragement for promoting a more stable relationship. Good instances of this are the French Network of Cancer Registries (FRANce-Cancer-Incidence et Mortalité – FRANCIM) and the Italian Network of Cancer Registries (Associazione Italiana Registri Tumori – AIRT). Following the experiences of and example set by other countries, this network of Spanish cancer registries should be a key player in providing guidance, training, technical assistance and quality audits [58].

A pilot study conducted by eight Spanish cancer registries within the framework of the European Cancer Health Indicator Project (Phase 2) revealed that, while measuring diagnostic and treatment delays and adherence to clinical guidelines was feasible, manually reviewing clinical records for all cancer cases was time consuming and unrealistic [59]. The swift development of information technology over the last 10 years (computerised clinical records, powerful tools for record-linkage), coupled with advances in automating cancer registration procedures (identification of duplicates, selection and coding of cancer site and histology), will make operating PBCRs far less labour intensive and afford an enhanced capability to produce indicators for cancer surveillance programmes at a reasonable cost.

Aside from information technology and development of electronic health records, other factors have a positive effect on the role of PBCRs, including the increasing demand for public information and public health activities. At the same time, however, registries will have to make an effort to demonstrate the potential of cancer registration to clinicians and health authorities, in terms of how such data could be used by them, the limitations of such use and the way in which registries could be supported and influenced during this changeover period [60].

disclosures

The authors have indicated no conflicts of interest.

Other members of the Working group: M. Argüelles (Asturias Cancer Registry, Directorate-General of Public Health and Participation, Health and Medical Services Authority, Oviedo); I. Garau (Mallorca Cancer Registry, Epidemiology Department, Directorate-General of Public Health and Participation, Palma de Mallorca); E. Almar (Albacete Cancer Registry, Health and Social Welfare Authority, Castile–La Mancha); Á. Izquierdo (Girona Epidemiology Unit and Cancer Registry, Department of Health, Girona); J. M. Díaz (Cuenca Cancer Registry, Health and Social Welfare Authority, Castile–La Mancha); D. Rojas (Canary Islands Cancer Registry, Directorate-General of Public Health, Canary Service of Health, Canary Island); J. Perucha (La Rioja Cancer Registry, Department of Epidemiology and Health Prevention, Logroño); A. Torrella (Castelló Cancer Registry, Directorate-General of Public Health, Castelló); M.L. Vicente-Raneda (Comunitat Valenciana Childhood Cancer Registry).

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Author notes

Other members of the Working group are listed in the Acknowledgements.