Drug Can Reduce Risk of Breast Cancer, Study Says

Two drugs, tamoxifen and raloxifene, are already approved to prevent breast cancer but both are rarely used for that purpose, in part because they can have serious side effects like blood clots. The researchers said the new option, exemestane, does not have those side effects and might be more acceptable.

“There’s a very safe therapy that looks highly effective in preventing breast cancer,” Dr. Paul E. Goss, professor of medicine at Harvard and Massachusetts General Hospital, said at a news conference at the annual meeting of the American Society of Clinical Oncology. He was the lead investigator in the study, which was presented at the conference and published online by the New England Journal of Medicine.

Exemestane, also known by the brand name Aromasin, is one of a class of compounds known as aromatase inhibitors. These drugs stop the production of estrogen, which fuels tumor growth. They have proven superior to tamoxifen in preventing recurrence of cancer after a breast tumor is removed.

So researchers have long suspected that aromatase inhibitors would also reduce the risk of an initial occurrence of breast cancer, though this is the first big randomized study to demonstrate that.

The trial involved 4,560 post-menopausal women in the United States, Canada, France and Spain who were considered to be at a higher than normal risk of developing breast cancer either because of being over at least 60 or other factors. After a follow-up of about three years, 11 women getting the drug had developed invasive breast cancer compared with 32 of the women receiving a placebo. That is a reduction in risk of 65 percent.

But in absolute terms, 1.4 percent of women in the placebo group developed cancer compared with about one-half of 1 percent of women taking the drug.

About 94 women would have to be treated for three years to prevent one case of breast cancer, Dr. Goss said. In the trial, exemestane side effects were acceptable, he said. But women who took exemestane had more hot flashes and arthritis than those who had the placebo.

Still, whether exemestane will catch on where the other drugs have not remains to be seen.

Some doctors and patient advocates said that aromatase inhibitors had known side effects like bone pain and joint pain that caused many women who already had had cancer to stop taking them. For healthy women, that would be an even harder sell.

“People are going to think very, very hard about it before they are going to take an aromatase inhibitor in this setting,” said Dr. Eric Winer, a breast cancer specialist at the Dana-Farber Cancer Institute in Boston. He noted the study was not designed to show whether women who took exemestane lived longer.

Diana Zuckerman, president of the Cancer Prevention and Treatment Fund, a patient education group, said that the results were promising but that women in the study were followed for only three years, too short a period to judge long-term effects from taking the drug.

Dr. J. Leonard Lichtenfeld, deputy medical director of the American Cancer Society, said the drugs would be more accepted if there were a way to better predict who was truly at risk of getting breast cancer.

Another factor working against broad use is that aromatase inhibitors are now prescribed by oncologists. But for prevention, “They would have to be prescribed by gynecologists and family doctors,” said Dr. George W. Sledge Jr., a breast cancer specialist at Indiana University. “These doctors are not comfortable with these drugs.”

Patent protection on the drug expired in April. Generic versions will mean lower prices.

But generic competition also means that Pfizer, which sells Aromasin, has little incentive to seek regulatory approval for the drug for preventing breast cancer. The drug could still be available to women off label, but insurers might be reluctant to pay.

Pfizer declined to comment on whether it would seek such approval. Pfizer helped pay for the study, and Dr. Goss has received honorariums from the company.

Two other studies presented at the conference show that the widely used cancer drug Avastin is effective in delaying the progression of ovarian cancer. But both studies so far have narrowly missed showing that the drug can prolong lives, the ultimate test of a cancer drug. That threatens to embroil the use of Avastin for ovarian cancer in a debate similar to the one surrounding its use in breast cancer.

The drug’s manufacturer, Roche, has filed for approval in Europe to market the drug as a treatment for ovarian cancer. But its American subsidiary, Genentech, is still in discussions with the Food and Drug Administration about whether there is enough evidence for an approval. One question is whether it will be necessary to show that the drug prolongs lives, said Dr. Sandra Horning, who runs cancer clinical trials for Genentech. The F.D.A. is now moving to revoke the approval of Avastin for use in treating breast cancer in part because the drug has not prolonged lives in clinical trials. The F.D.A. will hold a hearing on this issue soon.

One study presented here involved 484 women whose ovarian cancer had recurred after an initial drug treatment. All received two standard drugs, and half of them also received Avastin.

The median time that women lived before their cancer worsened was 12.4 months for those who got Avastin compared with 8.4 months for those who received only the two other drugs.

After two years, more women given Avastin were alive, but the difference was not quite statistically significant. Too few women had died to draw conclusions.

“It really is not appropriate statistically to say we really know anything about overall survival here,” said Dr. Carol Aghajanian of the Memorial Sloan-Kettering Cancer Center, the lead investigator. The trial was sponsored by Genentech.

The other trial, partly paid for by Roche, involved adding Avastin to the standard drugs used as initial therapy. There were 178 deaths in the Avastin arm and 200 among those who got the standard drugs, a finding that narrowly missed statistical significance. However, in a subset of patients considered to be at higher risk of recurrence, there was a statistically significant improvement in survival.

View the original article here

Review Casts More Doubts on a Lung Cancer Study

 

But the doctors who conducted a controversial, widely publicized lung cancer study involving more than 50,000 patients at numerous hospitals were unable to locate 90 percent of the consent forms, according to a confidential review provided to The New York Times.

The finding casts further doubt on a clinical trial that made headlines in 2006 when it concluded that fully 80 percent of lung cancer deaths could be prevented through wide use of CT scans.

That trial, led by Dr. Claudia I. Henschke at Weill Cornell Medical College in New York City, drew sharp criticism from skeptics of cancer screening; the criticism intensified when The Times reported in March 2008 that the research was being financed in part by $3.6 million in grants from the parent company of the Liggett Group, a cigarette maker.

The confidential report on patient consent, dated Oct. 7, 2008, recommended that the trial be stopped. But it continues to this day, although not at Weill Cornell.

Several ethicists said the hospital was legally required to disclose the ethical problems documented by the secret review. That has not happened either.

The confidential report was commissioned by Weill Cornell after The Times’s 2008 article and other revelations about the study in the newsletter The Cancer Letter. The hospital hired four prominent professors from other universities to undertake an independent review of Dr. Henschke’s research, known as the International Early Lung Cancer Action Program, or I-Elcap.

In their report, the reviewers scolded Weill Cornell administrators for failing to supervise the research more closely, “especially knowing that scientific controversy has surrounded I-Elcap almost from its inception.”

One reviewer, Dr. David P. Carbone, a professor of medicine and cancer biology at Vanderbilt, said in an interview that he and the other reviewers never found out “whether these consents were obtained and lost or whether they weren’t obtained at all.”

He said that Dr. Henschke acted with the best of intentions, “but there’s no way for me to justify any of the problems” documented by the group’s review.

Dr. Henschke, who has since left Weill Cornell for Mount Sinai Medical Center in New York, declined to respond to the findings of the 2008 review, saying it was confidential. But in an e-mail, she said the responsibility for keeping track of consent forms lay with all the hospitals where the experiments were done.

“I-Elcap is a non-federally funded academic consortium of independent, autonomous sites that share certain data,” she wrote.? “Accountability and responsibility for human protection lie at the local level.”

But Dr. Henschke’s research has been supported by grants from the National Institutes of Health, and federal rules governing research conducted at multiple sites have long required that the coordinating center either collect copies of patient consent forms or ensure that they are being kept appropriately.

“The responsible conduct of a study requires that informed consent documents be kept on file,” said Dr. P. Pearl O’Rourke, director of human research affairs at Partners HealthCare, part of Harvard University. “There should be a system so that every consent form can be found no matter if individuals were enrolled at a single site or multiple sites.”

John D. Rodgers, a spokesman for Weill Cornell, wrote in an e-mail that the medical school followed federal research regulations “and there were no issues regarding the safety of the research subjects.”

Dr. Bruce A. Chabner, director of clinical research at Massachusetts General Hospital Cancer Center and editor in chief of The Oncologist journal, said he would ask Weill Cornell for an explanation of the problems outlined in the 2008 scientific review, as well as a follow-up to the report. His journal has published research by Dr. Henschke, and “if we find there was no informed consent for those patients, the paper would have to retracted,” he said.

The American Cancer Society helped finance Dr. Henschke’s research, and some of her work was published in cancer journals owned by the society. Dr. Otis W. Brawley, the society’s chief medical officer, said any study underwritten by the organization must conform to federal research rules, including those that require that problems with informed consent be reported to federal science agencies.

He added that the society’s journals might have to correct or retract any study that proved unable to document that patients had given informed consent. “But I don’t want to prejudge the case,” Dr. Brawley said.

In November, a huge federal study found that annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent and, even more surprising, seemed to reduce the risks of death from other causes as well.

Although the scale of the benefit was substantially less than Dr. Henschke claimed her research showed, the federal study was widely interpreted as confirming her longtime contention that CT screening can save lives from lung cancer, which kills more than 150,000 people each year in the United States. Most patients discover their disease too late for treatment, and 85 percent die from it.

 

Review Casts More Doubts on a Lung Cancer Study

But the doctors who conducted a controversial, widely publicized lung cancer study involving more than 50,000 patients at numerous hospitals were unable to locate 90 percent of the consent forms, according to a confidential review provided to The New York Times.

The finding casts further doubt on a clinical trial that made headlines in 2006 when it concluded that fully 80 percent of lung cancer deaths could be prevented through wide use of CT scans.

That trial, led by Dr. Claudia I. Henschke at Weill Cornell Medical College in New York City, drew sharp criticism from skeptics of cancer screening; the criticism intensified when The Times reported in March 2008 that the research was being financed in part by $3.6 million in grants from the parent company of the Liggett Group, a cigarette maker.

The confidential report on patient consent, dated Oct. 7, 2008, recommended that the trial be stopped. But it continues to this day, although not at Weill Cornell.

Several ethicists said the hospital was legally required to disclose the ethical problems documented by the secret review. That has not happened either.

The confidential report was commissioned by Weill Cornell after The Times’s 2008 article and other revelations about the study in the newsletter The Cancer Letter. The hospital hired four prominent professors from other universities to undertake an independent review of Dr. Henschke’s research, known as the International Early Lung Cancer Action Program, or I-Elcap.

In their report, the reviewers scolded Weill Cornell administrators for failing to supervise the research more closely, “especially knowing that scientific controversy has surrounded I-Elcap almost from its inception.”

One reviewer, Dr. David P. Carbone, a professor of medicine and cancer biology at Vanderbilt, said in an interview that he and the other reviewers never found out “whether these consents were obtained and lost or whether they weren’t obtained at all.”

He said that Dr. Henschke acted with the best of intentions, “but there’s no way for me to justify any of the problems” documented by the group’s review.

Dr. Henschke, who has since left Weill Cornell for Mount Sinai Medical Center in New York, declined to respond to the findings of the 2008 review, saying it was confidential. But in an e-mail, she said the responsibility for keeping track of consent forms lay with all the hospitals where the experiments were done.

“I-Elcap is a non-federally funded academic consortium of independent, autonomous sites that share certain data,” she wrote.? “Accountability and responsibility for human protection lie at the local level.”

But Dr. Henschke’s research has been supported by grants from the National Institutes of Health, and federal rules governing research conducted at multiple sites have long required that the coordinating center either collect copies of patient consent forms or ensure that they are being kept appropriately.

“The responsible conduct of a study requires that informed consent documents be kept on file,” said Dr. P. Pearl O’Rourke, director of human research affairs at Partners HealthCare, part of Harvard University. “There should be a system so that every consent form can be found no matter if individuals were enrolled at a single site or multiple sites.”

John D. Rodgers, a spokesman for Weill Cornell, wrote in an e-mail that the medical school followed federal research regulations “and there were no issues regarding the safety of the research subjects.”

Dr. Bruce A. Chabner, director of clinical research at Massachusetts General Hospital Cancer Center and editor in chief of The Oncologist journal, said he would ask Weill Cornell for an explanation of the problems outlined in the 2008 scientific review, as well as a follow-up to the report. His journal has published research by Dr. Henschke, and “if we find there was no informed consent for those patients, the paper would have to retracted,” he said.

The American Cancer Society helped finance Dr. Henschke’s research, and some of her work was published in cancer journals owned by the society. Dr. Otis W. Brawley, the society’s chief medical officer, said any study underwritten by the organization must conform to federal research rules, including those that require that problems with informed consent be reported to federal science agencies.

He added that the society’s journals might have to correct or retract any study that proved unable to document that patients had given informed consent. “But I don’t want to prejudge the case,” Dr. Brawley said.

In November, a huge federal study found that annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent and, even more surprising, seemed to reduce the risks of death from other causes as well.

Although the scale of the benefit was substantially less than Dr. Henschke claimed her research showed, the federal study was widely interpreted as confirming her longtime contention that CT screening can save lives from lung cancer, which kills more than 150,000 people each year in the United States. Most patients discover their disease too late for treatment, and 85 percent die from it.

 

Review Casts More Doubts on a Lung Cancer Study

But the doctors who conducted a controversial, widely publicized lung cancer study involving more than 50,000 patients at numerous hospitals were unable to locate 90 percent of the consent forms, according to a confidential review provided to The New York Times.

The finding casts further doubt on a clinical trial that made headlines in 2006 when it concluded that fully 80 percent of lung cancer deaths could be prevented through wide use of CT scans.

That trial, led by Dr. Claudia I. Henschke at Weill Cornell Medical College in New York City, drew sharp criticism from skeptics of cancer screening; the criticism intensified when The Times reported in March 2008 that the research was being financed in part by $3.6 million in grants from the parent company of the Liggett Group, a cigarette maker.

The confidential report on patient consent, dated Oct. 7, 2008, recommended that the trial be stopped. But it continues to this day, although not at Weill Cornell.

Several ethicists said the hospital was legally required to disclose the ethical problems documented by the secret review. That has not happened either.

The confidential report was commissioned by Weill Cornell after The Times’s 2008 article and other revelations about the study in the newsletter The Cancer Letter. The hospital hired four prominent professors from other universities to undertake an independent review of Dr. Henschke’s research, known as the International Early Lung Cancer Action Program, or I-Elcap.

In their report, the reviewers scolded Weill Cornell administrators for failing to supervise the research more closely, “especially knowing that scientific controversy has surrounded I-Elcap almost from its inception.”

One reviewer, Dr. David P. Carbone, a professor of medicine and cancer biology at Vanderbilt, said in an interview that he and the other reviewers never found out “whether these consents were obtained and lost or whether they weren’t obtained at all.”

He said that Dr. Henschke acted with the best of intentions, “but there’s no way for me to justify any of the problems” documented by the group’s review.

Dr. Henschke, who has since left Weill Cornell for Mount Sinai Medical Center in New York, declined to respond to the findings of the 2008 review, saying it was confidential. But in an e-mail, she said the responsibility for keeping track of consent forms lay with all the hospitals where the experiments were done.

“I-Elcap is a non-federally funded academic consortium of independent, autonomous sites that share certain data,” she wrote.? “Accountability and responsibility for human protection lie at the local level.”

But Dr. Henschke’s research has been supported by grants from the National Institutes of Health, and federal rules governing research conducted at multiple sites have long required that the coordinating center either collect copies of patient consent forms or ensure that they are being kept appropriately.

“The responsible conduct of a study requires that informed consent documents be kept on file,” said Dr. P. Pearl O’Rourke, director of human research affairs at Partners HealthCare, part of Harvard University. “There should be a system so that every consent form can be found no matter if individuals were enrolled at a single site or multiple sites.”

John D. Rodgers, a spokesman for Weill Cornell, wrote in an e-mail that the medical school followed federal research regulations “and there were no issues regarding the safety of the research subjects.”

Dr. Bruce A. Chabner, director of clinical research at Massachusetts General Hospital Cancer Center and editor in chief of The Oncologist journal, said he would ask Weill Cornell for an explanation of the problems outlined in the 2008 scientific review, as well as a follow-up to the report. His journal has published research by Dr. Henschke, and “if we find there was no informed consent for those patients, the paper would have to retracted,” he said.

The American Cancer Society helped finance Dr. Henschke’s research, and some of her work was published in cancer journals owned by the society. Dr. Otis W. Brawley, the society’s chief medical officer, said any study underwritten by the organization must conform to federal research rules, including those that require that problems with informed consent be reported to federal science agencies.

He added that the society’s journals might have to correct or retract any study that proved unable to document that patients had given informed consent. “But I don’t want to prejudge the case,” Dr. Brawley said.

In November, a huge federal study found that annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent and, even more surprising, seemed to reduce the risks of death from other causes as well.

Although the scale of the benefit was substantially less than Dr. Henschke claimed her research showed, the federal study was widely interpreted as confirming her longtime contention that CT screening can save lives from lung cancer, which kills more than 150,000 people each year in the United States. Most patients discover their disease too late for treatment, and 85 percent die from it.

 

Magazine Preview: Do Cellphones Cause Brain Cancer?

  Bruce Gilden/Magnum, for The New York Times

On Jan. 21, 1993, the television talk-show host Larry King featured an unexpected guest on his program. It was the evening after Inauguration Day in Washington, and the television audience tuned in expecting political commentary. But King turned, instead, to a young man from Florida, David Reynard, who had filed a tort claim against the cellphone manufacturer NEC and the carrier GTE Mobilnet, claiming that radiation from their phones caused or accelerated the growth of a brain tumor in his wife.

“The tumor was exactly in the pattern of the antenna,” Reynard told King. In 1989, Susan Elen Reynard, then 31, was told she had a malignant astrocytoma, a brain cancer that occurs in about 6,000 adults in America each year. To David Reynard, the shape and size of Susan’s tumor — a hazy line swerving from the left side of her midbrain to the hindbrain — uncannily resembled a malignant shadow of the phone (but tumors, like clouds, can assume the shapes of our imaginations). Suzy, as she was known, held her phone at precisely that angle against her left ear, her husband said. Reynard underwent surgery for her cancer but to little effect. She died in 1992, just short of her 34th birthday. David was convinced that high doses of radiation from the cellphone was the cause.

Reynard v. NEC — the first tort suit in the United States to claim a link between phone radiation and brain cancer — illustrated one of the most complex conceptual problems in cancer epidemiology. In principle, a risk factor and cancer can intersect in three ways. The first is arguably the simplest. When a rare form of cancer is associated with a rare exposure, the link between the risk and the cancer stands out starkly. The juxtaposition of the rare on the rare is like a statistical lunar eclipse, and the association can often be discerned accurately by observation alone. The discipline of cancer epidemiology originated in one such a confluence: in 1775, a London surgeon, Sir Percivall Pott, discovered that scrotal cancer was much more common in chimney sweeps than in the general population. The link between an unusual malignancy and an uncommon profession was so striking that Pott did not even need statistics to prove the association. Pott thus discovered one of the first clear links between an environmental substance — a “carcinogen” — and a particular subtype of cancer.

The opposite phenomenon occurs when a common exposure is associated with a common form of cancer: the association, rather than popping out, disappears into the background, like white noise. This peculiar form of a statistical vanishing act occurred famously with tobacco smoking and lung cancer. In the mid-1930s, smoking was becoming so common and lung cancer so prevalent that it was often impossible to definitively discern a statistical link between the two. Researchers wondered whether the intersection of the two phenomena was causal or accidental. Asked about the strikingly concomitant increases in lung cancer and smoking rates in the 1930s, Evarts Graham, a surgeon, countered dismissively that “the sale of nylon stockings” had also increased. Tobacco thus became the nylon stockings of cancer epidemiology — invisible as a carcinogen to many researchers, until it was later identified as a major cause of cancer through careful clinical studies in the 1950s and 1960s.

But the most complex and most publicly contentious intersection between a risk factor and cancer often occurs in the third instance, when a common exposure is associated with a rare form of cancer. This is cancer epidemiology’s toughest conundrum. The rarity of the cancer provokes a desperate and often corrosive search for a cause (“why, of all people, did I get an astrocytoma?” Susan Reynard must have asked herself). And when patients with brain tumors happen to share a common exposure — in this case, cellphones — the line between cause and coincidence begins to blur. The association does not stand out nor does it disappear into statistical white noise. Instead, it remains suspended, like some sort of peculiar optical illusion that is blurry to some and all too clear to others. (A similarly corrosive intersection of a rare illness, a common exposure and the desperate search for a cause occurred recently in the saga of autism and vaccination. Vaccines are nearly universal, and autism is relatively rare — and many parents, searching to explain why their children became autistic, lunged toward a common culprit: childhood vaccination. An avalanche of panic ensued. It took years of carefully performed clinical trials to finally disprove the link.)

The Florida Circuit Court that heard Reynard v. NEC was quick to discern these complexities. It empathized with David Reynard’s search for a tangible cause for his wife’s cancer. But it acknowledged that too little was known about such cases; “the uncertainty of the evidence . . . the speculative scientific hypotheses and [incomplete] epidemiological studies” made it impossible to untangle cause from coincidence. David Reynard’s claim was rejected in the spring of 1995, three years after it was originally filed. What was needed, the court said, was much deeper and more comprehensive knowledge about cellphones, brain cancer and of the possible intersection of the two.

Allow, then, a thought experiment: what if Susan Reynard was given a diagnosis of astrocytoma in 2011 — but this time, we armed her with the most omniscient of lawyers, the most cutting--edge epidemiological information, the most powerful scientific evidence? Nineteen years and several billion cellphone users later, if Reynard were to reappear in court, what would we now know about a possible link between cellphones and her cancer?

To answer these questions, we need to begin with a more fundamental question: How do we know that anything causes cancer?

The crudest method to capture a carcinogen’s imprint in a real human population is a large-scale population survey. If a cancer-causing agent increases the incidence of a particular cancer in a population, say tobacco smoking and lung cancer, then the overall incidence of that cancer will rise. That statement sounds simple enough — to find a carcinogen’s shadow, follow the trend in cancer incidence — but there are some fundamental factors that make the task complicated.

Siddhartha Mukherjee (smukherj2011@gmail.com) is an assistant professor of medicine in the division of medical oncology at Columbia University. He is the author of “Emperor of All Maladies: A Biography of Cancer.” Editor: Ilena Silverman (i.silverman-MagGroup@nytimes.com).

 

Bowel cancer op survival rates 'vary'

11 April 2011 Last updated at 20:37 ET By James Gallagher Health reporter, BBC News  Laparoscopic surgery is used to remove some bowel cancers The survival rate for bowel cancer surgery varies widely between hospitals, a study suggests.

It is the first time the number of people dying within 30 days of an operation has been reported across England for any cancer.

Some 6.7% of the 160,920 who had surgery from 1998 to 2006 died but some hospitals had much higher mortality rates, the report in Gut journal says.

Cancer Research UK said the situation was "worrying".

Bowel cancer is the third most common cancer in the UK.

Significantly higher

The outcomes of all 160,920 people who had surgery to remove a tumour between 1998 and 2006 were analysed.

The overall mortality rate in that period dropped from 6.8% to 5.8%.

Looking at data for the last three years of the study, five hospital trusts had significantly higher death rates and three had significantly lower ones.

The proportion of patients dying within a month of surgery ranged from 15.6% at Burton Hospitals NHS Foundation Trust to 1.7% at Central Manchester University Hospitals NHS Foundation Trust.

Continue reading the main story Burton Hospitals - 15.6%The Whittington Hospital - 13.1%The Rotherham - 11.2%Northampton General Hospital - 10.5%Colchester Hospital University - 10.4%Preliminary data suggests the five hospitals which appeared to perform poorly had all improved by 2008, by when they all had achieved mortality rates close to the average.

Consultant surgeon at Burton Hospitals Trust, James Eccersley, said: "The Trust is aware that constant vigilance and improvement has reduced our mortality rate after surgery. We always strive to take on board new innovations to make surgery even safer."

Variation

The explanation for the variation remains unclear.

Professor Paul Finan, from Leeds General Infirmary, said possible reasons included: "the degree of surgical specialisation, how guidelines were followed, the quality of high-dependency units (after-care surgery), anaesthetic services and whether the surgery was laparoscopic, which is less invasive."

In heart surgery, outcomes improved significantly after death rates were published. By finding out what more successful hospitals do differently, it is hoped bowel cancer care can be improved across the country.

Professor Philip Quirke, consultant pathologist at the University of Leeds, said: "In the past there's not been enough emphasis on routine clinical practice. We can learn a lot, especially from the best. Why are they so good?"

The government's national cancer director, Sir Mike Richards, wants statistics to become available for other cancers.

He said: "It's taken time to get this far, but we've demonstrated this as a proof of principle and are working out how to do the same with other cancers."

It is difficult to make international comparisons as other countries do not have data on a full national scale.

Studies in Scandinavia, Canada and the US have shown mortality rates between 2.7% and 5.7%. However, researchers cautioned against making direct comparisons.

Mark Flannagan, chief executive of Beating Bowel Cancer, said: "This study shows worrying variations in bowel cancer survival that need to be addressed.

"Bowel cancer is the UK's second-biggest cancer killer, yet there are still significant inequalities in survival which need to be better understood before they can be tackled."