Death certification

Owing to the variable prognosis of different cancers, mortality cannot be taken as a surrogate measure of incidence, except for those cancers from which death is invariable, for example those of lung or pancreas. However, mortality statistics are relevant to many analytical studies and the mechanism of death certification should be understood.

It is generally accepted that death certificates provide more accurate statistics than does cancer registration, but errors between the underlying cause of death on the death certificate and that on postmortem examination vary from 20% to 40%. Similar errors occur between clinical and autopsy causes of death. These errors are less likely to occur for cancer deaths as a clinical diagnosis of cancer tends to be accurate.

Towards the end of the last century, certification of the cause of death became obligatory in many countries. Statutory registration of deaths replaced parish registers in England and Wales in 1837 and in Scotland in 1885. However, it was only in 1956 that comparative data on cancer mortality in different countries first became available through the World Health Organization.

The statutory death certificate consists of two parts. In Part I, the sequence of events leading to death are recorded, the immediate cause of death being listed first, followed by one or two antecedent conditions. The cause that is listed last is the 'underlying cause' of death. Part II lists unrelated conditions which may have adversely affected the outcome.

Internationally agreed rules for identification of the underlying cause of death have been laid down by the World Health Organization. The general rule states that the underlying cause of death is either that which has been listed alone in Part I, or should more than one condition be entered, that which was entered last. This underlying cause of death is underlined by the registrar on the certificate and is recorded as its ICD code. Should it appear improbable that the last entered condition led to the sequence of events leading to death, the registrar will first seek clarification from the person who completed the certificate and if this is not possible, he may apply three subsidiary rules which allow him to select the most likely underlying cause of death from those listed.

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