Estimates of the worldwide incidence of 25 major cancers in 1990

Authors

  • D. Maxwell Parkin,,

    Corresponding author
    1. Unit of Descriptive Epidemiology, International Agency for Research on Cancer, Lyon, France
    • Unit of Descriptive Epidemiology, International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon Cedex 08, France. Fax: (33)4–7273–8575.
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  • Paola Pisani,

    1. Unit of Descriptive Epidemiology, International Agency for Research on Cancer, Lyon, France
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  • Jacques Ferlay

    1. Unit of Descriptive Epidemiology, International Agency for Research on Cancer, Lyon, France
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Abstract

The annual incidence rates (crude and age-standardized) and numbers of new cases of 25 different cancers have been estimated for the year 1990 in 23 areas of the world. The total number of new cancer cases (excluding non-melanoma skin cancer) was 8.1 million, just over half of which occur in the developing countries. The most common cancer in the world today is lung cancer, accounting for 18% of cancers of men worldwide, and 21% of cancers in men in the developed countries. Stomach cancer is second in frequency (almost 10% of all new cancers) and breast cancer, by far the most common cancer among women (21% of the total), is third. There are large differences in the relative frequency of different cancers by world area. The major cancers of developed countries (other than the 3 already named) are cancers of the colon-rectum and prostate, and in developing countries, cancers of the cervix uteri and esophagus. The implications of these patterns for cancer control, and specifically prevention, are discussed. Tobacco smoking and chewing are almost certainly the major preventable causes of cancer today.Int. J. Cancer 80:827–841, 1999. © 1999 Wiley-Liss, Inc.

This is the 4th review of the burden of cancer worldwide. Cancer incidence was reflected by the annual number of new cancers at different sites and in different world areas. These estimates were based on the year 1990, and were for 25 different cancers; this review follows the sequence of estimates for 12 cancers in 1975 (Parkin et al., 1984), 16 in 1980 (Parkin et al., 1988) and 18 in 1985 (Parkin et al., 1993).

The methods are much the same as those used in preparing the previous estimates (Parkin et al., 1993). However, although the basic sources of data remain the same (the Cancer Incidence in Five Continents series and the World Health Organization [WHO] mortality data bank), for several countries new sources have become available (particularly in the developing countries and Newly Independent States of the former Soviet Union). As a result, the new estimates are not fully comparable with the previous estimates (although we believe the current estimates to be more accurate) for several world areas, and care must be exercised in interpreting the apparent changes between 1985 and 1990 as trends in overall risk for different cancers.

As previously, the basic units for estimation are national populations, although we present the results here (as numbers of new cases and incidence rates) only for the aggregated “World Areas”. The availability of modern techniques of electronic data dissemination (CD-ROM/personal computer and the Internet) has allowed us to make the full dataset available. The “GLOBOCAN” package (Ferlay et al. 1998) contains the full database (estimates by cancer site, country, sex and age group) with a special software for extraction and presentation of results. The database is also available on the Internet (http://www-dep.iarc.fr/globocan/globocan.htm), although with less flexibility for interactive analysis and in presentational formats.

MATERIAL AND METHODS

In this report, we present results for 23 world areas (Fig. 1). These results are based on the areas for which the United Nations publishes regular population estimates and projections. These areas and their estimated populations in 1990 (UN, 1995) are shown in Table I. Note that there is 1 major change compared with our previous world estimates, that is the division of the previous Area 24 (USSR) between Eastern Europe (Belarus, Moldova, Russian Federation, Ukraine), Northern Europe (Estonia, Latvia, Lithuania), Western Asia (Armenia, Azerbaijan, Georgia) and South-Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan). The very small (in population terms) areas of Micronesia and Polynesia are combined in a single area.

Table I. POPULATION ESTIMATES, BY WORLD AREA, 1990
AreasPopulation (millions)Age distribution (%)
TotalMalesFemalesUnder 15 years65 years or older
  1. Source: UN (1994).

1. Eastern Africa195.897.498.446.42.8
2. Middle Africa70.534.735.846.13.2
3. Northern Africa143.072.370.740.93.6
4. Southern Africa42.221.021.338.94.2
5. Western Africa181.189.991.345.62.8
6. Caribbean33.516.716.831.26.4
7. Central America113.156.556.639.43.8
8. South America (temperate)48.824.024.830.28.4
9. South America (tropical)244.2122.0122.235.64.4
10. Northern America277.8135.7142.121.612.4
11. East Asia: China1155.3595.9559.427.55.6
12. East Asia: Japan123.560.762.918.412.0
13. East Asia: Other72.536.336.326.85.0
14. South East Asia442.3220.2222.136.74.0
15. South Central Asia1243.3640.6602.738.14.0
16. Western Asia149.176.972.238.53.9
17. Eastern Europe310.4147.0163.322.910.7
18. Northern Europe92.345.047.319.415.2
19. Southern Europe143.170.073.119.413.0
20. Western Europe176.085.490.517.814.4
21. Australia/New Zealand20.210.110.222.111.1
22. Melanesia5.22.72.540.22.7
23. Micronesia/Polynesia1.00.50.540.63.3
Total5284.42661.42623.032.36.2
Figure 1.

Figure1

Map showing the 23 world areas studied.

Twenty-five different cancers have been studied. They are (with the ICD-9 codes): oral cavity (140–145), nasopharynx (147), other pharynx (146, 148 and 149), esophagus (150), stomach (151), colon plus rectum (153 and 154), liver (155), pancreas (157), larynx (161), lung (162), melanoma of skin (172), female breast (174), cervix uteri (180), corpus uteri (182), ovary, etc. (183), prostate (185), testis (186), bladder (188), kidney and urinary tract (189), brain and nervous system (191 and 192), thyroid (193), Hodgkin's disease (201), non-Hodgkin lymphoma (200 and 202), myeloma (203) and leukemia (204–208). The total (all cancers) excludes non-melanoma skin cancer. This exclusion was because of the well-known difficulties in obtaining accurate information on these often trivial tumors, and the problem of defining “incident” cancers when a single individual develops many tumors.

Estimates of incidence have been prepared for 5 broad age groups: 0–14, 15–44, 45–54, 55–64 and 65 years and older. Age-standardized incidence rates were calculated using the weights of the “world standard” population (0.31, 0.43, 0.11, 0.08 and 0.07 in these 5 age classes).

Methods of estimation

Incidence rates by age group and sex were estimated for as many individual countries as possible. The country estimates were then combined to produce a weighted average, using (unless specified otherwise) the age and sex-specific populations of the component countries in an area. The sources of data for the countries of the 23 world areas and the methods used to produce estimates of incidence in each of them are summarized in the Appendix.

The methods used to produce country-specific estimates of incidence fall into 1 of the following 6 categories:

  • 1National incidence data. When incidence rates for a country, or a representative sample of the country deriving from good quality cancer registries, were available, these were the preferred choice. The principal source was “Cancer Incidence in Five Continents”, Volume VII [CI5VII], which covers the period around 1990 (Parkin et al., 1997), and occasionally, Volume VI [CI5VI] (Parkin et al., 1992), covering the period around 1985.
  • 2National mortality data. The source of these data were WHO mortality database, as published in the World Health Statistics Annuals, and available on computer tape, and on the Internet (www-dep.iarc.fr).

The method of estimating incidence from mortality was as follows: we assumed that the logarithm of the incidence rate of a given cancer can be expressed as a linear function of the logarithm of mortality in each sex-age group. Separate models were fitted for different geographical areas, as specified below. Following this assumption we estimated the parameters of such regressions separately for the 25 sites and all other neoplasms, based on the data of those cancer registries accepted for publication in Volume VII of “Cancer Incidence in Five Continents” and providing both incidence and mortality rates. The parameter estimators were those of maximum likelihood and were obtained by means of the SAS package (SAS Institute, Cary, NC, 1985). This approach was taken by Black et al. (1997) to obtain estimates of incidence in the European Union countries around 1990, figures that we used directly.

Twelve sets of the 26 models were established. Five were for single countries with multiple regional registries: the USA (10 registries), Japan (6), Switzerland (8), Australia (4) and China (3). The other 7 were for regions or groups of countries. These comprised, for Europe, the 2 (Western Europe, Southern Europe) of Black et al. (1997), plus a model for Eastern Europe (EE); for the Americas, 2 models were used: Temperate South America (TSA) based on data from registries in Argentina and Uruguay, and Other Latin America and the Caribbean (OLAC), based on data from registries elsewhere. In Asia, a model incorporating data from some registries in Central Asia and the Caucasus (CAC) was developed, whereas for a few countries, a model based on the data from 17 registries in developing countries (Dev) was used.

To describe the models obtained, mortality/incidence ratios specific for site, sex and area are reported in Table II. These are the ratios of the predicted age-standardized incidence to a constant set of age-standardized mortality rates also given in the table.

Table II. MORTALITY/INCIDENCE RATIOS (AGE-STANDARDIZED RATES) OBTAINED BY APPLYING AREA-SPECIFIC MODELS TO THE ESTIMATED WORLDWIDE MORTALITY, BY CANCER SITE AND SEX
SiteE. EuropeCACTSAOLACDevelopingChinaJapanUSAAustraliaSwitzerlandMortality ASR*
  1. Abbreviations: CAC, Central Asian Countries (ex-URRS); OLAC, Other Latin America Countries; TSA, Temperate South America.–* = Mortality ASR = Standard age-standardized mortality rates (100,000) adopted as reference.

Men
 Mouth0.610.450.490.420.650.360.220.436.6
 Oropharynx0.780.780.690.550.500.582.4
 Nasopharynx1.170.520.541.110.720.801.021.1
 Esophagus1.140.770.760.790.970.800.730.931.140.939.3
 Stomach0.860.890.740.720.730.680.400.720.720.7619.1
 Colon and rectum0.590.710.400.600.530.530.400.370.410.4810.7
 Liver1.759.301.541.740.840.770.941.440.9114.2
 Pancreas0.631.140.910.890.980.954.4
 Larynx0.400.550.410.570.650.330.300.430.473.1
 Lung0.730.860.620.920.990.800.810.800.870.8133.7
 Melanoma of skin0.430.150.340.380.670.150.040.130.8
 Prostate0.611.350.560.510.520.490.180.350.358.2
 Testis0.230.290.290.070.070.040.3
 Bladder0.400.340.480.440.320.160.280.374.2
 Kidney, etc.0.360.620.410.360.410.362.3
 Brain and nervous system0.610.940.610.450.530.552.3
 Thyroid0.320.310.210.130.240.210.3
 Non-Hodgkin lymphoma0.590.651.130.440.590.500.310.350.313.3
 Hodgkin's disease0.320.811.321.110.230.320.270.7
 Multiple myeloma0.751.100.810.540.700.631.1
 Leukemias0.650.740.780.830.850.760.510.490.634.4
 Other sites0.680.690.730.440.470.5311.7
Women
 Mouth0.670.660.460.370.560.280.260.432.3
 Oropharynx0.730.870.470.800.480.640.550.5
 Nasopharynx0.980.520.471.290.800.701.220.4
 Esophagus1.750.520.610.790.880.780.660.890.830.963.8
 Stomach0.830.700.920.710.740.710.440.710.830.939.2
 Colon and rectum0.600.910.360.590.530.560.430.370.400.448.6
 Liver1.244.691.311.630.880.791.141.511.154.9
 Pancreas0.781.230.960.851.001.043.1
 Larynx0.510.800.300.480.580.710.270.490.670.4
 Lung0.810.791.060.820.920.860.780.710.820.859.2
 Melanoma of skin0.360.190.320.310.800.140.030.090.6
 Breast0.410.520.260.350.320.250.290.210.200.2312.9
 Cervix0.440.510.280.320.410.660.430.730.400.628.0
 Corpus uteri0.160.210.380.100.150.181.7
 Ovary, etc.0.440.590.610.480.530.514.2
 Bladder0.500.390.450.510.420.230.310.411.1
 Kidney, etc.0.330.550.400.320.330.421.2
 Brain and nervous system0.620.950.560.440.470.521.7
 Thyroid0.260.160.090.100.190.170.6
 Non-Hodgkin lymphoma0.680.700.970.430.530.490.310.350.302.2
 Hodgkin's disease0.270.770.821.160.170.240.190.4
 Multiple myeloma0.661.120.700.560.630.610.9
 Leukemias0.670.730.710.830.760.820.580.570.693.2
 Other sites0.560.530.620220.370.380.4410.1

The precise methods for using national mortality data depend on the degree of detail and accuracy of the available material, and can be summarized as 1 of 3 variants:

  • 2AThe national mortality data are complete and available at the level of 3-digit ICD-9 code for underlying cause of death. Other than some reallocation of deaths coded to ICD179 (Uterus unspecified) to either cervix (180) or corpus (182), the mortality rates can be converted directly to age-sex specific incidence estimates.
  • 2BThe mortality data are only available for major sites, or groups of sites (for example, the “Basic Tabulation List” of the ICD-9). The regression models are used to produce estimates for these sites, and for “All Other sites”. Other sources of data (see 3 and 5 below) must then be used to:
    • Divide the grouped sites (e.g., oral cavity and pharynx, lymphatic and hematopoietic neoplasms) into their component parts.

    • Subdivide the residual group “All Other sites” into the missing sites required, and a much smaller residuum of “other” cancers.

  • 2CAs for 2B, except that the national mortality data are known to be under-estimates of the true mortality. PAHO (1995) have produced quantitative evaluations of the extent of under-registration in countries of Latin America and the Caribbean. When this rate was between 10 and 40%, these under-registration factors were used to “correct” mortality data for several countries in Latin America and the Caribbean (assuming constancy of the under-registration by cause of death).
  • 3Local (regional) incidence data. These are data from cancer registries covering only part of a country (a city, province, etc.). Sometimes several registries may be present, and some sort of weighting by regional populations has been used (as specified in the Appendix) when combining their results to produce a national estimate. Other times, data from a single registry has been used as an estimate for the corresponding country, or even of a neighboring country.

There were 2 broad approaches to the use of local incidence data:

  • 3AComplete incidence data. These are considered to be reasonably accurate reflections of the true incidence. Most of them are from Cancer Incidence in Five Continents, Volume VII (CI5VII), published reports or journal articles. Others have been obtained directly from the cancer registries themselves. The rates are used directly.
  • 3BIncomplete/unpublished incidence data. Some correction has been applied, because of known under-reporting.
  • 4Local mortality data. For China, the mortality data were derived from the sample survey of deaths at so-called “Disease Surveillance Points” (DSP) (WHO, 1993). We used results from 1993, at which time there were some 100 surveillance points throughout the country, selected to provide a representative sample of the Chinese population by geography and urban/rural residence. Because the sample was representative, it was used directly as reflecting mortality rates by age, sex and cause for the whole country (the sample is estimated to comprise 10% of all deaths in China).
  • 5Frequency data. For several developing countries in Africa and parts of Asia, no data are available on cancer incidence, and mortality statistics are not available by cause, or are hopelessly inaccurate. In these circumstances, the procedure adopted was to use a set of age/sex-specific incidence rates for “all cancers” and to partition these between the different cancer types using any available data on the relative frequency of different cancers (by age and sex), but avoiding series that were felt to be too biased (e.g., from histopathology series).

Three sets of age-sex specific incidence rates for “all sites” were used: Sub-Saharan Africa (SSA), Middle East-North Africa (MENA) and Other Oceania (OOCE). These rates were produced from the unweighted averages of the observed rates (by sex and age group) in registries from Africa (Mali, Uganda, Zimbabwe, Reunion, South Africa [Elim] and Guinea) and North Africa/W. Asia (Algeria-Setif, Israel [non-Jews], Kuwait [Kuwaitis], Oman, Saudi Arabia) and Oceania (Fiji, French Polynesia and Guam). The African rates were calculated after excluding Kaposi's sarcoma (KS), which in current datasets accounts for a variable but often very high proportion of cancers; these rates were partitioned by relative frequencies excluding KS, rates of which were then estimated separately then added to the total.

All sites incidence rates for SSA (excluding KS), MENA and OOCE are shown in Table III.

Table III. AGE-SPECIFIC INCIDENCE RATES PER 100,000 (ALL CANCERS, EXCLUDING SKIN)
 0–14 years15–44 years45–55 years55–64 years65+ yearsASR (world)
  • Abbreviation: ASR, age-standardized rate.

  • 1

    Rates exclude Kaposi's sarcoma.

Males
 Middle East/North Africa12.928.0138.7348.6710.0108.9
 Other Oceania13.829.8229.1580.21161.5170.0
 Sub-saharan Africa17.635.4253.1471.8875.5144.4
Females
 Middle East/North Africa9.637.8173.0323.3453.495.9
 Other Oceania9.070.2401.4575.2898.2186.0
 Sub-saharan Africa16.748.7265.4393.6541.0121.6
  • 6No data. No useable data could be identified. The country-specific rates therefore represent simply those of the corresponding Area (calculated from the other countries for which estimates could be made). The method used and the corresponding data source(s) are given in summary form for each country of the world in the Appendix.

RESULTS AND DISCUSSION

The estimated crude rates of incidence (per 100,000) by world area, are shown for 25 sites and for all cancer sites in Table IV. Table V shows the corresponding numbers of cases in each area and for the world as a whole. Table VI gives the estimated age-standardized incidence rates by area, cancer site and sex.

Table IV. ESTIMATED CRUDE RATES OF CANCER INCIDENCE BY SITE, SEX AND AREA, 1990 (PER 100,000)
   OtherMouth/  Colon/     
MouthNasopharynx pharynx pharynxOesophagusStomach rectumLiverPancreasLarynxLungMelanoma
(140–5) (147) (146, 8–9) (140–149) (150) (151) (153–154) (155) (157) (161) (162) (172)
MFMFMFMFMFMFMFMFMFMFMFMF
1. Eastern Africa3.72.91.30.51.00.26.03.65.72.74.22.83.73.19.43.11.00.91.10.22.21.01.11.6
2. Middle Africa2.61.60.50.20.80.33.82.11.10.110.39.01.29.416.89.40.92.51.30.13.30.51.71.5
3. Northern Africa2.51.21.91.10.60.14.92.41.51.03.41.73.51.52.61.50.60.33.00.57.11.60.40.4
4. Southern Africa9.72.21.90.40.80.312.43.021.68.16.93.06.74.712.74.71.71.34.20.618.15.63.03.3
5. Western Africa3.11.70.60.20.20.14.01.91.00.66.13.62.64.012.64.01.40.81.30.21.20.60.81.2
6. Caribbean6.74.40.70.33.41.310.85.96.11.813.57.113.44.06.74.04.83.16.01.224.89.10.80.6
7. Central America2.21.20.50.11.10.43.81.81.80.99.98.24.82.53.12.53.84.12.70.610.14.80.90.8
8. South America (Temperate)6.61.60.40.23.90.610.92.510.85.623.310.526.81.82.71.86.36.18.21.253.38.85.34.0
9. South America (Tropical)5.62.20.40.12.40.38.42.74.81.319.611.19.61.52.11.53.22.74.10.715.15.12.12.0
10. North America9.45.60.70.33.81.413.97.36.32.310.66.756.82.14.02.110.410.78.12.187.149.712.69.8
11. Eastern Asia: China1.00.62.91.50.20.14.02.117.28.634.816.910.910.329.910.32.01.11.30.427.411.70.30.2
12. Eastern Asia: Japan4.12.20.60.21.90.36.62.713.22.9106.754.054.312.138.212.113.39.74.60.354.219.40.50.3
13. Eastern Asia: Other2.41.12.81.11.30.26.52.44.61.036.820.814.48.323.28.33.72.73.00.425.310.40.20.2
14. South Eastern Asia2.31.84.21.91.50.58.04.21.80.95.43.57.24.111.34.11.20.92.20.517.46.30.30.3
15. South Central Asia7.44.80.50.25.31.413.36.45.64.84.32.83.31.01.81.01.00.74.30.77.51.80.30.3
16. Western Asia2.31.50.70.30.60.43.62.31.41.45.64.55.22.13.02.11.81.55.20.718.33.70.81.0
17. Eastern Europe10.32.60.60.34.30.515.23.57.11.740.127.027.74.75.74.710.08.113.40.984.716.33.34.1
18. Northern Europe7.13.60.50.22.61.010.24.810.16.526.116.452.92.74.12.712.412.47.01.391.037.98.010.5
19. Southern Europe13.52.61.20.36.90.621.63.66.50.829.217.840.36.112.66.17.96.215.10.781.312.03.87.1
20. Western Europe14.93.60.90.212.81.428.65.29.52.123.616.757.23.16.93.19.18.812.10.976.414.66.910.1
21. Australia/New Zealand17.76.40.70.34.00.822.57.55.63.813.37.355.71.43.31.48.47.56.00.758.622.832.130.5
22. Melanesia19.213.70.10.20.90.320.214.31.81.53.32.55.66.311.36.30.60.31.90.64.01.93.11.9
23. Micronesia/Polynesia3.22.02.60.72.70.68.53.32.20.85.84.18.52.65.62.61.91.63.30.525.09.11.91.9
Developed countries10.43.60.70.35.40.916.54.88.12.334.621.146.44.69.74.610.29.110.51.180.325.76.87.3
Developing countries4.02.41.70.82.20.67.93.88.04.415.28.06.94.612.54.61.71.22.90.515.55.60.60.6
ALL AREAS5.32.71.50.72.90.79.74.08.03.919.211.015.14.611.94.63.43.04.50.729.010.11.92.1
   Corpus           All sites
BreastCervix uteriOvaryProstateTestisBladderKidneyBrain, CNSThyroidNHLHodgkin'sMyelomaLeukaemia excl. skin
(174) (180) (182) (183) (185) (186) (188) (189) (191–2) (193) (200, 202) (201) (203) (204–208) (140–208)
       MFMFMFMFMFMFMFMFMF
1. Eastern Africa10.621.91.74.76.60.42.61.21.00.80.60.40.81.35.63.11.50.60.40.21.91.591.686.9
2. Middle Africa8.615.91.82.112.30.11.40.31.11.00.20.00.81.33.45.40.70.20.71.20.90.885.879.2
3. Northern Africa17.17.31.12.02.60.413.83.11.20.72.01.30.62.13.22.50.80.40.30.43.32.264.564.9
4. Southern Africa22.830.45.23.816.90.76.92.21.81.42.31.60.72.24.13.01.00.51.10.94.22.9155.2137.2
5. Western Africa10.914.91.14.19.30.23.61.51.00.60.80.50.71.17.24.72.91.00.80.33.12.472.371.3
6. Caribbean29.530.06.15.835.80.86.62.32.61.83.53.00.83.64.53.32.11.32.41.66.55.1168.1158.1
7. Central America17.231.24.75.112.42.32.71.12.21.84.23.61.14.93.32.21.81.11.00.84.94.488.3120.6
8. South America (Temperate)76.128.214.310.122.94.012.73.48.33.74.53.20.62.64.54.01.91.20.30.75.94.8249.4259.8
9. South America (Tropical)28.624.55.45.116.81.65.91.73.12.14.02.31.02.95.43.71.60.90.90.85.24.2129.5136.3
10. North America117.710.721.815.5125.34.130.79.013.28.57.45.92.65.918.515.02.92.35.34.612.58.8467.5402.1
11. Eastern Asia: China11.04.41.52.60.80.32.50.91.20.70.61.40.10.81.20.90.30.40.20.14.13.3145.494.4
12. Eastern Asia: Japan38.313.65.78.612.01.212.33.57.33.62.72.21.77.59.16.10.50.22.12.36.54.5369.4258.8
13. Eastern Asia: Other17.025.72.14.43.00.45.61.62.61.22.31.71.16.43.22.20.50.00.51.25.13.2162.3164.1
14. South Eastern Asia17.213.92.65.03.10.72.50.61.10.61.30.90.93.63.32.50.60.30.50.43.63.082.486.6
15. South Central Asia15.917.81.54.12.60.62.70.71.00.61.91.30.61.52.61.51.20.50.50.42.81.970.681.0
16. Western Asia17.84.14.44.63.71.26.21.41.71.12.41.80.82.54.13.31.81.20.40.43.82.783.079.0
17. Eastern Europe47.316.914.215.515.03.113.83.610.47.05.94.51.23.65.23.43.22.11.81.97.86.6295.9248.3
18. Northern Europe102.416.117.619.658.25.330.811.211.67.47.65.81.23.313.211.22.92.05.44.911.38.9405.2392.6
19. Southern Europe69.613.516.411.625.33.231.45.98.64.37.15.21.14.112.28.73.01.82.92.810.57.9349.1269.8
20. Western Europe104.614.618.416.559.47.224.26.614.79.06.96.22.43.712.210.33.22.04.04.110.99.1409.7358.0
21. Australia/New Zealand88.812.912.312.364.64.618.16.99.67.37.26.11.43.015.111.72.11.74.43.912.48.5379.5336.4
22. Melanesia14.428.04.44.82.60.91.40.40.90.60.40.30.93.35.83.60.50.30.20.33.12.489.6115.0
23. Micronesia/Polynesia30.116.37.65.19.31.63.00.72.11.21.92.51.46.53.32.71.10.61.11.06.14.5106.7123.0
Developed countries80.014.116.314.754.24.023.06.311.37.06.45.11.84.611.79.02.81.93.53.310.07.7380.7319.1
Developing countries15.914.22.33.94.50.63.61.01.40.91.61.40.61.92.92.11.00.50.50.43.62.7103.793.9
ALL AREAS30.314.25.46.314.91.37.62.23.42.22.62.20.82.54.73.61.40.81.11.14.93.8161.3144.5
Table V. ESTIMATED NUMBER OF NEW CANCER CASES (THOUSANDS) BY SITE, SEX AND AREA, 1990
   OtherMouth/  Colon/     
MouthNasopharynx pharynx pharynxOesophagusStomach rectumLiverPancreasLarynxLungMelanoma
(140–5) (147) (146, 8–9) (140–149) (150) (151) (153–154) (155) (157) (161) (162) (172)
MFMFMFMFMFMFMFMFMFMFMFMF
1. Eastern Africa3.62.81.30.50.90.25.93.55.62.74.12.83.62.29.13.10.90.81.10.22.21.01.11.6
2. Middle Africa0.90.60.20.10.30.11.30.80.40.03.63.20.40.75.83.40.30.90.40.01.20.20.60.5
3. Northern Africa1.80.91.30.80.40.13.51.71.10.72.41.22.52.01.91.00.40.22.20.35.11.10.30.3
4. Southern Africa2.00.50.40.10.20.12.60.64.51.71.40.61.41.22.71.00.40.30.90.13.81.20.60.7
5. Western Africa2.81.50.50.20.20.13.61.80.90.55.53.32.32.011.33.71.20.81.10.21.10.50.71.1
6. Caribbean1.10.70.10.00.60.21.81.01.00.32.31.22.22.41.10.70.80.51.00.24.11.50.10.1
7. Central America1.20.70.30.10.60.22.11.01.00.55.64.62.72.81.81.42.12.31.50.35.72.70.50.4
8. South America (Temperate)1.60.40.10.10.90.22.60.62.61.45.62.66.47.30.60.41.51.52.00.312.82.21.31.0
9. South America (Tropical)6.82.70.50.12.90.410.23.25.91.623.913.611.711.62.61.93.93.35.00.918.46.22.62.5
10. North America12.78.01.00.45.11.918.810.38.63.214.49.577.177.45.43.014.115.310.92.9118.270.717.013.9
11. Eastern Asia: China5.83.317.18.21.10.524.012.0102.347.8207.794.464.950.4178.157.511.86.27.92.2163.165.51.61.1
12. Eastern Asia: Japan2.51.40.40.11.10.24.01.78.01.864.734.032.925.623.27.68.16.12.80.232.912.20.30.2
13. Eastern Asia: Other0.90.41.00.40.50.12.40.91.70.413.37.55.24.68.43.01.41.01.10.19.23.80.10.1
14. South Eastern Asia5.24.09.34.23.31.217.79.44.11.911.97.815.913.924.89.02.51.94.81.138.314.00.60.6
15. South Central Asia47.629.23.11.234.38.485.038.835.728.827.716.721.016.711.56.36.24.327.44.247.810.81.71.6
16. Western Asia1.81.10.50.20.50.32.81.71.11.04.33.34.03.82.31.51.41.14.00.514.12.60.70.7
17. Eastern Europe15.14.30.80.56.40.922.35.610.42.758.944.140.848.48.47.714.813.219.71.5124.526.64.96.6
18. Northern Europe3.21.70.20.11.20.54.62.34.53.111.87.823.824.41.91.35.65.93.10.641.017.93.65.0
19. Southern Europe9.41.90.80.24.80.515.12.64.50.620.513.028.225.28.84.55.64.610.60.556.98.82.75.2
20. Western Europe12.73.30.70.211.01.224.44.78.11.920.115.248.953.05.92.87.77.910.30.865.313.25.99.1
21. Australia/New Zealand1.80.70.10.00.40.12.30.80.60.41.30.75.65.10.30.10.90.80.60.15.92.33.23.1
22. Melanesia0.50.30.00.00.00.00.50.40.00.00.10.10.20.10.30.20.00.00.00.00.10.00.10.0
23. Micronesia/Polynesia0.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.10.00.00.0
Developed countries57.521.24.11.630.05.391.628.144.813.6191.7124.2257.3259.253.927.056.653.658.16.6444.7151.837.743.2
Developing countries83.749.235.716.146.712.1166.177.3167.989.5319.3163.0144.6121.7262.494.135.025.360.410.7327.1113.312.412.3
ALL AREAS141.270.339.817.776.817.4257.7105.4212.6103.2511.0287.2401.9381.0316.3121.191.678.9118.517.3771.8265.150.155.4
   Corpus           All site
BreastCervix uteriOvaryProstateTestisBladderKidneyBrain, CNSThyroidNHLHodgkin'sMyelomaLeukemia excl. skin
(174) (180) (182) (183) (185) (186) (188) (189) (191–2) (193) (200, 202) (201) (203) (204–208) (140–208)
       MFMFMFMFMFMFMFMFMF
1. Eastern Africa10.521.51.64.66.40.42.51.21.00.80.60.40.81.25.43.01.50.60.40.21.81.489.285.5
2. Middle Africa3.15.70.70.74.30.00.50.10.40.30.10.00.30.51.21.90.20.10.20.40.30.329.828.3
3. Northern Africa12.15.20.81.41.90.310.02.20.80.51.40.90.41.52.31.70.60.30.20.32.41.646.645.9
4. Southern Africa4.96.51.10.83.50.11.40.50.40.30.50.30.20.50.90.60.20.10.20.20.90.632.529.2
5. Western Africa10.013.61.03.78.40.23.21.40.90.60.80.50.61.06.44.32.61.00.70.32.82.265.065.1
6. Caribbean5.05.01.01.06.00.11.10.40.40.30.60.50.10.60.80.60.30.20.40.31.10.928.126.6
7. Central America9.717.72.72.97.01.31.50.61.21.02.42.00.62.71.81.31.00.60.60.42.82.549.868.3
8. South America (Temperate)18.97.03.62.55.51.03.10.82.00.91.10.80.10.61.11.00.50.30.10.21.41.259.864.4
9. South America (Tropical)35.029.96.66.220.51.97.22.03.82.54.92.81.23.66.64.51.91.11.11.06.35.1158.0166.5
10. North America167.315.231.022.0170.05.641.712.817.912.110.08.43.58.425.121.33.93.27.26.617.012.5634.3571.5
11. Eastern Asia: China61.424.78.214.54.71.614.94.86.93.73.78.10.64.46.94.91.82.00.90.724.518.6866.4528.1
12. Eastern Asia: Japan24.18.53.65.47.30.77.52.24.42.31.61.41.14.75.53.80.30.11.31.44.02.8224.1162.7
13. Eastern Asia: Other6.29.30.81.61.10.12.00.60.90.40.80.60.42.31.20.80.20.00.20.41.81.258.959.5
14. South Eastern Asia38.330.95.811.06.81.55.41.42.51.42.81.92.08.07.35.51.30.61.20.98.06.6181.4192.4
15. South Central Asia95.8107.09.324.416.64.017.14.26.43.612.27.73.99.016.49.28.03.03.42.417.811.7452.5488.4
16. Western Asia12.93.03.23.32.80.94.81.01.30.81.81.30.61.83.12.41.40.90.30.32.91.963.857.1
17. Eastern Europe77.227.523.225.322.14.520.25.815.411.48.77.41.85.87.75.64.73.42.73.011.510.8435.1405.6
18. Northern Europe48.47.68.39.326.22.413.95.35.23.53.42.70.61.65.95.31.31.02.42.35.14.2182.5185.6
19. Southern Europe50.99.912.08.517.72.322.04.36.03.25.03.80.83.08.66.42.11.32.02.17.45.7244.4197.2
20. Western Europe94.713.216.614.950.76.120.65.912.68.15.95.62.13.410.59.32.71.83.43.79.38.2350.0324.1
21. Australia/New Zealand9.01.31.31.26.50.51.80.71.00.70.70.60.10.31.51.20.20.20.40.41.30.938.334.2
22. Melanesia0.40.70.10.10.10.00.00.00.00.00.00.00.00.10.20.10.00.00.00.00.10.12.42.9
23. Micronesia/Polynesia0.10.10.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.00.50.6
Developed countries471.583.395.986.7300.522.1127.737.162.541.335.330.09.827.264.852.815.311.019.419.555.445.12108.71881.0
Developing countries324.1287.946.578.895.713.674.921.129.017.333.627.811.937.961.541.821.610.79.98.074.955.82184.81908.8
ALL AREAS795.6371.2142.4165.5396.135.6202.558.291.558.668.957.821.865.2126.394.636.921.729.327.5130.3100.94293.53789.8
Table VI. ESTIMATED AGE STANDARDIZED RATES OF CANCER INCIDENCE BY SITE, SEX AND AREA, 1990
   OtherMouth/  Colon/     
MouthNasopharynx pharynx pharynxOesophagusStomach rectumLiverPancreasLarynxLungMelanoma
(140–5) (147) (146, 8–9) (140–149) (150) (151) (153–154) (155) (157) (161) (162) (172)
MFMFMFMFMFMFMFMFMFMFMFMF
1. Eastern Africa7.65.22.50.82.00.412.16.412.55.39.05.38.14.218.55.72.21.72.50.44.92.02.13.1
2. Middle Africa5.32.70.80.21.50.67.53.52.10.220.014.82.33.428.413.61.74.12.40.26.50.83.42.4
3. Northern Africa4.72.02.71.41.00.28.43.52.81.75.92.66.04.24.72.41.00.65.60.812.82.60.70.6
4. Southern Africa16.03.22.90.51.40.520.24.232.611.911.54.311.28.420.16.62.81.96.90.929.17.74.54.5
5. Western Africa6.42.71.00.30.50.27.93.22.11.212.46.64.73.922.16.72.51.62.60.42.20.91.72.3
6. Caribbean8.14.70.80.34.11.513.06.57.52.116.27.916.015.58.04.45.73.57.41.329.810.10.90.7
7. Central America4.12.00.70.12.30.77.02.83.41.418.613.38.87.95.44.07.36.95.10.919.37.91.51.1
8. South America (Temperate)6.91.40.40.24.00.511.32.211.14.523.88.727.224.42.71.56.44.98.61.155.17.65.43.7
9. South America (Tropical)8.53.20.60.13.70.512.83.77.72.031.115.915.013.63.22.25.04.06.51.124.17.22.92.6
10. North America7.83.80.60.23.21.011.75.05.21.48.44.044.332.83.21.48.26.46.81.469.632.910.97.7
11. Eastern Asia: China1.10.73.31.60.20.14.72.421.69.943.619.013.310.235.811.52.51.21.70.434.713.40.30.2
12. Eastern Asia: Japan3.11.40.50.11.40.24.91.79.51.677.933.339.524.627.66.99.65.43.30.138.911.20.40.2
13. Eastern Asia: Other3.51.23.31.11.90.28.72.57.31.154.322.821.314.132.29.55.73.04.90.540.411.60.20.2
14. South Eastern Asia3.82.65.92.32.50.812.25.73.21.39.05.111.98.917.65.81.91.33.80.729.79.30.40.3
15. South Central Asia11.46.80.60.38.42.020.59.19.07.06.74.05.03.82.81.51.51.16.81.011.92.60.40.4
16. Western Asia3.82.21.00.41.00.65.73.22.42.09.46.68.87.65.03.13.12.38.41.030.55.21.31.4
17. Eastern Europe9.31.70.50.23.90.413.72.36.41.036.316.925.318.55.22.89.24.812.00.675.910.33.03.1
18. Northern Europe5.02.00.40.21.90.67.32.86.73.116.98.134.426.12.71.48.16.04.90.859.120.26.27.8
19. Southern Europe10.21.61.00.25.30.416.52.24.90.520.810.028.820.28.93.45.83.511.30.458.87.33.15.5
20. Western Europe11.32.10.70.29.80.921.83.26.91.116.48.239.829.04.91.56.34.28.90.554.18.25.47.2
21. Australia/New Zealand15.14.80.70.23.40.619.25.64.62.410.84.945.834.82.81.16.84.95.20.547.616.127.925.0
22. Melanesia36.923.10.20.31.90.639.024.03.62.66.54.811.15.320.19.91.00.53.60.97.83.76.33.3
23. Micronesia/Polynesia6.03.64.31.04.91.215.25.84.51.512.37.817.611.310.94.54.02.96.50.952.517.33.72.6
Developed countries8.42.30.60.24.50.613.53.06.41.327.112.635.925.47.62.67.95.08.50.762.615.55.75.5
Developing countries5.83.32.31.03.30.811.55.112.26.223.111.010.28.117.96.22.51.74.40.724.17.80.80.8
ALL AREAS6.62.91.80.73.60.712.14.310.24.224.511.619.415.314.74.94.43.15.70.737.510.82.32.2
 BreastCervixCorpusOvaryProstateTestisBladderKidneyBrain, CNSThyroidNHLHodgkin'sMyelomaLeukaemiaAll sites
(174) (180) uteri (183) (185) (186) (188) (189) (191–2) (193) (200, 202) (201) (203) (204–208) excl. skin
   (182)            (140–208)
       MFMFMFMFMFMFMFMFMF
1. Eastern Africa18.637.43.07.816.80.65.82.31.60.80.90.51.62.28.83.92.10.90.80.43.11.9178.0145.3
2. Middle Africa13.626.63.02.929.60.22.80.51.50.70.10.01.32.15.18.40.90.31.72.31.31.0160.4124.9
3. Northern Africa25.011.31.62.85.10.623.34.81.80.92.61.70.82.84.33.41.00.30.50.73.92.7105.694.6
4. Southern Africa31.540.47.45.331.00.811.73.02.71.72.31.61.13.25.84.01.20.61.81.45.43.5247.4187.8
5. Western Africa19.026.22.16.523.90.38.02.71.61.01.60.71.41.611.05.94.91.61.50.64.93.8140.0118.5
6. Caribbean33.533.27.06.342.40.77.92.53.12.03.93.20.93.85.23.62.21.32.91.87.35.6199.0175.5
7. Central America25.544.47.77.624.82.45.11.73.92.75.84.51.66.64.73.22.11.21.91.35.95.0154.7180.1
8. South America (Temperate)69.127.712.69.122.94.013.02.88.43.24.63.00.62.44.63.42.01.20.30.56.04.4255.1230.1
9. South America (Tropical)39.131.87.96.928.11.69.52.44.72.75.12.71.43.77.24.91.81.01.51.26.14.7196.9185.0
10. North America86.39.115.011.292.43.723.85.411.05.76.64.82.35.015.610.12.61.94.12.810.56.3369.9277.5
11. Eastern Asia: China11.85.01.72.71.10.33.31.01.50.70.81.60.10.81.30.90.30.30.20.14.53.5179.2105.3
12. Eastern Asia: Japan28.69.73.96.38.51.18.92.05.42.22.51.91.35.37.04.00.40.21.51.35.73.7270.9166.8
13. Eastern Asia: Other17.826.62.34.65.40.48.81.83.81.32.81.81.36.54.02.30.40.00.81.34.93.4235.7179.9
14. South Eastern Asia22.518.63.66.25.90.84.30.91.60.81.51.01.34.24.63.10.70.30.90.64.03.2130.4115.7
15. South Central Asia21.223.82.25.44.50.74.41.01.40.82.31.50.81.93.42.01.40.60.90.63.12.2106.3109.9
16. Western Asia24.35.56.56.37.11.310.92.02.61.53.12.11.13.25.24.11.91.30.70.64.52.9131.4108.3
17. Eastern Europe36.013.79.911.514.12.812.62.19.54.85.63.91.12.94.92.53.02.01.61.27.65.0269.4172.8
18. Northern Europe68.312.510.812.734.74.919.95.68.14.36.44.60.92.59.66.62.51.83.52.48.45.7270.0234.5
19. Southern Europe49.510.410.68.016.92.922.03.26.42.76.24.30.92.99.75.92.61.52.01.68.65.8256.0177.6
20. Western Europe67.310.911.110.039.66.516.63.110.64.95.74.61.92.49.25.82.81.82.82.08.55.6294.8210.4
21. Australia/New Zealand71.711.29.19.649.74.214.54.58.15.46.65.31.22.512.98.51.91.43.62.510.86.5312.7254.0
22. Melanesia23.943.47.47.76.01.42.70.61.31.00.40.41.84.89.04.80.80.40.30.74.03.3165.4185.6
23. Micronesia/Polynesia51.726.012.98.421.22.26.71.33.41.72.03.12.19.45.44.01.20.82.21.77.55.6204.5205.2
Developed countries56.411.210.710.340.13.617.63.59.14.55.74.21.53.69.65.82.51.72.71.98.65.5299.6208.9
Developing countries20.418.23.14.97.60.75.61.42.01.12.01.60.82.23.72.51.20.60.70.54.13.0152.4122.5
ALL AREAS33.015.55.96.819.81.39.92.34.32.43.02.31.02.65.63.81.50.81.41.15.64.0203.5154.6

There are estimated to be a grand total of 8.1 million new cancer cases in 1990, divided almost exactly between developed and developing countries. The number by world-area ranges from 1.4 million in China to about 1,100 in Micronesia/Polynesia. The numbers and ranking of the 12 most common cancers are shown by sex in Table VII. Figure 2 (males) and Figure 3 (females) show the number of cases and the ranking of the 25 sites in developed and developing countries.

Table VII. THE MOST FREQUENT CANCERS WORLDWIDE, 1990
 Numbers (1000s)Percent of total
  1. NHL, non-Hodgkin lymphoma.

Males
 Lung771.817.9
 Stomach511.011.9
 Colon/rectum401.99.4
 Prostate396.19.2
 Liver316.37.4
 Esophagus212.64.9
 Bladder202.54.7
 Mouth141.23.3
 Leukemia130.33.0
 NHL126.32.9
 Larynx118.52.8
 Kidney91.52.1
Females
 Breast795.621.0
 Colon/rectum381.010.1
 Cervix uteri371.29.8
 Stomach287.27.6
 Lung265.17.0
 Ovary165.54.4
 Corpus uteri142.43.8
 Liver121.13.2
 Esophagus103.22.7
 Leukemia100.92.7
 NHL94.62.5
 Pancreas78.92.1
Both sexes
 Lung1036.912.8
 Stomach798.39.9
 Breast795.69.8
 Colon/rectum782.89.7
 Liver437.45.4
 Prostate396.14.9
 Cervix uteri371.24.6
 Esophagus315.83.9
 Bladder260.73.2
 Leukemia231.22.9
 NHL220.92.7
 Mouth211.52.6
Figure 2.

Figure2

Estimated numbers of new cases of 21 cancers in men in developed and developing areas of the world.

Figure 3.

Figure3

Estimated numbers of new cases of 23 cancers in women in developed and developing areas of the world.

The significance of these findings for the major sites and world areas is discussed below. As noted in the introduction, care must be taken when comparing the estimates for 1990 with those for 5 years earlier (1985), because there have been important changes in the availability of data and methodology. For example, for the largest area (China), although the basic data source remained the same (mortality rates from the Disease Surveillance Points [DSP]) the nature of the DSP sample changed considerably from 58 points in 1985–1987 to 100 points in 1993. This change was made in order to improve the representativity of the sample, and the reported rates for several sites differ considerably. The age-standardized mortality rate of cervical cancer, for example, was 9.3 in 1985 and 2.8 in 1990, and that for breast cancer, which was 7.5 in 1985, was 4.3 in 1990.

As previously, we have favored maximum accuracy of our estimates even at the expense of stability of data sources and methods. Crude incidence rates will be affected by the aging of the world population [the median age has increased from 23.4 in 1985 to 24.3 in 1990 (UN, 1995)] and numbers of cases are also, of course, increased by population growth, which was 1.73% per year on average between 1985 and 1990. Estimating the increased number of cases due to these 2 components is easy by applying our 1990 estimated age-specific rates to the 1985 population. The rest of the increase in numbers of cases, compared with 1985 (Parkin et al., 1993), is the result of the change in data sources, and/or real increases in incidence rates.

Thus, the increase in the total (estimated) numbers of cancer cases since 1985 was 445,000, representing an increase of 5.8% (11.4% in males, 0.2% in females). This increase was the net result of population increase and aging that with constant rates would have increased incidence by 10.6% (11.1% in men, 9.9% in women), and a change in rates, increasing incidence by 0.2% in men, but decreasing incidence by 8.8% in women (overall, in both sexes, −4.3%).

Lung cancer was the most common cancer in the world in 1990, with 1.04 million new cases, or 12.8% of the total, about 58% of which occurred in developed countries. This finding represents an increase of 16% since the 1985 estimate (+14% in men, and +21% in women). Worldwide, lung cancer is by far the most common cancer among men (18.0% of all new cancers) and it is in first place in Europe (all areas), North America, Central America and the Caribbean, Temperate South America, Australia/New Zealand (NZ), Western, South-Central and Southeastern Asia, and Micronesia/Polynesia. Age-standardized rates in men range from 2.2 per 100,000 (Western Africa) to 75.9 per 100,000 (Eastern Europe). In females, incidence rates are much lower, the highest estimated rate is 32.9 per 100,000 in North America (where it is now the third most frequent cancer of women) and worldwide it is only the fifth most frequent cancer of women (Table VII).

Stomach cancer is the second most frequent cancer (9.9% of cases), although only in 4th rank among women. The estimated number is just 6% more than in 1985, which, given the observed population increase and aging, represents a decline of around 4–5% in age-adjusted risk. Thirty-eight percent of cases occur in China, where stomach cancer remains the most common cancer in both sexes, as it is elsewhere in Eastern Asia. Stomach cancer remains the most frequent cancer of men (ahead of lung cancer) in Tropical South America, and high rates are also present in both sexes in Eastern Europe.

Age-standardized incidence rates (ASRs) are highest in Japan (77.9 per 100,000 in men, 33.3 in women) and low in East and North Africa, North America and South and South East Asia (ASR in men 5.9–9.0 per 100,000, and 2.6–5.3 in women).

Breast cancer is by far the most frequent cancer among women (21% of all cancers) and ranks third overall when both sexes are considered together. It is the most common cancer among women in all the “developed” areas (except for Japan, where it is third after stomach and colon-rectal cancer), as well as in Northern Africa, South America, East, Southeast and Western Asia and Micronesia/Polynesia. The estimated cases are some 11% more than in 1985. The age-standardized incidence is highest in North America (86.3 per 100,000) and lowest in China (11.8). The latter figure is lower than the estimated age-standardized rate for 1985 (14.6), probably reflecting the modification in the data source.

Colorectal cancer is the second most common malignancy of both sexes in developed countries (Figs. 2 and 3), where age-standardized rates range in males from 25.3 per 100,000 (Eastern Europe) to 45.8 (Australia/NZ) and in females from 18.5 (Eastern Europe) to 34.8 (Australia/NZ). Incidence rates have risen (especially in men) in most areas (North America is an exception) since 1985, so that the estimated number of cases in 1990 is 15.5% greater (21% in men, 10% in women) than in 1985. About 34% of the cases occur in the developing countries, where the highest age-standardized rate observed is in Temperate South America (27.2 per 100,000 in men and 24.4 per 100,000 in women). Rates in Africa, except for South Africa, are very low.

Liver cancer is largely a problem of developing countries where 81% of the world total occurs. There are high incidence rates in sub-Saharan Africa (where liver cancer accounts for 13.4% of cancer in men), Eastern and Southeastern Asia and in Melanesia. China alone accounts for 53.9% of the world total of cases! The incidence is low in developed areas: only in Southern Europe is there any substantial risk. The overall sex ratio is around 2.6, rather greater in the high-risk areas and less in low-risk areas.

Prostate cancer is the 4th most frequent cancer of men overall (9.2% of all new cancer cases). Because it is a tumor of older men, the crude incidence rates are highest in those areas where there are relatively large numbers of elderly: North America (where it is now by far the most commonly diagnosed cancer of men), Northern and Western Europe and Australia/NZ. The age-adjusted rates show that several developing areas have relatively high incidence rates also: sub-Saharan Africa, Latin America and the Caribbean in particular. By contrast, the incidence rates in Asia and particularly in China are low. Even when comparison is made after age standardization, the difference in risk between China and North America is more than 80-fold. The estimated number of cases is substantially higher (36%) than 5 years earlier; most of this increase is the result of the huge increase in incidence rates in North America from an age-standardized rate of 61.3 per 100,000 in 1985 to 92.4 per 100,000 in 1990 (an annual increase of 8.5%).

Cervical cancer is 7th in frequency overall, 3rd in frequency in women, in whom it comprises 9.8% of all cancers (371,200 new cases a year). South-central Asia contributes almost 30% of this total. The estimate for 1990 is some 15% lower than that in 1985. The largest contribution to this change is the decline in the estimate for China. The estimated age-standardized incidence rate in 1990 was 5.0, compared with 17.8 in 1985. This low rate derives from the most recent mortality survey, and corresponds with the very low age-standardized incidence rates recorded for the period around 1990 in cancer registries in Shanghai (3.3), Qidong (2.6) and Tianjin (4.4) (Parkin et al., 1997).

Since 1985, cervical cancer has ceded its place as the leading cancer in developing countries to breast cancer, and only in sub-Saharan Africa, Central America, South-central Asia and Melanesia is it now the main cancer among women. In developed countries, the incidence rates are generally low, with age-standardized rates less than 14 per 100,000.

Esophageal cancer shows a wide variation in risk between areas: in men the difference in risk is some 15-fold between high-risk Southern Africa and low-risk Western Africa, and in women it is some 20-fold (high risk in Southern Africa and China, low risk in Southern Europe). Other areas of relatively high risk are Eastern Africa, South America and Southern Asia (particularly in women).

Bladder cancer is considerably more common in men than women (ratio worldwide is about 3.5:1). In general, the highest incidence is observed in developed areas (with the exception of Japan). However, Northern Africa is an area of high risk, and rates are also relatively high in Western Asia; these latter observations probably relate to the presence of urinary schistosomiasis [known to be associated with high rates of bladder cancer (IARC, 1994)] as well as a high prevalence of tobacco smoking in men.

Leukemia shows relatively little geographic variation, although rates appear to be low in sub-Saharan Africa (possibly partly related to under-recording in some of the data sources used). The incidence is highest in North America and Australia/NZ.

The lymphomas, which were previously considered as a single group, have now been subdivided. Non-Hodgkin lymphomas are by far the most common, with 221,000 new cases annually, compared with 59,600 cases of Hodgkin's disease and 56,600 cases of myeloma. For the non-Hodgkin lymphomas, the highest incidence is observed in the developed areas of North America, Australia/NZ and Europe. However, high incidence rates are also observed in some parts of Africa, in part because of high incidence rates in the childhood age range due to Burkitt's lymphoma. The lowest rates are observed in Eastern Asia and Southern Asia.

Hodgkin's disease has a similar geographic distribution. Incidence is especially low in the Eastern Asian areas and the Pacific islands. For myeloma, the highest rates are, again, observed in developed countries, but a few populations of African origin also display moderately elevated rates, for example, in males from the Caribbean and Southern Africa, in females from Middle Africa.

In previous estimates, all cancers of the mouth and pharynx were considered together as a single group. In the current estimates, we have divided this group into 3 categories: cancers of the mouth, nasopharynx and other pharynx. Of these, mouth cancers (which include cancers of the lip and salivary gland, as well as the mouth, gum, and tongue) are the most frequent, with 212,000 new cases worldwide (2.6% of the total), followed by other pharyngeal cancers with 94,000 cases (1.2%) and cancers of the nasopharynx with 57,500 cases (0.7%). All of these are much more common among males than females: the gender-ratio (M:F) is 2.0 for mouth cancer 4.4 for pharynx cancer and 2.2 for nasopharynx cancer.

There are some similarities to the geographic patterns for cancers of the mouth, and “other pharynx”. In men, both are high in Western and Southern Europe, and South Asia, whereas mouth cancers (but not pharynx) have high rates in Melanesia, Southern Africa and Australia/NZ. In females, both types of cancer have relatively high incidence rates in South-central Asia and (mouth cancers only) Melanesia and Australia/NZ. These patterns reflect prevalence of specific risk factors: tobacco/alcohol in Western and Southern Europe and Southern Africa, and the chewing of betel quid in South-central Asia and Melanesia. The high rate of oral cancer in Australia is due to lip cancer (related to solar irradiation).

Surprisingly, the incidence of cancer of the nasopharynx is not high in China, reflecting the fact that the areas of high-risk are confined to certain southern provinces, with low rates in the north (Li et al., 1979). On an area basis, the highest ratios are observed in South-east Asia (ASR 5.9 in men, 2.3 in women).

Pancreatic cancer (170,000 cases a year, 2.1% of the total) is most common in all of the developed areas, rarer elsewhere, although age-adjusted rates suggest that the risk in much of Latin America and the Caribbean is not much less than that observed in developed areas.

Ovarian cancer (165,000 cases, 2.0% of all cancers, 4.4% of cancers in women) and cancer of the corpus uteri (142,000 cases, 1.8% of all cancer, 3.8% of cancer in women) show similar geographic distributions. The highest rates are in North America and other developed areas (except Japan). The ASRs reduce the regional differences considerably, for ovarian cancer in particular, for which there is only about a 4–5-fold difference in risk (China, Northern Europe).

Kidney cancer (150,000 new cases, 1.9% of the world total) has the highest rates in North America and Western, Northern and Eastern Europe, whereas incidence rates are low in Africa, Asia (except Japanese males) and the Pacific.

Larynx cancer (136,000 new cases) is predominantly a cancer of men, in whom it comprises 2.8% of cases (1.7% overall). The sex ratio (almost 7:1) is greater than for any other site and Figure 3 emphasizes the rarity of larynx cancer in women, particularly in developed countries. For men, the high-risk areas are Europe (East, South, West), Temperate South America and Western Asia. In Western Asia, larynx cancer accounts for more than 6% of cancers in men.

Cancers of the brain and nervous system account for some 127,000 new cases annually (1.6% of new cancers). The highest rates are observed in developed areas (Australia/NZ, North America, Northern Europe) and lowest in Africa and the Pacific islands. This frequency suggests that the availability of diagnostic facilities may well be important in determining geographic patterns, at least in part. The quality of cancer registry data is dependent on the diagnostic facilities available, and mortality data are notoriously inaccurate for cancers of the brain and nervous system. The figures are likely to be something of an under-estimate of the true incidence of these cancers.

Malignant melanoma of skin accounts for 105,000 new cases annually, with slightly more occurring in women than in men (gender-ratio 0.9). This total is some 15% greater than the 1985 estimate. The highest rates are observed in Australia/NZ, North America and Northern Europe: these regions have seen annual increases of between 1.5% and 4.5% in incidence (age-adjusted) of melanoma over the 5-year period. The lowest rates are observed in East and South-East Asia, and in South Asia.

The moderate incidence rates in some African areas appears surprising. Melanoma in African populations occurs mainly on the sole of the foot. The high rates probably reflect the frequency with which such tumors were included in some of the case series used in the estimation process. The age-standardized incidence rates in cancer registry data were 1.3 (males) and 1.1 (females) in Kyadondo, Uganda, 1.8 (males) and 3.8 (females) in Africans in Harare, Zimbabwe, and 1.1 (males) and 1.4 (females) based on histologically proved cases in South African blacks.

Cancer of the thyroid (87,000 new cases) is much more common in females than in males (sex ratio (M:F) is 0.33), and it comprises 1.7% of cancers in women. The highest estimated incidence is in Micronesia/Polynesia [an area well known for a high frequency of those cancers (Paksoy, 1992)]. Rates are also high in Central America, Japan and “Other” East Asia (Korea and Hong Kong).

Testicular cancer is relatively rare: 36,000 new cases annually, or 0.8% of cancers in men. The highest rates are observed in Europe (West, North), Temperate South America, North America and Australia/NZ. The highest risk is in the age group 15–44 years, so that testis cancer is the most common cancer of men in developed countries in this age group (11.5% of new cases, compared with 9.4% due to lung cancer).

CONCLUSIONS

These 1990 estimates use a wider range of data sources than those for 1985. The methodology remains essentially similar, however, with the rather minor exception of abandoning altogether incidence rates for all cancers based on regression models of all-cause mortality (Preston, 1976). This regression-model approach was widely used by Murray and Lopez (1997) to prepare the estimates of mortality by cause. Because these models often produce results at variance with actual observations, it is preferable to use the latter whenever possible. For example, Gupta et al. (1994) pointed out that the model-based estimates of cancer mortality in India published by Murray and Lopez (1997) bear little relation to the actual profile of cancer, as recorded by the now more than 10 functioning cancer registries. Similarly, the number of cancer deaths estimated for Sub-Saharan Africa (429,000) somewhat exceeds our estimated number of incident cancers (425,000). It is for this reason that we have made every effort to obtain actual data on incidence and/or mortality, and as a consequence we believe that the results presented here represent the most accurate appraisal currently possible. Naturally, the accuracy of the estimates varies widely between the 23 world areas, depending on the nature and extent of the information on cancer occurrence available in the component countries (accuracy can be evaluated by scrutiny of the data sources used, which are listed in the Appendix). There is also considerable heterogeneity of incidence rates between countries within the same area (detailed country-specific estimates are available in the computer database “Globocan” (Ferlay et al., 1998) and also, of course, within the larger countries.

Information on cancer patterns and trends provides the basis for evaluating priorities for cancer control in different regions and worldwide. Although deaths and years of life lost from cancer have been used widely for this purpose, clearly the incidence of the disease is the most relevant parameter in the context of prevention, where the aim is to reduce morbidity as well as mortality.

With lung cancer emerging as the most commonly occurring cancer worldwide, it is clear that tobacco smoking is at present the most avoidable cause of cancer. In 1985, we estimated that 16% of all cancers (25% in men and 5% in women) could be attributed to this cause (Parkin et al. 1993); using the estimates presented here for 1990, and the same methodology, these percentages are unchanged, and the total number of tobacco-attributable cancers is almost 1.3 million.

The second great opportunity for primary prevention is liver cancer; 352,000 cases a year occur in the high-risk areas (sub-Saharan Africa, Eastern and Southeastern Asia, Melanesia) where some 67% of cases are related to chronic carriage of the hepatitis B virus (Parkin et al., 1998). Hence liver cancer is theoretically preventable by the introduction of hepatitis B virus vaccination into the primary immunization schedule for infants. A further 26% are related to the hepatitis C infection.

Several other cancers are related to infectious agents: the total of infection-attributable cases was estimated as 15% in 1990 (Parkin et al., 1998). These cases include cervical cancer and human papilloma virus, gastric cancer and lymphoma and Helicobacter pylori, nasopharynx cancer, Burkitt's lymphoma and Hodgkin's disease and Epstein-Barr virus, and Kaposi's sarcoma and other non-Hodgkin lymphomas and human immunodeficiency virus. For none of these agents are there currently available vaccines of potential use in primary prevention.

Prevention of the cancers related to westernized lifestyles (involving diets high in calories and animal products and low in fibre, overweight, sedentary life): cancers of the colon, rectum and possibly of the breast and prostate, are likely to present more of a challenge. These dietary patterns remain a perceived aspiration in many of the developing countries, and seem relatively difficult to change once they are established. The estimated incidence rates for these cancers have all increased between 1985 and 1990. It is perhaps fortunate that the increase in cancers anticipated from such dietary evolution will be partly offset by the decline in stomach cancer, thought to be related to changes in methods of food processing and storage.

Prevention of cancer occurrence by detection and treatment of pre-malignant conditions, is at present largely confined to cancers of the oral cavity and cervix. In theory, the heavy burden of oral cancer, particularly in Southern Asia, could be reduced by programs of screening for pre-cancerous lesions (WHO, 1984). However, although limited feasibility studies have been performed, the effectiveness of such strategies remains unclear (Sankaranarayanan, 1997). In contrast, screening by cytology (the Pap smear test) has been shown to be highly effective in preventing invasive carcinoma of the cervix (Hakama et al., 1985). The problem is that, to be effective, screening programs must be well organized and work in a defined, coordinated manner (WHO, 1986), conditions usually difficult to achieve in developing countries, where 78% of cases occur. The challenge appears to be in developing simple, affordable programs, which can be implemented despite the logistic difficulties.

APPENDIX

ESTIMATES OF THE WORLDWIDE INCIDENCE OF 25 MAJOR CANCERS IN 1990
Country/regionMethodNotes2
  1. 1 Incomplete/unpublished incidence data (see text: 3.B).

  2. 2 Abbreviations and symbols: → I, converted to Incidence; *, multiplied by; CI5VI, Cancer incidence in five continents. Vol. VI; CI5VII, Cancer incidence in five continents. Vol. VII; CAC, Central Asian Countries (ex-USSR) model (Table II); CERP, Cancer Epidemiology Research Programme; DEV, Developing Country model (Table II); EE, Eastern Europe model (Table II); ICMR, Indian Council for Medical Research; ICO, Iranian Cancer Organisation; LAC, Latin America and Caribbean countries; MENA, Middle East-North Africa rates (Table III); MV, morphologically verified; OOCE, Other Oceanic rates (Table III); OLAC, other Latin America & Caribbean countries model (Table II); q.v., quod vide; SSA, Sub-Saharan Africa rates (Table III); TSA, Temperate South America model (Table II).

1. Eastern Africa
Burundi6Average
Comoros6Average
Djibouti6Average
Eritrea6Average
Ethiopia5All sites (SSA) + proportions [Lindtjorn, 1987 (except melanoma; from Uganda, Harare African)]
Kenya5All sites (SSA) + proportions [Parkin, 1986; (except melanoma; from Uganda, Harare African)]
Madagascar6Average
Malawi3BMalawi Cancer Registry scaled to SSA all sites rates1
Mauritius2AWHO mortality → I (Dev model)
Mozambique6Average
France, La Reunion1CI5VII
Rwanda5All sites (SSA) + proportions (Newton et al.,1996)
Seychelles6Average
Somalia6Average
Uganda3ACI5VII (Kyadondo)
United Republic of Tanzania5All sites (SSA) + proportions [Average of Kilimanjaro/Muhumbili (Parkin, 1986)]
Zambia5All sites (SSA) + proportions (Parkin, 1986)
Zimbabwe3ACI5VII (Harare)
2. Middle Africa
Angola5All sites (SSA) + proportions [Report from National Registry 1987–1990 (C.N.O. 1991)]
Cameroon5All sites (SSA) + proportions, Yaoundé Registry, 1995–19961
Central African Republic6Average
Chad6Average
Congo3BBrazzaville Cancer Registry, 19961
Equatorial Guinea6Average
Gabon5All sites (SSA) + proportions (Nze-Nguene et al.,1996)
Zaire5All sites (SSA) + proportions (Bourdeaux et al.,1988)
3. Northern Africa
Algeria3A/3BSetif (CI5VII) + Algiers (Registre des Tumeurs d'Alger 1993, 1994)—average
Egypt5+2BAll sites (MENA) + proportions (M → I Dev, Algeria to split remainder)
Libya6Average (All except Egypt, because of high bladder rates)
Morocco5All sites (MENA) + proportions Institut National d'Oncologie, 1986–87 (Chaouki and Gueddari, 1991)
Sudan5All sites (MENA) + proportions (Parkin, 1986)
Tunisia5All sites (MENA) + proportions (Ben Abdallah, 1997)
4. Southern Africa
Botswana5All sites (SSA) and proportions [South Africa Blacks (qv.)]
Lesotho5All sites (SSA) and proportions [South Africa Blacks (qv.)]
Namibia5All sites (SSA) + proportions (Namibia National Cancer Registry Report, 1989–1994)
South Africa3BBlack, white, asian and coloured rates combined, with corresponding populations at risk (true incidence est. from S.A. Cancer Registry data 1990–1991 (Sitas et al.,1996)) converting pathology based rates using % MV cases by site/sex/age group observed in Harare (black population) and UK (others)
Swaziland5All sites (SSA) + proportions (1979–83) (Parkin, 1986)
5. Western Africa
Benin6Average
Burkina Faso6Average
Cape Verde6Average
Côte d'Ivoire5All sites (SSA) + proportions [from Abidjan cancer registry]1
Gambia1CI5VI
Ghana6Average
Guinea3AConakry Cancer Registry, 1992–1995 (Koulibaly et al.,1997)
Guinea-Bissau6Average
Liberia5All sites (SSA) + proportions (1976–1980) (Parkin, 1986)
Mali3ACI5VII (Bamako)
Mauritania6Average
Niger5All sites (SSA) + proportions, Niamey Cancer Registry1
Nigeria5All sites SSA + proportions [average of Ibadan 1960–1969 (Waterhouse et al.,1976) and Ife-Ilesha Cancer Registry]1
Senegal5All sites (SSA) + proportions (Dakar Registry, 1969–1974, Waterhouse et al.,1982)
Sierra Leone6Average
Togo6Average
6. Caribbean
Bahamas2BWHO Mortality → I (OLAC). Residual split by proportions in 7 combined LAC Registries (CI5VII)
Barbados2BWHO Mortality → I (OLAC). Residual split by proportions in 7 combined LAC Registries (CI5VII)
Cuba3ACI5VI
Dominican Republic2CWHO Mortality* 1.47 → I (OLAC). Residual split by proportions in 7 combined LAC Registries (CI5VII)
France, Guadeloupe2BMortality (France) → I (OLAC) + proportions of Martinique for residual
Haiti5Area average all sites rate + proportions (Mitacek et al.,1986)
Jamaica2CWHO Mortality* 1.16 → I (OLAC). Residual split by proportions in 7 combined LAC Registries (CI5VII)
France, Martinique1Cancer Registry, 1988–19921
Netherlands Antilles1CI5VI
Trinidad and Tobago2BWHO Mortality → I (OLAC). Residual split by proportions in 7 combined LAC registries (CI5VII)
Puerto Rico1CI5VII
7. Central America
Belize6Average
Costa Rica1CI5VII
El Salvador2CWHO Mortality* 1.47 → I (OLAC). Residual split by proportions in Costa Rica
Guatemala6WHO Mortality* 1.15 → I (OLAC). Residual split by proportions in Costa Rica
Honduras6Average
Mexico2CWHO Mortality* 1.12 → I (OLAC). Residual split by proportions in Costa Rica
Nicaragua5Area average all sites rate + proportions (WHO Mortality data → Incidence (OLAC) Residual split by proportions in Costa Rica)
Panama2CWHO Mortality* 1.39 → I (OLAC). Residual split by proportions in Costa Rica
South America
8. Temperate
Argentina2BWHO Mortality → I (TSA) Residual split by proportions in Concordia (CI5VII)
Chile2BWHO Mortality → I (TSA) Residual split by proportions in Concordia + Montevideo (CI5VII)
Uruguay2BWHO Mortality → I (TSA) Residual split by proportions in Montevideo (CI5VII)
9. Tropical
Brazil3A/3BIncidence rates from Belem, North (CI5VII), Fortaleza, North East (Rebelo et al.,1995), Goiania, Centre CI5VII), Campinas, South East (Rebelo et al.,1995) and Porto Alegre, South (CI5VII) weighted by regional populations.
Bolivia3BIncidence rates from La Paz cancer Registry (1988–1992)1
Colombia2CWHO Mortality* 1.23 → I (OLAC) + Residual split by proportions in Cali (CI5VII)
Ecuador2CWHO Mortality* 1.32 → I (OLAC) + Residual split by proportions in Quito (CI5VII)
9. Tropical (continued)
Guyana2CWHO Mortality* 1.25 → I (OLAC) + Residual split by proportions in 7 combined LAC registries (CI5VII)
Paraguay3ACI5 VI (Asuncion)
Peru3AMean of Lima and Trujillo rates (CI5VII)
Suriname2CWHO Mortality* 1.15 → I (OLAC). Residual split by proportions in 7 combined LAC Registries CI5VII)
Venezuela2BWHO Mortality I (OLAC). Residual split by proportions in 7 combined LAC Registries CI5VII)
10. Northern America
Canada1CI5VII
United States of America2AWHO Mortality → I, using model based on US registries (CI5VII)
Asia
Eastern Asia
11. China4DSP mortality → I (China Model) Residual split by proportions in Shanghai, Tianjin and Qidong (CI5VII)
12. Japan2AWHO Mortality → I using model based on Japanese registries in CI5VII
13. Other Eastern Asia
Republic of Korea3AAverage of Kangwha (CI5VII) and Seoul 1994 (Cancer Registry, data) except 200–2081 Kangwha only
Mongolia5All sites incidence from WHO Mortality for China Rural → I (Dev Model) + Proportions in Chinese Registries (CI5VII)
Hong Kong1CI5VII
14. South Eastern Asia
Brunei Darussalam6Average
Cambodia3AMean of rates of Thailand (q.v.) and Ho Chi Minh City, Vietnam (Quoc et al.,1998)
East Timor6Average
Indonesia3AMeans of rates for Singapore Malays (CI5VII) + Semarang 1985/87 (Semarang Cancer Registry)1
Lao PDR3AIncidence rates for Khon Kaen, Thailand (CI5VII) except liver (mean of other rates in Area)
Malaysia3ARates for Singapore (CI5VII) weighted 0.54* Malay, 0.37* Chinese and 0.09* Indian
Myanmar3AIncidence for Rangoon (Yangon) 1983–85 (Aye, 1991)
Philippines3AAverage of rates in Manila (CI5VII) + Rizal (1988–1992)1
Singapore1CI5VII
Thailand3APopulation-weighted mean of rates in regional registries (Vatanasapt et al.,1993)
Viet Nam3AAverage of rates in Hanoi (CI5VII) and Ho Chi Minh City (Quoc et al.,1998)
15. South Central Asia
Afghanistan6Average of estimates for Pakistan, Iran, Tajikistan (q.v.)
Bangladesh5Indian all sites rates + Proportions in CERP (1976–81) (Parkin, 1986)
Bhutan6Average
India3AAverage of rates for Bombay, Barshi, Delhi, and Southern registries [average of Bangalore, Madras, Trivandrum and Karnagapally (CI5VII and ICMR, 1996 (Delhi)].
Iran, Islamic Rep. of5MENA rates + proportions ICO (Parkin, 1986)
Kazakhstan2BWHO Mortality → I (CAC) + Residual from proportions in Alma Alta registry 1983–871
Kyrgyzstan2BWHO Mortality → I (CAC) + Residual from proportions in Kyrgyzstan (CI5VI)
Maldives6Average
Nepal6Average
Pakistan3ACancer Registry of Karachi (South) 1995 (Y. Bhurgri, personal communication)
Sri Lanka5Indian All sites rates + proportions for Maharagama Cancer Centre (1977–1978) (Parkin, 1986)
Tajikistan2BWHO Mortality → I (CAC) + Residuals from proportions in Kyrgyzstan (CI5VI)
Turkmenistan2BWHO Mortality → I (CAC) + Residuals from proportions in Kyrgyzstan (CI5VI)
Uzbekistan2BWHO Mortality → I (CAC) + Residuals from proportions in Kyrgyzstan (CI5VI)
16. Western Asia
Azerbaijan2BWHO Mortality → I (CAC) + Residuals proportions from Tbilisi (1983–87)1
Armenia2BWHO Mortality → I (CAC) + Residuals proportions from Tbilisi (1983–87)1
Cyprus2A/6Rates for Greece
Iraq5MENA rates + proportions (1976–82) from Al-Fouadi and Parkin, (1984)
Israel1CI5VII
Jordan3A/6Israel, Non-Jews (CI5VII)
Kuwait1CI5VII
Lebanon3A/6Israel, Non-Jews (CI5VII)
Oman3AResults from Oman Cancer Registry (1994–1996)
Qatar3A/6Average Kuwait (Kuwaitis) + Saudi Arabia (q.v.)
Saudi Arabia3AResults from Saudi Arabia Cancer Registry (1995)
Syrian Arab Republic3A/6Israel, Non-Jews (CI5VII)
United Arab Emirates3A/6Kuwait (Kuwaitis) + Saudi Arabia (q.v.)
Turkey5MENA rates + proportions (Akoguz, 1988) and residual from Izmir Cancer Registry1
Yemen6Average
Bahrain3A/6Kuwait (Kuwaitis) + Saudi Arabia
Georgia2BWHO Mortality → I [(CAC) + Residual sites from proportions in Tbilisi (1983–87)1
Europe
17. Eastern Europe
Bulgaria2AWHO Mortality → I (EE)
Belarus1CI5VII
Czech Republic1CI5VII
Hungary2AWHO Mortality → I (EE)
Moldova2BWHO Mortality → I (EE) + Residual sites from proportions in combined data of 8 East European Registries (CI5VII)
Poland2BWHO Mortality → I (EE) + Residual sites from proportions in 4 Polish Registries (CI5VII)
Romania2BWHO Mortality → I (EE) + Residual sites from proportions in combined data of 8 East European Registries (CI5VII)
Russian Federation2BWHO Mortality → I (EE) + Residual sites from proportions in combined data of 8 East European Registries (CI5VII)
Slovakia1CI5VII
Ukraine2BWHO Mortality → I (EE) + Residual sites from proportions in combined data of 8 East European Registries (CI5VII)
18. Northern Europe
Denmark1CI5VII
Estonia1CI5VII
Finland1CI5VII
Iceland1CI5VII
Ireland2ABlack et al. (1997). 140–149 split by proportions in Ireland, Southern 1988–92 (CI5VII)
Norway1CI5VII
Sweden1CI5VII
United Kingdom1CI5VII
Latvia1CI5VII
Lithuania1Cancer Registry 1988–19921
19. Southern Europe
Albania3A/6Average Croatia + Vojvodina + Slovenia (CI5VII)
Bosnia and Herzegovina3A/6Average Croatia + Vojvodina (CI5VII)
Croatia1CI5VII
FYROM (Macedonia)2A/6Rates from Greece
Greece2ABlack et al. (1997) and 140–149 split using rates in 27 South European Registries (CI5VII)
Italy2ABlack et al. (1997) and 140–149 split using rates from 13 Italian Registries (CI5VII)
Malta1CI5VII
Portugal2ABlack et al. (1997) and 140–9 split using data from 3 Portuguese Registries1
Slovenia1CI5VII
Spain2ABlack et al. (1997) and 140–9 split using rates from 9 Spanish Registries (CI5VII)
Yugoslavia3AVojvodina (1988–92) CI5VII
20. Western Europe
Austria2ABlack et al. (1997) and 140–9 split using data from Tyrol Registry (CI5VII)
Belgium2ABlack et al. (1997) and 140–9 split using data from 20 W. European Registries (CI5VII)
France2ABlack et al. (1997) and 140–149 split using data from 8 French Registries (CI5VII)
Germany2ABlack et al. (1997) and 140–149 split using data from 2 German Registries (CI5VII)
Luxembourg2ABlack et al. (1997) and 140–149 split using data from Luxemburg histology Registry1
Netherlands1CI5VII
Switzerland2AWHO mortality data → I using model based on Swiss Registries (CI5VII)
Oceania
21. Australia-New Zealand
Australia2AWHO mortality data → I using model based on Australian registries (CI5VII)
New Zealand1CI5VII
22. Other Oceania Melanesia
Fiji1Fiji Cancer Registry (1990–1991)1
New Caledonia1New Caledonia Cancer Registry (1988–1992)1
Papua New Guinea5OOCE rates and proportions (histo-pathology Registry, 1978–83)
Solomon Islands6Average
Vanuatu5OOCE rates and proportions from Vanuatu Cancer Registry (1980–1985)
Micronesia
Guam1Cancer Registry (1984–1989)1
Polynesia
French Polynesia1CI5VII
Samoa5OOCE rates and proportions from Paksoy et al. (1991)

Ancillary