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Keywords:

  • cancer;
  • Europe;
  • mortality;
  • time trends

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

BACKGROUND

In May 2004, 10 additional countries joined the European Union (EU), including a total of 75 million inhabitants. Most of these were from central and eastern European countries with comparably high cancer mortality rates and with relatively unfavorable trends. Therefore, it is important to provide updated mortality data regarding major cancers in various countries and to analyze trends for the current population of the EU.

METHODS

The authors considered mortality rates (directly standardized to the world standard population) for all cancers and for 8 major cancer sites in the year 2000 in the 25 countries of the EU and analyzed corresponding trends since 1980 using data derived from the World Health Organization data base.

RESULTS

For men, overall cancer mortality in the year 2000 varied by a factor > 2 between the highest rate of 258.5 per 100,000 men in Hungary and the lowest rate of 122.0 per 100,000 men in Sweden. Central and Eastern European accession countries had the highest rates not only for lung and other tobacco-related cancers but also for gastrointestinal cancers and leukemias. The geographic pattern was different and the range of variation was smaller for women, i.e., between 136.7 per 100,000 women in Denmark and 76.4 per 100,000 women in Spain in the year 2000. In the EU as a whole, lung cancer mortality in men peaked at 55.4 per 100,000 men in 1988 and declined thereafter to 46.7 per 100,000 men in 2000. Gastric cancer steadily declined from 19.7 per 100,000 men in 1980 to 10.1 per 100,000 men in 2000. Other major sites showed moderately favorable trends over the last few years. In women, breast cancer peaked at 21.7 per 100,000 in 1989 and declined to 18.9 per 100,000 in 2000. Mortality from gastric, (cervix) uterus, and intestinal cancers demonstrated steady decreases, but lung cancer increased from 7.7 per 100,000 women in 1980 to 11.1 per 100,000 women in 2000. The increase in lung cancer mortality in women age < 55 years was 38% between 1990 and 2000 (from 2.16 per 100,000 women to 2.99 per 100,000 women), reflecting the spread of tobacco smoking among women in the EU over the last few decades.

CONCLUSIONS

The priority for further reduction of cancer mortality in the EU remains tobacco control together with more widespread availability of modern diagnostic and treatment procedures for neoplasms that are amenable to treatment. Cancer 2004. © 2004 American Cancer Society.

In May 2004, 10 additional countries joined the European Union (EU), including approximately an additional 75 million inhabitants. Of these, only approximately 1 million (from Cyprus and Malta) are from Mediterranean populations, whereas the others are from central and eastern European areas, areas in which mortality from several major cancer sites has been comparatively high and in which trends have been unfavorable over the last few decades.1–4

Because, for most of the 25 member states of the EU, cancer mortality rates are available since at least 1980 and until at least 2000, we have provided annual age-standardized rates for 8 major cancer sites among both genders and in each separate country for the most recent calendar year available as well as trends in cancer mortality in the EU as a whole over the last 2 decades.1

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Official death-certification numbers for all cancers and for 8 major cancer sites, for the 15 member states of the EU in 2003 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands, Portugal, Spain, Sweden, and the U.K.), and for the 9 accession countries to the EU in May 2004 (the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, and Slovenia), were derived from the World Health Organization (WHO) data base.5 Data for Cyprus were not available. During the calendar period considered (1980–2000), 3 different revisions of the International Classification of Diseases (ICD) were used. The classification of cancer deaths was recoded for all calendar periods and countries according to the ICD-ninth revision (for further details, see Tables 3 and 4). To improve the validity and comparability of data throughout different countries, we pooled together all intestinal sites, including the rectum, and all uterine cancers (cervix and endometrium), because, in several countries, large (and variable) proportions of deaths were registered as intestines or uterus, unspecified.

Table 1. Age-Standardized (World standard population) Mortality Rates per 100,000 Men for Selected Cancers in the 25 Member Countries (Cyprus not available) of the European Union in 2000 (Unless otherwise specified in parentheses)
CountryCancer site
Total, all sitesMouth or pharynxEsophagusStomachIntestinesPancreasLarynxLungProstateTestisBladderHodgkin's diseaseNon-Hodgkin lymphomasLeukemias
Hungary258.4921.098.5816.3933.5110.747.7079.9316.850.877.650.903.807.42
Slovakia221.3216.547.5215.9734.259.926.2360.8115.600.555.360.942.976.01
Czech Republic216.976.834.7912.0435.8110.613.5761.6216.810.637.010.773.597.12
Poland206.075.904.8316.1119.498.076.3767.9412.550.568.360.933.085.34
Estonia203.819.404.4022.6318.2410.043.5762.3319.670.525.770.263.565.39
Lithuania200.8510.315.8822.7319.6210.016.0754.2417.490.707.730.792.896.60
Latvia195.947.945.5420.4617.5910.595.4355.4514.550.928.870.903.706.71
Slovenia195.867.924.5117.1823.958.405.0952.5617.880.155.100.153.925.21
Belgium (1996)189.645.515.297.4017.487.853.9865.7618.550.227.770.594.405.93
France (1999)186.9710.018.416.5419.077.724.4246.3915.750.276.620.384.825.41
Denmark (1998)174.314.326.265.1823.108.502.4743.1818.860.438.590.305.206.03
The Netherlands170.973.197.318.2819.536.941.6750.5517.480.286.050.455.054.96
Spain168.336.334.9910.5118.526.055.6345.9712.420.178.110.543.625.01
Luxembourg166.107.895.526.5318.368.622.8347.6616.810.326.000.522.525.33
Italy164.824.392.9811.3515.497.263.1946.4110.290.216.450.464.855.69
Ireland161.223.718.268.4019.667.182.0438.3318.640.423.320.505.455.68
Portugal160.376.755.7019.3519.355.824.9729.6319.740.335.250.515.07
Germany159.265.734.869.6519.928.202.0841.8314.380.365.040.363.895.27
Austria148.906.243.469.3118.748.902.6236.4816.280.374.430.304.025.15
United Kingdom150.262.588.457.5016.536.571.3839.1514.920.235.550.384.974.56
Greece (1999)144.111.841.268.6410.646.523.1048.889.510.146.601.751.565.87
Malta135.472.711.568.8816.347.030.9935.4013.100.716.940.376.034.73
Finland129.452.312.507.6312.378.210.5733.4817.320.183.290.365.464.44
Sweden122.002.032.905.3014.767.520.5320.8921.870.124.000.374.304.77

Estimates of the resident population, generally based on official censuses, were obtained from the same WHO data base. From the matrices of certified deaths and resident populations, age-specific rates for each 5-year age group (from birth–4 years to 80–84 years and ≥ 85 years), by annual and 3-year calendar period, were computed. Age-standardized rates per 100,000 population, at all ages and at ages birth–54 years, 55–74 years, and ≥ 75 years, were computed using the direct method based on the world standard population.6 Annual percent changes in rates were computed using a standard log-linear model.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Table 1 provides the overall age-standardized death certification rates for EU countries for all neoplasms and for 13 major cancer sites in men around the year 2000 ranked by total mortality rates. Total cancer mortality varied by a factor > 2, between the highest rates of 258.5 per 100,0000 men in Hungary and the lowest rate of 122.0 per 100,000 men in Sweden. All central and eastern accession countries had exceedingly high rates, ranking from 1 to 8, from 258.5 per 100,000 men in Hungary to 195.9 per 100,000 men in Slovenia. Belgium was the first-ranked western country, with 189.6 per 100,000 men. This pattern also was observed for most major sites considered, including oral cancer (21.1 per 100,000 men in Hungary vs. 2.0 per 100,000 men in Sweden), esophageal cancer (8.6 per 100,000 men in Hungary vs. 1.3 per 100,000 men in Greece), gastric cancer (22.7 per 100,000 men in Lithuania vs. 5.2 per 100,000 men in Denmark), intestinal cancer (35.8 per 100,000 men in the Czech Republic vs. 10.6 per 100,000 men in Greece), pancreatic cancer (10.7 per 100,000 men in Hungary vs. 5.8 per 100,000 men in Portugal), laryngeal cancer (7.7 per 100,000 men in Hungary vs. 0.5 per 100,000 men in Sweden), lung cancer (79.9 per 100,000 men in Hungary vs. 20.9 per 100,000 men in Sweden), and leukemias (7.4 per 100,000 men in Hungary vs. 4.4 per 100,000 men in Finland). For bladder cancer, however, the range was between > 8 per 100,000 men in Denmark and Latvia and 3.3 per 100,000 men in Finland. For prostate cancer, the range was between 21.9 per 100,000 men in Sweden and 9.5 per 100,000 men in Greece.

Corresponding figures for women are provided in Table 2. The geographic pattern was different, and the range of countries was smaller (i.e., with overall rates for all cancers combined between 136.7 per 100,000 women in Denmark and 76.4 per 100,000 women in Spain). After Denmark, high total cancer mortality rates were noted not only in Hungary, the Czech Republic, and Poland but also in Ireland, the Netherlands, and the U.K. With reference to specific major cancer sites, the range of variation was between 9.5 per 100,000 women in Estonia and 1.9 per 100,000 women in Luxembourg for gastric cancer, between 19.6 per 100,000 women in Hungary and 8.2 per 100,000 women in Greece for colorectal cancer, between 7.3 per 100,000 women in Malta and 3.3 per 100,000 women in Portugal for pancreatic cancer, between 27.1 per 100,000 women in Denmark and 4.6 per 100,000 women in Spain for lung cancer, between 31.8 per 100,000 women in Malta and 14.3 per 100,000 women in Spain for breast cancer, between 13.2 per 100,000 women in Lithuania and 3.6 per 100,000 women in Greece for uterine cancer (cervix and corpus), between 9.4 per 100,000 women in Denmark and 3.4 per 100,000 women in Portugal for ovarian cancer, and between 4.7 per 100,000 women in Luxembourg and 2.8 per 100,000 women in Sweden and the U.K. for leukemias.

Table 2. Age-Standardized (World standard population) Mortality Rates per 100,000 Women for Selected Cancers in the 25 Member Countries (Cyprus not available) of the European Union in 2000 (Unless otherwise specified in parentheses)
CountryCancer site
Total, all sitesMouth or pharynxEsophagusStomachIntestinesPancreasLarynxLungBreastUterus, totalOvaryBladderHodgkin's diseaseNon-Hodgkin's lymphomasLeukemias
Denmark (1998)136.721.741.552.6916.046.360.4727.1425.767.239.392.390.213.303.72
Hungary133.513.001.347.2419.576.350.5821.1222.609.346.221.640.562.434.07
Czech Republic119.641.090.605.7217.686.850.2012.4518.729.497.401.650.602.464.30
Ireland119.391.313.074.1812.494.800.1419.0125.024.678.361.340.553.772.85
Poland110.321.010.765.8112.065.120.5312.5015.0110.506.731.220.541.613.22
The Netherlands108.691.182.053.7513.525.160.3616.8523.074.116.001.560.283.153.06
United Kingdom110.261.143.283.1110.204.820.2519.9621.444.597.701.960.263.332.74
Slovakia106.901.080.535.9116.035.380.328.0318.2710.826.621.040.651.833.43
Estonia104.871.170.229.5011.895.130.197.1122.349.557.891.330.292.733.59
Malta101.881.200.184.0211.957.250.337.8831.833.746.040.720.271.823.90
Slovenia101.421.090.587.6312.775.380.2210.4618.207.485.711.040.462.623.22
Lithuania100.271.170.649.1710.324.500.114.9717.6713.239.141.160.681.193.84
Belgium (1996)100.081.511.403.4612.084.840.349.5225.234.847.401.690.342.343.61
Germany97.771.250.925.2112.695.470.2210.7319.534.756.201.510.252.483.33
Latvia96.710.570.319.2711.455.460.215.8118.0310.266.221.290.431.563.85
Sweden95.430.970.892.9011.086.690.1513.3216.474.517.351.180.162.882.80
Austria95.291.510.645.3011.216.450.2411.5418.875.485.731.270.192.433.07
Luxembourg95.231.151.151.8611.224.230.4410.9321.654.434.250.810.293.474.70
Italy90.301.070.555.409.314.990.218.3017.793.904.230.980.343.073.49
France (1999)87.631.321.062.4610.664.410.327.5119.834.745.341.230.242.793.25
Finland84.840.810.983.869.485.930.177.6015.964.065.440.800.283.502.82
Portugal84.131.020.778.9110.813.250.135.2015.926.103.441.340.372.82
Greece (1999)76.670.560.313.708.184.210.186.8314.733.624.221.011.131.003.44
Spain76.410.790.474.4110.483.780.124.6414.334.284.081.100.362.372.96

Figure 1 illustrates the trends for 8 major cancer sites in the EU between 1980 and 2000 in men in all EU countries (Fig. 1A), in the 15 countries of the EU before May 2004 (Fig. 1B), and in the 9 accession countries that provided data (Fig. 1C). For all cancer sites, trends were more favorable systematically in former EU countries than in accession countries, whose rates started to level off only over the last few years. Table 3 provides corresponding changes in rates at all ages and in three separate age groups between 1990 and 2000 in all EU countries. Lung cancer peaked at 55.4 per 100,000 men in 1988 and declined thereafter to 46.7 100,000 men in 2000. The decrease was 13.6% in the last decade and was greater among men aged < 75 years. Gastric cancer steadily declined from 19.1 per 100,000 men in 1980 to 10.1 per 100,000 men in 2000. The decrease was 31.4% over the last decade and was of similar magnitude in subsequent age groups. All other major neoplasms demonstrated relatively modest trends, with some early increases noted until the late 1980s and subsequent declines. However, all disease types, except pancreatic cancer, were reported to have declined by 5–14% over the last decade.

thumbnail image

Figure 1. Trends in age-standardized (world standard population) mortality rates per 100,000 men for selected cancers in (A) the 25 countries of the European Union (EU), (B) the 15 countries of the EU before May 2004, and (C) the 10 accession countries from 1980 to 2000.

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Table 3. Trends in Age-Standardized (World standard, in selected age groups) and All-Age Mortality Rates per 100,000 Men for Selected Cancers in the European Union between 1990 and 2000
Site (ICD-9)Ages Birth–54 yrsAges 55–74 yrsAges ≥ 75 yrsAll ages
19902000Annual % change in rate19902000Annual % change in rate19902000Annual % change in rate19902000Annual % change in rate
  • ICD-9: International Classification of Diseases, 9th revision.

  • a

    P < 0.01.

  • b

    P < 0.05.

Lung (162)9.468.01− 1.7a278.17234.65− 1.8a492.57468.81− 0.7a54.0546.69− 1.6a
Intestines, mainly colorectum (152–154, 159.0)2.942.43− 1.8a86.7282.29< 0.5b327.14300.67− 0.9a20.3218.78− 0.8a
Prostate (185)0.300.28− 1.0b50.344.81− 1.1a414.45417.12− 0.315.0814.4− 0.6a
Stomach (151)2.401.67− 3.6a64.3943.77− 3.9a212.35147.67− 3.9a14.6610.06− 3.9a
Pancreas (157)1.481.41− 0.235.5235.81− 0.0387.2487.72− 0.37.627.6− 0.1
Bladder (188)0.530.48− 1.7a30.6825.18− 2.4a142.05128.86− 1.4a7.286.26− 1.9a
Mouth or pharynx (140–149)2.642.49− 0.8b27.3825.34− 1.0a34.2428.23− 1.9a6.495.98−1.0a
Esophagus (151)1.581.44− 1.0a28.8626.46− 0.8a49.2248.44− 0.5b6.085.63− 0.9a
Leukemias (204–208)2.241.75− 2.5a19.2118.54− 0.3b71.0172.26− 0.35.835.34−1.0a

Corresponding values for women are given in Table 4 and Figure 2. Breast cancer mortality peaked at 21.7 per 100,000 women in 1989 and declined thereafter to 18.9 per 100,000 women in 2000. Intestinal, gastric, and uterine (mainly cervical) cancers demonstrated steady decreases, whereas pancreatic and ovarian cancers were found to show no major changes, and lung cancer increased from 7.8 per 100,000 women in 1980 to 11.1 per 100,000 women in 2000. Over the last decade, the overall decrease in women was 31% for gastric cancer, 20% for uterine cancer (mainly cervical), 16% for colorectal cancer, and 11% for breast cancer and leukemias. The pancreatic cancer mortality rate rose by 6%, and the lung cancer mortality rate rose by 17%. The increase in lung cancer in women aged < 55 years was > 38% (from 2.11 to 2.99 per 100,000 women) (Table 4). As in men, among women, the trends systematically were more favorable in former EU countries than in the accession countries.

Table 4. Trends in Age-Standardized (World standard, in selected age groups) and All-Age Mortality Rates per 100,000 Women for Selected Cancers in the European Union between 1990 and 2000
Site (ICD-9)Ages Birth–54 yrsAges 55–74 yrsAge ≥ 75 yrsAll ages
19902000Annual % change in rate19902000Annual % change in rate19902000Annual % change in rate19902000Annual % change in rate
  • ICD-9: International Classification of Diseases, 9th revision.

  • a

    P < 0.01.

  • b

    P < 0.05.

Breast (174)8.687.26− 2.0a82.8173.8− 1.3a156.75155.27− 0.6b21.2818.87− 1.4a
Intestines, mainly colorectum (152–154, 159.0)2.331.93− 1.8a54.645.24− 1.8a229.69198.69− 1.7a13.6711.49− 1.8a
Lung (162)2.162.99+ 3.2a46.3550.78+ 0.7a80.4598.76+ 1.9a9.4711.12+ 1.2a
Uterus, total (179,180,182)2.452.08− 2.0a27.3220.84− 2.9a57.3148.74− 2.0a6.785.45− 2.5a
Stomach (151)1.280.97− 2.9a25.4917.47− 4.9a112.3375.33− 4.6a6.654.6− 4.0a
Ovary (183)1.971.76− 1.3a27.7226.63− 0.6b44.7950.38+ 0.66.175.97− 0.6a
Pancreas (157)0.720.74+ 0.0821.0522.38+ 0.368.5973.33+ 0.24.725.01+ 0.2
Leukemias (204–208)1.701.27− 2.8a11.2110.48− 0.6a38.2339.84− 0.033.663.24− 1.3a
thumbnail image

Figure 2. Trends in age-standardized (world standard population) mortality rates per 100,000 women for selected cancers in (A) the 25 countries of the European Union (EU), (B) the 15 countries of the EU before May 2004, and (C) the 10 accession countries from 1980 to 2000 (C).

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DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

The current analysis of cancer rates and trends in all countries that were included in the EU in May 2004 essentially has descriptive value and, consequently, is necessarily simplistic. Furthermore, it obscures important variations observed in various countries that, nonetheless, have been addressed in a separate report on cancer mortality up to 1999.1 However, this analysis has relevant descriptive value, in that it documents cancer mortality rates around the year 2000 in all countries (except Cyprus) of the EU, as defined in 2004, hence, offering a baseline cancer picture for the new definition of the EU.

It is unlikely that cancer mortality data for the major sites considered have substantial problems of reliability and validity. Consequently, it is unlikely that any such problem has introduced any appreciable trends over the last few decades in any of the countries considered, although minor influences due to changes in classification and coding remain possible in various countries.7–9

The inclusion of data from accession countries has led to some increases in average cancer mortality and to some (quantitatively) less favorable trends, because the rates in central and eastern European countries that entered the EU in 2004 were higher than in the existing EU member countries.1 More important, the difference in cancer mortality rates across various EU countries has become substantial, calling for urgent action toward cancer control in most of former accession countries from central and eastern Europe. These actions include control of both tobacco and alcohol consumption10–15; wider availability of favorable components of diet, such as vegetables, fiber, and fruit; and wider and more uniform adoption of earlier diagnosis and treatment procedures.16–23

The overall pattern of trends has not changed, however, with increases for lung and other tobacco-related neoplasms noted in men until the late 1980s and decreases thereafter, whereas lung cancer in women continues to increase, although it remains at comparatively lower levels compared with the trend in the U.S..10–15 In addition, breast cancer, colorectal cancer, and several other common neoplasms had a tendency to level off and decline moderately over the last decade, whereas steady and persisting decreases were observed for gastric and uterine (cervix) cancers.16–18 These favorable changes most likely are related chiefly to advancements in screening and early diagnosis for cervical, breast, and colorectal cancer; improvements in treatment; and a richer, more favorable diet for gastric and colorectal cancers.16–18, 23

Due to the worrisome increase in lung cancer rates in young women (> 38% over the last decade), the priority for further progress and reduction in cancer mortality in Europe remains tobacco control, together with a more widespread availability of modern diagnostic and treatment procedures for neoplasms that are amenable to treatment throughout various areas of the continent.19–24 Such progress should be larger in countries with currently high rates.

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES