Published OnlineFirst July 20, 2010; DOI: 10.1158/1055-9965.EPI-10-0437
Cancer
Epidemiology,
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bal Patterns of Cancer Incidence and Mortality Rates
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ile incidence and mortality rates for most cancers (including lung, colorectum, female breast, and pros-re decreasing in the United States and many other western countries, they are increasing in severalveloped and economically transitioning countries because of adoption of unhealthy western lifestyless smoking and physical inactivity and consumption of calorie-dense food. Indeed, the rates for lunglon cancers in a few of these countries have already surpassed those in the United States and othern countries. Most developing countries also continue to be disproportionately affected by cancers re-to infectious agents, such as cervix, liver, and stomach cancers. The proportion of new cancer casessed in less developed countries is projected to increase from about 56% of the world total in 2008 tothan 60% in 2030 because of the increasing trends in cancer rates and expected increases in life expec-and growth of the population. In this review, we describe these changing global incidence and mor-
eral migrant studies have documented that cancerin successive generations of migrants shift in theion of the prevailing rates in the host country, sug-g that the international variations in cancer ratesost cancers largely reflect differences in environ-l risk factors (including lifestyle and culture) ratherenetic differences (1, 2). In general, smoking, die-atterns, and reproductive behaviors have beenn to be the major risk factors for cancer in westerncountries, and infectious agents in economicallyoping countries. However, these patterns areing rapidly. While smoking prevalence is decliningnomically developed countries, it is increasing indeveloping countries in South America, Asia, and(3). For example, current smoking prevalence
g adult men in the West, including the United, is about 20%, compared with more than 60% in, Indonesia, Greece, and Jordan (3). Further, fol-g earlier trends in several western countries, con-
aturated fat and calorie-dense food andvity are increasing in less developed and
deaththe chmortaand mIARC
Data
Highave1960sFive C
: Surveillance and Health Policy Research Department,ociety, Atlanta, Georgia
ary data for this article are available at Cancer Epide-rs & Prevention Online (http://cebp.aacrjournals.org/).
thor: Ahmedin Jemal, Surveillance and Health Policyent, American Cancer Society, 250 Williams Streetor, Atlanta, GA 30303-1002. Phone: 404-329-7557;. E-mail: [email protected]
mically transitioning countries, leading to increasesesity among segments of the population in someries where poverty and malnutrition are still majorems (4, 5).hough the full impacts of these unhealthy lifestylees on the cancer burden in less developed or eco-ally transitioning countries are likely to take dec-o be realized, new alarming trends in cancer ratesalready emerged in these countries (6-8). Cancersnce were rare and considered the diseases of west-untries, such as colon, breast, and lung cancers, arerequently diagnosed in less developed or econom-transitioning countries and their rates are on the). In addition to the increasing trends, the futuren of cancer in the developing world is likely tosperated by the expected increases in life expectan-aging and growth of the population (10). The pro-
n of cases diagnosed in less developed countries isted to increase from about 56% in 2008 to more0% in 2030 (11). It is also projected that cancer willss ischemic heart disease as the leading cause ofworldwide in 2010 (12). In this review, we describeanging global patterns of cancer incidence andlity for select common cancer sites using incidenceortality data compiled in CancerMondial by the(13).
Source and Methods
h-quality population-based cancer incidence databeen collected throughout the world since the early
and published periodically in Cancer Incidence inontinents (CI5). IARC has made these data available
Published OnlineFirst July 20, 2010; DOI: 10.1158/1055-9965.EPI-10-0437
public in the CancerMondial database (13). Thisase also provides cancer mortality statistics for se-untries, extracted from the WHO database. Onlyxth of the world population is covered by popula-ased cancer registries, and one third by death certi-n system (13). For this review, we mainly usence data for 45 select cancer registries with long-data from CI5 and mortality data from WHO (13).dence and mortality rates are age standardized to60 world standard population to be consistent withRC and other international publications on cancer.fore, these rates cannot be compared with thoseardized to the 2000 U.S. standard population,gives more weight to rates occurring in the oldest
roups (14). Except for childhood cancers and can-hat commonly occur in young adults, rates stan-zed to the 2000 U.S. standard population arentially higher than those standardized to the 1960population, by as much as 60% for colon, stomach,ng cancers (15).
ncer sitesas estimated that there were about 12.7 millionancer cases and 7.6 million cancer deaths in 2008wide (11). Overall incidence rates (per 100,000)98-2002 among the 45 select cancer registries world-vary by nearly 6-fold in men, from 86.3 in Algeriato 453.3 in U.S. blacks, and by nearly 4-fold inn, from 80.3 in Algeria (Setif) to 302.3 in U.S.ispanic whites (whites; Supplementary Fig. S1).wever, regional variations in overall cancer ratesask important differences in composition of can-he most frequently diagnosed cancers by sex varyerably across country (Supplementary Fig. S2). Thecommonly diagnosed cancer among men is lungr in most parts of Eastern Europe and Asia; prostater in North America, Australia, Western and North-urope, and South America; liver cancer in parts ofAfrica; Kaposi sarcoma in central parts of Africa;agus in East Africa; and bladder cancer in Egypt.g women, the most frequently diagnosed cancerast cancer in most parts of the world, includingalia, Western Asia, North Africa, North America,arts of South America; cervical cancer in Centralica, parts of South America, Sub-Saharan Africa,ndia; liver cancer in Mongolia and Vietnam; andcancer in China and North Korea. We briefly de-the international incidence and mortality patternsese common cancers, except for Kaposi sarcomaladder cancers, for brevity.
and bronchusrldwide, lung cancer is the leading cause of cancers in men and the second leading cause of cancers in women, with about 1.6 million new lung can-ses and 1.4 million deaths expected to occur in 2008
n men, the highest lung cancer incidence rates areted in the United States (blacks) and in Eastern
ean countries and the lowest rates are found in, Central and South America, and South Central(Supplementary Fig. S3). In women, the highestcancer rates are reported in North America andof Europe, including the United Kingdom andark and the lowest rates are found in Africa, Southal Asia, and Latin America. U.S. Hispanic men andn have higher rates than those of most registries orries in Latin America (Supplementary Fig. S3). Inast, several countries or registries in Asia haver lung cancer rates than U.S. Asians for both menomen. Notably, the lung cancer rates in Chinesend women, Filipino men, and Thai women exceedtes among women in many European countries,ing Germany and Finland.rnational variations in lung cancer rates and trendsy reflect differences in the stage and degree of theco epidemic (16, 17) because smoking accounts for80% of global lung cancer deaths in men and 50%deaths in women (18, 19). In several western
ries where the tobacco epidemic was establishedeaked by the middle of the last century, includingnited States, the United Kingdom, Canada, andalia, lung cancer rates have been decreasing innd plateauing in women (20, 21). In contrast, inries where the epidemic has been established moretly and smoking has just peaked or continues tose, including China, Korea, and several countriesrica, lung cancer rates are increasing (Fig. 1), andre likely to continue to increase at least for the nextecades barring interventions to accelerate smokingion (16, 22).response to the globalization of the tobacco epi-(23-26), WHO established the WHO Framework
ention on Tobacco Control to provide a frameworkoven tobacco control measures (27), including rais-e price of tobacco products, banning smoking inplaces, restricting tobacco advertising and promo-
counteradvertising, and providing treatment andeling for tobacco dependence (28). This frameworkeen ratified by 168 countries or parties as of MarchAccording to the 2009 summary progress report onmentation of the Framework Convention on To-Control, 65 countries claimed to have developed
mplemented comprehensive national tobacco con-trategies, plans, and programs according to thework (29).ironmental exposures other than smoking thatontribute to regional variations in lung cancer ratese radon and asbestos, certain metals (chromium,ium, arsenic), some organic chemicals, radiation,llution, coal smoke, and indoor emissions fromng other fuels (30). For example, Chinese womenhigher lung cancer rates than women in severalean countries, despite their low smoking preva-(31). This is thought to reflect indoor air pollution
unventilated coal-fueled stoves and from cooking(22, 32, 33).
men anew cpecteddifferand feest inportedand SGermfoundCentrAsianU.S. wer ratAsia;high rtary FWh
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and rectumorectal cancer is the third most common cancer innd the second in women. Worldwide, 1.2 millionolorectal cancer cases and 609,000 deaths were ex-to occur in 2008 (11). There is a more than 10-fold
ence in the regional incidence rates in both malesmales (Supplementary Fig. S4). Generally, the high-cidence rates among both men and women are re-in Eastern European countries (Czech Republic
lovakia), Japan (Miyagi), New Zealand, Australia,any, and U.S. blacks, whereas the lowest rates arein Africa, Central and South America, and Southal Asia (India and Pakistan). U.S. Hispanic andmen and women have lower incidence rates thanhite or black men and women, but they have high-es than their counterparts in Latin America andexceptions to these patterns are the substantiallyates in Japan (Miyagi) and Singapore (Supplemen-igs. S4 and S5).ile colorectal cancer incidence rates are stabilizinglining in historically high-risk areas (United States,Zealand, Canada), they are rapidly increasing inl historically low-risk countries, including Japan,, China, and Eastern European countries (Slovakia,nia, and Czech Republic; Supplementary Fig. S6;, 34). Indeed, rates among males in the Czech Re-
Figure 1. Trends in lung cancer mortality rates
and Japan have already exceeded the peak ratesved in long-standing developed countries such as
nited States, Canada, and Australia (8, 34). Notably,ese in California have substantially higher inci-rates (per 100,000) than Caucasians in Californiath men (42.9 versus 36.6) and women (33.5 versusupplementary Fig. S5). Spain is the only Southernstern European country with a large increase in thence rate (8, 34).increase in the incidence rates in several Asian andn European countries and Spain is thought to re-hanges in dietary and lifestyle factors associatedwesternization, including smoking and obesity (8,. For example, in some Eastern European countriesas the Czech Republic, nearly 60% of men are cur-igarette smokers (3) and more than 25% of adultsese (38). The decrease in the incidence rate in thed States in the most recent time period largely re-detection and removal of precancerous lesionsgh colorectal cancer screening (39).ontrast to the less favorable incidence trends, colo-cancer death rates have been decreasing in severalof the world (8). This may be attributed, in part, toved treatment and increased awareness and earlytion (39-42). Mortality rates, however, continue tose in countries with limited resources and healthtructure, including Mexico and Brazil in Centralouth America and Romania in Eastern Europe (8).
in select countries, 1950-2006.
ear survival rates for colorectal cancer in develop-untries range from 28% to 42% (43, 44), compared
Cancer Epidemiol Biomarkers Prev; 19(8) August 2010 1895
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more than 60% in the United States, Japan, anderland (45, 46).ventive measures for reducing the burden of colo-cancer in both low- and high-resource countries in-being physically active, maintaining a healthy bodyt, minimizing consumption of redmeat and alcohol,izing consumption of fruit and vegetables, and ces-of smoking (6). High-resource countries could ben-om the implementation of colorectal screening thats detection and removal of precancerous polypsarly-stage cancers (47-49). However, few countriesh Republic, Germany, Israel, Japan, and Poland)ational colorectal cancer screening programs; most
screening initiatives consisting of recommendationsr guidelines with opportunistic screening or pilots (8, 50).
le breastast cancer is the most commonly diagnosed cancere leading cause of cancer death in women world-with an estimated 1.4 million new breast cancerand 458,000 deaths in 2008 (11). Incidence andlity rates vary internationally by more than 5-foldlementary Fig. S7). Generally, the highest inci-rates are found in Switzerland, U.S. whites, Italy,any other European countries, whereas low ratesund in Africa, Asia, and South America. The rates. Hispanics and Asians are substantially higherared with the rates in most cancer registries in Asiaatin America. Regional patterns in mortality ratesnerally similar to the incidence patterns, althoughhites, Hispanics, and Asian-Pacific Islanders and
alia have relatively low rates, whereas U.S. blacksrinidad and Tobago have the highest rates (Supple-ry Fig. S7).high breast cancer incidence rates in white womenUnited States and in most European countries re-he long-standing high prevalence of reproductives associated with increased risk of breast cancer, in-g early menarche, late child bearing, fewer preg-es, use of menopausal hormone therapy, as wellreased detection through mammography (51, 52).dition to these factors, the high breast cancer inci-rates in Israel may reflect the disproportionatelyrevalence of BRCA1 and BRCA2 mutations in thenazi Jewish population (about 2%; ref. 53). The life-isk of being diagnosed with breast cancer in womenBRCA1 or BRCA2 mutation is about 50% (54),ared with 13% in all U.S. women (55). The relativelyortality rates in the United States and many otherrn countries reflect the availability of early detec-nd improved treatments.ast cancer incidence rates in the United States havesed since the early 2000s largely due to reductionuse of menopausal hormone therapy (56-58); de-s in utilization of mammography (59) or decreases
number of preclinical cases found by screeninghe past 20 years may also have contributed to the
ase in the incidence rates (60, 61). Similar decreasings, in part due to reduction in the use of menopausalone therapy, have also been noted in many otherrn countries, including the United Kingdom,e, and Australia (62-64). In contrast to the incidences, breast cancer mortality rates in these and severalwestern countries have been stable or decreasingg the past 25 years (Supplementary Fig. S8) becausely detection through mammography and improvedent (65-68). The favorable mortality trend in the
recent period in the United States, the United King-Australia, and France may also partly reflect reduc-the incidence rates.paredwith the trends in the United States, Canada,
nited Kingdom, and several other western Europeanries, breast cancer incidence and mortality ratesg women have been increasing rapidly in manyrn European, Asian, Latin American, and Africanries (Fig. 2; refs. 65, 69-71). For example, incidenceincreased by 140% in Miyagi (Japan) from 1973-o 1998-2002, by 40% in Chennai (India) from 1983-o 1998-2002 (13), and by 4.5% per year in Kampalada) from 1991-2006 (72). Factors that contribute toincreasing trends are not fully understood, butht to reflect lifestyle changes associated with west-tion, including late child bearing, having fewer chil-and consumption of calorie-dense food, physicalvity, and obesity (5, 38, 73-75). The unfavorable mor-trend in several of these countries may have beenrbated by poor survival because of lack of or limitedto early detection services and treatment. Only 40%men in Campinas (Brazil) and Setif (Algeria) survivers after a diagnosis of breast cancer (45), compared89% of women in the United States and more thanf women in Northern and Central Europe (46).lementation of population-based, organized mam-aphy screening programs for early detection is costbitive in many low- and middle-income countriesncreasing awareness of early signs and symptomsreening by clinical breast examinations are the onlyoptions in these countries (77). Access to treatmentreast cancer and for all cancers in developingries are limited by the small numbers of trainedal personnel, the availability and cost of cancer, and the insufficiency or lack of modern equipmenting radiotherapy machines (77). For example, alation of about 80 million people in Ethiopia isby a single radiotherapy machine, compared with
opean standard of one machine for every 250,000e (78).
atestate cancer is the second most frequently diag-cancer and the sixth leading cause of cancer deathg men worldwide, with 914,000 new cases and0 deaths projected to occur in 2008 (11). More than
f these cases and deaths are expected to occur indeveloped countries (11). Incidence rates (per
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0) vary by nearly 50-fold worldwide, ranging fromIndia to 178.8 in U.S. blacks (Fig. 3). Generally, thest rates are recorded in North America, Oceania,orthern and Western Europe, whereas the lowestare found in Asia and North Africa.ch of the international variations in prostate cancernce rates reflect differences in the use of prostate-ic antigen (PSA) testing, which detects indolentte cancer cases that may not otherwise have beened in one's lifetime (79-81). According to recent es-s, 23% to 42% of prostate cancer cases in Europehe United States could be due to overdiagnosis
Figure 2. Trends in female breast cancer incidenc
gh PSA testing (82, 83). The relatively low mortalityin U.S. whites and in some European countries,
PSA testing is common, may also support the roleerdiagnosis to the high incidence rates in theseries. However, some of the international variationsbe real. Two studies, conducted before the intro-n of PSA testing, reported strong international eco-correlation between per capita fat consumption andnce or mortality rates, suggesting the role of animalthe occurrence of prostate cancer (84, 85). Thesegs were supported by subsequent analytic studies7). Further, the high prostate cancer incidence andlity rates (Fig. 3) among black populations in thed States and other parts of the world [including
s for select registries, 1973-2006.
ca (88) and Trinidad and Tobago (89)] may reflectences in genetic susceptibility (90, 91).
Cancer Epidemiol Biomarkers Prev; 19(8) August 2010 1897
Figure 3. Prostate cancer incidence and mortality rates in select registries, 1998-2002.
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idence rates in the United States, Canada, andalia are generally decreasing after increasing dra-ally between the late 1980s and early 1990s be-of rapid dissemination of PSA testing, while
in the United Kingdom and elsewhere in Europeue to increase slightly because of increased aware-nd gradual adoption of PSA testing (80). Prostater mortality rates have been decreasing in mostrn countries, including the United States, Canada,d, France, Israel, Italy, the Netherlands, Norway,gal, Sweden, and Australia (80). The reason fornot clear, but may reflect both improved treat-and early detection (92, 93). However, a recentmized trial in the United States failed to shownefit of PSA testing in reducing deaths from pros-ancer, although another trail in Europe showed ait (94, 95).ontrast to the prostate cancer incidence and mor-trends in western countries, rates are increasinge Asian and Eastern European countries, such as
, Singapore, and Poland, where PSA testing is notonly used (Supplementary Fig. S9). The increase in
countries is thought to reflect westernization, in-g increased consumption of animal fat, obesity,hysical inactivity (80).
achmach cancer is the fourth most commonly diag-cancer and the second leading cause of cancerworldwide, with an estimated 990,000 new cases38,000 cancer deaths in 2008 (11). Incidence rates00,000) vary from 3.3 in men and 2.0 in womenypt to 65.9 in men and 25.9 in women in Korea). These large regional variations mainly reflect dif-es in prevalence of H. pylori infection, which ac-s for more than 60% of gastric cancer worldwideifferences in smoking prevalence may also, in part,bute to this variation because it accounts for aboutf all stomach cancer cases worldwide (18, 97). Theal variations in gastric cancer mortality rates haveeen linked with differences in dietary sodium ande intake in an ecologic study (98), although the con-
ion of salt intake to the worldwide stomach cancern has not been quantified.
In ccidenin theratesproximmanyUnitereflecciatedhistolesophto theesophPre
ance oing inincreaand r
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idence rates for stomach cancer have declinedly in several western countries (99), with rates de-ng by more than 80% since 1950 in the United(100). Similar decreasing trends, albeit at muchmagnitudes, have been noted in more recent yearsntries with historically high stomach cancer inci-rates including Japan, China, Korea, Columbia,or, Ukraine, and Russia (99). Reasons for this re-ble worldwide decrease in incidence and mortali-es are not fully understood, but are thought toe decreased reliance on salted and preservedand increased availability of fresh fruits and vege-due to the invention of refrigeration, reduction inic H. pylori infection due to improved hygiene andantibiotics (96), and increased screening activitiesan; ref. 99). Reduction in smoking may have alsobuted to the decrease in stomach cancer rates innited States, the United Kingdom, and other west-
untries, where the tobacco epidemic has long beenished.
hygieJapan
Figure 4. Stomach cancer incidence rates by sex in
ontrast to the decreasing overall stomach cancer in-ce rates, which are largely determined by the trendsfundus and distal stomach (pylorus), incidence
have increased for cancer of the gastric cardia (theal part of the stomach) in the United States andEuropean countries, including Denmark and thed Kingdom (101, 102). This increase is thought tot a rise in the gastroesophageal reflux disease asso-with the obesity epidemic (103). Improvements inogic diagnosis and verification of tumors of theagus and stomach are also thought to contributeincrease in gastric cardia adenocarcinoma of theagus (101, 104).ventive measures for stomach cancer include avoid-f foods preserved by salting and pickling, decreas-itiation and increasing cessation of smoking,sing consumption of fresh fruits and vegetables,eduction of H. pylori infection through improved
ne (105). Early detection programs are available inand Korea (106, 107). There is also considerable
select registries, 1998-2002.
Cancer Epidemiol Biomarkers Prev; 19(8) August 2010 1899
expla(HBVHBVincludtion dof EutionsHCVconvefor 78deathfromand S
ex in s
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st in H. pylori screening and treatment in high-riskations, such as China, Japan, and Korea, where thelence of H. pylori infection in the general populations as high as 50% (108), although there is a concernxtensive use of antibiotics could lead to develop-of antibiotic-resistant strains of H. pylori (109).
er cancer is the sixth most commonly diagnosedr and the third leading cause of cancer deathwide, with an estimated 748,000 new liver cancerand 696,000 deaths during 2008 (11). Nearly 85% ofcases occur in less developed countries, with Chinaaccounting for more than 50% of the total (11).is a 20- to 40-fold difference in international varia-in liver cancer rates (Fig. 5). Generally, the highestre found in Asia and West and Central Africa, andwest in Europe, Oceania, and North America. U.S.
Figure 5. Liver cancer incidence rates by s
nics and Asians have higher rates than U.S. whites,ey have lower rates than their counterparts in Asia
atin America (Fig. 5; Supplementary Fig. S10).g primary liver cancers occurring worldwide, he-ellular carcinoma accounts for 70% to 85% of theases (110).rnational variation in liver cancer rates is largelyined by the distribution of chronic hepatitis B virus) and hepatitis C virus (HCV) infections (111), withinfection generally dominating in high-risk areas,ing Asia and Sub-Saharan Africa, and HCV infec-ominating in low-risk areas, including most partsrope and North America (96, 110, 112, 113). Excep-to these patterns are the much higher prevalence ofthan HBV in Japan, Pakistan, and Egypt, and therse in Greece (110, 113). These two viruses account% (HBV, 53%; HCV, 25%) of the total liver cancers globally, with the estimates by region varyingabout 64% in the Americas to about 90% in Japaningapore (110). Other known risk factors that con-
elect registries, 1998-2002.
e to the international variations in liver cancer ratese dietary exposure to aflatoxins in low-resource
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al countries and alcohol-related cirrhosis, smoking,onalcoholic fatty liver disease (obesity) in mostrn countries (111, 113, 114). Most of these factors,ver, are thought to act as cofactors in the presencexisting chronic viral infections (6, 111). Substantialions in liver cancer rates also occur within countryion or subpopulation due, in part, to differences instorical prevalence of HBV and HCV chronic infec-(39, 115-117). In New Zealand, for example, liverr rates and prevalence of hepatitis B surface antigento 10 times higher in the Maori population than ins (116).rpretation of temporal trends in liver cancer ratesbe affected by changes in classification of diseasesr by difficulties in distinguishing primary liver
r from secondary liver cancer (118-120). Neverthe-ver cancer rates have decreased during the past de-n select European (especially southern Europe) andcountries (111, 119, 121). The decrease in southernean countries is thought to reflect screening ofproducts for HCV and HBV markers, reductionsohol consumption and smoking prevalence, and/proved treatment for liver cancer as well as for cir-(mortality rates only; refs. 111, 119, 121). The de-in select Asian countries, including China and
, is thought to reflect reduction in transmission ofduring childhood and adulthood through im-d hygienic and sanitary conditions and reductiontamination of food with aflatoxins through betterstorage system (111, 121, 122). Infant hepatitis im-zation programs implemented over the past twoes in these and other countries have been shownstantially decrease the trend in children and adoles-(123, 124), but are too recent to affect the trends inor at all ages (125).
contrast to the decreasing trends in high-riskries, especially in Asia, liver cancer rates are increas-several parts of the world, including the United
, Egypt (126), Japan (127), Oceania, and Europe, inue to widespread HCV infection through injecteduse and contaminated blood transfusion and/ores used for medical purposes (111, 119, 128-133).besity epidemic and associated diabetes are alsoht to contribute to the growing burden of liver can-the United States and several other countries (119,According to the American Cancer Society Cancerntion Study II, liver cancer death rates were fourhigher in obese people than in those with normalweight (134).ventive strategies for liver cancer include preven-f HBV and HCV infections and avoidance of exces-lcohol consumption, as well as implementation ofes to reduce aflatoxin contamination of food supply-resource tropical countries (6). A vaccine that pro-gainst HBV has been available on the market sinceand in 1992, WHO recommended that all countries
e HBV vaccine as part of the routine infant immu-on program (135). As of 2008, a total of 177 countries
had introduced HBV vaccine into their national in-mmunization schedules (136). However, countriesave yet to implement the program include manyaharan Africa and Asian countries, where the viralion rate and the disease burden are among the high-35). In contrast to HBV, no vaccine is availablest HCV. Therefore, HCV prevention strategies in-screening of blood, organ, tissue, and semen donorstibodies to HCV and instituting adequate infectionl practices during all medical, surgical, and dentaldures.
ageal cancerphageal cancer is the eighth most frequently diag-cancer and the sixth leading cause of cancer deathswide, with an estimated 482,000 new cases and0 deaths in 2008 (11). The highest incidence ratesund in Asia and Sub-Saharan Africa and the lowestare found in Europe and North America (Supple-ry Fig. S11). Generally, rates are much higher inhan in women.cer of the esophagus occurs in two major histologic, esophageal squamous cell carcinoma (ESCC) andageal adenocarcinoma (EAC; ref. 137), each withct geographic patterns (138-140). ESCC dominatesst parts of the world, especially in high-risk areasas China and Iran, where it accounts for aboutf the total esophageal cases (141-143). Smokinglcohol consumption are the major risk factors for, whereas smoking and obesity are major risk fac-or EAC (144, 145). Smoking and alcohol consump-ccount for more than 90% of ESCC in the Unitedand several other western countries (144, 145),ese risk factors play a less significant role for ther burden in high-risk areas such as Linxian (China)olestan (Iran; refs. 143, 146). In these regions, bothing prevalence and alcohol consumption are lowand the incidence of ESCC in women is as high asn, despite the low prevalence of smoking in womenared with men (141). Suggested risk factors forin these high-risk areas include poor nutrition, lackit and vegetables, drinking hot beverages, and opi-43, 146, 148-151).ddition to differences in geographic patterns andrisk factors, ESCC and EAC show markedly differ-mporal trends. ESCC incidence rates continue to de-in most western countries and in some high-risk
ries due, in part, to the decrease in smoking preva-(men only) and alcohol consumption, improved so-nomic status, and the availability of more fruit andables in high-risk areas (102, 138, 152). However, in-ce rates for ESCC have continued to increase incountries such as Taiwan due, in part, to increasedmption of cigarettes, alcohol, and betel nuts (153).stark contrast to the trends for ESCC in mostries, incidence rates for EAC are increasing in sev-
conomically developed countries, including thed States, the United Kingdom, and Denmark (138,
Cancer Epidemiol Biomarkers Prev; 19(8) August 2010 1901
tries w(Shan45 inof Suand Sof can(160).cancebut loand APer
papillcerviccountsexuaimmufactorcance
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54). This increase is thought to primarily reflect in-s in gastroesophageal reflux disease and Barrett'sagus, a precursor of esophageal cancer, related toesity epidemic in these countries (103, 155). Othersted contributing factors for this pattern include theing prevalence of H. pylori infection due to im-d sanitation and widespread utilization of antibio-56-158) and increased tendency to classify cancersd in gastroesophageal junction as EAC, rather thantric cardia (159). H. pylori is hypothesized to be pro-e against EAC because it reduces the acidity ofch contents and thereby reduces esophageal dam-om reflux (145).
x uterivical cancer is the third most commonly diagnosedr and the fourth leading cause of cancer death inn worldwide, with an estimated 529,000 new cases
75,000 deaths expected to occur in 2008 (11). Thence rates (per 100,000) among select cancer regis-
cancealence
Figure 6. Cervical cancer incidence and mortality rates
orldwide range from less than 5 in Egypt, Chinaghai), and many European countries to more thanSub-Saharan Africa countries (Fig. 6). In most partsb-Saharan Africa, South America, the Caribbean,outhern Asia, cervical cancer is the leading causecer death and premature death among womenU.S. Hispanics and Asians have higher cervicalr incidence and mortality rates than U.S. whites,wer rates than their counterparts in Latin Americasia (Fig. 6; Supplementary Fig. S12).sistent infection with about 15 high-risk humanomavirus (HPV) types is the major risk factor foral cancer, with HPV-16 and HPV-18 infections ac-ing for about 70% of the total cases (161); multiplel partners, younger age at first sexual intercourse,nosuppression, and cigarette smoking serve as co-s to the HPV persistent infection and progression tor (162, 163). The large regional variation in cervical
r rates reflects geographic differences in HPV prev-(164) and/or the availability of Pap test screening
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nized or opportunistic) that allows the detectionmoval of precancerous lesions (165-168). In severalrn countries, where screening programs have longstablished, cervical cancer rates have decreased bych as 65% over the past four decades. For example,land, cervical cancer incidence rates decreased from1966 to 7.3 in 2007 (13). Rates have also decreased
h-risk areas, including China, Taiwan, Korea, andin part due to improved screening activities andconomic conditions (70, 167, 169-171), althoughcreases in proportionate terms were much smallerared with those in western countries.ontrast to the favorable trends at all ages combined,al cancer rates have been increasing among youn-nerations in several countries, including Finland,nited Kingdom, Denmark, and China (165, 170,This unfavorable trend is thought to reflect in-s in HPV prevalence from changing sexual beha-(165, 170, 172). The exceptionally low overallal cancer rates in the Middle East and other partsdeveloping world are thought to reflect low prev-of HPV infections due to societal disapproval ofarital sexual activity (173).implementation of conventional cytology-baseding, a Pap test followed by colposcopy/biopsyeatment, is not feasible in most low- and middle-e countries because of cost and less developedcare infrastructure. However, many low-tech, af-ble, and effective screening techniques have beenoped for use in these countries, including visual in-on of cervix for lesions using either acetic acid or's iodine and DNA testing for HPV in cervical cellles (174-176). Vaccination of adolescents against16 and HPV-18 infections, which cause about 70%cervical cancer worldwide, is another new oppor-for substantially reducing the future burden of
al cancer in both low- and high-resource countries.ver, the current high cost of the vaccine (more than0 for all three doses) will be the major impedimentintroduction and wide application of these vac-in poor-resource countries, at least in the short(177).
s in Data Interpretation
interpretations of international incidence and mor-patterns presented here could be affected by severals. First, we describe the international variations inr rates largely based on 45 select cancer registries,e variations for some cancer sites could be muchthan given here. Second, the high incidence rates
stern countries for some cancers may, in part, reflection practices through screening and imaging tech-s, rather than true disease occurrence. Third, com-with developed countries, information on routineal records and death certificates is more likely to be
plete and population estimates are less likely to bete in less developed countries, affecting the accura-
the rates (13). Finally, most population-based cancerries worldwide are regional rather than national,egional data may not be representative of nationalbecause of substantial regional differences in risks, socioeconomic status, and access to early detec-ervices. Further, most cancer registries in the devel-world are located in metropolitan areas, wherelthy lifestyle factors and western behaviors that in-cancer risk are far more prevalent than in the gen-opulation (178, 179).
mary
ile cancer rates in general are decreasing in thed States and many western countries, they are in-ng in less developed and economically transition-ountries, including Eastern European countries,se of adoption of unhealthy western lifestyles suchoking and physical inactivity and consumption ofe-dense food. Cancers that were once known as dis-of industrialized countries, such as lung, colon, andcancers, are now commonly occurring in econom-transitioning and less developed countries. Most ofcountries also continue to be disproportionately af-by cancers related to infectious agents, such as cer-
iver, and stomach cancers, which are potentiallyntable.O has developed guidelines and policies for estab-g an effective national cancer control program to ac-te the translation of cancer control knowledge intoaccording to capacity and economic development82). In economically developing countries, this in-s raising awareness on the increasing burden of can-ducing the prevalence of major risk factors (obesity,co, and infectious agents), the application of low-ology and cost-effective approaches to preven-early detection of cervical cancer, and improvingailability of palliative care. A number of develop-untries, including Vietnam and Tanzania, have de-ed national cancer control programs, although theseams are funded inadequately because of limited re-es and other competing public health programsInternational public health agencies and privateovernment donors can play significant roles inthening existing cancer control programs and/ormenting new programs to arrest the growing bur-f cancer in economically developing countries (184).opment of a cancer control program should includetablishment of a cancer registry to asses the cancern and identify priorities and to evaluate the effec-ss of the program.
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