GlobalCancerStatistics
AhmedinJemal,DVM,PhD1;FreddieBray,PhD2;MelissaM.Center,MPH3;JacquesFerlay,ME4;
ElizabethWard,PhD5;DavidForman,PhD6Abstract
Theglobalburdenofcancercontinuestoincreaselargelybecauseoftheagingandgrowthoftheworldpopulationalongsideanincreasingadoptionofcancer-causingbehaviors,particularlysmoking,ineconomicallydevelopingcountries.BasedontheGLOBOCAN2008estimates,about12.7millioncancercasesand7.6millioncancerdeathsareestimatedtohaveoccurredin2008;ofthese,56%ofthecasesand64%ofthedeathsoccurredintheeconomicallydevelopingworld.Breastcanceristhemostfrequentlydiagnosedcancerandtheleadingcauseofcancerdeathamongfemales,accountingfor23%ofthetotalcancercasesand14%ofthecancerdeaths.Lungcanceristheleadingcancersiteinmales,comprising17%ofthetotalnewcancercasesand23%ofthetotalcancerdeaths.Breastcancerisnowalsotheleadingcauseofcancerdeathamongfemalesineco-nomicallydevelopingcountries,ashiftfromthepreviousdecadeduringwhichthemostcommoncauseofcancerdeathwascer-vicalcancer.Further,themortalityburdenforlungcanceramongfemalesindevelopingcountriesisashighastheburdenforcer-vicalcancer,witheachaccountingfor11%ofthetotalfemalecancerdeaths.Althoughoverallcancerincidenceratesinthedevelopingworldarehalfthoseseeninthedevelopedworldinbothsexes,theoverallcancermortalityratesaregenerallysimilar.Cancersurvivaltendstobepoorerindevelopingcountries,mostlikelybecauseofacombinationofalatestageatdiagnosisandlimitedaccesstotimelyandstandardtreatment.Asubstantialproportionoftheworldwideburdenofcancercouldbepreventedthroughtheapplicationofexistingcancercontrolknowledgeandbyimplementingprogramsfortobaccocontrol,vaccination(forliverandcervicalcancers),andearlydetectionandtreatment,aswellaspublichealthcampaignspromotingphysicalactivityandahealthierdietaryintake.Clinicians,publichealthprofessionals,andpolicymakerscanplayanactiveroleinacceleratingthe
C
applicationofsuchinterventionsglobally.CACancerJClin2011;61:69–90.V2011AmericanCancerSociety,Inc.
Introduction
Canceristheleadingcauseofdeathineconomicallydevelopedcountriesandthesecondleadingcauseofdeathindevelopingcountries.1Theburdenofcancerisincreasingineconomicallydevelopingcountriesasaresultofpopulationagingandgrowthaswellas,increasingly,anadoptionofcancer-associatedlifestylechoicesincludingsmoking,physicalinactivity,and‘‘westernized’’diets.Inthisarticle,weprovideanoverviewoftheglobalcancerburden,includingtheestimatednumberofnewcancercasesanddeathsin2008andtheincidenceandmortalityratesbyregionforselectedcancersites.ThesestatisticsarebasedonGLOBOCAN2008,2thestandardsetofworldwideestimatesofcancerincidenceandmortalityproducedbytheInternationalAgencyforResearchonCancer(IARC)for2008.Wecommentontherecentincidenceandmortalitypatternsobservedforanumberofcommoncancerforms,alongsideestablishedpreventivemeasuresthatcanreducetheworldwidecancerburden.
DataSourcesandMethods
Incidencedata(thenumberofnewlydiagnosedcaseseachyear)arederivedfrompopulation-basedcancerregistries,whichmaycoverentirenationalpopulationsbutmoreoftencoversmaller,subnationalareas,and,particularlyindevelopingcountries,onlyurbanenvironments,suchasmajorcities.Althoughthequalityof
1VicePresident,SurveillanceResearch,AmericanCancerSociety,Atlanta,GA;2DeputyHead,SectionofCancerInformation,InternationalAgencyforResearchonCancer,Lyon,France;3Epidemiologist,SurveillanceResearch,AmericanCancerSociety,Atlanta,GA;4InformaticsOfficer,SectionofCancerInformation,InternationalAgencyforResearchonCancer,Lyon,France;5NationalVicePresident,IntramuralResearch,AmericanCancerSociety,Atlanta,GA;6Head,SectionofCancerInformation,InternationalAgencyforResearchonCancer,Lyon,France.
Correspondingauthor:AhmedinJemal,DVM,PhD,SurveillanceResearch,AmericanCancerSociety,250WilliamsStreet,NW,Atlanta,GA30303-1002;ahmedin.jemal@cancer.org
DISCLOSURES:Theauthorsreportnoconflictsofinterest.
CV
2011AmericanCancerSociety,Inc.doi:10.3322/caac.20107.
Availableonlineathttp://cajournal.organdhttp://cacancerjournal.org
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informationfrommostofthedevelopingcountriesmightbeconsidered,inrelativeterms,oflimitedqual-ity,itoftenremainstheonlysourceofinformationavailableontheprofileofcancerandassuchprovidesvaluableinformation.ThetotalnumberofcancerdeathsbycountryarecollectedannuallyandaremadeavailablebytheWorldHealthOrganization(WHO).3Theadvantagesofthissourceofdataareitsnationalcoverageandlong-termavailability,althoughnotalldatasetsareofthesamequalityorcomplete-ness.Provisionalestimatesoftheage-andsex-specificdeathsfromcancer(ofalltypes)for2008havebeenused1inregionsoftheworldwitheithernodeathin-formationorwhereofficialstatisticsaredeemedunre-liable,andcorrectedforpossibleincompleteness.
Incidenceandmortalityrates(numberofcasesordeathsper100,000personsperyear)wereestimatedinGLOBOCAN2bycountry,usingthemostrecentlyavailabledatacollectedattheIARCoravail-ableinroutinereportsfromtheregistriesthemselves.Nationalincidencerateswereestimatedusingoneofseveralmethods,dependantontheavailabilityandqualityofdata,inthefollowingorderofpriority:
1.Nationalincidencedata.Whenhistoricaldataandasufficientnumberofrecordedcaseswereavailable,incidencerateswereprojectedto2008.2.Nationalmortalitydataandlocalregistrydata.Estimationofincidencebasedonregressionmodels,specificforsex,site,andage,derivedfromsubnationalorregionalcancerregistrydata.3.Regionalincidencedatafromoneormorecan-cerregistriesbutnomortalitydata.Nationalincidencederivedfromasinglesetoraweightedaverageoflocalrates.
4.Frequencydata.Onlydataontherelativefre-quencyofdifferentcancers(bysex,site,andagegroups)available.Theseproportionsareappliedtoestimatesoftheall-cancerincidencerateforthecountry,derivedfromcancerregistrydatawithinthesameregion.
5.Nodataavailable.Country-specificratesequatedtothoseofneighboringcountriesinthesameregion.Similarprocedureswereusedtoestimatecountry-specificmortalityrates,inthefollowingorderofpriority:
1.Nationalmortalitydata.Projectionsto2008wherepossible.
2.Samplemortalitydata.Theage-andsex-specificall-cancermortalityenvelopesprovidednationally
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for2008bytheWHOwerepartitionedbysiteusingthesamplemortalitydata.
3.Nomortalitydata.Nationalmortalitywasderivedfromincidenceandcancer-andcountry-specificsurvivalprobabilities(basedonlevelofgrossdomesticproduct),andthenscaledtotheWHOall-cancermortalityenvelopefor2008.Country-specificincidenceandmortalityrateswerepreparedfor27typesofcancer(includingKaposisarcoma[KS]forsub-SaharanAfricancoun-tries),bysexandfor10agegroups(0-14,15-39,40-44,45-49,…70-74,and75þyears).AfulldescriptionofthedataandmethodsusedforeachcountryandthecorrespondingresultsareavailableinGLOBOCAN2008(availableathttp://www.globocan.iarc.fr).4Estimatesforthe20worldregions(Fig.1)andformoreandlessdevelopedregions,asdefinedbytheUnitedNations(UN),5wereobtainedasthepopulation-weightedaverageoftheincidenceandmortalityratesofthecomponentcountries.Theserateswereage-standardized(ASRs)(per100,000person-years)usingtheWorldStandardPopulationasproposedbySegiandmodifiedbyDolletal.6,7Thecumulativeriskofdevelopingordyingfromcancerbeforetheageof75years(intheabsenceofcompetingcausesofdeath)wasalsocalculatedandisexpressedasapercentage.
ResultsandDiscussion
EstimatedNumberofNewCancerCasesandDeaths
About12.7millioncancercasesand7.6millioncancerdeathsareestimatedtohaveoccurredin2008world-wide(Fig.2),with56%ofthecasesand64%ofthedeathsintheeconomicallydevelopingworld.Breastcancerinfemalesandlungcancerinmalesarethemostfrequentlydiagnosedcancersandtheleadingcauseofcancerdeathforeachsexinbotheconomicallydevelopedanddevelopingcountries,exceptlungcan-cerisprecededbyprostatecancerasthemostfrequentcanceramongmalesineconomicallydevelopedcoun-tries.Thesecancerswerefollowed,withoutspecificrankorder,bystomachandlivercancersinmalesandcervixandlungcancersinfemalesineconomicallydevelopingcountriesandbycolorectalandlungcan-cersinfemalesandcolorectalandlungorprostatecancersinmalesintheeconomicallydevelopedworld.
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FIGURE1.TwentyWorldAreas.
IncidenceandMortalityRatesforAllCancersCombinedandTop22CancerSites
Whileincidenceratesforallcancerscombinedineconomicallydevelopedcountriesarenearlytwiceashighasineconomicallydevelopingcountriesinbothmalesandfemales(Table1),mortalityratesforallcancerscombinedindevelopedcountriesareonly21%higherinmalesandonly2%higherinfemales.Suchdisparitiesinincidenceandmortalitypatternsbetweendevelopedanddevelopingcountrieswillreflect,foragivencancer,regionaldifferencesintheprevalenceanddistributionofthemajorriskfactors,detectionpractices,and/ortheavailabilityanduseoftreatmentservices.Prostate,colorectal,femalebreast,andlungcancerratesare2to5timeshigherindevelopedcountriescomparedwithdevelopingcountries,aresultofvariationsinadisparatesetofriskfactorsanddiagnosticpractices.Theconverseistrueforcancersrelatedtoinfectionssuchasstomach,liver,andcervicalcancers(Table1).Table2showstheoverallcancerincidenceandmortalityratesbysexaccordingtoworldareas.Theincidencerateforbothsexescombinedismorethan3timesashighinAustralia/NewZealandasthatinMiddleAfrica.Itshouldalsobenotedthatcancertendstobediagnosedatlaterstagesinmanydevelopingcoun-
triescomparedwithdevelopedcountriesandthis,combinedwithreducedaccesstoappropriatethera-peuticfacilitiesanddrugs(Fig.3),hasanadverseeffectonsurvival.ArecentcomparativesurveyofcancersurvivalratesinAfrica,Asia,andCentralAmerica8basedonpatientsdiagnosedinthe1990sindicatessubstantiallylowersurvivalratesinpartsofAfrica,India,andthePhilippinesthanforthosediagnosedinSingapore,SouthKorea,andpartsofChina.Forexample,breastcancer5-yearsurvivalrateswere50%orlessintheformerpopulationsandover75%inthelatter.Suchcomparisonsweresimi-lartothoseobservedintheCONCORDstudy9foranearliertimeperiod.
SelectedCancers
FemaleBreastCancer
Breastcanceristhemostfrequentlydiagnosedcan-cerandtheleadingcauseofcancerdeathinfemalesworldwide,accountingfor23%(1.38million)ofthetotalnewcancercasesand14%(458,400)ofthetotalcancerdeathsin2008(Fig.2).Abouthalfthebreastcancercasesand60%ofthedeathsareestimatedtooccurineconomicallydevelopingcountries.Ingeneral,incidenceratesarehighinWesternand
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FIGURE2.
2008.
EstimatedNewCancerCasesandDeathsWorldwideforLeadingCancerSitesbyLevelofEconomicDevelopment,2008.Source:GLOBOCAN
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TABLE1.IncidenceandMortalityRatesandCumulativeProbabilityofDevelopingCancerbyAge75bySexandCancer
SiteforMoreDevelopedandLessDevelopedAreas,2008
MOREDEVELOPEDAREASINCIDENCEASR
CUMULATIVERISK(%)[AGE0-74]
MORTALITYASR
CUMULATIVERISK(%)[AGE0-74]
LESSDEVELOPEDAREASINCIDENCEASR
CUMULATIVERISK(%)[AGE0-74]
MORTALITYASR
CUMULATIVERISK(%)[AGE0-74]
Males
Allcancers*(C00-97,butC44)Bladder(C67)
Brain,nervoussystem(C70-72)Colorectum(C18-21)Esophagus(C15)Gallbladder(C23-24)Hodgkinlymphoma(C81)Kidney(C64-66)Larynx(C32)Leukemia(C91-95)Liver(C22)Lung(C33-34)Melanomaofskin(C43)Multiplemyeloma(C88þC90)Nasopharynx(C11)
Non-Hodgkinlymphoma(C82-85,C96)Oralcavity(C00-08)
Otherpharynx(C09-10,C12-14)Pancreas(C25)Prostate(C61)Stomach(C16)Testis(C62)Thyroid(C73)Females
Allcancers*(C00-97,butC44)Bladder(C67)
Brain,nervoussystem(C70-72)Breast(C50)Cervixuteri(C53)Colorectum(C18-21)Corpusuteri(C54)Esophagus(C15)Gallbladder(C23-24)Hodgkinlymphoma(C81)Kidney(C64-66)Larynx(C32)Leukemia(C91-95)Liver(C22)
225.53.64.466.49.024.212.91.22.11.95.80.66.02.7
22.00.40.47.10.92.71.60.10.20.20.70.10.60.3
87.31.02.615.33.29.72.41.01.50.31.70.22.92.5
9.10.10.31.70.31.00.30.10.20.00.20.00.30.3
138.01.42.827.317.89.45.95.72.20.51.40.63.67.6
14.00.20.32.81.91.10.70.70.30.10.20.10.30.9
85.40.72.010.89.85.41.74.71.70.30.80.42.97.2
9.00.10.21.21.10.60.20.50.20.00.10.00.30.8
300.116.66.037.66.52.42.211.85.59.18.147.49.53.30.610.36.94.48.262.016.74.62.9
30.11.90.64.40.80.30.21.40.70.91.05.71.00.40.11.10.80.51.07.82.00.40.3
143.94.63.915.15.31.60.44.12.44.87.239.41.81.90.33.62.32.27.910.610.40.30.3
15.00.50.41.70.60.20.00.50.30.50.94.70.20.20.00.40.30.30.90.91.20.00.0
160.35.43.212.111.81.40.92.53.54.518.927.80.70.92.14.24.63.02.712.021.10.81.0
17.00.60.31.41.40.20.10.30.40.42.23.30.10.10.20.50.50.40.31.42.50.10.1
119.32.62.66.910.11.10.61.32.13.717.424.60.30.81.43.02.72.52.55.616.00.30.3
12.70.30.30.81.20.10.10.10.30.32.02.90.00.10.20.30.30.30.30.51.90.00.0
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TABLE1.(Continued)
MOREDEVELOPEDAREASINCIDENCEASR
CUMULATIVERISK(%)[AGE0-74]
MORTALITYASR
CUMULATIVERISK(%)[AGE0-74]
LESSDEVELOPEDAREASINCIDENCEASR
CUMULATIVERISK(%)[AGE0-74]
MORTALITYASR
CUMULATIVERISK(%)[AGE0-74]
Lung(C33-34)Melanomaofskin(C43)Multiplemyeloma(C88þC90)Nasopharynx(C11)
Non-Hodgkinlymphoma(C82-85,C96)Oralcavity(C00-08)
Otherpharynx(C09-10,C12-14)Ovary(C56)Pancreas(C25)Stomach(C16)Thyroid(C73)
18.68.62.20.27.02.40.89.45.47.39.1
2.30.90.30.00.80.30.11.00.60.80.9
13.61.11.30.12.20.60.35.15.14.70.4
1.60.10.10.00.20.10.00.60.60.50.0
11.10.60.71.02.82.60.85.02.110.03.4
1.30.10.10.10.30.30.10.50.31.10.4
9.70.30.60.61.91.50.63.12.08.10.7
1.10.00.10.10.20.20.10.40.20.90.1
ASRindicatesage-standardizedrateper100,000.RatesarestandardizedtotheWorldStandardPopulation.*Excludesnonmelanomaskincancer.Source:GLOBOCAN2008.
NorthernEurope,Australia/NewZealand,andNorthAmerica;intermediateinSouthAmerica,theCarib-bean,andNorthernAfrica;andlowinsub-SaharanAfricaandAsia(Fig.4).Thefactorsthatcontributetotheinternationalvariationinincidencerateslargelystemfromdifferencesinreproductiveandhormonalfactorsandtheavailabilityofearlydetectionser-vices.10,11Reproductivefactorsthatincreaseriskincludealongmenstrualhistory,nulliparity,recentuseofpostmenopausalhormonetherapyororalcon-traceptives,andlateageatfirstbirth.12Alcoholcon-sumptionalsoincreasestheriskofbreastcancer.13,14ThebreastcancerincidenceincreasesobservedinmanyWesterncountriesinthelate1980sand1990slikelyresultfromchangesinreproductivefactors(includingtheincreaseduseofpostmenopausalhor-monetherapy)aswellasanincreasedscreeninginten-sity.15Incidenceratesinsomeofthesecounties,includingtheUnitedStates,UnitedKingdom,France,andAustralia,sharplydecreasedfromthebeginningofthemillennium,partlyduetoloweruseofcom-binedpostmenopausalhormonetherapy.16-21Incon-trast,breastcancerdeathrateshavebeendecreasinginNorthAmericaandseveralEuropeancountriesoverthepast25years,largelyasaresultofearlydetectionthroughmammographyandimprovedtreat-ment.10,15,22InmanyAfricanandAsiancountries
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however,includingUganda,SouthKorea,andIndia,incidenceandmortalityrateshavebeenrising,23,24withchangesinreproductivepatterns,physicalinac-tivity,andobesitybeingthemaincontributoryfac-tors10,25,26;increasesinbreastcancerawarenessandscreeningactivitymaybepartiallyresponsiblefortherisingincidenceinthesepopulations.
Maintainingahealthybodyweight,increasingphysicalactivity,andminimizingalcoholintakearethebestavailablestrategiestoreducetheriskofdevelopingbreastcancer.27Earlydetectionthroughmammographyhasbeenshowntoincreasetreat-mentoptionsandsavelives,althoughthisapproachiscostprohibitiveandnotfeasibleinmosteconomi-callydevelopingcountries.28Recommendedearlydetectionstrategiesinthesecountriesincludethepromotionofawarenessofearlysignsandsymptomsandscreeningbyclinicalbreastexamination.29ColorectalCancer
Colorectalcanceristhethirdmostcommonlydiag-nosedcancerinmalesandthesecondinfemales,withover1.2millionnewcancercasesand608,700deathsestimatedtohaveoccurredin2008(Fig.2).ThehighestincidenceratesarefoundinAustraliaandNewZealand,Europe,andNorthAmerica,whereasthelowestratesarefoundinAfricaand
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TABLE2.EstimatedAge-StandardizedIncidenceandMortalityRatesPer100,000by
WorldArea,2008*
INCIDENCEMALE
FEMALE
OVERALL
EasternAfricaMiddleAfricaNorthernAfricaSouthernAfricaWesternAfricaEasternAsiaSouth-CentralAsiaSouth-EasternAsiaWesternAsiaCaribbeanCentralAmericaNorthernAmericaSouthAmerica
CentralandEasternEuropeNorthernEuropeSouthernEuropeWesternEuropeAustralia/NewZealandMelanesiaMicronesiaPolynesia
121.288.1109.2235.992.0222.199.7143.9152.8196.3136.2334.0186.7259.2292.3289.9337.4356.8146.0153.8225.0
125.396.798.9161.0123.5158.1110.8141.7119.5153.5134.4274.4162.9184.2249.5212.2250.9276.4133.4164.4201.5
122.891.8103.2189.6107.6188.4104.6141.5133.8172.6134.4299.9171.9210.6266.1245.0287.7313.3138.5157.5209.8
*Excludesnonmelanomaskincancer.Source:GLOBOCAN2008.
South-CentralAsia(Fig.5).Ratesaresubstantiallyhigherinmalesthaninfemales.
Colorectalcancerincidenceratesarerapidlyincreas-inginseveralareashistoricallyatlowrisk,includingSpain,andanumberofcountrieswithinEasternAsiaandEasternEurope.30,31Notably,ratesamongmalesintheCzechRepublicandJapanhavealreadyexceededthepeakofincidenceobservedintheUnitedStates,Canada,andAustralia,whereratesaredeclin-ingorstabilizing.30,31Suchunfavorabletrendsarethoughttoreflectacombinationoffactorsincludingchangesindietarypatterns,obesity,andanincreasedprevalenceofsmoking.30-34TheUnitedStatesistheonlycountrywithsignificantlydecreasingincidenceratesinbothmalesandfemalesinthemostrecenttimeperiod,whichlargelyreflectsdetectionandre-movalofprecancerouslesionsthroughcolorectalcan-cerscreening.18,31Whilecolorectalcancerdeathrates
havebeendecreasinginseveralWesterncoun-tries,31largelyresultingMORTALITY
fromimprovedtreatment
MALEFEMALEOVERALL
andincreasedawareness
105.495.999.9
andearlydetection,18,35-3778.575.676.4ratescontinuetoincrease89.568.278.0inmanycountrieswith172.1108.1133.2morelimitedresources
andhealthinfrastructure,80.191.285.4
particularlyinCentraland155.587.3120.1
SouthAmericaandEast-78.071.774.5
31ernEurope.112.389.499.5
Modifiableriskfactors113.974.392.2
forcolorectalcancerin-116.686.299.9
cludesmoking,physical
84.780.682.0
inactivity,overweightand
122.491.5105.1
obesity,redandprocessed
116.688.2100.3meatconsumption,and181.594.0128.1excessivealcoholconsump-134.699.7114.5tion.38-40Population-based149.981.2111.7colorectalscreeningpro-gramsarefeasibleonlyin138.484.3108.0
economicallydeveloped125.686.0104.1
countries,althoughfuture119.895.9106.8
attentionshouldalsobe104.770.386.1
focusedinthoseareasof
133.687.9109.1
theworldwithanagingpopulationandincreas-inglywesternizedlifestyle(eg,Brazil).41-44Accordingtoarecentrandomized
trialintheUnitedKingdom,aone-timeflexiblesig-moid-oscopyscreeningbetween55and64yearsofagereducedcolorectalcancerincidenceby33%andmor-talityby43%.45LungCancer
Lungcancerwasthemostcommonlydiagnosedcan-ceraswellastheleadingcauseofcancerdeathinmalesin2008globally(Fig.2).Amongfemales,itwasthefourthmostcommonlydiagnosedcancerandthesecondleadingcauseofcancerdeath.Lungcanceraccountsfor13%(1.6million)ofthetotalcasesand18%(1.4million)ofthedeathsin2008.Inmales,thehighestlungcancerincidenceratesareinEasternandSouthernEurope,NorthAmerica,MicronesiaandPolynesia,andEasternAsia,whileratesarelowinsub-SaharanAfrica(Fig.6).In
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FIGURE3.
NumberofPeopleServedbyEachRadiotherapyCenterbyCountry.Sources:InternationalAtomicEnergyAgency,DirectoryofRadiotherapy
Centers,http://www-nawebiaea.org/nuhu/dirac/,PopulationDivisionoftheDepartmentofEconomicandSocialAffairsoftheUnitedNationsSecretariat,WorldPopulationProspects:The2008Revision,andhttp://esa.un.org/unpp.
females,thehighestlungcancerincidenceratesarefoundinNorthAmerica,NorthernEurope,andAus-tralia/NewZealand.Despitetheirlowerprevalenceofsmoking(lessthan4%adultsmokers),46Chinesefemaleshavehigherlungcancerrates(21.3casesper100,000females)thanthoseincertainEuropeancountriessuchasGermany(16.4)andItaly(11.4),withanadultsmokingprevalenceofabout20%.46Therelativelyhighburdenoflungcancerinwomenisthoughttoreflectindoorairpollutionfromunventi-latedcoal-fueledstovesandfromcookingfumesinChina.47-49Otherknownriskfactorsforlungcancerincludeexposuretoseveraloccupationalandenviron-mentalcarcinogenssuchasasbestos,arsenic,radon,andpolycyclicaromatichydrocarbons.50Theobservedvariationsinlungcancerratesandtrendsacrosscountriesorbetweenmalesandfemaleswithineachcountrylargelyreflectdifferencesinthestageanddegreeofthetobaccoepidemic.51,52Smok-ingaccountsfor80%oftheworldwidelungcancerburdeninmalesandatleast50%oftheburdeninfemales.53,54Malelungcancerdeathratesaredecreas-inginmostWesterncountries,includingmanyEuro-peancountries,NorthAmerica,andAustralia,wherethetobaccoepidemicpeakedbythemiddleofthelastcentury.52,55,56Incontrast,lungcancerratesareincreas-ingincountriessuchasChinaandseveralothercoun-76
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triesinAsiaandAfrica,wheretheepidemichasbeenestablishedmorerecentlyandsmokingprevalencecontinuestoeitherincreaseorshowsignsofstability.10,47,51Generally,lungcancertrendsamongfemaleslagbehindmalesbecausefemalesstartedsmokinginlargenumbersseveraldecadeslaterthanmales.57Therefore,lungcancerratesinfemalesareincreasinginmanycountries52excepttheUnitedStates,Can-ada,theUnitedKingdom,andAustralia,wheretheyareplateauing.Notably,inSpain,France,Belgium,andtheNetherlandsratesareincreasinginmorerecentfemalebirthcohorts,suggestingthatthelungcancerburdeninfemalesinthesecountrieswilllikelycontinuetoincreaseforseveraldecadesbarringanymajorinterventions.52Mostoftheworldwideburdenoflungcancercouldbeavoidedbyapplyingproventobaccocontrolinter-ventionsthatincluderaisingthepriceofcigarettesandothertobaccoproducts,banningsmokinginpublicplaces,therestrictionofadvertisingoftobaccoprod-ucts,counteradvertising,andtreatingtobaccodepend-ence.58Toillustrate,a10%increaseincigarettepriceshasbeenshowntoreducecigaretteconsumptionby3%to5%.59In2003,theWHOestablishedtheFrameworkConventiononTobaccoControltoenableinternationalcoordinatedeffortstocurbthetobacco
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FIGURE4.
Age-StandardizedBreastCancerIncidenceandMortality
RatesbyWorldArea.Source:GLOBOCAN2008.
Age-StandardizedLungCancerIncidenceRatesbySexand
WorldArea.Source:GLOBOCAN2008.
FIGURE6.
epidemic.60TheUnitedStatesisamongthefewcoun-triesthathaveyettoratifythetreaty.ProstateCancer
Prostatecanceristhesecondmostfrequentlydiag-nosedcancerandthesixthleadingcauseofcancer
FIGURE5.Age-StandardizedColorectalCancerIncidenceRatesbySexandWorldArea.Source:GLOBOCAN2008.
deathinmales,accountingfor14%(903,500)ofthetotalnewcancercasesand6%(258,400)ofthetotalcancerdeathsinmalesin2008(Fig.2).Incidenceratesvarybymorethan25-foldworldwide,withthehighestratesrecordedprimarilyinthedevelopedcountriesofOceania,Europe,andNorthAmerica(Fig.7),largelybecauseofthewideutilizationofpros-tate-specificantigen(PSA)testingthatdetectsclini-callyimportanttumorsaswellasotherslow-growingcancersthatmightotherwiseescapediagnosis.Incon-trast,malesofAfricandescentintheCaribbeanregionhavethehighestprostatecancermortalityratesintheworld,whichisthoughttoreflectpartlydifferenceingeneticsusceptibility.61,62TemporaltrendsinincidenceratesincountrieswithhigheruptakeofPSAtestingsuchastheUnitedStates,Australia,Canada,andtheNordiccountriesfollowedsimilarpatterns.63,64Ratesroserapidlyintheearly1990s,soonaftertheintroductionofPSAtest-ing,followedbyasharpdeclineduetoasmallerpoolofprevalentcases.Inotherhigh-incomecountrieswithalowandgradualincreaseintheprevalenceofPSAtesting,suchasJapanandtheUnitedKingdom,ratescontinuetoincreaseslightly.63Deathratesforprostatecancerhavebeendecreas-inginmanydevelopedcountries,including
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(Table1).ThehighestincidenceratesareinEasternAsia,EasternEurope,andSouthAmericaandthelow-estratesareinNorthAmericaandmostpartsofAfrica(Fig.8).Regionalvariationsinpartreflectdifferencesindietarypatterns,particularlyinEuropeancountries,andtheprevalenceofHelicobacterpyloriinfection.70Stomachcancerrateshavedecreasedsubstantiallyinmostpartsoftheworld,71inpartduetofactorsrelatedtotheincreaseduseandavailabilityofrefriger-ationincludingtheincreasedavailabilityoffreshfruitsandvegetables,andadecreasedrelianceonsaltedandpreservedfoods.OthermajordeterminantsforthefavorabletrendsarereductionsinchronicH.pyloriinfectioninmostpartsoftheworld72-74andsmokinginsomepartsofthedevelopedworld.71InJapan,mor-talityratesmayhavedeclinedviatheintroductionofscreeningusingphotofluorography,75whichmayhavealsocontributedtothepersistentlyhighincidenceratesinthecountry.
FIGURE7.Age-StandardizedProstateCancerIncidenceandMortalityRatesbyWorldArea.Source:GLOBOCAN2008.
Australia,Canada,theUnitedKingdom,theUnitedStates,Italy,andNorwayinpartbecauseoftheimprovedtreatmentwithcurativeintent.63,65,66TheroleofPSAtestinginthereductionofthepros-tatecancermortalityratesatthepopulationlevelhasbeendifficulttoquantify.AlargeUS-basedrandomizedtrialontheefficacyofPSAtestinginreducingmortalityfromprostatecancerfoundnoben-efit,67whileanothersimilarEuropean-basedtrialfoundamodestbenefit.68Differencesinstudydesign,samplesize(statisticalpower),followup,andpossiblecontaminationofcontrolsmayhavecontributedtothedifferentfindingsbetweenthese2studies.IncontrasttothetrendsinWesterncountries,incidenceandmor-talityratesarerisinginseveralAsianandCentralandEasternEuropeancountries,suchasJapan.63,65Olderage,race(black),andfamilyhistoryremaintheonlywell-establishedriskfactorsandtherearenoestab-lishedpreventableriskfactorsforprostatecancer.69StomachCancer
Atotalof989,600newstomachcancercasesand738,000deathsareestimatedtohaveoccurredin2008,accountingfor8%ofthetotalcasesand10%oftotaldeaths(Fig.2).Over70%ofnewcasesanddeathsoccurindevelopingcountries.Generally,stomachcan-cerratesareabouttwiceashighinmalesasinfemales
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LiverCancer
Livercancerinmenisthefifthmostfrequentlydiag-nosedcancerworldwidebutthesecondmostfre-quentcauseofcancerdeath.Inwomen,itistheseventhmostcommonlydiagnosedcancerandthesixthleadingcauseofcancerdeath.Anestimated748,300newlivercancercasesand695,900cancer
FIGURE8.
Age-StandardizedStomachCancerIncidenceRatesbySex
andWorldArea.Source:GLOBOCAN2008.
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FIGURE9.
Age-StandardizedLiverCancerIncidenceRatesbySexand
WorldArea.Source:GLOBOCAN2008.
deathsoccurredworldwidein2008(Fig.2).HalfofthesecasesanddeathswereestimatedtooccurinChina.2Globally,ratesaremorethantwiceashighinmalesasinfemales.ThehighestlivercancerratesarefoundinEastandSouth-EastAsiaandinMid-dleandWesternAfrica,whereasratesarelowinSouth-CentralandWesternAsia,aswellasNorth-ernandEasternEurope(Fig.9).Amongprimarylivercancers,hepatocellularcarcinoma(HCC)rep-resentsthemajorhistologicalsubtype,accountingfor70%to85%ofthetotallivercancerburdenworldwide.76Cholangiocarcinomasthatarisepri-marilyfromtheepithelialliningofthebileduct(intra-andextrahepaticbileduct)arerelativelyrare,buthighincidenceratesarefoundinThailandandotherpartsofEasternAsialargelyduetotheele-vatedprevalenceofliverflukeinfection.77Thehighlivercancer(HCC)ratesinpartsofAsiaandsub-SaharanAfricalargelyreflecttheele-vatedprevalenceofchronichepatitisBvirus(HBV)infection,withover8%ofthepopulationsintheseregionschronicallyinfectedwiththevirus.78HBVinfectionaccountsforabout60%ofthetotallivercancerindevelopingcountriesandforabout23%ofcancerindevelopedcountries70;thecorrespondingpercentagesforhepatitisCvirus(HCV)infection
are33%indevelopingcountriesand20%indevel-opedcountries.70InteractionofaflatoxinB1(AFB)exposurewithchronicHBVinfectionhasbeennotedtoincreaselivercancer.78,79However,thecontributionofAFBexposuretothelivercancerburdeninpartsofAfricaandAsia,wheretheexpo-sureisprevalent,isunknown.80IntheUnitedStatesandseveralotherlow-riskWesterncountries,alcohol-relatedcirrhosisandpossiblynonalcoholicfattyliverdisease,associatedwithobesity,arethoughttoaccountforthemajorityoflivercancer.81LivercancerincidenceratesareincreasinginmanypartsoftheworldincludingtheUnitedStatesandCentralEurope,possiblyduetotheobesityepi-demicandtheriseinHCVinfectionthroughcon-tinuedtransmissionbyinjectiondrugusers.81-83Incontrasttothetrendinthelow-riskareas,ratesdecreasedinsomehistoricallyhigh-riskareas,possi-blyduetotheHBVvaccine.83Universalinfanthep-atitisvaccinationprogramsinTaiwanreducedlivercancerincidenceratesbyabouttwo-thirdsinchil-drenandyoungadults.84Asof2008,atotalof177countries(91%)hadintroducedtheHBVvaccineintotheirnationalinfantimmunizationschedules(Fig.10),85althoughin2006only27%ofinfantsworldwidereceivedthefirstdosewithin24hoursofbirth,asrecommendedbytheWHO.86PreventivestrategiesagainstHCV,forwhichnovaccineisavailable,includescreeningofdonor’sbloodforantibodiestoHCV,institutingadequateinfectioncontrolpracticesduringmedicalpro-ceduresincludingtheuseoforaldeliveryofmedicineswherepossible,andneedleexchangeprogramsamonginjectiondrugusers.Cropsubstitutionandimprovedgrainstoragepracticeshavebeenshowntoreducecon-taminationwithAFBinsub-SaharanAfrica.87CervicalCancer
Cervicalcanceristhethirdmostcommonlydiag-nosedcancerandthefourthleadingcauseofcancerdeathinfemalesworldwide,accountingfor9%(529,800)ofthetotalnewcancercasesand8%(275,100)ofthetotalcancerdeathsamongfemalesin2008(Fig.2).Morethan85%ofthesecasesanddeathsoccurindevelopingcountries.India,thesec-ondmostpopulouscountryintheworld,accountsfor27%(77,100)ofthetotalcervicalcancerdeaths.2Worldwide,thehighestincidenceratesareinEast-ern,Western,andSouthernAfrica,aswellas
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FIGURE10.ProportionofInfantsCoveredbyNationalInfantHepatitisBImmunizationPrograms,2008.Source:WorldHealthOrganization/UNICEFcoverageestimates,1980-2008,July2009.*IncludessomecountriesthathaveintroducedhepatitisBinadolescentimmunizationschedules.
South-CentralAsiaandSouthAmerica.RatesarelowestinWesternAsia,Australia/NewZealand,andNorthAmerica(Fig.11).
Thedisproportionatelyhighburdenofcervicalcancerindevelopingcountriesandelsewhereinmedicallyunderservedpopulationsislargelyduetoalackofscreeningthatallowsdetectionofprecancer-ousandearlystagecervicalcancer88-90;thehealthcareinfrastructureinthesecountriesdoesnotsup-portPapanicolaoutestingorothertypesofscreeningtests.Themostefficientandcost-effectivescreeningtechniquesinlow-resourcecountriesincludevisualinspectionusingeitheraceticacidorLugol’siodineandDNAtestingforhumanpapillomavirus(HPV)DNAincervicalcellsamples.91ArecentclinicaltrialinruralIndia,alow-resourcearea,foundthatasin-gleroundofHPVDNAtestingwasassociatedwithabouta50%reductionintheriskofdevelopingadvancedcervicalcancerandassociateddeaths.92TheexpectationsthatvaccineswhichprimarilyprotectagainstthemostcommonstrainsofHPVinfections(HPVtypes16and18),whichcauseabout70%ofcervicalcancers,maypreventcervicalcancerworldwideareatpresenthigh.However,affordablepricingisthemostcriticalfactortofacili-tatetheintroductionofHPVvaccinesinlow-and
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medium-resourcecountriesintheshortterm.93Itisalsoextremelyimportantthatwomencontinuetoreceivescreeningservicesbecausethecurrentvac-cinesarebeinggiventoadolescentgirlsonly,and
FIGURE11.Age-StandardizedCervicalCancerIncidenceandMortalityRatesbyWorldArea.Source:GLOBOCAN2008.
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FIGURE12.Age-StandardizedEsophagealCancerIncidenceRatesbySexandWorldArea.Source:GLOBOCAN2008.
evenvaccinatedgirlsshouldbeginscreeningwhentheyreachtherecommendedscreeningagesincethevaccinesdonotprovideprotectionforthe30%ofchronicinfectionsbyHPVtypesotherthanHPV16,18,6and11thatcausecervicalcancer.94,95EsophagealCancer
Anestimated482,300newesophagealcancercasesand406,800deathsoccurredin2008worldwide.Incidenceratesvaryinternationallybynearly16-fold,withthehighestratesfoundinSouthernandEasternAfricaandEasternAsiaandlowestratesobservedinWesternandMiddleAfricaandCentralAmericainbothmalesandfemales(Fig.12).Esophagealcanceris3to4timesmorecommonamongmalesthanfemales.
Esophagealcancerusuallyoccursaseithersquamouscellcarcinomainthemiddleorupperone-thirdoftheesophagus,orasadenocarcinomainthelowerone-thirdorjunctionoftheesophagusandstomach.10,96Inthehighestriskarea,stretchingfromnorthernIranthroughthecentralAsianrepublicstoNorth-CentralChina,oftenreferredtoasthe‘‘esophagealcancerbelt,’’90%ofcasesaresquamouscellcarcinomas.97,98Majorriskfactorsforsquamouscellcarcinomasintheseareasarenotwellunderstood,butarethoughttoinclude
poornutritionalstatus,lowintakeoffruitsandvegeta-bles,anddrinkingbeveragesathightemperatures.99-101Inlow-riskareassuchastheUnitedStatesandseveralWesterncountries,smokingandexcessivealcoholcon-sumptionaccountforabout90%ofthetotalcasesofsquamouscellcarcinomaoftheesophagus.102Smok-ing,overweightandobesity,andchronicgastroesopha-gealrefluxdisease,whichtriggersBarrett’sesophagus,arethoughttobethemajorriskfactorsforadenocarci-nomaoftheesophagusintheUnitedStatesandsomeWesterncountries.102,103Anumberofstudiesalsofoundsmokelesstobaccoproductsandbetelliquid(withorwithouttobacco)asriskfactorsforesophagealcancerincertainpartsofAsia.104-106Temporaltrendsinesophagealcancerratesforthe2majorhistologicaltypesvarywithincountriesandacrosscountries.IncidenceratesforadenocarcinomaoftheesophagushavebeenincreasinginseveralWesterncountries,107-109inpartduetoincreasesintheprevalenceofknownriskfactorssuchasover-weightandobesity.110,111Incontrast,ratesforsqua-mouscellcarcinomaoftheesophagushavebeensteadilydeclininginthesesamecountriesbecauseoflong-termreductionsintobaccouseandalcoholconsumption.107However,squamouscellcarcinomaoftheesophagushasbeenincreasingincertainAsiancountriessuchasTaiwan,probablyasaresultofincreasesintobaccouseandalcoholconsumption.112BladderCancer
Anestimated386,300newcasesand150,200deathsfrombladdercanceroccurredin2008worldwide.Themajorityofbladdercanceroccursinmalesandthereisa14-foldvariationinincidenceinternation-ally.Thehighestincidenceratesarefoundinthecoun-triesofEurope,NorthAmerica,andNorthernAfrica(Fig.13).Egyptianmaleshavethehighestmortalityrates(16.3per100,000),whichistwiceashighasthehighestratesinEurope(8.3inSpainand8.0inPoland)andover4timeshigherthanthatintheUnitedStates(3.7).2ThelowestratesarefoundinthecountriesofMelanesiaandMiddleAfrica(Fig.13).SmokingandoccupationalexposuresarethemajorriskfactorsinWesterncountries,whereaschronicinfectionwithSchistosomahematobiumindevelopingcountries,particularlyinAfricaandtheMiddleEast,accountsforabout50%ofthetotalburden.70Amajorityofbladdercancersassociatedwithschistosomiasisaresquamouscellcarcinoma,
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FIGURE13.
Age-StandardizedUrinaryBladderCancerIncidenceRates
bySexandWorldArea.Source:GLOBOCAN2008.
whilethoseassociatedwithsmokingaretransitionalcellcarcinoma.113Itiseasiertointerprettrendsinbladdercancermor-talityratesthantrendsinincidenceratesbecausetrendsinmortalityareaffectedlessbydifferencesinreportingoflow-gradetumors.IntheUnitedStates,mortalityrateshavestabilizedinmalesanddecreasedinfemalesfrom1997through2006,18andinEuropedeclineshavebeenobservedinmostcountriessincethe1990s,114dueinparttoreductionsinsmokingpreva-lenceandreductionsinoccupationalexposuresknowntocausebladdercancer.BladdercancercontinuestobethemostcommoncanceramongmalesinEgypt,2de-spitethelargedecreasesinschistosoma-associatedblad-dercancer.115,116Thisislikelytheresultofareductioninschistosoma-relatedbladdercancersbeingoffsetbyanincreaseintobacco-relatedbladdercancers.115Non-HodgkinLymphoma
Anestimated355,900newcasesand191,400deathsfromnon-Hodgkinlymphoma(NHL)occurredin2008.NHLencompassesawidevarietyofdiseasesubtypesforwhichincidencepatternsvary.NHLismorecommonindevelopedareas,withthehighestincidenceratesfoundinNorthAmerica;Australia/NewZealand;andNorthern,Western,and
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SouthernEurope.ThelowestratesarefoundinSouth-CentralandEasternAsiaandtheCaribbean(Fig.14).Ingeneral,theincidenceofNHLislowinAfricawiththeexceptionofsomeareaswithahighincidenceofBurkitt’slymphoma(asubtypeofNHLcausedbyEpstein-Barrvirus[EBV])amongchil-dren.InadditiontoEBVandotherinfectionssuchasthehumanimmunodeficiencyvirus(HIV),NHLisassociatedwithoccupationalexposurestoherbi-cidesandchlorinatedorganiccompounds.117TheincidencerateofNHLincreasedinmostdevelopedcountriesduringthe1990sandhasleveledoffinrecentyears.18,118,119Theincreasespriorto1990maybedueinparttoimprovementsindiag-nosticproceduresandchangesinclassification,120aswellastheonsetoftheacquiredimmunedeficiencysyndrome(AIDS)epidemic,particularlyamongwhitemales.SubsequentdeclinesinAIDS-relatedNHLtypesafterthe1990sarepartlyduetothedecliningincidenceofHIVinfectionandthesuccessofantiretroviraltherapiesthatdelaytheonsetofAIDS.121However,non-AIDS–associatedNHLsubtypescontinuedtoincreaseorstabilizeduringthesametimeperiod.121NHLincidenceratesarealsoincreasingindevelopingcountriessuchasThailandandUganda,122,123dueinparttotheAIDSepidemic.
FIGURE14.Age-StandardizedNon-HodgkinLymphomaIncidenceRatesbySexandWorldArea.Source:GLOBOCAN2008.
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IncreasesinNHL,particularlyamongolderagegroups,havealsobeenobservedinEgypt,wheretheAIDSepidemicislessprominent.TheexactcausesforthisincreasearenotentirelyclearbutcouldberelatedtoalteredimmunefunctionassociatedwitholderageaswellasHCVinfection,whichisprevalentamongolderEgyptiansandhasrecentlybeenclassifiedbytheIARCashavingacausallinktoNHL.124,125CancersoftheLipandOralCavity
Anestimated263,900newcasesand128,000deathsfromoralcavitycancer(includinglipcancer)occurredin2008worldwide.Generally,thehighestoralcavitycancerratesarefoundinMelanesia,South-CentralAsia,andCentralandEasternEuropeandthelowestinAfrica,CentralAmerica,andEasternAsiaforbothmalesandfemales(Fig.15).Smoking,alcoholuse,smokelesstobaccoprod-ucts,andHPVinfectionsarethemajorriskfactorsfororalcavitycancer,withsmokingandalcoholhav-ingsynergisticeffects.126,127Thecontributionofeachoftheseriskfactorstotheburdenvariesacrossregions.126,128-131Worldwide,smokingaccountsfor42%ofdeathsfromcancersoftheoralcavity(includingthepharynx)andheavyalcoholconsump-tionfor16%ofthedeaths;thecorrespondingper-centagesinhigh-incomecountriesareabout70%and30%,respectively.132Smokelesstobaccoprod-uctsandbetelquidwithorwithouttobaccoarethemajorriskfactorsfororalcavitycancerinTaiwan,India,andotherneighboringcountries.128,133,134TheriseintheincidencerateoforalcancerinTai-wanmayhavebeeninpartduetotheincreasedcon-sumptionofbetelquidandalcohol.135Oralcavitycancermortalityratesamongmalesdecreasedsignificantlyinmostcountries,includingthoseofEuropeandAsia,overthepastdeca-des.136,137ButratescontinuedtoincreaseinseveralEasternEuropeancountries,includingHungaryandSlovakia.136TheincreaseinfemalesinmostEuro-peancountrieslargelyreflectstheongoingtobaccoepidemic.136ThiscontrastswiththedecreasingtrendsatallagesinbothmalesandfemalesintheUnitedStatesandUnitedKingdom,56,136,138wherethetobaccoepidemicbegananddeclinedearlier.However,incidenceratesfororalcancersitesrelatedtoHPVinfections,suchastheoropharynx,tonsil,andbaseofthetongue,areincreasinginyoungadultsintheUnitedStatesandinsomecountriesin
FIGURE15.
Age-StandardizedOralCavityCancerIncidenceRatesby
SexandWorldArea.Source:GLOBOCAN2008.
Europe,139-143whichishypothesizedtobeinpartduetochangesinoralsexualbehavior.130,144NasopharyngealCancer
Thetermnasopharyngealcarcinoma(NPC)isusedhereasasurrogatefornasopharyngealcancers(InternationalClassificationofDiseases,10threvi-sion[ICD-10]codeC11),giventhatcarcinomasrep-resentthevastmajorityofnasopharyngealtumors.Therewereanestimated84,400incidentcasesofNPCand51,600deathsin2008,representingabout0.7%oftheglobalcancerburden,andthediseasemaybeconsideredoneoftherarercancerformsglobally,rankingasthe24thmostfrequentlydiagnosedcancerformworldwideand22ndwithinthedevelopingworld.Theglobalstatisticsbyworldregionrevealthedistinctfeaturesofitsdescriptiveepidemiology,how-ever,andthecontrastinggeographicalandethnicvaria-tionsinthedistributionofincidenceworldwide.
NPCismorefrequentinmalesthanfemalesinboththedevelopinganddevelopedworld,withincidenceratescommonly2to3timeshigherinmalesinhigherresourcecountries,withmale-to-femalerateratiosoftenconsiderablyhigherindevel-opingregions(Table1)(Fig.16).ThegeographicaldisparitiesintheburdenofNPCinrelationto
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FIGURE16.Age-StandardizedNasopharyngealCancerIncidenceRatesbySexandWorldArea.Source:GLOBOCAN2008.
resourcearenoteworthy,withanestimated92%ofnewcasesoccurringwithineconomicallydevelopingcountries.Accordingtoworldarea,incidenceratesarehighestinSouth-EasternAsia,inbothsexes(Fig.16),withthediseasebeingthesixthmostcommonamongmalesintheregion.Indeedinglobalterms,the3highestnationalincidenceratesareestimatedinMalaysia,Indonesia,andSingapore,whereratesarehighamongtheChineseandMalaypopulations.24ElsewhereinAsia,highincidenceratesareobservedinanumberofprovincesinSouth-EasternChina,includingGuangdongandHongKong,andinotherpartsofSouthernAsia(thePhilippinesandThai-land).145-147RatesarealsoelevatedinPolynesia,SouthernAfrica,andNorthernAfrica(Fig.16),partic-ularlywithinthelatterregioninTunisiaandAlgeria.OtherpopulationswhereNPCisrelativelyfrequentincludetheInuitpopulationsofAlaska,Greenland,andNorthCanada,aswellasChineseandFilipinoslivingintheUnitedStates.145-147Ratesofthismalig-nancytendtobeconsiderablylowerinmostpopula-tionslivingelsewherewithintheAmericas,Europe,Africa,andCentralandEasternAsia(Fig.16).
NPChasviral,environmental,andgeneticcompo-nentstoitsetiology.148,149Migrantsfromhigh-tolow-riskcountriesretainincidenceratesintermediate
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tonativesoftheirhostcountryandtheircountryofor-igin,150implicatingaroleforenvironmentaland/orgeneticfactors,andapossibleinteractionwithEBV.WhilethevirusisconsideredanimportantstepinNPCprogression,onlyafractionoftheEBV-infectedpopulationdevelopsthedisease.Moreover,infectionwiththevirusisconsideredbothlifelongandubiqui-tousinmostareasoftheworld.151Manystudieshavereportedincreasedrisksassoci-atedwithcertainfoodseatenwithinhigh-riskareasincludingsaltedfishandcertainpreservedfoodsandhotspices,allofwhicharehighinnitrosocom-poundsandvolatilenitrosamines.149Exposuretosuchfoodsduringthetimewindowthatincludesweaningandchildhoodmaybeimportant,asmaybethetimingofinfectionwithEBVinearlylife.152WhiletrendsinNPChavebeenreportedasreasonablystableinhigh-riskareasofSouthernChina,153declineshavebeenobservedinseveralpopulationsofChineseoriginoverthelast2decades.154-156NPCinhigherresourcesettingsismoreassociatedwithlifestyle-relatedriskfactors;thedecreasingsmokingprevalenceamongUSmales,forexample,hasbeenpostulatedasacontributortotheoveralldeclineinNPCincidence.157KaposiSarcoma
KSisacancerofcellsthatlinelymphandbloodves-selsandisunusualinthat,unlikemostothercancers,itismultifocalinorigin,growinginseveralareasofthebodyatonce.BeforetheAIDSepidemic,KSwasregardedasextremelyrareinnearlyallareasoftheworld,withexceptionallyelevatedratesobservedincertainpopulationsofMediterranean,middleEastern,oreasternEuropeandescent,predomi-nantlyinmalesagedolderthan50years,158and,morenotably,insub-SaharanAfricapopula-tions.159,160TheAfricanformofKS(sometimestermed‘‘endemic’’)hasbeendiagnosedatyoungeragesthanhasbeenthecaseinEuropeanpopulationsandaffectsproportionallymorefemales,althoughthemale-to-femaleratiomaystillbeashighas9to1.159,161KSisalsodiagnosedinimmunosuppressedpatientpopulations,includingtransplantrecipientsand,especially,peopleinfectedwithHIV.Thediagno-sisofKSisregardedasAIDS-defininginthosewhoareHIVpositiveand,formanyyears,KSwasthemostcommoncancerobservedinAIDSpatientsandindeedthis,inpart,initiallydefinedtheAIDSepidemic.162However,sincetheadventofhighlyactiveantiretroviral
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TABLE3.EstimatedNumberofCasesand
Age-StandardizedIncidenceRatesforKaposiSarcomainRegionsofSub-SaharanAfrica,2008
MALESNUMBEROFCASES
INCIDENCERATE(PER100,000)
FEMALESNUMBEROFCASES
INCIDENCERATE(PER100,000)
EasternAfrica*SouthernAfrica†MiddleAfrica‡WesternAfrica§Sub-SaharanAfrica
16,0002,7001,5002,00022,000
14.911.54.11.98.1
9,0001,6003001,50012,000
6.85.10.61.23.6
´union),Kenya,*Burundi,Comoros,Djibouti,Eritrea,Ethiopia,France(LaRe
Madagascar,Malawi,Mauritius,Mozambique,Rwanda,Somalia,Tanzania,Uganda,Zambia,Zimbabwe.
†‡Botswana,Lesotho,Namibia,SouthAfricanRepublic,Swaziland.
Angola,Cameroon,CentralAfricanRepublic,Chad,Congo,DemocraticRepublicCongo,RepublicofEquatorialGuinea,Gabon.
Benin,BurkinaFaso,CapeVerde,Coted’Ivoire,TheGambia,Ghana,Guinea-Bissau,Guinea,Liberia,Mali,Mauritania,Niger,Nigeria,Senegal,SierraLeone,Togo.Source:GLOBOCAN2008.
§therapies(HAART)forHIVinthe1990s,thisisnolongerthecase.InpopulationswhereHAARTisread-ilyavailabletothoseinfectedwithHIV,KShasagainbecomeararediagnosis.163Duetothelimitedavailabil-ityofHAART,thisisnotthecaseinmuchofsub-SaharanAfrica,whereKScannowbeoneofthemostcommonformsofcancerandtheagerangeatdiagnosiscanincludeyoungchildren.23TherareoccurrenceofKSinmanyareasoftheworldandtherapidincreaseinincidencefollowingtheemergenceofAIDS,followedbytherapiddecreaseassociatedwithHAART,meansthatitisnotpossibletoprovidemeaningfulestimatesoftheglobalburdenofKSapartfrominsub-SaharanAfrica.Inthisregion,anestimated22,000casesinmalesand12,000casesinfemaleswerediagnosedin2008(Table3).Thecorre-spondingestimatedage-standardizedincidencerateswere8.1and3.6per100,000,respectively.Themajor-ityofthesecasesoccurredinthecountriesofEasternAfrica(whichincludesEthiopia,Rwanda,Uganda,Zambia,andZimbabwe).InthecountriesofEasternAfricaoverall,therewereanestimated16,000casesinmalesand9,000casesinfemalesandcorrespondingestimatedage-standardizedincidencerateswere14.9and6.8per100,000,respectively.KSwas,therefore,themostcommoncancerinmalesandthethirdmostcommoninfemales(afterbreastandcervical
cancers)inEasternAfrica.InZimbabwe,ratesreachedashighas40.9and21.9per100,000,respec-tively,basedonanestimated1500and1100casesinmalesandfemales,respectively.ThecountriesofSouthernAfrica(includingBotswana,Namibia,andSouthAfrica)hadthehighestratesofKS(11.5and5.1per100,000,respectively)afterEasternAfrica,followedbyMiddleAfrica(4.1and0.6per100,000,respectively)andWesternAfrica(1.9and1.2per100,000,respectively).
Outsideofsub-SaharanAfrica,populationsinwhichKShadbeenreportedtotheninthvolumeofCancerIncidenceinFiveContinents145withmaleage-standardizedincidenceratesof1.0per100,000peryearorgreaterintheperiodbetween1998and2002wereUSBlacks(highestrate:6.2intheDistrictofColumbia);IsraelJews(2.9);Colombia,Cali(2.5);USWhites(highestrate:2.3intheDistrictofCo-lumbia);Italy(highestrate:2.2inBrescia);Portugal(highestrate:2.1inSouthregion);USHispanicWhites(highestrate:2.0inLosAngeles);Brazil(highestrate:1.8inSaoPaolo);Switzerland(highestrate:1.4inGeneva);andSpain(highestrate:1.3inCanaryIslands).FemaleratesofKSexceeded1.0per100,000inonlyonepopulation(Italy,Sassari,witharateof1.2).TheKSinthesepopulationsrepresentsamixofthepre-AIDSeraandHIV-associatedforms.ItisnoteworthythatnoAsianpopulationsreportedincidenceratesgreaterthan1.0per100,000.
ItisnowevidentthattheKS-associatedherpesvi-rus(humanherpesvirustype8[HHV-8])isthemajorcausativefactorforKSbutgenerallyrequiresimmunosuppressiveconditionsinwhichtofunctionpathogenically.164HHV-8infectioniscommoninsub-SaharanAfrica,inthoseEuropeanpopulationsathigherriskofKS,andinallHIVtransmissionhigh-riskgroups.164AcombinationofHIVandHHV-8positivityconfersanover1000-foldriskofKS.165ThoseareasofAfricawhereendemicKSandHHV-8infectionwererelativelycommonhaveseenarapidincreaseintheincidenceofKSsincetheonsetoftheHIVepidemic.Inrecentdecades,theincidenceofKShasincreasedabout20-foldinUganda,Zimbabwe,andothersub-SaharanAfricancountries.23,166,167Limitations
Theglobalandregion-specificestimatespresentedherearebuiltupfromthosefor182countriesor
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territories,togetherwithasetofmethodsbasedontheavailabilityofcancerincidenceandmortalitydataatthecountryorregionallevel.Therefore,itshouldbeemphasizedthattheestimatespresentedinGLOBO-CAN2008arevariableinaccuracy,dependingontheextentandthevalidityofavailabledatabycountry,rangingfromrealandvalidcountsofcasesanddeaths,toestimatesbasedonsamples,throughtothosebasedonneighboringrates.Aroundtheyear2000,lessthan25%oftheworld’spopulationwascoveredbycancerregistration(11%whenconsideringdataofgoodqual-ity[publishedinthelastvolumeIX145oftheCancerIncidenceinFiveContinents(CI5)series])andonly33%oftheworldpopulationwascoveredbymortalityschemesbasedonmedicallycertifieddeaths.Thecoun-triesinNorthernEuropeandNorthAmericatendtohavehigherqualityincidenceandmortalitydataavail-able,whileinmostAfricancountriesandinsomepop-ulouscountriesinAsiatherearenovitaldataathand.Anotableimprovementtotheprevioussetofesti-mates168hasbeentheprovisionbytheWHOofcountry-specificcancermortalityestimatesbysexandagegroupfor2008,basedonbroadcause-of-deathmodels.ThesedatawereusedinestimatingtheoverallburdenofcancerinseverallargecountriesofAsiaforwhichnoorverylimitedinformationwasavailable(eg,Indonesia,Pakistan),andalsotodefinetheoverallburdenofcancerinsomelargecountriesinSouthAmericaandAsia,suchasBrazilandIndia.TheAfricancountry-specificcancerincidenceandmortalityrateswerebasedondatareportedbylocalcancerregis-triesthatgenerallycoverthecapitalcityorpredomi-nantlyurbanareas.Under-enumerationofcancercases(particularlyinelderlypersons)maybeacharacteristicofanumberofthedatasetsutilized,buttheverysparsedataavailableforruralAfricaalsosuggestthatinci-denceratesforthemostcommoncancersaremuchlowerthanthosereportedbycancerregistriesinurbanareas.Since40%oftheAfricanpopulationlivesinurbanenvironments,5theincidenceestimatescouldrepresentanoverestimation.
Despitetheprovisosconcerningdataqualityandthemethodsofestimation,theGLOBOCAN2008estimatesrepresentthebestavailableevidenceandmaybeusedinthesettingofprioritiesforcancercontrolactionsindifferentregionsandcountriesoftheworld.TheGLOBOCAN2008onlinetool2canbeusedformakingforwardprojectionsofestimatednumbersofnewcancerdiagnosesanddeathsbycountryandregionto2030usingthe2008baselineandutilizingtheUNestimatesforfuturepopulationchanges.Theseprojectionsmaketheassumptionthattheincidenceandmortalityratesestimatedfor2008willnotchangeandwhilethisallowsforthedevelopmentofscenarioplanning,areviewsuchasthatcontainedinthispublicationismostrobustifbuiltfromthe2008baseline.
Conclusions
Theglobalburdenofcancercontinuestoincreaselargelybecauseoftheagingandgrowthoftheworldpopulationandanincreasingadoptionofcancer-causingbehaviors,particularlysmoking,withineconomicallydevelopingcountries.Femalebreast,lung,andcolo-rectalcancersareoccurringinhighfrequenciesinmanyeconomicallydevelopingcountries,inadditiontothedisproportionatelyhighburdenofcancersrelatedtoinfections.Asignificantproportionoftheworldwideburdenofcancercouldbepreventedthroughtheappli-cationofexistingcancercontrolknowledge,andbyimplementingprogramsfortobaccocontrol,vaccina-tion(forliverandcervicalcancers),andearlydetectionandtreatment,aswellaspublichealthcampaignspro-motingphysicalactivityandhealthierdietarypatterns.Muchremainstobelearnedaboutthecausesofseveralmajorcancersincludingprostateandcolorectalcancers.Implementingandsustainingsuchactionsrequiresconcertedeffortsamongprivateandgovernmentpublichealthagenciesandthepharmaceuticalindustry,aswellasindividualandgovernmentdonors.n
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