Cancers du tractus digestif: données épidémiologiques et tendances en Europe

Cancers du t rac tus digest i f : donn6es ( pid( miologiques et t endances en Europe

C. LA V E C C H I A *' **, Franca LUCCH IN I ***, Eva N E G R I *, F. LEVI ***' ****

* Istituto di Ricerche Farmacologiche ~ Mario Negri ~, Milano (Italie)

** Istituto di Statistica Medica e Biometria, Universitgl degli Studi di Milano (Italie)

*** Unitd d'Epiddrniologie du cancer, Institut Universitaire de Mddecine Sociale et prdventive, Lausanne (Suisse)

**** Registres Vaudois et Neuchdtelois des Tumeurs, Institut Universitaire de Mddecine Sociale et Prdventive, Centre Hospitalier Universitaire Vaudois, Lausanne (Suisse)

Cancers of the digestive tract : epidemiological data and trends in Europe

RESUMt~

La pr6sente 6tude prend en compte les donn6es et les tendances relatives ~ la mortalit6 par cancer du tractus digestif dans 35 pays europ6ens. Elle eonfirme la poursuite du long d4clin de la mortalit4 par cancer gastrique avec cependant une persistance de taux 61ev6s en Europe de l'est (et au Portugal). Elle indique aussi que l'4volution des cancers colorectaux est devenue relativement favorable dans plusieurs pays europ6ens depuis le milieu des ann4es 80, principalement pour la femme. Aprhs une p4riode de hausse, depuis le d6but des ann6es 90, les cancers de la eavit4 buecale, du pharynx et de l'o~sophage se sont stabilis4s chez l 'homme ~ des Sges de plus en plus jeunes. En revanche, l'6vo- lution des cancers h6patiques est extr4mement difficile a interpr6ter et la mortalit6 par cancer pancr6atique reste en hausse dans plusieurs, bien que pas tous, pays europ6ens.

Remerciements : Ce travail a 6t6 soutenu par la Ligue Suisse contre le cancer, la Fondation Suisse de Recherche sur le Cancer et l'Association Italienne de Recherche sur le Cancer.

S U M M A R Y

A comprehensive analysis is given on patterns and trends in digestive tract neoplasms mortality in 35 European countries. This confirms the long-term steady decline in gastric cancer mortality, together with the persistence o f substantially high rates in Eastern Europe (and Portugal). It also indicates that trends for colorectal cancer have become relatively favourable in several European countries, mostly for women, from the mid 1980's onwards. Likewise, the earlier rise for oral and pharyngeal, and oesophageal cancers in males have tended to level o f f from the early 1990"s onwards. While trends for liver cancer are extremely difficult to interpret, mortality from pancreatic cancer remains upwards in several (though not all) European countries.

Acknowledgements : This work was supported by the Swiss League against Cancer, the Swiss Foundation for Cancer Research, and the Italian Association for Cancer Research.

Dans un pr6c6dent article, nous avions analys6 les donn6es et les tendances relatives ~ la mortalit6 des principaux cancers, y compris ceux du tractus digestif, sur une p6riode s '6tendant de 1955 ~ 1989, ceci en vue d 'ob ten i r un document r6capitulat i f pe rme t t an t d'6valuer les variations de la mortalit6 par cancer en Europe au cours des 4 derni6res d6cades [1].

Ensuite , une mise ~ jour a 6t6 rdalis6e qui t ient compte des faits nouveaux : modifications politiques survenues en Europe, apparition de nouvelles entit6s, possibilit6 d 'ob ten i r des donndes d 'au t res pays (Albanie, Estonie, Lettonie). Ce travail a un important impact sur l '6pid6miologie analytique. En effet,

on a observ6 au cours des derni6res ann6es d' impor- tants changements de mode de vie et de l 'exposition plusieurs facteurs de risque, principalement dans certains pays de l 'Europe centrale et de l'est, autrefois 6trangers ~ l '6conomie de march6 [2-8].

Ces modifications ont eu un effet majeur et radical sur la mortalit6 totale et ont influenc6 - quoique dans une moindre mesure - la mortal i t6 cons6cutive au cancer [9-11], y compris par n6oplasme du tractus digestif.

En revanche, depuis quelques ann6es, aux Etats- Unis [12] et dans l 'Union Europ6enne [9], la morta- lit6 totale par cancer donne des signes de d6clin. Une

Tir6s ~ part : Fabio LEVI, Registre Vaudois des Tumeurs, CHUV-Falaises 1, 1011 Lausanne (Suisse). (Fax: +41-21-3230303; E-mail: fabio.levi@inst .hospvd.ch).

Mots-cl~s: 6pid6miologie, Europe, mortalit6, n6oplasmes, tendances, tractus digestif. Key-words : digestive tract, epidemiology, Europe, mortality, neoplasms, trends.

Acta Endoscopica Volume 31 - N ~ 4 - 2001 453

6tude g6n6rale de la mortalit6 par cancer dans 35 pays europ6ens a 6t6 pr6c6demment publi6e ; elle concerne les ann6es 1990-1994 et les tendances obser- v6es entre 1955 et 1994 [10].

Le pr6sent article, en partie extrait de cette pr6c6- dente publication, est sp6cialement centr6 sur les n6oplasmes du tractus digestif.

MATIERIEL ET MIETHODES

Les donn6es des certificats officiels de d6c~s de 35 pays europ6ens comprenant la F6ddration Russe, mais sans inclure Andorre et le Liechtenstein, ont 6t6 r6unies gr~ce aux informations fournies par l'Organi- sation Mondiale de la Sant6 (OMS). Bien que le Royaume-Uni constitue en principe un tout, les don- n6es sont pr6sent6es s6par6ment pour l'Angleterre, le Pays de Galle, l'Ecosse et l'Irlande du Nord. Pour l'Albanie, les donn6es couvrent seulement la p6riode 1992-1993 et les p6riodes disponibles sont 1990-1193 pour la Bi61orussie, la Rdpublique Tch6que et le Danemark, 1990-1992 pour la Belgique et l'Ukraine et 1991-1994 pour la Mac6doine.

Deux r6visions diff6rentes de la Classification Internationale des Maladies (CIM) sont survenues au cours de la p6riode 6tudi6e [13, 14]. Les classifications des d6c~s par cancer furent recod6es pour toutes les p6riodes de calendrier et tous les pays, selon la Neuvi6me R6vision (CIM-9). Le tableau I donne les cancers ou les groupes de cancers consid6- r6s et le code CIM correspondant aux diff6rentes r6visions. Pour am61iorer la comparaison des don- n6es entre les diff6rents pays, nous avons regroup6 tousles sites de cancers intestinaux, en particulier le c61on et le rectum.

TABLEAU I

CANCERS OU GROUPES DE CANCERS CONSIDt~RI~S

Type de cancer 8 CIM (1) 9 CIM (1)

Bouche ou pharynx (Esophage Estomac Intestins, principalement c61on et rectum Foie V6sicule et canaux biliaires

Pancr6as

140-149 150 151

152-154

155 156 157

140-149 150 151

152-154

155 156 157

(1) CIM = Classification Internationale des Maladies.

Les estimations des populations r6sidentes, g6n6- ralement bas6es sur les relev6s officiels de population, furent aussi obtenues ~ partir de la m6me banque de donn6es de I'OMS. A partir des matrices des d6c~s certifi6s et des populations r6sidentes, des taux sp6cifiques furent calcul6s par groupes d'~ge et par p6riodes de calendrier quinquennaux. Les taux de mortalit6 pour tousles gtges et pour les gtges 35- 64 ans, ont 6t6 standardis6s pour l'~ge par rapport la population mondiale type [15].

RES UL TATS ET COMMENTAIRES

Pour chaque site de cancer, deux figures sont pr6- sent6es. La premi6re figure repr6sente un histo- gramme des taux de mortalit6 standardis6s pour l'~ge (population mondiale type) pour la p6riode 1990- 1994 selon le sexe et pour chaque site du tractus digestif.

La figure 2 pr6sente les courbes des taux standardi- s6s (pour tousles gtges et pour les ~ges 35-64 ans) dans 24 pays et s6par6es selon les sexes par p6riodes de 5 ans de 1955-1959 ?~ 1990-1994.

L'6tude a pour but de donner une description syn- th6tique et de documenter l'6volution globale des tendances de la mortalit6 par cancer du tractus digestif en Europe. Nous nous limitons h des commentaires g6n6raux afin d'aider le lecteur dans l'interpr6- tation des tendances pour chacun des sites de cancer digestif les plus fr6quents.

I1 est tout d'abord important de consid6rer les pro- blames li6s aux fluctuations al6atoires qui sont inver- sement li6es a la taille des populations et ~ la fr6- quence des cancers. Ensuite, plus complexes encore, surviennent les probl6mes de fiabilit6 des certificats de d6c~s et de leur validit6 dans certains pays [16, 17]. En g6n6ral, pour de nombreux sites communs de cancer, comme les cancers de la cavit6 buccale, du pharynx, de l'oesophage, de l'estomac, et du colorectum, le certificat est suffisamment valide pour permettre une inter- pr6tation raisonnable des taux et des tendances dans la plupart des pays europ6ens, particuli6rement ceux de l'Europe de l'ouest, tout comme pour la Hongrie et la Pologne, et plus sp6cialement pour les ~ges inf6- rieurs ?a 65 ans. Une plus grande prudence est requise pour quelques autres pays et certains sites de cancer pour lesquels le diagnostic et la certification peuvent ~tre partiellement influenc6s par les techniques de diagnostic et la pr6cision du certificat de d6cbs [16, 19]. Ceci est le cas pour les cancers du foie, de la v6sicule et des canaux biliaires ainsi que du pancr6as.

Chez les hommes, en France et en Italie, les taux de mortalit6 par cancer de la cavit6 buccale et du pharynx les plus 61ev6s furent enregistr6s au cours des ann6es 1970, mais les taux dans ces pays ont diminu6 au cours de la derni~re d6cade. En revanche, une 616- vation significative rut observ6e en Allemagne et dans la plupart des pays d'Europe centrale et de l'est, avec un taux nettement plus 61ev6 en Hongrie (42/100 000 pour les hommes ~g6s de 35-64 ans). Une 16g~re augmentation rut observ6e pour les hommes jeunes en Grande-Bretagne, tandis que les tendances sont variables dans les pays scandinaves. Ces profils 6volutifs refl~tent vraisemblablement les tendances de la consommation d'alcool et de tabac dans les dif- f6rents pays europ6ens au cours des derni6res d6cades et mettent en 6vidence l'ampleur et l'importance de l'6pid6mie r6cente de cancer de la bouche chez l 'homme dans plusieurs r6gions europ6en- nes [20]. Chez les femmes, les taux de cancer de la bouche et du pharynx sont beaucoup plus bas et les tendances 6volutives ne sont pas 6videntes. Cepen-

454 V o l u m e 31 - N ~ 4 - 2001 A c t a E n d o s c o p i c a

MOUTH OR

0

HUNGARY

CROATIA S L O ~ MQ.DOVA

L I K ~ E RUSS~ ~

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UK, SCOTLAND IREL/~D

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UK, NORTHERN IRELAND ' MACEDON~ i

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RNLANO ICEL/~ND GREBOE

PHARYNX (ICD-9: 140-9), MALES

5 10 15 20

1 3 . 5 1 3 . 2

1 3 . 1 1 3 . o 1 2 . 8 / 2 . e / ~ , . s 1 2 . 2 1 1.8 1 1.8

MOUTH OR PHARYNX (ICD-9: 140-9), FEMALES

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Figure 1 a

0

~ I A ~ 1.6 UK, SCOTLAND ~ 1.5

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B 1.0

1 .0

1 .0

E l . 0

1 .0

0 . 9

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�9 0,7 � 9 110.8 I o.s

5 10 15 20 I = I i I | I

~urce: W ~

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~ , ~ I A 1 2 . o A L B A N I A ' / 1 .5

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10

OESOPHAGUS (ICD-9: 150), FEMALES

UK, SCOTLAND ' IRELAND

UNrrED K~GDOM 1 UK, ENGLAND AND WALES ' I

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SWITZERLAND '

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B ~ '

[]

1 2 . 0 / 1 . 8 1 1 . 7 1 1.6

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5

1=4.8

Source: WHO

Figure 1 b

I 0 I

A c t a E n d o s c o p i c a V o l u m e 31 - N ~ 4 - 2001 455

S T O M A C H ( ICD-9: 151) , M A L E S

0 10 20

nu~t,~ FEDERA~O. I I I I I BELARUS UKP, A~E

LATVIA LITHUANIA

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HUNGARY ' 23,1 SLOVENIA ' 22.6 CROATIA ' 22.3

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ALBANIA MALTA ' ~ 12.8

UK, NORTHERN IRELAND ' UK, SCOTLAND ' ~ 11.8

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UNITED KINGDOM ~ 11.3 FIM.AND

UK, ENGLAND AND WALES L ~ ~ 10.6

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9.0 S ~ h l i z ~ U ~ )

~ E m 7.9 SWmB~ m 7 . 6

DENMm~ B 7 . 1

3O

I I 31.3

28.2 28.1 28.0

4O 1 39.7

37.0

S T O M A C H ( ICD-9: 151) , F E M A L E S

RUSSIAN FEDERATION BELARUS " ESTONIA ' UK, P,J~NE '

LATVIA ' LITHUANIA ' m

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CROATIA

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UK, SCOTLAND UK, NORTHERN IRELAND

L L ~ NORWAY

UNITED KINGDOM N E T H E ~

GFIB~E UK, ENC-CAND AND WALES

BB.GlUM

SWIT21=pLAND DENMAP~

10 20

I I 1166' 15.6

~ 12.6

m & 7 m & o m 7 & m m 7.5 m 7 . 6

7.2 m 6 9 m 6ms m & 1 m m 6o m 6.9 m 6.6 m 6 . 7 m 6.3 m m 6.o m 4.6 m 4.7 m m 4.6 m 4.6 m m 4.6 m, , , , 4.5 m 4.5 m 4 . 1 m 3.9 m 3.9

roB31

30 40 I i I

Source: WHO

Figure 1 c

INTESTINES. CHIEFLY COLON AND RECTUM (ICD-9: 152-4), MALES

CZECH REPUBUC HUNGARY IRB.AND

U~ NORTHEF~ IRELAND AUSTRIA

UK, SCOTLAND DENMAR< SLOVRNIA GERMANY

L ~ UNITED KINGDOM

UK, ENGLAND AND WALES R ~

NORWAY N E T H B ~

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ROMANIA ' MACEDONIA '

(~E~E ' ALBANIA '

10 20 30 40

I I I I I i I ' 373 32.2

24.8 24.0

23,5 23.4 23.3 22.9 22.6

21.6 21.3 21.1 20.6 20.6 20.1

19.5 19.2 19.1 18.8

18.3 1&1 18.0 17.8 17.6

17.0 16.8 16.8 16.7

16.0 15.8

lS.3 15.2

m t1.~ m 11.; BB 11.E m 11.~

J 11.! 111.,"

m 3.4

INTESTINES, CHIEFLY COLON AND RECTUM (ICD-9: 152-4), FEMALES

CZECH REPUBLIC H ~ D~,tARK

UK. NORTHE P~I IRELAND

UK, SCOTLAND IRELAND

L ~ NETH~NDS

NORWAY UNITED KINGDOM

UK, ENGLAND AND WN.ES AUSTRIA

SLOVENIA ESTONIA

ITALY BELC~UM

R ~ I A N FEDERATION P O R T ~

MALTA FRANCE LAI'VIA

BULGARIA LITHUANIA

CROATIA ~ E SWEDB~ PO-N~D

swrrzERI_/~O SPAIN '

MOLDOVA BEIJ~I.~ ' ICBJ~D FINLAND

ROMANIA '

MACEDONIA ' ALBANIA '

10 20

I I I 12o.4 19.6

17.4 16.6

16.0 15.7 15.4

14.7 14.6 14.4 14.2

10.6 m m m ~ m m 10.6

10.6

m 9,6 m m m m 7.6

7.6 7.3

mm 2.7

30 40 i I i I

Source: WHO

Figure I d


L IVER

o | HUNGARY

ITALY

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POLAND

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BELGIUM PORTUG/r

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UK, SCOTLAND '

ICELAND

MALTA

UNITED KINGOOM

UK, ENGLAND AND WALES

NORWAY

I R B . . ~ '

t .~ NORTHERN IRN.~D '

( ICD-9: 155.0), M A L E S

2 4 6 . | . i . = o

6.2

- - 7 B

|

6.1

5.6

6.9

B

- - 1 ~ 1.3

m l.2

m 1.1

m 1.1

0.8

0.8

11o .6 �9 6.5

8 i , 8,3

8.1

8.0

( ICD-9:

lO 0 i

POLAND

BULGARIA

HUNGARY

ITALY '

FINLAND

ROMANIA

cZECH REPUBLIC

SWITZERLAND

SPAIN

SLOVENIA

DENMARK '

BELGIUM '

AUSTRIA '

~ R T t ~

UK, SCOTLAND


UNITED KINGDOM

NOF~NAY

N E T H ~

MALTA

UK, NORTHERN IRELAND

IRELAND

Figure 1 e

L IVER

m1.1 H I.0

t o o . 9

t o o . 9 o o . 8 �9 0.6

[ ] 0.5

oo.4 �9 0.4

too.4 ~ 0.4

too.4

0.2

0.2

0.1

155.0), FEMALES

4 6

Source: WHO

lO

G A L L B L A D D E R AND BILE DUCTS (ICD-9: 156), MALES G A L L B L A D D E R AND B IL IARY DUCTS (ICD-9: 156), FEMALES

0

C71=C~

GERM/~IY '

AUSTRIA '

ITALY CROATIA ' FINLAND BELGIUM

SWWZERI.J~ID ' PORTUGAL'

NETHERLAND6 ' L ~ '

LITHUANIA ' ~ E ' SPAIN '

DENMAR( MALTA

NORWAY IRELAND

UK, SCOTLAND '

~ST~IA BULGARIA '

UK, NORTHERN IREL/~D ' UK, ENGLAND AND WALES

UNITED KINGDOM

ICB.N~ID

ALBANIA

2 4 6 8 10 0 2 4 6 8

I I I ' '

- - 1

E

[] 2.1 1.1

m 2 . 1 i 1.( 12.( i 1,4

i l.g i 1,4 m 1.9 i 1.4 i 1.9 i 1.4

i 1.3 ~ 1 . 3

1.2 1.2

m 1.o m o.9 m 0.8 m 0.7

o.7 o.7

i 0.7 �9 0.6 �9 0.6 �9 0.6 �9 0.6 �9 o.5

CZECH RB:4JBLIC

SLOVENIA GERMANY AUSTRIA

ITALY FINLAND CROATIA

SWlT2~P4.AND SPAIN

NETHEPL,qdD6

L ~ LITHUANIA DENMN:~ BELGIUM

PORTUGAL

ESTONIA MALTA

IRELAND BULGARIA

UK. NORTHERN IRELAND NOF~/AY ICELAND

UK, SCOTLAND UNITED KINGDOM

GREBE


ALBANIA

2.7 ~ 1 2 . 7

m 1.6 m 1.E i 1.5

1.5 1.5

1.3 1.3

m 1.2

1.0 i n 1.0 i m 0.8

m 0.8 �9 0.7

m o.4

Figure 1 f

6.0

Source: WHO

10 !


0

CZECH REPUEUC I HUNGARY

MALTA ESTONIA'

LITHUANIA ' AUSTRIA ' R ~

leE.AND MOLDOVA SLOVENIA

POLAND GerMANY DENMARK

SWllzU-LAND

hlErHERLANDS NORWAY

ITALY

CROATIA BS.GIUM

UK, SCOTLAND UK, NORTHEI~I I R ~

JK, ENGLAND AND WALES ~ KINGDOM

BULGARIA ROMANIA

GREB~E SPAIN

PORTUGAL MACEDONIA

ALBANIA i 2.1

10 15

, I 11'3 ~ I C2~'CH REPUEUC

11.0 11.0 FINLAND

10.6 9.9

9.1 8.6 AUSTRIA 8,5 ESTONIA 8.5 NORWAY

8.3 IRELN~ID 8,2 NETHER.ANDS 8.2 GERMANY' 8.2 UK, SCOTLAND ' 8.2 UK, NORTHERN IRELAND '

7.8 SLOVE~IIA ' 7.7 S W i R L e D ' 7.7 I ~ D ' 7.6 I LITHUANIA i

7.4 IlK, F . N G ~ AND WALES 7.4 UNITED KINGDOM ' 7.4 ITALY ' 7.3 BELGIUM ' 7.3 I ~ . T A ' 72 L ~

7.0 CROATIA 6.9 MOLDOVA 6,9 FRN~CE 6.9

6.6 SPAIN 6.1 ROMANIA

MACEDONIA

BULGARIA ALBANIA

Figure 1 g

Figure 1 (a, b, c, d, e, f, g)

4.3

3.1 �9 0.8

5

! 6.7 6.6 6.6 6.5 6.5 6.4

6.2

10 15 I | !

Source: WHO

Taux moyens annuels de certification de deces par cancers du tractus digestif en Europe standardis~e pour I'&ge (population mondiale) pour 100 000 hommes et femmes de tous &ges,1990-1994.

Average age-standardized (world population) death certification rates per 100,000 from digestive tract cancers in Europe,1990-1994.

dant, un 16ger d6clin des taux de cancer de la bouche et du pharynx est observ6 pour les femmes en Fin- lande et en Grande-Bretagne et une sensible augmentation en Allemagne, en Hongrie et en Pologne. Au cours des ann6es 1990-1994, les taux les plus 61e- v6s de mortalit6 furent enregistr6s en Hongrie (17,3/100 000 chez les hommes et 2,2/100 000 chez les femmes) ; les taux les plus bas furent enregistr6s en Grace (1,8 et 0,5/100 000 respectivement pour les hommes et pour les femmes).

Pour plusieurs aspects, le tableau est analogue pour le cancer de l'eesophage, autre n6oplasme forte- ment 1i6 ~ la consommation d'alcool et de tabac [21]. En particulier au cours des quelques derni~res ann6es, des augmentations substantielles furent enre- gistr6es au Danemark, en Allemagne, en Angleterre, en Hongrie et en Pologne, confirmant les 6volutions ant6rieures, mises en relation avec l'6volution de la consommation d'alcool dans ces pays [21]. En 1990- 1994, les taux les plus 61ev6s de mortalit6 furent enre- gistr6s en France et en Ecosse chez les hommes (10,3/100 000) et en Ecosse chez les femmes (4,8) ; les taux les plus bas 6taient observ6s en Mac6doine et en Gr6ce chez les hommes (1,4/100 000) et en Bi61orus- sie, Gr6ce et Roumanie chez les femmes (0,4).

En ce qui concerne le cancer gastrique, les diminutions r6guli~res des taux observ6es dans l'ensemble de l'Europe se sont poursuivies au cours des ann6es

les plus r6centes, m~me si, en valeur absolue, les taux restent marqu6s par une forte h6t6rog6n6it6 g6ogra- phique [22]. En 1990-1994, les taux de mortalit6 les plus 61ev6s 6taient enregistr6s dans la F6d6ration Russe (39,7/100 000 chez les hommes, 16,6/100 000 chez les femmes) et les plus bas au Danemark chez l'homme (7,1/100 000). A relever, au sein de l'Europe de l'ouest, les taux 61ev6s pour le Portugal (23,2/100 000 chez les hommes et 11,1/100 000 chez les femmes).

En revanche, les taux de cancer colorectal augmen- tent nettement en Europe de l'est et du sud (?a l'ex- ception de la France et de l'Italie), tandis qu'ils dimi- nuent dans les pays d'Europe centrale et du nord, ce qui conduit ~ une r6partition plus uniforme des taux h travers toute l'Europe [11]. En 1990-1994, c'est en R6publique Tch~que que furent enregistr6s les taux les plus 61ev6s (37,3/100 000 hommes, 20,4/100 000 femmes), les taux les plus bas, ?a l'exclusion de l'Alba- nie, la Mac6doine et la Roumanie) 6tant observ6s en Grace (9,5/100 000 hommes, 7,6/100 000 femmes). Au cours des derni6res ann6es, les tendances 6taient sys- t6matiquement plus favorables pour les femmes dans plusieurs pays.

Les taux de cancer du foie doivent ~tre interpr6t6s avec une extreme pr6caution en raison des probl~mes de fiabilit6 des certificats de d6c6s et de validit6 du diagnostic de la 16sion primaire, le foie 6tant le site le


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Tendance evolutive des taux de certification de deces standardises pour I'&ge (population mondiale type) pour 1 O0 000 hommes et femmes par cancers du tractus digestif dans 24 pays europeens,1955-1994.

(+ + Hommes, tous &ges; [] [] Femmes, tous &ges : + - - - - - - + , hommes, 35-64 arts; [] . . . . [] Femmes, 35-64 ans).

Trends in age-standardized (world population) death certification rates per 100,000 from digestive tract cancers in 24 European countries,1955-1994.

(+ + Males, all ages ; [] [] Females, all ages : +- - -- --+, Males, 35-64 years ; [] -- -- -- [ ] Females,35-64 years).


plus commun de m6tastases [19]. Dans les diff6rents pays europ6ens, il n'existe aucun profil clair des tendances enregistr6es qui refl~tent essentiellement des modifications dans les classifications utilis6es dans les diff6rents pays au cours des p6riodes de calendrier consid6r6es.

En ce qui concerne les cancers de la v6sicule, et des canaux biliaires, des diminutions constantes sont not6es dans plusieurs pays du nord et de l'Europe centrale (mais pas en Europe du sud ou de l'est) vraisemblablement en relation avec les diff6rences de taux de chol6cystectomies effectu6es dans ces pays [23].

En Grande-Bretagne et darts quelques pays nor- diques, il est int6ressant de noter une tendance r6cente h une stabilisation et ~ une diminution des taux de cancers du pancr6as apr~s des d6cennies pas- s6es ~ la hausse [18]. Ces tendances h la hausse per- sistent dans la plupart des pays du sud et de l'est de l'Europe, de m6me qu'en France et en Allemagne. Entre 1990 et 1994, les taux de mortalit6 les plus 61e-

v6s ont 6t6 enregistr6s en R6publique Tch6que (11,3/100 000 hommes, 6,7/100 000 femmes) et les plus bas, en excluant l'Albanie, furent observ6s au Portu- gal (5,8/100 000 hommes) et en Bulgarie (3,1/100 000 femmes).

En conclusion, une analyse exhaustive des taux de mortalit6 par cancer du tractus digestif confirme la diminution r6guli~re de la mortalit6 par cancer gastrique, avec une persistance de taux notablement 61e- v6s dans l'Europe de l'est (et au Portugal). Ces taux indiquent 6galement que, depuis le milieu des ann6es 1990 et principalement pour les femmes, les tendances 6volutives du cancer colorectal sont devenues relativement favorables dans plusieurs pays europ6ens. De m~me, apr6s une p6riode initiale de hausse, les cancers de la bouche et du pharynx et les cancers de l'oesophage chez les hommes se sont stabilis6s ~ partir des ann6es 90. Les tendances relatives au cancer du foie sont extr~mement difficiles h 6valuer, alors que la mortalit6 par cancer du pancr6as reste en hausse dans plusieurs pays europ6ens.

REFERENCES

1. LA VECCHIA C., LUCCHINI F., NEGRI E., BOYLE P., MAISONNEUVE P., LEVI F. - - Trends of cancer mortality in Europe,1955-1989 : I, Digestive sites; II, Respiratory tract, bone, connective and soft tissue sarcomas, and skin ; III, Breast and genital sites ; IV, Urinary tract, eye, brain and nerves, and thyroid ; V, Lymphohaemopoietic and all cancers. Eur. J. Can- cer, 1992,28, 132-235, 514-599, 927-998, 1210-1281, 1509-1581.

2. DOLL R. - - Health and the environment in the 1990's. Am. J. Publ. Health, 1992, 82, 933-941.

3. NEGRI E., LA VECCHIA C., FRANCESCHI S., LEVI F. - - Patterns of mortality from major cancers in Europe. Cancer Epidemiol. Biomarkers Prey., 1994,3, 531-536.

4. H A D J U P. , M C K E E M . , B O J A N F. - - Changes in premature mortality differentials by marital status in Hungary and in England and Wales. Eur. J. Publ. Health, 1995, 5, 259-264.

5. ZATONSKI W.A., BOYLE P. - - Health transformations in Poland after 1988. J. Epidemiol. Biostat., 1996, 1, 183-187.

6. BOYLE P. - - Global burden of cancer. Lancet, 1997, 349 ( s u p p l 2), SII23-26.

7. EVST1FEEVA T., MACFARLANE G., ROBERTSON C. - - Trends in cancer mortality in central European countries. Eur. J. Publ. Health, 1997, 7, 169-176.

8. LA VECCHIA C., LEVI F., LUCCHINI F., NEGRI E. - - Trends in mortality from major diseases in Europe,1980-1993. Eur. J. Epidemiol., 1998,14, 1-8.

9. LEVI F., LUCCHINI F., BOYLE P., NEGRI E., LA VEC- CHIA C. - - Cancer incidence and mortality in Europe,1989- 1992. J. Epidemiol. Biostat., 1998, 3, 295-373.

10. LEVI F., LUCCHINI F., NEGRI E., BOYLE P., LA VEC- CHIA C. - - Cancer mortality in Europe,1990-1994, and an overview of trends from 1955 to 1994. Eur. J. Cancer, 1999, 35, 1477-1516.

11. LA VECCHIA C., NEGRI E., LEVI F., DECARLI A., BOYLE P. - - Cancer mortality in Europe : effects of age, cohort of birth and period of death. Eur. J. Cancer, 1998, 34, 118-141.

12. COLE P., RODU B. - - Declining cancer mortality in the Uni- ted States. Cancer, 1996, 76, 2045-2048.

13. World Health Organization. International Classification of D i s e a s e : 8 th Revision. World Health Organization, Geneva, 1967.

14. World Health Organization. International Classification of D i s e a s e : 9 th Revision. World Health Organization, Geneva, 1977.

15. DOLL R., SMITH P.G. - - Comparison between registries : age-standardized rates. In : Waterhouse JAH, Muir CS, Shan- mugaratnam K. et al. (eds). Cancer Incidence in Five Conti- nents, Vol. IV. IARC Scient Publ N ~ 42. Lyon, International Agency for Research on Cancer, 1982, 671-675.

16. PERCY C., STANECK E., GLOECKLER L. - - Accuracy of cancer death certification and its effects on mortality statistics. Am. J. Publ. Health, 1981, 71,242-250.

17. BOYLE P. - - Relative value of incidence and mortality data in cancer research. Recent Results Cancer Res., 1989, 114, 41-63.

18. FERNANDEZ E., LA VECCHIA C., PORTA M., NEGRI E., LUCCHINI F., LEVI F. - - Trends in pancreatic cancer mortality in Europe,1955-89. Int. J. Cancer, 1994,57, 786-791.

19. DOLL R., PETO R. - - The causes of cancer : quantitative e s t i m a t e s of avoidable risk of cancer in the United States today. J. Natl. Cancer Inst., 1981, 66, 1191-1308.

20. LA VECCHIA C., TAVANI A., FRANCESCHI S., LEVI F., CORRAO G., NEGRI E . - - Epidemiology and prevention of oral cancer. Eur. J. Cancer B. Oral. Oncology, 1997, 33, 302- 313.

21. MOLLER H., BOYLE P., MAISONNEUVE P., LA VEC- CHIA C. , J E N S E N O . M . - - Changing mortality from esopha- geal cancer in males in Denmark and other European countries in relation to changing level of alcohol consumption. Cancer Causes Control., 1990,1,181-188.

22. FRANCESCHI S., LEVI F., LA VECCHIA C. - - Epidemio- logy of gastric cancer in Europe. Eur. J. Cancer Prey., 1994, 3S2, 5-10.

23. ZATONSKI W., LA VECCHIA C., LEVI F., NEGRI E., LUCCHINI F. - - Descriptive epidemiology of gall-bladder cancer in Europe. J. Cancer Res. Clin. Oncol., 1993, 119, 165- 171.

4 6 6 Volume 31 - N ~ 4 - 2001 Acta Endoscopica

We reviewed patterns o f trends in mortality from major cancers, including digestive tract sites, in Europe over the period 1955-1989, to provide a summary documentation o f the extent o f variation in cancer mortality across Europe over the last 4 decades [1].

This work has been updated, including the changed political boundaries within Europe, with the conse- quent definition of new national entities, and the availability o f data for a few other countries (Albania, Estonia, Latvia). This work has relevant implications for analytical epidemiology, since substantial changes in standard of life and several risk factor exposures have been observed over the last few years, mostly in a few former non market economy countries of central and eastern Europe [2-8]. These had major and dra- matic implications on increasing total mortality, and have influenced - though to a lesser extent - cancer mortality as well [9-11], including digestive tract neoplasms.

In contrast, over the last few years, some declines in total cancer mortality have been reported from the US [12] and the European Union [9]. A comprehensive presentation of cancer mortality in 35 European countries during the quinquennium 1990-1994 and of trends between 1955 and 1994 has been given else- where [10]. This report, derived from the above paper is specifically focused on digestive tract neoplasms.

MATERIALS AND METHODS

Official death certification numbers for 35 Euro- pean countries (including the Russian Federation, but excluding a few small countries such as Andorra and Lichtenstein) were derived from the World Health Organization (WHO) database. Besides the United Kingdom as a whole, data were presented separately also for England and Wales, Scotland and Northern Ireland. For Albania, data were available only for 1992-1993 ;for Belarus, the Czech Republic, and Den- mark for 1990-1993; for Belgium and Ukraine for 1990-1992; and for Macedonia for 1991-94.

During the calendar period considered, two different revisions of the International Classification o f Diseases (ICD) were used [13, 14]. Classifications of cancer deaths were thus re-coded, for all calendar periods and countries, according to the Ninth Revision (ICD-9). Table I gives the cancers or groups of cancers

TABLE I

CANCERS OR GROUPS OF CANCERS CONSIDERED

Type of cancer 8 ICD (1) 9 ICD (1)

Mouth or pharynx (Esophagus Stomach Intestines, chiefly colon and rectum Liver Gallbladder and bile ducts Pancreas

140-149 150 151

152-154 155 156 157

(1) 1CD = International Classification of Diseases.

140-149 150 151

152-154 155 156 157

considered, together with the corresponding ICD codes under subsequent revisions. To improve compa- rability of data throughout different countries, we poo- led together all intestinal sites, including chiefly colon and rectum.

Estimates o f the resident population, generally based on official censuses, were obtained from the same WHO databank. From the matrices of certified deaths and resident populations, age-specific rates for each 5-year age group and calendar period were com- puted. Age-standardized rates, at all ages and truncated 35-64 years, were based on the world standard population [15].

RESULTS AND COMMENTS

For each cancer site, two figures are presented. The first one includes for the period 1990-1994, for each digestive tract site and sex, the histogram of age- standardized (world standard) overall mortality rates.

Figure 2 includes world standardized rates (at all ages' and truncated 35 to 64 years) for 24 countries and 5-year calendar periods from 1955-1959 to 1990-1994 for males and females.

This report has the major aim of providing a summary description and documentation of the global pattern o f trends in digestive tract cancer mortality in Europe. Only a few general comments are included, to assist reading and interpreting trends for major cancer sites.

First, it is important to consider problems related to random variation, which are clearly greater in relation to smaller populations and rarer cancers. Secondly, and more complex, are problems of death certification reliability and validity in various countries [16, 17]. In general, for several common cancer sites, including oral cavity and pharynx, oesophagus, stomach, and colorectum, certification is sufficiently reliable to per- mit meaningful inference on rates and trends for most European countries, particularly those from western Europe, as well as for Hungary and Poland, and mainly under age 65. Greater caution is required for a few other countries and cancer sites the diagnosis and certification of which may be substantially influenced by the availability o f diagnostic techniques and the accuracy of death certification [16-19]. These include liver, gallbladder and bile ducts, and pancreas.

The highest mortality rates from cancer of the oral cavity and pharynx in males were registered in the 1970's in France and Italy, but rates in those countries have been levelling o f f over the last decade. In contrast, substantial rises were observed in Germany and most other central and eastern European countries, reaching exceedingly high rates in Hungary (42/100,000 males aged 35-64). Some rise in young males was observed also in Britain over the most recent calendar period, while trends were inconsistent in Scandinavian countries. These patterns likely reflect trends in alcohol and tobacco consumption in various


European countries over the last few decades, and fur- ther stress the size and importance of the recent oral cancer epidemic in males in several areas of Europe [20]. Oral and pharyngeal rates were much lower, and trends generally unremarkable, for females. However, some decline in female oral and pharyngeal cancer rates was observed in Finland and UK, and some rise in Germany, Hungary and Poland. In 1990- 1994 the highest mortality rate were registered in Hun- gary (17.3/100,000 in males and 2.2/100,000 in females) ; the lowest ones were registered in Greece (1.8 and 0.5/100,000 males and females, respectively).

In several aspects, the pattern was similar for oesophageal cancer, another neoplasm strongly related to alcohol and tobacco consumption [21]. Over the last few years, in particular, substantial rises were observed in Denmark, Germany, Britain, Hungary and Poland, confirming previous patterns, which had been related to changes in alcohol drinking in those countries [21]. In 1990-1994, the highest mortality rates were registered in France and Scotland for males (10.3/100,000) and in Scotland for females (4.8) ; the lowest ones were observed in Macedonia and Greece for males (1.4/100,000) and in Romania, Greece and Belarus for females (0.4).

With reference to gastric cancer, the steady declines in rates observed throughout the whole of Europe persisted over the last few years, although absolute values remain substantially heterogeneous [22]. In 1990-1994 the highest mortality rates were registered in the Russian Federation (39.7/100,000 males, 16.6/100,000 females); the lowest ones were observed in Denmark for males (7.1/100,000) and in France for females (3.1/100,000). Within western Europe, high rates were observed in Portugal (23.2/100,000 males, 11.1/ l O0,O00 females).

In contrast, colorectal cancer rates steadily increased in Eastern and Southern Europe (except France and Italy), while levelling of f in most northern and central European countries, thus leading to a more uniform pattern of colorectal cancer rates across Europe [11]. In 1990-1994 the highest mortality rates were registered in Czech Republic (37.3/100,000 males, 20.4/100,000 females) ; the lowest ones (excluding Albania, Mace-

donia and Romania) were both registered in Greece (9.5/100,000 males, 7.6/l O0,O00 females). Over the last few years, trends tended to be systematically more favourable for females in several countries.

Liver cancer rates have to be interpreted with utmost caution, due to the substantial problems of death certification reliability and validity for this neoplasm, which is one o f the most common sites o f metas- tases [19]. No clear pattern, in any case, was evident across various European countries and the trends registered essentially reflected changes in classification in various countries and calendar periods.

With reference to cancers of the gallbladder and bile ducts, steady declines were observed in several countries of northern and central (but not southern or eastern) Europe, which are likely related to different trends in cholecystectomy rates across various countries [23].

Of major interest, for pancreatic cancer, are some recent levelling of f and decline in Britain, and a few Nordic countries, after decades of upward trends [18]. Such upward trends, however, persisted in most countries o f southern and eastern Europe, as well as in France and Germany. In 1990-1994 the highest mortality rates were registered in the Czech Republic (11.3/100,000 males, 6.7/100,000 females); the lowest ones, excluding Albania, were observed in Portugal (5.8/100,000 males) and Bulgaria (3.1/100,000 females).

In conclusion, therefore, the present comprehensive analyses o f digestive tract cancer mortality rates confirm the steady decline in gastric cancer mortality, together with the persistence of substantially high rates in Eastern Europe (and Portugal). They also indicate that trends for colorectal cancer have become relatively favourable in several European countries, mostly for women, from the mid 1990's onwards. Likewise, the earlier rise for oral and pharyngeal, and oesophageal cancers in males have tended to level of f from the early 1990's onwards. While trends for liver cancer are extremely difficult to interpret, mortality from pancreatic cancer remains upwards in several (though not all) European countries.

468 Volume 31 - N ~ 4 - 2001 Acta Endoscopica

Documents

Cancers du tractus digestif: données épidémiologiques et tendances en Europe