Cancer prevalence in Northern Europe: the EUROPREVAL study

T. Möller1,+, H. Anderson1, T. Aareleid2, T. Hakulinen3, H. Storm4, L. Tryggvadottir5, I. Corazziari6 and E. Mugno7,§

1 Department of Cancer Epidemiology, Lund University, and Regional Tumour Registry, Lund University Hospital, Lund, Sweden; 2 Department of Epidemiology and Biostatistics, Institute of Experimental and Clinical Medicine, and Estonian Cancer Registry, North Estonian Regional Hospital Foundation, Tallinn, Estonia; 3 Finnish Cancer Registry and Department of Public Health, University of Helsinki, Helsinki, Finland; 4 Department of Cancer Prevention and Documentation, Danish Cancer Society, Copenhagen, Denmark; 5 Icelandic Cancer Registry, Reykjavik, Iceland; 6 Department of Epidemiology and Biostatistics, Istituto Superiore di Sanita, Roma; 7 Division of Epidemiology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy

Received 10 January 2002; revised 31 January 2003; accepted 24 February 2003


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Background:

Information on cancer prevalence is of importance for health planning and resource allocation, but is not always available. In order to obtain such data in a comparable way a systematic evaluation of cancer prevalence in Europe was undertaken within the EUROPREVAL project.

Patients and methods:

Standardised data were collected from 38 population-based registries on almost 3 million cancer patients diagnosed between 1970 and 1992. The prevalence of 11 specific cancer types was estimated at the index date of 31 December 1992. This study deals with the northern countries Denmark, Estonia, Finland, Iceland and Sweden.

Results:

There were large differences between these countries, Sweden having the highest prevalence rate of 3050 per 100 000 and Estonia the lowest, 1339 per 100 000. This difference is mainly due to a high proportion of cancers with favourable prognosis such as breast cancer, prostate cancer and melanoma, better survival and longer life expectancy in Sweden, whereas Estonia has a higher proportion of stomach and lung cancer with poor prognosis, worse survival and much shorter life expectancy, especially for males. For most tumour types, the Nordic countries did better than Estonia. There are indications that cancer patients in Estonia, as well as in Denmark, have a more advanced stage at diagnosis and that the Estonian health-care system is less efficient.

Conclusions:

Despite many similarities and a common historical background, the northern countries in Europe that participated in the EUROPREVAL study display quite different cancer patterns and prevalence. Reasons for these variations are discussed.

Key words: cancer, EUROPREVAL study, incidence, Northern Europe, prevalence, survival


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Information on cancer prevalence is of importance for health planning and resource allocation, but is not always available. In order to obtain such data in a comparable way a systematic evaluation of cancer prevalence in Europe was undertaken within the EUROPREVAL project. The methodology and results have been published recently [1, 2].

Northern European countries participating in the EUROPREVAL study are Denmark, Estonia, Finland, Iceland and Sweden (four out of the five Nordic countries and the northernmost of the three Baltic countries). Except for Iceland, they are located around the Baltic Sea (Östersjön). All countries have a long history of close relations. The four Nordic countries share a common cultural background, but Estonia has been strongly influenced by Russia since 1940 when it was annexed by the Soviet Union. It regained its independence in 1991. Danish, Icelandic and Swedish originate from a common language spoken by the Vikings, while Finnish and Estonian—as well as the language of the Lapps (Sapmis) in the far north—belong to the totally unrelated Finnish–Ugrian language family.

The people in the Nordic countries enjoy a high standard of living. Estonia is now rapidly approaching the same level. Life expectancy is among the highest in the world, being in 1996 in Sweden 76.5 years for males and 81.5 years for females, in Iceland 76.2 and 80.6, in Finland 73.0 and 80.5, and in Denmark 72.6 and 77.8, respectively. Life expectancy is, however, considerably lower in Estonia, at 64.5 years for males and 75.5 years for females [3].

The health-care systems are similar and nearly totally financed by taxes in all five countries. The private sector plays a minor role. Cancer care is integrated in the general health care. There are no formal cancer hospitals, but for more specialised treatments patients are usually referred to a regional/university hospital. In Estonia, a state-controlled national health-care system prevailed during the study period.

All five countries have a long tradition of cancer registration, Denmark being one of the oldest registries in the world, starting in 1942. In Finland, Iceland and Sweden registration started in 1953, 1954 and 1958, respectively. The Estonian Cancer Registry was officially founded in 1978 but has collected data since 1968. Reporting to all registries but the Icelandic one is compulsory by law. All registries are population-based with a national coverage. However, in this study the Southern Swedish Regional Tumour Registry, encompassing 17% of the Swedish population, represents Sweden. Prevalence figures have been reported from several of the participating registries, as part of the annual reports [4, 5] as well as separately [610].

The aim of this work is to give a unified estimation and presentation of prevalence figures for Denmark, Estonia, Finland, Iceland and Sweden in a way comparable to figures presented in separate papers from other European areas participating in the EUROPREVAL project [11]. Eleven types of cancer have been considered: stomach, colon, rectum, lung, melanoma, breast, uterine cervix, uterine corpus, prostate, Hodgkin’s disease, leukaemias and all malignancies combined (excluding non-melanoma skin tumours, which were not included in the EUROCARE database).


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Data sources
The registries cover a total population of ~13 million, with Denmark and Finland accounting for ~5 million each, South Sweden and Estonia 1.5 million each, and Iceland 250 000. The age structure of the countries is quite different, with Iceland and Estonia having the youngest population while South Sweden has the oldest, with a high proportion of persons aged ≥65 years. Data were collected during the period 1978 to 1992, except for Iceland where data were collected during 1970–1992.

All five cancer registries provided incidence and survival data needed to estimate prevalence. The study is based on 661  000 incident cases. All registries assured complete follow-up for vital status at least until 31 December 1992, which is the index date for the estimation of prevalence.

Incidence figures are quoted from Cancer Incidence in Five Continents—Volume VII as age-standardised (world standard population) rates per 100  000 person years for the time period 1988–1992 (for Finland 1987–1992) [12]. Survival figures are the age-standardised 5-year relative survival rates reported in the EUROCARE II study of the time period 1978–1989 [13, 14].

Calculation of prevalence and validation
Total prevalence is the number of all incident cases living at a given date. The general method to estimate prevalence in the EUROPREVAL studies is by means of the completeness index, R(L). This factor adjusts the observed prevalence NO(L) for a certain diagnosis, sex and age class in a population covered by cancer registration for a limited number of years, L. The total prevalence is estimated by NT(e) = NO(L)/R(L), where R(L) is based on models for incidence and survival for the cancer diagnosis under study. For incidence, logistic functions of age, adjusted for birth cohort, were used. For survival, so-called cure models were used, in which a proportion of the patients is assumed to be cured and have the same mortality as the general population. The survival of the non-cured patients was modelled using a Weibull distribution including coefficients for age and period. By means of the models, incidence and survival have been predicted for calendar years before cancer registration started. For a comprehensive account of the methodology, see Capocaccia et al. [1].

Prevalence is also presented by time since diagnosis, and then the cases diagnosed within a certain time before the index date are included. The largest time considered is 15 years, coinciding with the number of years that the registers contributed incidence data. Hence, prevalence by time since diagnosis was determined by the direct method.

The paper by Capocaccia et al. [1] also contains a validation section using the fact that some of the registries included in the present study have been in operation for a long time, e.g. Denmark and Finland. The estimated number of prevalent cases for various diagnoses was compared with the directly observed numbers. For the studied diagnoses the estimated prevalences were in the range of 87–107% of the observed. The relatively lower estimated values may be explained by multiple tumours not included in the estimated values. For cancer of the cervix and Hodgkin’s disease the discrepancy was larger, though, and hence only 15-year prevalences are presented for these diagnoses.

Special study of the effect of multiple tumours
The prevalence estimates in the EUROPREVAL study are based only on the first registered malignant tumour for an individual. Thus, when estimating the prevalence of a certain type of cancer, cases are not included if they have been preceded by another malignancy. To study the effect of multiple tumours, we have for South Sweden estimated the prevalence of the various cancer types by the direct method in two ways. First, we only considered the first malignant diagnosis in the period 1958–1992, and secondly we considered the first tumour of the respective studied diagnoses, disregarding other previous malignancies. The latter estimates (also individual-based) will be larger, especially for diagnoses that occur in older patients.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Cancer prevalence is presented by cancer site. Since these figures depend on cancer incidence and survival, the results should be viewed in the light of incidence and survival figures for each particular site. These figures can be found in Micheli et al. [2]. Since the main aim of estimating prevalence is to describe the cancer burden and its effects on the health-care system and society in general, the prevalence rates are not age-standardised. Age distribution is thus also an important determinant of prevalence.

Total cancer prevalence in Northern Europe by country, age class and cancer site is given in Table 1A for men and Table 1B for women, and also illustrated in Figures 1 and 2. The combined group ‘northern countries’ is calculated from population-unweighted rates. Hence, these prevalence rates are slightly underestimated since only one-fifth of Sweden (which has a high prevalence) is included.


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Table 1A. Total prevalence proportion per 100 000 by country, age class (years) and cancer site (ICD9 code) in men
 

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Table 1B. Total prevalence proportion per 100 000 by country, age class (years) and cancer site (ICD9 code) in women
 


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Figure 1. Total prevalence by site and country: males.

 


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Figure 2. Total prevalence by site and country: females.

 
All malignant neoplasms
Total prevalence for all types of malignant disease (except non-melanoma skin tumours, ICD9 173) and men and women combined, is highest in South Sweden with 3047 per 100  000, followed by Denmark with 2389, Iceland with 2018, Finland with 1867 and Estonia with 1339. The order is the same for both genders separately. For men aged 0–44 years, Denmark has the highest prevalence, closely followed by South Sweden, while for men aged 45–64 years Sweden, Iceland and Denmark have approximately the same level. In all age groups for both genders separately, Finland and especially Estonia show lower prevalence rates. The prevalence rates for all sites are in all countries significantly higher for females than for males, especially in the age group 45–64 years.

The almost three-fold difference in total prevalence between Sweden and Estonia is attributable to a better survival, higher incidence of tumours with favourable prognosis such as prostate, breast and melanoma, and longer life expectancy in Sweden, in contrast to Estonia’s higher proportion of cancers with poor prognosis such as stomach and lung cancer, and much shorter life expectancy, especially in males. The high total cancer incidence in Denmark does not result in the highest prevalence, mainly due to worse survival.

Stomach (ICD9 151)
Stomach cancer constitutes 4% of total prevalence in males in the northern countries and 2% of female cases. For males, Estonia and Iceland have almost identical highest prevalence figures (101), Sweden and Finland intermediate (71), and Denmark the lowest (31). For females the pattern is essentially the same, with a range of 100 in Estonia to 22 in Denmark.

Colon and rectum (ICD9 153 and 154)
Cancer of the large bowel and rectum account for 14% of prevalent cases in males and 10% in females in the northern countries. This tumour shows a different pattern compared with stomach cancer; the highest prevalence rates for both men and women being observed in South Sweden and the lowest rates in Estonia, with a three-fold difference for colon and a two-fold difference for rectum.

Lung (ICD9 162)
For men, lung cancer makes up 7% of all prevalent cases in northern countries. The highest prevalence rates are observed in Finland (131), followed by Denmark (113) and Estonia (101), while Sweden and Iceland have the lowest figures (82 and 70, respectively). In contrast to this, prevalence for the age group 0–44 years is highest in Iceland. For women, it constitutes 1% of all prevalent cases in northern countries, the highest prevalence being observed in Iceland (67), followed by Denmark (58) and Sweden (38). In the two younger age groups, the prevalence in females is highest in Iceland.

Melanoma (ICD9 172)
Melanoma accounts for 6% of total cancer prevalence in northern countries in both genders. Melanoma prevalence shows a very distinctive pattern with the highest rates for men as well as for women, in all age groups and total, in South Sweden. In men, the figures are almost 10-fold higher than the figures for Estonia with the lowest prevalence (175 versus 20), and for women a five-fold difference (282 versus 51) is observed.

Breast (ICD9 174)
Prevalence figures have only been estimated for women, in whom this cancer accounts for 34% of all prevalent cases in the northern countries. Denmark and South Sweden show the highest prevalence rates and also have similar age patterns. In the age group 0–44 years, Denmark has the highest prevalence (101), in the age group 45–64 years Iceland has the highest prevalence (2040), and in the age group ≥65 years as well as all ages combined, Sweden has the highest prevalence (3632 and 1213, respectively).

Cervix uteri (ICD9 180)
As mentioned in the Patients and methods section above, figures for cervix uteri refer to prevalence at 15 years from diagnosis. This constitutes 4% of total female prevalence in northern countries. The highest 15-year prevalence figures, for all ages, are observed in Denmark (186), followed by Estonia (142). Finland has the lowest figures for all ages combined (39) as well as for the individual age groups.

Corpus uteri (ICD9 182)
For this diagnosis, accounting for 10% of all prevalent female cancer cases in the northern countries, the variation in prevalence between the countries is less pronounced, Denmark showing the highest rate (308) and Iceland the lowest (186). The incidence is almost the same in all countries (12.0–14.7) but survival is different, with 65% in Estonia, around 75% in Denmark, Finland and Iceland, and 82% in Sweden. The apparent discrepancy in total prevalence for all ages between Iceland and Denmark in spite of similar incidence and survival probably depends on the age distribution, with Iceland having a much younger population.

Prostate (ICD9 185)
Cancer of the prostate accounts for 17% of total prevalence in males in the northern countries. Great variability is observed, with the highest prevalence figure for all ages combined in South Sweden (575) and the lowest in Estonia (83). As expected, the figures for the age group ≥65 years are very high with similar levels in Sweden and Iceland (3406 and 3656, respectively) but considerably lower levels in Finland (2355), Denmark (1580) and especially Estonia (841).

Hodgkin’s disease (ICD9 201)
For both genders, Hodgkin’s disease only accounts for a minor proportion of total prevalence, 2% in males and 1% in females. As mentioned above, only 15-year prevalences are considered. For males Iceland and Denmark have the highest prevalence rates (28 for both), and Estonia the lowest (18). Female prevalence, all ages combined, is highest in Finland and Denmark (18 for both) and lowest in Iceland (12).

Leukaemia (ICD9 204–208)
Leukaemias contribute little to total prevalence: 3% in males and 1% in females. South Sweden and Denmark show the highest prevalence figures for men (53 and 47, respectively) and women (42 and 37, respectively). The lowest rates are found in Iceland both for men (30) and women (23).

Prevalence pattern by time since diagnosis
As shown in Table 2A and 2B, and also illustrated by Micheli et al. [2], the cumulative prevalence rates increase with time period since diagnosis, i.e. the longer the inclusion time of surviving patients the higher the rates.


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Table 2A. Prevalence by time since diagnosis, cancer site and country (prevalence proportions per 100 000 and percentage of total prevalence in men)
 

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Table 2B. Prevalence by time since diagnosis, cancer site and country (prevalence proportion per 100 000 and percentage of total prevalence in women)
 
The highest diagnosis-specific 1-year prevalence in males in the northern countries is noted for lung cancer (30%), measured as the proportion of total lung cancer prevalence, due to the poor prognosis of this tumour with relatively few long-term survivors. In contrast, the lowest 1-year prevalence proportion is found for Hodgkin’s disease (10%), which mainly occurs at a young age and has a good prognosis. In females, the highest 1-year prevalence proportion is also found for lung cancer (33%) and the lowest for melanoma (7%).

An example of using these rates to estimate the proportion of patients in different stages of their disease process is given in the Discussion section below.

The difference between 15-year prevalence and total prevalence is a plausibility measure since the 15-year prevalence is directly observed and the total prevalence a result of modelling. The largest difference between these two rates for males is found in stomach cancer and lung cancer (23%), while the smallest (disregarding Hodgkin’s disease, where no total prevalence was calculated) is seen in prostate cancer (3%). This is explained by prostate cancer usually occurring at an older age and thus patients surviving 15 years or more after diagnosis are few. For females, the largest difference between 15-year prevalence and total prevalence rates is found in melanoma (27%) and corpus uteri (26%), and the smallest difference between these rates (disregarding Hodgkin’s disease and cervix cancer) is seen for leukaemia (7%).

The effect on prevalence of multiple tumours
A separate analysis of the material from South Sweden showed that 92.3% of the patients had one cancer diagnosis only, 6.9% had two diagnoses, 0.7% three and 0.1% four or more. Thus, calculating prevalence based on all index tumours instead of index tumour as first or only tumour implies a higher prevalence figure, especially for tumours occurring in older age groups. This effect is illustrated in Table 3. The effect increases with age, and for the age group ≥65 years the prevalence figures for separate diagnoses are in the order of 10% higher.


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Table 3. Increase in total prevalence considering all index tumours relative to prevalence based on index tumour or first tumour (%) by age group (years), gender and cancer site; data from South Sweden
 

    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
The countries representing Northern Europe in the EUROPREVAL study have different cancer incidence patterns. Denmark and Sweden have a similar and more western type with a high total incidence, high incidences of colo-rectal cancer, breast cancer, melanoma and leukaemia, and low incidence of stomach cancer. However, Denmark also has high incidences of lung and cervical cancers. Estonia, on the other hand, shows a more typical eastern type with high incidences of stomach, lung and cervix cancers, and low incidences of cancer of the rectum, breast and prostate, and melanoma. The patterns in Finland and Iceland are more mixed.

Since the Southern Health Care Region represents Sweden in this study, it is of importance to note that the difference in incidence between South Sweden and all Sweden for most tumour sites is marginal (<10%). Higher incidence rates in South Sweden are observed in males for all sites combined (+12%), colon (+20%) and lung (+20%), and higher rates are found in females for rectum (+13%) and lung (+13%), and lower rates for stomach (–11%) [15]. The incidence pattern in South Sweden thus has certain similarities with that of Denmark.

The incidence pattern reflects to a certain extent some basic properties of the society, such as life-style factors, population awareness, and the presence of screening programmes and accessibility of health care. One of the most important life-style factors is smoking. The proportion of daily smokers among adult males is smallest in Sweden (17%) and greatest in Estonia (45%), and among females smallest in Estonia with 15% and greatest in Denmark with 35%. Thus, Estonia has a high incidence of male lung cancer and Denmark a high incidence of female lung cancer, while Estonia’s low proportion of female smokers is reflected in a low incidence of female lung cancer [16, 17]. The peculiar Swedish habit of using moist snuff raises the consumption of nicotine in Sweden to the same level as that in Denmark but it has not been shown to be carcinogenic [18, 19]. The sun-bathing and tanning habits of the Swedish and Danish populations, such as frequent leisure trips to Mediterranean countries and use of sunbeds, have contributed to a high incidence of malignant melanoma in these countries [20, 21].

Change in incidence over time also influences prevalence since it reflects the cumulative effects of incidence and survival over many years. In all countries, stomach cancer is declining. Declining incidence is also seen in cervical cancer in Finland, Iceland and Sweden, which is attributable to screening being introduced in these countries in the 1960s [22]. A screening programme was also introduced in Denmark in the 1970s, lowering the incidence considerably, although it is still high. Organised screening has never been introduced in Estonia and the incidence of invasive cervical cancer is 3.5-fold higher than in Finland [23].

The introduction of screening with mammography on a nation-wide level in Finland and Sweden around 1990 resulted in an increase in breast cancer incidence in the last part of the study period [24]. Since the data in this study are collected only from South Sweden, the Malmö screening trial, which started in 1976, might have a small impact on the figures [25].

Low incidence and survival of patients with prostate cancer in Estonia diagnosed between 1985 and 1989 reflects a large proportion of advanced cases compared to other Nordic countries with higher diagnostic activity, except in Denmark [10, 26]. Since the early 1990s a dramatic increase in incidence has been observed in Estonia as well as in the Nordic countries. This is explained mainly by the use of prostate-specific antigen as an opportunistic screening method.

The majority of the other cancer types also show increasing trends [27]. Lung cancer incidence in Sweden has levelled out and even started to decline in males, while the incidence in females is rising at a high rate [5].

Survival also varies between the countries. Finland, Iceland and Sweden have some of the highest 5-year relative survival figures in Europe, while Denmark has about 10 and Estonia about 20 percentage units lower 5-year relative survival rates [13, 28]. In a Nordic study it was shown that survival of Danish cancer patients was initially about the same as that of cancer patients in the other Nordic countries, but in the early 1970s survival in Denmark started to lag behind the improvement in survival noted in the other Nordic countries. This was especially marked for cancer of the stomach, colon, rectum, lung, breast and prostate, but not for cervix, corpus uteri and melanoma [11]. Analysis of time trends in cancer mortality in Estonia for 1965–1989 showed an increase of 12% in males but a decrease of 5% in females [29].

The specific cancer sites included in this study account for approximately one-half of the total prevalence in males and two-thirds in females. All of these cancer types, except Hodgkin’s disease and leukaemia, have surgery as the main treatment modality, in some sites (rectum, lung, breast, cervix, corpus and prostate) often combined with radiotherapy. The ultimate outcome of treatment—survival—is a function of patient’s awareness and delay in seeking medical advice and the efficient functioning of the health-care system, from primary care to highly specialised treatments. For several of the cancer types in this study, there are indications that a high proportion of patients in Denmark and Estonia have advanced disease at diagnosis [30, 31]. This explains, at least to a certain extent, the lower survival rates observed in these countries. Inefficiencies in the functioning of the health-care system and shortage of resources are also important factors. For example, the availability of diagnostic equipment such as computed tomographic scanners (CTs) and magnetic resonance imaging units (MRIs) was very low in 1990 in Estonia, with 1.3 (n = 2) and 0 per million inhabitants, respectively, in comparison with 12.2 (n = 104) CTs per million in Sweden and 4.0 MRIs per million in Iceland (A. Micheli, personal communication; data collected in a project on survival in elderly cancer patients in Europe). In a study of radiotherapy resources and productivity during 1987 in the Nordic countries, it was concluded that Denmark (and Norway) probably did not provide adequate levels of radiotherapy to their cancer patients [32]. A study of Estonian immigrants to Sweden showed a much better survival in patients with cancer of the colon, lung, breast or prostate than in Estonian patients living in Estonia. The differences were attributed to delay in diagnosis, inferior treatment and inefficiencies in the public health-care system in Estonia [33].

Cancer prevalence is a measure of the number of patients handled by the health-care system at a given time. It is a mix of newly diagnosed patients undergoing primary treatment, patients being treated for recurrent disease or in need of palliative care, as well as patients without signs and symptoms of active disease. An approach to estimate the size or proportion of these groups of patients is to study prevalence after time of diagnosis for the different cancer types. One-year prevalence, i.e. all patients diagnosed within 1 year before index date and alive at that date, may be taken as a proxy measure of the need for primary treatment, except for cancer types with very short survival such as lung cancer. After initial treatment patients are usually subject to follow-up for up to 5 years, during which time span most recurrences appear. This fraction can be estimated by subtracting 1-year prevalence from the 5-year prevalence. The proportion of ‘cured’ patients may be estimated as total prevalence minus 5-year prevalence for most tumours.

If this formula is applied to corpus cancer, for example, it can be estimated that of all prevalent corpus cancer cases in the northern countries at the index date 8% are undergoing primary treatment, 24% are in the phase of follow-up or treatment for recurrent or advanced disease, and 68% of cases have survived more than 5 years after diagnosis and thus probably are cured and not a ‘burden’ to the health-care system (Table 2B).

The difference between estimating prevalence on first tumour only and on all tumours diagnosed in a patient is small and in most cases <10%. Higher values are, as expected, seen in the age group ≥65 years (Table 3). This is explained by the fact that elderly patients have a higher chance of getting multiple tumours. It is especially obvious for tumour types occurring at an older age, such as cancers of the gastointestinal tract and prostate. Of interest is the marked difference in females aged ≥65 years with lung cancer. These results are in good agreement with those presented by Capocaccia et al. [1].

With increasing life expectancy, increasing incidence rates, and better survival—due not only to lead-time bias in screening-detected cancers and earlier diagnosis of other cancers, but also improved treatment being available to all patients—the prevalence rates inevitably will increase markedly. In a Swedish study it was estimated that of the increase in prevalence from 1961 to 1995, 45% could be attributed to population dynamics (ageing and growth), 30% to better survival and 25% to increasing incidence [34]. The authors conclude: "The health-care system is faced with ever increasing numbers of cancer patients. But from the point of view of health monitoring, the increase in cancer prevalence is mainly driven by what could be called ‘good forces’, i.e. better chances of surviving cancer, and increased general life expectancy."


    Acknowledgements
 
The Estonian participation was supported by the Estonian Science Foundation, and participation of the Southern Swedish Regional Tumour Registry was supported by grants from Region Skåne.

The EUROPREVAL Working Group consists of the following members. Austria: W. Oberaigner (Cancer Registry of Tyrol). Denmark: H. Storm, G. Engholm (Danish Cancer Society Institute of Cancer Epidemiology). Estonia: T. Aareleid (Estonian Cancer Registry). Finland: T. Hakulinen (Finnish Cancer Registry). France: G. Hédelin (Bas-Rhin Cancer Registry); H. Lefevre (Calvados Digestive Cancer Registry); J. Mace-Lesec’h (Calvados General Cancer Registry); J. Faivre (Côte d’Or Digestive Cancer Registry); G. Chaplain (Côte d’Or Gynaecologic Cancer Registry); P. M. Carli (Côte d’Or Malignant Haemopathies Registry); P. Arveux (Doubs Cancer Registry); J. Estève (University of Lyon); M. Colonna (Isère Cancer Registry); N. Raverdy, P. Jun (Somme Cancer Registry). Germany: J. Michaelis (German Registry of Childhood Malignancies); H. Ziegler, C. Stegmaier (Saarland Cancer Registry). Iceland: L. Tryggvadottir (Icelandic Cancer Registry). Italy: R. Capocaccia (Project Leader); I. Corazziari, R. De Angelis, S. Francisci, S. Hartley, F. Valente, A. Verdecchia, A. Zappone (National Institute of Health, Rome); F. Berrino, G. Gatta, A. Micheli, E. Mugno, M. Sant (National Institute for the Study and Cure of Tumors, Milan); P. Crosignani (Lombardy Cancer Registry); E. Conti (Latina Cancer Registry); M. Vercelli, C. Casella, A. Puppo (Liguria Cancer Registry, NCI, Genova); M. Federico (Modena Cancer Registry); M. Ponz De Leon (Modena Colorectal Cancer Registry); V. De Lisi (Parma Cancer Registry); R. Zanetti (Piedmont Cancer Registry); C. Magnani (Piedmont Childhood Cancer Registry); L.Gafà (Ragusa Cancer Registry); F. Falcini (Romagna Cancer Registry); E. Paci, E. Crocetti (Tuscany Cancer Registry); S. Guzzinati (Venetian Cancer Registry). Poland: J. Rachtan (Cracow Cancer Registry); M. Bielska-Lasota (Warsaw Cancer Registry). Slovakia: I. Plesko (National Cancer Registry of Slovakia). Slovenia: V. Pompe-Kirn (Cancer Registry of Slovenia). Spain: I. Izarzugaza (Basque Country Cancer Registry); A. Izquierdo (Girona Cancer Registry); C. Martinez-Garcia (Granada Cancer Registry); I. Garau (Mallorca Cancer Registry); E. Ardanaz, C. Moreno (Navarra Cancer Registry); J. Galceran (Tarragona Cancer Registry); V. Moreno (Catalan Institute of Oncologia). Sweden: T. Möller, H. Anderson (Southern Swedish Regional Tumour Registry). Switzerland: J. Torhorst (Basel Cancer Registry); C. Bouchardy, J. M. Lutz, M. Usel (Geneva Cancer Registry); J. E. Dowd (WHO, Geneva). The Netherlands: J. W. W. Coebergh, M. Janssen-Heijnen (Eindhoven Cancer Registry); R. A. M. Damuhis (Rottermam Cancer Registry). Scotland: R. Black, V. Harris, D. Stockton (Scottish Cancer Intelligence Unit). UK: T. W. Davies (East Anglian Cancer Registry); M. P. Coleman, S. Harris (London School of Hygiene and Tropical Medicine); E. M. I. Williams (The Merseyside and Cheshire Cancer Registry); D. Forman, R. Iddenden (Northern and Yorkshire Cancer Registry and Information Service & Centre for Cancer Research); M. J. Quinn (Office for National Statistics); M. Roche (Oxford Cancer Intelligence Unit); J. Smith (South and West Cancer Intelligence Unit); H. Moller (Thames Cancer Registry); P. Silcocks (Trent Cancer Registry); G. Lawrence, K. Hemmings (West Midlands Cancer Intelligence Unit).


    Footnotes
 
+ Correspondence to: Dr T. Möller, Department of Cancer Epidemiology, Lund University, Regional Tumour Registry, Lund University Hospital, SE-221 85 Lund, Sweden. Tel: +46-46-17-75-50; Fax: +46-46-18-81-43; E-mail: torgil.moller{at}cancerepid.lu.se Back

§ Members of the EUROPREVAL Working Group are listed in the Acknowledgements. Back


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
1. Capocaccia R, Colonna M, Corazziari I et al. Measuring cancer prevalence in Europe: the EUROPREVAL project. Ann Oncol 2002; 13: 831–839.[Abstract/Free Full Text]

2. Micheli A, Mugno E, Krogh V et al. Cancer prevalence in European registry areas. Ann Oncol 2002; 13: 840–865.[Abstract/Free Full Text]

3. Statistics Yearbook of Sweden 2000. Stockholm: Statistics Sweden 2000.

4. Cancer Incidence in Denmark 1996. Sundhetsstatistikken 1999: 3. Köbenhavn: Danish National Board of Health 1999.

5. Cancer Incidence in Sweden 1997. Stockholm: The Cancer Registry, Centre for Epidemiology, The National Board of Health and Welfare 1999.

6. Hakama M, Hakulinen T, Teppo L, Saxén E. Incidence, mortality or prevalence as indicators of the cancer problem. Cancer 1975; 36: 2227–2231.[ISI][Medline]

7. Adami H-O, Gunnarsson T, Sparén P, Eklund G. The prevalence of cancer in Sweden 1984. Acta Oncol 1989; 28: 463–470.[ISI][Medline]

8. Hakulinen T, Kenward M, Luostarinen T et al. Cancer in Finland 1958–2008. Incidence, mortality and prevalence by county (Cancer Society of Finland Publication no. 42). Helsinki: Finnish Cancer Registry and Finnish Foundation for Cancer Research 1989.

9. Engeland A, Haldorsen T, Tretli S et al. Prediction of cancer mortality in the Nordic countries up to the years 2000 and 2010, on the basis of relative survival analysis. Acta Pathol Microbiol Immunol Scand 1995; 103 (Suppl 49).

10. Thomson H, Rahu M, Aareleid T, Gornoi K. Cancer in Estonia 1968–1992—Incidence, mortality, prevalence, survival. Tallinn: Institute of Experimental and Clinical Medicine 1996.

11. Verdeccia A, Micheli A, Colonna M, Izarzugaza M. A comparative analysis of cancer prevalence in cancer registry areas of France, Italy and Spain. Ann Oncol 2002; 13: 1128–1139.[Abstract/Free Full Text]

12. Parkin DM, Whelan SL, Ferlay J et al. (eds). Cancer Incidence in Five Continents—Volume VII. IARC Scientific Publication no. 143. Lyon: International Agency for Research on Cancer 1997.

13. Berrino F, Capocaccia R, Estève J et al. (eds). Survival of cancer patients in Europe: The EUROCARE II study. IARC Scientific Publication no. 151. Lyon: International Agency for Research on Cancer 1999.

14. Coebergh JW, Sant M, Berrino F, Verdeccia A (eds). Survival of adult cancer patients in Europe diagnosed from 1978–89: The EUROCARE II study. Eur J Cancer 1998; 34 Special Issue.

15. Cancer Incidence in Southern Sweden 1988–92. Lund: Oncological Centre 1994.

16. Health Statistics in the Nordic Countries 1997. København: Nordisk Medicinalstatistisk Komité 1999.

17. Lipand A, Kasmel A, Kivilo M et al. Health Behaviour Among Estonian Adult Population, spring 1990. Publication B1/1992. Helsinki: National Public Health Institute 1992.

18. Lewin F, Norell SE, Johansson H et al. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer 1998; 82: 1367–1375.[CrossRef][ISI][Medline]

19. Schildt EB, Eriksson M, Hardell L, Magnusson A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case–control study. Int J Cancer 1998; 77: 341–346.[CrossRef][ISI][Medline]

20. Westerdahl J, Olsson H, Ingvar C et al. Southern travelling habits with special reference to tumour site in Swedish melanoma patients. Anticancer Res 1992; 12: 1539–1542.[ISI][Medline]

21. Westerdahl J, Olsson H, Måsbäck A et al. Use of sunbeds or sunlamps and malignant melanoma in southern Sweden. Am J Epidemiol 1994; 140: 691–699.[Abstract]

22. Hakama M. Trends in the incidence of cervical cancer in the Nordic countries. In Magnus K (ed): Trends in Cancer Incidence. Causes and Practical Implications. Washington, DC: Hemisphere 1982; 279–292.

23. Aareleid T, Pukkala E, Thomson H, Hakama M. Cervical cancer incidence and mortality trends in Finland and Estonia: a screened vs. an unscreened population. Eur J Cancer 1993; 239: 745–749.

24. Hakama M, Pukkala E, Söderman B, Day N. Implementation of screening as a public health policy: issues in design and evaluation. J Med Screen 1999; 6: 209–216.[ISI][Medline]

25. Andersson I, Andrén L, Hildell J et al. Breast cancer screening with mammography: a population-based, randomized trial with mammography as the only screening mode. Radiology 1979; 132: 273–276.[Abstract]

26. Tretli S, Engeland A, Haldorsen T et al. Prostate cancer—look to Denmark? JNCI 1996; 88: 128.

27. Engeland A, Haldorsen T, Tretli S et al. Prediction of cancer incidence in the Nordic countries up to the years 2000 and 2010. A collaborative study of the five Nordic cancer registries. Acta Pathol Microbiol Immunol Scand Suppl 1993; 38: 1–124.

28. Leinsalu M, Rahu M. Time trends in cancer mortality in Estonia, 1965–1989. Int J Cancer 1993; 53: 914–918.[ISI][Medline]

29. Engeland A, Haldorsen T, Dickman P et al. Relative survival of cancer patients: A comparison between Denmark and the other Nordic countries. Acta Oncol 1998; 37: 49–59.[CrossRef][ISI][Medline]

30. Aareleid T, Rahu M. Cancer survival in Estonia 1978 to 1987. Cancer 1991; 68: 2088–2092.[ISI][Medline]

31. Karjalainen S, Aareleid T, Hakulinen T et al. Survival of female breast cancer patients in Finland and in Estonia: stage at diagnosis important determinant of the difference between countries. Soc Sci Med 1989; 28: 233–238.[CrossRef][ISI][Medline]

32. Lote K, Möller T, Nordman E et al. Resources and productivity in radiation oncology in Denmark, Finland, Iceland, Norway and Sweden during 1987. Acta Oncol 1991; 30: 555–561.[ISI][Medline]

33. Nilsson B, Gustavson-Kadaka E, Hakulinen T et al. Cancer survival in Estonian migrants to Sweden. J Epidemiol Community Health 1997; 51: 418–423.[Abstract]

34. Stenbeck M, Rosén M, Sparén P. Causes of increasing cancer prevalence in Sweden. Lancet 1999; 354: 1093–1094.[CrossRef][ISI][Medline]





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