1 Cancer Epidemiology Unit and Cancer Registries of Vaud and Neuchâtel, Institut Universitaire de Médecine Sociale et Préventive, Lausanne, Switzerland; 2 Laboratory of Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Milan; 3 Istituto di Statistica Medica e Biometria, Università degli Studi di Milano, Milan, Italy
*Correspondence to: Dr F. Levi, Cancer Epidemiology Unit and Cancer Registries of Vaud and Neuchâtel, Institut Universitaire de Médecine Sociale et Préventive, CHUV-Falaises 1, 1011 Lausanne, Switzerland. Fax: +41-21-323-03-03; Email: fabio.levi{at}inst.hospvd.ch
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Abstract |
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Introduction |
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Tobacco smoking is strongly related to renal pelvis carcinomas, but alsoalthough less stronglyto renal cell carcinomas [25
]. Obesity is another major recognised risk factor for renal cell carcinomas [1
, 3
, 4
, 6
]. The role of other factors, including phenacetin, diuretics and calcium channel blockers [7
, 8
], diet (i.e. a protective role of vegetables and fruit, and an association with meat, fats and protein) [1
, 9
, 10
], alcohol drinking [11
13
] and selected occupations (i.e. cadmium, dry cleaning workers [1
, 4
]) has also been reported, but quantification of its impact on national mortality rates remains undefined [14
, 15
].
Between the mid-1950s and the late 1980s, mortality from kidney cancer increased substantially across Europe. The average rise between 1955 and 1989 was 73% in men and 48% in women, and corresponding figures in the late 1980s were 17% in men and 16% in women [16]. Incidence of renal cell cancer also rose between 1975 and 1990 in the USA [17
, 18
].
In the early 1990s, however, some levelling or decline in kidney cancer rates has been observed in Sweden and other Scandinavian countries, France and Switzerland, mostly in men [1921
].
To further monitor recent trends in Europe, we examined the trends in mortality observed in various European countries over the last two decades.
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Patients and methods |
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For this analysis we considered recent trends in mortality from kidney cancer for 27 individual European countries and the 15 countries of the European Union (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands, Portugal, Spain, Sweden and the UK). Since, up to 1989, data were only available for former Yugoslavia as a whole, it was not possible to provide long-term trends for Croatia, Slovenia and other former Yugoslavia countries.
In the 1980s most countries used the ninth revision of the International Classification of Diseases (ICD), although some were still using the eighth revision, and from 1995 onwards some countries had adopted the tenth revision. Since differences between various revisions were minor, kidney cancer deaths were re-coded for all countries according to the ninth revision of the ICD (ICD-9: 189 [22]).
From the matrices of certified deaths and resident population, age-standardised rates (in 5-year age groups) at all ages and at ages 3564 years were computed, on the basis of the world standard population.
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Results |
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Discussion |
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Tobacco smoking is the single best recognised risk factor for kidney cancer, and particularly for renal pelvis neoplasms, the RR being over 2 for smoking, with a proportional attributable risk of about one-quarter of cancer in men and 10% in women in developed countries [1, 14
16
, 24
]. Thus, the decline in smoking prevalence in men over the last few decades [25
] in most of western Europe may explain, at least in part, the decline in kidney cancer rates. The pattern of tobacco consumption across Europe can also explain the less favourable trends registered in central and eastern European countries, with rising smoking prevalence and consumption and, consequently, rates of tobacco-related diseases have remained higher than in western Europe over the last decade [26
]. Tobacco, however, cannot account for the trends observed in women.
Obesity, the second best recognised risk factor for kidney cancer [1, 6
, 14
, 15
], accounted for >20% of cases in a population from Minnesota [15
]. The prevalence of overweight and obesity is lower in Europe than in the USA [5
, 27
], but overweight and obesity have tended to increase throughout Europe during the last decades, and thus cannot explain the favourable trends observed in mortality from kidney cancer.
Dietary factors may play some role but their influence on renal carcinogenesis remains unclear. Still, a diet poor in fruit and vegetables, and hence in ß-carotene, accounts for 17% of cases in an Italian dataset [14], and several studies found an inverse relation between a diet rich in vegetables and fruit, and kidney cancer [1
, 4
, 9
11
]. A wider availability of fruit and vegetables across Europe over the last few decades may therefore have contributed to the favourable trend in kidney cancer mortality. It is also conceivable that declined exposure to occupational carcinogens has played some role, although the impact of occupational exposures on kidney cancer risk remains unquantified [4
, 28
]. Likewise, better control of urinary tract infections may have favourably influenced kidney cancer rates [1
, 4
, 29
].
At least part of the upward trends observed until the early 1990s may be related to improved diagnosis and certification of the disease, following the introduction of ultrasound, computed tomography and other newer diagnostic techniques. However, the similar pattern of trends in middle age (3564 years) and in the elderly weighs against a major role of changed diagnosis and certification criteria on kidney cancer risk, at least in major eastern and central European countries.
In conclusion, therefore, the present update analysis of kidney cancer in Europe documents and quantifies an appreciable reduction in mortality. The decline in tobacco smoking in men has played a role in these favourable trends, but the potential influence of other factors remains undefined.
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Acknowledgements |
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Received for publication February 13, 2004. Revision received March 2, 2004. Accepted for publication March 3, 2004.
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References |
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