NEWS

Diversity in Cancer Rates, Control Programs Matches Diversity of European Union

Sarah L. Zielinski

The European Union has grown from a group of six countries—that banded together in 1951 to integrate the coal and steel industries of Western Europe—to a much more diverse group of 25 that continues to expand. Although economics may be the backbone of the European Union, groups such as Europe Against Cancer and the International Agency for Research on Cancer (IARC) have tried to unite the entire continent in tackling its cancer burden.

According to IARC, men in Europe have a 29% risk of being diagnosed with a cancer (other than nonmelanoma skin cancer) by age 74, and women have a 20% risk. In 2004, nearly 2.9 million Europeans were diagnosed with cancer and 1.7 million died from the disease. And despite efforts to increase cancer screening and produce better treatments, these numbers are expected to rise as the European population ages. "That will definitely be the biggest challenge," said Matti Rautalahti, M.D., Ph.D., chief medical officer for the Cancer Society of Finland.

But just as the languages and politics differ between—and even within—the countries of Europe, so too do the cancer rates and risk factors and the health systems that treat cancer patients. What these countries have done in the past and are doing now to control cancer and its risk factors is reflected in these widely varying statistics.

In Europe, lung cancer is the most common nonskin cancer and cause of cancer death, accounting for 13.3% of all cases and one-fifth of all cancer deaths in 2004. But incidence and mortality vary geographically, from a high of 65.7 cases and 59.9 deaths per 100,000 men in Eastern Europe in 2002 to a low of 44.3 cases and 40.8 deaths per 100,000 men in Northern Europe. In women, however, the trend is nearly opposite, with incidence and mortality in Northern Europe (21.3 cases and 18.2 deaths per 100,000 women) more than twice that found in Southern and Eastern Europe.

These differences have their roots in the differing histories of the smoking epidemics in the regions. In the former Eastern bloc, for example, although there may have been no advertising, cigarettes were given freely to members of the armies, and there was no antitobacco movement such as those that could be found in the West, said Anna Gilmore, M.B.B.S., clinical lecturer in public health at the European Centre on Health and Societies in Transition at the London School of Hygiene and Tropical Medicine.

For women, however, lung cancer rates in Eastern Europe have been low because "traditionally, female smoking has not [been] seen to be acceptable," said Ruatalahti. But "that is changing," and "women are taking up smoking fast." When the communist governments fell, said Gilmore, the multinational tobacco companies came into these countries, advertising and selling their products, particularly to women. Women started smoking in increasing numbers, and therefore lung cancer mortality rates can be expected to rise in many European countries in coming years.

The European Union, however, has taken several steps to curb the tobacco industry. Tobacco subsidies are being phased out next year, and advertising in print, radio, and the Internet was banned earlier this year. (Television advertising has been banned since the early 1990s.) Former communist countries that have joined the European Union, such as Poland and Hungary, have joined in some of these efforts.

But attitudes may take longer to change. "In general, smoking is still more acceptable in Europe than in much of America," said Gilmore. "I think there are differences, but we're seeing an increase in the number of countries that are passing antismoking laws, and that will change attitudes." In 2004, Ireland banned workplace smoking and Norway outlawed smoking in public places, and this past January, Italy banned indoor smoking.

Although it may take up to two decades for these efforts to affect lung cancer rates, said Rautalahti, smoking rates should begin to drop in only about 5 years. However, there is a need for more programs to both prevent youth smoking and help adults quit smoking, he said.

Also, "some of these countries claim to have good control policies, like Germany, but they're really not so good," said Gilmore. Some have incomplete advertising bans or youth antismoking programs that are ineffective. "Tobacco control policies have got to be comprehensive and they've got to be enforceable," she said.

Many European countries are creating screening programs in attempts to reduce the mortality rates of other cancers, mainly breast and cervical cancers. Unlike the United States, Europeans have not yet adopted colon or prostate cancer screening on a large scale.

Cervical cancer screening programs began as early as the 1960s in several European countries. But at the time, nations had "different views on the potential effectiveness of cervical cancer screening," said Anthony Miller, M.D., professor emeritus from the Department of Public Health Sciences at the University of Toronto. Norwegians, for example, were skeptical and a pilot screening program had only mixed results, whereas in Finland people felt screening had potential and instituted one of the first screening programs. Finland's bet paid off in the form of decreasing cervical cancer rates, said Miller.

Other countries that instituted screening programs around the same time as Finland have also seen big declines in cervical cancer, as much as 4% per year in places like France, Sweden, and Switzerland and more than 2% per year in Denmark and the United Kingdom. But in many places, "people didn't initially believe in it," so they didn't invest in it, said Miller.

One IARC study estimated that screening women aged 35–64 every 3–5 years within high-quality screening programs reduces cervical cancer incidence by at least 80% among those screened. By the end of the 1990s, many other countries, including Norway, or regions within countries had instituted organized screening programs—programs in which women are identified as needing screening, receive appointments and reminders, and receive proper follow-up care after abnormal screening results.

However, none of the programs have yet incorporated human papillomavirus (HPV) testing. HPV testing is an accepted practice as a triage for equivocal cytology results in the United States, said Gary Clifford, Ph.D., of IARC. "I think it's going in the same direction [in Europe as in the United States], just slightly behind," he said.

HPV testing is currently undergoing evaluation in European trials, but its use as a triage method may be limited because many European health practices still rely on a more traditional Pap smear instead of the liquid cytology test—which can be used to test for HPV on the same slide—that is commonly used in the United States, said Clifford.



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Unlike cervical cancer screening, organized breast cancer screening programs were put into place much more quickly when first proposed in the 1980s. These programs also tend to be better organized than the older cervical cancer screening programs, said Miller, because the evidence for breast cancer screening came at a time when governments, like the United Kingdom, were willing to invest the money.

Sweden was the first country to implement a breast cancer screening program, followed by many others in the late 1980s and early 1990s. In 2003, the Resolution on Breast Cancer was passed by the European Union. The legislation calls for setting up breast cancer screening programs based on European guidelines with the goal of reducing breast cancer mortality by 25% by 2008 in addition to reducing disparities in 5-year survival rates between countries. Most E.U. nations have now created at least pilot programs for breast cancer screening, and nearly all of these programs screen women every 2 years starting at age 50.

Breast cancer incidence has tended to be highest in the socioeconomically well-developed countries of Western and Northern Europe, countries where the risk factors for breast cancer—including avoidance or postponement of childbirth and hormone use—are common. This pattern of incidence has influenced where and when screening programs have been instituted, although the availability of resources has also played a role. These decisions are often made at a national level, and "a country like Hungary has to be really careful about where they put their resources," said Rachel Ballard-Barbash, M.D., Ph.D., associate director for the Applied Research Program at the National Cancer Institute.

But whether breast cancer screening is responsible for lower breast cancer mortality is not yet known. Breast cancer mortality began to decline in Europe before these programs were created "almost certainly due to the use of tamoxifen and adjuvant therapy," said Miller. But if screening does prove to have an effect, he expects this will show up within the next 5 years.

In the coming years, Europe will face many more challenges in the continent's anticancer efforts. Europe's population is aging, too many people continue to smoke, governments need to find resources for both cancer control and treatment, and few have organized national cancer programs such as those that the World Health Organization is now recommending. "Europe is good about treatment," said Miller, "but hasn't done much on the other aspects of cancer control."



Lung Cancer Incidence* in Europe, 2002

 Region/Country        Males        Females      

 Eastern Europe        65.7        8.7      
 Hungary        94.6        24.9      
 Poland        82.0        14.6      
 Czech Republic        66.1        13.3      
 Southern Europe        56.9        9.2      
 Croatia        76.4        12.7      
 Italy        58.0        10.7      
 Portugal        34.2        6.0      
 Western Europe        50.9        12.0      
 Belgium        75.3        12.2      
 France        52.6        8.8      
 Germany        46.7        12.7      
 Northern Europe        44.3        21.3      
 United Kingdom        48.1        24.9      
 Denmark        45.3        29.8      
 Sweden        21.1        14.4      

* Rates are per 100,000 and are age-adjusted to the world standard population.

Source: GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide, IARC CancerBase No. 5, Version 2.0, IARCPress, Lyon, 2004.

 



             
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