Seasonality of presentation of cutaneous melanoma, squamous cell cancer and basal cell cancer in the Oxford Region.

The seasonality of presentation of 1019 skin melanomas in Oxford Region 1952-1975, and of 1,523 squamous cell and 4,865 basal cell skin cancers in the region 1967-1975, were analysed using data from the Oxford Cancer Registry. For males and for females, for each of the histologies there was a peak of presentations during July to September. In further subdivisions of the data by age and by skin site, a summer or autumn peak was generally present except where numbers of cases were small. Amplitude of seasonality did not show consistent differences by histology, sex, or skin site, but for both melanoma and squamous cell cancer amplitude was greater for persons aged under 55 years than for older persons. There was no substantial seasonality for presentations of cancers of all non-skin sites in the region. The seasonality of presentation of skin cancers appeared not to be mainly an artefact of the cancer registration process or of organisational aspects of medical care attendance, and only a small proportion of it could be explained as an artefact of the longer term increase in registrations of these cancers. The visibility of skin cancers might have lead to seasonal variation in rapidity of presentation to medical care, for instance for social reasons, or the results might reflect a short induction period effect of exposure to a seasonal insult, perhaps sun radiation, on the aetiology, growth or symptoms of skin cancers; for melanoma there is previous evidence suggesting a short induction period aetiological effect of sun radiation

Interpretation of England and Wales cancer mortality data: the effect of enquiries to certifiers for further information.

For some death certificates in England and Wales the cause information coded and published in national data is not that initially submitted by the certifier, but instead derives from a subsequent enquiry to the certifier for further information. These enquiries can lead to substantial artefacts in secular mortality data, and also to substantial non-comparability between mortality data for special study groups, such as subjects in cohort studies, and published mortality data. A description of current enquiry policy relevant to cancers, and changes in this policy over recent years is given to aid interpretation of mortality data. The effects on secular data of changes in enquiry policy are illustrated. At 4-digit level of the ICD, changes in enquiry policy can alter published mortality rates by several hundred per cent. At 3-digit level the greatest effects of enquiries at present are to increase the number of deaths coded to cancer of the eye by 35% and cancer of the body of the uterus by 31%; cancers of the thymus, heart and mediastinum are increased by 18%, and pleural cancer by 17%, while decreases of more than 10% are caused for several 'other' and 'unspecified' rubrics, and a decrease of 6% for deaths coded to melanoma

Completeness of cancer and death follow-up obtained through the National Health Service Central Register for England and Wales.

For the last 20 years the National Health Service Central Register (NHSCR) has been used as the principal source of follow-up for mortality, and often for cancer incidence, in many cohort and clinical follow-up studies in England and Wales. Completeness of notification of childhood cancer registrations and deaths from the NHSCR was investigated by comparison between cancers and deaths notified to the Childhood Cancer Research Group (CCRG) from this source and notifications received directly from regional cancer registries and the national death registry. Six thousand, seven hundred and seventy-six (91.8%) of 7,379 cancers incident 1971-84, and 588 (95.8%) of 614 deaths occurring 1953-88, were successfully notified. Failures in cancer notification occurred mainly between the regional cancer registries and the National Cancer Register (3.3%), and between the National Cancer Register and the NHSCR (3.0%). An additional 1.9% of cancer notifications failed between the NHSCR and the CCRG. Incompleteness of registration of childhood cancers by regional cancer registries was estimated to be 4.7%. A total of 12.5% of incident childhood cancers were not notified by NHSCR. Incompleteness of notification may be greater for adults, for whom registration and record linkage may be more difficult. Failures in death notifications occurred mostly because deaths entered on the NHSCR were not notified to the CCRG (3.3%). This incompleteness of notification needs to be taken into account in the interpretation of published studies and in the analysis of studies using NHSCR flagging. It also implies similar incompleteness in published national cancer survival data, which use the same system of flagging. Nevertheless it is a notable achievement that NHSCR has successfully monitored such a high proportion of a population of 50 million people, by entirely clerical procedures, for 40 years

Thymus cancer epidemiology in England and Wales.

Thymus cancer epidemiology has been little investigated, but recent clinical studies have suggested an association with the Epstein-Barr virus. We studied thymus cancer incidence 1963-83 and mortality 1959-86 in England and Wales, using data from the National Cancer Register and national mortality files. Mean age-standardised incidence rates of the tumour were 0.72 per million per annum for males and 0.64 for females; mortality rates were about half of this: 0.43 for males and 0.29 for females. There was no significant change in rates over time, nor any consistent pattern of risk by region of residence. Birth cohort analysis of mortality showed in each sex, lowest risk for persons born during the Second World War. The age distribution of the tumour was unusual: a progressive rise in both incidence and mortality rates occurred in each sex at ages up to 60-69, at which there was a striking peak, more marked for males and for incidence data, with a sharp decline thereafter. Immigrants from China and Cyprus had significantly high proportional registration ratios, but based on small numbers

Ovarian germ cell malignancies in England: epidemiological parallels with testicular cancer.

The epidemiology of germ cell cancer of the ovary has been little investigated. We studied ovarian germ cell cancers incident 1971-84 in England, using data from the England and Wales national cancer register. The age distribution showed a sharp peak at ages 15-19, to which both teratomas and dysgerminomas contributed equally, and a secondary, much wider peak, at ages 65-69, mainly due to teratomas. For teratomas there were diverging secular trends by age: incidence has been increasing at ages 0-44 (P around 0.05) and decreasing at ages over 44 (P less than 0.01). Birth cohort analysis showed an increase in risk at ages 0-44 for more recent generations of women. There were no changes over time for dysgerminomas. There was no clear geographic pattern of distribution across the regions of England. The early age peak, and the increase in incidence of ovarian germ cell cancers at young ages but decrease at older ages, resembles testicular cancer epidemiology. Interestingly, discrepancies and similarities in the age distribution of these tumours between the sexes parallel lifetime profiles of gonadotropin levels in each sex

Geographic distribution of lung and stomach cancers in England and Wales over 50 years: changing and unchanging patterns.

The distribution of cancers of the lung and stomach in the counties of England and Wales in 1968-81 was mapped, and compared to the distribution in the country in 1921-30 described by Stocks. The high risk of stomach cancer in North Wales noted by Stocks was found still to exist in each sex, although its disparity from the rest of the country has diminished. In general the geographic distribution of stomach cancer in both periods has paralleled that of post-neonatal mortality, at the same time and earlier, as an index of general poverty, but postneonatal mortality in North Wales has not been exceptionally high. In 1921-30 the highest risk of lung cancer was in and around London. In the modern data this was still true for older women, but for men and women under 45 years of age, and to a lesser extent for older men, the pattern has changed greatly; the epidemic has moved north, and highest risk is now in Northumberland and Durham. This spread appears to have occurred earlier for men than for women, and for urban than for rural areas, occurring latest of all for women in rural areas. Regional disparity has also increased, especially in males: risks in the northern regions are now over twice those in much of Wales and the South

Thyroid cancer epidemiology in England and Wales: time trends and geographical distribution.

Thyroid cancer incidence has been increasing in many countries, whereas mortality has been falling due to better survival. Radiation is the best-established risk factor and there has been concern that recent rises in incidence might be related to fallout radiation from atmospheric nuclear weapon tests. We examined thyroid cancer time trends and geographical distribution in England and Wales and possible interpretations of these. During 1962-84, there were significant increases in incidence (P < 0.001) in each sex at ages under 45. Cohort analysis by single year of birth showed an overall increase in incidence risks in women aged 0-44 born since 1920, with a sudden rise in risk for the birth years 1952-55 followed by a lower risk for the more recent cohorts. In men, there was an overall increase in risk at ages 0-44 in successive birth cohorts, but the pattern was irregular. In each sex, the risk in persons aged 45 and over decreased slightly in successive generations. Geographically, highest incidence risks were in countries in North and Mid Wales, in which the risk was almost twice that in the rest of the country. This pattern was present only at ages 45 and over and was most clear in rural areas. The peak of thyroid cancer risk in women born in 1952-55 is consistent with a carcinogenic effect of fallout radiation, since these women were children in the late 1950s and early 1960s when fallout radiation was greatest in England and Wales. The focus of high thyroid cancer risks in Wales was in areas with high levels of fallout radiation. However, thyroid cancer risks in Wales were not high for more recent cohorts (the ones who were exposed to fallout early in life), and a focus on high risk of benign thyroid diseases was present in Wales well before nuclear weapons existed. The distributions of these benign thyroid diseases, or of factors causing them, seem more likely than fallout to explain the high risk areas for thyroid cancer in the country

Sex differences in time trends of colorectal cancer in England and Wales: the possible effect of female hormonal factors.

Differences between the sexes in time trends of colorectal cancer incidence 1962-87 and mortality 1960-91 in England and Wales are examined in relation to changes in female hormonal factors. There was a trend in the sex ratio of this tumour, particularly marked for the descending colon, whereby the female excess in risk at young ages has almost disappeared but the male excess at older ages has increased. This trend started for cohorts born since the 1920s and coincided with the increase in the use of oral contraceptives and, to a lesser extent, with increases in fertility. The decline has been particularly pronounced for women at young ages born since 1935-39, coinciding with the spread of oral contraceptive use to younger age groups. These results are consistent with the hypothesis that female hormonal factors may play a role in the aetiology of colorectal cancer and with the possibility that oral contraceptive use might exert a protective effect in the descending colon

Recent trends in incidence of and mortality from breast, ovarian and endometrial cancers in England and Wales and their relation to changing fertility and oral contraceptive use.

Reproductive-related factors play a major role in the aetiology of cancers of the breast, ovary and endometrium. Pregnancy history influences the risk of each of these cancers, and oral contraceptive use modifies the risks of ovarian and endometrial cancers, although its effect on breast cancer risk is less certain. We analysed recent time trends in the incidence and mortality of these cancers in England and Wales and assessed whether they can be explained by changes in fertility and oral contraceptive use. During 1962-87, there were significant increases in the overall incidence of breast cancer (0.95% increase per annum) and ovarian cancer (0.76% per annum) but little increase in endometrial cancer (0.13% per annum). At young ages incidence of each of the cancers has declined in recent years, whereas at older ages there have been substantial increases. Mortality data show similar time trends. In analyses by birth cohort, incidence of each of the cancers increased steeply for successive cohorts born before the turn of the century, and more slowly for cohorts thereafter, reaching a maximum for those born in the 1920s, and decreased for those born subsequently. The increases in incidence for women born before the turn of the century paralleled marked declines in their fertility. The fall in risk for women born after the 1920s was not accompanied by significant increases in their fertility, but coincided with the introduction and increase in use of oral contraceptives. For ovarian and endometrial cancers this accords with strong evidence from person-based studies of the protective effect of oral contraceptives. For breast cancer, the reasons for the recent decline are not clear. It would accord with recent suggestions of a long-term protective effect of oral contraceptives, on which further studies are needed. It is also possible, however, that changes in other risk factors such as dietary fat intake and menarcheal age might have contributed to the recent declines in the risk of these cancers