Pompe-Kirn, Vera

Primic-Žakelj, Maja

Volk, Neva

English

Digital repository of Slovenian research organizations

Radio/ Oncol 19 9 4; 28: 290 -7. Epidemiological features of Jung cancer in Slovenia Vera Pompe-Kirn, Maja Primic Žakelj, Neva Volk Institute of Oncology, Zaloška 2, Ljubljana, Slovenia Lung cancer is the most frequent cancer in the world with wide geographical variations in risk. In Europe its incidence trends in men are decreasing in the most affected countries such as Scotland and Finland, increasing moderately in Eastern Europe, and increasing steeply in Southern Europe. The incidence trends in women are increasing everywhere. Many risk factors have been identified, and the overwhelming role of tobacco smoking has been repeatedly demonstrated. According to the data of the Cancer Registry of Slovenia in the tirne period 1961-1990, the incidence of lung cancer in Slovenia was increasing. In the 80's the increase was moderate in men and steep in women. The cumulative rates in men were in the middle of those established for selected European states and regions while the rates in women were at the bottom. The results of the birth cohort analysis indicated a stabilisation of the rates in men and further increase of the rates in women. About 25 % of casesin both sexes were diagnosed in a localised stage. In men the percentage of the localised stage was increasing by age which was explained by a decreasing percentage of the more aggressive small cel! carcinoma. More squamous cel! carcinomas were registered in men, and more adenocarcinomas in women. The observed survival of lung cancer patients was around 7 % for men and 6 % far women,and has not changed since 1970. In 1989, 42 % of adult men and 24 % of adult women in Slovenia were smokers. In the period 1975-1994, the percentage of smokers was decreasing in men, and increasing in women. These results are a challenge for more efficient antismoking campaigns, especially among women. Key words: Jung neopJasm-epidemioJogy; SJovenia Introduction Lung cancer is now the most frequent cancer in the worJd. Pisani, Parkin and Ferlay estima­ted that in the year 1985 the worJd burden had been: 896 000 new Jung cancer cases (677 000 in men and 219 000 in women) and 785 000 Correspondence to: Professor Vera Pompe -Kirn, MD, PhD, Institute of Oncology, Zaloška 2, 61105 Ljublja­na, Slovenia. Phone: + 3 8661 13 24113. UDC: 611.24-006.6-0 36.2 deaths due to lung cancer (600000 in men, and 185 000 in women). 1 There are wide geographicaJ variations in the risk. In Europe alone the crude incidence rates are varying from 180-45/100 000 in men, and from 55-5/100 000 in women.2 In men the time­trends in incidence are different. They are decreasing in most affected countries such as Scotland, EngJand and FinJand, increasing mo­derateJy in Eastern Europe, and increasing steepJy in Southern Europe. In women the trends are increasing everywhere.3 Epidemiological f eatures of lung cancer in Slovenia 291 Study of the epidemiology of lung cancer has been one of the most rewarding aspects of medica! research in the past 40 years. It has been shown how a disease that has become the most common type of cancer throughout the world can be made to become relatively rare.4 Many risk factors have been identified: tobacco smoking, atmospheric pollution, occupational hazards, ionising radiation, some familial, gene­tic and other host factors as well as the protect­ive role of diet rich in fruit and vegetable. The overwhelming role of tobacco smoking in the causation of lung cancer has been repeatedly demonstrated. 4• 5 The aim of our study was to analyse lung cancer incidence in Slovenia in depth and to compare the obtained results with the available <lata on Slovenian smoking habits. Material and methods Lung cancer incidence and survival <lata were drawn from the <lata base of the Cancer Regi­stry of Slovenia. This Registry was established in 1950 at the Institute of Oncology as a popu­lation-based cancer registry. Data from the period 1961-1990 were analysed. Data on smoking habits have been gathered regularly within the framework of- Slovenian public opinion survey on a random sample of 2093 adult men and women since 1975.6 These <lata were kindly supplied by the Faculty of Social Sciences. Standard methods in descriptive epidemio­logy were used.7 Crude incidence rate has been defined as the rate of total annual number of new cases per 100 000 popuJation in the relevant year. Comulative incidence rate is a speciaJ age-standardised rate. It is the sum over each year of age of the age-specific incidence rates taken from birth to age 74. It can be interpreted either as a directly age standardised rate with the same popuJation size in each age-group, or as an approximation to the cumulative risk. Staging was based on the international cancer registries regulation. According to this reguJa­tion, ali investigation methods including surgery are considered in stage determination of soJid tumours. In the case that patient was not trea­ted previously, the autopsy repo rt is considered as weJI. The lung cancer cases were coded as JocaJised when tumour was confined to the same site of the Jung and no nodes or distant metastasis were present. Results Lung cancer incidence and survival In SJovenia the incidence of Jung cancer was increasing in both sexes (Figure 1). In men the increase was steep in the sixties and seventies, and moderate in the eighties, whiJe in women the increase was steeper in the eighties than before. o o O) ....ro a: I ..... J. . /, .. _,' � � \�/;\ _ _," .. / ,�,, :;,\/· ,, 1 ' . l ·,-1/ Fm=-1 � Q1 A ro' ro":J roCo roOJ :'.'\'1, :'.'\<o :'.'\<o ro' rol>' ro' R>o .... Oj .... Oj .... Oj .... Oj .._OJ .._OJ .._OJ .._<?> .._05 .._05 .._05 Year Figure 1. Crudc annual Jung canccr incidcncc ratcs by scx, Slovcnia 1961-90. 292 Pompe-Kirn V et al. Q) OJ +-' C 20 15 ,. - \ ------ \ Men - -women.... - - - .... u, 1 O Q) (L 5 :'.\'l, :'.\� :'.\'o :'.\'o fbC) fb'l, � fb'o fb'o ?>0 "qj "qj "qj "qj ,<?J ,<?J ,<?J ,<1> ,<1> "qj Year l<igure 2. Perccntagc of clclerly population by scx. Slovcnia 1971-90. In this Jong tirne period the population tree of Slovenia changed.8 The percentage of theelderly popuJation was growing till 1982 to be temporarily stabilised in the eighties (Figure 2). We have to take this changing age distribution into account and Jook at the age standardized cumuJative rates, at the risk of getting Jung cancer till the age of 75 years (Figure 3). In men a steeper increase in the risk to get Jung cancer in the sixties and at the beginning of seventies, and in women a steacly increase in the eighties was confirmecl. These cumulative rates in men place Slovenia in the miclc!Je of the rank order of seJected European states and regions (Figure 4). In Slovenia the risk of getting Jung cancer in a man till the age of 75 years was almost 8/100, in comparison to the Netherlancls ancl Lower Silesia in Poland where it was about 11/100, oooo o Q) +-' co a:: 100�--,,101· ........... "'1" .\ -· 1 I' ... ' I \ l -,-.... \ .,., .. ·,·,. 1. . ..... - ., . ._,,_, \ I f ,.. ; ,,, - \ I ( - ' "!� ·1 � � 1 u_LLU_LLJ_J_J_j_LJ_J_J_Ll _LJ_I 1 1 1 1 1 1 1 1 1io" io':> io'o ioqj :'.\'l, :'.\0 :'.\'o fb" fb� � ?>0 "qj ,<!i ,<!i ,<!i "qj "qj "qj ,C?J ,C?J ,<1> "qj Year Figure 3. Cumulativc annual lung canccr inciclcncc ratcs by scx, Slovcnia 1961-90. ancl with Norway and Sweden where the rates were the lowest 3-4/100. With the cumulative rates in women (0.9/100), Slovenia was placecl at the bottom, very close to different regions of Germany (Figure 5). In Slovenia itseJf, the cumuJative rates varied. In men high rates were found in inclustrial and mining settJements, whiJe in women they were founcl in the capitaJ region of Slovenia. 9 In the commune of Idrija stable high rates were found in both sexes. To preclict properly further trends of Jung cancer in SJovenia a detailecl analysis on trencls in the inciclence of specific age-groups by tiine periods (Figure 6a, b) and by birth cohorts was neecled (Figure 7 a, b). In men the peak of the rates plotted by tirne periocls shiftecl to the left ancl a stabilisation in the eighties was observed. Epidemiological features of lung cancer in Slovenia 293 NL, Eindhoven PL, Lower Silesia UK, Scotland CZ, Boh.& Moravia ltaly, Trieste Slovakia D, Saarland Finland H, Szabolcs UK, South T hames D, former GOR CH, Geneva S/ovenia Denmark Bel aru s S, Tarragona Norway Sweden o 10 20 30 other ■ lung40 Figure 4. Cumulativc avcragc annual lung canccr incidcncc ratcs in men, Europc 1983-87. In women the peak remained in the oldest age groups and the curve was higher in each subse­quent time period. We tried to explain such a different behaviour by sex with a birth cohort analysis. In the birth cohort analysis (Figure 7) we presented the same <lata in a different way. The rates were plotted by birth cohorts, by the year of birth of newly diagnosed Jung cancer patients. There was a clear cohort effect in both sexes. An encouraging one in men with lower rates in younger generations, bom around 1931 and later, and a warning one in women, with higher rates in younger generations in ali age groups. In the period 1981-90 in Slovenia about 25 % of patients of both sexes were diagnosed in the localised stage (Figures 8 and 9). The stage distribution differed by age however. In men only, a growing percentage of the localised stage in the elderly was obvious. To explain this observation, we analysed the histologic types of lung cancer in Slovenia by age in men and women (Figure 10a, b). The distribution differed by sex. More adenocarcinomas were registered in women, and more squamous celi carcinomas in men, while approximately the same percentage of carcinomas were nonspeci­fied or microscopically 11011 verified. The per­centage of small celi carcinoma decreased by age in both sexes. Population survival of Jung cancer patients in Slovenia did not change in the period 1970-1989. The observed five year survival rate of patients aged 0-74 years was around 7 % for men and around 6 % for women. Smoking habits In 1989, 42 % of adult men and 24 % of adult women in Slovenia were smokers. With these <lata Slovenia was placed in the middle of the EC countries. In men the highest percentage 294 Pompe-Kirn V et al. UK, Scotland Denmark UK, South T hames CH, Geneva 1, Trieste PL, Lower Silesia Norway Sweden CZ, Boh.& Morav. %<.h ·•:•:.:_:::WJ❖tr� .H , Szabo I c s ;;:;❖·•;;···"···:::·;:·;;·:�·;;'······::·:::;-;·:·;·:·:::::;;,n, ... h-x.L .•l NL, Eindhoven D, Saarland D, former GDR SI o veni a •=.:.�;:;,.,�=-:i,.,;;.,._�;;�,.;,::;,. ,::,.;_;;:;; __ ,.,.:, ...,;;::i��;;� ....::,.,..,:: ... ,�.=-«"=· · ·•;;.❖.•;; __ ,_,__::., .... = ... ,iD other■ lungs, o 10 20 30 40 Figure 5. Cumulative average annual Jung cancer incidence rates in womcn, Europe 1983-87. of smokers was seen in the age group 31-40 years while in women it was in the age group 26-30 years. The percentage of ex-smokers washigher in men in all age groups after the ageof 25. Smoking habits differed by education.The highest percentages were seen in men withelementary and professional education, andthey were highest in women with professionaland middle education. In the tirne-period 1975-1994, the percentage of smokers ainong menwas decreasing whereas among women it wasincreasing (Figure 11). The decrease in menwas observed in all age groups after the age of 26, while the increase in women was observedtill the age of 61.Smoking habits differed by communes of Slovenia. In 1989, more smokers were found in industrial and mining settlements.9 Unfortu­nately, an analysis by sex was not performed. Discussion and conclusion In the tirne period 1961-1990 the incidence of lung cancer in Slovenia was increasing. In the eighties the increase was moderate in men and steep in women. The cumulative rates in men were in the middle of those established for selected European states and regions, while the rates in women were at the bottom. The results of the birth cohort analysis indicate a stabilisa­tion of the rates in men and further increase of the rates in women in the near future. About 25 % of cases in both sexes were diagnosed in the localised stage. In men, the stage distribution differed by age, however. The localised stage was increasing with age. With age also the percentage of more aggressive small cell carcinoma was decreasing. A similar observation was reported by Teeter and cowor­kers in 1990.10 Epidemiological features of lung cancer in Slovenia 295 1,ooo�-------------:-:----:-:--:-:1 1,000�-------- -- -, g 1//// .. q ........ ... ······ o ·········· ..... ..o . . . .. . ... ·· 1 o . .. o .... q .. o o ,-! 1 // . .. ... . . j * a: \, O'Oj ':.l � \)< I>< O'<,j � � <oO Age _,.. 1981-85 + 1986-90 O''\I>< '\ <o<:Š Figure 6a. Age-specific Jung cancer incidence rates in men by tirne periods, Slovenia 1961-90. More squamous cell carcinomas were registe­red in men, and more adenocarcinomas in women. Such results were expected according to other reports in the literature.11 The observed survival of lung cancer patients was around 7 % for men and 6 % for women, and has not changed since 1970. This statement is a challenge not only for clinicians in their search for additional pieces to the unresolved puzzle of a more efficient treatment, but first 0.11>< (JOJ ':.l � b< I>< O'<,j � � <oO Age � 1976-80 * 1981-85 + 1986-90 '\O''\I>< <o<:Š Figure 6b. Age-specific lung canccr incidence rates in women by tirne periods, Slovenia 1961-90. of all for health educators and general practitio­ners in their attempt to develop more efficient antismoking campaigns, especially among wo­men. According to the described smoking habits in 1989 in Slovenia, (42 % of adult men and 24 % of adult women were smokers), and the fact that by eliminating tobacco smoking, the worldwide potential to reduce the incidence of lung cancer would reach 80-90 % for men and 60--80% for women,12 a lot of work still waits to be done in the future. 296 Pompe-Kirn Vet al. 1,000·· o o o o o C\l a: 75°79 ··� S5-:0-54 �::: 101 �'" 1 L-----L........---.....-.1 .. _L_�� -� -��-�� 0" 0\() !'s"- !'s\() fl> [!,\() r.,"- r.,'0 �" �\() �" ,05 ,05 ,<?> ,<?> ,<?> ,<?> ,<?> ,<?> ,05 ,05 ,<?S Year of birth Figure 7a. Agc-spccific lung canccr inciclcncc ratcs in men by birth cohorts, Slovcnia 1961-90. 35-44 45-49 50-54 55-59 60-64 65-69 70-7475-79 80+ 0% 25% 50% 75% N=208 N=365 N=787 N=1238 N=1136 N=809 N=648 N=316 100% 111 localised ■ regional li\:l remote O unknown Figure 8. Stage clistribution of Jung canccr in men by age, Slovcnia 1981-90. o o o o o (1) ...., C\l a: 100�---------------, 10 60-64··� 55-5950-5'4: 1 ��-�-� -��-0" 0\() !'s" !'s\() fl> � r.,"- r.,'0 �" �\() �" ,05 ,05 ,<?> ,<?> ,<?> ,<?> ,<?> ,<?> ,05 ,05 ,05 Year of birth Figure 7b. Agc-spccific lung canccr inciclcnce ratcs in womcn by birth cohots, Slovenia 1961-90. N=59 N=54 N=104 N=144 N=175 N=163 N=155 N=151 80+ N=110 0% 25% 50% 75% 100% il localised ■ regional remote O unknown Figure 9. Stage clistribution of Jung canccr in womcn by agc, Slovcnia 1983-90. Epidemiological features of lung cancer in Slovenia 297 II squnII10us li�111;1llcell [] adeno u1 nonsp i Jn1ln 11011sp N 168 N 256 N 601 N 1036 N 985 N 710 N- 604 N -533 N - 263 Figure 10a. Histologic types of lung cancer in men by age Slovenia 1983-90. -'�=,-----· -···· i N" 53 N 52 N 88 N 117 N 1,19 N 137 N 171 N 13<1 N 10\J Figure 10b. Histologic types of lung cancer in women by agc, Slovenia 1983-90. 3 � 60· �'b ,0 ,'b'l, g,'b ,CJ:>fb ...,_OJ Year g,0 ,0 llf rnen [Jwomcn l #,cs Figure 11. Pcrccntagcs of smokcrs by scx, Slovcnia 1975-94. Reference l .  Pisani P, Parkin DM, Ferlay J. Estimates of theworldwide mortality from eighteen major cancersin 1985: implications for prevention and project­ions of future burden. lnt I Cancer 1993; 55: 891-903.2. Cancer incidence in five continents. Vol 6. IARCSci Pubi 1992; No 120.3. Trenc/s in cancer incidence and mortality. IARCSci Publ 1993; No 121.4. Doli R. Introduction and overview. In: Samct JMcd. Epidemiology of lung cancer. New York:Marcel Dckker Inc, 1994: l-14.6. Žakelj M. Zdravstvena prosvetljenost polnoletnihSlovencev o raku. Specialistična naloga. Ljubljana:Onkološki inštitut, 1991.7. Cancer registra/ion: principles and methods. IARCSci Publ 1991; No 95.8. Statistični letopis R Slovenije. Ljubljana: Zavod RSlovenije za statistiko, 1993.9. Pompe-Kirn V, Primic-Žakelj M, Fcrligoj A, ŠkrkJ. Zemljevidi incidence raka v Sloveniji 1978-1987.Ljubljana: Onkološki inštitut, 1992.10. Tcctcr SM, Holmes FF, McFarlanc MJ. Lungcarcinoma in thc cldcrly population: influence ofhistology on thc invcrsc rclationship of stagc toage. Cancer 1987; 60: 1331-6.11. Mason TJ. Thc descriptivc epidemiology of lungcanccr. In: Samct JM cel. Epidemiology of lungcancer. New York: Marcel Dckkcr Inc, 1994:51-69.12. Canccr: causes, occurrcncc and control. IARC SciPub] 1990; No 100.

Epidemiological features of lung cancer in Slovenia

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Epidemiological features of lung cancer in Slovenia

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