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Epidemiology of tumours of the uterine cervix
Europ. 07. Cancer Vol. 3, pp. 491-495. Pergamon Press 1968. Printed in Great Britain
Epidemiology of Tumours of the Uterine Cervix*t LUCIA J. DUNHAM Laboratory of Pathology, Wational Cancer Institute, Bethesda, Md. 20014, U.S.A.
of the uterine cervix have not been encountered in most species of animals below man, even when large series have been examined [2]. Extensive study of captive wild animals, cattle, horses, swine, dogs, cats, the rodents maintained in scientific laboratories, and primates, has resulted in only a few reports of unequivocal spontaneous cancer in the cervix. Cancer of the uterine cervix is primarily a disease of the h u m a n species, and its frequency in relation to all cancer in females ranges from 5 to 60% in different population groups. Age-adjusted mortality rates per 100,000 females are available from some areas and range from 3 to 64. D u n h a m and Bailar have prepared a map and accompanying table that shows ranges of risk for cancer of the cervix in nearly 90 population groups [3]. The highest risks are in Latin America, in parts of Africa, and in Asia. The lowest risks are in Israel, in North America, Australia, New Zealand, and Europe, especially Poland and Ireland. Though cancer of the cervix is usually infrequently found in Jewish women, recent data from North Africa suggest that it may not be unusually low among Jews in North Africa [4-6]. Within the United States, cervical cancer is less frequent in white women than in non-white women.
There is an excess risk of cancer of the cervix for populations living in cities compared to rural areas, for populations of high density within industrial environments, and for populations at low rather than high socio-economic levels [7-10]. Cancer of the cervix is more frequent in married women than in single or celibate women [11, 12]. The median age at diagnosis is about 51 years, 13 years younger than the median age at diagnosis of cancer at other sites combined [13]. A working hypothesis in m a n y studies of cancer of the cervix has been that its causes are most likely to be found in the environment of patients. Studies have not indicated that there is an hereditary or familial factor [14, 15]. It has been thought that the social and sexual environments of patients with cervical cancer m a y be different from those of patients without this cancer. A number of investigators have tried to explain the low frequency of cervical cancer in Jewish women. Jewish women differ from non-Jewish women in their history of intercourse virtually only with circumcised male partners, and the patients' observance of the ritual laws of Niddah, dictating abstinence from intercourse for periods up to seven days after the cessation of menses. Cancer of the cervix has not been investigated from the viewpoint of cultural differences in diet. There have been disagreements about factors found in past studies associated with cancer of the cervix. For instance, all investigators have not agreed about the significance of such factors in the pregnancy history as ever-pregnant, early age at first pregnancy, or large number of preg-
SPONTANEOUS c a n c e r s
*Reference no. 1 presents the full report of a National Cancer Institute Study on cancer of the uterus: a rates study, interview study, and pathology study. "~Presented at the "Second International Symposium on the Biological Characterization of H u m a n Tumours", Rome, April 24--26, 1967.
491
492
Lucia o7. Dunham
nancies. The factors that characterize the patients in the control groups in a study are the basis for the comparisons with the cancer patients. The way that the control patients were selected to represent the total background population of patients with cancer of the cervix has varied from one interview-type study to another. Control patients are often selected from the same hospitals or clinics as the cancer patients, in the same age groups, at the same socio-economic levels, or are matched by marital status, number of pregnancies, or these in various combinations. Differences in results and conclusions between studies are in part due to differences in the characteristics of the control groups. Our National Cancer Institute interview study comprised 338 white non-Jews and 96 Jews with cancer of the cervix, and corresponding control groups of 594 and 1583 patients [1]. We selected the control patients for interview from the same age groups and the same hospitals as the cancer patients. We interviewed the large numbers of control patients both in New York City and in Israel, to improve stability in comparisons of factors with those of the cancer patients, especially since there were comparatively few Jewish patients with cancer of the cervix. There were additional control groups, 164 white non-Jews and 230 Jews with cancer of the corpus, an(] 440 Israeli Jews with cancer of the breast and 65 Israeli Jews with cancer of the ovary. The factors of all control patients were compared with those of patients with cancer of the cervix. At the same time as the interview study, the incidence rates were established, and there was a review and classification of the pathologic diagnoses of more than 98% of the patients with cancer of the cervix who were interviewed. Data on constitutional and environmental factors of patients were analyzed. Direct
associations were not found with most of the factors studied, such as aspects of marriage and marital practises, characteristics of the menstrual history, the history of diseases, operations and treatments related to the female genital and endocrine gland systems, and characteristics of the pregnancy history (Table 1). Uncircumcised male partners were associated with cancer of the cervix in one of three population groups of patients only. The association was noted in relation to control patients without cancer, but not in relation to patients with cancer of the corpus. In most past studies there has been agreement that cancer of the cervix is somewhat related, statistically, to early age at first marriage or at first intercourse. With the exception of the Jews in New York City there were larger percentages with ages at first intercourse under 20 years among patients with cancer of the cervix than among control patients. It is doubtful that it can be concluded from these data that first intercourse at an early age causes cancer of the cervix. More than half of the patients with cancer of the cervix, except for Sephardi-Orientals, did not have the early ages at first intercourse below 20 years; that is, numerous individual patients did not report the associated factor, and something else must have caused their cancer. The late Dr. Harold F. Dorn, failed to find a relationship of the risk of cervical cancer to the strength of the factor, first intercourse at early ages [16]. The analysis was extended to determine whether factors studied led to comparatively young ages at diagnosis of cancer of the cervix in white nonJews, but no such effects were found. In theory, if a factor is carcinogenic, its presence should shorten the induction time of the cancer. The latent period of the induction time of cancer of the cervix was not affected, either by early age at first intercourse or by uncircumcised male partners, or other factors analyzed.
Table 1. Factors in NCI study not significantly associated with cancer of cervix Widowhood, divorce, separation Semipermanent extramarital relationships More than one marriage Frequent intercourse Practice of ritual laws of Niddah (Jewish women) Abstinence from intercourse in relation to menses Use of contraceptives Age at menarche or menopause Characteristics of the menstrual cycle Selected past diseases, surgical operations, and types of treatment Age at first or last pregnancy Number of pregnancies; crowding of pregnancies Trimester at termination of pregnancy; method of delivery
Epidemiology of Tumours of the Uterine Cervix 50
I
I
I
I
493
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Non-Jewish White, New York City
_
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l
¢:
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Jew, New York City
/
/ '
15,.24
25-54
"
:55-44
"
45-54
55-64
)\] 65-74
75+
AGE
Fig. I. Cancerof the uterine cervix by age. Incidenceratesfor non-Jewish white women and three groups of Jewish women, 1952-1953. One of the interesting aspects of the study was the inter-relationship and interdependence of factors related to social and sexual history. Age at first intercourse and circumcision status of partners were related to each other, the percentages of circumcised partners being smaller for the groups with younger than for those with older ages at first intercourse. Median ages at first marriage were considerably younger for all those patients in the study who had more than one marriage than for those patients who had a single marriage only. Three and more pregnancies were associated with first intercourse under age 20, and we found m a n y additional factors that have been suggested as causes of cancer of the cervix that were closely related with each other. An important part of the National Cancer Institute study was the comparison among the Jewish women in New York City and the Jewish women of Israel. These are three culturally different groups of women, two living within the confines of Israel, Israeli
Table 2.
Ashkenazi Jews and Israeli Sephardi-Oriental Jews. The Israeli Ashkenazi had emigrated mainly from Western and Northern European countries, while the Sephardi-Orientals came from parts of the Near East, South-Eastern Europe, and Africa. Rates of cancer of the cervix were almost the same in the three groups, 4.1 in New York City Jews, and 4.7 and 4.9 respectively in the two groups of Israeli Jews. Incidence rates by age of cervical cancer in the three groups of Jews were similar, with the peak incidence at about 65 to 74 years, between 10 and 20 years later than for white non-Jews in New York City (Fig. 1). We assembled the data on a number of factors in the large control groups of Jewish women (Table 2), the data presumably representing cultural characteristics of these population groups. T h e New York City Jews differed from the Ashkenazi Jews in the percentages of nevermarried women, first marriage before age 20, first pregnancy before age 25, and total pregnancies 5 or more. There were still
Cultural factors qf oTewish control patients in percentages Israeli Jews New York City Jews
Never married First marriage before age 20 Non-practice of laws of Niddah Married never pregnant First pregnancy before age 25 Total pregnancies, 5 or more No formal education Education at ninth grade level, and above
5.3 23 "4 No. into. 12.8 56.2 2 I. 3 6-9 45.6
Ashkenazi 2.1 17.0 68.5 10-6 45.9 30.3 5.5 46.9
SephardiOrientals 1-3 47-6 48.0 6.5 73.2 58.3 45.0 17.3
494
Lucia 07. Dunham
greater differences between the two subgroups of Israeli Jews, and nearly three times as m a n y of the Sephardi-Oriental as Ashkenazi women reported first marriage before age 20, and also much larger percentages of women in this population reported first pregnancy before age 25 and total pregnancies of five or more. Education grade levels of Ashkenazi and
Sephardi-Orientals were widely different. Our conclusions are that the cultural differences between the three groups of Jewish women did not affect the risks of cervical cancer. Possibly Jews have some degree of genetically determined resistance to cancer of the cervix, but this is unproved.
RESUME Le cancer du col ut&in a ses caract&istiques propres, distinctes de celles de tout autre cancer: (1) II est rare chez les mamm~res autres que l'homme. (2) // est plus frdquent dans les pays en vole de d&eloppement que dans les pays gvolugs, dans les populations urbaines que dans les populations rurales, dans les rdgions a forte population industrielle que dans ceUes or, la population est moins dense, ainsi que dans les classes sociales et gconomiques infgrieures. Il est relativement frgquent chez les Noirs et assez rare chez les Juifs, ~ l'exception des Juifs d'Afrique du Word. (3) Une plus grande proportion de malades atteintes de cancer du col ut&in que de patientes souffrant d'autres types de cancer prgsentent certaines caract&istiques li&s au mariage et aux pratiques sexuelles, permettant dYtablir une dventuelle corrdlation entre ceux-ci et la prdsence du cancer. Cenpendant, on a ddmontrd que les risques de cancer du col ne sont pas augment& par la pr&ence des facteurs qui ont dtd gtudi&. Les taux de cancer du col ut&in ne sont pas sup&ieurs chez les Juifs oi~ ces caracteristiques existent que dans d' autres groupes de Juifs. Chez les non-Juifs, la prdsence d' un facteur extrins~que n' entra~ne pas de dgveloppement prdmaturd de cetteforme de cancer. Le cancer du col est tr& probablement da a l'influence de facteurs externes, mais nous n'avons pas encorepu dgterminer ses causes exactes.
SUMMARY Cancer of the cervix has its own distinctive characteristics, separatefrom any other cancer: (1) It is infrequent in mammals below man. (2) It is more frequent in developing than developed countries, urban than rural populations, dense than less dense industrial populations, and at low than high socioeconomic levels. It is relativelyfrequent in Negroes and relatively infrequent in Jews, with the possible exception of Jews in North Africa. (3) Slightly larger proportions of patients with cancer of the cervix than corresponding control patients have reported certain factors related to marriage and sexual practices. However, the risk of cancer of the cervix was not enhanced by the presence of the factors that were investigated. Rates in groups of Jews with large proportions of some of these factors were not greater than rates in other groups of Jews. In non-Jews the presence of a factor did not cause the cancer to develop at an earlier age. Cancer of the cervix is very likely an "environmental" cancer at least in part, but we do not know its causes.
ZUSAMMENFASSUNG Das Kollumkarzinom ist haupts&hlich eine Krankheit der Menschen. Das hiiehste Risiko besteht in Lateinamerika und in einigen Gebieten von Afrika und Asien. Ausserdem ist das KoUumkarzinom verhaltnismdssig hi~ufig bei Negerinnen in den Vereinigten Staaten. Das niedrigste Risiko besteht in Israel, Nordamerika, Australien, Neuseeland und Europa, besonders Polen und Irland. Neue Angaben aus Nordafrika deuten darauf him, dass Krankheit durchaus nicht so selten unter Jiidinnen in Nordafrika ist wie unter Jiidinnen in Israel. Verschiedene Umstiinde, die mit geographischen, kultureUen, sozialen und sexueUen Gegebenheiten assoziiert sind, werden untersucht. Die Giiltigkeit dieser
Epidemiology of Tumours of the Uterine Cervix Assoziationen scheint bei den vershiedenen Studien zu variieren, zum Teil wegen der verschieden yon den Forschern angewandten Methoden. Die Ergebnisse der Untersuchung uber den Gebarmutterkrebs des National Cancer Institute unterstuetzen nicht die Annahme, nicht dass irgend einer der gepriiften Faktoren das Kollumkarzinom verursacht. REFERENCES I. H . L . STEWART, L. J. DUNHAM,J. CASPER, H. F. DORN, L. B. THOMAS,J. H. ]~DOCOMB and A. SYMEONIDIS,Epidemiology of cancers of uterine cervix and corpus, breast and ovary in Israel and New York City. 07. nat. Cancer Inst. 37, I (1966). 2. E. COTCHIN, Spontaneous uterine cancer in animals. Brit. 07. Cancer 18, 209, (1964). 3. L . J . DUNHAMand J. C. BAILAR,III. World maps of cancer mortality rates and frequency ratios. To be published. 4. F. ARDOIN, Bilan de trois anndes d'6tude statistique du cancer au Maroe, 19541957. Personal communication of unpublished data. 5. M . J . BREHANTand MME. MUSSlNI-MONTPELLIER,Esquisse de la physionomie du cancer en Alg6rie. Bull Acad. nat. Mid. (Paris) 1't5, 536 (1961). 6. A. CHADLIand E. PHILIPPE, La physionomie du cancer en Tunisie. Arch. Inst. Pasteur Tunis 37, 397 (1960). 7. J. C. BAILAR III and S. L. RICE, Geographic variadon in uterine cancer incidence in Connecticut. Publ. Hlth Rep. (Wash.) 77, 157 (1962). 8. J. CLEMMESENand A. NIELSEN,The social distribution of cancer in Copenhagen, 1943 to 1947. Brit. 07. Cancer 5, 159 (1951). 9. W. M. HAENSZEL,S. C. MARCUS and E. G. ZIMMERER,Cancer morbidity in urban and rural Iowa. Pub. Health Monograph No. 37, U.S. Government Printing Office, Washington, D.C. (1956). 10. P. STOCKS, Cancer of the uterine cervix and social conditions. Brit. 07. Cancer 9, 487 (1955). 11. F. GAGNON,Etat marital et grossesse dans l'~closion du cancer du col de l'ut~rus. Laval todd. 20, 654 (1955). 12. R. S. TAYLOR, B. E. CARROLLand J. W. LLOYD, Mortality among women in 3 Catholic religious orders with special reference to cancer. Cancer 12, 1207 (1959). 13. New York State Department of Health, Bureau of Cancer Control. Annual Report (1955). 14. A. CmESSERI, L. GIANF~RRAm, P. MALCOVATI, G. MORGANTI and P. E. BEOLGHINI,Genetical researches on uterine cancer. Acta. genet. (Basel) 6~ 301 (1956). 15. M. T. MACKLIN, Etiologic factors in carcinoma of the uterus, especially the cervix. J. int. Coll. Surg. 21, 365 (1954). 16. H. F. DORN, Some problems arising in prospective and retrospective studies of the etiology of disease. New Engl. 07. Med. 261, 571 (1959).
495
Epidemiology of Tumours of the Uterine Cervix*t LUCIA J. DUNHAM Laboratory of Pathology, Wational Cancer Institute, Bethesda, Md. 20014, U.S.A.
of the uterine cervix have not been encountered in most species of animals below man, even when large series have been examined [2]. Extensive study of captive wild animals, cattle, horses, swine, dogs, cats, the rodents maintained in scientific laboratories, and primates, has resulted in only a few reports of unequivocal spontaneous cancer in the cervix. Cancer of the uterine cervix is primarily a disease of the h u m a n species, and its frequency in relation to all cancer in females ranges from 5 to 60% in different population groups. Age-adjusted mortality rates per 100,000 females are available from some areas and range from 3 to 64. D u n h a m and Bailar have prepared a map and accompanying table that shows ranges of risk for cancer of the cervix in nearly 90 population groups [3]. The highest risks are in Latin America, in parts of Africa, and in Asia. The lowest risks are in Israel, in North America, Australia, New Zealand, and Europe, especially Poland and Ireland. Though cancer of the cervix is usually infrequently found in Jewish women, recent data from North Africa suggest that it may not be unusually low among Jews in North Africa [4-6]. Within the United States, cervical cancer is less frequent in white women than in non-white women.
There is an excess risk of cancer of the cervix for populations living in cities compared to rural areas, for populations of high density within industrial environments, and for populations at low rather than high socio-economic levels [7-10]. Cancer of the cervix is more frequent in married women than in single or celibate women [11, 12]. The median age at diagnosis is about 51 years, 13 years younger than the median age at diagnosis of cancer at other sites combined [13]. A working hypothesis in m a n y studies of cancer of the cervix has been that its causes are most likely to be found in the environment of patients. Studies have not indicated that there is an hereditary or familial factor [14, 15]. It has been thought that the social and sexual environments of patients with cervical cancer m a y be different from those of patients without this cancer. A number of investigators have tried to explain the low frequency of cervical cancer in Jewish women. Jewish women differ from non-Jewish women in their history of intercourse virtually only with circumcised male partners, and the patients' observance of the ritual laws of Niddah, dictating abstinence from intercourse for periods up to seven days after the cessation of menses. Cancer of the cervix has not been investigated from the viewpoint of cultural differences in diet. There have been disagreements about factors found in past studies associated with cancer of the cervix. For instance, all investigators have not agreed about the significance of such factors in the pregnancy history as ever-pregnant, early age at first pregnancy, or large number of preg-
SPONTANEOUS c a n c e r s
*Reference no. 1 presents the full report of a National Cancer Institute Study on cancer of the uterus: a rates study, interview study, and pathology study. "~Presented at the "Second International Symposium on the Biological Characterization of H u m a n Tumours", Rome, April 24--26, 1967.
491
492
Lucia o7. Dunham
nancies. The factors that characterize the patients in the control groups in a study are the basis for the comparisons with the cancer patients. The way that the control patients were selected to represent the total background population of patients with cancer of the cervix has varied from one interview-type study to another. Control patients are often selected from the same hospitals or clinics as the cancer patients, in the same age groups, at the same socio-economic levels, or are matched by marital status, number of pregnancies, or these in various combinations. Differences in results and conclusions between studies are in part due to differences in the characteristics of the control groups. Our National Cancer Institute interview study comprised 338 white non-Jews and 96 Jews with cancer of the cervix, and corresponding control groups of 594 and 1583 patients [1]. We selected the control patients for interview from the same age groups and the same hospitals as the cancer patients. We interviewed the large numbers of control patients both in New York City and in Israel, to improve stability in comparisons of factors with those of the cancer patients, especially since there were comparatively few Jewish patients with cancer of the cervix. There were additional control groups, 164 white non-Jews and 230 Jews with cancer of the corpus, an(] 440 Israeli Jews with cancer of the breast and 65 Israeli Jews with cancer of the ovary. The factors of all control patients were compared with those of patients with cancer of the cervix. At the same time as the interview study, the incidence rates were established, and there was a review and classification of the pathologic diagnoses of more than 98% of the patients with cancer of the cervix who were interviewed. Data on constitutional and environmental factors of patients were analyzed. Direct
associations were not found with most of the factors studied, such as aspects of marriage and marital practises, characteristics of the menstrual history, the history of diseases, operations and treatments related to the female genital and endocrine gland systems, and characteristics of the pregnancy history (Table 1). Uncircumcised male partners were associated with cancer of the cervix in one of three population groups of patients only. The association was noted in relation to control patients without cancer, but not in relation to patients with cancer of the corpus. In most past studies there has been agreement that cancer of the cervix is somewhat related, statistically, to early age at first marriage or at first intercourse. With the exception of the Jews in New York City there were larger percentages with ages at first intercourse under 20 years among patients with cancer of the cervix than among control patients. It is doubtful that it can be concluded from these data that first intercourse at an early age causes cancer of the cervix. More than half of the patients with cancer of the cervix, except for Sephardi-Orientals, did not have the early ages at first intercourse below 20 years; that is, numerous individual patients did not report the associated factor, and something else must have caused their cancer. The late Dr. Harold F. Dorn, failed to find a relationship of the risk of cervical cancer to the strength of the factor, first intercourse at early ages [16]. The analysis was extended to determine whether factors studied led to comparatively young ages at diagnosis of cancer of the cervix in white nonJews, but no such effects were found. In theory, if a factor is carcinogenic, its presence should shorten the induction time of the cancer. The latent period of the induction time of cancer of the cervix was not affected, either by early age at first intercourse or by uncircumcised male partners, or other factors analyzed.
Table 1. Factors in NCI study not significantly associated with cancer of cervix Widowhood, divorce, separation Semipermanent extramarital relationships More than one marriage Frequent intercourse Practice of ritual laws of Niddah (Jewish women) Abstinence from intercourse in relation to menses Use of contraceptives Age at menarche or menopause Characteristics of the menstrual cycle Selected past diseases, surgical operations, and types of treatment Age at first or last pregnancy Number of pregnancies; crowding of pregnancies Trimester at termination of pregnancy; method of delivery
Epidemiology of Tumours of the Uterine Cervix 50
I
I
I
I
493
l
z
o
40
f . . . . .
J
o. 0
-.
/
30-
I
0 o
1
o
/
/
~..
\
Non-Jewish White, New York City
_
"'x \
l
¢:
20
'~
I0
/
Jew, New York City
/
/ '
15,.24
25-54
"
:55-44
"
45-54
55-64
)\] 65-74
75+
AGE
Fig. I. Cancerof the uterine cervix by age. Incidenceratesfor non-Jewish white women and three groups of Jewish women, 1952-1953. One of the interesting aspects of the study was the inter-relationship and interdependence of factors related to social and sexual history. Age at first intercourse and circumcision status of partners were related to each other, the percentages of circumcised partners being smaller for the groups with younger than for those with older ages at first intercourse. Median ages at first marriage were considerably younger for all those patients in the study who had more than one marriage than for those patients who had a single marriage only. Three and more pregnancies were associated with first intercourse under age 20, and we found m a n y additional factors that have been suggested as causes of cancer of the cervix that were closely related with each other. An important part of the National Cancer Institute study was the comparison among the Jewish women in New York City and the Jewish women of Israel. These are three culturally different groups of women, two living within the confines of Israel, Israeli
Table 2.
Ashkenazi Jews and Israeli Sephardi-Oriental Jews. The Israeli Ashkenazi had emigrated mainly from Western and Northern European countries, while the Sephardi-Orientals came from parts of the Near East, South-Eastern Europe, and Africa. Rates of cancer of the cervix were almost the same in the three groups, 4.1 in New York City Jews, and 4.7 and 4.9 respectively in the two groups of Israeli Jews. Incidence rates by age of cervical cancer in the three groups of Jews were similar, with the peak incidence at about 65 to 74 years, between 10 and 20 years later than for white non-Jews in New York City (Fig. 1). We assembled the data on a number of factors in the large control groups of Jewish women (Table 2), the data presumably representing cultural characteristics of these population groups. T h e New York City Jews differed from the Ashkenazi Jews in the percentages of nevermarried women, first marriage before age 20, first pregnancy before age 25, and total pregnancies 5 or more. There were still
Cultural factors qf oTewish control patients in percentages Israeli Jews New York City Jews
Never married First marriage before age 20 Non-practice of laws of Niddah Married never pregnant First pregnancy before age 25 Total pregnancies, 5 or more No formal education Education at ninth grade level, and above
5.3 23 "4 No. into. 12.8 56.2 2 I. 3 6-9 45.6
Ashkenazi 2.1 17.0 68.5 10-6 45.9 30.3 5.5 46.9
SephardiOrientals 1-3 47-6 48.0 6.5 73.2 58.3 45.0 17.3
494
Lucia 07. Dunham
greater differences between the two subgroups of Israeli Jews, and nearly three times as m a n y of the Sephardi-Oriental as Ashkenazi women reported first marriage before age 20, and also much larger percentages of women in this population reported first pregnancy before age 25 and total pregnancies of five or more. Education grade levels of Ashkenazi and
Sephardi-Orientals were widely different. Our conclusions are that the cultural differences between the three groups of Jewish women did not affect the risks of cervical cancer. Possibly Jews have some degree of genetically determined resistance to cancer of the cervix, but this is unproved.
RESUME Le cancer du col ut&in a ses caract&istiques propres, distinctes de celles de tout autre cancer: (1) II est rare chez les mamm~res autres que l'homme. (2) // est plus frdquent dans les pays en vole de d&eloppement que dans les pays gvolugs, dans les populations urbaines que dans les populations rurales, dans les rdgions a forte population industrielle que dans ceUes or, la population est moins dense, ainsi que dans les classes sociales et gconomiques infgrieures. Il est relativement frgquent chez les Noirs et assez rare chez les Juifs, ~ l'exception des Juifs d'Afrique du Word. (3) Une plus grande proportion de malades atteintes de cancer du col ut&in que de patientes souffrant d'autres types de cancer prgsentent certaines caract&istiques li&s au mariage et aux pratiques sexuelles, permettant dYtablir une dventuelle corrdlation entre ceux-ci et la prdsence du cancer. Cenpendant, on a ddmontrd que les risques de cancer du col ne sont pas augment& par la pr&ence des facteurs qui ont dtd gtudi&. Les taux de cancer du col ut&in ne sont pas sup&ieurs chez les Juifs oi~ ces caracteristiques existent que dans d' autres groupes de Juifs. Chez les non-Juifs, la prdsence d' un facteur extrins~que n' entra~ne pas de dgveloppement prdmaturd de cetteforme de cancer. Le cancer du col est tr& probablement da a l'influence de facteurs externes, mais nous n'avons pas encorepu dgterminer ses causes exactes.
SUMMARY Cancer of the cervix has its own distinctive characteristics, separatefrom any other cancer: (1) It is infrequent in mammals below man. (2) It is more frequent in developing than developed countries, urban than rural populations, dense than less dense industrial populations, and at low than high socioeconomic levels. It is relativelyfrequent in Negroes and relatively infrequent in Jews, with the possible exception of Jews in North Africa. (3) Slightly larger proportions of patients with cancer of the cervix than corresponding control patients have reported certain factors related to marriage and sexual practices. However, the risk of cancer of the cervix was not enhanced by the presence of the factors that were investigated. Rates in groups of Jews with large proportions of some of these factors were not greater than rates in other groups of Jews. In non-Jews the presence of a factor did not cause the cancer to develop at an earlier age. Cancer of the cervix is very likely an "environmental" cancer at least in part, but we do not know its causes.
ZUSAMMENFASSUNG Das Kollumkarzinom ist haupts&hlich eine Krankheit der Menschen. Das hiiehste Risiko besteht in Lateinamerika und in einigen Gebieten von Afrika und Asien. Ausserdem ist das KoUumkarzinom verhaltnismdssig hi~ufig bei Negerinnen in den Vereinigten Staaten. Das niedrigste Risiko besteht in Israel, Nordamerika, Australien, Neuseeland und Europa, besonders Polen und Irland. Neue Angaben aus Nordafrika deuten darauf him, dass Krankheit durchaus nicht so selten unter Jiidinnen in Nordafrika ist wie unter Jiidinnen in Israel. Verschiedene Umstiinde, die mit geographischen, kultureUen, sozialen und sexueUen Gegebenheiten assoziiert sind, werden untersucht. Die Giiltigkeit dieser
Epidemiology of Tumours of the Uterine Cervix Assoziationen scheint bei den vershiedenen Studien zu variieren, zum Teil wegen der verschieden yon den Forschern angewandten Methoden. Die Ergebnisse der Untersuchung uber den Gebarmutterkrebs des National Cancer Institute unterstuetzen nicht die Annahme, nicht dass irgend einer der gepriiften Faktoren das Kollumkarzinom verursacht. REFERENCES I. H . L . STEWART, L. J. DUNHAM,J. CASPER, H. F. DORN, L. B. THOMAS,J. H. ]~DOCOMB and A. SYMEONIDIS,Epidemiology of cancers of uterine cervix and corpus, breast and ovary in Israel and New York City. 07. nat. Cancer Inst. 37, I (1966). 2. E. COTCHIN, Spontaneous uterine cancer in animals. Brit. 07. Cancer 18, 209, (1964). 3. L . J . DUNHAMand J. C. BAILAR,III. World maps of cancer mortality rates and frequency ratios. To be published. 4. F. ARDOIN, Bilan de trois anndes d'6tude statistique du cancer au Maroe, 19541957. Personal communication of unpublished data. 5. M . J . BREHANTand MME. MUSSlNI-MONTPELLIER,Esquisse de la physionomie du cancer en Alg6rie. Bull Acad. nat. Mid. (Paris) 1't5, 536 (1961). 6. A. CHADLIand E. PHILIPPE, La physionomie du cancer en Tunisie. Arch. Inst. Pasteur Tunis 37, 397 (1960). 7. J. C. BAILAR III and S. L. RICE, Geographic variadon in uterine cancer incidence in Connecticut. Publ. Hlth Rep. (Wash.) 77, 157 (1962). 8. J. CLEMMESENand A. NIELSEN,The social distribution of cancer in Copenhagen, 1943 to 1947. Brit. 07. Cancer 5, 159 (1951). 9. W. M. HAENSZEL,S. C. MARCUS and E. G. ZIMMERER,Cancer morbidity in urban and rural Iowa. Pub. Health Monograph No. 37, U.S. Government Printing Office, Washington, D.C. (1956). 10. P. STOCKS, Cancer of the uterine cervix and social conditions. Brit. 07. Cancer 9, 487 (1955). 11. F. GAGNON,Etat marital et grossesse dans l'~closion du cancer du col de l'ut~rus. Laval todd. 20, 654 (1955). 12. R. S. TAYLOR, B. E. CARROLLand J. W. LLOYD, Mortality among women in 3 Catholic religious orders with special reference to cancer. Cancer 12, 1207 (1959). 13. New York State Department of Health, Bureau of Cancer Control. Annual Report (1955). 14. A. CmESSERI, L. GIANF~RRAm, P. MALCOVATI, G. MORGANTI and P. E. BEOLGHINI,Genetical researches on uterine cancer. Acta. genet. (Basel) 6~ 301 (1956). 15. M. T. MACKLIN, Etiologic factors in carcinoma of the uterus, especially the cervix. J. int. Coll. Surg. 21, 365 (1954). 16. H. F. DORN, Some problems arising in prospective and retrospective studies of the etiology of disease. New Engl. 07. Med. 261, 571 (1959).
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