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International Variations in Bladder Cancer Incidence and Mortality
EUROPEAN UROLOGY 66 (2014) 59–73
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Review – Bladder Cancer Editorial by Lambertus A. Kiemeney on pp. 74–75 of this issue
International Variations in Bladder Cancer Incidence and Mortality Saurabh Chavan a, Freddie Bray b, Joannie Lortet-Tieulent a,b, Michael Goodman c, Ahmedin Jemal a,* a
American Cancer Society, Atlanta, GA, USA; b Section of Cancer Information, International Agency for Cancer Research, Lyon, France; c Emory University,
Atlanta, GA, USA
Article info
Abstract
Article history: Accepted October 5, 2013 Published online ahead of print on October 16, 2013
Context: Previous studies have reported substantial worldwide regional variations in bladder cancer (BCa) incidence and mortality. Objective: To describe contemporary international variations in BCa incidence and mortality rates and trends using the most recent data from the International Agency for Research on Cancer (IARC). Evidence acquisition: Estimated 2008 BCa incidence and mortality rates for each country by sex were obtained from GLOBOCAN. Recent trends in incidence for 43 countries and in mortality for 64 countries were assessed by join-point model using data from the IARC’s Cancer Incidence in Five Continents and from the World Health Organisation’s mortality database, respectively. Evidence synthesis: The highest incidence rates for both men and women are found in Europe, the United States, and Egypt, and the lowest rates are found in sub-Saharan Africa, Asia, and South America. Mortality rates are highest in parts of Europe and northern Africa and lowest in Asia, Central America, and middle Africa. Incidence rates among men decreased in 11 of 43 countries (46 registries) (North America, western and northern Europe), remained stable in 20, and increased in 12 countries (southern, central, and eastern Europe). Among women, incidence rates decreased in 10 countries, stabilised in 22 countries, and increased in 12 countries. Mortality rates among men decreased in 32 of 65 countries (throughout all world regions except Central and South America), stabilised in 30 countries, and increased in 3 (Romania, Slovenia, and Cuba). Among women, mortality rates decreased in 24 countries, remained stable in 36 countries, and increased in 5 countries (central and eastern Europe). Conclusions: Incidence and mortality rates in general decreased in most Western countries but increased in some eastern European and developing countries. These patterns in part may reflect differences in the stage and extent of the tobacco epidemic, changes in coding practices, prevalence of schistosomiasis (Africa), and occupational exposure. # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords: Urinary bladder cancer Trends Incidence Mortality Schistosoma haematobium Registries Epidemiology
* Corresponding author. American Cancer Society, 250 Williams Street NW, Atlanta, GA 30303, USA. Tel. +1 404 329 7557; Fax: +1 404 327 6450. E-mail address: [email protected] (A. Jemal).
0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.10.001
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1.
EUROPEAN UROLOGY 66 (2014) 59–73
Introduction
Bladder cancer (BCa) is the 11th most commonly diagnosed cancer and the 14th leading cause of cancer deaths worldwide, with an estimated 382 700 new cases and 150 300 deaths in 2008 [1]. Incidence and mortality rates vary globally, mainly due to differences in risk factors. Wellestablished risk factors for BCa include tobacco use, infections with Schistosoma haematobium, and occupational exposures to aromatic amines and polycyclic aromatic hydrocarbons [2,3]. Other suspected risk factors for BCa include dietary patterns, environmental pollution, and genetic predisposition [3]. While smoking is the predominant cause of BCa in the United States, infection with S. haematobium is the major cause of the disease in most parts of Africa [4]. Previous studies of international patterns in BCa rates are limited because they are confined to specific geographic regions or based on rather old data [5–8]. In this paper, we present the contemporary information on variation in BCa rates and trends worldwide by using the GLOBOCAN 2008 data [1], Cancer Incidence in Five Continents (CI5) [9], and the World Health Organisation (WHO) mortality data [10] for five continents (Africa, Asia, Oceania, Europe, and the Americas) from the International Association on Research on Cancer (IARC) website [11]. 2.
Evidence acquisition
Data on estimated BCa incidence and mortality rates (per 100 000 person-years) for the year 2008 for each country were obtained from GLOBOCAN 2008 [1]. GLOBOCAN is an IARC database that provides estimates of incidence, mortality, prevalence, and disability-adjusted life years for major type of cancers at a national level for 184 countries. These estimates were prepared using methods that are described elsewhere in detail, and they depend on the availability and accuracy of the incidence and mortality data for each individual country [12]. Observed BCa incidence rates for 88 national or regional registries were obtained from the CI5 series [9], and these data were supplemented with the most recent information from the registries’ websites, where available. Overall incidence data for 43 countries (national, regional, or local registries) were analysed, with varying time periods ranging from 10 yr to 31 yr from 1985 onwards. Incidence was coded according to the International Classification of Diseases (ICD) in use at the time of diagnosis and converted to the 10th revision code (C67) [13]. IARC also abstracts mortality data from the WHO mortality database, which covers nearly 30% of the world population (country-specific coverage ranges from <10% for China to 100% for most developed nations such as France, Germany, and the United States) [10]. We analysed BCa mortality trends for 65 countries from 1985 onwards, with data years ranging from 18 yr to 26 yr. BCa as the underlying cause of death was selected according to the version of the ICD codes and the selection rules in use at the time of death (ICD-7 through ICD-10).
We calculated average age-standardised rates by country or registry for the years 2000–2006 (mortality) for the purpose of synthesising global temporal developments in BCa. Temporal trends in age-standardised cancer incidence and death rates were analysed using join-point regression, which involves fitting a series of joined straight lines to the trends in the annual age-standardised rates, with at least three data points between changes in join points [14]. Up to three join points were allowed in models for the long-term trend analyses (1980s to the 2000s) [14] and two joint points for the short-term trend analyses (last 10 yr of available data). The number of join points (inflexion points) is determined by the number of intervals available to identify the years in which there was a statistically significant change in the trends using a Monte Carlo permutation method [14]. For the long-term trend analysis, data with three join points will have four trends (trend 1, trend 2, trend 3, trend 4), those with two join points will have three trends (trend 1, trend 2, trend 3), those with one join point will have two trends (trend 1, trend 2), and those with no join points will have one trend (trend 1). The resulting trends of varying time periods were described by the slope of the line segment or annual percentage change (APC). Trends for the last 10 yr of data from the join-point model were summarised using average APC (AAPC) to describe country-specific contemporary trends and to compare these trends across countries. The AAPC is estimated as the geometric weighted average of the different APCs from the previous join-point trend analysis, with the weights being equal to the length of each segment during the specified time interval [15]. The terms increase and decrease were used to describe the direction of the statistically significant change, and the term stable was used if the AAPC was not statistically significant. The World Standard Population [16] was used to age-standardise all of the rates to facilitate the comparison of data across all countries. 3.
Evidence synthesis
A total of 382 700 new BCa cases (294 400 in men and 88 300 in women) and 150 300 cancer deaths (112 300 in men and 38 100 in women) were estimated to have occurred worldwide (Table 1). Age-standardised rates (per 100 000 person-years) were more than three times as high in men than in women for both incidence (8.9 vs 2.2) and mortality (3.3 vs 0.9). Incidence and mortality rates significantly varied by world region for both men and women. In men, for example, rates ranged from 1.5 in middle Africa to >20 in southern Europe and North America for incidence and from 1.2 in middle Africa and Central America to nearly 10 in northern Africa for mortality. 3.1.
Geographic variation in the incidence and mortality rates
In 2008, estimated incidence rates per 100 000 person-years were highest at 29.7 in Israel among men and at 7.8 in Iceland among women. Generally, the highest estimated incidence rates in 2008 in both men and women were found
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 1 – Estimated number of new bladder cancer cases and deaths, all ages in both sexes, by world areas, 2008 [1] Area
Cases Both sexes
Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Eastern Asia South central Asia South eastern Asia Western Asia The Caribbean Central America Northern America South America Central and Eastern Europe Northern Europe Southern Europe Western Europe Australia/New Zealand Melanesia Micronesia/Polynesia World
Deaths
Men
Women
Both sexes
Men
Women
n
ASR
n
ASR
n
ASR
n
ASR
n
ASR
n
ASR
3900 500 12 000 1600 4000 78 900 27 700 13 400 11 600 1800 2900 73 200 14 200 36 800 17 600 37 000 42 200 3000 70 30 382 700
2.5 0.8 8.2 4.2 2.6 3.8 2.2 2.7 7.4 3.7 2.2 12.0 3.7 7.2 8.2 11.2 9.8 6.3 1.6 3.5 5.3
2400 400 10 200 1100 2900 60 800 21 600 9800 9600 1300 2100 54 500 10 700 28 700 12 900 30 500 32 500 2300 60 30 294 400
3.4 1.5 14.5 7.3 3.9 6.2 3.6 4.5 13.1 5.8 3.5 20.1 6.3 14.6 13.7 20.7 17.2 10.5 2.7 6.7 8.9
1500 100 1800 500 1200 18 100 6100 3600 2000 500 800 18 700 3500 8100 4700 6600 9700 800 10 4 88 300
1.8 0.3 2.4 2.1 1.4 1.6 0.9 1.3 2.4 1.9 1.1 5.5 1.6 2.6 3.8 3.3 3.9 2.7 0.5 0.8 2.2
2800 400 7900 1000 2900 29 800 15 800 7100 5900 900 1200 16 000 6500 16 800 7500 13 600 13 200 1100 50 10 150 300
1.9 0.7 5.5 2.7 2.0 1.3 1.3 1.5 3.8 1.7 0.8 2.2 1.6 3.0 2.9 3.3 2.5 2.0 1.2 1.1 2.0
1700 300 6600 700 2100 22 000 12 400 5200 4700 600 700 11 300 4500 13 400 5000 10 900 9400 800 40 10 112 300
2.6 1.2 9.9 4.9 3.1 2.1 2.1 2.4 6.7 2.5 1.2 3.7 2.6 6.5 4.7 6.2 4.4 3.1 2 2.4 3.3
1100 100 1200 300 900 7900 3400 1900 1100 300 400 4700 2000 3400 2400 2800 3800 400 10 0 38 100
1.3 0.2 1.6 1.3 1 0.6 0.5 0.7 1.3 1 0.5 1.1 0.9 0.9 1.6 1.1 1.2 1.1 0.4 0 0.9
ASR = age-standardised rate per 100 000 person-years. Numbers are rounded to the nearest 10 or 100 and may not sum up to total.
in most parts of Europe, North America, Oceania, and northern Africa, whereas the lowest rates were found in sub-Saharan Africa and south-central Asia and most of South America for both men and women (Fig. 1a and 1b). In Egypt, BCa is the most commonly diagnosed cancer in men. Estimated mortality rates per 100 000 person-years in 2008 were highest at 16.3 in Egypt among men and at 4.5 in Mali among women. The highest estimated mortality rates in 2008 occurred in southern, central, and eastern Europe, northern Africa, and western Asia in men and in parts of eastern Europe, northern and eastern Africa, and western Asia in women (Fig. 2a and 2b). The mortality rates were lowest for most parts of Africa, Oceania, the Americas, and most parts of Asia in both men and women. Incidence rates (per 100 000 person-years) for the period 2000–2006 for selected registries or countries ranged from 0.5 to 8.3 for men, with the lowest rates found in South American and Asian countries and the highest rates reported in Europe (Fig. 3a). The range for the mortality rates among women was lower (0.2–2.4) (Fig. 3b); however, the regional patterns were generally similar. 3.2.
Incidence and mortality trends
Table 2a and 2b show temporal trends in incidence rates for men and women for varied time periods from 1985 onwards, with the data for 32 selected countries portrayed in Figure 4a and 4b; however, we describe country- or region-specific trends (AAPC) based on the last 10 yr of available data. By country, the largest significant increase in incidence rates was observed in Croatian men (4.3% per year) and Bulgarian women (6.7% per year) (Table 3a and 3b, Fig. 5), whereas the largest decreases during the
corresponding time intervals were found in France among men (5.2% per year) and in Germany among women (8.4% per year). For mortality, the largest significant decrease was found in Kazakhstan and Egypt in both men and women, and the largest significant increase was found in Brazil and Poland for women and in Cuba for men (Table 3a and 3b, Fig. 5). The following sections present incidence and mortality trends by region. 3.2.1.
North America
BCa incidence rates in Canada decreased by 1.2% per year in men and 0.9% per year in women over the 1993–2002 period. In the United States, rates decreased by 0.6% per year in men and by 1.4% per year in women over the 2000–2009 period. Mortality rates decreased by 0.4% per year in both US men (1999–2008) and US women and by 0.7% per year in Canadian men (2000–2009) but remained stable in Canadian women. 3.2.2.
Central and South America and the Caribbean
In Central and South America, over the 1993–2002 period, stable trends were observed with the exception of Costa Rican women, in whom incidence rates increased by 2.7% per year. Mortality trends were stable in Central and South American countries, except in Argentina (2001– 2010) and Trinidad and Tobago (1993–2002), where rates decreased in both sexes, and in Cuban men and women (2001–2010) and Brazilian women (1999–2008), in whom rates increased. 3.2.3.
Western Europe
Most of the region recorded significantly decreasing incidence rates ranging from 1.0% per year for Dutch
[(Fig._1)TD$IG]
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EUROPEAN UROLOGY 66 (2014) 59–73
Fig. 1 – Estimated international variation in age-standardized (world) bladder cancer incidence rates for all ages (a) in men and (b) in women. Data are from GLOBOCAN 2008 [1].
men (1999–2008) to 8.4% per year for German women (1993–2002). The only increase was in Dutch women at 2.1% per year. Mortality rates decreased for both men and women in all six western European countries included in this analysis. However, these decreases were less pronounced in women, ranging from 0.5% per year in the Netherlands (2001–2010) to 2.8% per year in Luxembourg (2000–2009), compared with 1.8% and 3.9% observed for men in the Netherlands (2001–2010) and Germany (2001–2010), respectively.
3.2.4.
Northern Europe
No consistent pattern was observed in this region. Incidence rates increased in the Baltic states of Estonia and Latvia by 3.4% and 2.5% per year (1993–2002), respectively, in men and by 2.7% and 2.4% per year, respectively, in women. In contrast, rates decreased in both men and women in Denmark, Finland (both in 2001–2010), and the United Kingdom (1998–2007). In Ireland (1998–2007) and Iceland (2001–2010), trends in incidence rates were stable in both men and women. Mortality rates decreased for both men and
EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._2)TD$IG]
63
Fig. 2 – Estimated international variation in age-standardized (world) bladder cancer mortality rates for all ages (a) in men and (b) in women. Data are from GLOBOCAN 2008 [1].
women for 5 of the 12 countries considered in this analysis. Rates decreased among men in Denmark (1997–2006), Ireland (2001–2010), and Sweden (2001–2010) and also in Icelandic women (2000–2009). Mortality rates were stable in both men and women in Estonia (2001–2010) and in Latvia and Lithuania (both 2001–2010). 3.2.5.
Southern Europe
Incidence rates among both men and women increased in Croatia (1993–2002), Slovenia (1999–2008), and Spain
(1991–2000). However, rates in Italian men and women were stable (1993–2002). Greece (2000–2009) and Italy (1994–2003) were the only two southern European nations to show a decrease in BCa mortality for both men and women. For men, rates also decreased in Spain at an average of 1.1% per year (2001–2010). Rates were stable in women from Spain and Slovenia (2001–2010) and in both men and women of the remaining southern European countries, including Portugal (2000–2009), Malta (1991–2000), and Croatia (2001–2010).
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EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._3)TD$IG]
a
Spain Poland Latvia Lithuania Denmark Russian Federation Malta Czech Republic Greece Egypt Croatia Slovenia France Slovakia The Netherlands United Kingdom Norway Bulgaria Israel Germany Austria Switzerland Cuba New Zealand United States South Africa China, Hong Kong Japan Brazil Singapore Kuwait Trinidad and Tobago Colombia Barbados Mexico Ecuador Thailand Nicaragua 0.0
0.8 0.7 0.5
2.6 2.5 2.3 2.1 2.0 1.8
1.4 1.2 1.2
1.0
2.0
4.1 3.9 3.7 3.7
3.0
3.0
Northern Europe North America Oceania
4.0
4.4 4.4
4.8 4.7
5.2 5.1
7.2 7.0 7.0 6.8 6.6 6.4 6.3 6.1 6.0 5.8 5.7 5.7
5.0 6.0 ASR (W) per 100 000
Central and Eastern Europe Central and South America Asia
7.0
8.3 8.3
7.6
8.0
Western Europe Caribbean
9.0
Southern Europe Africa
b Denmark United Kingdom Kuwait The Netherlands Norway Czech Republic Switzerland Slovenia Poland Germany Egypt Croatia Israel Cuba Austria United States Slovakia New Zealand Lithuania Latvia France Bulgaria Spain Malta Greece South Africa Russian Federation Brazil Japan China, Hong Kong Singapore Colombia Trinidad and Tobago Mexico Ecuador Barbados Nicaragua Thailand
0.2
0.3
0.4 0.4
0.0
0.5 0.5
0.5
Northern Europe North America Oceania
0.6 0.6
0.7 0.7
0.8 0.8
0.9
1.0 1.0 1.0
1.0
1.1 1.1 1.1 1.1 1.1 1.1 1.1
1.2 1.2 1.2
1.6 1.6 1.6
1.3 1.3 1.3 1.3 1.3 1.3
1.5 ASR (W) per 100 000
Central and Eastern Europe Central and South America Asia
Western Europe Caribbean
2.4
1.8 1.8
2.0
2.5
Southern Europe Africa
Fig. 3 – Bladder cancer mortality for all ages for select registries, 2000–2006, (a) in men and (b) in women. Data are from the World Health Organization mortality database [10]. ASR (W) = age-standardized rate (world). *Average of rates for =7 yr in the time period 2000–2006.
3.2.6.
Central and Eastern Europe
Incidence rates increased in both men and women in four of the six countries included in the analysis, with the largest increase occurring in Bulgarian women at 6.7% per year and
Bulgarian men at 4% per year (1999–2008) (Table 2a and 2b). Rates remained unchanged in Poland (1993–2002) and the Czech Republic (1999–2008). Nations of central and eastern Europe showed variable trends in BCa mortality
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 2 – Trends in bladder cancer incidence rates for (a) men and (b) women of all ages from selected registries and Cancer Incidence in Five Continents (national and regional data) [9] (a) Join-point analyses Trend 1 Years North America Canada (regional) United States Central and South America Brazil, Goiania a Colombia, Cali Costa Rica Ecuador, Quito Western Europe Austria a France (regional) a Germany, Saarland The Netherlands a Switzerland (regional) Northern Europe Denmark Estonia Finland Iceland Ireland a Latvia Lithuania Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom, Wales a United Kingdom a Southern Europe Croatia a Italy (regional) a Slovenia Spain (regional) Central and eastern Europe Belarus Bulgaria a Czech Republic Poland (regional) a Russian Federation a Slovakia Asia China (regional) a India (regional) Israel Japan (regional) Jordan a Philippines, Manila Republic of Korea b Saudi Arabia a Singapore Thailand, Chiang Mai Oceania Australia New Zealand
Trend 2 APC
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
1985–2002 1985–2009
1.2* 0.6*
1993–2002 2000–2009
1.2* 0.6*
1993–2002 1985–2002 1985–2002 1985–2002
3.3 1.3 0.9 0.9
1993–2002 1993–2002 1993–2002 1993–2002
3.3 1.3 0.9 0.9
2000–2009 1993–2002 1985–1996 1999–2001 1985–2002
0.8 5.2* 1.5 4.4* 1.6*
2000–2009 1993–2002 1993–2002 1999–2008 1993–2002
0.8 5.2* 7.4 1.0* 1.6*
1985–1998 1985–2002 1985–1993 1985–2010 1998–2007 1985–2002 1985–2002 1985–1994 1985–2009 1985–1993 1985–1996 1999–2006 1998–2002
0.0 3.4* 1.8* 0.1 0.1 2.5* 3.9* 3.9* 0.2* 0.3 0.4 1.2 7.2*
2001–2010 1993–2002 2001–2010 2001–2010 1998–2007 1993–2002 1993–2002 2000–2009 2000–2009 1993–2002 1999–2008 1999–2008 1998–2007
1.9* 3.4* 1.7* 0.1 0.1 2.5* 3.9* 0.0 0.2* 5.3* 3.2* 6.6* 4.2*
1993–2002 1993–1995 1985–2008 1985–2000
4.8* 2.4 3.2* 2.7*
1993–2002 1993–2002 1999–2008 1991–2000
4.8* 0.1 3.2* 2.7*
1985–1988 1999–2008 1985–1995 1993–2002 1999–2008 1985–2000
9.2* 4.0* 4.3* 1.0 0.5* 0.2
1993–2002 1999–2008 1999–2008 1993–2002 1999–2008 1998–2007
1.7* 4.0* 0.2 1.0 0.5* 2.1*
1993–2002 1985–1994 1985–1991 1985–2002 1998–2001 1985–2002 1999–2007 1999–2008 1985–2007 1985–2002
1.3* 3.9* 5.8* 0.1 14.3 0.2 0.4 3.8* 0.1 0.1
1993–2002 1993–2002 1998–2007 1993–2002 1998–2007 1993–2002 2003–2007 1999–2008 1998–2007 1993–2002
1.3* 2.3 0.4 0.1 1.6 0.2 0.4 3.8* 0.1 0.1
1985–2008 1985–2002
2.7* 1.2
1999–2008 1999–2008
2.7* 9.8*
1996–1999 2001–2008
24.6 0.0
1998–2010
1.9*
1993–2010
1.7*
1994–2009
0.0
1993–1999 1996–1999 2006–2008 2002–2007
3.0* 18.3* 23.4* 1.8
1995–2002
0.8*
1988–2002
1.7*
1995–2008
0.2
2000–2007
2.7*
1994–2002 1991–2007
3.1 0.4
2001–2007
5.4*
2002–2008
14.8*
1999–2002
3.6
9.7* 3.2*
1999–2002 1999–2008
(b) Join-point analyses Trend 1 Years North America Canada (regional)
1985–2002
Trend 2 APC
0.9*
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
1993–2002
0.9*
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 2 (Continued ) (b) Join-point analyses Trend 1
United States (SEER) Central and South America Brazil, Goiania a Colombia, Cali Costa Rica Ecuador, Quito Western Europe Austria a France (regional) a Germany, Saarland The Netherlands a Switzerland (regional) Northern Europe Denmark Estonia Finland Iceland Ireland a Latvia Lithuania Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom, Wales a United Kingdom a Southern Europe Croatia a Italy (regional) a Slovenia Spain (regional) Central and eastern Europe Belarus Bulgaria a Czech Republic Poland (regional) a Russian Federation a Slovakia Asia China (regional) a India (regional) Israel Japan (regional) Jordan a Philippines, Manila Republic of Korea b Saudi Arabia a Singapore Thailand, Chiang Mai Oceania Australia New Zealand
Trend 2
Years
APC
Years
1985–1999
0.0
1999–2009
1993–2002 1985–2002 1985–2002 1985–2002
Trend 3 APC
Years
Trend 4 APC
Years
APC
Last 10 yr 2000–2009
1.4*
3.0 1.6 2.7* 1.0
1993–2002 1993–2002 1993–2002 1993–2002
3.0 1.6 2.7* 1.0
2000–2009 1993–2002 1985–1995 1999–2008 1985–2002
0.3 5.2* 4.5 2.1* 1.2
2000–2009 1993–2002 1993–2002 1999–2008 1993–2002
0.3 5.2* 8.4* 2.1* 1.2
1985–2010 1985–2002 1985–1992 1985–2010 1998–2007 1985–2002 1985–1999 1985–2009 1985–2009 1985–1998 1985–1996 1999–2006
0.6* 2.7* 4.4* 0.1 1.5 2.4* 5.3* 1.7* 0.2 0.6 1.2* 0.9
2001–2010 1993–2002 2001–2010 2001–2010 1998–2007 1993–2002 1993–2002 2000–2009 2000–2009 1993–2002 1999–2008 1999–2008 1998–2007
0.6* 2.7* 1.7* 0.1 1.5 2.4* 1.4 1.7* 0.2 4.5* 1.1 7.3* 4.2*
1993–2002 1993–2002 1985–2008 1985–2000
5.6* 1.4 4.3* 2.0*
1993–2002 1993–2002 1999–2008 1991–2000
5.6* 1.4 4.3* 2.0*
1985–2002 1999–2008 1985–1996 1993–2002 1999–2008 1985–2007
2.4* 6.7* 6.7* 3.2 1.7* 1.7*
1993–2002 1999–2008 1999–2008 1993–2002 1999–2008 1998–2007
2.4* 6.7* 0.5 3.2 1.7* 1.7*
1993–2002 1985–2002 1985–1992 1985–2002 1998–2007 1985–2002 1999–2007 1999–2008 1985–2007 1985–2002
0.7 0.1 3.7 0.9* 2.0 0.8 0.5 1.1 0.2 0.8
1993–2002 1993–2003 1998–2007 1993–2002 1998–2007 1993–2002 2003–2007 1999–2008 1998–2007 1993–2002
0.7 0.1 1.4* 0.9* 2.0 0.8 0.5 1.1 0.2 0.8
1985–1992 1985–2003
5.3* 1.2*
1999–2008 1999–2008
3.6* 5.2
1995–2002
1.4*
AAPC
11.8*
1992–2010
1.7*
1999–2002
6.0
1998–2002 1996–1999 2006–2008
9.3* 19.7* 26.8*
1996–2008
1999–2008
1.1
0.5
1992–2007
1.4
1992–2002 2003–2006
1.4 27.9
*
2002–2008 2006–2008
4.6* 25.3
APC = annual percent change; AAPC = average annual percent change; SEER = Surveillance Epidemiology and End Results. The AAPC is statistically different from zero. a Last 10 yr of data only. b Last 9 yr of data only, AAPC for last 5 yr of data. *
rates. For example, in Romania (2001–2010), rates increased in men but decreased in women. In contrast, in Hungary (2000–2009), rates decreased in men but increased in women. Overall, rates decreased in men in four of the eight countries: the Czech Republic, Hungary, the Russian Federation, and Slovakia (all 2001–2010).
Rates increased for women in Bulgaria and Poland (both 2001–2010). 3.2.7.
Asia
BCa incidence rates remained stable in all Asian countries or regions considered in this analysis, except they
67
EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._4)TD$IG] a
Germany* Denmark Switzerland* Italy* Republic of Korea Singapore Austria United Kingdom France* Australia The Netherlands Russian Federation* Israel Costa Rica Slovakia Czech Republic Finland Spain* Norway Japan* Ecuador* Canada* United States (SEER) Lithuania Sweden Poland* Brazil* China* Latvia Colombia* Croatia Slovenia Bulgaria
-3.9
-1.9
-3.3
-1.6
-3.1 -3.1 -2.6 -2.5 -2.3
-4.2
-1.9
-5.2 -2.7
-1.9 -1.8 -1.8
-1.0 0.5
-1.7 -1.6
2.1
-1.6 -1.4 -1.7 -1.3
2.7
-1.1 -1.1
-1.2
-0.7 -0.6 -0.4
3.9
-0.2 -0.3
1.3 2.5 4.3 3.2
0.8
-11.0
-10.0
-9.0
-8.0
-7.0
-6.0
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
4.0
1.0
2.0
3.0
4.0
5.0
AAPC Mortality
Incidence
b Republic of Korea Germany* Austria Singapore Japan* Italy* United Kingdom Latvia Switzerland* France* Lithuania Finland Ecuador* Norway Israel Russian Federation* The Netherlands China* Costa Rica United States (SEER) Canada* Denmark Sweden Czech Republic Croatia Spain* Slovakia Australia Bulgaria Colombia* Slovenia Poland* Brazil*
-2.7
-8.4
-2.6 -2.2 -2.1
-0.9
-2.0 -1.8
-4.1
-1.7
2.4
-1.5
-5.2
-1.1 -1.7
-1.0 1.7
-1.4 1.7 2.1
-0.5
2.7 -1.4 -0.9
-0.4
-0.6
5.6 2.0 1.7 -3.6 6.7
0.8
-1.6
4.3 1.3 1.4
-10.0
-9.0
-8.0
-7.0
-6.0
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
AAPC Mortality
Incidence
Fig. 4 – Average annual percent change (AAPC) in incidence and mortality trends, all ages for last 10 yr of available data (a) in men and (b) in women. Values shown across the bars indicate the AAPC are statistically significant. SEER = Surveillance Epidemiology and End Results. * Incidence rates from regional registries.
increased in Saudi Arabian men (1999–2008) and Chinese men (1993–2002) and decreased in Israeli women (1998– 2007) and Japanese women (1993–2002), with the Saudi Arabian men showing the largest AAPC at 3.8% per year. In China, the mainland urban areas and the rural areas (1991–2000) had stable mortality rates in both men and women; however, residents of Hong Kong (2000–2009)
experienced decreasing mortality rates with AAPC of 3.4% for men and 3.8% for women. Rates also decreased for both men and women in Singapore (2000–2009), the Republic of Korea (2001–2010), and Israel (2000–2009) for men and in Japan (2001–2009) for women. Mortality rates remained stable for all of the other countries examined.
68
EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 – Trends in bladder cancer mortality rates in (a) men and (b) women of all ages from selected registries and the World Health Organisation mortality database [10] (a) Join-point analyses Trend 1 Years North America Canada United States Central and South America Argentina Brazil Chile Colombia Costa Rica Ecuador El Salvador a Guatemala a Mexico Nicaragua a Panama b Uruguay b Venezuela a Caribbean Cuba Trinidad and Tobago Western Europe Austria France Germany Luxembourg Switzerland The Netherlands Northern Europe Denmark Estonia a Finland Iceland Ireland Latvia a Lithuania a Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom Southern Europe Croatia FYROM a Greece Italy Malta Portugal Serbia a Slovenia Spain Central and eastern Europe Bulgaria Czech Republic Hungary Poland a Republic of Moldova a Romania Russian Federation Slovakia Asia China a China, Hong Kong China Rural a China Urban a
Trend 2 APC
Years
Trend 3 APC
Years
Trend 4 APC
Years
AAPC APC
Last 10 yr
1985–2009 1985–2008
0.7* 0.4*
2000–2009 1999–2008
0.7* 0.4*
1985–2010 1985–2008 1985–2009 1990–2009 1985–1997 1985–2010 1999–2008 1999–2008 1985–2010 1997–2006 1996–2004 1993–2001 1998–2007
1.9* 0.1 0.2 0.3 2.6* 0.7 8.5 1.3 0.0 3.1 1.3 1.7 0.9
2001–2010 1999–2008 2000–2009 2000–2009 2000–2009 2001–2010 1999–2008 1999–2008 2001–2010 1997–2006 2000–2004 1997–2001 1998–2007
1.9* 0.1 0.2 0.3 1.6 0.7 8.5 1.3 0.0 3.1 1.3 1.7 0.9
1985–2004 1985–2002
–0.5 3.9*
2001–2010 1993–2002
2.5* 3.9*
1985–2010 1985–1997 1985–1992 1985–2009 1985–2007 1985–2010
2.3* 0.6* 0.3 2.8* 3.1* 1.8*
2001–2010 2000–2009 2001–2010 2000–2009 1998–2007 2001–2010
2.3* 1.9* 3.9* 2.8* 3.1* 1.8*
1985–1998 2001–2010 1985–2010 1985–2009 1985–2010 2001–2010 2001–2010 1985–2010 1985–2010 1985–1992 1985–1989 1985–1992
0.8 0.5 1.3* 0.5 1.1* 0.2 0.3 1.1* 0.3* 0.6 2.9 1.1
1997–2006 2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
3.3* 0.5 1.3* 0.5 1.1* 0.2 0.3 1.1* 0.3* 1.7* 2.6* 1.9*
1985–2010 1994–2003 1985–2009 1985–1993 1985–2000 1985–2003 2000–2009 1985–2010 1985–1993
0.3 2.1 0.5* 0.4 1.0 0.2 0.5 0.8* 1.5*
2001–2010 1994–2003 2000–2009 1994–2003 1991–2000 1994–2003 2000–2009 2001–2010 2001–2010
0.3 2.1 0.5* 3.1* 1.0 0.2 0.5 0.8* 1.1*
1985–1995 1986–2010 1985–1991 2001–2010 2001–2010 1985–2010 2000–2002 1992–2010
1.4* 1.4* 1.5* 0.2 0.3 0.8* 1.6 0.5
2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.9 1.4* 1.1* 0.2 0.3 0.8* 1.7* 1.5*
1991–2000 1985–2009 1991–2000 1991–2000
0.2 3.4* 0.1 0.2
1991–2000 2000–2009 1991–2000 1991–2000
0.2 3.4* 0.1 0.2
1997–2000
19.9
2004–2010
4.1*
1997–2009 1992–2010
1.9* 3.9*
1998–2006
3.6*
1992–2005 1989–2010 1992–2005
3.0* 2.6* 0.5
2000–2002
1.6
2005–2010
0.6
2005–2010
3.0*
1993–1996
7.0
1996–2003
2.0*
1993–1996
2.3
1996–2003
0.5
2003–2010
1.5*
1995–2003
1.2
2003–2006
7.8
2006–2010
2.9
1991–2009
1.1*
2002–2010
2.2*
69
EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 (Continued ) (a) Join-point analyses Trend 1 Years Israel Japan Kazakhstan a Kuwait a Kyrgyzstan a Philippines a Republic of Korea Singapore Africa Egypt a Mauritius South Africa a Oceania Australia New Zealand
Trend 2 APC
1985–2009 1985–2001 2000–2009 2000–2009 2000–2009 1993–2002 1985–2002 1985–2009
1.6* 0.9* 9.0* 3.2 0.6 2.4 4.3* 2.5*
2001–2010 1985–1990 2000–2009 1985–2004 1985–2008
Years
Trend 3 APC
Years
Trend 4 APC
Years
AAPC APC
Last 10 yr 2000–2009 2001–2010 2000–2009 2000–2009 2000–2009 1993–2002 2001–2010 2000–2009
1.6* 0.7 9.0* 3.2 0.6 2.4 2.6* 2.5*
4.3* 2.7* 0.6
2001–2010 2001–2010 2000–2009
4.3* 2.7* 0.6
1.8* 1.6*
1995–2004 1999–2008
1.8* 1.6*
2001–2010
0.7
2003–2010
3.5*
(b) Join-point analyses Trend 1 Years North America Canada United States Central and South America Argentina Brazil Chile Colombia Costa Rica Ecuador El Salvador a Guatemala a Mexico Nicaragua a Panama b Uruguay b Venezuela a Caribbean Cuba Trinidad and Tobago Western Europe Austria France Germany Luxembourg Switzerland The Netherlands Northern Europe Denmark Estonia a Finland Iceland Ireland Latvia a Lithuania a Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom Southern Europe Croatia FYROM a
Trend 2 APC
1985–2009 1985–2008
0.3 0.4*
1985–2010 1985–1988 1985–2009 2000–2009 1985–2009 1985–2010 1999–2008 1999–2003 1985–2005 1997–2006 1996–2004 1993–2001 1998–2007
0.9* 6.8 0.5 0.9 0.4 1.0 1.8 24.8 0.4 2.7 6.7 1.1 0.3
1985–2010 1985–2002
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
2000–2009 1999–2008
0.3 0.4*
2001–2010 1999–2008 2000–2009 2000–2009 2000–2009 2001–2010 1999–2008 1999–2008 2001–2010 1997–2006 2000–2004 1997–2001 1998–2007
0.9* 1.4* 0.5 0.9 0.4 1.0 1.8 4.8 0.1 2.7 6.7 1.1 0.3
1.1* 4.4*
2001–2010 1993–2002
1.1* 4.4*
1985–2010 1985–2009 1985–1993 1985–2009 1985–2007 1985–2010
2.2* 1.1* 0.7 2.8* 1.5* 0.5*
2001–2010 2000–2009 2001–2010 2000–2009 1998–2007 2001–2010
2.2* 1.1* 2.6* 2.8* 1.5* 0.5*
1985–1998 2001–2010 1985–2010 1985–2009 1985–2010 2001–2010 2001–2010 1985–2010 1985–2010 1985–1992 1985–2010 1985–1990
0.2 0.9 1.0* 5.3* 0.6 3.3 1.8 0.9* 0.2 0.5 1.2* 0.6
1997–2006 2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.2 0.9 1.0* 5.3* 0.6 3.3 1.8 0.9* 0.2 1.7* 1.2* 1.7*
2001–2010 1994–2003
0.2 2.1
1985–2010 1994–2003
0.2 –2.1
1988–2008
2003–2008 2005–2008
1993–2010
1.4*
14.9 15.4
2.6*
1992–2010
1.7*
1990–2010
1.7*
2008–2010
20.2*
70
EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 (Continued ) (b) Join-point analyses Trend 1 Years Greece Italy Malta Portugal Serbia a Slovenia Spain Central and eastern Europe Bulgaria Czech Republic Hungary Poland a Republic of Moldova a Romania Russian Federation Slovakia Asia China a China, Hong Kong China Rural a China Urban a Israel Japan Kazakhstan a Kuwait a Kyrgyzstan a Philippines a Republic of Korea Singapore Africa Egypt a Mauritius South Africa a Oceania Australia New Zealand
Trend 2 APC
1985–2009 1985–1992 1985–2000 1985–2003 2000–2009 1985–2010 1985–1997
1.8* 0.3 2.2 0.8 1.1 0.9 1.9*
1985–1995 1986–2010 1985–1991 2001–2010 2001–2010 1985–2010 2000–2010 1992–2010
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr 2000–2009 1994–2003 1991–2000 1994–2003 2000–2009 2001–2010 2001–2010
1.8* 1.8* 2.2 0.8 1.1 0.9 0.5
0.8* 0.2 0.7* 1.3* 1.7 0.7* 0.8 0.5
2001–2010 2009–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.8* 0.2 0.7* 1.3* 1.7 0.7* 0.8 0.5
1991–2000 1985–2009 1991–2000 1991–2000 1985–2009 1985–1987 2000–2009 2000–2009 2000–2009 1993–2002 1985–2003 1985–2009
0.9 3.8* 0.6 1.4 0.8 5.5* 19.3* 10.8 3.6 1.4 4.6* 2.1*
1991–2000 2000–2009 1991–2000 1991–2000 2000–2009 2001–2010 2000–2009 2000–2009 2000–2009 1993–2002 2001–2010 2000–2009
0.9 3.8* 0.6 1.4 0.8 2.0* 19.3* 10.8 3.6 1.4 2.7* 2.1*
2001–2010 1985–1990 2000–2009
4.7* 29.8* 3.1*
2001–2010 2001–2010 2000–2009
4.7* 2.4 3.1*
1985–2002 1985–2008
1.9* 1.7*
1995–2004 1999–2008
0.6 1.7*
1992–1998
4.5*
1987–2008
0.0*
2003–2010
4.7*
1990–1993
31.3
2002–2004
9.9
1998–2003
0.5
2008–2010
8.7*
1993–2010
2.4
APC = annual percent change; AAPC = average annual percent change; FYROM = former Yugoslav Republic of Macedonia. The APC or AAPC is statistically different from zero. a Last 10 yr of data only. b Last 9 yr of data only, AAPC for last 5 yr of data. *
3.2.8.
Africa
Long-term data for African countries were not available, and only three countries from this continent could be studied. Mortality rates in Egypt (2001–2010) decreased by >4% per year for both men and women. Rates also decreased in South African women (2000–2009) and in Mauritian men (2001–2010) by roughly 3% per year. Trends were stable in South African men and Mauritian women. 3.2.9.
Oceania
Incidence rates decreased in Australian men and women (1999–2008) and in New Zealander men (1999–2008). Rates were stable in New Zealander women. Mortality rates in Australian men (1995–2004) and New Zealander men (1999–2008) decreased by 1.8% per year and 1.6% per year, respectively. Rates also decreased by 1.7% per year in New Zealander women but remained unchanged in Australian women.
3.3.
Discussion
The highest estimated BCa incidence rates are found mainly in the high-resource nations of western Europe and North America and a few countries in southern, central, and eastern Europe and in the developing economies of northern Africa. In northern and western Europe, men tended to experience a greater decrease in incidence rates than women. In contrast, the highest mortality rates tend to be observed in certain low- to medium-resource countries of northern and southern Africa, in western Asia, and in some countries of southern, central, and eastern Europe. For both men and women, the decrease in mortality rate was more pronounced in North America and western and northern Europe. Tobacco use is the most important risk factor for BCa in most parts of the world [2], with an attributable risk of up to 50% in Europe [17]. A recent meta-analysis demonstrated
71
EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._5)TD$IG] Colombia
Costa Rica
Canada
Sweden
USA
20
M
M
10
20
M
Austria
France
M
F
F M
M
M
M
1
F
F M
F
F M
M F
M
F
2
F
F
M
M
4
F
F
0.5
M
M
10
4 2
UK, Scotland
40
40
F
F
1
F
F
0.5 1975
1990
2010 1975
Japan
1990
2010 1975
Philippines
1990
2010 1975
Rep of Korea
1990
1975
2010
2010 1975
1990
2010 1975
Netherlands
1990
2010 1975
Switzerland
1990
2010
Croatia
40
40 20
M
20
10
M
M
M M
4 2
M
F
M
F
1
F
M
F M
F
0.5
1975
1990
2010 1975
Israel
1990
F
F
F
2010 1975
Australia
1990
2010 1975
Denmark
1990
2010
Estonia
40 M
20
M
10
M M
4
M
M
F
F
F
2 1
M
MF
F
F
F
F
Age−standardised (World) rate per 100 000, all ages
Age−standardised (World) rate per 100 000, all ages
1990
Germany
China
4 2
F
M
F
F
F
F
1
M
F
M F
M
F
0.5 1975
1990
2010 1975
Italy 40
1990
2010 1975
Slovenia
1990
2010 1975
Spain
1990
20
Bulgaria
M
M
10 F
2010
M
M
M
M F
M
4 2
M F
F
F
1
0.5
M
M
M
10
F
F
F
0.5 1975
1990
2010 1975
Finland
1990
2010 1975
Ireland
1990
2010 1975
Lithuania
1990
1975
2010
1990
2010 1975
Czech Rep.
Norway
1990
2010 1975
Poland
1990
2010 1975
Russian Fed.
1990
2010
Slovakia
40
40 20 10
M
M
M
M
M
F M
F
4 F
2
M
M
1
F F
F
M
M
M M
10
M M
M F
4
F
F
0.5
20
M F
F
2
F
F
F
F
1
F
0.5 1975
1990
2010 1975
1990
2010 1975
1990
2010 1975
1990
2010
Incidence
1975
1990
2010 1975
1990
2010 1975
1990
2010 1975
1990
2010
Year
Year Mortality
Incidence
Mortality
Fig. 5 – Trends in bladder cancer incidence and mortality age-standardized (world) rates for selected countries and in all ages in men and in women. Incidence data are from Cancer Incidence in Five Continents [10]; mortality data are from the World Health Organization mortality database [10]. Solid lines represent fitted values based on join-point analyses. Dots represent observed rates. M = males; F = females.
that smoking is associated with a threefold increase in risk for cancer of the lower urinary tract (predominantly bladder) [18]. The urothelial carcinoma variant of BCa is associated with tobacco smoke and constitutes >90% of all cases [19]. The fall in BCa incidence and mortality in the industrialised nations of North America, northern and western Europe, and Oceania may thus be said to largely reflect the decrease in smoking prevalence in these regions. For example, current smoking prevalence in US adults decreased from about 45% in 1965 to about 19% in 2010 [20]. In the United Kingdom, smoking prevalence among men decreased from >70% in 1950s to about 20% in 2010 [21]. Similar substantial decreases in smoking prevalence have been reported in Canada and Australia [22,23]. A few studies have proposed that a reduction in occupational exposures may contribute to a fall in incidence rates [24–26]. However, it is difficult to attribute this decrease in incidence and mortality rates in these regions to reduction in occupational exposures of known carcinogens (e.g.,
benzidine and 2-naphthylamine), given the paucity of large studies measuring trends in occupational exposures. Similarly, there is no evidence-based screening method for early detection of urinary bladder [27] to contribute to the favourable mortality trends in Western countries and other economically developed countries. The countries of central and eastern Europe stand out from rest of the continent in that BCa mortality rates are mostly decreasing for men but are stable or even rising for women. This is possibly because the tobacco epidemic among women lags behind that of men by many decades, and the epidemic has yet to mature in women. However, some of the unevenly changing incidence and mortality rates may reflect artefacts of coding or reporting changes [28–30], as is evident in Scotland and Germany. The relatively high incidence of BCa in North Africa has been largely attributed to the Schistosoma parasite, at least until recently. Egypt, in this regard, serves as a good model to study the heterogeneity of BCa as a disease with multiple
72
EUROPEAN UROLOGY 66 (2014) 59–73
risk factors. After the successful control of schistosomiasis, Egypt experienced a decrease in the proportion of squamous cell carcinoma cases, which are associated with schistosomiasis, alongside an increase in the proportion of carcinoma related to smoking [31]. The more advanced age observed among recently diagnosed cases is consistent with the increased proportion of tobacco-related BCa because smoking-induced tumours tend to present later in life [32]. A comparison of male and female incidence rates reveals high male-to-female ratios in Western countries and in the northern African region, especially in Egypt. Possible explanations might be higher smoking prevalence among men in the Western nations and higher exposure to S. haematobium among men in North Africa. However, unlike in Egypt, where the male-to-female incidence ratio is >6, this ratio in most other African nations seldom exceeds 3, possibly due to comparable involvement of women in farming and other activities like acquiring water, which puts them at a nearly equal risk of exposure to the parasite, as suggested by Heyns et al. [33]. Nonetheless, a study by Hartge et al. reports that some proportion of the male excess remains unexplained by the established risk factors [34]. The strength of our study is the use of worldwide cancer incidence and mortality data from IARC to compare and contrast BCa rates and trends across countries. However, there are certain limitations in the interpretation of the data. First, the accuracy of estimates from GLOBOCAN 2008 vary across countries, depending on the extent and validity of available data in each county, ranging from actual national or regional data to those based on cancer information in neighbouring countries. In addition, recent incidence and mortality data are not available for many countries, and this restricts our ability to comment on the latest trends for all countries. The contemporary burden and interpretation of recent trends also may have been affected by reporting delays [15]. However, data from IARC are the only data to describe cancer rates and trends worldwide. Caution must also be exercised while interpreting the rates and trends in BCa rates due to differences in reporting of noninvasive urinary BCa across countries [35]. Benign neoplasms of the bladder have always been included in successive revisions of the ICD, but, with a better understanding of the biology of papilloma, some changes in the classification of tumour behaviour have emerged. Registry practices regarding the coding of invasiveness of bladder tumours have shifted accordingly. In addition, no distinction is made between the non–muscle-invasive and muscle-invasive carcinomas of the bladder, thereby limiting our ability to present separate epidemiologic trends for these types. Trends in BCa incidence are very difficult to interpret without exhaustive information on how registries have dealt with papillomas over time. Saxe´n has shown that, on exclusion of papillomas of the bladder, much of the variation in BCa incidence rates in the Scandinavian countries was removed [36]. In general, changes in registry procedures are more likely to affect comparisons between registries rather than trends in a single registry over time, provided such practices do not change over time [37].
For the geographical and temporal comparisons of cancer incidence, the coding practices of each registry should be reviewed, and successive volumes of CI5 should present the coding practices recorded in the questionnaires by each registry; for most registries, the BCa category includes both the in situ and unspecified categories [13,38,39]. 4.
Conclusions
BCa incidence and mortality rates vary substantially across countries due in part to differences in known risk factors, coding, detection and diagnostic practices, and availability of treatments (mortality only). Generally, the highest incidence rates are found in developed nations and some parts of Africa, whereas the highest mortality rates are found in North African and Middle Eastern countries. The decrease in mortality rates in Western countries in part reflects the reduction in smoking prevalence, whereas the decrease in African countries largely reflects control of S. haematobium and/or improved hygiene and sanitation. In contrast, the increase in incidence or mortality rates among women in some eastern European countries may reflect the growing burden of the tobacco epidemic. Progress in reducing BCa rates in all countries could be accelerated by applying known interventions, including tobacco control, improved sanitation and hygiene to reduce S. haematobium infection, and improved work site safety to reduce occupational exposures. Author contributions: Ahmedin Jemal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Bray, Lortet-Tieulent, Goodman, Jemal. Acquisition of data: Chavan, Bray, Lortet-Tieulent, Jemal. Analysis and interpretation of data: Chavan, Bray, Lortet-Tieulent, Goodman, Jemal. Drafting of the manuscript: Chavan, Jemal. Critical revision of the manuscript for important intellectual content: Chavan, Bray, Lortet-Tieulent, Goodman, Jemal. Statistical analysis: Chavan, Lortet-Tieulent. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: Jemal. Other (specify): None. Financial disclosures: Ahmedin Jemal certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
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available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Review – Bladder Cancer Editorial by Lambertus A. Kiemeney on pp. 74–75 of this issue
International Variations in Bladder Cancer Incidence and Mortality Saurabh Chavan a, Freddie Bray b, Joannie Lortet-Tieulent a,b, Michael Goodman c, Ahmedin Jemal a,* a
American Cancer Society, Atlanta, GA, USA; b Section of Cancer Information, International Agency for Cancer Research, Lyon, France; c Emory University,
Atlanta, GA, USA
Article info
Abstract
Article history: Accepted October 5, 2013 Published online ahead of print on October 16, 2013
Context: Previous studies have reported substantial worldwide regional variations in bladder cancer (BCa) incidence and mortality. Objective: To describe contemporary international variations in BCa incidence and mortality rates and trends using the most recent data from the International Agency for Research on Cancer (IARC). Evidence acquisition: Estimated 2008 BCa incidence and mortality rates for each country by sex were obtained from GLOBOCAN. Recent trends in incidence for 43 countries and in mortality for 64 countries were assessed by join-point model using data from the IARC’s Cancer Incidence in Five Continents and from the World Health Organisation’s mortality database, respectively. Evidence synthesis: The highest incidence rates for both men and women are found in Europe, the United States, and Egypt, and the lowest rates are found in sub-Saharan Africa, Asia, and South America. Mortality rates are highest in parts of Europe and northern Africa and lowest in Asia, Central America, and middle Africa. Incidence rates among men decreased in 11 of 43 countries (46 registries) (North America, western and northern Europe), remained stable in 20, and increased in 12 countries (southern, central, and eastern Europe). Among women, incidence rates decreased in 10 countries, stabilised in 22 countries, and increased in 12 countries. Mortality rates among men decreased in 32 of 65 countries (throughout all world regions except Central and South America), stabilised in 30 countries, and increased in 3 (Romania, Slovenia, and Cuba). Among women, mortality rates decreased in 24 countries, remained stable in 36 countries, and increased in 5 countries (central and eastern Europe). Conclusions: Incidence and mortality rates in general decreased in most Western countries but increased in some eastern European and developing countries. These patterns in part may reflect differences in the stage and extent of the tobacco epidemic, changes in coding practices, prevalence of schistosomiasis (Africa), and occupational exposure. # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords: Urinary bladder cancer Trends Incidence Mortality Schistosoma haematobium Registries Epidemiology
* Corresponding author. American Cancer Society, 250 Williams Street NW, Atlanta, GA 30303, USA. Tel. +1 404 329 7557; Fax: +1 404 327 6450. E-mail address: [email protected] (A. Jemal).
0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.10.001
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1.
EUROPEAN UROLOGY 66 (2014) 59–73
Introduction
Bladder cancer (BCa) is the 11th most commonly diagnosed cancer and the 14th leading cause of cancer deaths worldwide, with an estimated 382 700 new cases and 150 300 deaths in 2008 [1]. Incidence and mortality rates vary globally, mainly due to differences in risk factors. Wellestablished risk factors for BCa include tobacco use, infections with Schistosoma haematobium, and occupational exposures to aromatic amines and polycyclic aromatic hydrocarbons [2,3]. Other suspected risk factors for BCa include dietary patterns, environmental pollution, and genetic predisposition [3]. While smoking is the predominant cause of BCa in the United States, infection with S. haematobium is the major cause of the disease in most parts of Africa [4]. Previous studies of international patterns in BCa rates are limited because they are confined to specific geographic regions or based on rather old data [5–8]. In this paper, we present the contemporary information on variation in BCa rates and trends worldwide by using the GLOBOCAN 2008 data [1], Cancer Incidence in Five Continents (CI5) [9], and the World Health Organisation (WHO) mortality data [10] for five continents (Africa, Asia, Oceania, Europe, and the Americas) from the International Association on Research on Cancer (IARC) website [11]. 2.
Evidence acquisition
Data on estimated BCa incidence and mortality rates (per 100 000 person-years) for the year 2008 for each country were obtained from GLOBOCAN 2008 [1]. GLOBOCAN is an IARC database that provides estimates of incidence, mortality, prevalence, and disability-adjusted life years for major type of cancers at a national level for 184 countries. These estimates were prepared using methods that are described elsewhere in detail, and they depend on the availability and accuracy of the incidence and mortality data for each individual country [12]. Observed BCa incidence rates for 88 national or regional registries were obtained from the CI5 series [9], and these data were supplemented with the most recent information from the registries’ websites, where available. Overall incidence data for 43 countries (national, regional, or local registries) were analysed, with varying time periods ranging from 10 yr to 31 yr from 1985 onwards. Incidence was coded according to the International Classification of Diseases (ICD) in use at the time of diagnosis and converted to the 10th revision code (C67) [13]. IARC also abstracts mortality data from the WHO mortality database, which covers nearly 30% of the world population (country-specific coverage ranges from <10% for China to 100% for most developed nations such as France, Germany, and the United States) [10]. We analysed BCa mortality trends for 65 countries from 1985 onwards, with data years ranging from 18 yr to 26 yr. BCa as the underlying cause of death was selected according to the version of the ICD codes and the selection rules in use at the time of death (ICD-7 through ICD-10).
We calculated average age-standardised rates by country or registry for the years 2000–2006 (mortality) for the purpose of synthesising global temporal developments in BCa. Temporal trends in age-standardised cancer incidence and death rates were analysed using join-point regression, which involves fitting a series of joined straight lines to the trends in the annual age-standardised rates, with at least three data points between changes in join points [14]. Up to three join points were allowed in models for the long-term trend analyses (1980s to the 2000s) [14] and two joint points for the short-term trend analyses (last 10 yr of available data). The number of join points (inflexion points) is determined by the number of intervals available to identify the years in which there was a statistically significant change in the trends using a Monte Carlo permutation method [14]. For the long-term trend analysis, data with three join points will have four trends (trend 1, trend 2, trend 3, trend 4), those with two join points will have three trends (trend 1, trend 2, trend 3), those with one join point will have two trends (trend 1, trend 2), and those with no join points will have one trend (trend 1). The resulting trends of varying time periods were described by the slope of the line segment or annual percentage change (APC). Trends for the last 10 yr of data from the join-point model were summarised using average APC (AAPC) to describe country-specific contemporary trends and to compare these trends across countries. The AAPC is estimated as the geometric weighted average of the different APCs from the previous join-point trend analysis, with the weights being equal to the length of each segment during the specified time interval [15]. The terms increase and decrease were used to describe the direction of the statistically significant change, and the term stable was used if the AAPC was not statistically significant. The World Standard Population [16] was used to age-standardise all of the rates to facilitate the comparison of data across all countries. 3.
Evidence synthesis
A total of 382 700 new BCa cases (294 400 in men and 88 300 in women) and 150 300 cancer deaths (112 300 in men and 38 100 in women) were estimated to have occurred worldwide (Table 1). Age-standardised rates (per 100 000 person-years) were more than three times as high in men than in women for both incidence (8.9 vs 2.2) and mortality (3.3 vs 0.9). Incidence and mortality rates significantly varied by world region for both men and women. In men, for example, rates ranged from 1.5 in middle Africa to >20 in southern Europe and North America for incidence and from 1.2 in middle Africa and Central America to nearly 10 in northern Africa for mortality. 3.1.
Geographic variation in the incidence and mortality rates
In 2008, estimated incidence rates per 100 000 person-years were highest at 29.7 in Israel among men and at 7.8 in Iceland among women. Generally, the highest estimated incidence rates in 2008 in both men and women were found
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 1 – Estimated number of new bladder cancer cases and deaths, all ages in both sexes, by world areas, 2008 [1] Area
Cases Both sexes
Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Eastern Asia South central Asia South eastern Asia Western Asia The Caribbean Central America Northern America South America Central and Eastern Europe Northern Europe Southern Europe Western Europe Australia/New Zealand Melanesia Micronesia/Polynesia World
Deaths
Men
Women
Both sexes
Men
Women
n
ASR
n
ASR
n
ASR
n
ASR
n
ASR
n
ASR
3900 500 12 000 1600 4000 78 900 27 700 13 400 11 600 1800 2900 73 200 14 200 36 800 17 600 37 000 42 200 3000 70 30 382 700
2.5 0.8 8.2 4.2 2.6 3.8 2.2 2.7 7.4 3.7 2.2 12.0 3.7 7.2 8.2 11.2 9.8 6.3 1.6 3.5 5.3
2400 400 10 200 1100 2900 60 800 21 600 9800 9600 1300 2100 54 500 10 700 28 700 12 900 30 500 32 500 2300 60 30 294 400
3.4 1.5 14.5 7.3 3.9 6.2 3.6 4.5 13.1 5.8 3.5 20.1 6.3 14.6 13.7 20.7 17.2 10.5 2.7 6.7 8.9
1500 100 1800 500 1200 18 100 6100 3600 2000 500 800 18 700 3500 8100 4700 6600 9700 800 10 4 88 300
1.8 0.3 2.4 2.1 1.4 1.6 0.9 1.3 2.4 1.9 1.1 5.5 1.6 2.6 3.8 3.3 3.9 2.7 0.5 0.8 2.2
2800 400 7900 1000 2900 29 800 15 800 7100 5900 900 1200 16 000 6500 16 800 7500 13 600 13 200 1100 50 10 150 300
1.9 0.7 5.5 2.7 2.0 1.3 1.3 1.5 3.8 1.7 0.8 2.2 1.6 3.0 2.9 3.3 2.5 2.0 1.2 1.1 2.0
1700 300 6600 700 2100 22 000 12 400 5200 4700 600 700 11 300 4500 13 400 5000 10 900 9400 800 40 10 112 300
2.6 1.2 9.9 4.9 3.1 2.1 2.1 2.4 6.7 2.5 1.2 3.7 2.6 6.5 4.7 6.2 4.4 3.1 2 2.4 3.3
1100 100 1200 300 900 7900 3400 1900 1100 300 400 4700 2000 3400 2400 2800 3800 400 10 0 38 100
1.3 0.2 1.6 1.3 1 0.6 0.5 0.7 1.3 1 0.5 1.1 0.9 0.9 1.6 1.1 1.2 1.1 0.4 0 0.9
ASR = age-standardised rate per 100 000 person-years. Numbers are rounded to the nearest 10 or 100 and may not sum up to total.
in most parts of Europe, North America, Oceania, and northern Africa, whereas the lowest rates were found in sub-Saharan Africa and south-central Asia and most of South America for both men and women (Fig. 1a and 1b). In Egypt, BCa is the most commonly diagnosed cancer in men. Estimated mortality rates per 100 000 person-years in 2008 were highest at 16.3 in Egypt among men and at 4.5 in Mali among women. The highest estimated mortality rates in 2008 occurred in southern, central, and eastern Europe, northern Africa, and western Asia in men and in parts of eastern Europe, northern and eastern Africa, and western Asia in women (Fig. 2a and 2b). The mortality rates were lowest for most parts of Africa, Oceania, the Americas, and most parts of Asia in both men and women. Incidence rates (per 100 000 person-years) for the period 2000–2006 for selected registries or countries ranged from 0.5 to 8.3 for men, with the lowest rates found in South American and Asian countries and the highest rates reported in Europe (Fig. 3a). The range for the mortality rates among women was lower (0.2–2.4) (Fig. 3b); however, the regional patterns were generally similar. 3.2.
Incidence and mortality trends
Table 2a and 2b show temporal trends in incidence rates for men and women for varied time periods from 1985 onwards, with the data for 32 selected countries portrayed in Figure 4a and 4b; however, we describe country- or region-specific trends (AAPC) based on the last 10 yr of available data. By country, the largest significant increase in incidence rates was observed in Croatian men (4.3% per year) and Bulgarian women (6.7% per year) (Table 3a and 3b, Fig. 5), whereas the largest decreases during the
corresponding time intervals were found in France among men (5.2% per year) and in Germany among women (8.4% per year). For mortality, the largest significant decrease was found in Kazakhstan and Egypt in both men and women, and the largest significant increase was found in Brazil and Poland for women and in Cuba for men (Table 3a and 3b, Fig. 5). The following sections present incidence and mortality trends by region. 3.2.1.
North America
BCa incidence rates in Canada decreased by 1.2% per year in men and 0.9% per year in women over the 1993–2002 period. In the United States, rates decreased by 0.6% per year in men and by 1.4% per year in women over the 2000–2009 period. Mortality rates decreased by 0.4% per year in both US men (1999–2008) and US women and by 0.7% per year in Canadian men (2000–2009) but remained stable in Canadian women. 3.2.2.
Central and South America and the Caribbean
In Central and South America, over the 1993–2002 period, stable trends were observed with the exception of Costa Rican women, in whom incidence rates increased by 2.7% per year. Mortality trends were stable in Central and South American countries, except in Argentina (2001– 2010) and Trinidad and Tobago (1993–2002), where rates decreased in both sexes, and in Cuban men and women (2001–2010) and Brazilian women (1999–2008), in whom rates increased. 3.2.3.
Western Europe
Most of the region recorded significantly decreasing incidence rates ranging from 1.0% per year for Dutch
[(Fig._1)TD$IG]
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EUROPEAN UROLOGY 66 (2014) 59–73
Fig. 1 – Estimated international variation in age-standardized (world) bladder cancer incidence rates for all ages (a) in men and (b) in women. Data are from GLOBOCAN 2008 [1].
men (1999–2008) to 8.4% per year for German women (1993–2002). The only increase was in Dutch women at 2.1% per year. Mortality rates decreased for both men and women in all six western European countries included in this analysis. However, these decreases were less pronounced in women, ranging from 0.5% per year in the Netherlands (2001–2010) to 2.8% per year in Luxembourg (2000–2009), compared with 1.8% and 3.9% observed for men in the Netherlands (2001–2010) and Germany (2001–2010), respectively.
3.2.4.
Northern Europe
No consistent pattern was observed in this region. Incidence rates increased in the Baltic states of Estonia and Latvia by 3.4% and 2.5% per year (1993–2002), respectively, in men and by 2.7% and 2.4% per year, respectively, in women. In contrast, rates decreased in both men and women in Denmark, Finland (both in 2001–2010), and the United Kingdom (1998–2007). In Ireland (1998–2007) and Iceland (2001–2010), trends in incidence rates were stable in both men and women. Mortality rates decreased for both men and
EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._2)TD$IG]
63
Fig. 2 – Estimated international variation in age-standardized (world) bladder cancer mortality rates for all ages (a) in men and (b) in women. Data are from GLOBOCAN 2008 [1].
women for 5 of the 12 countries considered in this analysis. Rates decreased among men in Denmark (1997–2006), Ireland (2001–2010), and Sweden (2001–2010) and also in Icelandic women (2000–2009). Mortality rates were stable in both men and women in Estonia (2001–2010) and in Latvia and Lithuania (both 2001–2010). 3.2.5.
Southern Europe
Incidence rates among both men and women increased in Croatia (1993–2002), Slovenia (1999–2008), and Spain
(1991–2000). However, rates in Italian men and women were stable (1993–2002). Greece (2000–2009) and Italy (1994–2003) were the only two southern European nations to show a decrease in BCa mortality for both men and women. For men, rates also decreased in Spain at an average of 1.1% per year (2001–2010). Rates were stable in women from Spain and Slovenia (2001–2010) and in both men and women of the remaining southern European countries, including Portugal (2000–2009), Malta (1991–2000), and Croatia (2001–2010).
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EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._3)TD$IG]
a
Spain Poland Latvia Lithuania Denmark Russian Federation Malta Czech Republic Greece Egypt Croatia Slovenia France Slovakia The Netherlands United Kingdom Norway Bulgaria Israel Germany Austria Switzerland Cuba New Zealand United States South Africa China, Hong Kong Japan Brazil Singapore Kuwait Trinidad and Tobago Colombia Barbados Mexico Ecuador Thailand Nicaragua 0.0
0.8 0.7 0.5
2.6 2.5 2.3 2.1 2.0 1.8
1.4 1.2 1.2
1.0
2.0
4.1 3.9 3.7 3.7
3.0
3.0
Northern Europe North America Oceania
4.0
4.4 4.4
4.8 4.7
5.2 5.1
7.2 7.0 7.0 6.8 6.6 6.4 6.3 6.1 6.0 5.8 5.7 5.7
5.0 6.0 ASR (W) per 100 000
Central and Eastern Europe Central and South America Asia
7.0
8.3 8.3
7.6
8.0
Western Europe Caribbean
9.0
Southern Europe Africa
b Denmark United Kingdom Kuwait The Netherlands Norway Czech Republic Switzerland Slovenia Poland Germany Egypt Croatia Israel Cuba Austria United States Slovakia New Zealand Lithuania Latvia France Bulgaria Spain Malta Greece South Africa Russian Federation Brazil Japan China, Hong Kong Singapore Colombia Trinidad and Tobago Mexico Ecuador Barbados Nicaragua Thailand
0.2
0.3
0.4 0.4
0.0
0.5 0.5
0.5
Northern Europe North America Oceania
0.6 0.6
0.7 0.7
0.8 0.8
0.9
1.0 1.0 1.0
1.0
1.1 1.1 1.1 1.1 1.1 1.1 1.1
1.2 1.2 1.2
1.6 1.6 1.6
1.3 1.3 1.3 1.3 1.3 1.3
1.5 ASR (W) per 100 000
Central and Eastern Europe Central and South America Asia
Western Europe Caribbean
2.4
1.8 1.8
2.0
2.5
Southern Europe Africa
Fig. 3 – Bladder cancer mortality for all ages for select registries, 2000–2006, (a) in men and (b) in women. Data are from the World Health Organization mortality database [10]. ASR (W) = age-standardized rate (world). *Average of rates for =7 yr in the time period 2000–2006.
3.2.6.
Central and Eastern Europe
Incidence rates increased in both men and women in four of the six countries included in the analysis, with the largest increase occurring in Bulgarian women at 6.7% per year and
Bulgarian men at 4% per year (1999–2008) (Table 2a and 2b). Rates remained unchanged in Poland (1993–2002) and the Czech Republic (1999–2008). Nations of central and eastern Europe showed variable trends in BCa mortality
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 2 – Trends in bladder cancer incidence rates for (a) men and (b) women of all ages from selected registries and Cancer Incidence in Five Continents (national and regional data) [9] (a) Join-point analyses Trend 1 Years North America Canada (regional) United States Central and South America Brazil, Goiania a Colombia, Cali Costa Rica Ecuador, Quito Western Europe Austria a France (regional) a Germany, Saarland The Netherlands a Switzerland (regional) Northern Europe Denmark Estonia Finland Iceland Ireland a Latvia Lithuania Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom, Wales a United Kingdom a Southern Europe Croatia a Italy (regional) a Slovenia Spain (regional) Central and eastern Europe Belarus Bulgaria a Czech Republic Poland (regional) a Russian Federation a Slovakia Asia China (regional) a India (regional) Israel Japan (regional) Jordan a Philippines, Manila Republic of Korea b Saudi Arabia a Singapore Thailand, Chiang Mai Oceania Australia New Zealand
Trend 2 APC
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
1985–2002 1985–2009
1.2* 0.6*
1993–2002 2000–2009
1.2* 0.6*
1993–2002 1985–2002 1985–2002 1985–2002
3.3 1.3 0.9 0.9
1993–2002 1993–2002 1993–2002 1993–2002
3.3 1.3 0.9 0.9
2000–2009 1993–2002 1985–1996 1999–2001 1985–2002
0.8 5.2* 1.5 4.4* 1.6*
2000–2009 1993–2002 1993–2002 1999–2008 1993–2002
0.8 5.2* 7.4 1.0* 1.6*
1985–1998 1985–2002 1985–1993 1985–2010 1998–2007 1985–2002 1985–2002 1985–1994 1985–2009 1985–1993 1985–1996 1999–2006 1998–2002
0.0 3.4* 1.8* 0.1 0.1 2.5* 3.9* 3.9* 0.2* 0.3 0.4 1.2 7.2*
2001–2010 1993–2002 2001–2010 2001–2010 1998–2007 1993–2002 1993–2002 2000–2009 2000–2009 1993–2002 1999–2008 1999–2008 1998–2007
1.9* 3.4* 1.7* 0.1 0.1 2.5* 3.9* 0.0 0.2* 5.3* 3.2* 6.6* 4.2*
1993–2002 1993–1995 1985–2008 1985–2000
4.8* 2.4 3.2* 2.7*
1993–2002 1993–2002 1999–2008 1991–2000
4.8* 0.1 3.2* 2.7*
1985–1988 1999–2008 1985–1995 1993–2002 1999–2008 1985–2000
9.2* 4.0* 4.3* 1.0 0.5* 0.2
1993–2002 1999–2008 1999–2008 1993–2002 1999–2008 1998–2007
1.7* 4.0* 0.2 1.0 0.5* 2.1*
1993–2002 1985–1994 1985–1991 1985–2002 1998–2001 1985–2002 1999–2007 1999–2008 1985–2007 1985–2002
1.3* 3.9* 5.8* 0.1 14.3 0.2 0.4 3.8* 0.1 0.1
1993–2002 1993–2002 1998–2007 1993–2002 1998–2007 1993–2002 2003–2007 1999–2008 1998–2007 1993–2002
1.3* 2.3 0.4 0.1 1.6 0.2 0.4 3.8* 0.1 0.1
1985–2008 1985–2002
2.7* 1.2
1999–2008 1999–2008
2.7* 9.8*
1996–1999 2001–2008
24.6 0.0
1998–2010
1.9*
1993–2010
1.7*
1994–2009
0.0
1993–1999 1996–1999 2006–2008 2002–2007
3.0* 18.3* 23.4* 1.8
1995–2002
0.8*
1988–2002
1.7*
1995–2008
0.2
2000–2007
2.7*
1994–2002 1991–2007
3.1 0.4
2001–2007
5.4*
2002–2008
14.8*
1999–2002
3.6
9.7* 3.2*
1999–2002 1999–2008
(b) Join-point analyses Trend 1 Years North America Canada (regional)
1985–2002
Trend 2 APC
0.9*
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
1993–2002
0.9*
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 2 (Continued ) (b) Join-point analyses Trend 1
United States (SEER) Central and South America Brazil, Goiania a Colombia, Cali Costa Rica Ecuador, Quito Western Europe Austria a France (regional) a Germany, Saarland The Netherlands a Switzerland (regional) Northern Europe Denmark Estonia Finland Iceland Ireland a Latvia Lithuania Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom, Wales a United Kingdom a Southern Europe Croatia a Italy (regional) a Slovenia Spain (regional) Central and eastern Europe Belarus Bulgaria a Czech Republic Poland (regional) a Russian Federation a Slovakia Asia China (regional) a India (regional) Israel Japan (regional) Jordan a Philippines, Manila Republic of Korea b Saudi Arabia a Singapore Thailand, Chiang Mai Oceania Australia New Zealand
Trend 2
Years
APC
Years
1985–1999
0.0
1999–2009
1993–2002 1985–2002 1985–2002 1985–2002
Trend 3 APC
Years
Trend 4 APC
Years
APC
Last 10 yr 2000–2009
1.4*
3.0 1.6 2.7* 1.0
1993–2002 1993–2002 1993–2002 1993–2002
3.0 1.6 2.7* 1.0
2000–2009 1993–2002 1985–1995 1999–2008 1985–2002
0.3 5.2* 4.5 2.1* 1.2
2000–2009 1993–2002 1993–2002 1999–2008 1993–2002
0.3 5.2* 8.4* 2.1* 1.2
1985–2010 1985–2002 1985–1992 1985–2010 1998–2007 1985–2002 1985–1999 1985–2009 1985–2009 1985–1998 1985–1996 1999–2006
0.6* 2.7* 4.4* 0.1 1.5 2.4* 5.3* 1.7* 0.2 0.6 1.2* 0.9
2001–2010 1993–2002 2001–2010 2001–2010 1998–2007 1993–2002 1993–2002 2000–2009 2000–2009 1993–2002 1999–2008 1999–2008 1998–2007
0.6* 2.7* 1.7* 0.1 1.5 2.4* 1.4 1.7* 0.2 4.5* 1.1 7.3* 4.2*
1993–2002 1993–2002 1985–2008 1985–2000
5.6* 1.4 4.3* 2.0*
1993–2002 1993–2002 1999–2008 1991–2000
5.6* 1.4 4.3* 2.0*
1985–2002 1999–2008 1985–1996 1993–2002 1999–2008 1985–2007
2.4* 6.7* 6.7* 3.2 1.7* 1.7*
1993–2002 1999–2008 1999–2008 1993–2002 1999–2008 1998–2007
2.4* 6.7* 0.5 3.2 1.7* 1.7*
1993–2002 1985–2002 1985–1992 1985–2002 1998–2007 1985–2002 1999–2007 1999–2008 1985–2007 1985–2002
0.7 0.1 3.7 0.9* 2.0 0.8 0.5 1.1 0.2 0.8
1993–2002 1993–2003 1998–2007 1993–2002 1998–2007 1993–2002 2003–2007 1999–2008 1998–2007 1993–2002
0.7 0.1 1.4* 0.9* 2.0 0.8 0.5 1.1 0.2 0.8
1985–1992 1985–2003
5.3* 1.2*
1999–2008 1999–2008
3.6* 5.2
1995–2002
1.4*
AAPC
11.8*
1992–2010
1.7*
1999–2002
6.0
1998–2002 1996–1999 2006–2008
9.3* 19.7* 26.8*
1996–2008
1999–2008
1.1
0.5
1992–2007
1.4
1992–2002 2003–2006
1.4 27.9
*
2002–2008 2006–2008
4.6* 25.3
APC = annual percent change; AAPC = average annual percent change; SEER = Surveillance Epidemiology and End Results. The AAPC is statistically different from zero. a Last 10 yr of data only. b Last 9 yr of data only, AAPC for last 5 yr of data. *
rates. For example, in Romania (2001–2010), rates increased in men but decreased in women. In contrast, in Hungary (2000–2009), rates decreased in men but increased in women. Overall, rates decreased in men in four of the eight countries: the Czech Republic, Hungary, the Russian Federation, and Slovakia (all 2001–2010).
Rates increased for women in Bulgaria and Poland (both 2001–2010). 3.2.7.
Asia
BCa incidence rates remained stable in all Asian countries or regions considered in this analysis, except they
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EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._4)TD$IG] a
Germany* Denmark Switzerland* Italy* Republic of Korea Singapore Austria United Kingdom France* Australia The Netherlands Russian Federation* Israel Costa Rica Slovakia Czech Republic Finland Spain* Norway Japan* Ecuador* Canada* United States (SEER) Lithuania Sweden Poland* Brazil* China* Latvia Colombia* Croatia Slovenia Bulgaria
-3.9
-1.9
-3.3
-1.6
-3.1 -3.1 -2.6 -2.5 -2.3
-4.2
-1.9
-5.2 -2.7
-1.9 -1.8 -1.8
-1.0 0.5
-1.7 -1.6
2.1
-1.6 -1.4 -1.7 -1.3
2.7
-1.1 -1.1
-1.2
-0.7 -0.6 -0.4
3.9
-0.2 -0.3
1.3 2.5 4.3 3.2
0.8
-11.0
-10.0
-9.0
-8.0
-7.0
-6.0
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
4.0
1.0
2.0
3.0
4.0
5.0
AAPC Mortality
Incidence
b Republic of Korea Germany* Austria Singapore Japan* Italy* United Kingdom Latvia Switzerland* France* Lithuania Finland Ecuador* Norway Israel Russian Federation* The Netherlands China* Costa Rica United States (SEER) Canada* Denmark Sweden Czech Republic Croatia Spain* Slovakia Australia Bulgaria Colombia* Slovenia Poland* Brazil*
-2.7
-8.4
-2.6 -2.2 -2.1
-0.9
-2.0 -1.8
-4.1
-1.7
2.4
-1.5
-5.2
-1.1 -1.7
-1.0 1.7
-1.4 1.7 2.1
-0.5
2.7 -1.4 -0.9
-0.4
-0.6
5.6 2.0 1.7 -3.6 6.7
0.8
-1.6
4.3 1.3 1.4
-10.0
-9.0
-8.0
-7.0
-6.0
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
AAPC Mortality
Incidence
Fig. 4 – Average annual percent change (AAPC) in incidence and mortality trends, all ages for last 10 yr of available data (a) in men and (b) in women. Values shown across the bars indicate the AAPC are statistically significant. SEER = Surveillance Epidemiology and End Results. * Incidence rates from regional registries.
increased in Saudi Arabian men (1999–2008) and Chinese men (1993–2002) and decreased in Israeli women (1998– 2007) and Japanese women (1993–2002), with the Saudi Arabian men showing the largest AAPC at 3.8% per year. In China, the mainland urban areas and the rural areas (1991–2000) had stable mortality rates in both men and women; however, residents of Hong Kong (2000–2009)
experienced decreasing mortality rates with AAPC of 3.4% for men and 3.8% for women. Rates also decreased for both men and women in Singapore (2000–2009), the Republic of Korea (2001–2010), and Israel (2000–2009) for men and in Japan (2001–2009) for women. Mortality rates remained stable for all of the other countries examined.
68
EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 – Trends in bladder cancer mortality rates in (a) men and (b) women of all ages from selected registries and the World Health Organisation mortality database [10] (a) Join-point analyses Trend 1 Years North America Canada United States Central and South America Argentina Brazil Chile Colombia Costa Rica Ecuador El Salvador a Guatemala a Mexico Nicaragua a Panama b Uruguay b Venezuela a Caribbean Cuba Trinidad and Tobago Western Europe Austria France Germany Luxembourg Switzerland The Netherlands Northern Europe Denmark Estonia a Finland Iceland Ireland Latvia a Lithuania a Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom Southern Europe Croatia FYROM a Greece Italy Malta Portugal Serbia a Slovenia Spain Central and eastern Europe Bulgaria Czech Republic Hungary Poland a Republic of Moldova a Romania Russian Federation Slovakia Asia China a China, Hong Kong China Rural a China Urban a
Trend 2 APC
Years
Trend 3 APC
Years
Trend 4 APC
Years
AAPC APC
Last 10 yr
1985–2009 1985–2008
0.7* 0.4*
2000–2009 1999–2008
0.7* 0.4*
1985–2010 1985–2008 1985–2009 1990–2009 1985–1997 1985–2010 1999–2008 1999–2008 1985–2010 1997–2006 1996–2004 1993–2001 1998–2007
1.9* 0.1 0.2 0.3 2.6* 0.7 8.5 1.3 0.0 3.1 1.3 1.7 0.9
2001–2010 1999–2008 2000–2009 2000–2009 2000–2009 2001–2010 1999–2008 1999–2008 2001–2010 1997–2006 2000–2004 1997–2001 1998–2007
1.9* 0.1 0.2 0.3 1.6 0.7 8.5 1.3 0.0 3.1 1.3 1.7 0.9
1985–2004 1985–2002
–0.5 3.9*
2001–2010 1993–2002
2.5* 3.9*
1985–2010 1985–1997 1985–1992 1985–2009 1985–2007 1985–2010
2.3* 0.6* 0.3 2.8* 3.1* 1.8*
2001–2010 2000–2009 2001–2010 2000–2009 1998–2007 2001–2010
2.3* 1.9* 3.9* 2.8* 3.1* 1.8*
1985–1998 2001–2010 1985–2010 1985–2009 1985–2010 2001–2010 2001–2010 1985–2010 1985–2010 1985–1992 1985–1989 1985–1992
0.8 0.5 1.3* 0.5 1.1* 0.2 0.3 1.1* 0.3* 0.6 2.9 1.1
1997–2006 2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
3.3* 0.5 1.3* 0.5 1.1* 0.2 0.3 1.1* 0.3* 1.7* 2.6* 1.9*
1985–2010 1994–2003 1985–2009 1985–1993 1985–2000 1985–2003 2000–2009 1985–2010 1985–1993
0.3 2.1 0.5* 0.4 1.0 0.2 0.5 0.8* 1.5*
2001–2010 1994–2003 2000–2009 1994–2003 1991–2000 1994–2003 2000–2009 2001–2010 2001–2010
0.3 2.1 0.5* 3.1* 1.0 0.2 0.5 0.8* 1.1*
1985–1995 1986–2010 1985–1991 2001–2010 2001–2010 1985–2010 2000–2002 1992–2010
1.4* 1.4* 1.5* 0.2 0.3 0.8* 1.6 0.5
2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.9 1.4* 1.1* 0.2 0.3 0.8* 1.7* 1.5*
1991–2000 1985–2009 1991–2000 1991–2000
0.2 3.4* 0.1 0.2
1991–2000 2000–2009 1991–2000 1991–2000
0.2 3.4* 0.1 0.2
1997–2000
19.9
2004–2010
4.1*
1997–2009 1992–2010
1.9* 3.9*
1998–2006
3.6*
1992–2005 1989–2010 1992–2005
3.0* 2.6* 0.5
2000–2002
1.6
2005–2010
0.6
2005–2010
3.0*
1993–1996
7.0
1996–2003
2.0*
1993–1996
2.3
1996–2003
0.5
2003–2010
1.5*
1995–2003
1.2
2003–2006
7.8
2006–2010
2.9
1991–2009
1.1*
2002–2010
2.2*
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EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 (Continued ) (a) Join-point analyses Trend 1 Years Israel Japan Kazakhstan a Kuwait a Kyrgyzstan a Philippines a Republic of Korea Singapore Africa Egypt a Mauritius South Africa a Oceania Australia New Zealand
Trend 2 APC
1985–2009 1985–2001 2000–2009 2000–2009 2000–2009 1993–2002 1985–2002 1985–2009
1.6* 0.9* 9.0* 3.2 0.6 2.4 4.3* 2.5*
2001–2010 1985–1990 2000–2009 1985–2004 1985–2008
Years
Trend 3 APC
Years
Trend 4 APC
Years
AAPC APC
Last 10 yr 2000–2009 2001–2010 2000–2009 2000–2009 2000–2009 1993–2002 2001–2010 2000–2009
1.6* 0.7 9.0* 3.2 0.6 2.4 2.6* 2.5*
4.3* 2.7* 0.6
2001–2010 2001–2010 2000–2009
4.3* 2.7* 0.6
1.8* 1.6*
1995–2004 1999–2008
1.8* 1.6*
2001–2010
0.7
2003–2010
3.5*
(b) Join-point analyses Trend 1 Years North America Canada United States Central and South America Argentina Brazil Chile Colombia Costa Rica Ecuador El Salvador a Guatemala a Mexico Nicaragua a Panama b Uruguay b Venezuela a Caribbean Cuba Trinidad and Tobago Western Europe Austria France Germany Luxembourg Switzerland The Netherlands Northern Europe Denmark Estonia a Finland Iceland Ireland Latvia a Lithuania a Norway Sweden United Kingdom, England United Kingdom, Scotland United Kingdom Southern Europe Croatia FYROM a
Trend 2 APC
1985–2009 1985–2008
0.3 0.4*
1985–2010 1985–1988 1985–2009 2000–2009 1985–2009 1985–2010 1999–2008 1999–2003 1985–2005 1997–2006 1996–2004 1993–2001 1998–2007
0.9* 6.8 0.5 0.9 0.4 1.0 1.8 24.8 0.4 2.7 6.7 1.1 0.3
1985–2010 1985–2002
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr
2000–2009 1999–2008
0.3 0.4*
2001–2010 1999–2008 2000–2009 2000–2009 2000–2009 2001–2010 1999–2008 1999–2008 2001–2010 1997–2006 2000–2004 1997–2001 1998–2007
0.9* 1.4* 0.5 0.9 0.4 1.0 1.8 4.8 0.1 2.7 6.7 1.1 0.3
1.1* 4.4*
2001–2010 1993–2002
1.1* 4.4*
1985–2010 1985–2009 1985–1993 1985–2009 1985–2007 1985–2010
2.2* 1.1* 0.7 2.8* 1.5* 0.5*
2001–2010 2000–2009 2001–2010 2000–2009 1998–2007 2001–2010
2.2* 1.1* 2.6* 2.8* 1.5* 0.5*
1985–1998 2001–2010 1985–2010 1985–2009 1985–2010 2001–2010 2001–2010 1985–2010 1985–2010 1985–1992 1985–2010 1985–1990
0.2 0.9 1.0* 5.3* 0.6 3.3 1.8 0.9* 0.2 0.5 1.2* 0.6
1997–2006 2001–2010 2001–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.2 0.9 1.0* 5.3* 0.6 3.3 1.8 0.9* 0.2 1.7* 1.2* 1.7*
2001–2010 1994–2003
0.2 2.1
1985–2010 1994–2003
0.2 –2.1
1988–2008
2003–2008 2005–2008
1993–2010
1.4*
14.9 15.4
2.6*
1992–2010
1.7*
1990–2010
1.7*
2008–2010
20.2*
70
EUROPEAN UROLOGY 66 (2014) 59–73
Table 3 (Continued ) (b) Join-point analyses Trend 1 Years Greece Italy Malta Portugal Serbia a Slovenia Spain Central and eastern Europe Bulgaria Czech Republic Hungary Poland a Republic of Moldova a Romania Russian Federation Slovakia Asia China a China, Hong Kong China Rural a China Urban a Israel Japan Kazakhstan a Kuwait a Kyrgyzstan a Philippines a Republic of Korea Singapore Africa Egypt a Mauritius South Africa a Oceania Australia New Zealand
Trend 2 APC
1985–2009 1985–1992 1985–2000 1985–2003 2000–2009 1985–2010 1985–1997
1.8* 0.3 2.2 0.8 1.1 0.9 1.9*
1985–1995 1986–2010 1985–1991 2001–2010 2001–2010 1985–2010 2000–2010 1992–2010
Years
Trend 3 APC
Years
Trend 4 APC
Years
APC
AAPC Last 10 yr 2000–2009 1994–2003 1991–2000 1994–2003 2000–2009 2001–2010 2001–2010
1.8* 1.8* 2.2 0.8 1.1 0.9 0.5
0.8* 0.2 0.7* 1.3* 1.7 0.7* 0.8 0.5
2001–2010 2009–2010 2000–2009 2001–2010 2001–2010 2001–2010 2001–2010 2001–2010
0.8* 0.2 0.7* 1.3* 1.7 0.7* 0.8 0.5
1991–2000 1985–2009 1991–2000 1991–2000 1985–2009 1985–1987 2000–2009 2000–2009 2000–2009 1993–2002 1985–2003 1985–2009
0.9 3.8* 0.6 1.4 0.8 5.5* 19.3* 10.8 3.6 1.4 4.6* 2.1*
1991–2000 2000–2009 1991–2000 1991–2000 2000–2009 2001–2010 2000–2009 2000–2009 2000–2009 1993–2002 2001–2010 2000–2009
0.9 3.8* 0.6 1.4 0.8 2.0* 19.3* 10.8 3.6 1.4 2.7* 2.1*
2001–2010 1985–1990 2000–2009
4.7* 29.8* 3.1*
2001–2010 2001–2010 2000–2009
4.7* 2.4 3.1*
1985–2002 1985–2008
1.9* 1.7*
1995–2004 1999–2008
0.6 1.7*
1992–1998
4.5*
1987–2008
0.0*
2003–2010
4.7*
1990–1993
31.3
2002–2004
9.9
1998–2003
0.5
2008–2010
8.7*
1993–2010
2.4
APC = annual percent change; AAPC = average annual percent change; FYROM = former Yugoslav Republic of Macedonia. The APC or AAPC is statistically different from zero. a Last 10 yr of data only. b Last 9 yr of data only, AAPC for last 5 yr of data. *
3.2.8.
Africa
Long-term data for African countries were not available, and only three countries from this continent could be studied. Mortality rates in Egypt (2001–2010) decreased by >4% per year for both men and women. Rates also decreased in South African women (2000–2009) and in Mauritian men (2001–2010) by roughly 3% per year. Trends were stable in South African men and Mauritian women. 3.2.9.
Oceania
Incidence rates decreased in Australian men and women (1999–2008) and in New Zealander men (1999–2008). Rates were stable in New Zealander women. Mortality rates in Australian men (1995–2004) and New Zealander men (1999–2008) decreased by 1.8% per year and 1.6% per year, respectively. Rates also decreased by 1.7% per year in New Zealander women but remained unchanged in Australian women.
3.3.
Discussion
The highest estimated BCa incidence rates are found mainly in the high-resource nations of western Europe and North America and a few countries in southern, central, and eastern Europe and in the developing economies of northern Africa. In northern and western Europe, men tended to experience a greater decrease in incidence rates than women. In contrast, the highest mortality rates tend to be observed in certain low- to medium-resource countries of northern and southern Africa, in western Asia, and in some countries of southern, central, and eastern Europe. For both men and women, the decrease in mortality rate was more pronounced in North America and western and northern Europe. Tobacco use is the most important risk factor for BCa in most parts of the world [2], with an attributable risk of up to 50% in Europe [17]. A recent meta-analysis demonstrated
71
EUROPEAN UROLOGY 66 (2014) 59–73
[(Fig._5)TD$IG] Colombia
Costa Rica
Canada
Sweden
USA
20
M
M
10
20
M
Austria
France
M
F
F M
M
M
M
1
F
F M
F
F M
M F
M
F
2
F
F
M
M
4
F
F
0.5
M
M
10
4 2
UK, Scotland
40
40
F
F
1
F
F
0.5 1975
1990
2010 1975
Japan
1990
2010 1975
Philippines
1990
2010 1975
Rep of Korea
1990
1975
2010
2010 1975
1990
2010 1975
Netherlands
1990
2010 1975
Switzerland
1990
2010
Croatia
40
40 20
M
20
10
M
M
M M
4 2
M
F
M
F
1
F
M
F M
F
0.5
1975
1990
2010 1975
Israel
1990
F
F
F
2010 1975
Australia
1990
2010 1975
Denmark
1990
2010
Estonia
40 M
20
M
10
M M
4
M
M
F
F
F
2 1
M
MF
F
F
F
F
Age−standardised (World) rate per 100 000, all ages
Age−standardised (World) rate per 100 000, all ages
1990
Germany
China
4 2
F
M
F
F
F
F
1
M
F
M F
M
F
0.5 1975
1990
2010 1975
Italy 40
1990
2010 1975
Slovenia
1990
2010 1975
Spain
1990
20
Bulgaria
M
M
10 F
2010
M
M
M
M F
M
4 2
M F
F
F
1
0.5
M
M
M
10
F
F
F
0.5 1975
1990
2010 1975
Finland
1990
2010 1975
Ireland
1990
2010 1975
Lithuania
1990
1975
2010
1990
2010 1975
Czech Rep.
Norway
1990
2010 1975
Poland
1990
2010 1975
Russian Fed.
1990
2010
Slovakia
40
40 20 10
M
M
M
M
M
F M
F
4 F
2
M
M
1
F F
F
M
M
M M
10
M M
M F
4
F
F
0.5
20
M F
F
2
F
F
F
F
1
F
0.5 1975
1990
2010 1975
1990
2010 1975
1990
2010 1975
1990
2010
Incidence
1975
1990
2010 1975
1990
2010 1975
1990
2010 1975
1990
2010
Year
Year Mortality
Incidence
Mortality
Fig. 5 – Trends in bladder cancer incidence and mortality age-standardized (world) rates for selected countries and in all ages in men and in women. Incidence data are from Cancer Incidence in Five Continents [10]; mortality data are from the World Health Organization mortality database [10]. Solid lines represent fitted values based on join-point analyses. Dots represent observed rates. M = males; F = females.
that smoking is associated with a threefold increase in risk for cancer of the lower urinary tract (predominantly bladder) [18]. The urothelial carcinoma variant of BCa is associated with tobacco smoke and constitutes >90% of all cases [19]. The fall in BCa incidence and mortality in the industrialised nations of North America, northern and western Europe, and Oceania may thus be said to largely reflect the decrease in smoking prevalence in these regions. For example, current smoking prevalence in US adults decreased from about 45% in 1965 to about 19% in 2010 [20]. In the United Kingdom, smoking prevalence among men decreased from >70% in 1950s to about 20% in 2010 [21]. Similar substantial decreases in smoking prevalence have been reported in Canada and Australia [22,23]. A few studies have proposed that a reduction in occupational exposures may contribute to a fall in incidence rates [24–26]. However, it is difficult to attribute this decrease in incidence and mortality rates in these regions to reduction in occupational exposures of known carcinogens (e.g.,
benzidine and 2-naphthylamine), given the paucity of large studies measuring trends in occupational exposures. Similarly, there is no evidence-based screening method for early detection of urinary bladder [27] to contribute to the favourable mortality trends in Western countries and other economically developed countries. The countries of central and eastern Europe stand out from rest of the continent in that BCa mortality rates are mostly decreasing for men but are stable or even rising for women. This is possibly because the tobacco epidemic among women lags behind that of men by many decades, and the epidemic has yet to mature in women. However, some of the unevenly changing incidence and mortality rates may reflect artefacts of coding or reporting changes [28–30], as is evident in Scotland and Germany. The relatively high incidence of BCa in North Africa has been largely attributed to the Schistosoma parasite, at least until recently. Egypt, in this regard, serves as a good model to study the heterogeneity of BCa as a disease with multiple
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EUROPEAN UROLOGY 66 (2014) 59–73
risk factors. After the successful control of schistosomiasis, Egypt experienced a decrease in the proportion of squamous cell carcinoma cases, which are associated with schistosomiasis, alongside an increase in the proportion of carcinoma related to smoking [31]. The more advanced age observed among recently diagnosed cases is consistent with the increased proportion of tobacco-related BCa because smoking-induced tumours tend to present later in life [32]. A comparison of male and female incidence rates reveals high male-to-female ratios in Western countries and in the northern African region, especially in Egypt. Possible explanations might be higher smoking prevalence among men in the Western nations and higher exposure to S. haematobium among men in North Africa. However, unlike in Egypt, where the male-to-female incidence ratio is >6, this ratio in most other African nations seldom exceeds 3, possibly due to comparable involvement of women in farming and other activities like acquiring water, which puts them at a nearly equal risk of exposure to the parasite, as suggested by Heyns et al. [33]. Nonetheless, a study by Hartge et al. reports that some proportion of the male excess remains unexplained by the established risk factors [34]. The strength of our study is the use of worldwide cancer incidence and mortality data from IARC to compare and contrast BCa rates and trends across countries. However, there are certain limitations in the interpretation of the data. First, the accuracy of estimates from GLOBOCAN 2008 vary across countries, depending on the extent and validity of available data in each county, ranging from actual national or regional data to those based on cancer information in neighbouring countries. In addition, recent incidence and mortality data are not available for many countries, and this restricts our ability to comment on the latest trends for all countries. The contemporary burden and interpretation of recent trends also may have been affected by reporting delays [15]. However, data from IARC are the only data to describe cancer rates and trends worldwide. Caution must also be exercised while interpreting the rates and trends in BCa rates due to differences in reporting of noninvasive urinary BCa across countries [35]. Benign neoplasms of the bladder have always been included in successive revisions of the ICD, but, with a better understanding of the biology of papilloma, some changes in the classification of tumour behaviour have emerged. Registry practices regarding the coding of invasiveness of bladder tumours have shifted accordingly. In addition, no distinction is made between the non–muscle-invasive and muscle-invasive carcinomas of the bladder, thereby limiting our ability to present separate epidemiologic trends for these types. Trends in BCa incidence are very difficult to interpret without exhaustive information on how registries have dealt with papillomas over time. Saxe´n has shown that, on exclusion of papillomas of the bladder, much of the variation in BCa incidence rates in the Scandinavian countries was removed [36]. In general, changes in registry procedures are more likely to affect comparisons between registries rather than trends in a single registry over time, provided such practices do not change over time [37].
For the geographical and temporal comparisons of cancer incidence, the coding practices of each registry should be reviewed, and successive volumes of CI5 should present the coding practices recorded in the questionnaires by each registry; for most registries, the BCa category includes both the in situ and unspecified categories [13,38,39]. 4.
Conclusions
BCa incidence and mortality rates vary substantially across countries due in part to differences in known risk factors, coding, detection and diagnostic practices, and availability of treatments (mortality only). Generally, the highest incidence rates are found in developed nations and some parts of Africa, whereas the highest mortality rates are found in North African and Middle Eastern countries. The decrease in mortality rates in Western countries in part reflects the reduction in smoking prevalence, whereas the decrease in African countries largely reflects control of S. haematobium and/or improved hygiene and sanitation. In contrast, the increase in incidence or mortality rates among women in some eastern European countries may reflect the growing burden of the tobacco epidemic. Progress in reducing BCa rates in all countries could be accelerated by applying known interventions, including tobacco control, improved sanitation and hygiene to reduce S. haematobium infection, and improved work site safety to reduce occupational exposures. Author contributions: Ahmedin Jemal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Bray, Lortet-Tieulent, Goodman, Jemal. Acquisition of data: Chavan, Bray, Lortet-Tieulent, Jemal. Analysis and interpretation of data: Chavan, Bray, Lortet-Tieulent, Goodman, Jemal. Drafting of the manuscript: Chavan, Jemal. Critical revision of the manuscript for important intellectual content: Chavan, Bray, Lortet-Tieulent, Goodman, Jemal. Statistical analysis: Chavan, Lortet-Tieulent. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: Jemal. Other (specify): None. Financial disclosures: Ahmedin Jemal certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
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