Each year in Europe, cancer kills about 2 million

people and more than 3 million new cases appear.

Almost 6 million people are currently living with
cancer.
The most common sites at which cancers appear
are breast in women, prostate and lung in men and
colon and rectum in both sexes. Cancer is responsi-
ble for more than one death in four. Lung cancer
kills more people than any other cancer. More than Europes cancer burden
40% of cancer deaths in Europe are presently due
to tobacco, diet and infections. Tobacco smoking -
past and current - and unhealthy life-style habits,
together with the increasing proportion of elderly
people, will result in a doubling of the number of
new cases by 2020, particularly in Southern and
Eastern Europe. All over Europe, the five-year sur-
vival rate of cancer patients is between 30% and
60%. In recent decades, the survival rates from
many types of cancer have improved substantially,
except for cancers of the lung, pancreas and liver.

Europes cancer burden

Survival rates from cancer differ considerably from
one country to another, indicating that in many
places the cure rates could be improved.

16 17
 Europes cancer burden

Estimating the burden Hlne Sancho-Garnier Cancer control programmes com-
Epidaure, Department of
Geographical distribution Epidemiology and Prevention,
Time trends: Regional Cancer Centre,
Montpellier, France
Incidence, incidence by site, mortality,
and survival
Fabio Levi
Avoidable cancers Cancer Registry of the Canton
of Vaud, Lausanne, Switzerland
Paola Pisani
International Agency for
Research on Cancer,
Lyon, France
Elsebeth Lynge
Institute of Public Health,
University of Copenhagen,
Copenhagen, Denmark
each year throughout Europe,
prise two basic components:
assessing the magnitude of the
cancer burden and estimating the
effect of avoiding exposure to
identified causative agents.
Estimating the burden
The first step in implementing
efficient cancer prevention strate-
gies is to assess the magnitude of
the cancer problem in the geo-
graphical area in which the
strategies are to be implemented.
Much work has been focused on
quantifying patterns of mortality
and incidence and, more recently,
of the survival of cancer patients
[13]. At the end of the twentieth
century, almost 2.8 million new
placing cancer diseases as the
second cause of death. The pro-
portion represented by deaths
from cancer among deaths from
all causes varies from 24% in
Easter n Europe 1 to 27% in
Southern Europe for males and
from 21% in Eastern Europe to 28%
in Northern Europe for females [4].
The relatively low frequency
among women in Eastern Europe
is related to the fact that they
have a higher proportion of deaths
from cardiovascular diseases.
When the comparisons ar e
restricted to people aged 4564,
the relative frequency increases
to 4550% for both sexes in
almost all countries, placing

Europes cancer burden

cases and 1.9 million deaths cancer diseases as the first cause
from cancer were being observed of premature deaths.

1
For the purposes of this chapter, Europe is divided into four regions:
Eastern: Belarus, Bulgaria, Czech Republic, Hungary, Moldova, Poland, Romania, Russian
Federation, Slovakia, Ukraine. Northern: Denmark, Estonia, Finland, Iceland, Ireland, Latvia,
Lithuania, Norway, Sweden, United Kingdom. Southern: Albania, Bosnia and Herzegovina, Croatia,
Greece, Italy, Macedonia, Malta, Portugal, Slovenia, Spain, Federated Republic of Yugoslavia and
Montenegro. Western: Austria, Belgium, France, Germany, Luxembourg, Netherlands, Switzerland

18 19
 Figure 1
Incidence of and mortality from cancers at all sites except skin in males in Europe
< 248.1 < 271.1 < 283.4 < 299.7
GLOBOCAN 2000
Geographical distribution
Figure 1 shows the incidence and
mortality rates for males in Europe
(standardized by age to the world
population) [2] for all types of cancer
except skin cancer other than
melanoma. The incidence rates
vary from 263 per 100,000 males
in Northern Europe to 319 in
Western Europe. The age-stan-
dardized mortality rate is lowest
in Northern Europe (168) and
highest (200) in Eastern Europe.
There are, however, large variations
within areas of Europe, as shown on
the maps. The ratio of incidence/
mortality, which gives a rough
estimate of the proportion of cure,
is highest (1.71) in Western
Europe and lowest (1.45) in
Eastern Europe.
20 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
< 405.4 < 150.3 < 169.3 < 182.0 < 198.1
GLOBOCAN 2000
The incidence rates in the female
population (Figure 2) are generally
lower, with a smaller range than
among males, varying from 194 per
100,000 females in Southern Europe
to 235 in Northern Europe. The
mortality rate is lowest in the South
(93) and highest in the North (122).
The incidence/mortality ratios show
little variation, from 1.92 in Northern
Europe to 2.1 in Western Europe.
These ratios are clearly higher in
females than in males because
cancers in females are more readily
cured.
Figure 2
Incidence of and mortality from cancers at all sites except skin in females in Europe
< 272.3 < 185.0 < 199.9 < 217.7 < 234.6
GLOBOCAN 2000
The relative frequency of cancers
at different sites also varies from
one country to another and may
partly explain the disparities in
the incidence/mortality ratios for
males. Each country should ex-
amine its own data and determine
its priorities for cancer prevention
and care. Nevertheless, some
common goals can be identified
for Europe. The most frequent
cancers among men are those of
the prostate, lung and colon and
rectum in Northern and Western
Europe; cancers of the lung, colo-
rectum and bladder in Southern
Europe; and cancers of the lung,
stomach and colo-rectum in
Eastern Europe (Figure
Among women, the rates of
breast and colo-rectal cancers are
Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
< 296.9 < 89.4 < 98.0 < 104.8 < 113.8
GLOBOCAN 2000
high in all European regions; the
rates for lung cancer are high in
Northern and Western Europe,
and high rates are seen for cancer
of the corpus uteri in Southern
Europe and for cervical cancer in
Eastern Europe (Figure 4).
Time trends
Trends in cancer incidence
Data on the incidence of cancer
are provided by cancer registries.
Population-based cancer registra-
tion is a relatively recent develop-
ment and remains restricted to
certain countries or parts of
countries.
Incidence rates by country are fre-
3). quently estimates derived from
cancer mortality rates and the
available incidence/mortality ratios.
As the incidence of cancer increases
steeply with age, and because life
expectancy is improving everywhere
in Europe, the number of cancer
cases is on the increase. At the
same time, about one-third of new
cancer cases are related either to
greater exposure to risk factors or
to the fact that more have been
found by more intensive screening
[5]. During the next 20 years, the
impact of both ageing and increasing
exposure to risk factors on the
absolute numbers of cases will be
< 147.4
quite dramatic.
Cancer incidence rates have
generally increased in both males
and females throughout Europe
since the Second World War [6].
Three groups of trends have been
observed over the past 20 years:
In countries in Southern and
Western EuropeAustria, Belgium,
France, Germany, Luxembourg,
Italy, Spain and Switzerland
Europes cancer burden
men have experienced a large
increase in the incidence of pros-
tate cancer, a decrease or plateau
in the incidence of lung cancer
and a substantial decrease in
the incidence of stomach cancer.
Among women, the incidence of
breast cancer continues to increase
[7], lung cancer rates are rising
especially for young women [8],
and the incidences of stomach
and cervical cancers are greatly
decreasing. In both sexes, the
21
 Figure 3 Figure 4
Incidence of and mortality from major cancers in men in Europe Incidence of and mortality from major cancers in women in Europe
* ASR (World) rates standardized by age to the World population * ASR (World) rates standardized by age to the World population

Breast Breast
Lung Prostate
Colon/Rectum Colon/Rectum
Stomach Lung
Cervix uteri Ovary etc.
Colon/Rectum Colon/Rectum
Stomach Corpus uteri
Prostate Bladder

Bladder Stomach Corpus uteri Lung

Larynx Oral cavity Ovary etc. Cervix uteri

Kidney etc. Kidney etc. Lung Melanoma of skin

Pancreas Non Hodgkin lymphoma Leukaemia Non Hodgkin lymphoma

Oral cavity Other Pharynx Melanoma of skin Stomach

Incidence Incidence Incidence Incidence
Mortality Mortality Mortality Mortality
Oesophagus Leukaemia Pancreas Leukaemia
GLOBOCAN 2000 GLOBOCAN 2000 GLOBOCAN 2000 GLOBOCAN 2000
Non Hodgkin lymphoma Larynx Kidney etc. Kidney etc.

Lung Prostate
Breast Breast
Colon/Rectum Lung
Colon/Rectum Colon/Rectum
Bladder Colon/Rectum
Corpus uteri Lung
Prostate Bladder
Cervix uteri Ovary etc.
Stomach Stomach
Stomach Corpus uteri
Larynx Non Hodgkin lymphoma
Ovary etc. Cervix uteri
Liver Leukaemia
Lung Melanoma of skin
Non Hodgkin lymphoma Kidney etc.
Non Hodgkin lymphoma Non Hodgkin lymphoma
Oral cavity Incidence Melanoma of skin Incidence Incidence Incidence
Leukaemia Leukaemia
Mortality Mortality Mortality Mortality
Kidney etc. Oesophagus

Europes cancer burden

Thyroid Stomach
GLOBOCAN 2000 GLOBOCAN 2000 GLOBOCAN 2000 GLOBOCAN 2000
Leukaemia Brain, nervous system
Brain, nervous system Brain, nervous system

incidence of colo-rectal cancers matic increase among women, In Eastern Europe and part of Trends in incidence by cancer site incidence of lung cancer is cancer have been stable or slightly
is increasing slightly. whereas in Ireland and the Southern Europe, the inciden- The incidence of lung cancer increasing alarmingly all over increasing, except among younger
In Northern European countries- United Kingdom, womens lung ces of lung cancer in men and increased everywhere among men Europe, except in Ireland and the individuals in Denmark and the
Ireland, the Netherlands, the cancer rates have begun to fall breast cancer in women are still until the 196070s, when the United Kingdom where the inci- United Kingdom, where they are
Nordic countries and the United [8]. The trends for other cancer increasing. For both sexes, the beginning of a decrease was first dence has been decreasing since decreasing [6].
Kingdom-there has been a sites are similar to those in incidence of stomach cancers is observed in the United Kingdom. the 1980s [8]. Lung cancer inci-
decrease in the incidence of southern and western Europe. still high, and for women the A decrease or a plateau is now dence trends match the tobacco The incidence of prostate cancer
lung cancer among men. In the incidence of cervical cancers is also being observed in other consumption trends of previous is increasing in all countries. This
Netherlands and the Nordic also high. Northern and Western European decades in each country. increase may, however, reflect the
countries, there has been a dra- countries. Among women, the The incidence rates of colo-rectal increased diffusion of screening

22 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe 23
 for prostate-specific antigen over recently declined in Iceland and adenocarcinomas of the oesophagus observed for deaths from colo- Figure 6
the past 10 years [9] (Figure 5). Sweden [7]. The incidence of cer- and gastric cardia has been ob- rectal cancer. In contrast to the Trends in mortality rates from malignant neoplasms in some eastern European countries
Men have also had an increase in vical cancer has generally de- served in the past few years in increase in the incidence of prostate and in the European Union, between 195357 and 199397, in males and females
the incidence of cancers of the creased, except in Eastern Europe Denmark, Italy, Switzerland and cancer, the mortality rates from
head and neck and oesophagus, and among young women in the United Kingdom [11]. cancer at this site have tended to 300,0

except in France where the inci- Germany, Norway and the United The incidence rates for melanoma, stabilize or to decline somewhat HU (M)

250,0
dence of such cancers is clearly Kingdom. The decrease may be due non-Hodgkin lymphoma and renal over the past few years in some
decreasing, consequent to the in part to screening programmes. and thyroid cancers have been countries. The decrease in mor- 200,0
PL (M)

ASRW per 100,000 population

decrease in alcohol consumption The incidence of stomach cancer increasing in all parts of Europe. tality from gastric cancer has per- EU (M)
CS (M)
150,0 YU (M)
over the past 20 years [10]. has been decreasing for both men In Souther n Europe, increase sisted, with a fall of 30% during HU (F)
CS (F)

and women at an annual rate of incidences of pancreatic and liver the past decade alone. Pancreatic ASRW
100,0 per 100,000 population
PL (F)
EU (F)
YU (F)
The incidence of breast cancer 5% for the past 25 years, except cancers have been observed. cancer mortality rates have
has increased by 13% per year in Greece, Italy, Portugal and most shown a decline of 3% in recent 50,0
1953-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-1997

over the past 30 years. eastern European countries, years. During the past decade, Years

Trends in cancer mortality European Union (EU) (M) Former Czechoslovakia (CS) (M) Former Yugoslavia (YU) (M)

Nevertheless, the rates have sta- where the decrease has been mortality rates have decreased Hungary (HU) (M) Poland (PL) (M) Former Czechoslovakia (CS) (F)
Data on deaths from cancer (mor- Former Yugoslavia (YU) (F) Hungary (HU) (F) Poland (PL) (F)
bilized in England, France, Italy, much smaller and more recent. by 12% for urinary bladder cancer
tality rates) are derived from European Union (EU) (F)
Scotland and Wales, and have An increase in the incidence of and by over 5% for cancers of the
death certificates. In Europe, data ASR (world), rates adjusted by age to the world population Source: WHO [4]
mouth, pharynx and oesophagus.
are available in most countries
since 1950.
Figure 5
In the 15 Member States of the Corresponding figures for women
Trends in incidence of and mortality from prostate cancer and testing for prostate- Figure 7 Figure 9
European Union (EU), a long-term in the EU are given in Figure 9.
specific antigen (PSA), cantons of Neuchtel and Vaud, Switzerland [9]
rise in age-standardized mortality The mortality rates declined Trends in mortality rates from cancers at Trends in mortality rates from cancers at
rates, which peaked in 1988, fell during the past decade, by 7% for major sites among men in the European major sites among women in the European
60 40 000
Union Union
for males and females combined breast cancer, 21% for colo-rectal

Europes cancer burden

Incidence PSA by 9% between 1988 and 1997 [12]. cancer, 26% for uterine (cervix
35 000
50 In some countries, however, and and corpus) cancer, 31% for stom-
MEN
30 000 particularly in Eastern Europe, the ach cancer and 11% for leukae- WOMEN

40 trends in mortality rates are still mia. The mortality rates were sta-
25 000
rising [13], as illustrated in ble for ovarian and pancreatic
PSA
30 20 000 Figure 6. Long-term trends in cancers, but there was a 15% rise
Number of PSA tests performed

Mortality mortality from major cancers in female deaths from lung cancer
15 000
20 among men in the EU are shown between 1985 and 1995 all over
10 000 in Figure 7. The fall in mortality Europe, except in Ireland and the
Rate per 100 000

10 rates from lung cancer has been United Kingdom. Lung cancer is
5 000

Deaths per 100,000

PSA appreciable (11%), from a peak therefore approaching colo-rectal

Deaths per 100,000

0 0 of 52.4 per 100,000 men in cancer as the second leading
1974-76 1977-79 1980-82 1983-85 1986-88 1989-91 1992-94 1995-97
198589 to 46.6 in 199598 cause of mortality from cancer
Calendar period
(Figure 8). A fall of 11% was also among women in the EU [12]. Years Years

Source: Levi et al [12] Source: Levi et al [12]

24 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe 25
 Figure 8 Figure 10
Trends in age-adjusted mortality rates from malignant neoplasms of the lung among men in 11 European countries, between 195357 Trends in age-adjusted mortality rates from malignant neoplasms at all sites among men in 20
and 199397 European countries, between 195357 and 199397
In all, the rates of death from
280,0

80,00 HU
most of the common cancers have
Austria (AT)
260,0
Belgium (BE)
shown favourable trends for both
Former Czechoslovakia (CS)
70,00 BE
Denmark (DK)
sexes over the past decade in the
240,0
Finland (FI) 15 Member States of the EU, but
CS
NL France (FR)
60,00
220,0 Germany (DE) not in other European countries,
Greece (GR)
IT
PL
particularly in Eastern Europe
50,00
DK 200,0
Hungary (HU)
GB BE Ireland (IE)
(Figures 10 and 11) [4,14].
Italy (IT)
DE FR
IR 180,0
NL Netherlands (NL)
40,00 DK
AT IT Norway (NO)
FI
CH GB
AT
Poland (PL)
IE
160,0 DE

ASRW per 100,000 population

YU Portugal (PT)
30,00
ES PT
Spain (ES)
ASRW per 100,000 population

CH
NO
Sweden (SE)
140,0 FI
FI Switzerland (CH)
20,00
United Kingdom (GB)
GR SE
120,0 Former Yugoslavia (YU)

10,00

100,0
1953-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-1997

0,00 Years

53-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-97

ASR (world), rates adjusted by age to the world population Source: WHO (4)

Years

Austria (AT) Belgium (BE) Denmark (DK) Finland (FI) Germany (DE) Ireland (IR) Italy (IT)
Figure 11
Netherlands (NL) Sweden (SE) Switzerland (CH) United Kingdom (GB) Trends in age-adjusted mortality rates from malignant neoplasms at all sites among women in
ASR (world), rates adjusted by age to the world population Source: WHO (4) 20 European countries, between 195357 and 199397

150,00

Europes cancer burden

DK Austria (AT)
HU
Belgium (BE)

Former Czechoslovakia (CS)

130,00 Denmark (DK)

Finland (FI)
CS
France (FR)
IE Germany (DE)
GR
Greece (GR)

Hungary (HU)
110,00 NL
Ireland (IE)
PL
Italy (IT)
NO
BE Netherlands (NL)
AT
DE Norway (NO)

ASRW per 100,000 population

SE Poland (PL)
FR
IT Portugal (PT)
90,00 CH
YU Spain (ES)
FI
Sweden (SE)
PT
ES Switzerland (CH)

United Kingdom (GB)

GR Former Yugoslavia (YU)

70,00
53-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-97
Years

ASR (world), rates adjusted by age to the world population Source: WHO (4)

26 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe 27
 Figure 12 In the EU, some of the decrease Figure 15 These include pancreatic cancer

Trends in age-adjusted mortality rates from malignant neoplasms of the breast among in mortality from leukaemia and
women in 20 European countries, between 195357 and 199397 breast cancer is due to therapeutic
advances [15]. The decrease in
death from breast cancer is at-
Trends in age-adjusted mortality rates from malignant neoplasms of the lung among men for both sexes and ovarian can-
in 20 European countries, between 195357 and 199397 cer. The main difference in cancer
mortality rates between females
and males in the EU is for lung
DK

30,00
Austria (AT)
tributable to earlier diagnosis and 26,00 and other tobacco-related cancers
Belgium (BE) Austria (AT)

DK
Former Czechoslovakia (CS) screening, which could account Belgium (BE)
(Figures 15 and 16). Owing to de-
Former Czechoslovakia (CS)
NL Denmark (DK)
25,00
IR
BE
GB Finland (FI) for the differences between coun- 22,00
Denmark (DK) clines in incidence in some coun-
HU GB Finland (FI)
France (FR)
IE
AT Germany (DE)
tries (Figure 12). Screening is the HU
France (FR) tries, the mortality rates from lung
CS 18,00 Germany (DE)

20,00
DE
IT
FR
Greece (GR)
major determinant of the persis- IE
Greece (GR) cancer have decreased overall by
Hungary (HU) Hungary (HU)
NO

tent fall in mortality from cancer more than 10% among men over
ASRW per 100,000 population

PT
Ireland (IE) Ireland (IE)
SE
ES 14,00
FI Italy (IT) NO Italy (IT)

ASRW per 100,000 population

15,00 PL
YU
GR
Netherlands (NL) of the cervix uteri [16]. SE
Netherlands (NL)
the past 10 years. A similar fall
Norway (NO) CS Norway (NO)
PL
Poland (PL) Improvements in food preservation 10,00
AT
DE
Poland (PL)
was observed for urinary bladder
BE Portugal (PT)
10,00 Portugal (PT) CH

Spain (ES) and nutrition balance are probably IE

GR
Spain (ES)
cancer, which may also indicate
Sweden (SE)
NL
Sweden (SE) FR

Switzerland (CH)
the main determinants of the 6,00 Switzerland (CH)

United Kingdom (GB)

decreased exposure to occupa-
PT
5,00
United Kingdom (GB) ES
53-57 58-62 63-67 68-72
Years
73-77 78-82 83-87 88-92 93-97
Former Yugoslavia (YU)
favourable trends in stomach cancer Former Yugoslavia (YU)
tional carcinogens. With the excep-
2,00

in both sexes (Figures 13 and 14). 53-57 58-62 63-67 68-72 73-77

ASR (world), rates adjusted by age to the world population Source: WHO (4)
Mortality rates from several neo-
plasms that had shown long-term
increases up to the mid-1980s in
the EU have tended to level off
over the past decade.
Figure 13 Figure 14
Years
78-82 83-87 88-92 93-97
tion of France, where there were
ASR (world), rates adjusted by age to the world population Source: WHO (4)
large decreases [10], the decrease in
mortality from cancers of the
head and neck and oesophagus
Figure 16 was smaller (35%). These cancers
Trends in age-adjusted mortality rates from malignant neoplasms of the lung among are strongly related to consump-
women in 20 European countries, between 195357 and 199397 tion of both alcohol and tobacco.

Trends in age-adjusted mortality rates from Trends in age-adjusted mortality rates from mal-
malignant neoplasms of the stomach among ignant neoplasms of the stomach among

Europes cancer burden

Austria (AT)

men in 20 European countries, between women in 20 European countries, between HU

Belgium (BE) In contrast, except in Ireland and
80,00

195357 and 199397 195357 and 199397 Former Czechoslovakia (CS)

Denmark (DK) the United Kingdom, the rates of

PL
70,00 BE Finland (FI)
50,00 36,00
34,00
CS
France (FR) lung cancer mortality among
NL
45,00 32,00 60,00 Germany (DE)

30,00
IT
Greece (GR)
women in the EU have risen by
40,00 28,00 DK
GR Hungary (HU)
15% over the past decade, fol-
per 100,000 population

50,00
100,000 population

26,00 GB
ES Ireland (IE)
35,00 24,00 FR
(World) population
population

AT
Italy (IT)
22,00 IE
lowing the increase in incidence

ASRW per 100,000 population

40,00 FI
30,00 CH
20,00 Netherlands (NL)
18,00
25,00
NO Norway (NO)
which reflects the persistent
(World) per

16,00 30,00 PT
Poland (PL)
100,000
100,000

14,00
20,00
12,00 SE Portugal (PT)
spread of the tobacco epidemic
ASRW per ASR

20,00
ASRW perASR

10,00 Spain (ES)

15,00
8,00
6,00
Sweden (SE)
among European women. In some
10,00 10,00 Switzerland (CH)
4,00

5,00
2,00
United Kingdom (GB) northern European countries,
53-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-97 Former Yugoslavia (YU)
53-57 58-62 63-67 68-72 73-77 78-82 83-87 88-92 93-97 0,00
Years
Austria Belgium
Years

Former Czechoslovakia Denmark

53-57 58-62 63-67 68-72 73-77
Years
78-82 83-87 88-92 93-97
mortality from lung cancer
Austria Belgium Former Czechoslovakia Denmark Finland France Germany Greece
Finland
Hungary
France
Ireland
Germany
Italy
Greece
Netherlands
Hungary
Norway
Ireland
Poland
Italy
Portugal
Netherlands
Spain
ASR (world), rates adjusted by age to the world population Source: WHO (4) exceeds that from breast cancer.
Norway Poland Portugal Spain Sweden Switzerland United Kingdom Former Yugoslavia
Sweden Switzerland United Kingdom Former Yugoslavia
ASR (world),
Source: rates adjusted by age to the world population Source: WHO(4)
WHO [4] ASR (world),
Source: rates
WHO [4]adjusted by age to the world population Source: WHO(4)

28 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe 29
 With non-Hodgkin lymphomas in
both sexes, lung cancer among
women is therefore one of the few
cancers that has shown an
upwards trend in mortality rates
in the EU. The rates for death from
lung cancer among women in the
EU (except for the high rates in
Denmark, Ireland and the United
Kingdom) are, however, still about
one-third of those of women in the
USA and 50% lower than the rates
for death from breast cancer in the
EU [12]. Integrated, effective inter-
ventions to reduce smoking should
therefore still help European
women to avoid the current tobac-
co-related cancer epidemic occur-
ring presently in Denmark,
Ireland, the United Kingdom and
the USA.
Trends in survival from cancer
In the EU, the rates of long-term
(510 years) survival from many
types of cancer have improved
considerably over the past few
decades, because of advances in
early detection and treatment.
Other reasons are probably mani-
fold and vary with cancer site.
Early detection has probably made
a large contribution to increasing
survival rates after cancers of the
cervix, thyroid and prostate and
melanoma. Improvements in sur-
vival from other cancers, such as
of the testis, Hodgkin lymphoma
30 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
and childhood cancers, are attrib-
utable mainly to new treatments.
For breast cancer, early detection
and improvements in treatment
are the main explanations of the
increased survival. Nevertheless,
no progress has been made in the
prognoses for lung, liver or pan-
creatic cancers. Figure 17 presents
5-year survival rates from cancers
at various sites, estimated from
the numbers of incident cases in
1985 and 1989 in the EU [3].
The Eurocare-2 study [3] showed
that European populations vary
considerably in their rates of sur-
vival from cancer, possibly indi-
cating that cancer care facilities
could be improved in some areas.
The rates for tumours with a good
prognosis generally appear to be
lower in Eastern Europe than in
other areas. This study showed
that the significant factors that
influence survival rates are: the
proportion of the gross national
product spent on health, the per
cent unemployment, the number
of hospital beds, the number of
computed tomography scanners
available per million population,
life expectancy at birth, and sex.
For most tumours that affect both
sexes, women survive longer than
men, probably partly due to greater
body awareness, which leads to
earlier diagnosis. These findings
Figure 17
Five-year survival rates in 16 European
cancer registries
100%
90% Testis, most childhood
cancer
75% Thyroid, melanoma
Hodgkin disease, breast,
corpus uteri
cervix uteri, bladder
50% Prostate, colo-rectum
kidney, non-Hodgkin
lymphoma
Head and neck,
ovary, leukaemia
25%
Brain, stomach
lung, oesophagus
liver, pancreas
0%
indicate that inequality of access
to and availability of health facili-
ties may contribute to inter-coun-
try differences in survival.
Avoidable cancers
The second fundamental step in
any cancer control programme,
after the magnitude of the cancer
problem has been assessed, is to
estimate the expected effect,
expressed as the number of cases
or deaths that could theoretically
be prevented by avoiding exposure
to causative agents.
As mentioned above, the first step
is to quantify the proportion of
the cancer burden that can be
explained by known causes.
These figures provide the baseline
of maximum achievable benefit
relative to the total burden. In most
cases, however, the probable
impact will be smaller, as it depends
on whether the exposure can be
modified and, if so, on the efficacy
of the intervention in reducing
the prevalence of the exposure.
It has been known for a long time
that risks for cancer are determined
by the environment in general,
health behaviour and external
factors. This is illustrated, for
example, by the observation in 1713
of an excess risk for breast cancer
among nuns and the observation
in 1795 of an excess risk for scrotal
cancer among chimney sweeps.
Data on cancer-causing agents
accumulated during the 1970s,
and these are reviewed in the
Monographs on the Evaluation of
Carcinogenic Risks to Humans of
the International Agency for
Research on Cancer (IARC). Many
of the agents evaluated were
industrial chemicals, and the
evidence on carcinogenicity for
many of them came from ex-
periments in animals. Interest
therefore naturally arose in
quantifying the contribution of
these agents to the causation of
human cancer. In 1979, Higginson
and Muir [17] analysed data on
cancer incidence from 1973, to
identify the lowest observed rate
Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
for each cancer site. On the basis
of this analysis, they reached the
conclusion that 80% of all cancers
are due to environmental causes
and are therefore in principle
preventable.
The first comprehensive quantifi-
cation of the causes of human
cancer was performed in 1981 by
Doll and Peto [18], who quantified
the contributions of various causes
to cancer deaths in the population
of the USA under 65 years of age.
They identified two major causes:
tobacco smoking and diet. Tobacco
smoking was estimated to be the
cause of 35% of all cancers. The
evidence that diet was the other
main cause was mostly indirect,
however, and the data were often
inconsistent. It was thus assumed
that diet was responsible for
somewhere between 10% and
70% of human cancers, with 30%
as the best point estimate.
Since that time, few new causes
of cancer have been identified.
Identification of the role of human
papillomaviruses (HPVs) in cervical
cancer has nonetheless further
increased the perspectives for
cancer control through immuni-
zation, which were opened by the
finding that hepatitis B virus and
other viruses were associated
with cancer. In areas such as
nutrition, which once appeared to
be promising, little definitive
evidence amenable to primary
prevention has been obtained.
Table 1 lists the main groups of
factors that have been shown
consistently to increase the risks
for cancers at specified sites.
Not all the identified causes of
cancer are equally modifiable. For
example, women who have their
first child after the age of 35 have
twice the risk for breast cancer as
women who have their first child
before the age of 30. A distinction
must therefore be made between
identified causes of cancer and
avoidable causes of cancer. There
is, of course, no clear line between
the two, as it depends on the extent
to which we find our environment
modifiable.
In 1997, the number of avoidable
cancers was estimated for the Nordic
countries [19] on the basis of data
on cancer incidence, as all the Nordic
Europes cancer burden
countries have high-quality, nation-
wide cancer registers. In addition,
data on the prevalence of exposure
to cancer risk factors were used.
Diet was not included in the esti-
mation owing to uncertainty about
the associated risk estimates and
the lack of detailed data on food
intake, and all liver cancers were
attributed to excessive alcohol
consumption. The estimates are
listed in Table 2. A total of 27% of
all cancers were estimated to be
31
 Table 1
Factors that increase risks for cancer at the indicated sites
Cause group
Active and passive tobacco smoking
Diet, excess body weight,
little physical activity
Alcohol consumption
Reproductive history
Occupational exposures
Ionizing radiation, ultraviolet radiation
Infectious agents
Table 2
Proportions of all cancers avoidable in the Nordic countries annually, around the
year 2000, both sexes
Environmental or lifestyle factor
Tobacco smoking
Passive smoking
Alcohol consumption
Occupation
Radon
Man-made ionizing radiation
Solar radiation
Obesity (body mass index > 30)
Infection with human papillomavirus or Helicobacter pylori
Total
Source: Olsen et al [19]
avoidable, with tobacco smoking
as the main contributor.
Some cases of liver cancer in
(mostly Southern) Europe may be
caused by infection with hepatitis
viruses. This is the background
for the recent EU recommenda-
tion for hepatitis B virus immuni-
32 Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
Associated cancer site
Lung, oral cavity, pharynx, larynx,
oesophagus, urinary bladder, stomach,
pancreas, liver, kidney
Colon, breast after menopause,
endometrium, kidney
Head and neck, oesophagus, liver, breast
Breast, cervix, endometrium, ovary
Lung, urinary bladder, kidney, sinus,
larynx, haematopoietic system
All malignant neoplasms, skin,
brain and nervous system
Liver, stomach, cervix uteri, ano-genital
organs, haematopoietic system, urinary
bladder
% that removal of adenomas detected
14.2
0.1
1.1
1.7
0.2
1.9
4.2
0.6
2.6
26.6
zation programmes [20]. IARC
has since estimated that more
than 40% of cancer deaths in
Europe are presently due to
tobacco, diet and infections [21].
The estimates given above are for
cancers that can be avoided by
changing exposure, which is
usually considered to be primary
prevention. Another cancer
control measure is secondary pre-
vention in the form of early detec-
tion by screening and early diag-
nosis. The aim of early detection
is to reduce mortality from cancer.
Some cancer screening tests also
detect precancerous lesions, thereby
leading to prevention of the de-
velopment of invasive tumours.
Cervical dysplasia is detected by
Papanicolaou (Pap) smears, and it
has been estimated that 91% of
squamous-cell carcinomas of the
cervix uteri can be avoided by Pap
smear screening every third year
[22]. There is increasing evidence
in the large bowel by flexible
sigmoidoscopy and colonoscopy
[23] decreases the incidence of
colorectal cancer [23], and adeno-
mas. Cancers at some sites can
therefore be avoided by screening.
The following chapters discuss
the various possibilities for
decreasing cancer risks and
decreasing mortality due to these
diseases.
The following chapters discuss
the various possibilities for
decreasing cancer risks and
decreasing mortality due to
these diseases.
Key references
Parkin D, Whelan S, Ferlay
J et al. eds. Cancer inciden-
ce in five continents. Vol
VIII. IARC Scientific
Publications No. 155, Lyon:
IARCPress, 2002.
Ferlay J, Bray F, Pisani P et
al. Globocan 2000. Lyon:
IARCPress, 2001. On the
internet: www.iarc.fr
Berrino F, Capocaccia R,
Estve J et al., eds. Survival
of cancer patients in
Europe: the Eurocare-2
study. IARC Scientific
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Lyon:IARCPress, 1999.
Levi F, Lucchini F, Negri E
et al. Mortality from major
cancer sites in the
European Union,
19551998. Ann Oncol
2003;14:4905.
Boyle P, Autier P, Bartelink
H et al. European code
against cancer and scienti-
fic justification: Third ver-
sion. Ann Oncol
2003;14:9731005.
Acknowledgements
The work presented by Paola Pisani
was in part financially supported
by the European Union under
Contract N SOC 96 200 504.
Evidence-based Cancer Prevention: Strategies for NGOs - A UICC Handbook for Europe
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