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Cancer mortality trend analysis in Italy, 1980-2010, and predictions for 2015

Abstract

Aims

To update cancer mortality statistics in Italy, analyzing 1980-2010 trends, and to predict 2015 mortality rates.

Methods

World Health Organization cancer mortality and census data were extracted to calculate death rates for 30 cancer sites from 1980 to 2010. Trends were analyzed with joinpoint regression and predicted 2015 deaths rates were computed.

Results

In 2010 in Italy, there were 175,046 cancer deaths (98,847 men and 76,199 women), with total mortality rates, respectively, of 138.22 and 82.6/100,000. The leading cause of cancer death in men was lung cancer (25,457 deaths, 36.2/100,000), whereas in women it was breast cancer (12,115 deaths, 15.38/100,000). Total cancer mortality in men has been decreasing since the late 1980s, with an estimated annual percentage change (EAPC) of -1.8 in 1994-2010. In women, total cancer mortality rates decreased throughout the study period, with an EAPC of -1.1 in 1992-2010. Trends in mortality were decreasing for most cancers in both sexes. Only pancreatic and lung cancer trends in women were unfavorable. Total numbers of predicted cancer deaths in Italy for 2015 increased to 102,647 men and 82,047 women; however, the predicted rates decreased in men (129.1/100,000), while remaining stable in women (82.6/100,000).

Conclusions

Mortality rates for the most common cancers in Italy showed favorable trends that are likely to continue in the near future, with the exception of lung cancer mortality in women. Maintaining these trends requires continuous and improved control of tobacco, alcohol, and nutrition/overweight. Further improvements in diagnosis and treatment may also have a significant impact on cancer mortality.

Tumori 2015; 101(6): 664 - 675

Article Type: ORIGINAL RESEARCH ARTICLE

DOI:10.5301/tj.5000352

Authors

Tiziana Rosso, Paola Bertuccio, Carlo La Vecchia, Eva Negri, Matteo Malvezzi

Article History

Disclosures

Financial support: Italian Association for Cancer Research (AIRC, project N. 10264).
Conflict of interest: None.

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Introduction

Total cancer mortality in Italy has been declining since the 1980s in men and earlier in women (1), similarly to most ­European countries and the United States (2, 3). The favorable trend is due to a fall in tobacco-related cancers in men, as well as a decline in other cancer sites including stomach, colon-rectum, female breast, testis, prostate, uterus, and leukemia, Hodgkin lymphoma, and a few other treatable neoplasms (1). However, some rising trends have also been ­observed, notably for female lung cancer and pancreatic cancer in both sexes (1).

This report updates Italian cancer mortality statistics, with data up to 2010 (1). Furthermore, it gives predictions to 2015.

Methods

As in previous publications (1, 4), certified deaths for the period 1980-2010 (2004 and 2005 data were not available) for 31 selected cancer sites and total cancer mortality were derived from the World Health Organization mortality database (5), stratified by sex and 5-year age groups. Estimates of the resident population, based on official censuses, were obtained from the same database.

Two different revisions of the International Classification of Diseases (ICD-9 and ICD-10) were used. All cancer deaths were recoded according to the 10th revision of the ICD. Other sites were aggregated to include the following: Liver, unspecified; Overlapping lesion of heart, mediastinum, and pleura; Mesothelioma of peritoneum; Mesothelioma of pericardium; Mesothelioma of other sites; Mesothelioma, unspecified; ­Kaposi sarcoma; Malignant neoplasm of adrenal gland; Malignant neoplasm of other endocrine glands and related structures; Malignant neoplasms of ill-defined, secondary, and ­unspecified sites; Other specified types of T/NK-cell ­lymphoma; Malignant neoplasms of independent ­(primary) multiple sites; In situ neoplasms; Benign neoplasms; ­Neoplasms of uncertain or unknown behavior.

From the tables of certified deaths and resident population, age-specific mortality rates were computed for 18 5-year age groups (0-4, … , 85+) and for every calendar period from 1980 to 2010 (2004 and 2005 excluded). Age-standardized rates, at all ages and truncated 35-64 years, were computed using the direct method on the basis of the world standard population.

A joinpoint regression model was used to analyze the death rate trends over the studied period (6). For a trend described by the relationship y = a + bx, where y is ln (rate) and x is the calendar year, the estimated annual percent change (EAPC) is calculated by 100 × (eb-1). Joinpoint regression can be used to identify those points, called the joinpoints, where the linear slope of the trend increases or decreases significantly. Models with a maximum of 3 joinpoints (corresponding to up to 4 different trends) identified by the software according to best fit were considered; similarly, no a priori definition of selected calendar period was introduced.

To predict figures for 2015, joinpoint models were also fitted to the logarithm of each 5-year age-specific number of deaths, assuming a Poisson distribution, in order to identify the most recent trend segment. A linear regression was carried out on each age group over the time period identified by the joinpoint model, in order to compute the predicted age-specific numbers of deaths and the corresponding 95% prediction intervals (PI) (7). Using the projected EUROSTAT population data, we computed predicted age-specific and age-standardized death rates (world population) for 2015 with the corresponding 95% PI (8).

Results

Table I shows the number of certified deaths, crude death rates, world standard death rates, and the percentage of certified deaths with respect to the total, for all ages and the truncated age group (35-64 years), in 2010 in Italy, for men and women. The total number of certified deaths from all cancers was 98,847 men and 76,199 women, whereas the corresponding numbers for the truncated (35 to 64) age group in men and women were 19,312 and 15,272, respectively.

Cancer death certifications, mortality rates, and proportions per 100,000 men and women, Italy, 2010

Cancer ICD-10 Men Women
All ages Truncated (35-64 y) All ages Truncated (35-64 y)
Certified deaths, n Crude rate World standard rate Certified deaths, % Certified deaths, n Crude rate World standard rate Certified deaths, % Certified deaths,n Crude rate World standard rate Certified deaths, % Certified deaths, n Crude rate World standard rate Certified deaths, %
ICD = International Classification of Diseases.
Mouth or pharynx C00-C14 1933 6.59 3.27 1.96 783 6.09 5.87 4.05 812 2.61 0.97 1.07 214 1.62 1.54 1.40
Esophagus C15 1429 4.87 2.27 1.45 474 3.69 3.50 2.45 442 1.42 0.44 0.58 79 0.60 0.56 0.52
Stomach C16 5819 19.83 8.04 5.89 1158 9.00 8.60 6.00 4256 13.67 4.07 5.59 667 5.06 4.80 4.37
Intestines (colon and rectum) C17-C21, C26 11835 40.32 15.96 11.97 2136 16.61 15.78 11.06 10306 33.10 9.70 13.53 1576 11.96 11.21 10.32
Liver C22.0-C22.7 3604 12.28 5.42 3.65 865 6.73 6.41 4.48 1797 5.77 1.71 2.36 216 1.64 1.52 1.41
Gallbladder and ducts C23-C24 1389 4.73 1.84 1.41 222 1.73 1.63 1.15 1978 6.35 1.87 2.60 274 2.08 1.91 1.79
Pancreas C25 5083 17.32 7.50 5.14 1212 9.42 8.97 6.28 5429 17.44 5.31 7.12 795 6.03 5.60 5.21
Other digestive sites C48 326 1.11 0.53 0.33 100 0.78 0.74 0.52 464 1.49 0.53 0.61 110 0.83 0.78 0.72
Larynx C32 1533 5.22 2.29 1.55 432 3.36 3.20 2.24 177 0.57 0.21 0.23 46 0.35 0.32 0.30
Lung C33-C34 25457 86.73 36.16 25.75 5274 41.01 38.69 27.31 8277 26.59 9.78 10.86 2058 15.62 14.69 13.48
Pleura C38.4, C45.0 932 3.18 1.35 0.94 190 1.48 1.39 0.98 411 1.32 0.43 0.54 56 0.43 0.39 0.37
Other respiratory sites C30-C31, C37-C38.3, C39 580 1.98 0.97 0.59 164 1.28 1.23 0.85 312 1.00 0.40 0.41 84 0.64 0.61 0.55
Bone C40-C41 289 0.98 0.65 0.29 70 0.54 0.53 0.36 235 0.75 0.40 0.31 40 0.30 0.29 0.26
Connective and soft tissue sarcomas C47,C49 448 1.53 0.82 0.45 157 1.22 1.19 0.81 394 1.27 0.62 0.52 110 0.83 0.81 0.72
Skin C43-C44 1400 4.77 2.20 1.42 425 3.30 3.21 2.20 991 3.18 1.28 1.30 298 2.26 2.23 1.95
Breast C50 123 0.42 0.18 0.12 38 0.30 0.28 0.20 12115 38.91 15.38 15.90 3758 28.53 27.35 24.61
Uterus (cervix and corpus) C53-C55, C58 - - - - - - - - 2824 9.07 3.51 3.71 785 5.96 5.70 5.14
Ovary C56-C57.4 - - - - - - - - 3255 10.46 4.27 4.27 992 7.53 7.14 6.50
Prostate C61 7509 25.58 8.26 7.60 398 3.09 2.87 2.06 - - - - - - - -
Testis C62 84 0.29 0.23 0.08 27 0.21 0.21 0.14 - - - - - - - -
Other genital C51-C52,C57, C60, C63 132 0.45 0.19 0.13 33 0.26 0.25 0.17 746 2.40 0.69 0.98 103 0.78 0.74 0.67
Bladder C67 4484 15.28 5.40 4.54 485 3.77 3.54 2.51 1217 3.91 0.95 1.60 107 0.81 0.76 0.70
Kidney C64-C66, C68 2742 9.34 3.90 2.77 629 4.89 4.66 3.26 1364 4.38 1.35 1.79 205 1.56 1.46 1.34
Eye C69 77 0.26 0.11 0.08 14 0.11 0.10 0.07 95 0.31 0.12 0.12 21 0.16 0.15 0.14
Brain or nerves C70-C72 2245 7.65 4.17 2.27 851 6.62 6.40 4.41 2054 6.60 2.87 2.70 590 4.48 4.26 3.86
Thyroid C73 219 0.75 0.33 0.22 53 0.41 0.39 0.27 330 1.06 0.35 0.43 54 0.41 0.38 0.35
Hodgkin lymphoma C81 231 0.79 0.44 0.23 72 0.56 0.55 0.37 181 0.58 0.29 0.24 44 0.33 0.33 0.29
Non-Hodgkin lymphomas C82-C85,C96 2498 8.51 3.69 2.53 534 4.15 4.01 2.77 2197 7.06 2.21 2.88 322 2.44 2.30 2.11
Multiple myeloma C88, C90 1567 5.34 2.06 1.59 253 1.97 1.86 1.31 1533 4.92 1.41 2.01 176 1.34 1.23 1.15
Leukemias C91-C95 3186 10.86 4.70 3.22 557 4.33 4.18 2.88 2662 8.55 3.10 3.49 380 2.88 2.74 2.49
Other sites Other 11693 39.84 15.28 11.83 1706 13.26 12.64 8.83 9345 30.02 8.34 12.26 1112 8.44 7.93 7.28
All cancers C00-D48 98847 336.78 138.22 100.00 19312 150.16 142.93 100.00 76199 244.75 82.60 100.00 15272 115.92 109.72 100.00

The predicted total number of cancer deaths in Italy for 2015 shows a slight increase (102,647 for men and 82,047 women) compared to the values recorded in 2010 for both sexes. However, the rate is predicted to decrease from 2010 to 2015 in men (129.12/100,000), while remaining stable in women (82.61/100,000).

The leading sites of cancer mortality in men were lung (25,457 deaths, world standardized death rate/100,000 = 36.16/ 100,000), intestines (11,835 deaths, 15.96/100,000), prostate (7,509 deaths, 8.26/100,000), and stomach (5,819 deaths, 8.04/100,000). For women of all ages, the leading sites of cancer mortality were breast (12,115 deaths, 15.38/100,000), intestines (10,306 deaths, 9.70/100,000), lung (8,277 deaths, 9.78/100,000), and pancreas (5,429 deaths, 5.31/100,000).

Figures 1 and 2 show graphs resulting from joinpoint regression analysis, in which the points represent the actual data and the broken segments represent the joinpoint models. Plots display trends for all ages (asterisks) and the truncated age group (35-64 years; circles) rates by cancer from 1980 to 2010 in Italy for men and women, respectively. Tables II, III, IV, and V summarize these results for all ages and the truncated age group (35-64 years), respectively.

Joinpoint trend analysis of all ages (asterisks) and 35-64 years (circles), male cancer mortality rates.

Joinpoint trend analysis of all ages (asterisks) and 35-64 years (circles), female cancer mortality rates.

Joinpoint analysis of cancer mortality rates in men at all ages, in Italy, in 1980-2010, whenever available

Cancer Years EAPC Years EAPC Years EAPC Years EAPC
EAPC = estimated annual percent change.
aSignificantly different from 0 (p<0.05).
Mouth or pharynx 1980-1985 1.3 (-0.1, 2.7) 1985-1993 -1.9a (-2.7, -1.1) 1993-2010 -3.2a (-3.5, -3)
Esophagus 1980-1986 0.2 (-1.1, 1.5) 1986-2001 -3a (-3.3, -2.6) 2001-2006 -5.9 (-13.9, 2.8) 2006-2010 0 (-2.9, 3)
Stomach 1980-1983 -0.6 (-2.2, 1) 1983-1994 -3.4a (-3.7, -3.2) 1994-1997 -4.8a (-8.3, -1.3) 1997-2010 -3.5a (-3.7, -3.3)
Intestines (colon and rectum) 1980-1983 2.4a (0, 4.8) 1983-1994 0.3 (0, 0.6) 1994-2010 -1.3a (-1.5, -1.1)
Liver 1980-1993 4.5a (2.6, 6.4) 1993-2010 -3.4a (-4.5, -2.4)
Gallbladder and ducts 1980-1982 11.1 (-1.7, 25.6) 1982-1994 2a (1.3, 2.7) 1994-2010 -0.8a (-1.1, -0.4)
Pancreas 1980-1987 2.4a (1.4, 3.4) 1987-2010 0.1 (0, 0.2)
Larynx 1980-1985 -0.3 (-2.2, 1.7) 1985-2010 -4.3a (-4.5, -4.1)
Lung 1980-1987 1.5a (1, 2) 1987-1994 -1.1a (-1.7, -0.6) 1994-2010 -2.6a (-2.7, -2.5)
Pleura 1980-2001 2.1a (1.7, 2.5) 2001-2010 -1.1 (-2.3, 0.1)
Bone 1980-1987 -3a (-5.2, -0.8) 1987-1998 -7.8a (-9.4, -6.1) 1998-2010 0.7 (-1, 2.5)
Connective and soft tissue sarcomas 1980-1998 6.2a (5.2, 7.1) 1998-2010 -0.3 (-1.5, 0.9)
Skin 1980-2010 0.2 (0, 0.4)
Prostate 1980-1987 1.9a (0.8, 2.9) 1987-2003 -0.9a (-1.2, -0.6) 2003-2010 -3.3a (-4.7, -1.9)
Testis 1980-1996 -5.8a (-6.7, -4.9) 1996-2010 0.8 (-0.8, 2.3)
Bladder 1980-1982 7.5 (-0.7, 16.3) 1982-1993 -0.2 (-0.7, 0.4) 1993-1996 -7.1a (-13.4, -0.3) 1996-2010 -2.1a (-2.4, -1.7)
Kidney 1980-1989 3.3a (2.3, 4.3) 1989-2006 -1.3a (-1.7, -0.8) 2006-2010 2.2 (-0.6, 5)
Eye 1980-2010 -1.1a (-1.8, -0.5)
Brain or nerves 1980-2003 -1.2a (-1.6, -0.8) 2003-2010 0.8 (-3.4, 5.1)
Thyroid 1980-2010 -1.6a (-2, -1.2)
Hodgkin lymphoma 1980-1999 -6.6a (-7.1, -6.1) 1999-2010 0 (-1.7, 1.7)
Non-Hodgkin lymphomas 1980-1990 5.1a (4.3, 5.9) 1990-2000 1.3a (0.6, 2) 2000-2003 -6.8 (-13.7, 0.7) 2003-2010 -1.2 (-3, 0.6)
Multiple myeloma 1980-1983 9.3a (1, 18.3) 1983-2007 0.8a (0.4, 1.1) 2007-2010 -3.6 (-8.6, 1.7)
Leukemias 1980-1991 -0.6a (-1, -0.2) 1991-2008 -1.3a (-1.5, -1) 2008-2010 -4.9 (-9.8, 0.3)
All cancers 1980-1987 0.9a (0.5, 1.3) 1987-1994 -0.8a (-1.3, -0.3) 1994-2010 -1.8a (-1.9, -1.7)

Joinpoint analysis of cancer mortality rates in women at all ages, in Italy, in 1980-2010, whenever available

Cancer Years EAPC Years EAPC Years EAPC Years EAPC
EAPC = estimated annual percent change.
aSignificantly different from 0 (p<0.05).
Mouth or pharynx 1980-2010 -0.1 (-0.3, 0.1)
Esophagus 1980-2010 -1.9a (-2.1, -1.7)
Stomach 1980-1984 -1.6a (-2.7, -0.5) 1984-1994 -3.4a (-3.7, -3) 1994-1999 -4.6a (-5.8, -3.3) 1999-2010 -2.9a (-3.2, -2.5)
Intestines (colon and rectum) 1980-1982 2.9 (-0.9, 6.9) 1982-1993 -0.3a (-0.6, 0) 1993-2010 -1.7a (-1.8, -1.5)
Liver 1980-1994 0.4 (-1.1, 1.9) 1994-2010 -3a (-4.3, -1.7)
Gallbladder and ducts 1980-1992 2.1a (1.5, 2.7) 1992-2010 -2.1a (-2.4, -1.8)
Pancreas 1980-1989 3.1a (2.3, 3.9) 1989-2010 0.7a (0.5, 0.9)
Larynx 1980-2010 -2a (-2.4, -1.6)
Lung 1980-1986 2.8a (1.7, 3.9) 1986-2010 1.3a (1.2, 1.5)
Pleura 1980-1992 2.2a (0.8, 3.6) 1992-2010 -1a (-1.7, -0.4)
Bone 1980-2002 -5.2a (-5.8, -4.5) 2002-2010 3.5 (-1.5, 8.7)
Connective and soft tissue sarcomas 1980-1999 5a (4, 5.9) 1999-2010 -0.1 (-1.6, 1.5)
Skin 1980-2010 -0.2a (-0.4, -0.1)
Breast 1980-1984 1.9a (0.4, 3.4) 1984-1993 0.1 (-0.4, 0.6) 1993-1999 -2.3a (-3.2, -1.3) 1999-2010 -1.4a (-1.7, -1.1)
Uterus (cervix and corpus) 1980-2000 -3.9a (-4.1, -3.7) 2000-2010 -1a (-1.6, -0.4)
Ovary 1980-1986 3.7a (1.8, 5.6) 1986-2010 -0.7a (-0.9, -0.5)
Bladder 1980-1993 -0.6 (-1.2, 0) 1993-1999 -4.1a (-6.6, -1.5) 1999-2010 -0.8a (-1.6, 0)
Kidney 1980-1987 3.2a (1.2, 5.3) 1987-2010 -1.1a (-1.4, -0.8)
Eye 1980-2010 -0.3 (-1.2, 0.7)
Brain or nerves 1980-1993 0.2 (-0.4, 0.9) 1993-1996 -5.2 (-16.5, 7.7) 1996-2010 -0.2 (-0.8, 0.4)
Thyroid 1980-1990 -0.7 (-1.8, 0.5) 1990-2010 -3.4a (-3.8, -2.9)
Hodgkin lymphoma 1980-1998 -5.7a (-6.6, -4.9) 1998-2010 -0.9 (-3.2, 1.3)
Non-Hodgkin lymphomas 1980-1988 7.4a (5.9, 9) 1988-1998 2.7a (1.8, 3.7) 1998-2010 -3.3a (-3.9, -2.8)
Multiple myeloma 1980-1992 2.4a (1.6, 3.2) 1992-2006 0.3 (-0.4, 1) 2006-2010 -3.3a (-6.4, -0.1)
Leukemias 1980-2010 -1.3a (-1.5, -1.2)
All cancers 1980-1983 0.9 (-0.5, 2.4) 1983-1992 -0.3 (-0.6, 0.1) 1992-2010 -1.1a (-1.2, -1)

Joinpoint analysis of cancer mortality rates in men truncated at 35-64 years, in Italy, in 1980-2010, whenever available

Cancer Years EAPC Years EAPC Years EAPC Years EAPC
EAPC = estimated annual percent change.
aSignificantly different from 0 (p<0.05).
Mouth or pharynx 1980-1989 0.4 (-0.4, 1.2) 1989-2010 -3.4a (-3.7, -3.2)
Esophagus 1980-1987 0.9 (-0.3, 2.2) 1987-2008 -4.1a (-4.4, -3.8) 2008-2010 3 (-8.6, 16.1)
Stomach 1980-2010 -3.9a (-4, -3.8)
Intestines (colon and rectum) 1980-1982 -2.3 (-8.1, 3.8) 1982-1985 2.6 (-3.1, 8.6) 1985-2002 -0.8a (-1, -0.6) 2002-2010 -2.4a (-3.1, -1.7)
Liver 1980-1993 3.3a (1.7, 5) 1993-2010 -4.2a (-5.3, -3.2)
Gallbladder and ducts 1980-1993 0.9a (0.1, 1.8) 1993-2010 -1.4a (-2, -0.9)
Pancreas 1980-2007 0 (-0.2, 0.2) 2007-2010 -3.2 (-7.3, 1.1)
Larynx 1980-1984 0.1 (-3.1, 3.4) 1984-2001 -5.7a (-6.1, -5.2) 2001-2010 -3.6a (-5.1, -2.1)
Lung 1980-1987 0.4 (-0.1, 0.9) 1987-2010 -3.7a (-3.8, -3.6)
Pleura 1980-2001 1.8a (1.1, 2.5) 2001-2010 -4.3a (-6.7, -1.9)
Bone 1980-1998 -7.7a (-8.7, -6.6) 1998-2010 -1.1 (-3.9, 1.7)
Connective and soft tissue sarcomas 1980-1993 4.5a (1.6, 7.5) 1993-1998 13.2a (0.5, 27.4) 1998-2001 -14.2 (-40, 22.7) 2001-2010 2.9 (-0.6, 6.5)
Skin 1980-2010 -0.1 (-0.4, 0.2)
Prostate 1980-1987 1.5 (-0.4, 3.5) 1987-2010 -2.3a (-2.6, -1.9)
Testis 1980-1996 -5.6a (-7.2, -4) 1996-2010 -0.2 (-2.8, 2.5)
Bladder 1980-1991 -1.2a (-1.9, -0.5) 1991-1997 -7.3a (-9.8, -4.8) 1997-2010 -2.3a (-3, -1.5)
Kidney 1980-1987 2.5a (1.1, 3.9) 1987-2007 -2.1a (-2.4, -1.7) 2007-2010 3.7 (-1.5, 9.2)
Eye 1980-2010 -1.1a (-2, -0.1)
Brain or nerves 1980-2000 -2a (-2.5, -1.5) 2000-2010 0.1 (-1.4, 1.6)
Thyroid 1980-2010 -2.5a (-3.1, -2)
Hodgkin lymphoma 1980-1998 -7.8a (-8.5, -7.1) 1998-2010 -2.6a (-4.5, -0.7)
Non-Hodgkin lymphomas 1980-1989 4.6a (3.1, 6.1) 1989-1998 1.3 (-0.2, 2.7) 1998-2010 -4.1a (-4.9, -3.4)
Multiple myeloma 1980-1982 18.6 (-4.8, 47.8) 1982-2010 -0.6a (-0.9, -0.3)
Leukemias 1980-2001 -1.5a (-1.7, -1.2) 2001-2010 -3a (-4.1, -2)
All cancers 1980-1988 -0.3 (-0.6, 0) 1988-2010 -2.7a (-2.7, -2.6)

Joinpoint analysis of cancer mortality rates in women truncated at 35-64 years, in Italy, in 1980-2010, whenever available

Cancer Years EAPC Years EAPC Years EAPC Years EAPC
EAPC = estimated annual percent change.
aSignificantly different from 0 (p<0.05).
Mouth or pharynx 1980-2010 0.2 (-0.1, 0.5)
Esophagus 1980-2010 -1.3a (-1.7, -0.9)
Stomach 1980-2010 -2.8a (-3, -2.7)
Intestines (colon and rectum) 1980-1996 -0.5a (-0.8, -0.2) 1996-2010 -1.8a (-2.2, -1.5)
Liver 1980-2010 -2.6a (-3.2, -2.1)
Gallbladder and ducts 1980-1993 1a (0, 1.9) 1993-2010 -3a (-3.6, -2.3)
Pancreas 1980-1993 2a (1.5, 2.5) 1993-1996 -2.5 (-10.9, 6.6) 1996-2001 2.6 (-0.2, 5.5) 2001-2010 -0.1 (-0.9, 0.7)
Larynx 1980-2010 -1.6a (-2.2, -1)
Lung 1980-1998 1a (0.7, 1.3) 1998-2010 2.4a (1.9, 2.8)
Pleura 1980-2006 0.7a (0, 1.3) 2006-2010 -15.2a (-23.8, -5.7)
Bone 1980-1998 -7.8a (-9.2, -6.3) 1998-2010 0.4 (-3.4, 4.3)
Connective and soft tissue sarcomas 1980-2003 4.1a (3.1, 5.1) 2003-2010 -1.8 (-9, 6)
Skin 1980-2010 0.1 (-0.2, 0.4)
Breast 1980-1990 0.6a (0.1, 1) 1990-2010 -2a (-2.2, -1.9)
Uterus (cervix and corpus) 1980-1989 -5.2a (-5.8, -4.7) 1989-2002 -3.2a (-3.6, -2.7) 2002-2010 -1 (-2.1, 0.1)
Ovary 1980-1986 2.4a (0.3, 4.6) 1986-2010 -1.1a (-1.4, -0.9)
Bladder 1980-2010 -1.8a (-2.3, -1.2)
Kidney 1980-1987 2.8 (-0.7, 6.4) 1987-2010 -2.1a (-2.7, -1.5)
Eye 1980-2010 0.6 (-0.7, 1.9)
Brain or nerves 1980-2010 -1.4a (-1.7, -1.1)
Thyroid 1980-2010 -3.1a (-3.6, -2.6)
Hodgkin lymphoma 1980-1998 -6.6a (-7.7, -5.4) 1998-2010 -2 (-5.1, 1.2)
Non-Hodgkin lymphomas 1980-1988 6.6a (4.8, 8.5) 1988-1998 1.5a (0.2, 2.7) 1998-2010 -4.6a (-5.4, -3.8)
Multiple myeloma 1980-1993 1.6a (0.4, 2.8) 1993-2010 -1.6a (-2.4, -0.8)
Leukemias 1980-2010 -2.1a (-2.3, -1.8)
All cancers 1980-1988 -0.3 (-0.7, 0.1) 1988-2010 -1.2a (-1.3, -1.2)

In men, death rates for tobacco-related cancers such as mouth and pharynx, esophagus, larynx, lung, bladder, and kidney started falling between the end of the 1980s and the beginning of the 1990s. Lung cancer had an EAPC of -2.6 in the period 1994-2010 for all ages. Colorectal cancers had an EAPC of -1.3 in 1994-2010 for all ages. Cancers of the stomach, bone, testis, eye, brain and nervous system, thyroid, Hodgkin lymphoma, and leukemia showed decreasing trends during the study period in men for both age groups. Among these, the greatest EAPC values were recorded for stomach cancer (-3.5 in 1997-2010 for all ages) and leukemia (in middle-aged men -3 in 2001-2010). Prostate cancer showed an EAPC of -3.3 for all ages in the period 2003-2010 and an EAPC of -2.3 for men aged between 35 and 64 years in the period 1987-2010. Total cancer mortality for men rose until the end of the 1980s, after which it fell, with an EAPC of -1.8 in 1994-2010 for all ages and -2.7 in 1988-2010 for the truncated age group.

In women, decreasing trends were seen for most of the study period in cancers of the esophagus, stomach, colorectum, larynx, uterus, bladder, brain and nerves, thyroid, ­Hodgkin lymphoma, and leukemia. Rising trends emerged for pancreatic cancer (EAPC, 0.7 from 1989 to 2010 for all ages) and lung (EAPC, 1.3 in 1986-2010 for all ages). Trends for breast (EAPC, -1.4 from 1999 to 2010 for all ages) and ovarian cancer (EAPC, -0.7 from 1986 to 2010 for all ages) changed from rising to falling, similarly to liver, gallbladder, kidney, non-Hodgkin lymphomas, and multiple myeloma. In women, total cancer mortality rates decreased throughout the study period for both age groups, with significant EAPCs of -1.1 in the period 1992-2010 for all ages and -1.2 in the period 1988-2010 for the truncated age group.

Figure 3 shows bar plots of death rates per 100,000 population for 2010, and the predicted rates for 2015 with 95% PIs for the specific sites considered for men and women. The rates are predicted to decline from 2010 to 2015 in men and women for most of the cancers, with the exceptions of kidney, multiple myeloma, gallbladder and bile ducts, pleura, and connective and soft tissue cancers in men and cancers of the lung, ovary, and multiple myeloma in women, which increased, and skin and oral cancers, which are stable.

Age-standardized cancer mortality rates for 2010 (dark gray) and 2015 predictions with 95% prediction intervals (light gray).

Discussion

This up-to-date analysis of Italian cancer mortality shows recent favorable patterns in both sexes. However, while the favorable trends are predicted to continue in 2015 for men, for women a leveling-off of rates may occur.

The fall in total male cancer mortality rates started in the late 1980s and was mainly due to declining mortality from tobacco-related cancers, particularly lung cancer (9), which still represented about 26% of male cancer deaths in 2010. These trends are explained by the falls in smoking prevalence in men (10). Occupational, environmental, and dietary factors may also have influenced these trends (11). Conversely, lung cancer in women has been rising steadily, showing a steeper increase for middle-aged women in recent years (2, 7). This likely reflects differences between male and female tobacco consumption patterns over time (10).

The fall in overall male cancer mortality was also due to the reduced mortality in other tobacco-related cancers (11).

The decrease from the late 1980s in oral, pharyngeal, esophageal, and laryngeal cancer mortality trends in men, particularly in middle age, can be attributed to the reduction in tobacco smoking prevalence and, mainly, of alcohol consumption (11, 12-13-14).

Stomach cancer mortality in Italy showed a favorable trend throughout the study period. The reasons for this decline are complex, and probably include a more varied and nutrient-rich diet, better food conservation (including ­refrigeration), control of Helicobacter pylori infections, and, in men, reduced tobacco smoking (15). Improved diagnosis and treatment of the disease may also have played a role in these favorable trends (15).

Intestinal cancer mortality displayed favorable trends for both sexes. In men, rates fell from the early 1990s, while in women rates were already falling at the beginning of the 1980s. These declining trends are mainly attributable to early diagnosis and improved treatment of the disease (16), but changes in exposure to dietary risk factors may have had a role (17). In women, oral contraceptive use and hormone-replacement therapy may explain the earlier fall in trends compared to men (18).

Trends in liver cancer mortality are difficult to interpret, since this is one of the most common sites for secondary cancers, and the misclassification between primary and metastatic neoplasms in death certification data may have occurred (19). Nonetheless, the favorable trend starting in the 1990s is ­related to the main known causes for liver cancer: hepatitis B and C viruses infection and alcohol consumption (19). Decreased tobacco prevalence may have favorably affected trends in men, although its potential impact on national mortality rates remains difficult to evaluate (19).

Women have a higher mortality than men from gallbladder and bile duct cancers, but the trends have been decreasing in both sexes since the beginning of the 1990s. The main risk factor for gallbladder cancer is gallstones, which are more frequent in women than in men (20, 21). As such, these mortality trends likely reflect technological improvements in surgical techniques and hence more frequent cholecystectomies (20, 21).

Mortality from pancreatic cancer rose in men up to the late 1980s, but tended to level off thereafter. In women, it rose throughout the study period, less steeply from the 1990s. The earlier trends are partly explained by improved diagnosis and certification of the disease, and perhaps by a rise in diabetes (1122, 23). The stable trends recently observed in men may reflect different smoking patterns between the sexes and confirm the relevant role of tobacco in pancreatic carcinogenesis (24, 25).

Interpretation of pleural cancer mortality trends is complex due to difficulties in classification and diagnosis (26). These trends are largely determined by the asbestos-related mesothelioma epidemic (27). In men, trends rose until the beginning of the 2000s and decreased over the last decade, particularly in middle-age. However, since pleural cancer includes a variable proportion of misclassified lung cancers, the recent trends may be partly influenced by the fall in lung ­cancer in men. In women, the same classification problems make ­interpretation difficult, but recent trends appear to be stable.

The leveling of rates for skin cancer mortality in both sexes, mainly melanoma, seems to be largely due to earlier detection of the disease, with consequent improved survival. Sunburn control may also have played a role (28).

Breast cancer mortality has been falling since the early 1990s, particularly for middle-aged women, and is largely attributable to advancements in therapy and management, owing to mammography screening, the introduction of effective hormone and chemotherapies, and progress in surgery and radiotherapy (29-30-31).

Mortality from uterine cancer has been declining steadily over the last few decades. The observed fall is likely due to a decline in cervical cancer mortality, following the wider adoption of cervical screening programs over the last decades (1732). Organized cervical screening programs now cover most of the Italian regions (33). In Europe, endometrial cancer mortality has also decreased in cohorts born until 1940, but not in more recent ones (34).

The fall in ovarian cancer mortality started in the late 1980s and is probably related to the change in prevalence of oral contraceptive use, which has a long-term preventive effect on ovarian cancer (18). Ever use of oral contraceptives in the past has been around 50% in Italy (35). Part of the recent decline, mostly in young and middle-aged women, may be due to improved diagnosis and treatment (particularly, but not only, for germ-cell tumors) (32).

Prostate cancer mortality trends have been decreasing since the late 1980s, likely due to advances in disease management, including wider adoption of radical prostatectomy and a more widespread use of combined antiandrogen ­therapies and radiotherapy for patients with locally advanced disease (36, 37). The introduction of the prostate-specific antigen test has increased the proportion of anticipated diagnoses, arguably reducing mortality, though quantification of the various components to these favorable trends remains undefined (7, 37-38-39). Changes in incidence of the disease are uncorrelated to mortality.

Testicular cancer mortality decreased up to the mid-1990s, mainly due to the adoption of platinum-based therapies in the 1970s, making testicular cancer one of the most treatable neoplasms (11, 37). Despite smaller progress in survival for testicular cancer registered in the middle-aged and the elderly compared to the young, no significant difference was observed among all the ages and truncated trends on a national level (37).

The improvements in bladder cancer mortality in men reflect the changes in male smoking patterns and a decrease in occupational exposure to carcinogens, particularly aromatic amines (37, 40). The fall in female trends for this cancer is more difficult to explain and is probably due to a number of complex reasons including improved control of urinary tract infections (37).

Favorable trends in mortality from kidney cancer have been observed since the late 1980s in both sexes and not significantly increasing in recent years in men. This cancer is related to tobacco smoking, though less strongly than ­respiratory or bladder cancer, and to overweight and hypertension (41). Therefore, the favorable pattern started in the late 1980s may be related to decreased tobacco consumption in men (37). The fall in female kidney cancer mortality rate trend is difficult to explain.

Thyroid cancer mortality rates declined over the studied period, particularly in women, who have a higher incidence of this neoplasm than men. Since thyroid cancer incidence has been increasing (42), the decline in mortality is likely due to better diagnosis of thyroid nodules and improved treatment of thyroid neoplasms (42).

Mortality from Hodgkin lymphoma declined in both sexes up to the late 1990s and leveled off (not significantly) in the last decade. These trends reflect improvements in treatment, as it is a largely curable disease (43).

Non-Hodgkin lymphoma mortality rose until the late 1990s and declined over the last decade. This neoplasm is much less amenable to treatment than Hodgkin lymphoma, so the registered rise in mortality most likely reflects the increase in incidence up to the mid-1990s, and a subsequent plateau (44). Nevertheless, the causes of this form of neoplasm remain largely unknown, and the subsequent phases of the AIDS epidemic, the spread of hepatitis C virus, and the increased number of organ transplants can only explain a ­limited proportion of the earlier rises (45). The recent decline in mortality can, at least in part, be related to some improvements in management and therapy (45).

Mortality rates from leukemia, a heterogeneous group of neoplasms, have declined over the considered period in both sexes. This trend is likely due to therapeutic advancements, such as the introduction of targeted therapies for acute lymphoblastic leukemias in children and the young, and for chronic myeloid leukemia (46).

Given the small numbers of deaths from other sites and their uncertainty in classification for other sites (i.e., liver, unspecified; malignant neoplasms of ill-defined, secondary, and unspecified sites; neoplasms of uncertain or unknown behavior) and the changes in classification introduced by the 10th revision of the ICD in 2003 (47), no meaningful pattern of trends was observed for any of these sites.

In conclusion mortality from most common cancers in Italy showed favorable trends over the last decades, which seems to continue in the near future, with the main exception of female lung cancer. Furthermore, rates are projected to increase from 2010 to 2015 in men for kidney cancer due to unfavorable trends in men over 60, and to remain stable in women for ovarian cancer due to upward trends in older women, however the decreasing trends in the young are promising for the future and mid term. The less satisfactory projected trends in all cancers for 2015 in women as compared to men are heavily influenced by the increased tobacco consumption in women in the past, as indicated by the increasing lung cancer rates. Tobacco has an unfavorable effect on many different cancer sites, which taken together may counterbalance the favorable effects from other causes (48). To maintain and further improve these favorable trends in cancer mortality, strategies focusing on tobacco smoking control, particularly on smoking cessation for middle-aged men and women (49), on alcohol consumption, diet, and avoidance of excessive sun exposure are required. Early diagnosis for selected neoplasms including cervix, breast, colorectum, and perhaps prostate can also have a relevant impact. The recent advancements in the management and treatment of breast, colorectal, prostate, and lymphoid cancers and several other common cancers have also contributed to the recent decline in cancer mortality in Italy. However, on a public health level, the role of improved cancer treatment and management, and hence improved survival on future mortality rates in various European countries and specifically in Italy, remains difficult to quantify (50).

Acknowledgment

The authors thank Ivana Garimoldi for editorial assistance.

Disclosures

Financial support: Italian Association for Cancer Research (AIRC, project N. 10264).
Conflict of interest: None.
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Authors

Affiliations

  • Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan - Italy
  • Department of Epidemiology, IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri”, Milan - Italy

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