Cancer Epidemiology xxx (2013) xxx–xxx

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Cancer incidence and mortality in people aged less than 75 years:Changes in Australia over the period 1987–2007

Freddy Sitas a,b,c,*, Alison Gibberd a, Clare Kahn a, Marianne F. Weber a, May Chiew a,d,Rajah Supramaniam a, Louiza Velentzis a, Carolyn Nickson a,e, David P. Smith a,f,Dianne O’Connell a,b,c,g, Megan A. Smith a,1, Katie Armstrong a, Xue Qin Yu a,b,Karen Canfell a,b,1, Monica Robotin a,b, Eleonora Feletto a, Andrew Penman a

a Cancer Council NSW, Australiab University of Sydney, School of Public Health, Australiac University of NSW, School of Public Health and Community Medicine, Australiad Australian National University, National Centre for Epidemiology and Population Health, Australiae Melbourne School of Population and Global Health, University of Melbourne, Australiaf Griffith Health Institute, Griffith University, Australiag University of Newcastle, School of Medicine and Public Health, Australia

A R T I C L E I N F O

Article history:

Received 13 May 2013

Received in revised form 10 September 2013

Accepted 12 September 2013

Available online xxx

Keywords:

Australia

Incidence

Mortality

Cancer

A B S T R A C T

Background: Australia has one of the highest rates of cancer incidence worldwide and, despite improving

survival, cancer continues to be a major public health problem. Our aim was to provide simple summary

measures of changes in cancer mortality and incidence in Australia so that progress and areas for

improvement in cancer control can be identified.

Methods: We used national data on cancer deaths and newly registered cancer cases and compared

expected and observed numbers of deaths and cases diagnosed in 2007. The expected numbers were

obtained by applying 1987 age–sex specific rates (average of 1986–1988) directly to the 2007

population. The observed numbers of deaths and incident cases were calculated for 2007 (average of

2006–2008). We limited the analyses to people aged less than 75 years.

Results: There was a 28% fall in cancer mortality (7827 fewer deaths in 2007 vs. 1987) and a 21% increase

in new cancer diagnoses (13,012 more diagnosed cases in 2007). The greatest reductions in deaths were

for cancers of the lung in males (�2259), bowel (�1797), breast (�773) and stomach (�577). Other

notable falls were for cancers of the prostate (�295), cervix (�242) and non-Hodgkin lymphoma (�240).

Only small or no changes occurred in mortality for cancers of the lung (female only), pancreas, brain and

related, oesophagus and thyroid, with an increase in liver cancer (267). Cancer types that showed the

greatest increase in incident cases were cancers of the prostate (10,245), breast (2736), other cancers

(1353), melanoma (1138) and thyroid (1107), while falls were seen for cancers of the lung (�1705),

bladder (�1110) and unknown primary (�904).

Conclusions: The reduction in mortality indicates that prevention strategies, improvements in cancer

treatment, and screening programmes have made significant contributions to cancer control in Australia

since 1987. The rise in incidence is partly due to diagnoses being brought forward by technological

improvements and increased coverage of screening and early diagnostic testing.

� 2013 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Cancer EpidemiologyThe International Journal of Cancer Epidemiology, Detection, and Prevention

jou r nal h o mep age: w ww.c an cer ep idem io log y.n et

1. Introduction

Cancer is a significant health concern in Australia. Whilesurvival data show some substantial improvements in outcomesover the past few decades [1], the rate of cancer incidence in

* Corresponding author at: Cancer Council NSW, Australia. Tel.: +61 293341860.

E-mail address: freddys@nswcc.org.au (F. Sitas).1 Current address: University of NSW, Lowy Cancer Research Centre, Australia.

Please cite this article in press as: Sitas F, et al. Cancer incidence and

over the period 1987–2007. Cancer Epidemiology (2013), http://dx.

1877-7821/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.canep.2013.09.010

Australia is still amongst the highest in the world [2]. This highincidence ranking may give the impression that little progress incancer control is being made in Australia [3], while in fact therehave been many cancer related public health programmesintroduced since the late 1980s. These programmes haveaddressed early diagnosis, exposure to modifiable risk factorsand improvements in clinical guidelines and treatment protocols.While it is difficult to accurately assess any specific role theseprogrammes may have played in changing cancer mortality andincidence, by investigating changes over the past few decades for

mortality in people aged less than 75 years: Changes in Australiadoi.org/10.1016/j.canep.2013.09.010

F. Sitas et al. / Cancer Epidemiology xxx (2013) xxx–xxx2

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CANEP-635; No. of Pages 8

individual cancer types it is possible to identify some of thepossible relationships and areas that warrant further attention.

Rather than reviewing yearly trends in cancer incidence andmortality across all ages, which has been aptly done by others [1],our aim was to provide simple summary measures of changes incancer mortality and incidence in Australia over a 20 year period.We focused on the differences in cancer deaths and newlydiagnosed cases of cancer between two time periods, 1987 and2007, for people under 75 years of age. People aged 75 and overwere excluded from the analysis because (1) older age groupscomprise those who have survived premature mortality from otherchronic disease making cancer a more prevalent cause of death bydefault, (2) causes of death and diagnoses are less reliable at olderages, (3) screening programmes stop at approximately 70 years ofage, and (4) treatments tend to be less aggressive in older patients[4,5]. Australian mortality data are regarded as accurate andcomplete [6], so we focused on mortality in the first instance, thenaugmented this information with data on newly diagnosed cases.

2. Methods

Annual numbers of deaths from 1986 to 2008 for each majorcancer type, by age group and sex, were obtained from theAustralian Bureau of Statistics (ABS), which compiles yearlynational mortality statistics. To protect the identity of individuals,data were grouped into 0–14 years, 15–34 years and 5-year agegroups from 35 to 74 years, with the exception of Hodgkin’slymphoma (0–14, 15–49, 50–64 and 65–74 years). However, as theABS does not provide cells with counts between 1 and 4, weimputed values using data from the surrounding years and thetotal number of deaths for the cancer site, sex and year.

Counts of cancer cases diagnosed from 1986 to 2008, by sex and5-year age group, were obtained from the Australian Institute ofHealth and Welfare (AIHW), which compiles cancer registrationdata from each Australian State and Territory [7]. Age groups werecollapsed to match ABS groupings. For simplicity we refer todiagnosed cases as incident cases, while acknowledging thatchanges may be caused by diagnoses being brought forward byimprovements in screening, diagnostic methods or changes incancer registration.

The age- and sex-specific rates in 1987 and 2007 wereestimated by averaging the observed rates from 1986 to 1988and 2006 to 2008, respectively. These rates were applied to the2007 age and sex-specific population estimates from the ABS [8], tocalculate the expected and observed numbers of deaths andincident cases (i.e. events) for 2007. Finally, the observed numberswere compared to the 2007 expected numbers of events. The samemethods were used to calculate observed and expected events foreach year between 1987 and 2007 to determine the cumulativetotal of events over the entire period.

To ensure disease groups were standard, where possible anychanges between ICD-9 and ICD-10 were accounted for withbridging codes provided by the ABS. Mesothelioma was affected bythese changes and was therefore excluded. A few cancer types(noted in the tabulations) were grouped differently by ABS andAIHW.

To estimate trends over time, annual age- and sex-standardisedrates for each cancer type and all cancer types combined wereobtained by the method of direct standardisation, with the 1997Australian population as the reference population [8]. The analysiscovered the years 1986–2008 for mortality and incidence, but theaverage annual percent changes (AAPCs) were calculated for 1987–2007. AAPCs were calculated using joinpoint regression modelsand were fitted to annual age- and sex-standardised logarithmicrates. Options chosen included calculating AAPCs for the period ofinterest only (1987–2007), allowing 0–4 joinpoints, inputting

Please cite this article in press as: Sitas F, et al. Cancer incidence and

over the period 1987–2007. Cancer Epidemiology (2013), http://dx.

standard errors, and using the permutation method to determinethe optimal number of joinpoints. Data were analysed using R2.15.1 [9] and Joinpoint 3.5.4 [10].

3. Results

Tables 1 and 2 show the numbers of deaths and incident casesobserved in 2007 compared to those expected using 1987 rates,and AAPCs estimated from the age-standardised mortality andincidence rates.

3.1. Changes in cancer mortality

Overall, 7827 (28%) fewer cancer deaths occurred in 2007 thanwould have been expected based on mortality in 1987, and overthe entire period, 1987–2007, there were 61,190 fewer cancerdeaths than expected had the 1987 death rates remained constant.

The greatest reductions in deaths from 1987 to 2007 were forcancers of the lung in males (�2259, �46%), bowel (�1797, �47%),breast (�773, �31%), stomach (�577, �50%), and head and neck(�478, �46%). Improvements in mortality for these five cancer types(including only lung in males) accounted for 75% (n = 5884) of all thenet decrease in deaths. Other notable changes in mortality were forcancers of the prostate (�295, �27%), cervix (�242, �62%), non-Hodgkin lymphoma (NHL) (�240, �28%), melanoma (�89, �11%)and all cancers for children 0–14 (�64, �43%). Negligible changesoccurred in mortality for cancers of the lung in females, pancreas,brain and related, oesophagus and thyroid. A large increase inmortality from liver cancer was observed (267, 70%) (Table 1).

3.2. Changes in cancer incidence

There were 13,012 (21%) more cases of cancer diagnosed in2007 than would have been expected based on rates from 1987.Prostate cancer had the largest increase, by 276% (10,245),accounting for 79% of the rise in incident cases. Excluding prostatecancer, the highest incident increases were in cancers of the breast(2736, 34%), other cancers (1353, 18%), melanoma (1138, 17%) andthyroid (1107, 198%). Liver (465, 132%) and kidney (excludingrenal pelvis and ureter) (676, 55%) cancers and NHL (584, 27%) alsorecorded a higher number of cases than expected in 2007 (Table 2).Several cancer types recorded fewer cases than expected in 2007including cancers of the cervix (�690, �52%), bladder (�1110,�51%), unknown primary (�904, �41%), stomach (�578, �34%),head and neck (�562, �27%), and lung (�1705, �22%).

4. Discussion

By comparing the number of observed and expected events for2007 in Australia, we estimate a 28% fall in mortality and a 21%increase in incidence. AIHW estimates of age standardisedmortality (for all ages) were 212.1/100,000 in 1987 and 176.1/100,000 in 2007, which is a 17% reduction in mortality [7]. For thesame period AIHW found that incidence rates rose from 408.2/100,000 in 1987 to 490.1/100,000 in 2007, a 20% increase [7]. Thedominant reason for this fall in cancer mortality is due to theinclusion of only people under the age of 75 years in our analysis.

Since the late 1980s, many key interventions for the cancerprevention, screening and treatment have been introduced inAustralia with growing coverage (see Box 1). Over this same period,there have been marked improvements in cancer mortality andsurvival in Australia [7]. Although we are cautious of claiming anydirect causal link between specific programmes and changes incancer mortality and incidence, our analysis can provide someinsight into possible outcomes of some key interventionsimplemented during the period 1987–2007.

mortality in people aged less than 75 years: Changes in Australiadoi.org/10.1016/j.canep.2013.09.010

Table 1Changes in cancer mortality in Australia from 1987 to 2007 for people under 75 years.b

Cancer type Observed deaths in

2007 (O)

Expected deaths in

2007 (E)

Difference O-E Change in deaths (%)

(O-E)/E

Average annual percentage change (95% CI)

Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total

Lung (C33-34) 2668 1555 4223 4927 1450 6377 -2259 105 �2154 �46 7 �34 �3.0 (�3.3,�2.7) 0.2 (�0.1,0.4)a �2.1 (�2.3,�1.8)

Bowel (C18-20) 1197 791 1988 2205 1580 3785 �1008 �789 �1797 �46 �50 �47 �2.9 (�3.3,�2.5) �3.3 (�4.4,�2.2) �3.0 (�3.4,�2.7)

Breast (female) (C50) – 1691 1691 – 2464 2464 – �773 �773 – �31 �31 – �1.8 (�2.2,�1.5) �1.8 (�2.2,�1.5)

Stomach (C16) 368 203 572 809 340 1149 �441 �137 �577 �54 �40 �50 �3.8 (�4.5,�3.1) �2.8 (�3.3,�2.3) �3.4 (�3.6,�3.2)

Head and Neck (C00-C14, C30-C32) 450 109 560 843 196 1038 �393 �87 �478 �47 �44 �46 �3.0 (�3.5,�2.4) �2.7 (�3.4,�2.0) �2.9 (�3.5,�2.3)

Unknown primary (C77-80) 594 422 1017 891 573 1465 �297 �151 �448 �33 �26 �31 �1.9 (�3.5,�0.3) �1.5 (�2.4,�0.5) �1.8 (�3.1,�0.5)

Prostate (C61) 799 – 799 1094 – 1094 �295 – �295 �27 – �27 �1.5 (�2.1,�1.0) – �1.5 (�2.1,�1.0)

Cervix (C53) – 152 152 – 394 394 – �242 �242 – �62 �62 – �5.2 (�5.8,�4.6) �5.2 (�5.8,�4.6)

Non-Hodgkin lymphoma (C82-C85) 394 220 614 504 350 854 �110 �130 �240 �22 �37 �28 �1.3 (�2.1,�0.4) �1.8 (�2.5,�1.0) �1.5 (�2.0,�1.0)

Bladder (C67) 218 68 286 400 120 520 �182 �52 �234 �46 �43 �45 �2.6 (�3.0,�2.2) �2.4 (�3.1,�1.7) �2.6 (�2.9,�2.2)

Kidney (C64) 299 139 438 402 265 668 �103 �126 �230 �26 �48 �34 �1.5 (�1.9,�1.1) �3.0 (�3.6,�2.4) �1.9 (�2.4,�1.4)

Ovary (C56) – 487 487 – 690 690 – �203 �203 – �30 �30 – �1.8 (�2.2,�1.5) �1.8 (�2.2,�1.5)

Brain and related (C69-72) 535 334 869 607 411 1017 �72 �77 �148 �12 �19 �15 �0.7 (�1.2,�0.2) �0.8 (�1.6,�0.0)a �0.6 (�1.2,�0.1)

Myeloid leukaemia (C92) 275 174 450 341 241 582 �66 �67 �132 �19 �28 �23 �1.4 (�1.9,�0.9) �1.5 (�2.1,�1.0) �1.2 (�1.9,�0.6)

Melanoma (C43) 506 252 759 556 292 848 �50 �40 �89 �9 �14 �11 �0.5 (�0.8,�0.1) �0.9 (�1.5,�0.4) �0.6 (�0.9,�0.4)

Lymphoid leukaemia (C91) 126 60 185 184 90 274 �58 �30 �89 �32 �34 �32 �1.6 (�2.9,�0.4) �1.8 (�3.5,�0.1) �1.9 (�2.8,�0.9)

Hodgkin lymphoma (C81) 22 14 36 76 44 120 �54 �30 �84 �71 �68 �70 �5.7 (�7.0,�4.5) �5.2 (�6.3,�4.1) �5.6 (�6.4,�4.8)

Pancreas (C25) 678 442 1120 698 491 1189 �20 �49 �69 �3 �10 �6 �0.3 (�0.7,0.1)a �0.4 (�0.8,0.0)a �0.4 (�0.9,0.1)a

Oesophagus (C15) 506 112 618 504 178 682 2 �66 �64 0 �37 �9 �0.1 (�0.4,0.2)a �1.8 (�2.5,�1.1) �0.3 (�1.0,0.3)a

Uterus (C54-55) – 176 176 – 220 220 – �44 �44 – �20 �20 – �1.0 (�2.4,0.4)a �1.0 (�2.4,0.4)a

Thyroid (C73) 29 30 59 26 37 63 3 �7 �4 12 �19 �6 0.1 (�1.4,1.7)a �0.9 (�2.4,0.6)a �0.3 (�1.3,0.7)a

Liver (C22) 460 189 649 265 117 382 195 72 267 73 62 70 2.3 (1.9,2.7) 2.7 (2.0,3.3) 2.4 (2.1,2.7)

Other cancers 1410 951 2361 1233 823 2057 177 128 304 14 16 15 0.6 (0.3,0.9) 0.6 (�0.2,1.4)a 0.7 (0.4,1.0)

All cancers (C00-C97, D45-46, D47.1, D47.3) 11,535 8569 20,104 16,566 11,365 27,931 �5031 �2796 �7827 �30 �25 �28 �1.8 (�1.9,�1.6) �1.4 (�1.5,�1.2) �1.6 (�1.7,�1.5)

0–14 years (All cancers) 46 41 87 86 65 151 �40 �24 �64 �47 �37 �43 �2.9 (�4.5,�1.2) �2.3 (�3.0,�1.5) �2.7 (�3.8,�1.5)

a Trend is not statistically significantb All figures have been rounded

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Table 2Changes in cancer incidence in Australia from 1987 to 2007 for people under 75 years.b

Cancer Typec Observed incidence in

2007 (O)

Expected incidence

in 2007 (E)

Difference O-E Change in incidence

(%) (O-E)/E

Average Annual Percentage Change (95% CI)

Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total

Lung (C33-34) 3612 2302 5915 5786 1834 7620 �2174 468 �1705 �38 26 �22 �2.4 (�2.6,�2.2) 1.1 (0.9,1.3) �1.3 (�1.5,�1.1)

Bowel (C18-20) 5121 3653 8774 4921 3680 8600 200 �27 174 4 �1 2 0.2 (�0.1,0.4)a �0.1 (�0.3,0.1)a 0.1 (�0.2,0.4)a

Breast (female) (C50) – 10,681 10,681 – 7945 7945 – 2736 2736 – 34 34 – 1.5 (1.1,1.9) 1.5 (1.1,1.9)

Stomach (C16) 765 365 1131 1201 508 1709 �436 �143 �578 �36 �28 �34 �2.2 (�2.5,�2.0) �1.6 (�2.0,�1.3) �2.0 (�2.2,�1.8)

Head and neck (C00-C02,32)e 1209 307 1517 1735 344 2079 �526 �37 �562 �30 �11 �27 �1.8 (�2.5,�1.0) �0.5 (�1.3,0.3)a �1.5 (�2.1,�0.8)

Unknown primary (C77-80) 748 532 1281 1303 882 2185 �555 �350 �904 �43 �40 �41 �2.5 (�3.2,�1.7) �2.7 (�3.5,�1.9) �2.6 (�3.1,�2.2)

Prostate (C61) 13,961 – 13,961 3716 – 3716 10,245 – 10,245 276 – 276 6.6 (3.7,9.6) – 6.6 (3.7,9.6)

Cervix (C53) – 649 649 – 1339 1339 – �690 �690 – �52 �52 – �3.6 (�4.3,�2.8) �3.6 (�4.3,�2.8)

Non-Hodgkin lymphoma (C82-C85) 1617 1168 2785 1253 948 2201 364 220 584 29 23 27 1.3 (0.9,1.8) 1.1 (0.7,1.5) 1.2 (0.7,1.6)

Bladder (C67) 844 218 1062 1633 539 2172 �789 �321 �1110 �48 �60 �51 �3.2 (�3.4,�2.9) �4.2 (�5.3,�3.1) �3.3 (�3.5,�3.0)

Kidney (C64) 1285 620 1904 789 439 1228 496 181 676 63 41 55 2.1 (1.8,2.4) 1.6 (1.3,2.0) 2.2 (1.6,2.7)

Ovary (C56) – 910 910 – 1077 1077 – �167 �167 – �16 �16 – �1.1 (�1.4,�0.8) �1.1 (�1.4,�0.8)

Brain and related (C71)d 704 459 1162 739 490 1229 �35 �31 �67 �5 �6 �5 �0.1 (�0.4,0.2)a �0.4 (�1.5,0.8)a �0.3 (�1.6,1.0)a

Melanoma (C43) 4569 3446 8015 3635 3242 6877 934 204 1138 26 6 17 1.3 (0.7,1.9) 0.6 (0.2,0.9) 0.9 (0.6,1.2)

Hodgkin lymphoma (C81) 267 213 479 226 157 384 41 56 95 18 35 25 1.1 (0.7,1.5) 1.8 (1.3,2.3) 1.4 (1.0,1.7)

Pancreas (C25) 781 527 1308 730 540 1269 51 �13 39 7 �2 3 0.2 (�0.2,0.6)a 0.1 (�0.4,0.5)a 0.1 (�0.2,0.4)a

Oesophagus (C15) 573 161 734 524 235 759 49 �74 �25 9 �32 �3 0.3 (0.0,0.6) �1.7 (�2.3,�1.1) �0.2 (�0.5,0.1)a

Uterus (C54-55) – 1521 1521 – 1311 1311 – 210 210 – 16 16 – 0.9 (0.6,1.1) 0.9 (0.6,1.1)

Thyroid (C73) 408 1258 1666 147 412 559 261 846 1107 177 205 198 5.1 (4.6,5.5) 5.8 (5.4,6.1) 5.6 (5.3,5.9)

Liver (C22) 622 194 816 264 87 351 358 107 465 135 122 132 4.0 (3.6,4.3) 4.5 (3.9,5.1) 4.1 (3.8,4.4)

Other cancers 5611 3371 8982 4899 2729 7629 712 642 1353 15 24 18 0.8 (0.5,1.0) 1.0 (0.7,1.3) 0.8 (0.6,1.0)

All cancers (C00-C97, D45-46, D47.1, D47.3) 42,698 32,554 75,252 33,502 28,738 62,240 9196 3816 13,012 27 13 21 1.2 (0.7,1.7) 0.7 (0.5,0.8) 0.9 (0.5,1.4)

0–14 years (All cancers) 321 271 592 294 245 538 27 26 54 9 11 10 0.3 (�0.2,0.9)a 0.5 (0.1,0.9) 0.3 (0.1,0.6)

a Trend is not statistically significant.b All figures have been rounded.c Data on leukaemias were not available for full time period.d Only incidence data on brain cancer were available.e Only incidence data on lip, tongue and pharyngeal cancers were available.

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Box 1. Selected cancer control interventions in Australia.

Intervention Status – late 1980s Status – around 2010

Smoking 1987: 34% in males, 28% in females [12,90] 2010: 16% in males, 14% in females [12,90]

Cervical screening 2-year participation 1992: Western Australia 37% [91] 2009/10: National 57% [92]

Breast screening 1996/7: 51% coverage [93] 2008/9: 55% [94] a

Breast cancer management guidelines 1995: Clinical practice guidelines for the

management of early breast cancer [95]

2001: Clinical practice guidelines for the management of

early breast cancer 2nd Edition [95]

Bowel screening 2000: 18% 50 yrs and over 2008–2011: 38.4% [96]

1995/6: 24/1000 colonoscopies in 65–69 year

olds [23]

2005/6: 50/1000 colonoscopies in 65–69 year olds [23]

Bowel cancer management guidelines 1999: Guidelines for prevention, early detection

and management released [24]

2005: Guidelines for prevention, early detection and

management updated [28]

PSA testing Introduced in 1988 (�0%) 56% in NSW men over 45 Years [48]

Radiotherapy 1987: 18 RT Units [97] 2011: 56 RT Units (approximately 150 linear accelerators) [98]

Sun Protection 1981: ‘‘Slip! Slop! Slap!’’ campaign introduced 2012: NSW Skin Cancer Prevention Strategy 2012–15 [7,99]

1989: Campaign extended to ‘‘Slip! Slop! Slap!

Seek! Slide!’’ [68]

aAIHW report excludes women screened for breast cancer in the private sector. Participation could be higher, up to 68% in NSW [48].

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4.1. Cancers with a mortality improvement

Lung cancer in males showed the largest fall in the totalnumber of cancer deaths. A large proportion of lung cancer cases inAustralia are due to smoking, so it is likely that the fall in lungcancer can be largely attributed to changes in tobacco consump-tion. In 1987, adult smoking prevalence was 28% in females and34% in males [11], and anti-smoking campaigns were in theirinfancy [12,13]. While overall smoking rates in men have declined,smoking became popular with women later in the 20th centuryand only started to decline in the 1980s [14]. This has resulted in nodecline of lung cancer mortality and incidence in women duringthe study period. The relative contribution to lung cancer rates ofexposures other than tobacco is unclear. Head and neck cancerhas a complex aetiology. Smoking is the primary factor responsible[15], along with alcohol and, in some cases, human papillomavirus(HPV) infection [16], including a growing proportion of oropha-ryngeal cancers [17]. In contrast to lung cancer, similar declines inmortality were observed for both sexes.

Bowel cancer mortality fell by 47%, but incidence did notchange significantly. The National Bowel Cancer ScreeningProgramme (NBCSP), offering a one-off faecal occult blood test(FOBT), was piloted in 2002 and the full programme launched in2006, so far only targeting Australians turning 50, 55, 60 and 65years of age [18]. Participation in the programme dropped from45% during the pilot programme to 40% when rolled outnationally [19,20]. Screening trials have shown that biennialFOBTs in people aged 50 years and over could reduce mortality by15–30% [21,22]. The Australian Government recently announcedthe inclusion of additional age groups, with full implementationscheduled for 2034 [18]. In people aged 65–69 years, colonosco-pies performed increased from 24/1000 in 1995/6 to almost 50/1000 in 2005/6 [23]. The reduction in mortality could beattributed to improved treatment and adherence to nationalmanagement guidelines [24–28], and potentially a result of theincrease in colonoscopies [23] while the full benefits of theNBCSP have yet to be realised.

Smoking is an important behavioural risk factor associated withstomach cancer [29], in addition to chronic infection withHelicobacter pylori [30], the latter being associated with poorliving standards and overcrowding [31,32]. The observed 50% fallin mortality and 34% fall in incidence reflects improvements inliving standards from the 1920s, when the prevalence of H. pylori

began to fall [33,34]. The continuing decline in smoking rates andlower prevalence of H. pylori in younger adult groups [32], suggestfuture reductions in stomach cancer mortality and incidence.

Please cite this article in press as: Sitas F, et al. Cancer incidence and

over the period 1987–2007. Cancer Epidemiology (2013), http://dx.

The 31% fall in female breast cancer mortality is likely to bedue to a combination of reduced population risk, earlier detection,and improved treatment. After hormone replacement therapywas linked to an increase in breast cancer risk in 2001 its usedropped dramatically, corresponding with a concomitant 6.7% fallin breast cancer incidence in Australian women aged 50 years andover by 2003 [35]. Australia’s mammographic screening pro-gramme, established in 1990, has been estimated to reduce therisk of breast cancer mortality among participants by about half[36]. The management of early breast cancer has improvedthrough therapeutic innovations, and greater consistency wasachieved through the introduction of clinical practice guidelinesin 1995 that resulted in increased use of adjuvant radiotherapy,chemotherapy and hormone therapy [37,38]. While mortalitydecreased over this period, breast cancer incidence increasedoverall by 34%. This was partly due to earlier detection byscreening (including some cases that would never have beendiagnosed) and changes in lifestyle factors [39]. Breast cancerscreening programmes have been clouded by conflicting expertopinion on their benefit, with overdiagnosis being a growingconcern [40–44]. Measuring overdiagnosis is fraught withmethodological difficulties, however, in recent internationalreviews of screening programmes it was thought that ecologicalstudies are the least informative [45].

Prostate cancer mortality began to fall in Australia from themid-1990s. Early detection from prostate-specific antigen (PSA)testing has contributed to a significant increase in diagnosis andtreatment, a reduction in advanced stage disease and potentially,more recently, mortality [46]. PSA testing, first identified as amarker for prostate cancer progression in 1987 [47], has beenwidely used in screening for prostate cancer in asymptomatic menfrom 2001. In Australia PSA testing has now reached populationcoverage of other established screening programmes [46,48]. The27% fall in prostate cancer deaths is consistent with the decreaseobserved internationally [49–51]. Improved surgical and radio-therapy techniques in primary treatment appears to explain up toone-third of the mortality decline in the USA [52], which may beapplicable in Australia and is consistent with our data. Very fewlifestyle or other risk factors have been identified for prostatecancer, so it is likely that PSA testing is largely responsible for the276% increase in the number of cases diagnosed [53]. There hasbeen conflicting evidence from randomised controlled trials tosupport population based screening programmes for prostatecancer [54,55]. However, the increasing coverage of PSA testing insome countries has seen a large increase in prostate cancerincidence rates, which, when combined with post treatment

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co-morbidities [56], cast significant doubt around the benefits ofscreening being greater than the harm caused [57].

Falls in cervical cancer mortality and diagnosis occurred afterthe introduction of the National Cervical Screening Programme in1991, predominantly achieved over the first ten years of theprogramme [7]. A 62% fall in mortality is similar to reportedreductions in other developed countries following the introductionof organised screening programmes [58–61]. The reductions arelargely for squamous cell carcinomas, with comparatively littlereduction in glandular cancers since 1991 [62,63]. Other cases ofcervical cancer are thought to comprise women who areunscreened or underscreened and women with glandular abnor-malities that are difficult to detect or interpret using cytologicalscreening [63]. The programme is currently undergoing a review toensure access for all women and advocate best clinical practice[64]. Recent work shows that the current biennial programme canbe safely extended to a triennial programme in keeping withinternational recommendations [65]. The implementation of theNational HPV (quadrivalent) Vaccination Programme in girls aged12–13 years is anticipated to further reduce incidence andmortality over the long term and genital warts in the shorterterm [66]. The HPV vaccine was extended to boys aged 12–13 yearsin February 2013, with a two year catch-up for boys aged 14–15years [67]. It is anticipated that some male genital, oropharyngealand other HPV-related cancers (and male genital warts) may bereduced in the future, and that there may be further benefits infemales, due to herd immunity [66].

Melanoma, often referred to as Australia’s national cancer, ismainly caused by ultraviolet/sun exposure. Significant effort hasgone into sun protection: national campaigns, ‘‘Slip! Slop! Slap!’’introduced in 1981 evolved into ‘‘Slip! Slop! Slap! Seek! Slide!’’ in1989, recommending the public wear long sleeved clothes,sunscreen, sunglasses and a hat, and seek shade [68] and the‘‘Mole Patrol’’ campaign [69] started through the MelanomaFoundation. Considering the extensive sun protection campaigns,we observed a 17% increase in melanoma and an 11% decline inmortality over the study period, which seems low. Survival frommelanoma has improved but much of the gain has been due toimprovements in the treatment of thin melanomas. In NSW,survival from thick melanomas (>1 mm) remained unchangedbetween 1994 and 2002 [70]. A detailed age specific incidenceanalysis found a fall in incidence in younger age cohorts,suggesting positive behavioural changes in sun protection [71].Given the improvements, sun protection campaigns play animportant role in prevention and should be enhanced [69,72].

Bladder cancer incidence and mortality rates both fell, mainlydue to a fall in registration of non-invasive tumours of the bladdersince the late 1980s [73]. Despite the increasing numbersdiagnosed, mortality has fallen for lymphomas, specifically NHL,probably explained by improvements in NHL treatment, such as theintroduction of monoclonal antibody therapy in 1998 [74].

4.2. Cancers with little or no improvement in mortality

There were only small or non-significant reductions in deathsfrom cancers of the thyroid, uterus, brain and related, oesopha-gus and pancreas. Currently there is limited scope for theprevention of cancers with unknown or predominantly unmodifi-able risk factors. In these cases placing greater emphasis on theimprovement of detection and treatment should be a growingpriority. Although thyroid cancer mortality was stable over time, asignificant increase in incidence was observed, due to increaseduse of imaging technologies to diagnose related conditions,although it is possible that some of the increase is real and dueto other unknown risk factors [75]. Cancers of unknown primaryshowed a decline in mortality, potentially caused by changes in

Please cite this article in press as: Sitas F, et al. Cancer incidence and

over the period 1987–2007. Cancer Epidemiology (2013), http://dx.

coding between ICD-9 and ICD-10, better differentiation orimproved diagnosis of cancers previously of unknown origin tospecific sites [76].

4.3. Cancers which show increased cases and deaths

We found a 70% increase in mortality and 132% increase indiagnosed cases of primary liver cancer, similar to previouslyreported changes [77]. While alcoholic liver disease was the mainaetiological factor in the 1970s, this was supplanted by Hepatitis Band C infection in the following decades [78,79]. Australianimmigrants from Southeast Asia, Italy and some other parts of theworld have an increased risk of liver cancer compared to Australianborn residents [80]. The substantial burden of undiagnosed chronicHepatitis B infections in some of Australians immigrants, coupledwith the natural history of chronic Hepatitis B infection inpopulations where the infection is acquired early in life [81,82]contributes to about half of the increasing mortality and incidencein Australia [83].

4.4. Cancers in population subgroups

Although not a key element of the analysis, it is important toacknowledge Australia’s diverse ethnic composition affects cancerincidence and mortality rates [84,85]. Since 2008 efforts toquantify the effects of ethnicity on incidence and mortality havelead to improvements in recording Aboriginal and Torres StraitIslander status on pathology, hospital admission, outpatientsforms and the death certificate [86]. Similar improvements areneeded in country of birth registration to improve reporting forimmigrants. Finally, the inclusion of smoking status on the deathcertificate, found useful in other nations, could result in moreaccurate information on the largest cause of preventable deaths,including cancers, and help monitor the benefits of quittingsmoking [87–89].

5. Conclusion

This analysis shows that in Australians under 75 years of age,cancer mortality has decreased by 28% over the period 1987 to2007. Prevention, improvements in treatment, and screeningprogrammes, all appear to have an important role in reducingcancer mortality, and remain important elements of cancercontrol. Cancer incidence, however, has increased by 21%, largelydue to diagnoses brought forward by the use of more moderndiagnostic technologies and the increased coverage of screeningand testing programmes. The changes highlighted by our analysis,however, can only partially explain the observed effect of cancercontrol efforts. This type of analysis provides a useful tool fortracking changes in cancer incidence and mortality over time, andcan help to identify areas requiring further research.

Conflict of interest

The authors of this paper declare no conflict of interest.

Acknowledgements

We would like to thank Mark Short at AIHW and Julia Fitzgeraldfrom ABS for compiling the tables for us, and for providinginvaluable advice on ICD changes and conversion codes.

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