Freddie Bray -Regional Figures on Cervical Cancer and Cancer Registries

1. Regional figures on cervical cancer
and cancer registries
F Bray
Deputy Head
Section of Cancer Information
International Agency for Research on Cancer (IARC)
Lyon ◦ France • Cervix cancer burden
• Global
• EECARO and ASRO
• Population-Based Cancer Registries
(PBCR)
• Role / implementation
• Status of EECARO and ASRO
• Future collaborative developments

2. IARC Medium-Term Strategy 2010-14
Priority - Describing the Global Cancer Burden
• The definitive international point of reference for
collection, quality control, processing and statistical
analysis of accurate data on cancer occurrence
• Expanded coverage, continuity, and quality of cancer
registration activities, particularly in regions where
data are lacking
• Improved access to information
• A platform for research: risk factors; preventive
interventions and targeted screening programmes

3. Cancer registration – a priority for cancer
research, prevention and control
• UICC World Cancer Declaration 2020
Second target
• The measurement of the global cancer burden and the impact of
cancer control interventions will have improved significantly
• WHO 2008-2013 Action Plan
•
Global Strategy for the Prevention and Control of Non-
communicable Diseases
• Objective 6: To monitor NCDs and their determinants and
evaluate progress at the national, regional and global levels

4. Burden
• Of 57 million deaths in 2008, 2/3 due to NCDs.
• Cancer will be an increasingly important cause
of morbidity/mortality in next few decades in
all regions.
Cervix cancer control
• Early detection & treatment of lesions of early
stage cervical cancer will reduce the cancer
burden by 5%.
• New low-cost HPV screening tests, combined
with HPV vaccination, have potential to
improve cervical cancer control worldwide
Population-Based Cancer Registries
• Current capacities for NCD surveillance are
inadequate in many countries and urgently
require strengthening.
• Cancer morbidity is essential for planning &
monitoring cancer control initiatives.
• PBCR are core components of national
programmes - provide means to plan, monitor
and evaluate the impact of specific
interventions in targeted populations.

5. • cervical cancer – global burden

6. GLOBOCAN 2008 online http://globocan.iarc.fr

8. The Global Burden of Cervical Cancer
1. Cervical cancer is the third most common cancer in women,
and the seventh overall, with an estimated 529 000 new cases
in 2008.
2. More than 85% of the global burden occurs in developing
countries, where it accounts for 13% of all female cancers.
3. High-risk regions are Eastern and Western and Southern Africa,
South-Central Asia, South America and Middle Africa. Rates are
lowest in Western Asia, Northern America and Australia/New
Zealand.
4. Cervical cancer remains the most common cancer in women
only in Eastern Africa, South-Central Asia and Melanesia.
5. Cervical cancer is responsible for 275 000 deaths in 2008, about
88% of which occur in developing countries
Ferlay et al, IJC 2010

9. Estimated incidence of cervical cancer (2008)
Age-standardised rates per 100,000
GLOBOCAN 2008 (globocan.iarc.fr)

10. Cervical cancer: estimated
incidence & mortality (2008)
Age-standardised rates per 100,000
GLOBOCAN 2008 (globocan.iarc.fr)

12. Arbyn et al, 2011
Rank of cervical cancer mortality, among all female cancer sites women aged 15–44 years

13. Prediction of cervical cancer incidence and mortality
Estimated numbers (thousands)
Incidence
2008
2030*
0 200 400 600 800 1,000
Total
* Assuming cervical cancer rates in 2008 do not change

14. Trends in cervical cancer incidence in selected countries
Age-standardised rates per 100,000
Less developed regions More developed regions
70 70
Al geri a Aus tri a
(regi ona l )
Bra zi l Bul ga ri a
(regi ona l ) 60 60
Chi na Czech
(regi ona l ) Republ i c
Col ombi a 50 50 Denma rk
(regi ona l )
Cos ta Ri ca Fi nl a nd
Ecua dor 40 40
Fra nce
(regi ona l ) (regi ona l )
Indi a Ital y
(regi ona l ) 30 30 (regi ona l )
Phi l i ppi nes Ja pa n
(regi ona l ) (regi ona l )
Sa udi New
Ara bi a 20 20
Zea l a nd
Tha i l a nd Rus s i a n
(regi ona l ) Federa tion
Uga nda 10 10 Uni ted
(regi ona l ) Ki ngdom
Zi mba bwe USA
(regi ona l ) (regi ona l )
0 0
1977 1982 1987 1992 1997 2002 2007 1977 1982 1987 1992 1997 2002 2007
Rates have been smoothed using 3-year moving average
Data sources:
Cancer Incidence in Five Continents Vol. I to IX (CI5.iarc.fr)
Cancer registry reports

15. Thailand, Chiang Mai
Medium HDI China, Shanghai
Philippines, Manila
India, Mumbai
India, Chennai
China, Hong Kong
Lithuania
Latvia
Estonia
High HDI Slovakia
Poland, Kielce
Poland, Cracow City
Poland, Warsaw city
Colombia, Cali
Costa Rica
Brazil, Goiania
Ecuador, Quito
Japan, Yamagata Prefecture
Slovenia
Iceland
Finland
Israel: Jews
Very High HDI Spain, Granada
Italy, Parma
Canada, Alberta
Canada, New Brunswick
Italy, Modena
USA, California, Los Angeles: Japanese
USA, Louisiana, New Orleans: White
Canada, Saskatchewan
France, Tarn
Spain, Murcia
Japan, Miyagi Prefecture
Italy, Florence
Czech Republic
France, Doubs
Sweden
USA, Georgia, Atlanta: White
Spain, Navarra
USA, California, Los Angeles: Filipino
Canada, British Columbia
Italy, Lombardy, Varese province
USA, Hawaii
Italy, Romagna
USA, Iowa
USA, Michigan, Detroit: White
USA, California, Los Angeles: Non-Hispanic White
Norway
Canada, Nova Scotia
USA, California, San Francisco: White
France, Bas-Rhin
The Netherlands, Eindhoven
Canada, Ontario
USA, Michigan, Detroit: Black
USA, SEER (9 registries): White
Germany, Saarland
USA, California, Los Angeles: Hispanic White
USA, SEER (9 registries)
USA, Louisiana, New Orleans: Black
USA, Connecticut: White
USA, New Mexico
Spain, Tarragona
Switzerland, St Gall-Appenzell
Spain, Zaragoza
Canada, Manitoba
Singapore: Chinese
USA, Washington, Seattle
USA, Utah
UK, Scotland
Italy, Torino
France, Somme
USA, SEER (9 registries): Black
Denmark
USA, Georgia, Atlanta: Black
USA, California, Los Angeles: Korean
Canada, Prince Edward Island
Canada, Newfoundland
France, Calvados
France, Herault
Italy, Ragusa Province
USA, Connecticut: Black
USA, California, Los Angeles: Chinese
France, Haut-Rhin
Australia, New South Wales
Australia, Tasmania
UK, England, North Western
UK, England, Yorkshire
Singapore: Malay
USA, California, San Francisco: Black
USA, California, Los Angeles: Black
New Zealand
Japan, Osaka Prefecture
Austria, Tyrol
UK, England, Birmingham and West Midlands Region
Australia, Victoria
Switzerland, Geneva
Australia, Western
France, Isere
Australia, South
UK, England, Merseyside and Cheshire
UK, England, Oxford

16. Prediction of cervical cancer incidence and mortality
Estimated numbers (thousands)
Incidence
290000
Incidence
2008
2030*
0 200 400 600 800 1,000
Total
* Assuming cervical cancer rates in 2008 do not change

17. Prediction of cervical cancer incidence and mortality
Estimated numbers (thousands)
Incidence
2008
2030*
0 200 400 600 800 1,000
Total
* Assuming global declines in cervix cancer of 2% per year

18. • Cervical cancer burden - EECARO and ASRO

19. Country - EECARO Country - ASRO
Albania Algeria
Armenia Egypt
Azerbaijan Jordan
Belarus Lebanon
Bosnia & Herzegovina Morocco
Georgia Sudan
Kazakhstan Syria
Kyrgyzstan Tunisia
Russian Federation
Serbia
Tajikistan
Turkey
Turkmenistan
Ukraine
Uzbekistan

20. Cervix Cancer Estimates 2008, ages 0-74
Kyrgyzstan
Serbia
Kazakhstan
Armenia
Ukraine
Morocco
Russian Federation
Belarus
Uzbekistan
Algeria
Azerbaijan
Bosnia Herzegovena
Tajikistan
Sudan
Turkmenistan
Albania
Tunisia
Turkey
Lebanon
Jordan
Syrian Arab Republic
Egypt
Cumulative Risk of Incidence Cumulative Risk of Mortality
3 2 1 0 1 2 3

27. • Population-Based Cancer Registries (PBCR)

28. What is cancer registration?
• Cancer Registry
• The office or institution which is responsible for the collection
storage, analysis and interpretation of data on persons with cancer
• Cancer registration
• The process of continuing systematic collection of data on the
occurrence, characteristics, and outcome of reportable neoplasms
with the purpose of helping to assess and control the impact of
malignant disease in the community.
• Population-Based Cancer Registries (PBCRs)
• Collect information on all new cases of cancer in a defined
population
• The population covered is usually that of a geographic area
• The main interest is for epidemiology and public health

29. PBCR – basic requirements
• Clear definition of the catchment population
• Distinguish residents living within the area and those who
come from outside
• Availability of reliable population denominators
• Generally available medical care and ready access to
medical facilities
• Great majority of cases will come into contact with the
health care system at some point in their illness
• Easy access to case-finding sources
• Hospitals, pathology departments, death certificates etc.

30. Other types of registries
• Pathology-Based Cancer • Hospital-Based Cancer
Registries Registries
• Collect information from one or • Records all cases of cancer
more laboratories on treated in a given hospital
histologically-diagnosed cancers • The population from
• The population from which which the cases come is
the tumour tissue has come not defined
is not defined • The purpose is to serve the
• Information is of high diagnostic needs of the hospital
quality administration, the
- but is difficult to generalize hospital's cancer programme

31. Bias in Pathology Series
Fortaleza Cancer Registry NRTP Ceara State
(Males) (Males)
(1978-1980) (1976-1980)
Stomach Stomach
15.4% 10.3% Lung
Lung 1.0%
7.7%
Others
Others
48.7%
47.8%
Skin
20.0% Skin
36.0%
Lymphoma
Leukaemia 3.9% Leukaemia
Lymphoma
4.3% 0.8%
4.1%

32. Bias in Hospital Based Series
Bombay Cancer Registry Tata Memorial Hospital
(Males) (Males)
(1968-1972) (1970-1972)
Mouth/Pharynx Mouth/Pharynx
25.7% 49.0%
Others
Others 41.8%
50.3% Stomach
5.7%
Larynx
Lung 9.4% Lung Stomach
8.9% 5.7% Larynx 1.7%
1.8%

33. Planning for a PBCR – key requirements
• Advisory committee
• Seek cooperation / support of medical community.
• Representatives of funder(s), sources and users of data
• Population denominators
• Accurate, regularly-published population data.
• Legal aspects and confidentiality
• Size of population and number of cases
• Decide on optimal size of the population covered by the registry.
• Physical location of the registry
• Finance
• Dependant on size of area, data items collected, different sources etc.
• Personnel
• Leadership of PBCR Director.
• Necessity of adequate staffing, expertise and training
• Equipment (IT - linkage of sources) / office space

34. Difficulties in Low/Medium
resource countries
• Lack of resources
• Lack of appropriately-trained staff
• Lack of basic health facilities
• Lack of proper denominators
• Identity of individuals
• Lack of follow-up

35. INTERNATIONAL ASSOCIATION OF CANCER REGISTRIES
Membership 662
25
264
447 458
402 19 19
385
366 19
18
20 187
186
104
Oceania 163
171
144
Europe 75
191 68
67
N. America 15 68
134 70 48
91 46
S. America 91 11
83
40 137
38
55 28 92
Asia 7 87
39 54 68 74
37 59
Africa 26 12 12 16 57
88 3 12 24 28 30 42 44
7 11
1979 1982 1986 1992 1996 1997 2002 2003 2008

36. Coverage of cancer registration worldwide
% of the population covered (around 2000)
40.0
99.0
19.0
7.1
7.9
13.0
82.0
16.5% total
(21% in 2006 - 8% in Asia )

37. Cancer Incidence in Five Continents
% population covered by cancer registries in Vol. IX
(number of registries/number of countries providing data)
83.0 32.5
(100/29)
(54/2)
4.0
(44/15)
1.1
(5/5)
5.5
(11/7)
80.5
(11/2)
11.6 total
(225/60)

38. GLOBOCAN 2008: Incidence, methods of estimation
National Incidence data (62 of 182 countries, 34%)
Regional incidence (+ mortality) and national mortality (52, 29%)
Regional incidence data only (23, 13%)
Frequency data (13, 7%)
No data (32, 18%)

39. Cancer registries as a basis for cancer
prevention and control
1) Epidemiology
• Generating hypotheses of aetiology – geographic and
temporal variations in cancer incidence
• Understanding aetiology and evaluating interventions -
case identification, research endpoints e.g. in cohort
studies
2) Cancer control programmes
• Planning
• estimates of cancer burden (incidence, mortality, survival)
• targeting public health interventions
• Evaluating – temporal variations in incidence, survival
and mortality

43. Incidence and mortality data availability - EECARO
Included Mortality
Country Cancer Registry? in CI5? (WHO)? Compl.
Albania N N/A Y 58%
Azerbaijan N N/A Y 71%
Armenia N N/A Y
Belarus National PBCR Y Y 100%
Bosnia & Herzegovina N N/A Y 100%
Georgia N N/A Y 85%
Kazakhstan N N/A Y 89%
Kyrgyzstan N N/A Y 89%
Russian Federation (National) PBCR Y Y 100%
Serbia National PBCR N Y 100%
Tajikistan N N/A Y 60%
Turkey Regional PBCR Y Y
Turkmenistan N N/A Y 81%
Ukraine National PBCR N Y 100%
Uzbekistan N N/A Y 91%

44. Incidence and mortality data availability - ASRO
Included Mortality
Country Cancer Registry? in CI5? (WHO)? Compl.
Algeria Regional PBCR Y N
Egypt Regional PBCR Y Y 85%
Jordan National PBCR N Y
Lebanon Regional CR N N
Morocco Regional CR N N
Sudan Regional CR N N
Syria N N/A Y
Tunisia Regional PBCR Y N

45. • Future collaborative developments

46. http://www.who.int/hpvcentre/en/

47. Provision of support to countries
monitoring cervical cancer
burden in relation to the
introduction the HPV vaccine -
activities using cancer registries
Country-specific fact sheets/reports:
• situation analysis of cancer burden 2010
• info/contacts: data sources, availability,
quality of key indicators of burden
Technical advice to planners
• guide to establishing / improving PBCR
• measuring impact of the HPV vaccine /
screening programmes using PBCR
Collaborative research
• highlight patterns and trends in cervical
cancer in LMIC vs. HIC countries
• alert planners to the necessity of
population-based data to monitor the
cervical cancer burden in LMIC.

48. Conclusions
• The estimated 529 000 new cases of cervical cancer in 2008 will
increase to over 800 000 by 2030 assuming no change in rates.
• Cervix cancer incidence and mortality rates are decreasing in
many medium/high resource settings
• 2% declines worldwide would see numbers remain stable
- but rates increasing in a number of lower & higher resource settings.
• Regions with relatively high increasing risk include a number of
Eastern European / Central Asian countries.
• PBCR is an essential component of cancer control activities but
their extent and quality still remains limited.
• Positioning NCDs at the top of the global health agenda..
• ..will hopefully ameliorate the situation with respect to the availability
of cancer statistics on cervical cancer aiding the planning and
evaluation of targeted prevention and early detection strategies.