Abstract. In Cuba, the illness that produces most deaths among 1â64-year-olds is cancer. Over 65, it is the second cause of death after heart diseases. A Na-.
European Journal of Epidemiology 14: 287–297, 1998. 1998 Kluwer Academic Publishers. Printed in the Netherlands.
The Cuban National Cancer Registry: 1986–1990 Antonio A. Martín, Yaima H. Galán, Armando J. Rodríguez, Margarita Graupera, Patricia Lorenzo-Luaces, Leticia M. Fernández, Rolando Camacho & Marta Lezcano National Cancer Registry, National Institute of Oncology, Havana, Cuba Accepted in revised form 28 November 1997
Abstract. In Cuba, the illness that produces most deaths among 1–64-year-olds is cancer. Over 65, it is the second cause of death after heart diseases. A National Cancer Registry was created 1964. Its main goals are to register all malignant neoplasms diagnosed in the country, to study this disease from the statistical and epidemiological point of view and to aid in the health control and planning of cancer fighting resources. This paper presents the results based on cases registered from 1986 to 1990. More than 50% of incidence and mortality caused by cancer is confined to the five major primary sites: lung, prostate, colon, breast and cervix. World population standardised rates by 100,000 inhabitants for the period 1986–1990 were 218.2 in males and 183.7 in females for incidence
and 138.4 in males and 95.1 in females for mortality. Cancer incidence distribution by provinces shows two major regions: western-central, where higher risks of lung, breast, prostate and colon cancers are found, and eastern where very high risk of cervix cancer is observed. Although an improvement of the information quality indexes has been reported by the National Cancer registry in the studied period of time, quality of the data remained very poor according to the international standards. However, the results obtained by the National Cancer Registry seem to be a valuable tool to evaluate the cancer burden and, in particular, to control and eventually modify the tasks of the National Cancer Control Program in Cuba.
Key words: Cancer, Cancer registry, Epidemiology, Incidence, Mortality
Introduction Cuba is an archipelago in the western region of the Caribbean Sea. Its area is 114,471 square km and its population is estimated at 10,693,500 inhabitants in 1990, 22.5% children aged 0–14 years. The country is divided in 14 provinces. Seventy percent of Cubans live in urban areas. Havana City, the capital, is the highest concentration of population with more than 2 million people. Ethnically, most of the Cuban population is Caucasian, blacks representing 12% and mestizos 22% of the total. Nowadays, cancer is a serious social problem for humanity due to the high incidence and mortality indexes. In Cuba, in the last three decades, the heart diseases and malignant neoplasms have become the main health problems due to the improvement of sanitary levels, especially the prevention of transmissible illnesses (from 94.4 per 100,000 inhabitants in 1962 to 9.0 in 1987) and the increase of life expectancy at birth (from 62 years in 1960–1965 to 74 in 1985–1990) [22]. Cancer is the second cause of death for total population since 1958 [6]. Around 20–25000 new cases appear and 13–14000 deaths occur each year. This situa-
tion could be worse in the following next years due to the influence of changes in some demographic indexes associated with this disease. The change in the age composition of the Cuban population and the improvement in some health indicators as a consequence of the intervention programs (pregnant women care, massive vaccination, cervix cancer screening, etc.) are appropiate examples. The National Cancer Registry (NCR) started in Cuba in 1964 as part of the Health Statistics National System. Its principal goals are: to report all malignant neoplasms diagnosed in the country, to study this disease from the statistical and epidemiological point of view, and to help in the planning and control activities against cancer [4, 7, 17, 18]. In 1986, a new informative system was introduced in the NCR to improve the quality of registered data [5, 11, 12]. It included a detailed specification of the system procedures and responsibilities of each part of the system, the obligatory report of all diagnosed cases and the computerised processing of the information at national level [14, 24]. The data of the NCR have been published in ‘Cancer Incidence in Five Continents’ Vol. III, IV, VI [13,
288 17, 18] and in ‘International Childhood Cancer Inidence’[35].
Methods The structure of the Registry is based on the organisation of the Cuban National Health System that guarantees the free-of-charge access to all levels of the system for all citizens. The flow of information starts in the hospitals, when physicians report the cancer cases using a special form. These forms are sent to the Statistics Department of the hospital. There, an index card is filled for each report conforming a file which is useful to avoid possible duplicates at the hospital level. Periodically, the Pathology and Haematology laboratories send to the Statistics Department the ‘Oncology Patient’ forms, where histology/haematology confirmed cancer cases are listed. The consistency is controlled comparing the index-card with the lists from the laboratories and if some reports are not found, the assistance doctors are asked to fill in the forms. The cases with only clinical or radiological confirmation are controlled using the same procedure through the outcome patient lists. The cancer reports are periodically sent from the Statistics Department in the hospials to the corresponding Provincial Statistics Department. The data from received reports are introduced into a microcomputer-based system. The main objective of this is to improve the quality of the registered information. The inclusion of an automatic coding module, with the principal intention of assigning the right International Classification of Diseases (ICD-O) [31] codes, makes easier the system exploitation for non-specialised personnel in coding management. The computerised system validates the data consistency, mainly the relationships among the variables: sex, age, primary site and histology. Searching for duplicates is done using the personnel identification number which is unique for each Cuban citizen. A similar number, created by the own computerised system from the birth date and the patient’s sex, is also used for those cases whose official identity number is not specified. Detection of duplicates is done using record linkage techniques included in the computerised system. Twice a year, the data of each province are sent to the Central Offices of the Registry joining the information of all cases in the country. The necessary feedback to repair errors and to disseminate the outputs of the Registry is implemented as well. In the Central Offices of the NCR, the reports of the whole country are checked out again in order to detect possible inter-provincial duplicates. The information for those citizens who do not live in their re-
porting provinces is re-distributed, updating the files of the right province of residence. Therefore, at the moment, the NCR is formed by fourteen provincial registries and the Central Offices at the country capital [25]. The death certificate is another source of information. Each year, the National Offices of Stistics at the Ministry of Public Health sends to the NCR a computerised file including all deaths occurring in the country. The high consistency of the death notification system [37] and the existence of a unique identity number for the whole population makes it easier to compare the cases stored in the NCR with death cases. The matching between death and cancer cases files is carried out using record linkage techniques too. The fact that cancer cases that have died could be known, makes the passive follow up possible. On the other hand, the cases registered as dead of cancer, whose information is not stored in the NCR, are included then as death certificate only (DCO) cases. In order to analyse the cancer incidence and mortality burden, the data of the cases registered from 1986 to 1990 were used. Average annual crude, agespecific and world age standardised rates were calculated. Crude and age-specific rates were obtained multiplying the number of cases in the studied period by 100,000 and dividing the result by five times the population of the middle-year of the five-year period (1988) of the particular age-group. Rates were standardised by age using the direct method and the world population divided in the 5-year standard age-groups [10]. In order to compare the Cuban cancer rates, both incidence and mortality, to the other registries or countries, data published by two worldwide statistic publications were used [2, 34]. The population structure by age, sex and province of residence has been estimated by the State Committee of Statistics from data obtained by the population census carried out in Cuba in 1981 [20] (Table 1). For the geographic analysis, standardised rates Table 1. Cuban population by sex and age groups, 1988 Age group (years)
Female
Male
Total
0–14 15–24 25–34 35–44 45–54 55–64 65 and + Total
1268730 1158991 833888 661379 521105 365250 323758 5133101
1282632 1114474 794281 642133 503437 365269 322297 5024523
2551362 2273465 1628169 1303512 1024542 730519 646055 10157624
864
14.91
0.05 0.03 0.00 0.12 0.29 0.02 0.28 0.02 0.07 0.02 0.16 1.98 1.02 0.45 1.09 0.19 0.35 0.41 1.45 1.04 0.07 0.07 0.07 1.23 1.78 2.35
Rate
1922
12 6 0 20 38 20 10 3 9 8 31 85 25 30 170 20 284 69 600 109 2 11 8 53 160 105
No.
25–34
46.10
0.29 0.14 0.00 0.48 0.91 0.48 0.24 0.07 0.22 0.19 0.74 2.04 0.60 0.72 4.08 0.48 6.81 1.65 14.39 2.61 0.05 0.26 0.19 1.27 3.84 2.52
Rate
4684
53 19 9 80 108 53 43 31 25 39 220 105 25 23 472 30 1190 215 1198 193 21 27 5 95 202 103
No.
35–44
141.64
1.60 0.57 0.27 2.42 3.27 1.60 1.30 0.94 0.76 1.18 6.65 3.18 0.76 0.70 14.27 0.91 35.99 6.50 36.23 5.84 0.64 0.82 0.15 2.87 6.11 3.11
Rate
7415
108 50 51 154 308 132 108 84 93 84 493 179 38 39 885 39 1873 459 1131 299 54 49 11 165 165 159
No.
45–54
CR = crude rate; ASWR = standardised rates for the world population. All rates referred to 100,000 inhatants.
699
11.02
All sites
140–199
3 2 0 7 17 2 9 1 4 1 9 115 59 26 63 11 20 24 84 60 4 4 4 71 103 136
No.
No.
Rate
15–24
0–14
Age group (years)
0.09 0.00 0.00 0.03 0.05 0.00 0.24 0.00 0.00 0.03 0.02 3.12 0.65 0.73 0.08 0.02 0.05 0.00 0.00 0.11 0.00 0.76 0.38 2.07 0.22 1.45
Site
Mouth 6 Pharynx 0 Esophagus 0 Stomach 2 Colon 3 Rectum 0 Liver 15 Gall bladder 0 Pancreas 0 Larinx 2 Lung 1 Haematopoyetic 198 Bones 41 Soft tissues 46 Skin 5 Skin melanoma 1 174 Female breast 3 179–181–182 Uterus NOS, etc. 0 180 Cervix uteri 0 183 Ovary 7 188 Bladder 0 189 Kidney 48 190 Eye 2 191–192 Brain/CNS 131 193 Thyroids 14 196 Limphatic nodes 92
140–145 146–149 150 151 153 154 155 156 157 161 162 169 170 171 173
ICD-O
Table 2. Cancer incidence, Cuba 1986–1990. Frequencies and rates by age group for females
284.59
4.15 1.92 1.96 5.91 11.82 5.07 4.15 3.22 3.57 3.22 18.92 6.87 1.46 1.50 33.97 1.50 71.89 17.62 43.41 11.48 2.07 1.88 0.42 6.33 6.33 6.10
Rate
9875
173 52 72 228 571 270 24 183 172 161 905 316 62 57 1380 50 1983 723 908 335 124 87 13 147 127 215
No.
55–64
540.73
9.47 2.85 3.94 12.48 31.27 14.78 11.17 10.02 9.42 8.82 49.56 17.30 3.39 3.12 75.56 2.74 108.58 39.59 49.72 18.34 6.79 4.76 0.71 8.05 6.95 11.77
Rate
23950
514 124 333 889 2182 772 783 517 769 251 2979 826 116 136 3954 81 3203 1377 1040 434 556 182 46 208 142 465
No.
883 256 469 1385 3236 1258 1174 823 1072 551 4649 1842 367 357 7052 232 8579 2876 4967 1441 768 405 116 870 918 1284
No.
All ages
1,479.50 49688
31.75 7.66 20.57 54.92 134.79 47.69 48.37 31.94 47.50 15.51 184.03 51.03 7.17 8.40 244.26 5.00 197.86 85.06 64.25 26.81 34.35 11.24 2.84 12.85 8.77 28.73
Rate
65 and more
193.60
3.44 1.00 1.83 5.40 12.61 4.90 4.57 3.21 4.18 2.15 18.11 7.18 1.43 1.39 27.48 0.90 33.43 11.21 19.35 5.61 2.99 1.58 0.45 3.39 3.58 5.00
CR
183.65
3.19 0.95 1.66 4.89 11.44 4.51 4.13 2.96 3.67 2.13 16.66 6.9 1.37 1.34 25.29 0.87 33.02 10.89 19.24 5.57 2.63 1.56 0.44 3.48 3.44 4.77
ASWR
289
All sites
140–199
729
11.37
0.02 0.12 0.02 0.00 0.00 0.00 0.12 0.00 0.02 0.02 0.03 3.87 0.70 0.47 0.03 0.02 0.02 0.00 0.02 0.33 0.28 1.53 0.00 2.67 851
17 9 0 8 20 5 22 1 3 2 21 173 89 30 53 7 0 0 10 2 5 85 27 190 21.43
0.09 0.14 0.00 0.05 0.02 0.00 0.20 0.00 0.04 0.02 0.07 4.58 0.88 0.61 0.23 0.02 0.02 0.00 0.05 0.45 0.34 1.88 0.02 3.41
Rate
1007
36 15 2 30 34 29 18 3 7 16 73 91 20 29 169 14 1 6 16 17 6 83 35 167
No.
25–34
25.36
0.91 0.38 0.05 0.76 0.86 0.73 0.45 0.08 0.18 0.40 1.84 2.29 0.50 0.73 4.26 0.35 0.03 0.15 0.40 0.43 0.15 2.09 0.88 4.21
Rate
2469
106 40 27 93 89 55 41 15 39 90 417 150 24 39 577 19 4 22 82 42 17 118 23 199
No.
35–44
76.90
3.30 1.25 0.84 2.90 2.77 1.71 1.28 0.47 1.21 2.80 12.99 4.67 0.75 1.21 17.97 0.59 0.12 0.69 2.55 1.31 0.53 3.68 0.72 6.20
Rate
5629
337 128 130 257 252 131 104 48 107 364 1184 201 49 49 1099 40 7 156 188 80 17 180 49 265
No.
45–54
223.62
13.39 5.09 5.16 10.21 10.01 5.20 4.13 1.91 4.25 14.46 47.04 7.99 1.95 1.95 43.66 1.59 0.28 6.20 7.47 3.18 0.68 7.15 1.95 10.53
Rate
CR = crude rate; ASWR = standardised rates for the world population. All rates referred to 100,000 inhabiants.
175 185 188 189 190 191–192 193 196
Mouth 1 Pharynx 8 Esophagus 1 Stomach 0 Colon 0 Rectum 0 Liver 8 Gall bladder 0 Pancreas 1 Larinx 1 Lung 2 Haematpoyetic 248 Bones 45 Soft tissues 30 Skin 2 Skin melanoma 1 Male breast 1 Prostate 0 Bladder 1 Kidney 21 Eye 18 Brain/CNS 98 Thyroids 0 Lymphatic nodes 171
140–145 146–149 150 151 153 154 155 156 157 161 162 169 170 171 173
No.
No.
Rate
15–24
0–14
Age group (years)
Site
ICD-O
Table 3. Cancer incidence, Cuba 1986–1990. Frequencies and rates by age-group for males
10748
587 214 273 454 467 261 235 86 277 677 2417 362 53 70 1932 55 11 742 447 155 21 217 48 377
No.
55–64
588.44
32.14 11.72 14.95 24.86 25.57 14.29 12.87 4.71 15.17 37.07 132.34 19.82 2.90 3.83 105.79 3.01 0.60 40.63 24.48 8.49 1.15 11.88 2.63 20.64
Rate
38157
1383 502 920 1673 1821 832 875 294 983 1479 8372 1138 155 148 5508 116 32 7610 1934 329 73 279 60 677
No.
2485 925 1357 2528 2690 1322 1308 449 1418 2641 12502 2377 440 405 9498 252 57 8598 2704 653 160 1069 244 2053
No.
All ages
2,367.82 60010
85.82 31.15 57.09 103.82 113.00 51.63 54.30 18.24 61.00 91.78 519.52 70.62 9.62 9.18 341.80 7.20 1.99 472.24 120.01 20.42 4.53 17.31 3.72 42.01
Rate
65 and more
238.87
9.89 3.68 5.40 10.06 10.71 5.26 5.21 1.79 5.64 10.51 49.76 9.46 1.75 1.61 37.81 1.00 0.23 34.22 10.76 2.60 0.64 4.26 0.97 8.17
CR
218.20
9.32 3.49 5.00 9.12 9.73 4.81 4.76 1.64 5.17 10.70 45.75 8.91 1.61 1.52 34.8 0.94 0.21 28.82 9.63 2.50 0.60 4.13 0.91 7.78
ASWR
290
5.31
355
6.13
0.03 0.03 0.00 0.10 0.05 0.03 0.05 0.00 0.05 0.00 0.16 1.79 0.55 0.19 0.09 0.07 0.16 0.26 0.28 0.00 0.12 0.02 0.71 0.00 1.02
Rate
586
3 3 0 15 20 7 7 4 5 2 23 69 19 9 8 95 38 104 33 2 6 1 26 3 48
No.
25–34
14.05
0.07 0.07 0.00 0.36 0.48 0.17 0.17 0.10 0.12 0.05 0.55 1.65 0.46 0.22 0.9 2.28 0.91 2.49 0.79 0.05 0.14 0.02 0.62 0.07 1.15
Rate
1606
13 12 8 62 76 24 23 11 24 6 175 72 14 6 10 382 130 254 72 7 11 1 33 4 53
No.
35–44
48.57
0.39 0.36 0.24 1.87 2.30 0.73 0.70 0.33 0.73 0.18 5.29 2.18 0.42 0.18 0.30 11.55 3.93 7.68 2.18 0.21 0.33 0.03 1.00 0.12 1.60
Rate
3365
37 23 38 118 198 56 75 52 100 26 413 136 21 7 20 773 283 367 150 12 31 4 62 13 91
No.
45–54
129.15
1.42 0.88 1.46 4.53 7.60 2.15 2.88 2.00 3.84 1.00 15.85 5.22 0.81 0.27 0.77 29.67 10.86 14.09 5.76 0.46 1.19 0.15 2.38 0.50 3.49
Rate
CR = crude rate; ASWR = standardised rates for the world population. All rates referred to 100,000 inhabitans.
337
140–199
All sites
0.08 0.03 0.02 0.06 0.09 0.00 0.11 0.00 0.08 0.00 0.16 1.70 0.17 0.22 0.02 0.05 0.05 0.00 0.03 0.03 0.25 0.08 0.87 0.00 0.49
140–145 Mouth 5 146–149 Pharynx 2 150 Esophagus 1 151 Stomach 4 153 Colon 6 154 Rectum 0 155 Liver 7 156 Gall bladder 0 157 Pancreas 5 161 Larinx 0 162 Lung 10 169 Hematopoyetic 108 170 Bones 11 171 Soft tissues 14 173 Skin 1 174 Female breast 3 179–181–182 Uterus NOS, etc. 3 180 Cervix uteri 0 183 Ovary 2 188 Bladder 2 189 Kidney 16 190 Eye 5 191–192 Brain/CNS 55 193 Thyroids 0 196 Lymphatic nodes 31
2 2 0 6 3 2 3 0 3 0 9 104 32 11 5 4 0 15 16 0 7 2 41 0 59
No.
Rate
No.
Age group (years) 15–24
Site
0–14
ICD-O
Table 4. Cancer mortality, Cuba 1986–1990. Frequencies and rates by age-group for females
5053
67 35 64 163 453 92 164 121 177 66 768 265 35 11 36 883 397 342 211 42 42 6 80 24 137
No.
55–64
276.69
3.67 1.92 3.50 8.93 24.80 5.04 8.98 6.63 9.69 3.61 42.05 14.51 1.92 0.60 1.97 48.35 21.74 18.73 11.55 2.30 2.30 0.33 4.38 1.31 7.50
Rate
15128
248 92 289 733 1832 432 715 448 718 196 2650 701 108 50 196 1894 1091 573 348 295 148 18 92 66 342
No.
934.53
15.32 5.68 17.85 45.28 113.17 26.69 44.23 27.67 44.34 12.11 163.70 43.30 6.67 3.09 12.11 117.00 67.40 35.40 21.50 18.22 9.14 1.11 5.68 4.08 21.13
Rate
65 and more
26430
376 169 400 1101 2588 613 995 636 1032 296 4048 1455 240 108 276 4034 1951 1655 832 360 261 37 399 110 761
No.
All ages
102.98
1.47 0.66 1.56 4.29 10.08 2.39 3.88 2.48 4.02 1.15 15.77 5.67 0.94 0.42 1.08 15.72 7.60 6.45 3.24 1.40 1.02 0.14 1.55 0.43 2.97
CR
95.05
1.55 0.62 1.43 3.94 11.33 2.39 3.31 1.92 3.69 1.06 14.47 5.32 0.8 0.98 0.98 14.58 7.01 5.99 2.99 1.28 0.96 0.14 1.47 0.39 2.74
ASWR
291
Mouth 1 Pharynx 4 Esophagus 0 Stomach 0 Colon 6 Rectum 1 Liver 6 Gall bladder 1 Pancreas 5 Larinx 2 Lung 16 Haematopoyetic 142 Bones 15 Soft tissues 6 Skin 3 Male breast 0 Prostte 11 Bladder 5 Kidney 10 Eye 5 Brain/CNS 46 Thyroids 0 Lymphatic nodes 79
All sites
140–145 146–149 150 151 153 4 155 156 157 161 162 169 170 171 173 175 185 188 189 190 191–192 193 196
140–199
6.55
459
1 2 0 3 15 2 8 0 1 1 15 149 50 21 3 0 0 1 2 1 30 1 92 8.24
0.02 0.04 0.00 0.05 0.27 0.04 0.14 0.00 0.02 0.02 0.27 2.67 0.90 0.38 0.05 0.00 0.00 0.02 0.04 0.02 0.54 0.02 1.65
Rate
429
8 5 1 25 21 10 15 2 7 1 49 72 14 6 5 1 2 5 8 1 36 2 81
No.
25–34
1080
0.20 0.13 0.03 0.63 0.53 0.25 0.38 0.05 0.18 0.03 1.23 1.81 0.35 0.15 0.13 0.03 0.05 0.13 0.20 0.03 0.91 0.05 2.04
Rate
1162
24 31 19 76 65 22 25 12 33 21 332 118 10 15 12 1 15 9 13 2 60 2 127
No.
35–44
36.19
0.75 0.97 0.59 2.37 2.02 0.69 0.78 0.37 1.03 0.65 10.34 3.68 0.31 0.47 0.37 0.03 0.47 0.28 0.40 0.0 1.87 0.06 3.96
Rate
2975
97 72 113 199 179 52 87 28 85 109 981 165 28 19 34 3 84 55 43 1 114 8 179
No.
45–54
118.19
3.85 2.86 4.49 7.91 7.11 2.07 3.46 1.11 3.38 4.33 38.97 6.55 1.11 0.75 1.35 0.12 3.34 2.18 1.71 0.04 4.53 0.32 7.11
Rate
CR = crude rate; ASWR = standarised rates for the world population. All rates referred to 100,000 inhabitants.
420
0.02 0.06 0.00 0.00 0.09 0.02 0.09 0.02 0.08 0.03 0.25 2.21 0.23 0.09 0.05 0.00 0.17 0.08 016 0.08 0.72 0.00 1.23
No.
No.
Rate
15–24
0–14
Age group (years)
Site
CIE-O
Table 5. Cancer mortality, Cuba 1986–1990. Frequencies and rates by age-group for males
6165
206 156 252 357 342 101 167 60 259 276 2132 274 34 20 64 4 405 163 83 6 121 12 251
No.
55–64
337.56
11.28 8.54 13.80 19.55 18.73 5.53 9.14 3.29 14.18 15.11 116.74 15.00 1.86 1.10 3.50 0.22 22.18 8.92 4.54 0.33 6.63 0.66 13.74
Rate
25950
610 377 838 1473 1591 495 773 259 886 1072 7710 957 147 56 345 22 5507 1040 259 26 182 35 506
No.
947 650 1223 2133 2219 683 1081 362 1276 1482 11235 1877 298 143 466 31 6024 1278 418 42 579 60 1315
No.
All ages
1,610.32 37560
37.85 23.39 52.00 91.41 98.73 30.72 47.97 16.07 54.98 66.52 478.44 59.39 9.12 3.48 21.41 1.37 341.73 64.54 16.07 1.61 11.29 2.17 31.40
Rate
65 and more
149.51
3.77 2.59 4.87 8.49 8.83 2.72 4.30 1.44 5.08 5.90 44.7 7.47 1.19 0.57 1.85 0.12 23.98 5.09 1.66 0.17 2.30 024 5.23
CR
138.39
3.49 2.41 4.51 7.85 8.02 2.35 4.06 1.26 4.7 5.46 41.41 6.99 1.08 0.53 1.71 0.08 22.42 4.69 1.55 0.16 2.18 0.22 4.89
ASWR
292
293 Table 6. Standardised rates and incidence risks (IR) by province for the major sites in Cuba Province
Pinar del Río Havana Havana City Matanzas Villa Clara Cienfuegos Sancti Spiritus Ciego de Avila Camaguey Las Tunas Holguín Granma Santiago de Cuba Guantánamo Cuba
Lung
Female breast
Prostate
Female
Male
Rate IR
Rate IR
Rate IR
Rate IR
19.60 21.23 26.46 17.69 23.72 23.49 20.93 20.78 18.26 12.87 9.49 10.73 13.30 10.72 18.16
34.24 56.33 70.91 55.49 52.59 62.76 52.95 57.83 48.48 3854 30.40 26.82 37.25 33.15 48.07
23.38 33.47 57.71 38.07 31.81 41.29 27.88 30.00 35.23 22.16 26.20 20.01 26.56 17.28 33.51
27.38 34.81 45.55 30.08 32.7 45.14 34.25 38.85 43.70 23.17 20.45 23.49 28.39 25.99 33.06
1.08 1.17 1.46 0.97 1.31 1.29 1.15 1.14 1.01 0.71 0.52 0.59 0.73 0.59
0.71 1.17 1.48 1.15 1.09 1.31 1.10 1.20 1.01 0.80 0.63 0.56 0.77 0.69
0.70 0.99 1.72 1.14 0.95 1.23 0.83 0.89 1.05 0.66 0.78 0.59 0.79 0.52
0.83 1.05 1.38 0.91 0.99 1.36 1.04 1.17 1.32 0.70 0.62 0.71 0.86 0.79
Cervix uteri
Colon Females
Males
Rate IR
Rate IR
Rate IR
14.77 15.48 25.59 15.70 15.32 18.87 14.18 16.23 16.70 19.36 16.34 17.02 26.31 27.75 19.40
7.79 14.69 25.68 13.42 14.30 17.56 13.50 13.19 11.31 4.38 5.78 5.87 7.54 4.90 12.64
7.5 15.26 19.06 10.97 10.61 14.78 12.0 10.55 8.10 6.33 5.47 4.46 6.63 3.58 10.34
0.76 0.79 1.32 0.81 0.79 0.97 0.73 0.84 0.86 0.99 0.84 0.85 1.36 1.43
0.62 1.16 2.03 1.06 1.13 1.39 1.07 1.04 0.89 0.35 0.46 0.46 0.60 0.39
0.73 1.48 1.84 1.06 1.03 1.43 1.16 1.02 0.78 0.61 0.53 0.43 0.64 0.35
were calculated using the Cuban population (according to the census of 1981) in the major cancer sites by provinces. Additionally, an incidence risk was calculated dividing the local standard rate by the national one [22]. Percentages of cases histologically verified (HV), reported by death certificate only (DCO) and with unknown age were used as information quality indexes. Also the incidence/mortality ratio was included. All these measures were calculated according to the international standard definitions currently in use [29, 32, 40].
cer primary sites in Cuba by province of residence. Higher incidence risks for lung and colon (both sexes), female breast and prostate are reported by the western provinces, while cervix cancer risk is very high in the two most eastern provinces and in the capital of the country. In Table 7 the main quality indexes of the registry information are represented. Although the percentage of cases without known age is very low, both DCO and non-HV cases are very high. The ratio mortality/ incidence varies very much (from 0.04 in skin to 1.27 in unknown sites) according to the primary site.
Results
Discussion
Cancer is the main cause of death between 1–64-years old. From 65-years old on, it is the second cause, the first place in this group of age corresponds to heart diseases. In Cuba, one out of five deaths occurs due to cancer. It is important to point out that cancer mortality has an annual increase of 2 and 2.5% while heart diseases do it at 0.5% [30]. Tables 2–5 show the major sites in incidence and mortality by age groups. The major cancer primary sites in incidence are: lung, skin and colon in both sexes; prostate and larynx in males and breast and cervix in females. According to mortality, lung and colon rank first in both sexes; prostate, stomach and haematopoyetic for males; breast, cervix and uterus for females. Table 6 shows the rates and risks of the major can-
Cancer incidence and mortality in Cuba are, obviously, related to the mode and lifestyle in the Cuban population (Table 8). The incidence of lung cancer has been associated to the tobacco consumption [9, 38, 39]. Cuba, which is one of the major consumer per capita of cigarettes all over the world [16], shows high rates of incidence in males and females, ranking second among the Latin American registries [34] (Porto Alegre, Brazil was the first). In Cuba, each year about 3500 new cases are diagnosed. Lung is the main cause of cancer incidence in males and the second in females but the frequency in males almost tripled that of the women. The highest rates, both incidence and mortality, are notified in western and central provinces of the country, mainly in persons from 55-years-old in both sexes. Lung can-
294 Table 7. Quality indexes for incidence data for both sexes ICD-O
140–145 146–49 150 151 153 154 155 157 161 162 169 170 171 173 17 175 179 180 182 183 185 188 189 190 191 192 193 196 199
Site
Mouth Pharinx Esophagus Stomach Colon Rectum Liver Pancreas Larinx Lung Haematopoyetic system Bones Soft tissues Skin Female breast Male breast Non specified uteri Cervix uter Corpus uteri Ovary Prostate Bladder Kidney Eye Bin Others SNC Tiroids Lymphatic nodes Unknown site
140–199 All sites
Histologic verification
Death certificates
Unknown age
No.
%
No.
%
No.
%
2686 1016 601 1511 2473 1767 570 629 2202 5245 1949 422 529 15788 6289 36 453 4396 1226 975 3893 2383 615 221 729 100 1021 2256 307
79.8 86.0 32.9 38.6 41.7 68.5 23.0 25.3 69.0 30.6 46.2 52.3 69.4 95.4 73.2 63.2 30.9 88.5 87.0 67.6 45.2 68.6 58.1 80.1 41.7 52.4 87.9 67.6 28.0
630 340 1141 2179 3174 728 1777 1665 910 10307 2270 333 221 464 1958 19 951 513 160 424 4532 975 401 40 936 86 119 1081 739
18.7 28.8 62.4 55.5 53.4 28.1 71.6 66.8 28.1 60.0 53.8 41.2 28.8 2.80 22.4 32.8 63.3 5.80 11.1 29.3 51.8 27.8 37.7 13.8 53.4 44.8 10.2 32.4 67.4
26 10 9 14 15 17 3 0 17 20 16 1 9 264 23 1 3 6 5 3 62 30 3 8 3 0 4 15 8
0.77 0.84 049 0.36 0.25 0.66 0.12 0.00 0.53 0.12 0.38 0.12 1.18 1.59 0.27 1.75 0.20 0.12 0.35 0.21 0.72 0.86 0.28 2.90 0.17 0.00 0.34 0.45 0.73
0.39 0.69 0.88 0.83 0.81 0.50 0.83 0.93 0.56 0.89 0.79 1.00 0.33 0.04 0.47 0.60 0.93 0.33 0.40 0.59 0.70 0.48 0.64 0.32 0.52 0.33 0.14 0.62 1.27
64259
58.6
41068
35.8
616
0.56
0.58
cer is also the first cause of death of cancer in both sexes, in females the mortality rate is similar to the breast cancer. About 3000 deaths caused by lung cancer are reported per year in Cuba. The mortality rate is also about three times greater in males. In comparison with other countries, Cuba reports high lung canTable 8. Major cancer risk factors in the Cuban population • • • • • •
Tobacco adiction Sunlight exposition Alcohol consumption Age starting sexual intercourse Number of sexual partners Animal fat intake
From: Lorenzo-Luaces P, Galán Y, Abascal ME. Técnicas multivariadas en la investigación epidemiológica. Ejemplo en la prevalencia de factores de riesgo de ca´ncer en Cuba. Rev Cubana Oncol 1995; 11(1): 55–60.
M/I
cer mortality rates, similar to those of the developed countries, resulting in one of the highest all over the world in females [1]. Skin cancer has been associated to the sunlight over-exposure [38]. In Cuba, it ranks second in incidence for both sexes, showing high rates in all age groups. However, skin cancer mortality is very low. Each year about 3000 new case are reported to the NCR although a very large under-registration is suspected. Most cases are basal carcinomas (74%), follow by the epidermoid carcinomas (16%). Melanomas represent only 3% of the total cancer skin incidence. Breast cancer shows the highest rates in developed countries [19, 21]. In Cuba, it is also the main cause of cancer incidence in females. In all provinces breast cancer ranks first in incidence, except in Guantanamo where cervix is placed before. About 1750 new cases average are notified per year. Cuba has one of the lowest mortality rates among the analysed countries.
295 About 800 women die each year due to this cancer primary site. The highest risks, for both incidence and mortality, are observed from 65 years of age on, while the risk is almost null in young women before 35. Prostate cancer is the third cause of cancer incidence in males. Also in Cuba it is the most common neoplasm in males over 65 years of age and it is very rarely observed in younger persons [41]. Each year about 1800 new cases are diagnosed. Prostate cancer is the second cause of death of cancer in males in Cuba. Over 1200 deaths are reported each year. The highest risk to die is over 65 years of age; 90% of deaths occurs in this group of age. The higher rates, for both incidence and mortality, are found in the western part of the country, particularly in the capital. The incidence of colon cancer is higher in the western countries than in developing countries [33, 39]. In Cuba, this primary site ranks fifth in both sexes. Although incidence and mortality rates are about the same in males and females according to international reports [38], in Cuba higher rates are notified in fe-
Figure 1. Administrative division of Cuba.
males both in incidence and mortality in most age groups. Geographically, highest risks are found in western and central provinces. Two out of three of the cases are over 65 years and about 1700 new patients are reported per year. Colon cancer mortality rates show that, while in females the rates are very high, close to those of developed countries, the male rate is one of the lowest among the registries analysed. More than 1200 persons die of colon cance in Cuba per year. It is the third cause of death in both sexes. Only in individuals before 30 years of age, male rates are higher than female. More than 70% of the deaths are reported from 65 years of age on. Cervix is the most common cancer primary site in developing countries [2, 8, 36]. Most of the Latin American registries reported higher rates than Cuba in this period, Puerto Rico was the only exception [34]. In Cuba, cervix cancer is the third cause of incidence in females, reporting 1000 new cases average per year. Cervix cancer is also the fifth cause of death of cancer in Cuban females, being one of the countries
296 with the highest rates of mortality among the analysed countries. More than 300 dead patients are reported each year in Cuba. Most of the cases and deaths are notified from 35 to 54 years of age and by the eastern provinces. Total incidence cancer age-standardised rates were 218.2 per 100,000 inhabitants for males and 183.7 for females in the period 1986–1990. Cuban figures are among the highest reported by Latin American registries but lower than the developed countries [26]. In relation to the global standardised mortality rates, Cuba is one of the countries among the analysed ones [2], having the lowest rates (138.4 per 100,000 in males and 95.1 in females). Childhood cancer in Cuba is concentrated mainly in three major types: leukaemias (31%), lymphomas (18%) and brain and CNS tumours (1%) as has been reported elsewhere [26, 28]. Mortality shows a similar distribution [27]. These features are quite similar to those repoted by the rest of the Latin American countries [4, 34]. A light preference of male morbimortality until 25 years of age is noted. However, female rates are higher between 25 and 45. From this age on, the incidence and mortality return to be higher in man. It is due to female genital cancers being more frequent in reproductive ages, while in men most of the cases correspond to lung and prostate cancers which are more frequently observed from the fifties on. According to the cancer incidence distribution by province, the country can be divided into two major regions: (1) western and central provinces where higher risks of lung, breast, prostate and colon cancers are found, and (2) eastern provinces where low risks of above mentioned cancers appear while a very high risk of cervix cancer is observed (Figure 1). Previous papers have reported this division according to the cancer incidence and mortality, associating it to the socio-economic standard [22] and to the interrelation among the different risk factors observed in the Cuban population [23]. Although an improvement of the information quality indexes has been reported by the NCR in the studied time period (HV: 57.2 in 1985 and 58.6 in 1986– 1990; DCO: 48.6 in 1985 and 35.8 in 1986–1990) [Gago M (1991). Indicadores de Calidad del Registro Nacionl de Cáncer: 1982–1987. Thesis of Master in Public Health. Instituto Superior de Ciencias Me´dicas, Havana], quality of data remained very poor according to the international standards [15, 29, 32, 40]. NCR authorities are convinced that the coverage of registration and accuracy of information are highly necessary to guarantee the confidence in the registry outputs. In this sense, new procedures in order to trace back DCO cases into the original information sources (mainly
hospitals) have been implemented after the period of time analized in this work. The NCR, in spit of the mentioned difficulties with the information quality, has been a valuable tool to evaluate the cancer burden in Cuba and therefore it was useful to plan the first activities of National Cancer Control Program [3] commenced in 1989: Breast and Oral Cancer massive screening were started for the first time and the Cervix cancer screening was redefined. It is also expected that the NCR outputs contribute to control the future development of these tasks.
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Address for correspondence: Antonio A. Martín, National Cancer Registry, National Institute of Oncology, 29 and F, Vdado, 10400, Havana, Cuba Phone/Fax: (537) 32 8480; Additional Telefax: (537) 33 3837 E-mail: inor6infomed.sld.cu
