Int. J. Cancer: 121, 462–465 (2007) ' 2007 Wiley-Liss, Inc.
SHORT REPORT Trends in lung cancer among young European women: The rising epidemic in France and Spain Fabio Levi1*, Cristina Bosetti2, Esteve Fernandez3,4, Catherine Hill5, Franca Lucchini1, Eva Negri2 and Carlo La Vecchia2,6 1 Unit e d’ epid emiologie du cancer et Registres vaudois et neuchaˆtelois des tumeurs, Institut de m edecine sociale et pr eventive (IUMSP), Universit e de Lausanne, Bugnon 17, Lausanne, Switzerland 2 Istituto di Ricerche Farmacologiche «Mario Negri», Via Eritrea 62, Milan, Italy 3 Cancer Prevention and Control Unit, Institut d’Investigacio` Biom edica de Bellvitge (IDIBELL), Catalan Institute of Oncology, L’Hospitalet de Llobregat, Spain 4 Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Dr. Aiguader 80, Barcelona, Spain 5 Service d’Epid emiologie et de Biostatistique, Institut Gustave-Roussy, Villejuif, France 6 Istituto di Biometria e Statistica Medica, Universita` degli Studi di Milano, Via Venezian 1, Milan, Italy
Lung cancer mortality in young women in the European Union (EU) has steadily increased until the mid 1990s and has levelled off thereafter, but trends have been heterogeneous in various countries. We analyzed therefore age-standardized trends in lung cancer mortality in young women (20–44) for the 6 major European countries, using joinpoint regression. In the early 1970s the highest lung cancer mortality in young women was in the UK (2.1/ 100,000). UK rates, however, steadily declined and in 2000–2004 they were the lowest of all 6 major EU countries (1.2/100,000). The second lowest rate in 2000–2002 was in Italy, whose rates remained around 1.1/100,000 between 1970 and 1994, and increased to 1.4 thereafter. In Germany and Poland, lung cancer rates in young women rose from 0.8–1.0/100,000 in the early 1970s to 1.7–1.9 in the mid 1990s and levelled off during the last decade. Major rises over recent years were observed in France (from 0.8/ 100,000 in 1985–1989 to 2.2 in 2000–2003) and in Spain (from 0.8 in the 1985–1989 to 1.7 in 2000–2004). Thus, France showed both the highest rate observed over the last 3 decades and the largest rise over the last 2 decades. Since recent trends in the young give relevant information to the likely future trends in middle age, the female lung cancer epidemic is likely to expand in southern Europe from the current rates of 5.0/100,000 in Spain and 7.7 in France to approach 20/100,000 within the next 2–3 decades. Urgent interventions for smoking cessation in women are therefore required. ' 2007 Wiley-Liss, Inc. Key words: lung cancer; mortality; time trends; young women; Europe
Female lung cancer mortality is still rising in most European countries, but trends have been more favourable over recent calendar years in several countries, particularly in the young.1,2 Thus, in the 25 countries of the European Union (EU) as a whole, lung cancer mortality in women aged 20–44 increased by 2.8% per year between 1970 and 1991, but declined thereafter by 3.6% per year.3 This led to the suggestion that, if effective interventions to control tobacco smoking in women were implemented, lung cancer epidemic in EU women could be controlled, and will not reach the levels observed in North America.3 However, a few countries, including Spain and France showed unfavourable trends in lung cancer mortality, mainly among young and middle age women.1,3,4 To analyze and interpret the diverging trends in lung cancer mortality in young women, we updated trends to 2004 for the 6 major EU countries. Material and methods Official death certification numbers for female lung cancer for France, Germany, Italy, Poland, Spain and UK for the period 1970–2004 were derived from the World Health Organization Publication of the International Union Against Cancer
(WHO) database as available on electronic support.5 For Italy data were available only up to 2002, for France up to 2003. During the calendar period considered, 3 different revisions of the International Classification of Diseases (ICD) were used.6–8 Classification of lung cancer deaths was recoded, for all calendar periods and countries, according to the Ninth Revision of ICD.7 Estimates of the resident population in the 6 countries considered, based on official censuses, were obtained from the same WHO database.5 From the matrices of certified deaths and resident populations, age-specific rates for 5 age groups between age 20 and 44, and calendar year were computed. Age-standardized rates per 100,000 women at ages 20–44 were computed using the direct method, and based on the world standard population.9 In France, the definition of age in national mortality statistics has changed between 1997 and 1998, from age in a completed year to the age reached during the year.10 Before 1998, age was computed by subtracting the year of birth from the current year; from 1998 onwards, age is the integer part of the exact age. This modification has introduced a discontinuity in the data for France, which, however, had a limited impact in mortality trends. Joinpoint regression analysis was used to identify years where a significant change in the linear slope (on a log scale) of the temporal trend occurred.11 The best fitting points (the ‘‘joinpoints’’) are chosen where the rate significantly changes. The analysis starts with the minimum number of joinpoints (e.g., 0 joinpoints, which is a straight line, on a log scale), and tests whether one or more joinpoints (up to 3) are significant and must be added to the model. In the final model each joinpoint (if any) informs of a significant change in the slope. The estimated annual percent change (APC) and the corresponding 95% confidence interval y is then computed for each of those trends by fitting a regression line to the natural logarithm of the rates, using calendar year as a regressor variable [i.e., given y 5 a 1 bx, where y 5 ln(rate) and x 5 calendar year, the APC is estimated as 100 (eb 2 1)]. The joinpoint regression models were performed using the ‘‘Joinpoint’’ software from the Surveillance, Epidemiology, and End Results (SEER) Program of the US National Cancer Institute.12
Grant sponsor: Italian and Swiss Leagues Against Cancer; Grant number: OCS-01-467-02-2004; Grant sponsor: Italian Association for Cancer Research; Grant sponsor: Spanish Ministry of Health; Grant number: RD06/0020/0089. *Correspondence to: Unite d’epidemiologie du cancer, Institut de medecine sociale et preventive (IUMSP), Universite de Lausanne, Bugnon 17, CH 1011 Lausanne, Switzerland. Fax: 4121-3230303. E-mail:
[email protected] Received 6 December 2006; Accepted after revision 12 February 2007 DOI 10.1002/ijc.22694 Published online 20 March 2007 in Wiley InterScience (www.interscience. wiley.com).
LUNG CANCER IN FRENCH AND SPANISH WOMEN
463
FIGURE 1 – Joinpoint analysis for lung cancer mortality in women aged 20–44 from 6 major European countries, 1980–2004 (except France 2003 and Italy 2002).
464 21.6 (24.2, 1.1)
APC, annual percent of change; CI, confidence interval. Data for the years 2000–2003.–2Data for the years 2000–2002.
Results
1
24.3 (28.8, 0.4) 4.8 (3.9, 5.7) 1995–2004 1984–2004
1998–2004 1.9 (21.8, 5.8) 2.4 (1.1, 3.6) France Germany Italy Poland Spain UK
0.6 0.8 1.1 1.0 1.0 2.1
2.2 1.6 1.42 1.6 1.7 1.2
1970–1983 1970–1981 1970–2002 1970–1995 1970–1984 1970–2004
20.4 (22.7, 7.2) 1.3 (20.9, 3.5) 0.8 (0.5, 1.2) 3.2 (2.5, 4.0) 23.2 (25.4, 20.9) 21.7 (21.9, 21.4)
8.6 (7.2, 10.0) 9.2 (0.3, 1.9)
Estimates of the smoking prevalence in women aged 20–24 years in the 6 major EU countries were derived from Forey, 2002.13
1983–1998 1981–1986
1998–2003 1986–1998
FIGURE 2 – Smoking prevalence in women aged 20–24 years in the six EU countries in 1981–1985 and 1991–1995.13 [Color figure can be viewed in the online issue, which is available at www.interscience. wiley.com.]
1
Trend 4
APC (95% CI) Years APC (95% CI)
Trend 3
Years 1970–1974
2000–2004
Years
APC (95% CI)
Years
APC (95% CI)
Joinpoint analysis Trend 2 Trend 1 Age-standardized mortality rates/100,000
TABLE I – AGE-STANDARDIZED (WORLD POPULATION) LUNG CANCER MORTALITY RATES PER 100,000 WOMEN AGED 20–44 YEARS FROM SELECTED EUROPEAN COUNTRIES AND JOINPOINT REGRESSION ANALYSIS, 1970–2004
LEVI ET AL.
Figure 1 gives the trends in lung cancer mortality among women aged 20–44 in the 6 major EU countries (i.e., France, Germany, Italy, Poland, Spain, and UK) between 1970 and 2004. In the early 1970s the highest lung cancer mortality in young women was in the UK (2.1/100,000). UK rates, however, steadily declined and in 2000–2004 they were the lowest of all 6 countries considered (1.2/ 100,000). The second lowest rate in 2000–2002 was in Italy, whose rates remained constant around 1.1/100,000 between 1970 and 1994, and increased to 1.4 thereafter. In Germany and Poland, lung cancer rates in young women rose from 0.8–1.0/100,000 in the early 1970s to 1.7–1.9 in the late 1990s and levelled off over more recent years (1.6 in the early 2000s).1 Major rises over recent years were observed in France (from 0.8/100,000 in 1985–1989 to 2.2 in 2000–2003) and in Spain (from 0.8 in the 1985–1989 to 1.7 in 2000–2004). Thus, France showed both the highest rate observed over the last 3 decades in any of the 6 major EU countries and the largest rise over time in the last 2 decades. Table I gives the results of joinpoint regression analysis of mortality from lung cancer in young women from the 6 major EU countries. Mortality rates were moderately upwards in Italy (APC 5 10.8), and decreasing (APC 5 21.7%) in the UK throughout the period considered. Steady upward trends were observed in France between 1983 and 1998 (18.6%), in Germany between 1981 and 1986 (19.2%) and in Poland between 1970 and 1995 (13.2%). Rates, however, tended to level off after 1995 in Poland (24.3%), and after 1998 in Germany (21.6%). Rates were still rising in Spain (14.8% between 1984 and 2004) and France (11.9% between 1998 and 2003) over the last calendar years. Figure 2 gives an estimate of smoking prevalence in women aged 20–24 years in the 6 EU countries in 1981–1985 and 1991– 1995. In the last decade, the highest and rising prevalence in young women—approaching 50%—were reported in France and Spain, while reported smoking prevalence tended to decline in other major European countries. Discussion Lung cancer rates are low in the young, but their trends are important, particularly since they give information on the likely future trends in middle and elderly age, in the absence of smoking cessation.14–16 The present analysis of lung cancer mortality trends in young women in the 6 largest EU countries showed
LUNG CANCER IN FRENCH AND SPANISH WOMEN
broadly diverging patterns. Thus, the lung cancer epidemic in young women has been earlier and larger in the UK, but it has been declining in the last 3 decades. In Germany and Poland, the peak rates were reached in the mid 1990s, and rates have been leveling off or declining over the last decade. In contrast, in southern European countries major rises are still evident, particularly in Spain and France, where smoking initiation was rare in females until the 1960s, but rose substantially thereafter to converge with that of males.13,17–22 France and Spain were the only major European countries showing rising prevalence of smoking in young women, approaching 50% in the early 1990s. These countries showed in most recent years the highest lung cancer rates in young women, and the largest rises. In Italy, smoking prevalence in women has increased to about 20–25% in the 1970s, and had levelled off thereafter,23 by accounting for the smaller rise in lung cancer rates.1–3
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In the UK, the peak lung cancer mortality rate in women at age 20–44 was 2.3/100,000 in 1965–1969, and the peak rate in women of all ages was 20.9/100,000 25 years later in 1990–1994. Likewise, if similar trends are observed, and in the absence of widespread smoking cessation in middle age women,24,25 the female lung cancer epidemic is likely to expand in Spain and France from the current rates of 5.0/100,000 in Spain and 7.7 in France to approach 20/100,000 within the next 2–3 decades.4,16,17 Urgent and effective interventions for smoking cessation in women are therefore required, particularly in those countries. These include a comprehensive smoking ban in public places in all European countries, which has been shown to contribute to a fall in smoking prevalence and consumption in Italy,23,26 systematic and steady rises in the price of cigarettes,27 but also specific measures for (young) women, since smoking cessation has been later and more difficult in women than in men.28
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