Elsevier

European Journal of Cancer

Volume 83, September 2017, Pages 43-55
European Journal of Cancer

Original Research
Breast cancer in South-Eastern European countries since 2000: Rising incidence and decreasing mortality at young and middle ages

https://doi.org/10.1016/j.ejca.2017.06.011Get rights and content

Highlights

  • Breast cancer incidence and mortality trends in South-Eastern Europe have been detailed by age.

  • The breast cancer data quality was evaluated by internationally agreed indicators.

  • Annual incidence rates increased significantly in countries and age groups.

  • Mortality rates decreased in most countries, but increased above age 55 in some of them.

  • Cancer registries in the region have a potential to expand their role in breast cancer control.

Abstract

Background

Marked variations exist in the incidence and mortality trends of major cancers in South-Eastern European (SEE) countries which have now been detailed by age for breast cancer (BC) to seek clues for improvement.

Methods

We brought together and analysed data from 14 cancer registries (CRs), situated in SEE countries or directly adjacent. Age-standardised rate at world standard (ASRw) and truncated incidence and mortality rates during 2000–2010 by year, and for four age groups, were calculated. Average annual percentage change of rates was estimated using Joinpoint regression.

Results

Annual incidence rates increased significantly in countries and age groups, by 2–4% (15–39 years), 2–5% (40–49), 1–4% (50–69) and 1–6% (at 70+). Mortality rates decreased significantly in all age-groups in most countries, but increased up to 5% annually above age 55 in Ukraine, Serbia, Moldova and Cyprus. The BC data quality was evaluated by internationally agreed indicators which appeared suboptimal for Moldova, Bosnia and Herzegovina and Romania.

Conclusion

The observed variations of incidence trends reflect the influence of risk factors, as well as levels of early detection activities (screening). While mortality rates were mostly decreasing, probably due to improved cancer care and introduction of more effective systemic treatment regimens, the worrying increasing mortality trends in the 55-plus age groups in some countries have to be addressed by health professionals and policymakers. In order to assess and monitor the effects of cancer control activities in the region, the CRs need substantial investments.

Introduction

Breast cancer (BC) is the most common cancer in women worldwide, and its characteristics, distribution and risk factors have been extensively documented.

According to GLOBOCAN 2012 estimates (GLOBOCAN project being the comprehensive cancer surveillance database managed by the International Agency for Research on Cancer (IARC)), BC age-standardised incidence (71 per 100,000 women) and mortality (16 per 100,000 women) rates in Europe are among the highest in the world [1]. About 45,000 new female BC cases and 18,000 deaths annually occur in South-Eastern European (SEE) countries (approximately 14% and 20% of European total, respectively) [2]. Most of these countries share common patterns of socio-economic and demographic changes, such as increased longevity, low but rising age at childbirth, decreased fertility rates, and adoption of ‘western’ lifestyle patterns – increasing alcohol and tobacco use among younger women, as well as an increasing prevalence of obesity as a consequence of changes in diet and physical activity. Furthermore, there has been a rapid diffusion of use of mammography in the context of screening: organised in Czech Republic, Croatia, Cyprus, Malta and Slovenia or opportunistic in the rest of the region [3], [4], [5]. Previous studies of cancer incidence and mortality in SEE countries showed unfavourable trends in comparison with other European regions [2], [6].

Studies of trends in BC incidence and mortality are essential for evaluation of primary prevention policies and for planning and monitoring of organised screening programmes [7]. Therefore, in 2011, an informal cancer registry working group from SEE was established to promote the use of cancer registry data for cancer control in the region and to address the challenges ahead [8]. Adjacent CRs from countries outside European Union (EU) also joined the activities, both from the Balkans (Bosnia and Herzegovina, and Serbia) and nearby (Moldova, Ukraine and west-Turkey). Incidence and mortality trends of BC exhibited a marked variation during 1999–2008: a general increase in incidence and a steady fall in mortality, but less pronounced in Serbia and Bulgaria [2]. Given the impact of early detection (screening) and the potential effect of systemic treatment, analysis of the recent age-specific trends might provide more detailed and targeted information.

The aim of this study is two-fold: (1) to describe recent trends by age groups for BC incidence and mortality since 2000 and interpret them in the context of important determinants and (2) to address challenges for the CRs in SEE with respect to their role in cancer control.

Section snippets

Materials and methods

We analysed data on BC (C50, International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10)) from 14 Cancer Registries, situated in 13, mostly South-Eastern European countries, but also in neighbouring west-Turkey, Cyprus, Malta and Ukraine. Nine were national (Bulgaria, Croatia, Cyprus, Czech Republic, Malta, Moldova, Slovakia, Slovenia and Ukraine), whereas five were regional registries – Bosnia and Herzegovina (Republic of Srpska), Romania (Cluj

Results

In the All age group, incidence rates varied widely from 30 (Romania-NER) to 85 (Malta) per 100,000 – Table 2 and Supplementary Fig. 1. Incidence rates were generally increasing with significant AAPC from 1 to 3% – Table 2 and Fig. 1. Mortality rates varied less – from 11 (BHRS) to 20 (Serbia) per 100,000 – Table 3 and Supplementary Fig. 2. Annual mortality rates decreased by −2 to −4% particularly and significantly for Czech Republic, Slovakia and Slovenia – Table 3 and Fig. 1.

Incidence rates

Discussion

The population-based data from CRs in SEE and neighbouring countries exhibited marked age-specific variations in BC incidence and mortality patterns both in time and space, especially at middle and old ages. We identified the areas with favourable and unfavourable trends, also considering differential quality of the submitted breast cancer data.

Across countries in the region, there were 3–5-fold variations in incidence rates and 2–7-fold variations in mortality rates by age groups. While there

Conclusions

Health professionals in the participating countries – often confronted with emigrating colleagues in most of the countries, face an uphill journey in their efforts to lower BC mortality and therefore need support from policy makers. Informing – especially younger – women about healthy lifestyles may indeed curb the rising BC incidence [48]. Following the recommendations from the EUROpe against Cancer, Optimisation of the Use of Registries for Scientific Excellence in research (EUROCOURSE)

Conflict of interest statement

None declared.

Acknowledgements

The study was done in the scope of the Work Package 8 (Dissemination and Training) of the EU funded EUROCOURSE (EUROpe against Cancer, Optimisation of the Use of Registries for Scientific Excellence in research) project (www.eurocourse.org).

The authors would like to thank Simeon Tonev for his assistance regarding statistical analysis of the data.

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    SEE+ Working group: Dominic Agius (Malta National Cancer Registry, Guardamangia, Malta); Daniela Coza (Cluj Regional Cancer Registry, Cluj-Napoca, Romania); Raluca Gheorghiu (North-East Cancer Registry, Regional Center of Public Health, Iasi, Romania); Chakameh Safaei Diba (Cancer Registry of Slovakia, Bratislava, Slovakia); Pavlos Pavlou (Cyprus Cancer Registry, Nicosia, Cyprus); Anna Demetriou (Cyprus Cancer Registry, Nicosia, Cyprus); Sultan Eser (Hacettepe University, Institute of Public Health, Ankara and Cancer Registry of Izmir, Izmir, Turkey); Živana Gavrić (Cancer Registry Republic of Srpska, Banja Luka, Republic of Srpska, Bosnia and Herzegovina); Maja Primic-Žakelj (Epidemiology and cancer registry, Ljubljana, Slovenia); Anton Ryzhov (National Cancer Registry of Ukraine, National Institute of Cancer, Kyiv, Ukraine); Mario Sekerija (Croatian Institute of Public Health, Croatian National Cancer Registry, Andrija Stampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia); Sofia Topala (Institut of Oncology, Chisinau, Moldova); Snezana Živković (Cancer Registry of Central Serbia, Belgrade, Serbia); Miroslav Zvolsky (Institute of Health Information and Statistics of the Czech Republic, Praha, Czech Republic), Nadya Dimitrova (Bulgarian National Cancer Registry, Sofia, Bulgaria).

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