Cancer statistics in China, 2015中国癌症统计 - 图文

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CancerStatisticsinChina,2015

WanqingChen,PhD,MD1;RongshouZheng,MPH2;PeterD.Baade,PhD3;SiweiZhang,BMedSc4;HongmeiZeng,PhD,MD5;

FreddieBray,PhD6;AhmedinJemal,DVM,PhD7;XueQinYu,PhD,MPH8,9;JieHe,MD10Withincreasingincidenceandmortality,canceristheleadingcauseofdeathinChinaandisamajorpublichealthproblem.BecauseofChina’smassivepopulation(1.37billion),previousnationalincidenceandmortalityestimateshavebeenlimitedtosmallsamplesofthepopulationusingdatafromthe1990sorbasedonaspecificyear.Withhigh-qualitydatafromanadditionalnumberofpopulation-basedregistriesnowavailablethroughtheNationalCentralCancerRegistryofChina,theauthorsana-lyzeddatafrom72local,population-basedcancerregistries(2009-2011),representing6.5%ofthepopulation,toestimatethenumberofnewcasesandcancerdeathsfor2015.Datafrom22registrieswereusedfortrendanalyses(2000-2011).Theresultsindicatedthatanestimated4292,000newcancercasesand2814,000cancerdeathswouldoccurinChinain2015,withlungcancerbeingthemostcommonincidentcancerandtheleadingcauseofcancerdeath.Stomach,esophageal,andlivercancerswerealsocommonlydiagnosedandwereidentifiedasleadingcausesofcancerdeath.Residentsofruralareashadsignificantlyhigherage-standardized(Segipopulation)incidenceandmortalityratesforallcancerscombinedthanurbanresidents(213.6per100,000vs191.5per100,000forincidence;149.0per100,000vs109.5per100,000formortality,respectively).Forallcancerscombined,theincidencerateswerestableduring2000through2011formales(10.2%peryear;P5.1),whereastheyincreasedsignificantly(12.2%peryear;P<.05)amongfemales.Incontrast,themortalityratessince2006havedecreasedsignificantlyforbothmales(21.4%peryear;P<.05)andfemales(21.1%peryear;P<.05).Manyoftheestimatedcancercasesanddeathscanbepreventedthroughreducingtheprevalenceofriskfactors,whileincreasingtheeffectivenessofclinicalcaredelivery,particularlyforthoselivinginruralareasandindisadvantagedpopulations.CACancerJ

C2016AmericanCancerSociety.Clin2016;000:000–000.V

Keywords:cancer,China,healthdisparities,incidence,mortality,survival,trends

Introduction

CancerincidenceandmortalityhavebeenincreasinginChina,makingcancertheleadingcauseofdeathsince2010anda

majorpublichealthprobleminthecountry.1Muchoftherisingburdenisattributabletopopulationgrowthandageingandtosociodemographicchanges.Althoughpreviousestimatesofthenationalincidencerateshavebeenreported,theyeitherrepre-sentedasmallsampleoftheChinesepopulation(<2%)2orwerebasedondatafromaspeci?cyear.3,4Thishasabearingontheuncertaintyoftheestimatesandtheirdegreeofnationalrepresentativenessand,thus,wouldpotentiallylimittheevidenceavailabletodevelopappropriatepoliciesforeffectivecancercontrol.BecausethepreviousProgramofCancerPreventionandControlinChina(2004-2010)5wasreleasedmorethan10yearsago,amorecompletepictureofthenationalandregionalscaleandpro?leinChinawouldprovidegreaterclarityinprioritizinganddevelopingspeci?cpoliciesandprogramsacrossthespectrumofcancercontrolaimedatreducingtheburdenandsufferingfromthediseaseatthenationallevel.

Additionalsupportinginformationmaybefoundintheonlineversionofthisarticle.

1DeputyDirector,NationalOfficeforCancerPreventionandControl,NationalCancerCenter,Beijing,China;2AssociateResearcher,NationalOfficeforCancerPreventionandControl,NationalCancerCenter,Beijing,China;3SeniorResearchFellow,CancerCouncilQueensland,Brisbane,Queensland,Australia;4AssociateProfessor,NationalOfficeforCancerPreventionandControl,NationalCancerCenter,Beijing,China;5AssociateProfessor,NationalOfficeforCancerPreventionandControl,NationalCancerCenter,Beijing,China;6Head,SectionofCancerSurveillance,InternationalAgencyforResearchonCancer,Lyon,France;7VicePresident,SurveillanceandHealthServicesResearchProgram,AmericanCancerSociety,Atlanta,GA;8ResearchFellow,CancerCouncilNewSouthWales,Sydney,NewSouthWales,Australia;9AdjunctLecturer,SydneySchoolofPublicHealth,UniversityofSydney,Sydney,NewSouthWales,Australia;10Director,NationalCancerCenter,Beijing,China.Thelast2authorscontributedequallytothisarticle.

Correspondingauthor:JieHe,MD,Director,NationalCancerCenter,No.17Pan-jia-yuanSouthLane,ChaoyangDistrict,100021Beijing,China;hejie@cicams.ac.cnWethanktheBureauofDiseaseControl,NationalHealthandFamilyPlaningCommissionandCancerInstitute&Hospital,ChineseAcademyofMedicalSciencesfortheirsupporttothisstudy.Wewouldliketoexpressourgratitudetoallstaffofthecontributingcancerregistrieswhohavemadeagreatcontributiontothestudy,especiallyondatacollection,supplements,auditing,andcancerregistrationdatabasemanagement.

DISCLOSURES:ThisstudyissupportedbyaNationalProgramGranttotheCancerRegistryfromtheNationalHealthandFamilyPlanningCommissionofChinaandbyaProgramGrantinFundamentalResearchfromtheMinistryofScienceandTechnology(no.2014FY121100).Theauthorsreportnoconflictsofinterest.doi:10.3322/caac.21338.Availableonlineatcacancerjournal.com

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Thisstudyreportsthemostrecentcancerincidence,mortality,andsurvivalestimatesnationally;themostrecentincidenceandmortalitypatternsforseveralmajorcancersbygeographicareainChina;andtemporaltrendsforsomemajorcancersaswellastheimplicationsofthisinformationforcancercontrolinChina.

TABLE1.

ListofPopulation-BasedCancerRegistriesinChinaUsedforIncidence/MortalityEstimates,TemporalTrends,orSurvivalEstimates

REGISTRY

PROVINCE

REGISTRY

PROVINCE

BeijingHebei

DataSourcesandMethods

CancerRegistrationinChina

TheNationalCentralCancerRegistryofChina(NCCR),establishedin2002,isresponsibleforthecollection,evalua-tion,andpublicationofcancerdatainChina.Cancerdiagno-sesarereportedtolocalcancerregistriesfrommultiplesources,includinglocalhospitalsandcommunityhealthcen-tersaswellastheUrbanResidentBasicMedicalInsuranceprogramandtheNewRuralCooperativeMedicalScheme.Since2002,theimplementationofstandardregistrationprac-ticeshasseenamarkedimprovementinthequalityofcancerregistrationinChina.In2008,theNationalProgramofCancerRegistrieswaslaunchedbytheMinistryofHealthofChinathroughacentral?nancingmechanism.Sincethen,thenumberoflocalpopulation-basedregistriesinChinahasincreasedfrom54in2008(populationcoverageof110mil-lion)to308(populationcoverageof300million)in2014.3Notalloftheseregistriescurrentlyhavesuf?cientlyhighdataqualityforreportingpurposes.ThequalityofsubmitteddataforeachlocalregistrywascheckedandevaluatedbytheNCCRbasedontheGuidelinesforChineseCancerRegistra-tion6andInternationalAgencyforResearchonCancer/Inter-nationalAssociationofCancerRegistries(IARC/IACR)data-qualitycriteria.7Theassessmentsofqualitymeasuresinclude,butarenotlimitedto,theproportionofmorphologicveri?cation(MV%),thepercentageofcancercasesidenti?edwithdeathcerti?cationonly(DCO%),themortality(M)toincidence(I)ratio(M/I),thepercentageofuncerti?edcancer(UB%),andthepercentageofcancerwithunde?nedorunknownprimarysite(CPU%).Onlydatafromthoselocalregistriesthatconsistentlymetappropriatelevelsofqualitywereincludedintheseanalyses.Detailedqualitycategoriesoftheregistrydatacanbefoundinapreviouspublication(Table1).8Dataclassi?edascategoryAorBweredeemedacceptableforinclusioninthisstudy.Theproportionsofcancerregistriesthatsubmitteddatasetsandwereacceptedforinclusionvar-iedbyyearofsubmission,from69.2%(72of104registries)in2009,9to66.2%(145of219registries)in2010,4and75.6%(177of234registries)in2011.3Weincludeddatafromthe72cancerregistriesthatwereavailableforall3years.

ShanxiInnerMongoliaLiaoning

Beijing*,?,?QianxiShexianCixian*,?,?BaodingYangquanYangcheng*ChifengShenyangDalian?,?ZhuangheAn’shan?BenxiDandong

Donggang

DaoliDistrict,HarbinNangangDistrict,Harbin*,?ShangzhiShanghai*,?Jintan?SuzhouHaian

Qidong*,?,?HaimenLianyungangDonghaiGuanyun

HuaianDistrict,Huai’an?HuaiyinDistrict,Huai’anXuyiJinhuSheyangJianhu?Dafeng?Ganyu?,§Yangzhong?Taixing?

JilinZhejiang

AnhuiFujianJiangxiShandong

Heilongjiang

DehuiYanji

Hangzhou?Jiaxing*,?Jiashan*,?,?Haining*,?,?ShangyuXianjuFeixi

MaanshanTonglingChangle?,?Xiamen

ZhanggongDistrict,GanzhouLinqu?WenshangFeicheng?,?YanshiLinzhou?,?XipingWuhan?,?YunmengHengdongGuangzhou?Sihui?,?

Zhongshan*,?,?LiuzhouFusui

JiulongpoDistrict,ChongqingQingyangDistrict,ChengduZiliujingDistrict,ZigongYanting*Jingtai

LiangzhouDistrict,WuweiXiningXinyuan

HenanHubeiHunanGuangdongGuangxiChongqingSichuan

ShanghaiJiangsu

GansuQinghaiXinjiang

*TheseareregistriesfromwhichdatawereacceptedbytheInternationalAgencyforResearchonCancerforthemostrecentpublicationofCancerIncidenceinFiveContinents(2014).

?Thesedatawereusedfortemporaltrendsanalyses.?Thesedatawereusedforsurvivalanalyses.

§Allregistrydatawereusedtoestimateincidenceandmortalityin2015exceptdatafromGanyu.

CancerIncidenceData

ToestimatethenumbersofnewcancersinChinain2015,weusedthemostrecentdata(cancercasesregisteredduring2009-2011)from72localpopulation-basedcancerregistries

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(Table1),providingapopulationcoverageofabout85.5millionpeople,about6.5%ofthenationalpopulation.Amuchsmallernumberofregistries(n522)(Table1),whichprovidedapopulationcoverageof44.4million,haddataofsuf?cientqualityoverthe12-yearperiod(2000-2011)forinclusioninincidencetrendanalyses.Thelocationsofthese2setsofcancerregistriescanbefoundinFigure1.

Weincludedinvasivetumorsonlyinthisstudy,andmulti-pleprimarycancerswerede?nedusingtheinternationalrules

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FIGURE1.Mapsofthe2SetsofContributingCancerRegistriesandGeographicRegionsinChina.

Dotsindicatethelocationsofthecancerregistries.(A)Thisisamapfor22cancerregistries(datafrom2000to2011).(B)Thisisamapfor72cancerregis-tries(datafrom2009to2011).

formultipleprimarycancers.10IncidencedatawereextractedfromtheNCCRdatabase.AlthoughcancersiteinformationisavailablethroughcodesfromboththeInternationalClassi?-cationofDiseasesforOncology,3rdrevision(ICD-O-3),andtheInternationalClassi?cationofDiseases,10threvision(ICD-10),wehavereportedincidencedatausingtheICD-10

classi?cationforconsistency,withmortalitydatathatwereonlyavailableintheICD-10classi?cation.Thevariablesextractedweresex,age,dateofbirth,yearofdiagnosis,cancersite,morphology,residence(urbanandruralareas),andregion(NorthChina,Northeast,EastChina,CentralChina,SouthChina,Southwest,NorthwestChina).Forage-speci?c

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incidenceanalysis,5broadagegroupswereused(youngerthan30years,30-44years,45-59years,60-74years,and75yearsorolder).

CancerMortalityData

Mortalitydatacompiledby72localcancerregistrieswereusedtoestimatethenumbersofcancerdeathsinChinain2015.Toestimatetrendsinmortalitybecauseofcancerbetween2000and2011,mortalitydatawereobtainedfromthesame22localregistriesthatwereusedintheincidencetrendanalyses.Theseregistriescompiledataoncancerdeathsfromlocalhospitals,communityhealthcenters,vitalstatistics(includingdatafromthenationalDiseaseSurveillancePoints[DSP]system),andtheCivilAdministrationBureau.11TheDSPsystem,whichwasestablishedbytheMinistryofHealthintheearly1980s,routinelycollectsinformationondeathsbasedonthedeathcerti?cateprovidedbyhospitalsorobtainedfromthenextofkinbyahouseholdvisitifadeathcerti?catewasunavailable.11WhiletheDSPusesanationallyrepresentativesampleofsites,thesecoveronlyaverysmall(??1%)proportionofthepopulation.12,13CancerSurvival

Intheabsenceofprecisefollow-upinformationfromthe72cancerregistries,estimatesof5-yearrelativesurvivalinChinafor2015arepresentedinthisreportusingthecom-plementofthecancerM/Iratio(1-M/I)fromtheseregis-tries,amethodthathasbeenusedpreviously.14,15Wepresentthesesurvivalestimatesonlyforallcancerscom-bined,becausesurvivalfromcertaincancertypesmayhaveledtoanoverestimationorunderestimationusingthisproxymeasure.14WecalculatedtheM/Iratioforallcancerscombinedbyassumingthattheratiobetweenincidenceandmortalityhasnotchangedbetween2009to2011and2015,sowedividedtheage-standardizedmortalityrate(2009-2011)bytheage-standardizedincidencerate(2009-2011).

commoncancers,theseestimatednumbersofnewcasesandcancerdeathswerefurtherstrati?edbyurban/ruralregistriesandby7administrativeregionsthatcoverChina.Age-speci?cnumbersofnewcasesandcancerdeathsby5broadagegroups(youngerthan30years,30-44years,45-59years,60-74years,and75yearsorolder)arealsopresentedforallcancerscombinedandforthe6mostcommoncancersfor2015.

Temporaltrendsinincidenceandmortalityratesfrom2000to2011(22registries)wereexaminedby?ttingjoinpointmodels16,17tothelog-transformed,age-standardizedrates(per100,000population),standardizedaccordingtotheworldstandardpopulation.18Toreducethepossibilityofreportingspuriouschangesintrendsovertheperiod,allmodelswererestrictedtoamaximumof2joinpoints(3linesegments).Trendswereexpressedasanannualpercentagechange(APC),andtheZtestwasusedtoassesswhethertheAPCwasstatis-ticallydifferentfromzero.Indescribingtrends,theterms“increase”or“decrease”wereusedwhentheslope(APC)ofthetrendwasstatisticallysigni?cant(P<.05).Fornonstatisti-callysigni?canttrends,theterm“stable”wasused.Forallthoseanalyses,wepresenttheresultsforallcancerscombinedandforthe10mostcommoncancersstrati?edbysex.

Results

DataQuality

The3mainmeasures(MV%,DCO%,andM/Iratio)ofdataqualityforpopulation-basedcancerregistries,strati?edbycancertype,showthatoveralldataqualityisreasonablygoodforbothsetsofcancerregistries(Fig.2).Becausehalfofthe22cancerregistriesarecerti?edbytheIARC,theirdataqualitywasconsiderablyhigherthanwhenconsideringdatafromthecombined72cancerregistries,indicatedbyhigherMV%andlowerDCO%.Valuesofthesedata-qualitymeasuresplusUB%(thepercentageofuncerti?edcancer)andCPU%(thepercentageofcancerwithunde-?nedorunknownprimarysite)arepresentedSupportingTable1(seeonlinesupportinginformation).

PopulationData

Nationalpopulationdataby5-yearagegroupandsexwereobtainedfromstatisticsorpublicsecuritycensus(data.stats.gov.cn/;accessedApril20,2014).8Individualregistriespro-videdpopulationdataintherespectiveareastotheNCCR.ThesedataweresourcedfromlocalStatisticalorPublicSecurityBureausorfromcalculationsbasedoncensusdata.

ExpectedCancerIncidencein2015

Itispredictedthattherewillbeabout4292,000newlydiagnosedinvasivecancercasesin2015inChina,corre-spondingtoalmost12,000newcancerdiagnosesonaver-ageeachday.The5mostcommonlydiagnosedcancersamongmen,indescendingorder,are:cancersofthelungandbronchus,stomach,esophagus,liver,andcolorectum,accountingforabouttwo-thirdsofallcancercases.Thecorrespondingcancersamongwomenarebreast,lungandbronchus,stomach,colorectum,andesophagus,account-ingfornearly60%ofallcases.Breastcanceraloneisexpectedtoaccountfor15%ofallnewcancersinwomen(Table2).

StatisticalAnalysis

WeestimatedthenumbersofnewcasesinChinain2015forallcancerscombinedandfor26individualcancertypesbysexbyapplyingage-speci?cincidenceratesfrom72cancerregis-tries(2009-2011)totheprojectedage-speci?cpopulationinChinain2015.WeestimatedthenumbersofcancerdeathsinChinain2015usingthesamemethod.Forthe10most

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FIGURE2.ThreeMajorMeasuresofDataQualitybyCancerTypesforthe2SetsofCancerRegistriesinChina.

CodesinthefarleftcolumnarefromtheInternationalClassificationofDiseases,10thRevision.DCO%indicatesthepercentageofcancercasesidentifiedwithdeathcertificationonly;M/I,morality-to-incidenceratio;MV%,proportionofmorphologicalverification.

Theestimatedincidenceratesforallcancerscombinedandthenumberofnewcasesforthemostcommon10can-certypesbyurbanversusruralstatusandregionofresi-dencearepresentedinTable3.Forallcancerscombined,theage-standardizedincidenceratesper100,000popula-tionperyeararehigherinmenthaninwomen(234.9vs168.7per100,000)andarehigherinruralareasthaninurbanareas(213.6vs191.5per100,000).SouthwestChinahasthehighestcancerincidencerates,followedbyNorthChinaandNorthwestChina;andCentralChinahasthelowestincidencerate.

ExpectedCancerMortalityin2015

Itisestimatedthatabout2814,000Chinesewilldiefromcancerin2015,correspondingtoover7500cancerdeathsonaverageperday.The5leadingcausesofcancerdeathamongbothmenandwomenarecancersofthelungandbronchus,stomach,liver,esophagus,andcolorectum,accountingforaboutthree-quartersofallcancerdeaths(Table2).Similartotheincidencerates,theage-standardizedmortalityrateforallcancerscombinedissub-stantiallyhigherinmenthaninwomen(165.9vs88.8per100,000)andinruralareasthaninurbanareas(149.0vs

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TABLE2.EstimatedNewCancerCasesandDeaths(Thousands)bySex:China,2015*

INCIDENCE

MORTALITY

FEMALE

TOTAL

MALE

FEMALE

SITEICD-10TOTALMALE

Lip,oralcavity,&pharynx(exceptnasopharynx)NasopharynxEsophagusStomachColorectumLiver

GallbladderPancreasLarynxLung

OtherthoracicorgansBone

MelanomaoftheskinBreastCervixUterusOvaryProstateTestisKidneyBladderBrain,CNSThyroidLymphomaLeukemia

AllothersitesandunspecifiedAllsitesC00-C10,C12-C14C11C15C16C18-C21C22C23-C24C25C32C33-C34C37-C38C40-C41C43C50C53C54-C55C56C61C62

C64-C66,C68C67C70-C72C73

C81-C85,C88,C90,C96C91-C95A_OALL48.160.6477.9679.1376.3466.152.890.126.4733.313.228.08.0272.498.963.452.160.34.066.880.5101.690.088.275.3178.14291.631.143.3320.8477.7215.7343.724.552.223.7509.38.216.44.33.8———60.34.043.262.152.322.253.044.495.52512.116.917.3157.2201.4160.6122.328.337.92.6224.05.011.63.7268.698.963.452.1——23.618.449.367.935.230.982.61779.522.134.1375.0498.0191.0422.140.779.414.5610.26.520.73.270.730.521.822.526.61.023.432.961.06.852.153.494.02814.215.324.9253.8339.3111.1310.618.845.612.6432.44.112.41.81.2———26.61.015.225.135.82.532.732.055.01809.96.89.2121.3158.780.0111.521.833.81.9177.82.38.31.569.530.521.822.5——8.27.825.24.319.421.339.01004.4

CNS,centralnervoussystem;ICD-10,InternationalClassificationofDiseases,10threvision.

*Thetotalnumberofcasesprojectedfor2015arebasedontheaverageincidenceratesforthemostrecent3years(2009to2011)ofdatafrom72population-basedcancerregistries.

109.5per100,000)(Table4).Likewise,thehighestcancermortalityrateswerefoundinSouthwestChina,followedbyNorthChinaandNorthwestChina,withCentralChinaexhibitingthelowestrate.

ExpectedCancerSurvivalin2015

Itispredictedthat,forallcancerscombined,36.9%ofcan-cerpatientsinChinawillsurviveatleast5yearsafterdiag-nosisaround2015,withwomenhavingmuchbettersurvivalthanmen(47.3%vs29.3%)(Table6).Thereissubstantialvariationinthe5-yearsurvivalestimateaccord-ingtoresidenceatthetimeofdiagnosis:ruralpatientshavemuchlowersurvivalthantheircitycounterparts(30.3%vs42.8%).Likewise,thelowestsurvivalrateswerefoundinSouthwestChina(24.9%),withCentralChinashowingthehighestrate(41.0%).

Age-SpecificIncidenceandMortalityofSelectedCancersbySexin2015

Beforetheageof60years,livercanceristhemostcom-monlydiagnosedcancerandtheleadingcauseofcancerdeathinmen,followedbylungandstomachcancer,whicharethedominanttypesofcancerforbothcasesanddeathsinthegroupages60to74years(Table5).Lungcanceristhemostcommonlydiagnosedcancerandtheleadingcauseofcancerdeathinmenaged75yearsorolder.Mostnewcancercasesandcancerdeathsinmenoccurintheagerangefrom60to74years.

Amongwomen,thyroidcanceristhemostcommonlydiagnosedcancerbeforetheageof30years,followedbybreastcanceratages30to59years,andlungcancerinwomenaged60yearsorolder(Table5).Breastcanceristheleadingcauseofcancerdeathinwomenyoungerthan45years,followedbylungcancer.Thelargestproportionofnewcancercasesanddeathsamongwomenarediagnosedamongthosebetweenages60and74years.

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TrendsinCancerIncidenceandMortality

Forallcancerscombined,theage-standardizedincidencerateswerestableoverthestudyperiod(2000-2011)formales,whilesigni?cantupwardtrendswereobservedforfemales(P<.05)(Fig.3,Table7).Incontrast,theage-standardizedmortalityratesdecreasedsigni?cantlyforbothmalesandfemales(Fig.3,Table8).Despitethisfavorabletrend,however,thenumberofcancerdeathssubstantiallyincreased(73.8%increase)duringthecorrespondingperiod(from51,090in2000to88,800in2011)becauseoftheagingandgrowthofthepopulation(Fig.4).

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TABLE3.

Age-Standardized(SegiStandardPopulation)IncidenceRatesforAllCancersCombinedandEstimatedNewCases(Thousands)forSelectedCancersinChina,2015,byGeographicLocation

ESTIMATEDNEWCASES(THOUSANDS)

ALLCANCERS

AREASSEXASR*LUNGESOPHAGUSSTOMACHCOLORECTUMLIVERBREASTCERVIXTHYROIDBRAINPANCREAS

AllareasUrbanareasRuralareas

TotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemale

201.1234.9168.7191.5215.9168.9213.6259.6168.5213.2240.3187.0189.2208.4169.8193.7224.1165.8185.5208.3164.7202.4242.1165.2226.7281.4170.9207.9253.9158.5

4291.62512.11779.52305.81302.41003.41985.81209.7776.2528.1298.3229.8359.8199.6160.21280.2735.3544.8666.8374.9291.9427.3254.3173.0744.8469.7275.2284.5179.9104.6

733.3509.3224.0445.0306.0139.0288.3203.385.079.552.327.283.754.229.5218.6150.668.0115.782.932.880.555.425.1117.887.430.437.526.411.1

477.9320.8157.2113.887.426.5364.1233.4130.785.255.330.09.88.61.2122.884.238.670.744.126.610.89.01.8143.293.649.535.426.09.5

679.1477.7201.4235.2164.770.4444.0313.0130.997.771.925.836.126.29.9179.5124.554.991.162.228.924.316.97.3174.7118.256.575.757.817.9

376.3215.7160.6263.2150.8112.4113.264.948.238.822.116.741.524.516.9125.670.555.158.532.725.850.828.822.042.926.516.418.310.67.7

466.1343.7122.3205.2156.848.4260.9187.073.942.430.112.336.427.49.1126.894.132.770.551.519.068.855.813.192.664.628.028.420.38.2

268.6189.579.0

98.953.245.7

90.022.267.972.118.154.017.94.113.99.82.37.510.72.58.240.210.230.014.33.111.29.02.26.93.11.12.02.80.72.1

101.652.349.355.826.829.045.725.520.311.05.45.58.54.04.529.614.615.020.69.611.010.85.25.612.88.84.08.34.63.7

90.152.237.959.534.225.430.518.012.59.25.43.810.36.24.138.121.516.611.46.64.86.03.62.48.54.73.86.64.22.4

NorthChinaNortheastEastChinaCentralChinaSouthChinaSouthwestNorthwest

37.233.283.946.730.923.213.4

16.710.527.617.48.111.37.3

ASR,age-standardizedmortalityrate.

*Age-standardizedincidenceratesforallcancersarebasedontheSegistandardpopulation.

Amongthe10mostcommoncancersconsideredinthetemporaltrendanalysesformen,incidenceratesfrom2000to2011increasedfor6cancertypes(pancreas,colorectum,brainandcentralnervoussystem,prostate,bladder,andleukemia),whereastheratesdecreasedforcancersofthestomach,esophagus,andliver(P<.05).Astabletrendwasobservedforcancerofthelung(Fig.5,Table7).

Forwomen,6ofthe10mostcommoncancershadasigni?-cantupwardtrendinage-standardizedincidencerates(cancersofthecolorectum,lung,breast,cervix,uterinecorpus,andthy-roid;P<.05).Aswithmen,adownwardtrendwasseenforcancersofthestomach,esophagus,andliver(Fig.6,Table7).Anupwardtrendinage-standardizedmortalityrateswasobservedfor4ofthe10mostcommoncancersinmen(color-ectum,pancreas,prostate,andleukemia;P<.05),whereassta-bletrendswereseenforothercancertypes(cancersofthelung,bladder,andbrain)(Fig.7,Table8).Inwomen,anincreasingtrendinmortalitywasobservedfor3ofthe10mostcommoncancers(breast,cervix,andovary),withtrendsstableforcolor-ectum,lung,uterine,andthyroidcancers(Fig.8,Table8).

Similartothetrendsincancerincidencerates,decliningtrendsinage-standardizedmortalityrateswereobservedforcancersofthestomach,esophagus,andliverinbothsexes(Figs.(7and8)).Stabletrendswereobservedinbothmenandwomenforlungcancer,whichwastheleadingcauseofcancermortalityforbothmenandwomen.

Discussion

AlthoughnationalestimatesofcancerforChinahavebeenpreviouslyreported,thesearelimitedtoonlyasnapshotofthepatternsbycancersiteduringasingleyear3,4,12,19orarereportedforspeci?ccancers,20–22makingcomparisonsoftrendsacrosscancertypesdif?cult.ThisstudyprovidedmorecomprehensivenationwidecancerstatisticsinChinausingthelatestandmostrepresentativedataandincludinginformationontemporaltrends.

Cancerpreventionandcontrolrelyonpopulation-basedincidenceandmortalitydataasanincentivebothtoactandtoassesstheeffectivenessofcurrentinterventionsandpolicies.

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TABLE4.

Age-Standardized(SegiStandardPopulation)MortalityRatesforAllCancersCombinedandEstimatedDeaths(Thousands)forSelectedCancersinChina,2015,byGeographicLocation

ESTIMATEDDEATHS(THOUSANDS)

ALLCANCERS

AREASSEXASR*LUNGESOPHAGUSSTOMACHCOLORECTUMLIVERBREASTCERVIXTHYROIDBRAINPANCREAS

AllareasUrbanareasRuralareas

TotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemale

126.9165.988.8109.5142.977.1149.0195.1103.8134.5171.997.5116.4146.985.5115.6152.880.6109.4142.277.9122.4168.777.5170.2219.5119.7133.2171.591.9

2814.21809.91004.41382.3884.4497.91431.9925.5506.4338.6215.7122.9224.0142.981.2815.1517.1298.0409.5260.0149.5270.2180.989.3574.9371.5203.4182.0121.960.1

610.2432.4177.8373.4261.7111.6236.9170.766.164.243.121.171.746.924.8182.9128.954.094.069.125.068.848.320.4100.375.924.528.220.28.0

375.0253.8121.389.169.120.0285.9184.7101.267.545.621.97.96.90.994.364.330.053.433.819.68.87.61.2118.075.842.225.119.75.4

498.0339.3158.7162.9112.550.4335.1226.8108.268.649.618.924.818.06.9130.588.342.265.845.220.618.012.45.6141.088.852.349.337.112.2

191.0111.180.0126.673.752.964.537.427.119.411.38.118.811.37.462.735.127.627.015.112.024.814.310.529.118.810.39.25.14.0

422.1310.6111.5185.1139.745.4237.0170.966.138.427.510.933.625.28.3115.885.130.659.943.616.360.148.611.590.263.226.924.117.36.8

69.543.825.7

30.513.616.9

6.82.54.34.51.62.92.30.91.40.70.20.50.60.20.42.10.71.40.90.30.60.90.40.50.60.30.30.90.30.6

61.035.825.230.616.813.830.419.011.56.33.62.75.02.82.218.610.18.510.76.04.65.32.92.310.77.53.14.52.71.8

79.445.633.853.830.723.225.514.910.68.04.63.510.16.14.033.819.014.89.55.44.15.53.32.37.54.23.34.93.01.9

NorthChinaNortheastEastChinaCentralChinaSouthChinaSouthwestNorthwest

8.16.821.111.97.78.85.2

6.12.46.74.12.36.22.6

ASR,age-standardizedmortalityrate.

*ASRsforallcancersarebasedontheSegistandardpopulation.

Thus,theupdatednationwideestimatesofcancerburdenandtimetrendspresentedherearecriticaltounderstandingtheetiologyofcancerandtheeffectivenessofprevention,earlydetection,andmanagementofcancerinChina.TheseresultswillalsoserveasabaselineforfutureassessmentoftheoveralleffectivenessofthecancercontroleffortinChinaandwillprovideinsightsintotheareasofgreatestneedforprioritization.

BecauseofChina’slargepopulationsize,approximatelyone-?fthoftheworldpopulation,theseChinesedatacon-tributesigni?cantlytotheglobalburdenofcancer:almost22%ofglobalnewcancercasesandcloseto27%ofglobalcancerdeathsoccurinChina.23Moreimportantly,thecan-cerpro?leinChinaismarkedlydifferentfromthoseofdevelopedcountries.The4mostcommoncancersdiag-nosedinChinawerelung,stomach,liver,andesophagealcancer.Thesecancersaccountfor57%ofcancersdiagnosedinChina,comparedwith18%intheUnitedStates.24Also,thesecancersdiagnosedinChinacomprisebetweenone-thirdandone-halfoftheglobalincidenceburdenfrom

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lung,stomach,liver,andesophagealcancers.23,25Incom-parison,themostcommoncancersdiagnosedintheUnitedStatesarecancersofthelung,breast,prostate,andcolorec-tum.26ThemostcommoncancersinChinaarethoseasso-ciatedwithratherpoorsurvival;whereasthoseintheUnitedStates,withtheexceptionoflungcancer,aredomi-natedbycancerswithagoodtoexcellentprognosis,and,forprostateandbreastcancers,theincidencemaybein?atedbydiagnosticactivitieslinkedtoearlydetectionandscreening.24,27Thisdifferenceincancertypedistribu-tioncontributessigni?cantlytothehigheroverallcancermortalityrateinChina.

Ourcancerestimatesfor2015werebasedondatafrom72Chinesepopulation-basedcancerregistriescapturingcancerdiagnosesfrom2009to2011.Theseregistriescoveronlyabout6.5%oftheChinesenationalpopulation,buttheyremainthebest-availablenationwidedataforcancerincidence,representingabasepopulationof85.5millionpeople.Moreover,thedatausedinthisstudyhaveanenlargedpopulationcoveragecomparedwithprevious

CACANCERJCLIN2016;00:00–00

TABLE5.EstimatedNewCancerCasesandDeaths(Thousands)forSelectedCancersbyAgeGroups:China,2015

AGE,y

SITE<3030–4445–5960–74??75ALL

Male(thousands)IncidenceProstateColorectumEsophagusLiverStomachLungAllsitesMortalityPancreasColorectumEsophagusLiverStomachLungAllsites

Female(thousands)IncidenceThyroidCervixColorectumStomachLungBreastAllsitesMortalityBreastColorectumLiver

EsophagusStomachLungAllsites

0.11.10.24.41.91.341.60.10.50.13.51.30.819.86.11.51.11.00.74.338.80.50.30.70.10.60.311.0

0.113.07.441.315.815.8151.61.45.04.232.58.010.079.920.528.210.111.510.955.5202.98.73.45.81.45.25.852.8

3.458.089.0130.4134.1122.0707.510.122.556.0111.974.788.5434.027.845.740.749.253.9128.7566.628.313.726.919.129.232.5219.8

24.290.9161.3116.1232.7231.81061.819.341.6121.3106.4160.6188.7748.711.319.064.289.691.262.3623.218.827.444.856.166.569.7381.0

32.452.762.951.693.2138.4549.514.641.572.156.394.7144.5527.62.14.544.450.067.417.8348.013.235.133.244.557.269.4339.7

60.3215.7320.8343.7477.7509.32512.145.6111.1253.8310.6339.3432.41809.967.998.9160.6201.4224.0268.61779.569.580.0111.5121.3158.7177.81004.4

studies(withcoveragelessthan2%ofthepopulation),2,28includingmoreregistriesinthewesternregionsofChinaandarethusmorerepresentativeofthegeneralpopulationinChina.Inaddition,all12population-basedcancerregis-triesinmainlandChinawithhigh-qualitydatathatful?lledtheCancerIncidenceinFiveContinents(CI5)inclusioncri-teriaforthepresentCI5volumeXwereincludedintheanalysis.29ThesenationalincidenceestimatesforChinaarebroadlycomparabletothosepublishedpreviously.3,4,12The2mostrecentlypublishedannualreportsinChinafoundthattheestimatednumberofnewcancercaseswere3.09millionand3.37millionfor2010and2011,respectively.3,4Anearlierestimatewas2.96millionfor2005,althoughadifferentmethodwasused.12Ourestimateofcancerincidencefor2015(4.29millioncases)inChinaisconsiderablyhigherthanthatreportedbytheGLOBOCAN2012initiativeof3.40million.23,25Rea-sonsforthesediscrepanciesmayincludedifferencesindatatimelines(2009-2011vs2003-2007)andrepresentativenessandgeographiccoverage(72cancerregistriescovering6.5%ofthenationalpopulationvs23cancerregistriescov-ering3.0%ofthepopulation).Inparticular,ruralresidents,

whohaveahigherincidenceratethanurbanresidents(213.6per100,000vs191.5per100,000),accountfor32.7%thepopulationinourestimatescomparedwith21.5%inthe2012GLOBOCANestimates.Themethodsusedtoobtainthenationalincidenceestimatesarealsodif-ferent,becauseGLOBOCAN2012convertsnationalmor-talityestimatesfor2012toincidencebymodelingtheage-speci?c,sex-speci?c,andsite-speci?cM/Iratiosfromthe23Chinesecancerregistries.WhileacknowledgingthatnotallofthesecancerregistriesmettheIARCqualitystandards,15,30thesediscrepanciesinpublishedestimatesunderscoretheneedforfurtherimprovementsinthecover-ageandqualityofregistriesinChinatoprovidemoreaccu-ratestatisticsonthecancerburdeninthecountry.

Incontrasttoincidence,therewasgreaterconsistencyinourmortalityestimatesandthoseinGLOBOCAN.Weestimatedthattherewouldbe2.81millioncancerdeathsin2015,andthecorresponding?gurewas2.46millioninGLOBOCAN2012.23Thismayre?ectthatthemortalitydatausedbybothstudieswereobtainedfromasimilarsource:DSPdata(2004-2010)wereusedforGLOBO-CAN2012,whileweusedmortalitydatacollectedfrom

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TABLE6.

Expected5-YearSurvivalforAllCancers

CombinedbySexandGeographicArea:China,2015

SEX

ASRINCIDENCE*

ASRDEATHS*

1-(M/I)

AREAS

AllareasUrbanareasRuralareas

TotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemaleTotalMaleFemale

201.1234.9168.7191.5215.9168.9213.6259.6168.5213.2240.3187.0189.2208.4169.8193.7224.1165.8185.5208.3164.7202.4242.1165.2226.7281.4170.9207.9253.9158.5

126.9165.988.8109.5142.977.1149.0195.1103.8134.5171.997.5116.4146.985.5115.6152.880.6109.4142.277.9122.4168.777.5170.2219.5119.7133.2171.591.9

36.929.347.342.833.854.430.324.838.436.928.547.938.529.549.640.331.851.441.031.752.739.530.353.124.922.029.936.032.542.0

NorthChinaNortheastEastChinaCentralChinaSouthChinaSouthwestNorthwest

1-(M/I),complementtothemortality(M)toincidence(I)ratio;ASR,age-standardizedmortalityrate.

*Age-standardizedratesforallcancersarebasedontheSegistandardpopulation.

72cancerregistryareas(2009-2011)forwhichDSPdatawerepartofthewholesetofdataoncancerdeaths.TheDSPdatawerebasedoncountiesandstrati?edbygeo-graphicregions,withsamplingfurtherstrati?edbyurbanorrurallocationandpercapitagrossdomesticproduct,andtheDSPsystemwasspeci?callydesignedtobenationallyrepresentative.19Forbothincidenceandmortalityesti-mates,datafromHongKongandMacaowerealsousedintheestimatesfromGLOBOCAN2012butwereexcludedfromouranalyses.

Wefoundsigni?cantdifferencesincancerincidenceratesforallcancerscombinedbyplaceofresidence(ruralvsurbanandbetweenregions)inChina.Ruralresidentshavehigherincidencecomparedwiththeirurbancounterparts,andinci-denceratesvariedsubstantiallyacrossthe7administrativeregions.Itislikelythatmanyfactorscontributetothisgeo-graphicdifferential,butthehighersmokingprevalenceinruralpopulationscomparedwiththoseinurbanareas31,32likelyplaysadominatingrole.The12cancersformallyestab-lishedasbeingcausedbysmoking33accountforabout75%ofallcancerscombinedinChina.Consistentwiththis

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hypothesis,theareawiththehighestobservedcancerinci-dencerate,SouthwestChina,wasalsoreportedtohavethecitieswiththehighestsmokingprevalencein2002.34WefoundevengreatergeographicvariationsincancermortalityandthesurvivalproxiesacrossChina.Itislikelythatatleastpartofthesegeographicdisparitiescouldbeexplainedbythemorelimitedmedicalresources,lowerlevelsofcancercare,andalargerproportionofpatientsdiagnosedwithcanceratalatestageinruralandunderdevelopedareasinChina.27Recognizingthatdifferencesinotherfactors,suchascompetingcausesofdeathandcomorbidities,mayalsocontribute,theresultsreportedhere,togetherwiththosereportedpreviously,27,35provideastrongjusti?cationforprovidingmoregovernment-fundedhealthresourcesandservicesforcancercontrolinruralandunderdevelopedareasinChinatoreducetheseapparentinequalities.

Therehasbeenamarkedincreaseinthenumbersofcan-cersdiagnosedinChinabetween2000and2011.Muchofthisisexplainedbytheagingandgrowthofthepopulation.Otherfactorsthatmayhavecontributedtotheincreaseintheburdenofcancerincludeincreasesintheprevalenceofunheal-thybehaviorsorcancer-relatedlifestyleandimprovementsindiseaseawareness,detectionservices,anddatacompleteness.Thelargestincreaseinincidencewasseenforcancersoftheprostate,cervix,andthyroidforwomen.Thefactorsdrivingtheincreaseinprostatecancerarenotentirelyunderstood;however,theymayincludegradualimplementationofprostate-speci?cantigenscreeningandimprovedbiopsytech-niques36ortheimpactofanincreasinglywesternizedlife-style.37,38Westernizedlifestyle,particularlyincreasesintheprevalenceofobesityandphysicalinactivityinrecentdecadesinChina,islikelytohavehadanimpactontheobservedriseincolorectalandbreastcancerincidence.39,40Forbreastcancer,theincreasingtrendmayalsore?ectchangesinrepro-ductivebehaviorinChinainrecentdecadesbecauseoftheone-childpolicyimplementedsincethe1970s.41Incontrasttothedecreasingincidencetrendsindevel-opedcountries,asubstantialincreaseincervicalcancerinci-dencewasseeninChina.Thismayre?ecttheinadequacyofPapanicolaou(Pap)testscreeninginChina,becauseonlyone-?fthofChinesewomenreportedhavingeverhadaPaptestforcervicalcancerscreening.42,43Theincreasingprevalenceofhumanpapillomavirus(HPV)infection,espe-ciallyinyoungerwomen,44,45andthelackofHPVvaccinesinmainlandChinaduetotheabsenceofformaldrugapprovals,39suggestthatthedisparityincervicalcancerincidencetrendsbetweenChinaandinternationalcountriesmaycontinuefortheforeseeablefuture.

Thedramaticriseinthyroidcanceramongwomenisconsistentwiththatobservedinothercountries46–49;and,whileitmayre?ect“overdiagnosis”throughincreaseduseofnewimagingtechnologies(ultrasound,computed

CACANCERJCLIN2016;00:00–00

FIGURE3.TrendsinCancerIncidenceandDeathRates(Age-StandardizedtotheSegiStandardPopulation)forAllCan-

cersCombinedbySex:China,2000to2011.

Datasource:22population-basedChinesecancerregistries.

tomography,andmagneticresonanceimaging)intheassessmentofthethyroidgland,50,51intheabsenceofinformationaboutdiseasestage,itisnotpossibletoruleoutarealincreaseinincidence.

Asigni?cantlydecreasingincidenceandmortalitytrendwasobservedforcancersofthestomach,esophagus,andliverinChina.Despitethedecliningratesforthisgroupofcancers,populationgrowthandageingstillledtoalargeandrisingnumberofnewcasesin2015.Controlofinfec-tionsmaycontributeforthesetemporalpatterns,includinghepatitisBvirus(HBV)andhepatitisCvirus(HCV)forlivercancerandHelicobacterpyloriforstomachcancer.52PrimarypreventionofHBVinfectionthroughvaccinationofinfantshasbeenshowntobeeffective:livercancerdeathswerereducedby95%fortheyoungerpopulation(ages0-19years)15yearsafterimplementingHBVvacci-nationprograminhigh-riskareasinChinain1986.53DespitethesuccessofHBVvaccinetopreventlivercancerinchildreninChina,53,54itmaybetooearlytoaffecttheincidencetrendforallagescombined.FactorsthatmayhavecontributedtothedecreasingtrendinoveralllivercancerratesinChinaincludeareductionintheconsump-tionofcorncontaminatedwitha?atoxinsandimprovedqualityofdrinkingwaterbyremovalofcyanotoxinsfromwatersources.55Thesingle-childpolicy,whichreducesthehorizontal(child–to-child)transmissionofHBVinfectionathome,andsaferinjectionpractices,whichreduce

TABLE7.

TrendsinCancerIncidenceRates(Age-Stand-ardizedtotheSegiStandardPopulation)forSelectedCancersandAllCancersCombinedbySex:China,2000to2011

TREND1

TREND2

APC

YEARS

APC

ICD-10SITESYEARS

IncidencemaleC15C16C18-C21C22C25C33-C34C61C67C70-C72C91-C95ALL

IncidencefemaleC15C16C18-C21C22C33-C34C50C53C54-C55C56C73ALL

EsophagusStomachColorectumLiverPancreasLungProstateBladderBrain,CNSLeukemiaAllsitesEsophagusStomachColorectumLiverLungBreastCervixUterusOvaryThyroidAllsites

2000-20112000-20032000-20062000-20112000-20112000-20112000-20052000-20052000-20112000-20112000-201123.2*25.3*4.2*21.8*1.3*20.212.6*4.1*2.1*2.5*0.2

2003-201121.8*2006-20111.3*

2005-20112005-20114.7*0.1

2000-201125.5*2000-201122.7*2000-20063.2*2006-20110.22000-200821.5*2008-201124.4*2000-20110.9*2000-20113.9*

2000-200715.6*2007-20114.12000-20113.7*2000-20066.3*2006-201122.8*2000-20034.92003-201120.1*2000-20112.2*

APC,annualpercentagechange;CNS,centralnervoussystem;ICD-10,Inter-nationalClassificationofDiseases,10threvision.*TheAPCissignificantlydifferentfromzero(P<.05).

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TABLE8.

TrendsinCancerMortalityRates(Age-StandardizedtotheSegiStandardPopulation)forSelectedCancersandAllCancersCombinedbySex:China,2000to2011

TREND1

TREND2

APC

YEARS

APC

YEARS

TREND3

APC

ICD-10SITESYEARS

MaleC15C16C18-C21C22C25C33-C34C61C67C70-C72C91-C95ALLFemaleC15C16C18-C21C22C33-C34C50C53C54-C55C56C73ALL

EsophagusStomachColorectumLiverPancreasLungProstateBladderBrain,CNSLeukemiaAllsitesEsophagusStomachColorectumLiverLungBreastCervixUterusOvaryThyroidAllsites

2000-20042000-20032000-20112000-20032000-20112000-20032000-20112000-20112000-20032000-20112000-20032000-20112000-20032000-20112000-20032000-20112000-20112000-20112000-20112000-20032000-20112000-2003

26.1*27.5*1.6*25.5*1.2*24.1*5.5*20.325.91.6*24.4*26.4*27.1*0.524.5*20.41.1*5.9*0.021.6*1.622.7*

2004-20112003-20112003-20062003-20062003-20112003-20062003-20112003-2006

22.7*22.3*1.92.11.7*1.122.7*0.6

2006-2011

24.2*

2006-2011

21.4*

2006-20112006-2011

24.0*21.2

2003-20112003-2006

1.70.5

2006-2011

21.1*

APC,annualpercentagechange;CNS,centralnervoussystem;ICD-10,InternationalClassificationofDiseases,10threvision.*TheAPCissignificantlydifferentfromzero(P<.05).

FIGURE4.TrendsintheNumberofNewCancerCasesandDeathsforAllCancersCombinedbySex:China,2000to2011.

Datasource:22population-basedChinesecancerregistries.

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FIGURE5.TrendsinIncidenceRates(Age-StandardizedtotheSegiStandardPopulation)forSelectedCancersforMales:

China,2000to2011.

CNSindicatescentralnervoussystem.Datasource:22population-basedChinesecancerregistries.

nosocomialHBVandHCV,56mayalsohavecontributedtothedecreaseinoveralllivercancerrates.

ImplicationsforCancerPreventioninChina

Ithasbeenestimatedthatnearly60%ofcancerdeathscanbeavoidedbyreducingexposuretomodi?ableriskfactors.57ThelargestcontributortoavoidablecancerdeathsinChinaischronicinfection,whichisestimatedtoaccountfor29%of

cancerdeaths,predominantlyfromstomachcancer(H.pylori),livercancer(HBVandHCV),andcervicalcancer(HPV).Tobaccosmokingaccountedforabout23Wto25XofallcancerdeathsinChina;yetoverone-halfofadultChinesemenwerecurrentsmokersin2010,31andsmokingratesinadolescentsandyoungadultsarestillrising.59Evenifcurrentratesremainstable,ithasbeenestimatedthattheonemillionsmoking-relateddeathsinChinaannually

FIGURE6.TrendsinIncidenceRates(Age-StandardizedtotheSegiStandardPopulation)forSelectedCancersfor

Females:China,2000to2011.

Datasource:22population-basedChinesecancerregistries.

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FIGURE7.TrendsinMortalityRates(Age-StandardizedtotheSegiStandardPopulation)forSelectedCancersforMales:

China,2000to2011.

CNSindicatescentralnervoussystem.Datasource:22population-basedChinesecancerregistries.

duringthe2010swilldoubleby2030.60Withtheimpactofsmoking-relateddiseasebecomingevident20to30yearsaftertheonsetofsmoking,61itislikelythattheburdenofcancerinChinawillcontinuetoincreaseinthenextdecadesirrespectiveofchangesintobacco-controlprograms.Although,atpresent,thereremainsagenerallypositiveimageofsmokinginChina62withheavyexposuretotobaccopromotion,63legislativechangeshavebeenenforced,64includingstrictsmoking-controllawstakingeffectinBeijinginJune2015.65Ifimplementedonanationalscale,andifthetobaccoindustrycanbeseparatedfromthegovernmenttobacco-controlactivities,66thenthesechangeshavethepotentialtoprovidehopethatsubsequentgenerationsofChinesewillbene?tfromamuchlowerburdenoftobacco-relatedcancers.

FIGURE8.TrendsinMortalityRates(Age-StandardizedtotheSegiStandardPopulation)forSelectedCancersfor

Females:China,2000to2011.

Datasource:22population-basedChinesecancerregistries.

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TheeconomicgrowthandincreasinglyurbanizedandwesternizedlifestyleexperiencedinChinahasresultedinincreasedenvironmentalpollution.39Outdoorairpollution,consideredtobeamongtheworstintheworld,67indoorairpollutionthroughheatingandcookingusingcoalandotherbiomassfuels,andthecontaminationofsoilanddrinkingwatermeanthattheChinesepopulationisexposedtomanyenvironmentalcarcinogens.Whilethemeasuredattributableriskforenvironmentalpollutionislow(<1.0%),57theexistenceof“cancervillages”inChinathathaveparticularlyhighcancerincidenceandmortalitypro-videsstrongcircumstantialevidenceforanassociation.39,68Someeffortsarebeingmadetoreducetheburdenofenvi-ronmentalpollutioninChina68,69;however,thegapbetweenlegislationandimplementationremainshigh.TheimpactofenvironmentalpollutiononcancerandotherhealthoutcomesislikelytobefeltformanydecadesinChina,particularlyforpeopleinruralareaswhoarefacingveryrudimentarylivingenvironments.

ImplicationsforEarlyDetectionandManagementinChina

Althoughpreventioneffortsarecriticaltoreducethelong-termburdenofcancer,anyeffectswillnotbeseeninthenearfuture.70Forthisreason,facilitatingtheearlierdiagno-sisofcancerandimprovingtheaccessandavailabilityofoptimaltreatmentsmayholdthegreatestpotentialtohaveamoreimmediateimpactontheexistingburdenofcancerinChina.Inparticular,thelargesurvivaldifferencesbygeo-graphicregion27demonstratethepotentialtoimprovethesurvivalofChinesecancerpatientsthroughensuringequita-bletimelinessofdiagnosis,accesstocancercare,andqualityofcaredeliveredirrespectiveofwhereapersonresides.

OnebarriertoaddressingtheseissuesistheimmensescaleoftheChinesepopulationanditsgeographicdiversity.Evenwiththecurrentrateofexpansionforbreastscreeningprograms,itwouldtakeanestimatedadditional40yearstoscreeneachwomeninthetargetagegrouponce.70Inaddi-tion,theyoungermedianageatbreastcancerdiagnosiscomparedwithhigh-incomecountrieslimitsitscosteffec-tiveness,withsomesuggestionsthatChineseresourcesmightbebettertargetedinraisingawarenessandearlydetectionwhendetectingbreastlumps.71Despitethesegeographicandpopulationbarriers,endoscopyscreeningprogramsforesophagealcancerarebeingexpanded,72andnewgenerationsofscreeningtestsbasedonhigh-riskHPVarebeingdevelopedtoovercomethedif?cultyofmaintain-inghigh-coverage,cytology-basedcervicalscreeningpro-gramsinlow/middle-incomecountries.73BecausesurgicaltreatmentforstageIlungcancerhasdemonstratedsurvivalbene?ts,74usinglow-dosecomputedtomography75todetectlungcancersearliernotonlycould

reducetheexistingmortalitybutalsocouldindirectlyimprovetheeffectivenessofpublichealthpreventionandtobacco-controlcampaigns.74BecausemanyhospitalsinChinacontinuetousex-raystodetectlungcancer,74build-ingfunctionalmedicalcapacity,particularlyinruralChina,remainsapriority.

Toaddressthegeographicdiversityandtheinequitabledistributionofmedicalresourcestourbanareas(whichcon-tain30%ofthepopulationbutreceive70%ofthemedicalresources),Chinahasimplementedthestrategyofsuper-centersforcancercare,whichhaveextremelyhighconcen-trationsofcancersurgicalspecialistswithhighcaseloads.76However,removinggeographicand?nancialbarrierstoaccessoptimaltreatmentremainsapriority,withruralanddisadvantagedpeoplefacingnotonlyarelativeshortageofdoctorsbutgreatertraveldistancestoaccessthem.Inaddi-tion,whilebasicmedicalinsurancecoverageisnearlyuni-versal,77,78theseschemesdonotprovideevenpartialcoverageforcancertreatments,meaningthatpatientsareeitherforcedtopayout-of-pocketorgowithout.39,79Anyinitiativestoimprovetheearlierdetectionandtreat-mentofcancerinChinaneedtoconsidertheuniquetradi-tionsandculturalbeliefsamongtheChinesepopulation.Therearewidespreadfatalisticattitudestowardcancer,areluctancetodiscusstreatmentandprognosisforfearofprovokingunnecessaryworryandpooroutcomes,andaperceptionthat,regardlessofanytreatment,deathisinevi-tableafteracancerdiagnosis.39Betterunderstandingtherolesofthesebeliefsiscriticaltoenableappropriatepro-gramsandinterventionsandtofacilitatetrustingrelation-shipsbetweendoctorsandpatients.39Inparalleltothesebeliefs,traditionalChinesemedicinehasbeenembeddedintheChinesehealthsystemforthousandsofyearsandisentwinedwiththeculture,history,andpoliticsofChina.39Assuch,theremaybepotentialtointegratecancercareandtreatmentwiththeroleofclinicalcarethroughtheseexist-ingtraditionalmedicalacademiccenters.

Tobetterquantifytheimpactofearlydetectionandtreatmentontheobservedtrendsincancerincidenceandmortality,moredetaileddataonboththestageofdiseaseatpresentationandthetreatmentreceivedafterdiagnosisarerequired.80,81GiventhatthesetypeofdataarenotcurrentlyavailableintheChinesecancerregistrysystem,thiswillrequirespeci?cresearchstudieswithasuf?cientlylarge,representative,population-basedcohort.

Limitations

Althoughthedatapresentedinthisstudyrepresentadou-blingofthepopulationcoveragecomparedwithpreviousestimates,theystillonlyrepresentlessthanone-tenthofthetotalChinesepopulation.Thereremainsanunknownlevelofuncertaintyintheseestimates.Inaddition,while

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quality-controleffortscontinuetoimprovethecomplete-nessandvalidityofdatawithinspeci?clocalcancerregis-tries,asevidencedbytheincreasingnumberofChinesecancerregistriesbeingincludedintheCI5series(fromjust3registriesfrommainlandChinainvolumeVII[1997],to8involumeVIII[2002],andthen12involumeX[2014],82and23usedtoestimatethenationalincidenceburdeninGLOBOCANfor2012),23thereremainssomevariabilityinthequalityofdata,asevidencedbymanyregistriesnotbeingselectedforinclusioninthelastvolumeoftheIARCCI5series(ci5.iarc.fr;accessedJune10,2015).TheM/Iratiowasrequiredasanapproximationfor5-yearrelativesurvival.TheinterpretationoftheM/Iratiocanbeproblematic,becausethemortalityrateinvolvesadifferentcohortofpeo-plethantheincidencerate.83Thismakesitparticularlysus-ceptibletoanychangesinincidenceovertime,andsoprovidesamoreaccurateestimateofsurvivalforthosecan-cerswithhighcasefatality.However,unpublisheddatafromthe17ChinesecancerregistriesshowedthattheM/Iratioforallcancerscombinedwasonlyabout1.4%higher(inabsolutevalues)thanthecalculated5-yearrelativesurvivalreportedpreviously.27Finally,inacountryof1.4billionpeo-ple,thereremainmanychallengesinensuringthattheinci-denceandmortalitynumeratordatarepresentthesamepopulationatriskastheestimatedresidentpopulationdenominator,particularlywhenconsideringcasestreatedinmajorurbanfacilitiesandmigrantworkersfromruralareas.Geographicinformationofincidentcasesisbasedontheplaceofpermanentresidence,notplaceoftreatment.Inaddition,cancersdiagnosedamongthesizablepopulationofmigrantworkers(9%ofthepopulation39)throughtheUrbanResidentBasicMedicalInsuranceprogramortheNewRuralCooperativeMedicalScheme,whichcoverthemajorityoftheChinesepopulation,77,78bothofwhicharebasedontheirplaceofhouseholdregistration.

Conclusions

Todevelopanappropriatelytargetednationalcancercon-trolplaninChina,itiscriticaltohaveadetailedassessment

ofthecancerburdeninChinabasedonrepresentativeandaccurate,population-baseddata.TheseestimatesandtheongoingcancerregistrationeffortsinChinaareimportantstepssupportingthisaim.Whilethereisstillimprecisionassociatedwiththesenationalestimates,theseestimatesarebasedonthebestavailabledataoncancerincidenceandmortality.Theymayserveasabaselineforfuturecompari-sonsandfurtherassessmentstobetterunderstandtheover-alleffectivenessofcancercontrolinChinaandprovideinsightsintotheareasofgreatestneedfortargetedsupport.Internationally,thereisalonghistoryofgovernmentsandotherhealthprovidershavinggreaterincentivetoactwhenthereisclear,quantitativeevidencedemonstratingtheneed.Inthisregard,theselatestestimatesdemonstratethatChinafaceshugechallengesinmanagingtheverylargeandincreasingburdenofcancernowandinthefuture,requir-ingaconcertedeffortandcommitmentfromalllevelsofgovernmentandnongovernmentorganizations.

Keyareasmayincludetheimprovementofclinicalcancercaredeliveryatthepopulationlevel,throughtargetedpol-icychangesandinvestmentinincreasingaccesstohealthserviceinruralareasandprovidingbasichealthcaretothedisadvantagedpopulations.Primarypreventionprograms,suchasaneffectivetobacco-controlpolicyandinitiativestomitigatethenegativein?uencesofamorewesternizedlife-style,arecrucial,alongwitheffortstoincreasetheeffective-nessandcoverageofthediagnostictechniquesandscreeningprogramsthatarecriticaltoreversingthecancerepidemicinChina.Itremainsaprioritytoensurethattheexistingairandwaterpollution-controllegislationisadequatelyimplementedtoensurethatrealimprovementsoccurinpractice.GiventheimportanceofthecontributionofChinatotheworldwideburdenofcancer,especiallyforthe4majorcancers(cancersofthelung,liver,stomach,andesophagus),strategiesandpoliciestoreducetheseprevent-ablecancers(byreducingtheprevalenceoftobaccosmok-ingandtheprevalenceofinfectionsassociatedwithcancerrisk)willhaveagreatimpactonthefuturecancerburdenbothinChinaandworldwide.?

9.ChenW,ZhengR,ZhangS,etal.Theinci-dencesandmortalitiesofmajorcancersinChina,2009.ChinJCancer.2013;32:106-112.10.InternationalAssociationofCancerRegis-tries.Internationalrulesformultiplepri-marycancers.AsianPacJCancerPrev.2005;6:104-106.11.LiGL,ChenWQ.Representativenessof

population-basedcancerregistrationinChina—comparisonofurbanandruralareas.AsianPacJCancerPrev.2009;10:559-564.12.ChenW,ArmstrongBK,ZhengR,ZhangS,

YuX,ClementsM.CancerburdeninChina:aBayesianapproach[serialonline].BMCCancer.2013;13:458.

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