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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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