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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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