Cancer Incidence in Northern Ireland 1993-1995

Author(s): Anna Gavin, James Reid, Richard Middleton and J. H. Robinson
Commissioned by: The Northern Ireland Cancer Registry
Document Type: Report
Year: 1999
Publisher: The Stationery Office
Place of Publication: Belfast
ISBN: Dd 601 970 2/99 c32/9261
Subject Area(s): Health
Client Group(s) : Men, Women, Children

Abbreviations: NI - Northern Ireland, DHSS - Department of Health and Social Services, HPSS - Health and Personal Social Services

Background to the Research

  • Cancer is a major cause of illness and premature death in Northern Ireland. One in three people will get cancer and one in four will die from it.
  • Until recently, cancer research, the planning and evaluation of cancer services and epidemiological data on cancer in NI have been inhibited by a lack of accurate and up to date information. The NI Cancer Registry was set up in May 1994 and replaced the DHSS Registry which began in 1959. The new registry is funded by the DHSS and the Ulster Cancer Foundation.

Research Approach

  • The computer systems of HPSS hold much of the data needed for cancer registration in Northern Ireland. The new Registry collates and analyses data from this and a variety of sources in NI. These include the 13 hospitals Patient Administration systems, the Registrar General's Office, the 8 Radiology sites, the Central Services Agency's GP records of deceased patients, various disease specific registries and the 5 pathology laboratories.

Main Findings

All Cancers (1993-1995)

  • Over the period, on average 8,500 cancers per year were registered, with males having a higher overall rate than females. Lung, prostate and colorectal cancers were the most common cancers in men and non-melanoma skin cancers, breast, colon and lung cancer were the most common cancers in women. Non-melanoma skin cancer accounted for 25% (2,260) of all cancers diagnosed per year - these are easily treatable and rarely cause death.
  • Belfast, Newry & Mourne and Derry had higher than expected numbers of cancer in males. Higher than expected numbers were found in females in Limavady and Derry. Over half (51%) of all cancers diagnosed yearly were female, however, adjusting for differentials in age distribution, women are less likely to get cancer. The mortality rate amongst men is higher - males have a 1 in 6 chance of dying of cancer and females a 1 in 8 chance. Cancers are more common in younger females than males, male cancers occur mostly in old age - over two-thirds in those aged over 65 years. In sex specific cancers, the rates were highest in the oldest age group (85+ years). Female rates were higher in the 20-60 year age group reflecting the influence of sex specific cancers, especially breast and cervical cancers.

Cancer of the Head and Neck

  • On average, 111 cancers of the lip and mouth were registered annually, mouth cancers were twice as common in men as women. Survival for mouth cancer generally is poor, with incidence increasing with age; over 80% of cases occur in those over 50 year of age. On average, 48 cancers of the pharynx were registered per year and 80% of cases occurred in people over 50. Males from the Western Board area had a higher than expected rate of lip and mouth cancers and men in the Southern Board area had higher than expected rates of pharyngeal cancers.
  • Comment - In approximately 79-90% of cases cancer of the lip, mouth and pharynx is linked to tobacco use and excessive alcohol intake. An added risk factor is inadequate amounts of vitamin A and C in the diet. UV radiation has also been linked to lip cancer.
  • Specific Health Policies - The population should be encouraged to have regular dental check-ups, especially older people.

Cancer of the Oesophagus

  • On average, 171 cancers were registered per annum, and this form of cancer was almost twice as common in males as in females. There was no significant geographical variation. The median age at diagnosis was 67 for men and 73 for women and the rate for men is increasing. Survival rates are relatively poor.
  • Comment - Alcohol consumption (especially spirits) and cigarette smoking are the main risk factors in this form of cancer - where both are used together the cumulative risk is greater. Survival rates are poor but symptoms can be well managed.
  • Specific Health Policies - A diet rich in fruit and vegetables can protect against oesophical cancer and may be responsible for slowing down death rates in the rest of Europe.
  • Recommendations - The increased level of oesophical cancer in young men needs further investigation and initiatives need to be established to encourage reduced alcohol consumption.

Cancer of the Stomach

  • On average, 260 cancers were registered per year and men were 2.5 times more at risk than women. There was no significant geographical variation. Men over 69 years and women over 75 years accounted for half of all cases. Mortality is quite high and is associated with late diagnosis in most patients.
  • Comment - Stomach cancer rates are linked to social class, with those in the lower socio-economic groups having a higher rate. Possible risk factors include infection by the bacterium Helicobacter pylori (bacteria found in the stomach in particularly high rates in Northern Ireland) and low consumption of fruit and vegetables.
  • Specific Health Initiatives - Further research into and the prevention of Helicobacter pylori infection should be encouraged.

Cancer of the Colon

  • On average 624 cancers of the colon were registered per year, 52% in women and 48% in men. Half of cases were in men aged over 71 years and in women aged over 73 years. There was a lower than expected incidence in females from the Eastern Board area and a higher than expected incidence in females in Ballymoney District Council area. Survival rates were modest, with twice as many cases diagnosed as deaths recorded.
  • Comment - The causes of colonic cancer are not fully understood but three factors are broadly agreed on, genetic factors, added risk from chronic diseases - especially ulcerative colitis, and dietary factors - a high fat intake and low fruit and vegetable intake.
  • Specific Health Initiatives - Awareness of the need to have changes in bowel habit, weight loss or passing blood investigated should be heightened.
  • Those with a family history of colonic cancer - especially those with a young relative with the disease - should contact specialists for the advisability on regular surveillance.
  • Recommendations - Further research into the aetiology of colon cancer and the role of diet should be carried out in Northern Ireland.
  • The assignment of site within the colon should be as precise as possible.

Cancer of the Rectum

  • On average 309 cancers were registered per year and it is slightly more common in men than women. The average age for diagnosis for women was 73 years and for men 69 years. There was a higher than expected number of women in Ards with cancer of the rectum.
  • Comment - NI has a relatively high rate of rectal cancer compared to the rest of the British Isles. Given that the causes of rectal cancer are very similar to those for colon cancer, dietary habits account for much of the higher incidence of the disease.
  • Recommendations - Further research into the aetiology of rectal (and colon) cancers and the role of diet should be carried out in NI.

Cancer of the Lung

  • On average 895 cancerss were registered per year and this is the most common form of cancer in men and the third most common in women (excluding skin cancer). There were higher than expected numbers in the Eastern Board area, lower than expected numbers in the Southern Board area for men and women and higher than expected levels in Belfast and Derry District Council areas for men and women. The number of deaths was about 90% of the number of cases, indicating the poor survival rate.
  • Comment - Over 90% of lung cancers are caused by smoking. Exposure to radon-gas must also be considered among the risk factors.
  • There is an established link between smoking and lower socio-economic status; this pattern is replicated in NI where smoking levels rise in areas of deprivation.
  • Certain occupations where workers are exposed to carcinogens carry an increased risk of lung cancer as does 'passive smoking' in the environment.
  • Specific Health Initiatives - Reduction of smoking levels holds the best chance of reducing lung cancer rates. The numbers starting to smoke could be reduced by a ban on advertising, increased taxation, reduction of availability of tobacco products and enhanced heath education. Help should be given to those who want to stop smoking and measures taken to control 'passive smoking'.
  • People with a persistent cough, pain, etc. should be encouraged to seek medical advice.

Malignant Melanoma of Skin

  • On average 160 melanomas of the skin were registered per annum, and this form of cancer is twice as common in women as men. However, the number and rates of melanoma increased in males and fell significantly in females in the period 1993-1995.
  • There were higher than expected numbers in the Southern Boards area for females, and in North Down for males.
  • Comment - The incidence of malignant melanoma has increased rapidly over the past 25 years in NI from an average of 48 cases per year (1974-1978) to 160 per year.
  • Specific Health Initiatives - The public should be encouraged to avoid the sun between 11 am-3pm and seek shade, cover up with a hat, T-shirt and sunglasses and use a minimum factor 15 sunscreen.
  • The public must be encouraged to become aware of skin changes which could indicate skin cancer.
  • Professionals should ensure a fast track approach to the diagnosis of suspicious lesions.

Cancer of the Female Breast

  • On average 820 female breast cancers were registered per year, breast cancer accounts for 19% of all new cancers diagnosed in women. Four-fifths of these occur in post menopausal women.
  • Higher than expected levels were found in the District Council areas of Limavady and Moyle. This may be due to higher levels of disease surveillance.
  • Comment - Breast cancer is the most common cause of cancer death in women in Northern Ireland. Studies have shown that breast cancer is more common in women who consume a diet which is high in saturated fat, those groups/societies who have a low fat diet show particularly low levels of breast cancer.
  • The Breast Cancer Screening Programme was fully operational in Northern Ireland by 1993. Women aged between 50 and 64 years are routinely invited every 3 years for a breast x-ray (mammogram). Women over the age of 65 may attend, although not specifically invited.
  • Specific Health Initiatives - Women should ensure they eat a healthy diet and not exceed the recommended levels of fat intake.
  • Women between the ages of 50 and 64 should attend screening when invited.
  • Those with a strong family history should seek advice on the value of a mammogram at an earlier age.
  • Women should be encouraged to seek advice for symptoms of breast cancer.
  • Recommendations - Women with suspected breast cancer should have their disease stage, including lymph node status, assessed at diagnosis.

Cancer of the Cervix Uteri

  • On average 78 cases of invasive cervical cancer were registered per year, half of these occurred in women under the age of 49.
  • There were higher than expected numbers in the Eastern Board area.
  • Comments - The major risk factor for development of pre-invasive or invasive cancer of the cervix is human papilloma virus infection. This overshadows the other known risk factors such as high number of children, number of sexual partners, smoking history and socio-economic class - cervical cancer is more common in the lower socio-economic groups.
  • Over 90% of cervical cancers can be detected early by the PAP smear which allows examination of cells from the cervix. In 1988 the community cervical screening programme (which began in 1965) was replaced by the population based screening programme which invites women aged between 20 and 64 years to have a smear taken every five years. A regional audit indicates that half of these cancers occur in the 30% of women who have never had a smear.
  • Specific Health Initiatives - All eligible women should be encouraged to attend for a cervical smear.
  • Measures to reduce smoking among women should be promoted.

Cancer of the Ovaries

  • On average 164 cases of cancer of the ovary were registered per annum, half of the cases were aged over 62 years.
  • There were lower than expected numbers in the Western Board area.
  • Comment - Ovarian cancer occurs most frequently in white affluent countries - there is a reduced risk among Japanese women. The causes of ovarian cancer are poorly understood, a slight familial risk is shown and environmental factors are thought to be important.
  • Two protective factors have been demonstrated, the number of pregnancies (especially two or more) and the use of the combined oral contraceptive (use for as long as five years may reduce the risk by about half).
  • Specific Health Initiatives - Ensure symptoms are investigated as soon as possible, as the disease is often asymptomatic in the early stages.

Cancer of the Prostate

  • On average 450 cancers were registered per year, half were diagnosed in men over 75 years.
  • This is the second most commonly diagnosed cancer in men, and a higher than expected number were registered in the Southern Health Board area.
  • Comment - The cause of prostate cancer is poorly understood, endocrine/hormonal factors may play a significant part and it is much less common in the Asian population.
  • Specific Health Initiative - General health programmes should encompass a focus on male health, especially the importance of early investigation of symptoms.

Cancer of the Testis

  • On average 47 cases of the disease were registered per year, and the survival rate under treatment is excellent. There were no significant geographic variations.
  • It is a disease of young males, half of cases occurred in men under 33 years of age.
  • It is the most common form of cancer in men between the ages of 25 and 34.
  • Comment - Most western populations have recorded an increase in incidence, partly due to better detection rates.
  • Specific Health Initiatives - Men should be encouraged to carry out regular self-examination to detect any testicular change.

Cancer of the Bladder

  • On average 203 cases were registered per year and 2 in every 3 cases were male. There were no significant geographic variations.
  • Comment - Cigarette smoking is a recognised risk factor in bladder cancer.
  • Specific Health Initiative - Increased awareness among the population of the importance of early investigation into the symptoms.
  • A clear distinction should be made between invasive and non-invasive bladder tumours.

Cancer of the Kidney

  • On average 174 cancers of the kidney were registered per year, and 2 in 3 cases occurred in men. Half of the cases occurred in people over the age of 68 years.
  • There were lower than expected numbers of men in the Western Board area and higher than expected numbers in the Southern Board area.
  • Comment - Over a third of kidney cancers are associated with tobacco smoking.

Childhood Cancers

  • On average 52 childhood cancers were registered per year, there were higher rates in boys and the 0-4 year age group were at greater risk. Generally prognosis was good for the majority of cases.
  • Leukaemia and brain tumours accounted for half the childhood cancers.
  • Comment - Cancer in children is extremely rare, although the emotional and psychological consequences for patients and their families are profound.
  • The causes are largely unknown, the effects of power lines and pylons is still under investigation - the bulk of the evidence showing little or no effect.

Summary of Recommendations

General recommendation for all forms of cancer

  • People should be encouraged to stop smoking.
  • The population should be encouraged to eat a diet rich in fresh fruit and vegetables - at least five potions a day. The population should be encouraged to reduce their intake of saturated fat.
  • Tobacco use must be addressed in line with the Government White Paper on tobacco control, as tobacco use is responsible for the majority of preventable cancers.
  • Increased awareness among the population of the importance of early investigation of symptoms.
  • Participation in clinical trials, which can advise on the best outcomes, should be enhanced.
  • The organisation of services should be such as to ensure that those with the disease have as good an outcome as possible.
  • The full range of palliative care services should be available for those with established disease.
  • Recommendation to enhance the Registry:
  • The recording of stage diagnosis for all tumours should be enhanced.
  • A Unique Patient Client Identifier should be introduced to improve identification of individuals and prevent duplication.
  • Pathologically diagnosed CIN III (severe dysplasia) tumours should be consistently coded as SNOMED code M80772.
  • A clear distinction should be made between invasive and non-invasive bladder tumours.
  • Address information should conform to the British Standard BS6667.
  • Pathology systems should try to improve completeness of address information, especially post codes.
  • Haematology bone marrow records should be computerised.

 

 

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