Hospital-Based Cancer Registry

HOSPITAL-BASED CANCER REGISTRY

FRERE HOSPITAL, EAST LONDON CANCER INCIDENCE 1991-2009 TECHNICAL REPORT

OCTOBER 2017 COMPILED BY: NOMFUNEKO SITHOLE | SENIOR RESEARCH TECHNOLOGIST South African Medical Research Council Burden of Disease Research Unit Cape Town

NTUTHU SOMDYALA | SENIOR SCIENTIST South African Medical Research Council Burden of Disease Research Unit Cape Town

EDITED BY: DR ELVIRA SINGH | PUBLIC HEALTH SPECIALIST HEAD: NATIONAL CANCER REGISTER National Health Laboratory service Johannesburg

CONTACT DETAILS Nomfuneko Sithole South African Medical Research Council Burden of Disease Research Unit

Physical address Francie Van Zijl Drive Parow Valley

Tel: +27(0) 219380958 Fax: 0866769160 Email: [email protected] http://www.samrc.ac.za/intramural-research-units/BOD COPYRIGHT INFORMATION Copyright 2017, South African Medical Research Council. All materials in this report may be reproduced and copied for non- commercial purposes; citation as to source, however, is appreciated.

SUGGESTION CITATION Sithole N and Somdyala NIM. Hospital-Based Cancer Registry Frere Hospital, East London, Cancer Incidence 1991-2009 Technical Report. Cape Town: South African Medical Research Council, 2017. ISBN: 978-1-928340-24-9.

ACKNOWLEDGEMENTS The following individuals are acknowledged for their contribution and input in many ways including technical support:

• Dr BP Pokharel who is the Head of Frere Hospital Oncology and Radiation Department • Miss Bulelani Nodliwa who is the secretary at Frere Hospital Oncology and Radiation Department • Mr Jermaine Carelse of SAMRC IT Department • Miss Akhona Ncinitwa, Mr Linda Mbuthini, Mrs Ria Laubscher, Mr William Msemburi and Mr Ian Neethling who are SAMRC colleagues • Prof Ehimario Igumbor who was the supervisor for Masters in Public Health thesis upon which this report is based

PERMISSION AND FUNDING • Dr J Thomas who is the Director of Clinical Governance at Frere Hospital granted permission to use Frere Hospital Cancer Register • The Eastern Cape Health Research Committee granted permission for this study • The South African Medical Research Council funded the study

HOSPITAL-BASEDHOSPITAL-BASED CANCER CANCER REGISTRY: REGISTRY: FRERE FRERE HOSPITAL HOSPITAL | | CANCER CANCER INCIDENCE INCIDENCE 1991 1991 - - 2009 2009 | | TECHNICAL TECHNICAL REPORT REPORT | | PAGE PAGE I 1 TABLE OF CONTENTS

PREFACE 1

EXECUTIVE SUMMARY 2

BACKGROUND 4

POPULATION PROFILE 2011 5

METHODS 5

RESULTS 6

DISCUSSION 11

LIMITATIONS 12

CONCLUSION 12

REFERENCES 13

APPENDIX A 15

PAGE II | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT LIST OF TABLES

Table 1: Distribution of the top 10 cancer sites by sex, 1991-2009 7

LIST OF FIGURES

Figure 1: Eastern Cape Province population distribution by age and sex (Statistics South Africa, 2012) 5 Figure 2: Data exclusion steps 5 Figure 3: Annual number of malignant cases, 1991-2009 6 Figure 4: Percentage distribution of malignancy cases by race, 1991-2009 6 Figure 5: Percentage distribution of cases across municipalities, 1991-2009 6 Figure 6: Overall top 10 cancer sites (men and women combined), 1991-2009 6 Figure 7: Percentage distribution of boys cancers; 1991-2009 8 Figure 8: Percentage distribution of girls cancers; 1991-2009 8 Figure 9: Number of lung cancer cases by sex and year; 1991-2009 8 Figure 10: Number of lung cancer cases by age-group and sex; 1995-2000 8 Figure 11: Number of oesophageal cancer cases by year and sex; 1995-2009 8 Figure 12: Number of oesophageal cancer cases by age-group and sex; 1995-2009 9 Figure 13: Number of Kaposi sarcoma cases by sex; 1991-2009 9 Figure 14: Number of cases by selected cancer sites for three-time periods; 1995-1999, 2000-2004, 2005-2009 9 Figure 15: Lung cancer year and race interaction in men for three-time periods; 1995-1999, 2000-2004 & 2005-2009 9 Figure 16: Prostate cancer year and race interaction for three-time periods; 1995-1999, 2000-2004 & 2005-2009 9 Figure 17: Number of cases by selected cancer sites for three-time periods; 1995-1999, 2000-2004, 2005-2009 10 Figure 18: Cervical cancer year and race interaction for three-time periods; 1995-1999, 2000-2004 & 2005-2009 10 Figure 19: Breast cancer year and race interaction for three-time periods; 1995-1999, 2000-2004 & 2005-2009 10 Figure 20: Lung cancer year and race interaction for three-time periods; 1995-1999, 2000-2004 & 2005-2009 10 Figure 21: Comparison of ASRs per 100 000 population (World) of most common cancers in men; selected populations 11 Figure 22: Comparison of ASRs per 100 000 population (World) of most common cancers in women; selected populations 11

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE III

PREFACE

For the past 15 years, our Eastern Cape Cancer Registry (ECCR) may reflect the realities of current inequities in the health system team has visited Frere Hospital annually to follow-up on cancer in South Africa, such disparities in health care pose a major patients who have been referred from the former Transkei challenge to the proposed National Health Insurance. regions that are under surveillance in the population-based cancer registry. We have been made to feel welcome as we have The third surprise by her study has been the low numbers of searched through registers, folders and data bases to ensure oesophageal cancer cases reported in the data. Given the that we capture any cancer related visits that have been made historical studies of cancers based in this hospital as well as by our study population and we extract the clinical details to the contemporary data from the ECCR, we were very surprised include in our register. as it has been a leading cancer. We have noted a decline in oesophageal cancer death rates from the national mortality When Nomfuneko Sithole was a public health student, we data but also think that it may be possible that patients with decided to give her the task of examining the routinely collected oesophageal cancer have been treated in other wards without Oncology and Radiation Department data at the hospital and radiotherapy, and are missing from this data source. When setting investigate what it could tell us about the trends in cancer up a hospital-based cancer registry, it would be particularly patients treated in the hospital. Her study has surprised us in important to incorporate information from the surgical ward so several ways. as to include cancer patients who are given surgical treatment only. Firstly, she found that the routine data are reasonably complete and she has clearly demonstrated that they can easily be used to This study begs the question what is the incidence of describe the profile of cancer cases treated in the hospital. From oesophageal cancer? Our team harbors an interest in this, we learn that with limited additional resource, it would be complementing the ECCR with a population-based cancer possible for Frere Hospital to establish a hospital-based cancer registry in Buffalo City Municipality to measure the incidence registry. We believe that an ongoing registry would assist the and monitor changing cancer patterns in an urban setting and hospital with resource planning and future caseload prediction. thereby contribute towards cancer control initiatives. We hope It could also serve as a tool for research. that this report will ignite an interest in establishing a hospital- based cancer registry – they are one of the major sources of Secondly, her analysis has highlighted the changing patient information for population-based cancer registries. profile treated by the hospital since 1991, with an apparent shift to private sector care by a section of the population. While this

PROF DEBBIE BRADSHAW DIRECTOR: SAMRC Burden of Disease Research Unit September 2017

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 1 EXECUTIVE SUMMARY cancer patients increased from 74.3% in 1991 to 89.9% in 2009 while Whites decreased from 24.3% to 8.0%. Frere Hospital is a provincial government-funded referral hospital situated in East London in the Eastern Cape Province of South GEOGRAPHICAL DISTRIBUTION OF CASES Africa. It has an Oncology and Radiation Department that offers Cases originated from the Eastern Cape Province and beyond. A oncology services to patients coming from municipalities of large proportion was from Buffalo City Local Municipality (45.9%) Buffalo City, Amathole, OR Tambo, Chris Hani, uKhahlamba, while the remainder were from neighboring municipalities of Alfred Nzo and Cacadu. A few patients from Nelson Mandela Amathole (18%), OR Tambo (14%), Chris Hani (14%), UKhahlamba Municipality and even outside the Eastern Cape Province are also (4%), Alfred Nzo (2%), Cacadu (0.5%) and Nelson Mandela (0.4%). treated. Hospital-based cancer incidence has been investigated About 1.1% of the cases were from areas outside the Eastern periodically since the late 1950’s in this setting. This study sets out Cape Province. to examine trends in the radiotherapy administrative data system. MOST COMMON CANCERS DATA SOURCE Overall top 10 cancers recorded for both men and women Data clerks systematically record daily patient information include cervix (22.4%), female breast (14.0%), lung (9.4%), mouth using an administrative programme called the Radiotherapy (4.3%), colo-rectum (3.9%), larynx (3.7%), prostate (2.8%), tongue (RT) programme. The main objective of this registry is to keep (2.5%), oesophagus (2.2%) and Non-Hodgkin’s lymphoma (2.2%). patients’ information for planning for care and administration Unknown primary and ill-defined cancer sites featured among the of this hospital. Reasonably complete information has been most common cancers at 4.9% and 2.4%, respectively. collected in the RT programme from 01 January 1991. DISTRIBUTION OF COMMON CANCERS BY SEX This technical report includes cancer cases for the period 1991 TOP 5 CANCERS IN MEN: – 2009. Data were extracted from the RT programme into an • Lung (18.6%) excel spread sheet and checked for completeness and accuracy • Mouth (11.1%) of patients’ information details. Dates were formatted into • Larynx (8.3%) month-day-year sequence and checked so that the date of birth • Prostate (7.1%) precedes the date of diagnosis of the patient and the date last • Colo-rectum (5.3%) seen. A statistical analysis programme, STATA 14.0, was used to analyse the data. Age less than one year and greater than ninety- TOP 5 CANCERS IN WOMEN nine years was replaced as missing and excluded. Duplicates and • Cervix (36.6%) cases with missing diagnosis were also excluded during analysis. • Breast (22.0%) • Lung (3.5%) MALIGNANCIES • Colo-rectum (3.0%) A total of 20 350 malignant cases were recorded for the period • Mouth (3.0%) 1991-2009 with an annual average of 1 071. A consistent number of cases was observed each year with a noticeable increase from CHILDHOOD CANCERS (0-14 YEARS) 2003 to 2007. However, a decrease in 2008 was noticed. Only 19 A total of 360 cases were childhood cancers (0-14 years) which 737 cases had all the required variables for analysis i.e. 613 cases constituted 1.8% of the total cancers observed during this period. with missing age were excluded. BOYS CHARACTERISTICS OF CANCER CASES • Brain (21.1%) The majority of cases were female; 12 081 accounting for 61.2%. • Nephroblastoma (18.7%) There were 7 656 males accounting for 38.8% of the total. The • Retinoblastoma (14.8%) percentage of males dropped from 41.2% in 1991 to 28.7% in • Leukemia (9.6%) 2009 while female cases increased from 58.8% to 71.2%. Black • Hodgkin’s lymphoma (8.1%) Africans constituted most of the cases (80.3%), followed by • Bone (8.1%) Whites (14.5%), Coloureds (4.6%) and Asians (0.6%). Black African • Non-Hodgkin’s Lymphoma (7.7%)

PAGE 2 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT • Testis (5.7%) • Connective and soft tissue (4.3%)

GIRLS • Brain (20.4%) • Nephroblastoma (17.1%) • Retinoblastoma (13.8%) • Bone (12.7%) • Leukemia (9.9%) • Connective and soft tissue (7.7%) • Unknown primary (6.6%) • Non-Hodgkin’s lymphoma (6.1%) • Hodgkin’s lymphoma (5.5%)

TRENDS 1991-2009 Black African patients constituted many of the cancer patients seen at Frere Hospital and with some cancer sites showing progressive increase throughout the period of observation. These include breast, cervical and Kaposi sarcoma cancers in women. Conversely, White patients’ numbers progressively decreased which may reflect an increase in the number of private health facilities that cater for more affluent people who participate in medical aid schemes.

COMPARISON WITH OTHER POPULATIONS Oesophageal cancer is strikingly low when compared with earlier studies conducted in East London as well as contemporary data reported by the rural population-based Eastern Cape Cancer Registry. It is possible that due to the late presentation to the hospital of patients with oesophageal cancer, many are not treated by the Frere Hospital Oncology and Radiation Department as it will not be optimally benefiting.

CONCLUSION In conclusion, the Frere Hospital RT database was of reasonably good quality with an accepted level of completeness. Furthermore, good filing of medical records made it easy for the researcher to check data queries. The main purpose of a hospital-based cancer registry is to contribute to patient care administrative management. Nonetheless hospital-based cancer registries cannot provide measures of occurrence of cancer in a general population because it is not possible to define population from which cases come. Hospital-based cancer registries can be useful in epidemiology studies such as case-control studies to investigate, for example, aetiology of a cancer. They are one of the major sources of information for population-based cancer registries.

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 3 The Eastern Cape Cancer Registry (ECCR), National Cancer Registry BACKGROUND (NCR) and South African Paediatric Tumour Registry are the only three reliable cancer data sources in South Africa. The former The purpose of a hospital-based cancer registry is to serve the collects and reports incidence on all cancer sites in the rural Eastern needs of hospital administration, the hospital’s cancer programme, Cape Province and is population-based (Somdyala, et al., 2013). and above all, the individual patient (Young, 1991; Dos Santos NCR was established at the South African Institute for Medical Silva, 1999). It is recommended that every hospital practice proper Research (now the National Health Laboratory Service (NHLS) as a documentation of all patients visits and treatment, and subsequently collaborative venture with the Cancer Association of South Africa prepare annual reports of the cancer burden. The reports should (CANSA) and the Department of Health (Sitas, 1987). It provides be available to the hospital administration for resource planning national cancer incidence rates based on pathology reports from and future caseload prediction. The report should include at least both private and public laboratories (Sitas & Isaäcson, 1992; a statistical summary of the registry data for the calendar year and Mqoqi, Kellett, Sitas, & Musa, 2004). The South African Paediatric the distribution of primary sites, tables or graphs highlighting the Tumour Registry was established in 1987, collecting childhood most frequent sites, a detailed statistical analysis of one or more cancers. It is a central source of data provided by individual, major sites of cancer and an overall critique of the data (Young, hospital-based registries throughout the country (Stefan & Stones 1991). Subsequently, these reports can be used to develop 2012). Information produced by all these cancer registries plays a appropriate cancer control strategies, monitor the efficacy of the fundamental role not only to research communities in South Africa, existing cancer control programmes in the hospital as well as serve but regionally and internationally also assisting the South African the needs of research communities. government in developing appropriate cancer control strategies.

A systematic search of reports on cancer cases seen at Frere The growing awareness of the burden of cancer in South Africa Hospital showed that several cancer incidence reports were as provided by these different cancer registries has led to the produced by researchers: Burrell (1957), Rose (1965 & 1973) implementation of important initiatives to prevent and control and Rose and McGlashan (1975). Burrell (1957) reported that cancer. These include the amendment of the Tobacco Products oesophageal cancer incidence in East London showed marked Control Act as early as 1993 to restrict the advertising of tobacco racial disproportion which was higher in black men compared to products, prohibit smoking in public places and tobacco white. Other cancers reported in this report were cervix, tongue, manufacturers’ sponsorships, as well as raising the legal minimum breast and mouth. Supplementary reports showed a similar picture age for purchasing tobacco from 16 to 18 years (Stefan, et al., of high numbers of oesophageal cancer (Rose, 1965; Rose, 1973). 2013). This was a government effort to reduce lung cancer and Due to marked variation in the reported incidence of oesophageal other upper respiratory tract conditions associated with tobacco cancer, data collection methods were improved and a special smoking. The introduction of a cervical cancer screening programme Bantu Cancer Registry was established in East London specifically in 1999 was proposed for screening women over the age of 30 for oesophageal cancer. The focus was on cases coming from the years and offer asymptomatic women 3 free smears in a lifetime, former Transkei region of the Eastern Cape Province. 10 years apart (http://www.doh.gov.za, www.capegate.gov.za). However, the uptake and impact of this policy on cervical cancer Many funding sources supported the Bantu Cancer Register incidence in South Africa has been poor due to its fragmented and including the International Union Against Cancer (UICC). Since uncoordinated implementation (Denny, 2010; Stefan et al., 2013). 1986, the South African Medical Research Council took over and restructured the registry to concentrate only on four magisterial Other cancer control initiatives include the establishment of a new areas; two so-called oesophageal hotspots; Butterworth and regulation on cancer registration in April 2011 to enhance cancer Centane magisterial areas and other two low incidence areas; Bizana reporting, revitalization of the NCR by the South African Department and Lusikisiki (Jaskiewicz, Marasas & Van de Walt, 1987, Somdyala, of Health and the establishment of a Ministerial Advisory Committee et.al., 2003). Since 1998 this registry was further developed to on the prevention and control of cancer in year 2012 (Stefan et include 10 magisterial areas and named PROMEC (Programme al., 2013; South African Government, 2011). Cancer registration on Mycotoxins and Experimental Carcinogenesis). Recently, it has regulation makes it compulsory for every health facility to record become known as the Eastern Cape Cancer Registry (ECCR). These and notify every cancer case that is diagnosed. Proper keeping of magisterial areas include four initial areas (Butterworth, Centane, records is always a good practice that needs to be strengthened and Bizana and Lusikisiki), Idutywa, Nqamakwe, Willowvale, the last maintained. Analysis and reporting from time to time cannot be over two in the north; UMzimkhulu and Port St Johns which were later emphasized. It is the information generated by these reports that excluded due to change in municipal boundaries. guide better planning and cancer control initiates.

PAGE 4 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT department’s database software and transferring them into an POPULATION PROFILE 2011 excel spread sheet to prevent alterations to the database. Eastern Cape (EC) Province is the second largest province in South Africa and has the third largest population, approximately 6.5 DATA CHECKING AND CODING million people, which is 12.7% of South Africa’s population (Statistics Data checking included checks for completeness and accuracy South Africa, 2012). The demographic profile of the residents of both personal and tumour patient information details for each indicates that the population aged 14 years or below decreased case captured. Mandatory variables such as sex, age at diagnosis, from 36.6% in 2001 to 33.0% in 2011 whilst between ages 15 and cancer diagnosis and the date of diagnosis/incidence date were 64 years increased from 57.1% to 60.2% (Figure 1). The proportion also checked for each patient. All cases with errors were checked of females in this province is 52.9% whilst males are 47.1%. Black and verified with Clerks at Frere Hospital’s Oncology and Radiation Africans constitute the largest group of the population at 86.3%, Department. The accuracy of information was checked by followed by Coloureds (8.3%), Whites (4.7%), Asians (0.4%) and the performing consistency checks. remaining 0.3% are other. Consistency checks were carried out to ensure the concordance

There are two major urban areas within the EC Province which of specified data items against other recorded items e.g. prostate include Nelson Mandela Metropolitan and Buffalo City (BFC) the cancer in a female or cervical cancer in male. Dates were formatted latter is the key urban area of the eastern part of the EC. It consists into month-day-year and sequence checked so that the date of of several urban areas, stretching from the port city of East London birth preceded the date of diagnosis of the patient and the date to the east, through to Mdantsane and reaching Dimbaza in the last seen. Ages less than one year and greater than ninety-nine were west. Frere Hospital is situated in East London, and forms part of replaced as missing. Geographical areas were coded according to the East London Hospital Complex which offers specialist medical the South African Population Census and cancer sites manually care to the largest population in the province. This hospital is a coded for topography according to the International Classification major referral hospital for patients from Amathole, Chris Hani, OR of Diseases for Oncology (ICD-O), third edition (Fritz et al., 2000). Tambo, Ukhahlamba and Alfred Nzo Health Districts. Duplicate cases, non-malignant and those with missing diagnosis and age were excluded from analysis (Figure 2).

MALES FEMALES

80 - 84

70 - 74 22 173 records retrieved 60 - 64

50 - 54

40 - 44 1 823 records of cases were non-malignant 30 - 34

20 - 24 20 350 records of cases were 10 - 14 malignant 0 - 4 8,0 6,0 4,0 2,0 0,0 2,0 4,0 6,0 8,0 613 records of cases with PERCENTAGE missing age 2011 2001 2011 2001 19 737 records of cases were malignant and had all variables Figure 1: Eastern Cape Province population distribution by age and sex for analysis (Statistics South Africa, 2012)

Figure 2: Step by step cleaning of retrieved data; 1991-2009 METHODS ANALYSIS DATA COLLECTION Data were subsequently analysed using STATA 14.0 analysis software Frere Hospital Oncology and Radiation Department’s database to determine the proportion of cancer cases by year, sex, race, area dates back to the year 1990. The database was reviewed of origin/address and the most common cancer sites including retrospectively for a period of 19 years, from 01 January 1991 to childhood cancers. Frequency distribution tables were drawn and 31 December 2009. This was the most recent period for which cancer incidence rates estimated using population estimates from data were available and appeared up-to-date. An Information the 2007 Community Survey and the 2011 Population Census Technology (IT) specialist assisted with extracting data from the (obtained from Statistics South Africa during 2013). Age standardized

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 5 rates were calculated using the World Standard Population generally The geographical distribution of cases within the Eastern Cape (EC) applied to cancer incidence data. Poisson regression model was used is shown in Figure 5. A larger proportion of 45.5% of cases was to assess trends in cancer rates of most common cancers in men and from Buffalo City Local Municipality while the rest were distributed women over time, adjusted for age and sex, and interaction between around municipalities served by Frere Hospital Oncology and year and race, adjusted for age. Radiation Department that include Amathole (18%), OR Tambo (14%), Chris Hani (14%), UKhahlamba (4%), Alfred Nzo (2%), RESULTS Cacadu (0.5%) and Nelson Mandela (0.4%). About 1.1% were from areas outside the Eastern Cape Province. A total of 20 350 malignant cases (Figure 3) were recorded for the period 1991-2009 with an annual average of 1 071. For analysis 0.4 only 19 737 cases were included as they had all the variables as 0.5 1.1 Buffalo required in this study. This means 613 cases with missing age 2.6 Nelson Mandela were excluded. Consistent number of cases was observed with 3.7 a noticeable increase in number from 2003 to 2007. However, a Cacadu 14 decrease in 2008 was noticed. Alfred Nzo

45.5 Ukhahlamba 2000 1800 14.4 Chris Hani 1600 1400 OR Tambo 1200 17.8 1000 Amanthole 800 600 Other

NUMBER OF CASES 400 200 0 Figure 5: Percentage distribution of cases across municipalities, 1991-2009 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

YEAR MOST COMMON CANCERS Annual number of malignant cases, 1991-2009 Figure 3: Overall top 10 cancers observed in both men and women are shown in Figure 6. These include cervix (22.4%) breast (women) CHARACTERISTICS OF CANCER CASES (14.0%), lung (9.4%), mouth (4.3%), colo-rectum (3.9%), larynx The majority of cases were female; 12 081 accounting for 61.2%. (3.7%), prostate (2.8%), tongue (2.5%), oesophagus (2.2%) and There were 7 656 males accounting for 38.8% of the total. Male Non-Hodgkin’s Lymphoma (2.2%). patient percentage dropped from 41.2% in 1991 to 28.7% in 2009 while female cases increased from 58.8% to 71.2%. Black Africans constituted the majority of cases (80.3%), followed by Whites

(14.5%), Coloureds (4.6%) and Asians (0.6%) (Figure 4). Black Cervix 22,4 Breast 14,0 African cancer patients increased from about 74.3% in 1991 to Lung 9,4 89.9% in 2009 whilst Whites decreased from 24.3% to 8.0%. Mouth 4,3 Colo-Rectun 3,9 Larynx 3,7 Prostate 2,8 100 Tongue 2,5 90 Oesophagus 2,2 80 Non-Hodgkins 2,2 70 60 0 5 10 15 20 25 50 PERCENTAGE 40

PERCENTAGE 30 20 Figure 6: Overall top 10 cancer sites (men and women combined), 10 1991-2009 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

YEAR

ASIAN COLOURED WHITE BLACK

Figure 4: Percentage distribution of malignant cases by race, 1991-2009

PAGE 6 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT Table 1 shows the distribution of common cancers by sex for the (3.5%), colo-rectum (3.0%) and mouth (3.0%). Unknown primary period 1991-2009. The top 5 cancers in men were lung (18.6%), and ill-defined cancer sites in both men and women featured in the mouth (11.1%), larynx (8.3%), prostate (7.1%), and colo-rectum most common cancers’ list; 4.9% and 2.4%, respectively. (5.3%) whereas in women were cervix (36.6%), breast (22.0%), lung

Table 1: Distribution of the top 10 cancer sites by sex, 1991-2009

MALES FEMALES

CANCER SITE NUMBER % CANCER SITE NUMBER %

Lung 1421 18.6 Cervix 4427 36.6

Mouth 848 11.1 Breast 2662 22.0

Larynx 634 8.3 Lung 425 3.5

Prostate 546 7.1 Colo-Rectum 364 3.0

Colo-Rectum 407 5.3 Mouth 360 3.0

Tongue 395 5.2 Ovary 335 2.8

Unknown primary 376 4.9 Corpus Uteri 326 2.7

Other Skin 313 4.1 Other Skin 299 2.5

Oesophagus 251 3.3 Unknown primary 293 2.4

Pharynx 223 2.9 Non-Hodgkin Lymphoma 234 1.9

Non-Hodgkin Lymphoma 200 2.6 Oesophagus 187 1.5

Total 10 leading sites 5238 68.5 Total 10 leading sites 9619 79.6

Remaining sites 2242 29.2 Remaining sites 2356 19.5

Total 7656 100.0 Total 12081 100.0

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 7 CHILDHOOD CANCERS TRENDS OF MOST CANCERS A total of 360 cases were childhood cancers (boys and girls OVERALL CANCERS aged 0-14 years) which constituted 1.8% of the total cancers Lung cancer showed a progressive decrease especially in observed during this period. Distribution of cases according men while women had low stable numbers over the period of to sex as shown in Figure 7 is as follows: boys; brain (21.1%), observation (Figure 9). Nephroblastoma (18.7%), retinoblastoma (14.8%), leukemia (9.6%), Hodgkin’s lymphoma (8.1%), bone (8.1%), Non-Hodgkin’s lymphoma (7.7%), testis (5.7%), connective and soft tissue (4.3%). 120 100

80 BOYS 60 Brain 21,1 Nephroblastoma 18,7 40 Retinoblastoma 14,8 NUMBER OF CASES 20 Leukemia 9,6

Hodgkin’s Lymphoma 8,1 0 Bone 8,1

Non-Hodgkin’s 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Lymphoma 7,7 Testis 5,7 YEAR Connective & Soft tissue 4,3 MALES FEMALES 0 5 10 15 20 25 Figure 9: Number of lung cancer cases by sex and year; 1991-2009 PERCENTAGE

Figure 7: Percentage distribution of boys cancers; 1991-2009 Lung cancer starts very early in men with few cases observed from as early as under the age of 30 years whereas with women starts Girls cancers include the following; brain (20.4%), nephroblastoma from age 30 years with the peak at 60-69. Peak in men is observed (17.1%), retinoblastoma (13.8%), bone (12.7%), leukemia (9.9%), at 50-59 age –group (Figure 10) connective and soft tissue (7.7%), unknown primary (6.6%), Non- Hodgkin’s lymphoma (6.1%) and Hodgkin’s lymphoma (5.5%); Figure 8 below. MALES FEMALES

114 141

GIRLS 71 456 73 Brain 20,4 428 Nephroblastoma 17,1 8 210 222 15 Retinoblastoma 13,8 65 34 Bone 12,7 0 - 9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80+ Leukemia 9,9 AGE SPECIFIC GROUPS Connective and Soft Tissue 7,7 Figure 10: Number of lung cancer cases by age-group and sex; 1995-2009 Unknown Primary 6,6 Non-Hodgkin’s Lymphoma 6,1 Hodgkin’s Lymphoma 5,5 Both men and women had low number of oesophageal cancer

0 5 10 15 20 25 cases. However, from 2006 a distinct progressive increase was PERCENTAGE observed in women (Figure 11).

Figure 8: Percentage distribution of girls cancers; 1991-2009 80

20 NUMBER OF CASES 10

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

YEAR

MALES FEMALES

Figure 11: Number of oesophageal cancer cases by year and sex; 1995-2009

PAGE 8 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT Oesophageal cancer starts very early in men with few cases observed Poisson regression analysis for each of the common cancers in from as early as under the age of 30 years whereas with women starts men was done to show the interaction between year and race from age 30 years just above twice in age group 40-49 and peak at adjusted for age. Figure 15 shows year and race interaction 60-69. Peak in men is observed at 50-59 age –group (Figure 12). for lung cancer in men. White men contributed mostly to the decrease in lung cancer rates over time particularly during the 2000-2004 period. The rate continued to decrease for white MALES FEMALES men but increased for black men during 2005-2009.

53 55 32 LUNG (M)

25 1.2 77 58 58 1 39 13 9 7 9 0.8 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80+ AGE SPECIFIC GROUPS 0.6

0.4 Figure 12: Number of oesophageal cancer cases by age-group and sex; 1995-2009 0.2

INCIDENCE RATE RATIO (IRR) RATIO INCIDENCE RATE 0 Kaposi sarcoma is one of cancers of interest especially during 1995 - 1999 2000 - 2004 2005 - 2009 this era of high HIV infection in South Africa. Up to the year YEAR

2000, cases in both men and women were less than 10. Steady BLACKS WHITES OVERALL increase was observed since 2000. Figure 15: Lung cancer year and race interaction in men for three-time periods; 1995-1999, 2000-2004 & 2005-2009 35

30 Figure 16 shows year and race interaction for prostate cancer. 25 White men contributed mostly to the decrease in prostate 20 cancer rate over time compared to black men. Black men 15 showed an increase during 2005-2009 period. 10 NUMBER OF CASES 5 PROSTATE 0 1.2 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

YEAR 1

0.8 MALES FEMALES 0.6 Figure 13: Number of Kaposi sarcoma cases by sex; 1991-2009 0.4

MEN CANCERS 0.2

Selected cancers include lung, prostate and oesophageal cancers (IRR) RATIO INCIDENCE RATE 0 (Figure 14). These cancers had a downward progressive decrease 1995-1999 2000-2004 2005 - 2009 YEAR over the period of observation. However, an increase in oesophageal and prostate cancers was observed during the last period. BLACKS WHITES OVERALL

Figure 16: Prostate cancer year and race interaction for three-time

600 periods; 1995-1999, 2000-2004 & 2005-2009

500

400

300

200

NUMBER OF CASES 100

1995 - 1999 2000 - 2004 2005 - 2009

Figure 14: Number of cases by selected cancer sites for three-time periods; 1995-1999, 2000-2004 & 2005-2009

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 9 WOMEN CANCERS Figure 19 shows a distinct interaction for breast cancer rate Breast, cervix and oesophageal cancers in (Figure 17) have ratio. Breast cancer rate ratio in black women increased whilst an upward trend with distinct increase observed from 2005 in white women it decreased over the period of observation. to 2009. Major contribution to women cancers was from both breast and cervix cancers. The number of oesophageal cancers BREAST (F) was very low and a considerable decrease was observed during 1.8 mid-period (2000-2004). However, a pick-up was noticed on 1.6 the last period (2005-2009). 1.4

1.2 1400 1

1200 0.8

100 0.6

800 0.4 INCIDENCE RATE RATIO (IRR) RATIO INCIDENCE RATE 600 0.2

400 0 NUMBER OF CASES 1995-1999 2000-2004 2005 - 2009 200 YEAR

0 BREAST CERVIX OESOPHAGUS BLACKS WHITES OVERALL

1995 - 1999 2000 - 2004 2005 - 2009 Figure 19: Breast cancer year and race interaction for three-time periods;1995-1999, 2000-2004 & 2005-2009 Figure 17: Number of cases by selected cancer sites for three-time periods; 1995-1999, 2000-2004, 2005-2009 Figure 20 shows the interaction between year and race for lung cancer in women. The rate ratio over time in both black and Poisson regression analysis was also done for each of the white women decreased. common cancers in women. Figure 18 shows the year and race interaction for cervical cancer. Cervical cancer rate ratio over time slightly decreased in both black and white women, with LUNG (F) white women contributing more to the decrease than black 1.2 women. 1

0.8

CERVIX 0.6

1.2 0.4

1 0.2

0.8 (IRR) RATIO INCIDENCE RATE 0 1995-1999 2000-2004 2005 - 2009 0.6 YEAR 0.4 BLACKS WHITES OVERALL 0.2 Figure 20: Lung cancer racial variations for three periods; 1995-2000, INCIDENCE RATE RATIO (IRR) RATIO INCIDENCE RATE 0 1995-1999 2000-2004 2005 - 2009 2001-2004 & 2005-2009 YEAR

BLACKS WHITES OVERALL

Figure 18: Cervical cancer year and race interaction for three-time periods; 1995-1999, 2000-2004 & 2005-2009

PAGE 10 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT Prostate, colo-rectum and Kaposi sarcoma also rated the DISCUSSION lowest (Figure 21). Except for the lung cancer which rates were higher than the Africa continent and NCR but lower than The majority of patients are from Buffalo City (45.9%) while Southern Africa rates (Figure 21). The trend of lung cancer the rest were distributed around municipalities served by Frere over the period was observed to have decreased and this was Hospital Oncology and Radiation Department that include comparable to the national decrease in prevalence of smoking Amathole, OR Tambo, Chris Hani, UKhahlamba, Alfred Nzo, amongst adults as well as in learners (from 23% in 1999 to Cacadu and Nelson Mandela. Only 1.1% of the cases were from 16.9% in 2011) reported in South Africa (Reddy, et al., 2013; areas outside the Eastern Cape Province. Black African patients Mayosi et al., 2009). The decline in smoking prevalence rates constituted many cancer patients seen at Frere Hospital. Some together with the lung cancer percentages in this study could cancer sites showed progressive increase throughout the period be expected as South Africa is one of the leading countries in of observation, 1991-2009. These included breast, cervical and development and implementation of an appropriate tobacco Kaposi sarcoma cancers in women. Conversely, white patient’s control plan (Mayosi et al., 2009). numbers progressively decreased. Most common cancers in men were lung, prostate and oesophageal. In this study, women cancer which rated the highest was cervical cancer accounting for 36.6% of all female cancers COMPARISON OF MOST COMMON CANCERS recorded during this period (Table 1). Cervical cancer trends WITH OTHER SELECTED POPULATIONS remained stable over the period with an increase in numbers Previous reports on cancer profile in Frere Hospital according observed during 2007 and 2009 particularly in Black women to Burrell (1957) and Rose (1965,1973 & 1975) reported while White, Coloured and Asian progressively decreased. Age oesophageal cancer as leading cancer mainly in men and Standardise Rates (ASRs) when compared with other selected lung cancer did not feature. In this study, leading cancers populations rated the highest with ASR 44.1 per 100 000. differ significantly (Table 1). Though oesophageal cancer was These incidence rates were even higher than Southern Africa; amongst the top ten most common cancers, it accounted for ASR 31.5 per 100 000 (Ferlay, et al., 2013), National Cancer only 2.2% of all cancers observed during the period. Buffalo Registry; ASR 21 per 100 000. Eastern Cape Cancer Registry; City incidence rates (per 100 000) when compared with other which is population-based also has, generally very high rates populations rated the lowest (Figure 21). with the latest reported as high as ASR 29 per 100 000 but

MOST COMMON CANCERS IN MEN lower than Buffalo City’s.

Colo-rectum

Liver MOST COMMON CANCERS IN WOMEN

Kaposi sarcoma Colo-rectum

Prostate Liver

Lung Kaposi sarcoma

Oesophagus Lung

0 10 20 30 40 50 60 70 Breast WORLD AFRICA SOUTHERN AFRICA NCR ECR BF Cervix

0 10 20 30 40 50 Figure 21: Comparison of ASRs per 100 000 population (World) of most WORLD AFRICA SOUTHERN AFRICA NCR ECR BF common cancers in men; selected populations Sources: Ferlay et al., 2013, http://www.cansa.org.za/files/2016/08/NCR- Figure 22: Comparison of ASRs per 100 000 population (World) of 2011-cancer tables.pdf and Somdyala et al., 2013 most common cancers in women; selected populations

Oesophageal cancer is also strikingly low when compared with Sources: Ferlay et al., 2013, http://www.cansa.org.za/files/2016/08/ NCR-2011-cancer-tables.pdf and Somdyala et al., 2013 contemporary data reported by the rural population-based Eastern Cape Cancer Registry in the former Transkei region of the Most common cancers in women were cervical, breast, lung, province. This cancer has been reported as the leading cancer in liver, colo-rectum. Cervical and breast cancers particularly males and second leading in females in this rural area (Somdyala are also reported to be the most common cancers in Africa et al., 2010; Somdyala et al., 2013; Somdyala et al., 2014). It including South Africa (Parkin et al., 2008; Denny, 2010). As is possible that due to the late presentation to the hospital of reported by the Eastern Cape Cancer Registry ASRs per 100 patients with oesophageal cancer most of them are not referred 000 for the periods 1998-2002, 2003-2007 and 2008-2012 of to Frere Hospital Oncology and Radiation Department for further 21.7, 19.4 and 29.0, respectively (Somdyala et al., 2014). treatment as it will not be optimally benefiting.

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 11 Breast cancer was the second most common higher in white news is this problem was picked over only one year reflecting women when compared to those of black African. Breast a small percentage of cases missed in Frere Hospital Oncology cancer had lower rates; ASR 29 per 100 000 when compared and Radiation Department. with other selected populations. South Africa’s incidence rates (ASR 38.9 per 100 000) are the second highest to the world’s ASRs even higher when compared to Africa. Literature concurs CONCLUSIONS with these high rates (Verobiof, Sitas & Verobiof, 2001; Mqoqi et al., 2004; Parkin et al., 2008) particularly in white women. Frere Hospital database was of reasonably good quality with Conversely, breast cancer incidence rates in black African an accepted level of completeness. Good filing of medical women are low due to certain factors known to be important records made things easy for the researcher and facilitated in breast cancer epidemiology that is unique to black women double checks of information where doubts arose. Hospital- which include late mernache among others (Verobiof, Sitas based cancer registries record all patients treated in a & Verobiof, 2001). Somdyala et al., 2014, reported ASR of hospital. Their main purpose is to contribute to patient care 7.5 per 100 000 population during 2003-2007 period with an administrative management. Nonetheless hospital-based increase of ASR 12.2 per 100 000 during 2008-2012 period cancer registries cannot provide measures of occurrence of for the rural population of the Eastern Cape Province. This cancer in a general population because it is not possible to increase might reflect change in fertility patterns and social define population from which cases come. Hospital-based status in this rural population. cancer registries can be useful in epidemiology studies such as case-control studies to investigate, for example, aetiology Other cancers in women include lung (ASR 3.7 per 100 000), of a particular cancer. They are one of the major sources of liver (ASR 0.1 per 100 000) and colo-rectum (ASR 3.4 per 100 information for population-based cancer registries. 000) which were low compared to other selected populations. Kaposi sarcoma with ASR 2.4 per 100 000 was quite low. Human Herpes Virus 8 (HHV-8) causes Kaposi sarcoma. In the presence of other factors such as immune suppression or other effects of HIV in the body, HHV-8 is thought to encourage normal cells to change into tumour cells (Di Lorenzo, et al., 2007). In many cases, the best initial approach to treating Kaposi sarcoma may be to lower viral load and boost the immune system using HIV treatment. In this study a progressive increase was observed from 2000 onwards. Is this related to better diagnosis? With Anti-Retroviral therapy (ARVs) roll out in South Africa, Kaposi sarcoma is expected to decrease.

LIMITATIONS

One of quality indicators variables important in cancer registration is percentage of diagnoses verified pathologically. This kind of information i.e. basis of diagnosis was not documented as a result is not available. Database also included non-malignant cases such as thyrotoxicosis. This needed careful checks and exclusion of all those cases before analysis. A decrease of all cases particularly in 2008 is an indicative sign of administration problem; either recording was not done properly on daily basis or there is a month or months that had a problem with a recording clerk. The good

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PAGE 14 | HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT APPENDIX A

Table A 1.1: Overall malignant cases by site, age group and sex,1991-2009

MALES % OF CANCER SITE 0 - 9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80+ TOTAL ICD 10 TOTAL LIP 0 0 1 2 7 10 7 8 5 40 0.5 C00 TONGUE 0 0 1 12 47 125 120 69 21 395 5.2 C01-C02 MOUTH 0 2 4 21 143 228 242 159 49 848 11.1 C03-C08 PHARYNX 0 4 3 15 25 69 73 25 9 223 2.9 C10-C14 OESOPHAGUS 0 1 2 7 58 77 58 39 9 251 3.3 C15 STOMACH 0 0 0 3 11 14 17 4 0 49 0.6 C16 SMALL INTESTINE 0 0 1 1 3 0 1 0 1 7 0.1 C17 COLO-RECTUM 0 5 16 46 48 85 99 76 12 407 5.3 C18-C20 ANUS 0 0 3 10 13 14 11 5 6 62 0.8 C21 LIVER 0 1 5 5 2 3 2 4 0 22 0.3 C22 GALLBLADDER 0 0 0 1 0 2 1 0 0 4 0.1 C23 PANCREAS 0 0 1 0 3 7 9 2 0 22 0.3 C25 NASAL CAVITY & 0 0 0 1 1 1 1 2 1 7 0.1 C30 MIDDLE EAR ACCESSORY SINUS 0 2 6 9 24 32 34 19 7 133 1.7 C31 LARYNX 0 0 4 3 70 200 212 116 29 634 8.3 C32 LUNG 0 2 4 65 210 456 428 222 34 1,421 18.6 C33-C34 BONE 7 44 24 9 4 4 2 3 2 99 1.3 C40-C41 OTHER SKIN 0 1 9 20 45 68 79 61 30 313 5.1 C43-C44 MESOTHELIOMA 0 0 0 0 5 5 9 7 1 27 0.4 C45 KAPOSI SARCOMA 0 4 31 61 40 10 9 4 3 162 2.1 C46 CONNECTIVE & 3 24 23 10 17 22 26 13 5 143 1.9 C47-C49 SOFT TISSUE BREAST 0 0 0 3 9 21 27 23 9 92 1.2 C50 PENIS 0 0 1 5 5 11 5 2 3 32 0.4 C60 PROSTATE 0 0 0 1 9 65 245 171 55 546 7.1 C61 TESTIS 12 2 14 22 19 13 8 3 2 95 1.2 C62 KIDNEY 36 4 0 0 13 9 16 6 0 84 1.1 C64 BLADDER 0 2 2 2 8 19 31 39 14 117 1.5 C67 EYE 30 1 2 10 10 7 9 6 4 79 1.0 C69 BRAIN 31 18 8 20 15 29 17 5 0 143 1.9 C70-C72 THYROID GLAND 0 1 3 4 8 17 10 6 1 50 0.7 C73-C75 ILL-DEFINED 1 2 6 11 31 40 33 22 6 152 2.0 C76 LYMPH NODES 1 1 1 7 24 52 64 33 11 194 2.5 C77 UNKNOWN 1 2 8 12 43 54 62 35 7 224 2.9 C80 PRIMARY HODGKIN’S 11 21 32 23 13 16 10 14 1 141 1.8 C81 DISEASE NON-HODGKIN’S C82- 10 12 10 40 29 38 33 21 7 200 2.6 LYMPHOMA C85;C96 MULTIPLE 0 0 0 4 27 53 54 35 9 182 2.4 C90 MYELOMA LEUKEMIA 12 11 3 2 1 10 11 6 0 56 0.7 C91-C94 TOTAL 155 167 228 467 1,060 1,886 2,075 1,265 353 7,656 100.0

HOSPITAL-BASED CANCER REGISTRY: FRERE HOSPITAL | CANCER INCIDENCE 1991 - 2009 | TECHNICAL REPORT | PAGE 15 FEMALES % OF CANCER SITE 0 - 9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80+ TOTAL ICD 10 TOTAL LIP 0 0 3 0 4 9 10 8 3 37 0.3 C00 TONGUE 0 0 2 2 3 16 35 24 9 91 0.8 C01-C02 MOUTH 0 8 13 17 38 66 110 74 44 360 3.0 C03-C08 PHARYNX 0 1 3 6 12 14 19 9 8 72 0.6 C10-C14 OESOPHAGUS 0 0 0 13 32 53 55 25 9 187 1.5 C15 STOMACH 0 1 2 2 5 5 14 9 3 41 0.3 C16 SMALL INTESTINE 0 0 1 1 2 1 2 1 0 8 0.1 C17 COLO-RECTUM 0 3 21 39 69 68 92 50 21 364 3.0 C18-C20 ANUS 0 0 2 7 4 9 11 4 6 43 0.4 C21 LIVER 0 0 1 1 0 1 3 2 0 8 0.1 C22 GALLBLADDER 0 0 0 0 1 7 4 2 0 14 0.1 C23 PANCREAS 0 1 0 2 4 5 5 1 0 18 0.1 C25 NASAL CAVITY & 0 0 1 0 3 4 3 2 1 14 0.1 C30 MIDDLE EAR ACCESSORY SINUS 0 0 5 8 11 15 21 16 3 79 0.7 C31 LARYNX 0 0 0 5 13 29 32 12 2 93 0.8 C32 LUNG 0 0 3 8 71 114 141 73 15 425 3.5 C33-C34 BONE 2 45 18 4 9 6 3 1 1 89 0.7 C40-C41 OTHER SKIN 0 0 9 24 30 49 67 69 51 299 2.5 C43-C44 MESOTHELIOMA 0 0 0 0 1 0 2 1 1 5 0.0 C45 KAPOSI SARCOMA 0 3 56 69 28 15 4 1 2 178 1.5 C46 CONNECTIVE & 5 21 22 21 25 13 23 12 4 146 1.2 C47-C49 SOFT TISSUE BREAST 0 4 65 346 648 605 509 346 139 2,662 22.0 C50 VULVA VAGINA 0 3 8 10 29 28 46 25 9 158 1.3 C51-C52 CERVIX 0 1 64 465 940 1,064 1,156 569 168 4,427 36.6 C53 CORPUS UTERI 0 0 1 4 15 49 150 92 15 326 2.7 C54 OVARY 1 16 26 42 58 63 73 45 11 335 2.8 C56 PLACENTA 0 6 35 33 19 9 7 2 1 112 0.9 C58 KIDNEY 30 2 3 6 5 7 6 4 1 64 0.5 C64 BLADDER 0 0 0 3 0 11 13 18 11 56 0.5 C67 EYE 24 1 20 26 19 11 7 10 5 123 1.0 C69 BRAIN 25 25 7 18 19 18 14 6 0 132 1.1 C70-C72 THYROID GLAND 0 3 16 32 35 28 30 14 6 164 1.4 C73-C75 ILL-DEFINED 2 1 4 9 28 31 37 20 11 143 1.2 C76 LYMPH NODES 0 0 4 7 11 19 29 13 9 92 0.8 C77 UNKNOWN 0 2 3 16 21 31 40 31 6 150 1.2 C80 PRIMARY HODGKIN’S 6 13 18 21 15 9 12 9 2 105 0.9 C81 DISEASE NON-HODGKIN’S C82- 6 11 22 45 31 30 50 32 7 234 1.9 LYMPHOMA C85;C96 MULTIPLE 0 0 0 10 18 45 60 30 14 177 1.5 C90 MYELOMA LEUKEMIA 8 15 3 4 2 2 9 2 5 50 0.4 C91-C94 TOTAL 109 186 461 1,326 2,268 2,559 2,904 1,664 604 12,081 100.0

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