ARTICLE doi: 10.12032/TMRC201800077

TMR Cancer

Analysis of cancer incidence and mortality in cancer registries, 2016

Hui-Xin Sun1, 2, 3, Mao-Xiang Zhang1, 2, 3, Wan-Ying Wang3, Hai-Han Jia3, Bing-Bing Song1, 2, 3*

1Institute of Cancer Prevention and Treatment, Medical University, Harbin 150081, ; 2Heilongjiang Academy of Medical Science, Harbin 150081, China; 3Heilongjiang Cancer Center, Harbin 150081, China.

*Corresponding to: Bing-Bing Song. Institute of Cancer Prevention and Treatment, Harbin Medical University, No.6 Baojian Road, Nangang District, Harbin 150081, China. Email: [email protected].

Highlights

The article comprehensively analyzes the incidence and mortality of cancer in Heilongjiang Province, lists the location of cancer incidence and death, and comprehensively expounds the current status of cancer in Heilongjiang Province, and expounds the causes and susceptible factors of several cancers with high incidence rate, which can provide theoretical basis for the province to formulate relevant health policies.

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doi: 10.12032/TMRC201800077 ARTICLE Abstract Background: Cancer incidence rate has been increasing in recent years, and it has improved people’s living and financial burden. The incidence and mortality of malignant tumors in the Heilongjiang cancer registry area in 2016 were analyzed, which provided a scientific basis for the prevention and treatment of malignant tumors in Heilongjiang. Methods: The incidence and death data of tumors were collected from 10 tumor registration areas in Heilongjiang Province in 2016. According to the stratification of urban and rural areas and gender, the crude rate, standard rate, accumulative rates (0–74 years old) were calculated. The China 2000 population census data and Segi’s standard population were used for calculating age-standardized rates. Results: The incidence rate of malignant tumors in the Heilongjiang cancer registry area was 286.05/100,000 in 2016, age-standardized incidence rates by standard Chinese population and by standard world population were 168.11/100,000 and 164.69/100,000 with the cumulative incidence rate (0–74 years old) of 18.55%. The incidence of malignant tumors in urban areas was 313.60/100,000, and that in rural areas was 212.26/100,000. The frequency of malignant tumors in males was 295.94/100,000, higher than that in females (276.40/100,000). Lung cancer had the highest incidence followed by breast cancer, colorectal cancer, liver cancer and thyroid cancer. The mortality rate of malignant tumors in Heilongjiang cancer registration areas was 183.56/100,000, age-standardized mortality rates by standard Chinese population and by standard world population were 99.89/100,000 and 99.78/100,000 with the cumulative mortality rate (0–74 years old) of 10.95%. The mortality rate of malignant tumors in urban areas was 194.69/100,000, and that in rural areas was 153.73/100,000. The mortality rate of the male malignant tumor was 222.55/100,000, higher than that of a female malignant tumor (145.51/100,000). Lung cancer had the highest mortality followed by liver cancer, colorectal cancer, gastric cancer and breast cancer. Conclusion: Lung cancer, liver cancer, breast cancer and colorectal cancer were the most common cancers in Heilongjiang Province, which should be taken as the key cancer species for prevention and treatment. The incidence of thyroid cancer is higher in Heilongjiang Province, but the mortality rate is lower, which also needs attention. Key words: Tumor registry, Incidence, Mortality, Heilongjiang

Abbreviations: MV%, morphologically verified cases; DCO%, percentage of death certificate only; M/I, mortality to incidence ratio; ASIRC, age-standardized incidence rates by the standard Chinese population; ASIRW, age- standardized incidence rates by the standard world population; CR, cancer registration; HBV, hepatitis B virus; ASMRC, age-standardized mortality rates by standard Chinese population; ASMRW, age-standardized mortality rates by standard world population; HP, Helicobacter pylori. Competing interests: The authors declare that they have no conflict of interest. Citation: Hui-Xin Sun, Mao-Xiang Zhang, Wan-Ying Wang, et al. Analysis of cancer incidence and mortality in Heilongjiang cancer registries, 2016. TMR Cancer 2020, 3 (4): 153–160. Executive Editor: Yu-Ping Shi. Submitted: 01 June 2020, Accepted: 09 June 2020, Online: 23 June 2020

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ARTICLE doi: 10.12032/TMRC201800077 audited according to the requirements. A total of 10 Background CR areas were included, including seven urban areas (Nangang District，Harbin City, , In September 2019, National Health Commission and Harbin City, , Harbin City, Aimin other 10 departments jointly issued the District, City, Dongan District, implementation plan of Health China action: cancer Mudanjiang City, Xi’an District, Mudanjiang City, prevention and control (2019–2022) [1]. Heilongjiang Yangming District, Mudanjiang City) and three rural Province actively implemented comprehensive areas ( City, and Hailin City). prevention and control measures following the The 10 CR areas included 4,733,728 registered requirements of the plan, such as steadily promoted residents (2,337,946 males and 2,395,782 females), of system construction, tumor registration, early which 3,447,076 were in urban areas and 1,286,652 in diagnosis and treatment, standardized diagnosis and rural areas, accounting for 12.5% of the registered treatment, scientific and technological innovation and population in Heilongjiang Province in 2015. The other critical areas, and achieved initial results in total MV%, DCO% and M/I of CR areas in prevention and control [2]. However, the current Heilongjiang Province were 79.44%, 1.13% and 0.64 cancer prevention system and serviceability in our respectively. The indicators indicated that the data had province are still confusing to meet the demand of good integrity and reliability. people’s growing health. Moreover, cancer prevention and treatment of insufficient imbalance problem are Statistical analysis still outstanding, cancer prevention and control of form are still grim, to understand the current situation Crude incidence and mortality, sex and age-specific of incidence and mortality in our province. Now incidences and mortalities, age-standardized rates, finishing tumor incidence and mortality data in cumulative rates, and truncated rates were analyzed. Heilongjiang Province in 2016, through the review The top 10 malignant tumors in incidence and and the evaluation results, select quality qualified mortality were described emphatically. The Segi’s registry data analysis, now report as follows. world population and the China 2000 population census data were used as the population standards. Materials and methods Results Data sources Twelve registries in Heilongjiang Province reported The incidence of malignant tumors the data of cancer incidence, mortality and the In 2016, the crude incidence of malignant tumors was corresponding population database. The reporting 286.05/100,000 (295.94/100,000 males and time of the database was from January 1, 2016 to 276.40/100,000 females), age-standardized incidence December 31, 2016 for the first time confirmed new rates by the standard Chinese population (ASIRC) and malignant tumors (ICD10: C00.0–C97, D45–D47) by standard world population (ASIRW) were and benign tumors of the central nervous system 168.11/100,000 and 164.69/100,000 respectively, and (ICD10: D32.0–D33.9). Death cases were malignant the cumulative rate (0–74 years old) was 18.55%. tumor deaths in cancer registration (CR) areas during The crude incidence of malignant tumors in urban the same period. CR areas was 313.60/100,000 (323.85/100,000 males and 303.87/100,000 females), ASIRC and ASIRW Quality evaluation were 177.90/100,000 and 173.88/100,000, According to the Guidelines for Cancer Registration respectively, and the cumulative rate (0–74 years old) in China (2016) [3], and referring to Cancer Incidence was 19.61%. The crude incidence of malignant tumors in Five Continents Volume IX and the requirements in rural CR areas was 212.26/100,000 for registration quality of the International Cancer (224.95/100,000 males and 198.90/100,000 females). Research Center/International Association for Cancer ASIRC and ASIRW were 141.69/100,000 and Registration [4–5], SAS9.4 statistical software was 139.97/100,000, respectively, and the cumulative rate used to examine and evaluate the data. The integrity, (0–74 years old) was 15.52%. Compared with rural validity and timeliness of the data were assessed by areas, the total incidence of males and females in the main indicators such as percentage of urban areas is higher than that in rural areas (Table 1). morphologically verified cases (MV%), percentage of death certificate only (DCO%) and mortality to Age-specific morbidity incidence ratio (M/I). In 2016, the incidence of malignant tumors in the The quality evaluation criteria of CR data received Heilongjiang CR area increased slowly before 25 by the National Cancer Center in China are 55% < years old and rapidly after 25 years old. In the age MV% < 95%, 0.55% < M/I < 0.85, DCO% < 20%. group of 25–50 years old, the incidence of malignant The data reported in this study were assessed and tumors in females was higher than that in males. After Submit a manuscript: https://www.tmrjournals.com/cancer TMRC | June 2020 | vol. 3 | no. 4 | 155

doi: 10.12032/TMRC201800077 ARTICLE 55 years old, the incidence of malignant tumors in crude mortality rate of malignant tumors in urban males was higher than that in females. In urban areas, areas was 194.69/100,000, ASMRC and ASMRW the incidence rate of male and female in the age group were 99.76/100,000 and 99.56/100,000, respectively, of 0–20 years is rising slowly alternately; in the age the cumulative rate (0–74 years old) was 10.88%. In group of 25–50 years, the incidence rate of the female rural areas, the crude mortality rate of malignant is higher than that of the male; after the age of 55 years, tumors was 153.73/100,000, ASMRC and ASMRW the incidence rate of male is higher than that of the were 100.74/100,000 and 101.04/100,000, female. In rural areas, the incidence rate of females is respectively, and the cumulative rate (0–74 years old) higher than that of males in the age group of 15–50 was 11.22% (Table 3). years old. After 55 years old, the incidence rate of males is higher than that of females (Figure 1). Age-specific mortality In 2016, the mortality of malignant tumors in the Incidence of major cancers tumor registration area of Heilongjiang Province In 2016, lung cancer had the highest overall incidence increased slowly before the age of 35, and rapidly in tumor registries areas in Heilongjiang Province, after the age of 35, males have a higher mortality rate with a crude rate of 65.23/100,000, accounting for after age 30 than females. After the age of 40 in urban 22.81% of all new malignant tumor cases. It was areas, the incidence rate of males is higher than that of followed by breast cancer, colorectal cancer, liver females. After the age of 30 in rural areas, the cancer, thyroid cancer, stomach cancer, cervical incidence rate of males is higher than that of females cancer, ovarian cancer, pancreatic cancer and corpus (Figure 2). uteri cancer. Lung cancer has the highest incidence in urban areas, with a crude extent of 68.90/100,000, Mortality of malignant tumors accounting for 21.97% of all new malignant tumor Lung cancer ranked first among the malignant tumor cases. It was followed by breast cancer, colorectal death orders in the tumor registration areas of cancer, liver cancer, thyroid cancer, stomach cancer, Heilongjiang Province. Lung cancer with a crude cervical cancer, ovarian cancer, prostate cancer and mortality rate of 60.42/100,000, accounting for pancreatic cancer. Lung cancer was the most common 32.92% of all malignant tumor death cases, followed cancer in rural areas, with a crude incidence of by liver cancer, colorectal cancer, stomach cancer, 55.42/100,000, accounting for 26.11% of all new breast cancer, pancreatic cancer, cervical cancer, malignant tumor cases. Next were breast cancer, liver ovarian cancer, esophagus cancer and prostate cancer. cancer, stomach cancer, colorectal cancer, thyroid Lung cancer also ranks first in the death order of cancer, cervical cancer, pancreatic cancer, corpus uteri malignant tumors in urban areas, with a crude cancer, and esophageal cancer (Table 2). mortality rate of 62.95/100,000. The mortality rate was followed by liver cancer, colorectal cancer, Mortality of malignant tumors gastric cancer, breast cancer, pancreatic cancer, In 2016, the crude mortality rate of malignant tumors ovarian cancer, cervical cancer, esophageal cancer and in the Heilongjiang CR area was 183.56/100,000, age- prostate cancer. Lung cancer was the leading cause of standardized mortality rates by standard Chinese cancer mortality in rural areas, with a crude mortality population (ASMRC) and age-standardized mortality rate of 53.63/100,000. It was followed by liver cancer, ratesd by standard world population (ASMRW) were gastric cancer, colorectal cancer, pancreatic cancer, 99.89/100,000 and 99.78 /100,000, respectively, and breast cancer, cervical cancer, esophageal cancer, the cumulative rate (0–74 years old) was 10.95%. The brain cancer and leukemia (Table 4).

Table 1 Incidence of malignant tumors in Heilongjiang Province, 2016 Crued New Cumulative Area Gender incidence ASIRC (1/105) ASIRW (1/105) cases rate (0–74) (%) (1/105) Both 13,541 286.05 168.11 164.69 18.55 Total Male 6,919 295.94 173.45 173.11 20.05 Female 6,622 276.40 164.46 158.00 17.29 Both 10,810 313.60 177.90 173.88 19.61 Urban Male 5,435 323.85 182.62 181.98 21.15 Female 5,375 303.87 175.07 167.78 18.38 Both 2,731 212.26 141.69 139.97 15.52 Rural Male 1,484 224.95 149.72 150.50 17.04 Female 1,247 198.90 134.12 129.92 14.01 ASIRC, age-standardized incidence rates by the standard Chinese population; ASIRW, age-standardized incidence rates by the standard world population. 156 | no. 4 | vol. 3 | June 2020 | TMRC Submit a manuscript: https://www.tmrjournals.com/cancer

ARTICLE doi: 10.12032/TMRC201800077

Figure 1 Age-specific incidence of malignant tumors in CR areas of Heilongjiang Province. CR, cancer registration.

Figure 2 Age-specific mortality of malignant tumors in CR areas of Heilongjiang Province. CR, cancer registration.

Discussion carry out targeted prevention and control work, but also provide a theoretical basis for cancer prevention The health China action: cancer prevention and and control. The population covered by the 10 cancer control implementation plan (2019–2022) pointed out registries included in this study accounts for 12.5% of that the tumor registration and reporting system the total population of the province, and the results can should be improved. All districts and counties should reflect the latest cancer epidemic situation in be covered by 2022, and annual tumor registration Heilongjiang Province to a certain extent. reports should be issued at the provincial level. In 2016, the incidence of malignant tumors in the Heilongjiang Province achieved the full coverage of tumor registration areas of Heilongjiang Province was tumor registration districts and counties in 2020, and 286.05/100,000, which was the same as the national released the 2018 annual report of tumor registration average incidence level in 2015 (285.83/100,000) [8]. in Heilongjiang Province at the beginning of 2020 [6]. Compared with the 2015 data in this province Besides, Heilongjiang Province used the national CR (incidence of 259.90/100,000) [9], the incidence rate information platform system to report tumor incidence has increased. Compared with 2015, colorectal cancer and death data, which improved the reporting and pancreatic cancer increased by 1 position, liver efficiency and quality, and promoted the application cancer and uterus corpus cancer decreased by 1 research of big cancer data [7]. Timely understanding position, and other cancers did not change. The of cancer incidence trends in our province can not only incidence of cancer in urban areas was higher than that Submit a manuscript: https://www.tmrjournals.com/cancer TMRC | June 2020 | vol. 3 | no. 4 | 157

doi: 10.12032/TMRC201800077 ARTICLE in rural areas, and there was a big difference in the Tobacco Control in China in 2006, tobacco control rank of cancer species between urban and rural areas. policies have been introduced in various regions. In 2016, the mortality rate of malignant tumors in the Through legislation and measures such as raising tumor registration areas of Heilongjiang Province was tobacco tax rates, China’s public smoking rates drop 183.56/100,000, higher than the national average dramatically. However, the 2015 China Adult Tobacco death level in 2015 (the mortality rate was Survey Report issued by the China Center for Disease 170.05/100,000) and the provincial death rate in 2015 Control and Prevention points out that China’s (the mortality rate was 164.69/100,000). The crude tobacco consumption is prevalent and people still need mortality rate in urban areas is much higher than that to improve the awareness of the dangers of tobacco. in rural areas. Compared with 2015, colorectal cancer Breast cancer is associated with postmenopausal increased by 1 position, gastric cancer decreased by 1 hormone use, alcohol consumption and obesity, and position, and cervical cancer increased by 2 positions. breast-feeding and appropriate physical activity are Esophageal cancer decreased by 2 positions. protective factors against breast cancer [12]. The incidence and mortality of lung cancer ranked Helicobacter pylori (HP) is a significant risk factor first in our province, air pollution and occupational for gastric cancer. HP cause almost 90% of new cases exposure are also related to the occurrence of lung of non-cardia gastric cancer. Although the prevalence cancer. The development of industrialization has led of HP has a reasonable correlation with the incidence to increased air pollution in recent years, and long- rate of gastric cancer, in addition to HP, salt-cured term exposure to such an environment has foods, low fruit intake, alcohol consumption and significantly increased the risk of lung cancer. The smoking were also identified risk factors for gastric study shows that for every 10 μg/m3 increase of cancer [13]. World Cancer Research Fund/American PM2.5 in the surrounding environment, the risk of Institute for Cancer Research pointed out that salt and lung cancer increases 1.43 times [10–11]. Since the salted food may be the cause of gastric cancer. implementation of the Framework Convention on

Table 2 The incidences of top 10 types of cancer in Heilongjiang Province, 2016 Both Urban Rural Ra- Inciden Inciden Propo Proport- ASIRC ASIRC Incidence Proport ASIRC nk Site -ce Site -ce -rtion Site ion (%) (1/105) (1/105) (1/105) -ion (%) (1/105) (1/105) (1/105) (%) 1 Lung 65.23 22.80 35.05 Lung 68.90 21.97 34.99 Lung 55.42 26.11 35.91 2 Breast 50.00 8.92 31.43 Breast 56.99 9.40 34.96 Breast 30.31 7.03 20.47 3 Colorectum 32.98 11.53 17.89 Colorectum 39.05 12.45 20.13 Liver 29.38 13.84 18.94 4 Liver 27.25 9.53 15.30 Liver 26.46 8.44 14.21 Stomach 18.26 8.60 12.29 5 Thyroid 22.92 8.01 17.28 Thyroid 26.37 8.41 19.87 Colorectum 16.71 7.87 10.71 6 Stomach 21.12 7.38 11.66 Stomach 22.19 7.08 11.51 Thyroid 13.68 6.44 10.49 7 Cervix 15.28 2.70 9.42 Cervix 17.13 2.80 10.36 Cervix 10.05 2.31 6.74 8 Ovary 9.68 1.71 5.84 Ovary 10.85 1.78 6.31 Pancreas 8.86 4.17 5.75 Uterus 9 Pancreas 9.27 3.24 5.03 Prostate 9.47 1.47 4.74 corpus 6.86 1.57 4.46 Uterus 10 corpus 8.56 1.51 5.01 Pancreas 9.43 3.01 4.85 Esophageal 6.84 3.22 4.43 ASIRC, age-standardized incidence rates by the standard Chinese population.

Table 3 Cancer mortalities in Heilongjiang Province, 2016 Crued mortality ASMRC ASMRW Cumulative rate Areas Gender Deaths (1/105) (1/105) (1/105) (0–74) (%) Both 8689 183.56 99.89 99.78 10.95 Total Male 5203 222.55 124.64 125.52 14.20 Female 3486 145.51 77.13 76.04 7.98 Both 6711 194.69 99.76 99.56 10.88 Urban Male 3956 235.72 124.77 125.69 14.23 Female 2755 155.75 77.41 76.10 7.92 Both 1978 153.73 100.74 101.04 11.22 Rural Male 1247 189.03 124.90 125.85 14.13 Female 731 116.60 76.34 76.08 8.26 ASMRC, age-standardized mortality rates by standard Chinese population; ASMRW: age-standardized mortality rates by standard world population.

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Table 4 The mortality of top 10 types of cancer in Heilongjiang Province, 2016 Both Urban Rural Ra- Morta- Propo Morta- Propo Morta- Propo ASMRC ASMRC ASMRC nk Site lity -rtion Site lity -rtion Site lity -rtion (1/105) (1/105) (1/105) (1/105) (%) (1/105) (%) (1/105) (%) 1 Lung 60.42 32.92 31.76 Lung 62.95 32.33 30.91 Lung 53.63 34.88 34.69 2 Liver 26.47 14.42 14.68 Liver 24.80 12.74 13.05 Liver 30.93 20.12 20.01 3 Colorectum 16.88 9.20 8.74 Colorectum 19.29 9.91 9.36 Stomach 12.90 8.39 8.52 4 Stomach 15.70 8.55 8.36 Stomach 16.74 8.60 8.33 Colorectum 10.41 6.77 6.63 5 Breast 12.81 3.56 7.17 Breast 14.47 3.84 7.67 Pancreas 8.78 5.71 5.75 6 Pancreas 9.59 5.22 5.11 Pancreas 9.89 5.08 4.93 Breast 8.13 2.58 5.38 7 Cervix 5.93 1.63 3.58 Ovary 6.90 1.82 3.64 Cervix 5.10 1.62 3.62 8 Ovary 5.72 1.58 3.12 Cervix 6.22 1.64 3.56 Esophagus 4.90 3.19 3.08 9 Esophagus 5.64 3.07 2.95 Esophagus 5.92 3.04 2.92 Brain, CNS 2.88 1.87 1.98 10 Prostate 4.66 1.25 2.28 Prostate 5.84 1.46 2.63 Leukemia 2.64 1.72 2.07 ASMRC, age-standardized mortality rates by standard Chinese population; CNS, central nervous system.

High concentration of salt can lead to hyperplasia of promote the prevention of causes, reduce the damage gastric epithelium and damage of parietal cells, of external adverse factors. Also, it is recommended increase HP colonization, and improve the ability of that high-risk groups conduct early cancer screening HP to change the function of epithelial cells [14]. The to achieve the purpose of early detection, early main risk factors for liver cancer are chronic infection diagnosis and early treatment, so as to move forward with hepatitis B virus (HBV) or hepatitis C virus the prevention and treatment. More funds will be spent (HCV), aflatoxin-contaminated food, heavy alcohol on basic public health services, and suggest a consumption, obesity, smoking and type 2 diabetes. In comprehensive public health service system to countries with high rates of liver cancer, the key prevent and control incidence rate and mortality. determinants are chronic HBV infection and aflatoxin exposure. In contrast, in other countries (Japan, References Egypt), HCV infection may be the primary cause. The increased prevalence of obesity is believed to be a 1. Wang KC, Cheng FF, Hu JF, et al. Study on the contributing factor to the increased incidence of liver strategy of promoting “healthy China” action cancer in low-risk liver cancer areas [15]. Since 1982, from point to the area. Health Econ Res 2020, 37: primary prevention of the majority of liver cancer 15–172. cases has been possible through the HBV vaccine, 2. Huang WD, Yu HJ, Zheng EW, et al. Progress in which has significantly reduced the incidence of liver the economic evaluation of colorectal cancer cancer with HBV infection. However, there is screening. J Pract Oncol 2015, 29: 462–466. currently no vaccine to prevent HCV infection. 3. National Cancer Center. Guidelines for Cancer Although there has been a substantial decline in the Registration in China (2016). : People’s spread of HCV in resource-rich countries, however, Health Press, 2016. continued use of contaminated needles and unsafe 4. Bray F, Parkin DM. Evaluation of data quality in blood transfusions are still the routes of transmission the cancer registry: principles and methods. Part of the HCV [16]. The cause of thyroid cancer is I: comparability, validity and timeliness. Eur J unknown. The only established risk factor for thyroid Cancer 2009, 45: 747–755. cancer is ionizing radiation, especially in childhood. 5. Parkin DM, Bray F. Evaluation of data quality in However, there is evidence that other factors (obesity, the cancer registry: principles and methods. Part smoking, hormone exposure, and certain II. Completeness. Eur J Cancer 2009, 45: 756– environmental pollutants) may also play a role. The 764. incidence of thyroid cancer has been increasing in 6. Qu GF, Song BB, Liu YC. 2018 Heilongjiang many countries since the early 1980s, but the mortality Cancer Registration Annual Report. Harbin: rate has remained fairly stable. An increasing Heilongjiang Science and Technology Press, incidence of thyroid cancer is believed to be caused by 2019. overdiagnosis, especially after the introduction of new 7. Li C, Lan L, Yang C, et al. Analysis of the diagnostic techniques [17]. characteristics of cancer incidence and death in The burden of cancer in our province is still heavy, Harbin from 2015 to 2017. J Pract Oncol 2019, so we can take a three-level prevention model of 33: 62–66. cancer with community hospitals as the starting point, 8. Sun KX, Zheng RS, Zhang SW, et al. Analysis of

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