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Published in: BMC Cancer 1/2012

Open Access 01-12-2012 | Research article

Cancer incidence and mortality trends in Australian adolescents and young adults, 1982–2007

Authors: Fatima A Haggar, David B Preen, Gavin Pereira, Cashel DJ Holman, Kristjana Einarsdottir

Published in: BMC Cancer | Issue 1/2012

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Abstract

Background

Increasing incidence and lack of survival improvement in adolescents and young adults (AYAs) with cancer have led to increased awareness of the cancer burden in this population. The objective of this study was to describe overall and type-specific cancer incidence and mortality trends among AYAs in Western Australia from 1982–2007.

Methods

Age–adjusted incidence and mortality rates were calculated for all malignancies combined and for each of the most common diagnostic groups, using five-year age–specific rates. Joinpoint regression analysis was used to derive annual percentage changes (APC) for incidence and mortality rates.

Results

The annual incidence rate for all cancers combined increased in males from 1982 until 2000 (APC = 1.5%, 95%CI: 0.9%; 2.1%) and then plateaued, whilst rates for females remained stable across the study period (APC = −0.1%; 95%CI: −0.2%; 0.4%) across the study period. For males, significant incidence rate increases were observed for germ cell tumors, lymphoblastic leukemia and thyroid cancer. In females, the incidence of Hodgkin’s lymphoma, colorectal and breast cancers increased. Significant incidence rate reductions were noted for cervical, central nervous system and lung cancers. Mortality rates for all cancers combined decreased from 1982 to 2005 for both males (APC = −2.6%, 95%CI:−3.3%;−2.0%) and females (APC = −4.6%, 95%CI:−5.1%;−4.1%). With the exception of bone sarcoma and lung cancer in females, mortality rates for specific cancer types decreased significantly for both sexes during the study period.

Conclusions

Incidence of certain AYA cancers increased, whilst it decreased for others. Mortality rates decreased for most cancers, with the largest improvement observed for breast carcinomas. Further research is needed to identify the reasons for the increasing incidence of certain cancers.
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Literature
1.
go back to reference International Agency for Research on Cancer: GLOBOCAN 2008: Cancer Incidence and Mortality Worldwide in 2008. 2008 International Agency for Research on Cancer: GLOBOCAN 2008: Cancer Incidence and Mortality Worldwide in 2008. 2008
2.
go back to reference Bleyer W, Barr R, Hayes-Lattin B, Thomas D, Ellis C, Anderson B: The distinctive biology of cancer in adolescents and young adults. Nat Rev Cancer. 2008, 8 (4): 288-298. 10.1038/nrc2349.CrossRefPubMed Bleyer W, Barr R, Hayes-Lattin B, Thomas D, Ellis C, Anderson B: The distinctive biology of cancer in adolescents and young adults. Nat Rev Cancer. 2008, 8 (4): 288-298. 10.1038/nrc2349.CrossRefPubMed
3.
go back to reference Wu X, Groves F, McLaughlin C, Jemal A, Martin J, Chen A: Cancer incidence patterns among adolescents and young adults in the United States. Cancer Causes Control. 2005, 16: 309-320. 10.1007/s10552-004-4026-0.CrossRefPubMed Wu X, Groves F, McLaughlin C, Jemal A, Martin J, Chen A: Cancer incidence patterns among adolescents and young adults in the United States. Cancer Causes Control. 2005, 16: 309-320. 10.1007/s10552-004-4026-0.CrossRefPubMed
4.
go back to reference Bleyer A, Budd T, Montello M: Adolescents and young adults with cancer. Cancer. 2006, 107 (S7): 1645-1655. 10.1002/cncr.22102.CrossRefPubMed Bleyer A, Budd T, Montello M: Adolescents and young adults with cancer. Cancer. 2006, 107 (S7): 1645-1655. 10.1002/cncr.22102.CrossRefPubMed
5.
go back to reference Jemal A, Bray F, Center M, Ferlay J, Ward E, Forman D: Global cancer statistics. CA Cancer J Clin. 2011, 61 (2): 69-90. 10.3322/caac.20107.CrossRefPubMed Jemal A, Bray F, Center M, Ferlay J, Ward E, Forman D: Global cancer statistics. CA Cancer J Clin. 2011, 61 (2): 69-90. 10.3322/caac.20107.CrossRefPubMed
6.
go back to reference Adolescent and Young Adult Oncology Progress Review Group Department of Health and Human Services National Institutes of Health National Cancer Institute Alliance LYA: Closing the Gap: Research and Care Imperatives for Adolescents and Young Adults with Cancer. Report of the Adolescent and Young Adult Oncology Progress Review Group. 2006, National Cancer Institute, Bethesda Adolescent and Young Adult Oncology Progress Review Group Department of Health and Human Services National Institutes of Health National Cancer Institute Alliance LYA: Closing the Gap: Research and Care Imperatives for Adolescents and Young Adults with Cancer. Report of the Adolescent and Young Adult Oncology Progress Review Group. 2006, National Cancer Institute, Bethesda
9.
go back to reference Garner M, Turner M, Ghadirian P, Krewski D: Epidemiology of testicular cancer: an overview. Int J Cancer. 2005, 116 (3): 331-339. 10.1002/ijc.21032.CrossRefPubMed Garner M, Turner M, Ghadirian P, Krewski D: Epidemiology of testicular cancer: an overview. Int J Cancer. 2005, 116 (3): 331-339. 10.1002/ijc.21032.CrossRefPubMed
11.
go back to reference Cook M, Akre O, Forman D, Madigan M, Richiardi L, McGlynn K: A systematic review and meta-analysis of perinatal variables in relation to the risk of testicular cancer–experiences of the mother. Int J Epidemiol. 2009, 38 (6): 1532-1542. 10.1093/ije/dyp287.CrossRefPubMedPubMedCentral Cook M, Akre O, Forman D, Madigan M, Richiardi L, McGlynn K: A systematic review and meta-analysis of perinatal variables in relation to the risk of testicular cancer–experiences of the mother. Int J Epidemiol. 2009, 38 (6): 1532-1542. 10.1093/ije/dyp287.CrossRefPubMedPubMedCentral
12.
go back to reference Richardson D: Exposure to ionizing radiation in adulthood and thyroid cancer incidence. Epidemiology. 2009, 20 (2): 181-187. 10.1097/EDE.0b013e318196ac1c.CrossRefPubMed Richardson D: Exposure to ionizing radiation in adulthood and thyroid cancer incidence. Epidemiology. 2009, 20 (2): 181-187. 10.1097/EDE.0b013e318196ac1c.CrossRefPubMed
13.
go back to reference Mueller N, Evans A, Harris N, Comstock G, Jellum E, Magnus K, Orentreich N, Polk B, Vogelman J: Hodgkin’s disease and Epstein-Barr Virus. NEJM. 1989, 320 (11): 689-695. 10.1056/NEJM198903163201103.CrossRefPubMed Mueller N, Evans A, Harris N, Comstock G, Jellum E, Magnus K, Orentreich N, Polk B, Vogelman J: Hodgkin’s disease and Epstein-Barr Virus. NEJM. 1989, 320 (11): 689-695. 10.1056/NEJM198903163201103.CrossRefPubMed
14.
go back to reference Anders CK, Johnson R, Litton J, Phillips M, Bleyer A: Breast cancer before age 40 years. Semin Oncol. 2009, 36 (3): 237-249. 10.1053/j.seminoncol.2009.03.001.CrossRefPubMedPubMedCentral Anders CK, Johnson R, Litton J, Phillips M, Bleyer A: Breast cancer before age 40 years. Semin Oncol. 2009, 36 (3): 237-249. 10.1053/j.seminoncol.2009.03.001.CrossRefPubMedPubMedCentral
16.
go back to reference Devesa S, Bray F, Vizcaino A, Parkin D: International lung cancer trends by histologic type: Male:Female differences diminishing and adenocarcinoma rates rising. Int J Cancer. 2005, 117 (2): 294-299. 10.1002/ijc.21183.CrossRefPubMed Devesa S, Bray F, Vizcaino A, Parkin D: International lung cancer trends by histologic type: Male:Female differences diminishing and adenocarcinoma rates rising. Int J Cancer. 2005, 117 (2): 294-299. 10.1002/ijc.21183.CrossRefPubMed
17.
go back to reference Bray F, Weiderpass E: Lung cancer mortality trends in 36 European countries: secular trends and birth cohort patterns by sex and region 1970-2007. Int J Cancer. 2010, 126 (6): 1454-1466.PubMed Bray F, Weiderpass E: Lung cancer mortality trends in 36 European countries: secular trends and birth cohort patterns by sex and region 1970-2007. Int J Cancer. 2010, 126 (6): 1454-1466.PubMed
18.
go back to reference Jemal A, Thun M, Ries L, Howe H, Weir H, Center M, Ward E, Wu X, Eheman C, Anderson R, et al: Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst. 2008, 100 (23): 1672-1694. 10.1093/jnci/djn389.CrossRefPubMedPubMedCentral Jemal A, Thun M, Ries L, Howe H, Weir H, Center M, Ward E, Wu X, Eheman C, Anderson R, et al: Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst. 2008, 100 (23): 1672-1694. 10.1093/jnci/djn389.CrossRefPubMedPubMedCentral
19.
go back to reference Danaei G, Vander Hoorn S, Lopez A, Murray C, Ezzati M: Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factor. Lancet. 2005, 366: 1784-1789. 10.1016/S0140-6736(05)67725-2.CrossRefPubMed Danaei G, Vander Hoorn S, Lopez A, Murray C, Ezzati M: Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factor. Lancet. 2005, 366: 1784-1789. 10.1016/S0140-6736(05)67725-2.CrossRefPubMed
20.
go back to reference Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767. Edited by: Bleyer A, O’Leary M, Barr R, Ries LAG. 2006, Bethesda Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767. Edited by: Bleyer A, O’Leary M, Barr R, Ries LAG. 2006, Bethesda
21.
go back to reference Cancer Epidemiology and Prevention. Edited by: Schottenfeld D, Fraumeni JF. 2006, Oxford University Press, Oxford, Third edn Cancer Epidemiology and Prevention. Edited by: Schottenfeld D, Fraumeni JF. 2006, Oxford University Press, Oxford, Third edn
22.
go back to reference Campbell P, Newcomb P, Gallinger S, Cotterchio M, McLaughlin J: Exogenous hormones and colorectal cancer risk in Canada: associations stratified by clinically defined familial risk of cancer. Cancer Causes Control. 2007, 18 (7): 723-733. 10.1007/s10552-007-9015-7.CrossRefPubMed Campbell P, Newcomb P, Gallinger S, Cotterchio M, McLaughlin J: Exogenous hormones and colorectal cancer risk in Canada: associations stratified by clinically defined familial risk of cancer. Cancer Causes Control. 2007, 18 (7): 723-733. 10.1007/s10552-007-9015-7.CrossRefPubMed
23.
go back to reference Nichols H, Trentham-Dietz A, Hampton J, Newcomb P: Oral contraceptive use, reproductive factors, and colorectal cancer risk: findings from Wisconsin. Cancer Epidemiol Biomarkers Prev. 2005, 14 (5): 1212-1218. 10.1158/1055-9965.EPI-04-0845.CrossRefPubMed Nichols H, Trentham-Dietz A, Hampton J, Newcomb P: Oral contraceptive use, reproductive factors, and colorectal cancer risk: findings from Wisconsin. Cancer Epidemiol Biomarkers Prev. 2005, 14 (5): 1212-1218. 10.1158/1055-9965.EPI-04-0845.CrossRefPubMed
24.
go back to reference Kabat G, Miller A, Rohan T: Oral contraceptive use, hormone replacement therapy, reproductive history and risk of colorectal cancer in women. Int J Cancer. 2008, 122 (3): 643-646. 10.1002/ijc.23079.CrossRefPubMed Kabat G, Miller A, Rohan T: Oral contraceptive use, hormone replacement therapy, reproductive history and risk of colorectal cancer in women. Int J Cancer. 2008, 122 (3): 643-646. 10.1002/ijc.23079.CrossRefPubMed
25.
go back to reference Hiatt R, Fireman B: The possible effect of increased surveillance on the incidence of malignant melanoma. Prev Med. 1986, 15: 652-660. 10.1016/0091-7435(86)90070-8.CrossRefPubMed Hiatt R, Fireman B: The possible effect of increased surveillance on the incidence of malignant melanoma. Prev Med. 1986, 15: 652-660. 10.1016/0091-7435(86)90070-8.CrossRefPubMed
26.
go back to reference Whiteman D, Bray C, Siskind V, Green A, Hole D, Mackie R: Changes in the incidence of cutaneous melanoma in the west of Scotland and Queensland, Australia: hope for health promotion?. Eur J Cancer Prev. 2008, 17 (3): 243-250. 10.1097/CEJ.0b013e3282b6fe3f.CrossRefPubMed Whiteman D, Bray C, Siskind V, Green A, Hole D, Mackie R: Changes in the incidence of cutaneous melanoma in the west of Scotland and Queensland, Australia: hope for health promotion?. Eur J Cancer Prev. 2008, 17 (3): 243-250. 10.1097/CEJ.0b013e3282b6fe3f.CrossRefPubMed
27.
go back to reference McDermid I, AIHW AACR NCSG: Cancer incidence projections, Australia 2002 to 2011. 2005, , Canberra McDermid I, AIHW AACR NCSG: Cancer incidence projections, Australia 2002 to 2011. 2005, , Canberra
30.
go back to reference CCO PHAC Canadian Cancer Society: Cancer Care Ontario: Cancer in Young Adults in Canada. vol. 2008. 2006, Toronto CCO PHAC Canadian Cancer Society: Cancer Care Ontario: Cancer in Young Adults in Canada. vol. 2008. 2006, Toronto
31.
go back to reference De P, Ellison LF, Barr RD, Semenciw R, Marrett LD, Weir HK, Dryer D, Grunfeld E: Canadian adolescents and young adults with cancer: opportunity to improve coordination and level of care. Can Med Assoc J. 2011, 183 (3): E187-E194. 10.1503/CMAJ.100800.CrossRef De P, Ellison LF, Barr RD, Semenciw R, Marrett LD, Weir HK, Dryer D, Grunfeld E: Canadian adolescents and young adults with cancer: opportunity to improve coordination and level of care. Can Med Assoc J. 2011, 183 (3): E187-E194. 10.1503/CMAJ.100800.CrossRef
32.
go back to reference Gatta G, Zigon G, Capocaccia R, Coebergh J, Desandes E, Kaatsch P, Pastore G, Peris-Bonet R, Stiller C, the EUROCARE Working Group: Survival of European children and young adults with cancerdiagnosed 1995–2002. Eur J Cancer Prev. 2009, 45: 992-1005. 10.1016/j.ejca.2008.11.042.CrossRef Gatta G, Zigon G, Capocaccia R, Coebergh J, Desandes E, Kaatsch P, Pastore G, Peris-Bonet R, Stiller C, the EUROCARE Working Group: Survival of European children and young adults with cancerdiagnosed 1995–2002. Eur J Cancer Prev. 2009, 45: 992-1005. 10.1016/j.ejca.2008.11.042.CrossRef
33.
go back to reference Pacini F, Castagna M, Brilli L, Pentheroudakis G, Group ObotEGW: Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010, 21 (suppl 5): v214-v219.CrossRefPubMed Pacini F, Castagna M, Brilli L, Pentheroudakis G, Group ObotEGW: Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010, 21 (suppl 5): v214-v219.CrossRefPubMed
34.
go back to reference Cramer J, Fu P, Harth K, Margevicius S, Wilhelm S: Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry. Surgery. 2010, 148 (6): 1147-1145-1143-CrossRef Cramer J, Fu P, Harth K, Margevicius S, Wilhelm S: Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry. Surgery. 2010, 148 (6): 1147-1145-1143-CrossRef
35.
go back to reference Kilfoy B, Zheng T, Holford T, Han X, Ward M, Sjodin A, Zhang Y, Bai Y, Zhu C, Guo G, et al: International patterns and trends in thyroid cancer incidence, 1973-2002. Cancer Causes Control. 2009, 20 (5): 525-531. 10.1007/s10552-008-9260-4.CrossRefPubMed Kilfoy B, Zheng T, Holford T, Han X, Ward M, Sjodin A, Zhang Y, Bai Y, Zhu C, Guo G, et al: International patterns and trends in thyroid cancer incidence, 1973-2002. Cancer Causes Control. 2009, 20 (5): 525-531. 10.1007/s10552-008-9260-4.CrossRefPubMed
36.
go back to reference Chia V, Quraishi S, Devesa S, Purdue M, Cook M, McGlynn K: International trends in the incidence of testicular cancer, 1973-2002. Cancer Epidemiol Biomarkers Prev. 2010, 19 (5): 1151-1159. 10.1158/1055-9965.EPI-10-0031.CrossRefPubMedPubMedCentral Chia V, Quraishi S, Devesa S, Purdue M, Cook M, McGlynn K: International trends in the incidence of testicular cancer, 1973-2002. Cancer Epidemiol Biomarkers Prev. 2010, 19 (5): 1151-1159. 10.1158/1055-9965.EPI-10-0031.CrossRefPubMedPubMedCentral
37.
go back to reference Lacerda H, Akre O, Merletti F, Richiardi L: Time trends in the incidence of testicular cancer in childhood and young adulthood. Cancer Epidemiol Biomarkers Prev. 2009, 18 (7): 2042-2045. 10.1158/1055-9965.EPI-08-1140.CrossRefPubMed Lacerda H, Akre O, Merletti F, Richiardi L: Time trends in the incidence of testicular cancer in childhood and young adulthood. Cancer Epidemiol Biomarkers Prev. 2009, 18 (7): 2042-2045. 10.1158/1055-9965.EPI-08-1140.CrossRefPubMed
38.
go back to reference Bosetti C, Levi F, Lucchini F, Negri E, La Vecchia C: Lung cancer mortality in European women: recent trends and perspectives. Ann Oncol. 2005, 16 (10): 1597-1604. 10.1093/annonc/mdi313.CrossRefPubMed Bosetti C, Levi F, Lucchini F, Negri E, La Vecchia C: Lung cancer mortality in European women: recent trends and perspectives. Ann Oncol. 2005, 16 (10): 1597-1604. 10.1093/annonc/mdi313.CrossRefPubMed
39.
go back to reference Levi F, Bosetti C, Fernandez E, Hill C, Lucchini F, Negri E, La Vecchia C: Trends in lung cancer among young European women: the rising epidemic in France and Spain. Int J Cancer. 2007, 121 (2): 462-465. 10.1002/ijc.22694.CrossRefPubMed Levi F, Bosetti C, Fernandez E, Hill C, Lucchini F, Negri E, La Vecchia C: Trends in lung cancer among young European women: the rising epidemic in France and Spain. Int J Cancer. 2007, 121 (2): 462-465. 10.1002/ijc.22694.CrossRefPubMed
40.
go back to reference Rivera M: Lung cancer in women: the differences in epidemiology, biology and treatment outcomes. Expert Rev Respir Med. 2009, 3 (6): 627-634. 10.1586/ers.09.54.CrossRefPubMed Rivera M: Lung cancer in women: the differences in epidemiology, biology and treatment outcomes. Expert Rev Respir Med. 2009, 3 (6): 627-634. 10.1586/ers.09.54.CrossRefPubMed
41.
go back to reference Egleston B, Meireles S, Flieder D, Clapper M: Population-based trends in lung cancer incidence in women. Semin Oncol. 2009, 36 (6): 506-515. 10.1053/j.seminoncol.2009.09.003.CrossRefPubMedPubMedCentral Egleston B, Meireles S, Flieder D, Clapper M: Population-based trends in lung cancer incidence in women. Semin Oncol. 2009, 36 (6): 506-515. 10.1053/j.seminoncol.2009.09.003.CrossRefPubMedPubMedCentral
42.
go back to reference Bray F, Loos AH, McCarron P, Weiderpass E, Arbyn M, Moller H, Hakama M, Parkin D: Trends in cervical squamous cell carcinoma incidence in 13 European countries: changing risk and the effects of screening. Cancer Epidemiol Biomarkers Prev. 2005, 14 (3): 677-686. 10.1158/1055-9965.EPI-04-0569.CrossRefPubMed Bray F, Loos AH, McCarron P, Weiderpass E, Arbyn M, Moller H, Hakama M, Parkin D: Trends in cervical squamous cell carcinoma incidence in 13 European countries: changing risk and the effects of screening. Cancer Epidemiol Biomarkers Prev. 2005, 14 (3): 677-686. 10.1158/1055-9965.EPI-04-0569.CrossRefPubMed
43.
go back to reference Mathew A, George P: Trends in incidence and mortality rates of squamous cell carcinoma and adenocarcinoma of cervix–worldwide. Asian Pac J Cancer Prev. 2009, 10 (4): 645-650.PubMed Mathew A, George P: Trends in incidence and mortality rates of squamous cell carcinoma and adenocarcinoma of cervix–worldwide. Asian Pac J Cancer Prev. 2009, 10 (4): 645-650.PubMed
44.
go back to reference Llorca J, Rodriguez-Cundin P, Dierssen-Sotos T, Prieto-Salceda D: Cervical cancer mortality is increasing in Spanish women younger than 50. Cancer Lett. 2006, 240 (1): 36-40. 10.1016/j.canlet.2005.08.021.CrossRefPubMed Llorca J, Rodriguez-Cundin P, Dierssen-Sotos T, Prieto-Salceda D: Cervical cancer mortality is increasing in Spanish women younger than 50. Cancer Lett. 2006, 240 (1): 36-40. 10.1016/j.canlet.2005.08.021.CrossRefPubMed
45.
go back to reference Vizcaino A, Moreno V, Bosch F, Munoz N, Barros-Dios X, Borras J, Parkin D: International trends in incidence of cervical cancer: II. Squamous-cell carcinoma. Int J Cancer. 2000, 89 (2): 429-435.CrossRef Vizcaino A, Moreno V, Bosch F, Munoz N, Barros-Dios X, Borras J, Parkin D: International trends in incidence of cervical cancer: II. Squamous-cell carcinoma. Int J Cancer. 2000, 89 (2): 429-435.CrossRef
46.
go back to reference Holman C, Bass J, Rouse I, Hobbs M: Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health. 1999, 23 (5): 453-459. 10.1111/j.1467-842X.1999.tb01297.x.CrossRefPubMed Holman C, Bass J, Rouse I, Hobbs M: Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health. 1999, 23 (5): 453-459. 10.1111/j.1467-842X.1999.tb01297.x.CrossRefPubMed
Metadata
Title
Cancer incidence and mortality trends in Australian adolescents and young adults, 1982–2007
Authors
Fatima A Haggar
David B Preen
Gavin Pereira
Cashel DJ Holman
Kristjana Einarsdottir
Publication date
01-12-2012
Publisher
BioMed Central
Published in
BMC Cancer / Issue 1/2012
Electronic ISSN: 1471-2407
DOI
https://doi.org/10.1186/1471-2407-12-151

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