Data presented in this paper were obtained from the Health for All database, regularly published by the Regional Office for Europe of WHO (electronic availability of data is indicated in reference 5).Data published later than 2000 were excluded, and only references published in English were included.
ReviewCancer mortality in central–eastern Europe: facts behind the figures
Section snippets
Data accrual and analysis Measures of cancer burden
“Cancer burden” is a concept without formal definition, but it implies a quantity of a particular disease within a community. In this paper, age-standardised mortality rates are used as a measure of cancer burden. The use of incidence rates would have been more informative because they provide a direct measure of the probability of developing cancer and do not depend on either the biological aggressiveness of the tumour or the degree of medical intervention. However, the use of incidence data
Source of data
Mortality data have been obtained from the statistical database of the European Regional Office of the World Health Organization (WHO).5 This database contains national vital statistics from all member countries of WHO.
Data quality strongly influences the confidence with which conclusions can be drawn. In general, the quality of mortality data is only as good as the quality of death certification in any particular country, and similarly, mortality depends on the quality of medical care.
Geographical breakdown
The European Region of WHO includes all the countries of Europe. The WHO considers several additional countries, such as Israel and some central-Asian countries, which are not part of the geographically defined Europe, as member states of the European Region. Therefore, data from these countries are also included in the statistical database of the European Regional Office.
In this paper, the patterns and trends of cancer mortality are presented for Europe as a whole, and for its various
Cancer burden in Europe and the CEE countries Overall cancer mortality
The cancer mortality rates in Europe vary widely from country to country (figure 2), for example, from 400 deaths per 100 000 in Hungary to 120 deaths per 100 000 in Albania. In 1997, ten of the 11 highest mortality rates in Europe for all types of cancer in male populations were seen in the CEE countries (figure 2, top). Hungary, Croatia, the Czech Republic, Slovakia, and Slovenia topped the list. The only EU country in this group was Belgium, which, during the 1980s had the highest cancer
Premature death
Overall mortality is strongly influenced by the disease patterns of elderly people: most cancer deaths occur in people over 65 years of age. Therefore, the cumulative death rates of those people dying before their 65th year are considered as “rates of premature death”. The proportion of the population over 65 years old is increasing in most countries, and thus the practice of focusing on younger people in data analyses has been criticised because it may hide the importance of the cancer problem
Age-specific mortality
Age-specific death rates (in which both the numerator and denominator refer to the same age group, or birth cohort) provide a dynamic insight into the status of cancer death in Europe.7 A cohort analysis of age-specific death rates in Europe carried out by WHO8 has shown substantial regional differences (figures 6). In the CEE countries, cancer mortality has declined in the youngest age-groups (up to 24 years) but positive trends have not been seen in older-age groups. Conversely, in the rest
Site-specific mortality
Regional variations in site-specific mortality of cancers that are avoidable through primary and secondary prevention (ie, cancers of the lung, breast, and uterine cervix) are also seen throughout Europe (table 1).
Lung cancer is the largest contributor to the overall death toll in Europe: it is the leading cause of cancer death in men. Until the late 1980s, lung-cancer mortality for men was increasing in all regions, most notably western Europe (particularly Belgium and the Netherlands).
Summary
From 1970 until the mid-1980s, the prevalence of cancer in Europe continued to be a major health problem. Epidemiological data show very little success in curtailing the overall burden. However, a turning point was reached in the mid-1980s: both the overall and the site-specific European average mortality started to decline, particularly in the younger age-groups. These trends, however, were not seen throughout Europe; and cancer burden remains the heaviest, and continues to accumulate, in the
Cancer burden in CEE countries: possible reasons for variation
There are two groups of factors that can provide the most likely explanation for the striking regional differences in cancer burden and trends in Europe—the difference in cancer risk and the difference in the effectiveness of cancer treatment.
Environmental determinants of cancer
Over the past few decades, our perception of what constitutes cancer risk has gone through several phases. In 1964, a WHO expert committee first recognised that the majority of cancers occur as a result of environmental factors, as opposed to intrinsic or genetic factors.9 Since then, this opinion has been consolidated by, among others, Doll and Peto.10 The current view is that about 90% of all cancers are attributable to external causes and are therefore, theoretically, avoidable.
The
Social roots to personal lifestyle
In an attempt to explain the regional variations in cancer burden in Europe, and to understand the root of the problem that the CEE countries have to face, there is one important question: to what extent is an individual responsible for his or her health?
One may argue that an individual who has adopted certain health-damaging personal habits, such as smoking, drinking, or an unhealthy diet, is largely responsible for his or her own resultant health. However, the victim's behaviour is only the
Deterioration of eastern European health
Up to the late 1960s, there was no evidence of health deterioration in the populations of the CEE countries. The cause-specific mortality from epidemic infectious diseases (including tuberculosis) had substantially fallen. Infant mortality had also declined and adult mortality had decreased moderately. Since then, however, the health of these countries has started to worsen. Mortality from non communicable chronic diseases, cardiovascular diseases, and cancer has risen, and life expectancy has
Geopolitical trends in Europe: a widening gap
In Europe, there have always been some built-in inequalities among the countries of the north, south, east, and west. However, the post-war political division of Europe widened the gap between the affluent and underprivileged countries enormously. Over the past 50 years, Europe has gone through dramatic political and socioeconomic changes. This time has been an exceptionally successful period in the history of the “West”. Over these decades, the western European nations have developed not only
Inequalities
The negative correlation between socioeconomic status and cancer mortality is well known.15 A detailed analysis of the socioeconomic factors that have influenced the way of life in the CEE countries over the decades of political difference is beyond the scope of this paper. Moreover, in view of the short time that has elapsed since political change, comprehensive sociological analyses are still not available and therefore, we have to rely on empirical observations and anecdotal evidence, which
Smoking prevalence
Smoking represents the greatest lifestyle-related carcinogenic risk in most CEE countries. For example, in 1995, 47% of the male population of Hungary and 20% of the female population were smokers.16 The age distribution of cigarette consumption is very unfavourable: more than half of all smokers are adolescents and young adults (15-29 years of age). Furthermore, cigarette consumption per person is high compared with other European countries.
Exposures from the physical environment
The CEE countries suffer from many environmental and occupational health problems. Data on workplace exposure have been systematically collected in the Czech Republic and Slovakia; but very little information is available from Hungary, Romania, and Bulgaria. Data indicate that between 10% and 30% of the working population has been exposed to various occupational hazards, including chemical carcinogens. This exposure certainly contributed to excess cancer mortality, particularly lung cancer.17
The future burden Recent changes
After the collapse of the socialist regimes in the 1980s and 1990s, many new countries with democratic constitutions were created throughout eastern Europe. The advent of these new pluralistic societies brought about substantial change in the political, economic, and social structure. However, it also led, at least initially, to a severe economic downturn and an increase in social tension (a situation that caused the outbreak of war in several CEE countries). Economic polarisation of the
The time factor
Changes in regional cancer mortality statistics take time. The period may elapse between the exposure to a carcinogenic agent and the clinical manifestation of a cancer varies. For example, the development of a smoking-related cancer can take upwards of 15–20 years. Thus, the prevailing smoking habits 15–20 years ago are still influencing the current mortality rate. Any effects of antismoking measures or improved health-care provision on cancer mortality will not occur for several decades.
Conclusion
Europe is divided by the probability of dying from cancer: mortality rates and trends are worse in the CEE countries, and the gap is widening. The division is due to multifactorial differences between the various geopolitical regions. There is no doubt, however, that the worst is now over. Epidemiological data suggest that the unfavourable trends will continue initially, but given the current political and social will of the CEE countries, a gradual improvement in the overall cancer burden over
Search strategy and selection criteria
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He is currently a special adviser for the World Bank's “Close the gap in public health” programme, and for the Hungarian Ministry of Health's “Secondary prevention of cancer” project.