Media Documentation Canupis Study - Abteilung Kommunikation

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Media Documentation Canupis Study - Abteilung Kommunikation

Press release

Communication Section

12 July 2011

Childhood cancer in the vicinity of nuclear power plants:

Results of the CANUPIS study

A large nationwide longitudinal study found no evidence of an increased risk of

cancer in children born near nuclear power plants in Switzerland. The CANUPIS

study was performed by the Institute of Social and Preventive Medicine (ISPM) at

the University of Bern (Switzerland) in collaboration with the Swiss Childhood Cancer

Registry and the Swiss Paediatric Oncology Group.

Are there any risks to the health of people living close to nuclear power plants? This question has

been debated for over 20 years. Cancer in children, who are more sensitive to radiation than

adults, has been a particular concern. A case-control study from Germany published in December

2007 showed that the risk of leukaemia in small children living within 5 km of a nuclear power plant

was more than double that of children living further away. These findings caused anxiety in the

Swiss population and were the subject of a debate in parliament. As a result, the Federal Office of

Public Health (FOPH) and the Swiss Cancer League asked the Institute of Social and Preventive

Medicine (ISPM) at the University of Bern to perform a comparable study in Switzerland. The

CANUPIS study (Childhood Cancer and Nuclear Power Plants in Switzerland, see

www.canupis.ch) was conducted from September 2008 to December 2010. The results are published

today in the «International Journal of Epidemiology».

No evidence for an increased risk of leukaemia near nuclear power plants

In this study, the investigators compared the risk of leukaemia and other cancers in children born

close to nuclear power plants with the risk in children born further away. The study included all

children born in Switzerland since 1985: over 1.3 million children aged 0 to 15 years who were

followed during the years 1985 to 2009 (over 21 million person-years of observation).

Switzerland was divided into four zones: zone I included the area 0 to 5 km from the nearest nuclear

power plant; zone II 5 to 10 km; zone III 10 to 15 km and zone IV the rest of the country beyond

15 km. The risk of childhood cancer was calculated for each zone. The numbers of cancer

cases in zones I-III were then compared to the numbers expected based on the risk in zone IV (the

reference group).

1

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In children below 5 years of age, who are particularly sensitive to the effects of radiation, there

were 573 leukaemia diagnoses during the period 1985 to 2009. The risk in zone I was similar to the

risk in zone IV: there were 8 cases compared to expected 6.8 cases (difference: +1.2 case). In

zone II there were 12 cases compared to 20.3 expected cases (difference: -8.3 cases) and in zone

III the numbers were 31 observed and 28.3 expected cases (difference: +2.7 cases). Expressed

differently, the relative risk of leukaemia in children under 5 years of age in zone I was 1.20 compared

to zone IV, the reference group of children living more than 15 km from the nearest nuclear

power plant (relative risk 1.0). This corresponds to an increase in the risk by 20%. The relative risk

of leukaemia for children born in zone II was 0.60, corresponding to a reduction i n risk of 40%. In

zone III there was a slight increase in the risk, by 10% (relative risk 1.10). A statistically significant

increase or reduction in the risk of childhood cancer was not observed in any of the analyses.

«The risk of childhood cancer in the vicinity of Swiss nuclear power plants is similar to that observed

in children living further afield,» says Matthias Egger, director of ISPM. He stresses that the

slight deviations from the expected risk in the vicinity of nuclear power plants is most likely due to

the play of chance. Owing to the small number of cases there is, however, substantial statistical

uncertainty, according to Egger. For leukaemia in children below 5 years of age the relative risk of

1.20 is compatible with relative risks ranging from 0.60 to 2.41 («confidence interval» 0.60 to 2.41).

«The results are statistically compatible both with a reduction in risk and an increase in risk ,»

summarizes Matthias Egger.

CANUPIS: a national longitudinal study

There are five nuclear power plants in Switzerland (Beznau I and II, Mühleberg, Gösgen and Leibstadt)

which together produce about 40% of Switzerland’s electrical power. About 1% of the population

lives within 5 km of a nuclear power plant and 10% live within 15 km. In addition to the nuclear

power plants there are four research reactors at the Universities of Lausanne and Basel, at

the Paul Scherrer Institute (PSI) in Villigen, in Lucens (in operation 1968/69) and an intermediate

storage facility in Würenlingen. The CANUPIS study is based on an analysis of the place of residence

of all Swiss children as recorded in the censuses 1990 and 2000 and included in the data of

the Swiss National Cohort*. These geocoded data made it possible to precisely calculate the distance

from the domicile to the nearest nuclear power plant. The places of residence of the children

with cancer were obtained from the Swiss Childhood Cancer Registry** and were geocoded in the

context of the CANUPIS study.

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One of the first studies considering place of residence at birth

«Studies of atomic bomb survivors in Hiroshima and Nagasaki have shown that children are much

more sensitive to radiation than adults,» says Claudia Kuehni, Head of the Swiss Childhood Cancer

Registry. This is particularly true during intrauterine development and the first years of life. «For

this reason we focused on the place of residence at birth,» says the epidemiologist from the University

of Bern. «This focus and the fact that we could include all children in Switzerland in a longitudinal

study is a unique feature of the CANUPIS approach.»

Results in line with monitoring of radioactivity

The radioactive emissions in the vicinity of Swiss nuclear power plants are regularly monitored and

the data are published by the Division for Radiation Protection of the FOPH. The exposure due to

emissions from nuclear power plants in the vicinity of these plants is below 0.01 mSv (millisieverts)

per year. This corresponds to less than 1/500 of the average total radiation residents in Switzerland

are exposed to, mainly from radon gas, cosmic and terrestrial radiation and medical investigations

and therapies. The CANUPIS investigators therefore argue that the results of the CANUPIS

study are in line with the data from the monitoring of radioactivity by the FOPH.

Contacts:

PD Dr. med. Claudia Kuehni

Head of the Swiss Childhood Cancer Registry

Institute of Social and Preventive Medicine of the University of Bern

Finkenhubelweg 11, 3012 Bern (Switzerland)

Phone +41 (0)31 631 35 07

kuehni@ispm.unibe.ch

Prof. Dr. med. Matthias Egger

Director of the Institute of Social and Preventive Medicine of the University of Bern

Finkenhubelweg 11, 3012 Bern (Switzerland)

Phone +41 (0)31 631 35 01 / +41 (0)79 239 97 17

egger@ispm.unibe.ch

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Full publication of this study:

Spycher BD, Feller M, Zwahlen M, Röösli M, von der Weid NX, Hengartner H, Egger M, Kuehni

CE. Childhood cancer and nuclear power plants in Switzerland: A census based cohort study.

International Journal of Epidemioloy 2011 doi:10.1093/ije/DYR115

The paper can be downloaded from:

http://ije.oxfordjournals.org/content/early/2011/07/12/ije.dyr115.full (html version)

http://ije.oxfordjournals.org/content/early/2011/07/12/ije.dyr115.full.pdf+html (pdf version)

*Swiss National Cohort

The Swiss National Cohort (SNC, www.swissnationalcohort.ch) is a national longitudinal research

platform. Associations between the health of the Swiss population, the exact place of residence, environmental

exposures and sociodemographic conditions can be examined in this study. The study consists

of the anonymous information collected at the 1990 and 2000 censuses, which is linked to data

from the mortality files, birth statistics and emigration and immigration data. Combined with the data of

the cancer registries the SNC allows longitudinal analyses of important research questions, including

the association between environmental exposures at the place of residence and the occurrence of

cancer. The Swiss National Cohort is a collaborative project, which involves investigators from the

Universities of Basel, Bern, Geneva, Lausanne and Zurich. The data center is located in the Institute

of Social and Preventive Medicine (ISPM) at the University of Bern (www.ispm.ch). The Swiss National

Cohort is funded by the Swiss National Science Foundation (www.snf.ch).

**Swiss Childhood Cancer Registry

The Swiss Childhood Cancer Registry (SCCR, www.childhoodcancerregistry.ch) is the national cancer

registry for children and adolescents in Switzerland. It was established in 1976 and covers all cases

diagnosed up to the age of 20. In addition, the registry documents the therapies and conducts longterm

studies on the health and quality of life of cancer survivors. It contributes to the evaluation of the

causes of cancer in children and adolescents, the improvement of therapies and prevention of late

complications. The SCCR is located in the Institute of Social and Preventive Medicine (ISPM) at the

University of Bern (www.ispm.ch). It collaborates closely with the Swiss Paediatric Oncology Group

(SPOG, www.spog.ch), which includes all nine paediatric oncology clinics in the country. So far, over

8,000 children with cancer have been registered. The SCCR is funded through different sources.

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Additional material

Websites:

www.canupis.ch (website of CANUPIS study)

www.childhoodcancerregistry.ch (website of Swiss Childhood Cancer Registry)

www.swissnationalcohort.ch (website of Swiss National Cohort)

Reports:

1) Kuehni CE. Childhood Cancer in Switzerland. In: Cancer in Switzerland – Situation and

Development from 1983 to 2007. Federal Statistical Office (FSO), Neuchâtel 2011.

This chapter provides a brief and accessible summary of childhood cancer in Switzerland. Available

in German, French, Italian and English.

Download from:

http://www.bfs.admin.ch/bfs/portal/en/index/news/publikationen.html?publicationID=4251

2) Committee on Medical Aspects of Radiation in the Environment (COMARE) (2011). Fourteenth

report. Further consideration of the incidence of childhood leukaemia around nuclear

power plants in Great Britain. Health Protection Agency, London 2011.

This 142-page report and the corresponding press release summarize the relevant research on

nuclear power plants and childhood cancer, with detailed discussion of the studies from Germany

and the United Kingdom. Available in English only.

Download from:

http://www.comare.org.uk/press_releases/14thReportPressRelease.htm

http://www.comare.org.uk/press_releases/documents/COMARE14report.pdf

3) Jahresbericht: Umweltradioaktivität und Strahlendosen in der Schweiz: Ergebnisse 2009. Bundesamt

für Gesundheit, Abteilung Strahlenschutz, Bern 2010.

This report summarizes the annual exposure of the Swiss population to natural and manmade

sources of radioactivity, including emissions from nuclear power plants. Available in German and

French only.

Download from:

http://www.bag.admin.ch/themen/strahlung/00043/00065/02239/

5


14

Health

1180-1000

Cancer in Switzerland

Situation and development from 1983 to 2007

Swiss Childhood Cancer Registry (SCCR)

Schweizer Kinderkrebsregister (SKKR)

Registre Suisse du Cancer de l’Enfant (RSCE)

Registro Svizzero dei Tumori Pediatrici (RSTP)

Neuchâtel, 2011


The ”Swiss Statistics“ series published by the

Federal Statistical Office (FSO) covers the following fields:

0

Statistical Basis and Overviews

1 Population

2 Territory and Environment

3 Employment and Income

4 National Economy

5 Prices

6 Industry and Services

7 Agriculture and Forestry

8 Energy

9 Construction and Housing

10 Tourism

11 Mobility and Transport

12 Money, Banks and Insurance

13 Social Security

14 Health

15 Education and Science

16 Culture, Media, Information Society, Sports

17 Politics

18 Public Administration and Finance

19 Crime and Criminal Justice

20 Economic and Social Situation of the Population

21 Sustainable Development, Regional and International Disparities


Swiss Statistics

Cancer in Switzerland

Situation and development from 1983 to 2007

Authors

Prof. Christine Bouchardy (NICER),

Dr. Jean-Michel Lutz (NICER), PD Dr. Claudia Kühni (SCCR)

Charts/tables:

Pierre Pury (NICER), Natascha Wyss (FSO),

Marie-Pierre Strippoli (SCCR)

Editorial contributions

Dr. Walter Weiss, Dr. Christoph Junker (FSO),

Dr. Elodie Roy (FSO), Dr. Andrea Bordoni (NICER),

Dr. Kerri Clough-Gorr (NICER),

PD Dr. Nicolas von der Weid (SPOG)

Published by

Federal Statistical Office (FSO),

National Institute for Cancer Epidemiology and

Registration (NICER),

Swiss Childhood Cancer Registry (SCCR)

www.tumours.bfs.admin.ch

www.nicer.org

www.childhoodcancerregistry.ch

Office fédéral de la statistique (OFS)

Neuchâtel, 2011


IMpressum

Published by Federal Statistical Office (FSO), National Institute for Cancer Epidemiology and Registration (NICER),

Swiss Childhood Cancer Registry (SCCR)

Information

Authors

Charts/tables

Steering committee

Project management

Editorial contributions

Publication

Health information service, FSO, Population health section, tel: +41 (0)32 713 67 00, email: gesundheit@bfs.admin.ch

Prof. Christine Bouchardy (NICER), Dr. Jean-Michel Lutz (NICER), PD Dr. Claudia Kühni (SCCR)

Pierre Pury (NICER), Natascha Wyss (FSO), Marie-Pierre Strippoli (SCCR)

Peter Glauser (FSO), Rolf Heusser (NICER), Dr. Giorgio Noseda (NICER)

Natascha Wyss (FSO)

Dr. Walter Weiss, Dr. Christoph Junker (FSO), Dr. Elodie Roy (FSO), Dr. Andrea Bordoni (NICER),

Dr. Kerri Clough-Gorr (NICER), PD Dr. Nicolas von der Weid (SPOG)

DIAM/PP

Obtainable from Federal Statistical Office, CH-2010 Neuchâtel / Phone: +41 (0)32 713 60 60 / fax +41 (0)32 713 60 61

email: order@bfs.admin.ch. From the Swiss Statistics website – Topic – ”Health“: www.tumours.bfs.admin.ch

Order number 1180-1000

Price

Series

Domain

CHF 21 (VAT not incl.)

Swiss Statistics

14 Health

Original text German (chap. 1 and 5) and French (chap. 2, 3 and 4)

Translation

Cover graphics

Graphics/Layout

FSO language services (also available in French, German and Italian)

FSO Concept: Netthoevel & Gaberthüel, Bienne; Photograph: © Uwe Bumann – Fotolia.com

FSO

Copyright FSO, Neuchâtel 2011 (Status of data: June 2010)

Reproduction with mention of source authorised (except for commercial purposes)

ISBN 978-3-303-14146-5


Table of Contents

Table of Contents

Abbreviations 5

Forewords 6

Overview 8

1 Introduction 11

2 Data and Methods 12

2.1 Data Sources 12

2.1.1 Tumour Registries 12

2.1.2 Swiss Childhood Cancer Registry 13

2.1.3 Cause of Death Statistics 14

2.2 Indicators 14

2.2.1 Incidence 15

2.2.2 Mortality 15

2.2.3 Survival 15

2.2.4 Prevalence 16

2.2.5 Stage at Diagnosis 16

2.2.6 Effectiveness of Treatment 16

2.3 Quality of Data 17

2.3.1 Comparability 17

2.3.2 Completeness 17

2.3.3 Validity 17

2.3.4 Accuracy 17

3 General Remarks about Cancer

in Switzerland 18

3.1 Incidence and Risk of Cancer 18

3.2 Deaths and Years of Life Lost 18

3.3 Survival and Prevalence 20

3.4 Time Trends and Regional Comparisons 20

3.5 Risk, Prevention and Treatment Factors 22

3.6 Swiss Specificities 23

4 Cancer Sites 24

4.1 Stomach Cancer 24

4.1.1 General Observations 24

4.1.2 Trends 24

4.1.3 Regional Comparisons 26

4.1.4 International Comparisons 26

4.1.5 Risk Factors 26

4.1.6 Prevention and Screening 27

4.2 Colorectal Cancer 28

4.2.1 General Observations 28

4.2.2 Trends 28

4.2.3 Regional Comparisons 30

4.2.4 International Comparisons 30

4.2.5 Risk Factors 30

4.2.6 Prevention and Screening 31

2011 FSO Cancer in Switzerland

3


Table of Contents

4.3 Lung Cancer 32

4.3.1 General Observations 32

4.3.2 Trends 32

4.3.3 Regional Comparisons 34

4.3.4 International Comparisons 34

4.3.5 Risk Factors 34

4.3.6 Prevention and Screening 35

4.4 Melanoma 36

4.4.1 General Observations 36

4.4.2 Trends 36

4.4.3 Regional Comparisons 38

4.4.4 International Comparisons 38

4.4.5 Risk Factors 38

4.4.6 Prevention and Screening 39

4.5 Breast Cancer 40

4.5.1 General Observations 40

4.5.2 Trends 40

4.5.3 Regional Comparisons 41

4.5.4 International Comparisons 42

4.5.5 Risk Factors 42

4.5.6 Prevention and Screening 43

4.6 Uterine Cancer 44

4.6.1 General Observations 44

4.6.2 Trends 45

4.6.3 Regional Comparisons 46

4.6.4 International Comparisons 46

4.6.5 Risk Factors 48

4.6.6 Prevention and Screening 49

4.7 Prostate Cancer 50

4.7.1 General Observations 50

4.7.2 Trends 50

4.7.3 Regional Comparisons 51

4.7.4 International Comparisons 52

4.7.5 Risk Factors 52

4.7.6 Prevention and Screening 53

4.8 Thyroid Cancer 54

4.8.1 General Observations 54

4.8.2 Trends 54

4.8.3 Regional Comparisons 56

4.8.4 International Comparisons 56

4.8.5 Risk Factors 56

4.8.6 Prevention and Screening 57

4.9 Hodgkin’s Disease 58

4.9.1 General Observations 58

4.9.2 Trends 58

4.9.3 Regional Comparisons 60

4.9.4 International Comparisons 60

4.9.5 Risk Factors 60

4.9.6 Prevention and Screening 61

4.10 Non-Hodgkin Lymphoma 62

4.10.1 General Observations 62

4.10.2 Trends 62

4.10.3 Regional Comparisons 64

4.10.4 International Comparisons 64

4.10.5 Risk Factors 64

4.10.6 Prevention and Screening 65

4.11 Leukaemias 66

4.11.1 General Observations 66

4.11.2 Trends 66

4.11.3 Regional Comparisons 68

4.11.4 International Comparisons 68

4.11.5 Risk Factors 70

4.11.6 Prevention and Screening 71

5 Childhood Cancers 72

5.1 General Observations 72

5.2 Cancer Cases and Deaths 74

5.3 Cure and Survival Rates 74

5.4 International Comparisons 76

5.5 Causes and Risk Factors 77

5.6 Prevention and Early Detection 77

Bibliographic Notes 79

Annex 83

Glossary 89

4

Cancer in Switzerland FSo 2011


abbreviations

Abbreviations

ACCIS Automated Childhood Cancer Information System

AIDS Acquired immunodeficiency syndrome

ALL Acute lymphocytic leukaemia

AML Acute myeloid leukaemia

CCR Cantonal Cancer Registry

CI-Five Cancer Incidence in Five Continents

CLL Chronic lymphocytic leukaemia

CML Chronic myeloid leukaemia

COD Cause of Death Statistics

EBV Epstein Barr virus

DRE Digital rectal examination

ENCR European Network of Cancer Registries

ENT Ear, nose and throat (also known as ORL: otorhinolaryngology)

FOPH Federal Office of Public Health, Bern, Switzerland

FSO Federal Statistical Office, Neuchâtel, Switzerland

HHV-8 Human herpesvirus 8

HIV Human immunodeficiency virus

HPV Human papillomavirus

HRT Hormone replacement therapy

HTLV-1 Human T cell leukaemia/lymphoma virus type 1

IACR International Association of Cancer Registries

IARC International Agency for Research on Cancer, Lyon, France

ICCC-3 International Classification of Childhood Cancer, 3 rd revision

ICD-10 International (statistical) Classification of Diseases (and related health problems), 10 th revision

ICD-O-3 International Classification of Diseases for Oncology, 3 rd revision

NHL Non-Hodgkin’s lymphoma

NICER National Institute for Cancer Epidemiology and Registration, Zurich, Switzerland

PSA Prostate specific antigen

SACR Swiss Association of Cancer Registries (now NICER)

SCCR Swiss Childhood Cancer Registry

SPOG Swiss Paediatric Oncology Group

TNM Tumour-Node-Metastasis

WHO World Health Organisation, Geneva, Switzerland

YPLL Years of potential life lost

2011 FSO Cancer in Switzerland

5


Forewords

Forewords

The topic of cancer concerns us all, because the vast

majority of us have at some point in our life been confronted

with the suffering of a cancer patient in our family

or circle of friends and acquaintances. Cancer is the

second leading cause of death in Switzerland. Four out

of ten people are diagnosed with cancer at some point in

their life. Cancer can occur at any age and independently

of the environment.

But which types of cancer occur particularly frequently

at what age? What are the risk factors and what are

the chances of recovery?

This publication addresses such questions by applying

epidemiological expertise to analyse data from cantonal

cancer registries, the Swiss Childhood Cancer Registry

and the Cause of Death Statistics. It provides information

about incidence by age, cause and risk factors, about

prevention and the chances of cure, and numerous other

aspects of cancer. Although many questions about cancer

and its causes remain open, this publication makes it

possible to chart the spread of cancer in Switzerland.

In order to design health care in a targeted and costeffective

way for the benefit of the population, health

care policy makers depend on a statistical processing and

analysis of the relevant data. For this reason, the Federal

Office of Public Health commissioned the Federal Statistical

Office and the National Institute of Cancer Epidemiology

and Registration (NICER) to manage cancer monitoring

in Switzerland. This report has been coordinated

by the Federal Statistical Office and written in close

cooperation with NICER and the Swiss Childhood Cancer

Registry (SCCR).

The Federal Statistical Office intends to issue this

publication every five years from now on. In addition,

the Federal Statistical Office makes avaible on its Swiss

Statistics web portal cancer statistics that are updated

on an annual basis. With this publication, we hope to

make a substantial contribution to the fight against cancer.

Neuchâtel, January 2011

Dr. Jürg Marti

Director of the Federal Statistical Office

6

Cancer in Switzerland FSo 2011


Forewords

Every year, more than 35,000 people are diagnosed with

cancer and more than 16,000 die of it in Switzerland.

Nationally collected epidemiological data are essential to

understand the causes of cancer so as to be able to plan

targeted preventive measures and introduce effective

and efficient treatment strategies. At present, cancer

data are systematically registered in 16 cantons and

combined for evaluation in the NICER (National Institute

for Cancer Epidemiology and Registration) coordination

centre.

The report provides an overview of the national cancer

landscape and is addressed both to professionals and

to an interested lay audience. It was prepared on behalf

of the Federal Office of Public Health (FOPH) and is the

product of NICER's constructive cooperation with the

Federal Statistical Office (FSO). We would also like to

thank the cantonal cancer registries most warmly for

their support, because without the data they provided,

this report would not have been possible.

The next step will be to put the findings of the report

into practice. NICER is therefore working closely with its

national partners within the framework of the ”National

Cancer Programme 2011–2015“ to contribute to the formulation

of a coherent national strategy to fight cancer.

NICER also supports the current efforts of the Federal

Office of Public Health to establish federal statutory provisions

for the registration of cancers. A law to this effect

will make it possible to collect data on new cases

throughout Switzerland for the treatment of cancer and

to harmonise the framework conditions for monitoring.

These data provide the basis for evidence-based health

policy decisions and interventions; they are relevant to

the health of the entire population as well as to the

affected patients.

Zurich, January 2011

Prof. Dr. med. Giorgio Noseda

President of the NICER Foundation

2011 FSO Cancer in Switzerland

7


Overview

Overview

In 2010, 12 cantonal cancer registries covered

68% of the Swiss population

In Switzerland, cancer registration is organised at the

cantonal level by tumour registries. Twelve registries corresponding

to 16 cantons cover 68% of the Swiss population.

This coverage is now almost complete for Frenchand

Italian-speaking Switzerland, but there are gaps in

some major German-speaking regions. Paediatric tumours

are registered for the whole country by the Swiss

Childhood Cancer Registry. The Causes of Death Statistics

of the Federal Statistical Office records, for its part,

all deaths of persons resident in Switzerland, particularly

those caused by cancer.

Cancers of the prostate, breast, colon-rectum

and lung represent half of all new cancer cases

In Switzerland, an estimated 35,000 new tumours occur

every year, 19,000 among men and 16,000 among

women. In men, cancers of the prostate, lung and colonrectum

account for 53% of new cases. In women,

cancers of the lung, colon-rectum and breast account for

51% of cancers. No other site accounts for more than

6% of cancers.

The number of new cases of melanoma is rising

in Switzerland

Over the past 15 years, the number of new cases of

melanoma (skin cancer) has increased markedly in both

sexes. The same has been the case for lung cancer in

women, thyroid cancer (particularly among women) and

prostate cancer. Better detection methods may partly

explain some increases, such as in the case of prostate

cancer, thyroid cancer and melanoma. Conversely,

a sharp decrease has been observed for cancer of the

cervix uteri. The decrease is also considerable for stomach

cancer, and lung cancer in men.

Switzerland has high disease rates in international

comparison

In international comparison, Switzerland is particularly

affected by cancers of the breast, testis and prostate,

as well as by melanoma and Hodgkin’s disease.

In regards to other cancers, Switzerland is within

the average range in Europe: the high average range for

cancers of the colon-rectum and corpus uteri, non-

Hodgkin lymphomas and leukaemias; and the low average

range for cancers of the stomach and cervix uteri.

Some 3000 people die each year from lung cancer

Some 30% of men and 23% of women in Switzerland

die of cancer. In men, 23% of cancer deaths are due

to lung cancer, 15% to prostate cancer, and 10% to

colorectal cancer. In women, breast cancer is responsible

for 19% of cancer deaths, lung cancer for 13%, and

colorectal cancer for 11%.

Mortality is declining for most cancer sites

Over the past 15 years, this decline has been particularly

significant for cancers of the cervix uteri, stomach, lung

(in men), colon-rectum, breast and prostate, as well

as Hodgkin’s disease. The main exception is the sharp

increase that has been observed in mortality from lung

cancer among women.

8

Cancer in Switzerland FSo 2011


overview

Chances of survival differ depending on site

The chances of survival depend not only on the type

of cancer, but also on the availability and effectiveness of

screening, diagnostic and treatment services. At the

European level, the five-year survival rates are the lowest

(less than 20%) for cancers of the liver, lung, pancreas,

and oesophagus, as well as for acute myeloid leukaemia.

Conversely, persons suffering from cancer of the testis,

melanoma, thyroid cancer, Hodgkin’s lymphoma and

breast cancer have a five-year survival probability of

80% or more. The five-year survival rates observed in

Switzerland are among the best in Europe.

The vast majority of cancers are due to behavioural

and environmental factors

Many risk factors for cancers remain unknown. The risk

factors that have been identified are most often linked to

lifestyle, consumption habits (e.g. diet, alcohol, tobacco)

and environmental or occupational exposure to certain

substances or radiation. Lung cancer is strongly associated

with exposure to tobacco smoke, ambient pollution,

and radon. Ear, nose and throat (ENT) cancers are

related to smoking and alcohol consumption. The deleterious

effects of alcohol and a diet high in red or processed

meat have been shown for colorectal cancer.

Stomach cancer, for its part, is linked to a diet rich in

smoked, salted, dried, and pickled food. Melanoma is

related to overexposure to the sun. However, for many

cancers, such as breast cancer, family history and a genetic

component have also been identified as risk factors.

Prevention by avoidance of risk factors

The prevention of many cancers depends, first and foremost,

on non-exposure to risk factors where possible.

It can also be based on beneficial health habits in general,

such as the consumption of fruits and vegetables

and physical activity. Some medical treatments may also

have a preventive effect, such as vaccination against

hepatitis B (a risk factor for liver cancer) or the human

papillomavirus (HPV; a risk factor for cancer of the cervix

uteri) or treatment of infection with Helicobacter pylori

(a risk factor for stomach cancer).

Childhood cancers are rare but represent the second

leading cause of mortality in childhood

Cancer is generally rare in children. There are about

168 new cases and 37 deaths per year. The most common

childhood cancers are leukaemia (33%), tumours of

the central nervous system (21%) and lymphomas

(13%). The chances of cure have improved notably over

the past 60 years and have now reached 80%. Switzerland

is among the countries with the best treatment outcomes.

2011 FSO Cancer in Switzerland

9


Introduction

1 Introduction

Every year, approximately 35,000 people face a diagnosis

of cancer in Switzerland and nearly 16,000 die of the

disease. Among causes of death, cancer is responsible

for by far the largest number of years lost before age 70.

Nevertheless, for some time there has been no detailed

report about cancer in Switzerland which makes available

for health policy purposes nationwide estimates of

morbidity and mortality risks and regional differences.

The ”Cancer in Switzerland“ report is the result of

cooperation between the Federal Statistical Office (FSO),

which documents cancer mortality by means of the

Cause of Death Statistics (COD), the National Institute

for Cancer Epidemiology and Registration (NICER),

which is the coordination centre of cantonal cancer registries,

and the Swiss Childhood Cancer Registry (SCCR).

The report is based on two sources of data. First, from

the Cause of Death Statistics, which provides nationwide

information on deaths in the entire Swiss population.

Second, from the cancer registries created in the cantons

beginning in 1970 and the SCCR founded in 1976.

These registries systematically record all cancers that are

newly diagnosed (incident) in the cantonal health services

sector. Despite the frequency and related cancer

burden, not all regions of Switzerland have cancer registries;

only 68% of the Swiss population lives in an area

covered by a cancer registry. Nonetheless, it is now possible

to estimate the annual number of new patients

(incidence) and to extrapolate these figures to the whole

of Switzerland.

Cancer registration and cause of death statistics

complement each other, because different survival and

cure probabilities do not make it possible to make direct

inferences from the mortality rate to the morbidity rate.

Consequently, the aim of cancer registration remains to

build an uninterrupted network for the continuous epidemiological

monitoring of incident cases, so that even

small scale changes in the morbidity risk can be detected

without delay. In addition, cancer registration provides

evidence on the effectiveness of prevention and early

detection measures.

The second chapter describes the sources and quality

of data, the survey methods and the indicators used. It is

followed by a general overview of cancer in Switzerland:

the development of cancer morbidity and mortality since

1983, with an emphasis on the latest trends and regional

differences. The next chapter describes the location of

selected cancer types (sites). This chapter provides a

detailed discussion of various trends, age, sex and regional

differences against a backdrop of behavioural and

environmental risk factors known from the scientific

literature and also presents a series of prevention measures.

Cancer affects mainly older people and occurs relatively

rarely during childhood. Nevertheless, cancer is the

second leading cause of death in children. Therefore,

the situation of cancer in this age group is described in a

special chapter (cf. Chapter 5).

Bibliographic references are contained in numbered

endnotes, while explanations of the text are found in

footnotes below each page. The tables with complete

data on which the present report is based are available

on the websites of FSO (www.tumours.bfs.admin.ch),

NICER (www.nicer.org) and the

SCCR (www.childhoodcancerregistry.ch).

2011 FSO Cancer in Switzerland

11


Data and Methods

2 Data and Methods

2.1 Data Sources

The information used in this report stems primarily from

three major databases: cantonal cancer registries (CCR),

the Swiss Childhood Cancer Registry (SCCR) and the

Federal Statistical Office’s Cause of Death Statistics (COD).

The various sources, data access procedures and data

collection methods are described for each of these databases.

Their specific contributions to cancer epidemiology

and research are also presented. The information on

risk factors and prevention has been drawn from the

international scientific literature, while estimates of prevalence

and survival rates have been taken from the International

Agency for Research on Cancer (IARC a ). 1

2.1.1 Tumour Registries

The registration of cancers in Switzerland is organised at

the cantonal level by the cancer registries. b Each canton

has selected the institutional structure of its own registry.

To access the data, the registries maintain links with health

care facilities, pathology laboratories and any other institution

where information on people with cancer can be

found. In addition, the registries can contact the civil registry

offices to regularly check the status of each patient

(i.e. whether he or she is alive or dead). The persons

concerned can veto their data from being recorded in

the registries’ databases. The registries follow the recommendations

for data collection procedures and contents

established by the IARC. The registration of tumours

is done taking into account histological types of tumours

defined in the International Classification of Diseases

for Oncology (ICD-O-3).

The first tumour registry was created in 1970 in Geneva,

2 followed by the cantonal registries of Vaud and

Neuchâtel (1974), Zurich, St. Gallen-Appenzell (1980),

Basel-Stadt und Basel-Landschaft c (1981), Valais,

Graubünden (1989) and Glarus (1992), Ticino (1996)

and Fribourg (2005). The cancer registries included in

this report cover 62% of the Swiss population. For the

Canton of Jura, data have been collected since 2005. d

The newly founded Swiss Central Cancer Registry

started to record the data from the canton of Lucerne

in 2010. Thus, in 2010 some 68% of the Swiss population

lived in an area where cancers are registered (M 1).

In 1978, the Swiss Association of Cancer Registries

(SACR) was formed to harmonise data collection, create

an inter-cantonal database and promote research on

cancer epidemiology at the national level. In 2007, this

association became the National Institute for Epidemiology

and Cancer Registration (NICER), based at the University

of Zurich (www.nicer.org). Its organisational

structure brings together representatives of universities,

social and preventive medicine institutions at the federal

and cantonal level, registries as well as a scientific advisory

committee composed of international experts.

Functioning as a central scientific and administrative secretariat,

NICER provides assistance to cantonal registries

and has the following tasks:

– define standards and recommendations for collecting

and coding data,

– check the quality of registered data,

– establish the estimated national incidence,

– ensure the scientific coordination of epidemiological

research, particularly in collaborative studies conducted

between the registries or external partners.

a

b

The IARC obtains data from more than 400 population registries from

60 countries across the five continents.

The tumour registries search and record all cases of cancer diagnosis,

treatment and death in a defined population (residents of the canton),

irrespective their place of care. In contrast, hospital registers only collect

information on patients who have been hospitalised in their particular

hospital and therefore do not cover all cases within a given population.

c

The registry of Basel-Stadt and Basel-Landschaft was founded in 1969,

but the first available computerised data are from 1981.

d

The data were not available when this report was printed.

12

Cancer in Switzerland FSo 2011


Data and Methods

Cantons with cancer registration, 2010 M 1

Year of creation

JU

BS

SO

BL

AG

SH

ZG

ZH

TG

SG

AR

AI

1970 – 1979

1980 – 1989

1990 – 1999

2000 – 2007

New established

registries

Without registry

NE

BE

LU

NW

SZ

GL

FR

OW

UR

VD

GR

GE

VS

TI

0 25 50 km

Spatial division: Cantons

Source: NICER, CCR

© FSO, ThemaKart, Neuchâtel 2011

Thanks to the network of cantonal registries, their

links with university departments and clinics and NICER

as a coordination body, Switzerland has the capacity to

collect and manage data on the characteristics of cancer

patients and their diseases. It also has a reliable database

of all cancer cases that have been the subject of a diagnosis,

treatment or death certificate in a defined population.

By making full use of this database, the objectives

of cancer registration, monitoring and epidemiological

research are achieved. They include:

– observe and describe the frequency of various cancers

according to the socio-demographic characteristics of

patients and to regional differences,

– study the relationship between the occurrence of cancers

and risk factors (genetic factors, lifestyle, exposure

to pollution),

– observe the survival of patients to assess the effectiveness

of prevention and screening, as well as of

diagnostic and treatment methods,

2.1.2 Swiss Childhood Cancer Registry

Childhood cancers throughout Switzerland are registered

in the Swiss Childhood Cancer Registry (SCCR)

(www.childhoodcancerregistry.ch). The SCCR is based at

the Institute of Social and Preventive Medicine of the

University of Bern and collaborates closely with the Swiss

Paediatric Oncology Group (SPOG; www.spog.ch).

The SCCR was founded in 1976, making it one of the

oldest cancer registries in Europe. In the early years the

SCCR mainly registered children who took part in clinical

trials. Since the late 1980s the nationwide coverage has

also been very good for non-trial-included patients. Coverage

is mostly complete for the age group 0–15 years;

cancers among adolescents (aged 16–20 years at diagnosis)

are also registered but to date not nationwide.

The SCCR registers cases of leukaemia, lymphoma,

malignant solid tumours, malignant and benign brain

tumours, as well as Langerhans cell histiocytosis, the last

of which is not considered to be a cancer per se, but it

behaves similarly to cancer.

– estimate the prevalence of cancers in order to determine

patients’ care needs and organise and plan for

their care.

2011 FSO Cancer in Switzerland

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Data and Methods

The treating physicians provide information about the

Childhood Cancer Registry to patients and their families.

If the families do not avail themselves of their veto

power, information about the disease, therapy and treatment

results are forwarded to the SCCR, where it is registered

in accordance with the International Classification

of Childhood Cancer (ICCC-3).

Regular comparison of data with cantonal registries,

mortality statistics and other data sources (e.g. hospital

statistics, laboratory reports) aims to ensure that children

who are treated in smaller paediatric hospitals or clinics

for adults are also covered by the SCCR.

The Children’s Cancer Registry does not limit itself to

registering the frequency (incidence) of cancer. Rather,

it aims to contribute to the study of the causes of cancer

in children and to document and improve the quality of

treatment and long-term prognosis. Therefore, the quality

of life of patients who have been cured is monitored

through long-term follow-up questions to doctors or

directly to former patients. This information is evaluated

and made available to the treatment centres in anonymous

form. Thus, the therapies and follow-up can be

continually improved.

The SCCR is a member of the International Association

of Cancer Registries (IACR), the European Network

of Cancer Registries (ENCR) and the National Institute

for Cancer Epidemiology and Registration (NICER). In

2004, it obtained a special authorisation and in 2007 it

was granted a general approval to operate a cancer registry

by the Federal Expert Commission on Professional

Secrecy in Medical Research of the Federal Office of

Public Health (FOPH; www.foph.admin.ch).

2.1.3 Cause of Death Statistics

The Cause of Death Statistics has existed since 1876 and

has been available in electronic form since 1969. It is

based on civil registries and on death certificates indicating

the causes of death which are completed by the

physicians who declare the death. The coding of death

certificates is carried out by the FSO for the whole of

Switzerland. The International Classification of Diseases

(ICD) provides a standardised system of classification

and coding, as well as a format model for the death certificate.

An update of the coding rules led to a partial

break in the time series, 3 which was offset in this publication

by means of correction factors.

The Cause of Death Statistics makes available very

long time series of all deaths of persons residing in Switzerland.

This makes it possible to monitor the impact of

cancers in terms of mortality and years of life lost prematurely.

This monitoring can include various types of cancer

by comparing their impact and changes based on the

socio-demographic characteristics (e.g. gender, age, etc.)

of the deceased persons. This statistic also allows comparisons

between regions or cantons as well as with

other countries. It is, therefore, an important database

for epidemiological analysis and the study of risk factors

and the causes of cancer.

2.2 Indicators

Indicators from two different areas are used in this

report: on the one hand, epidemiological indicators such

as cancer incidence, cancer mortality, survival rate and

the prevalence of people living with the disease. On the

other hand, indicators that reflect the quality of care

in the health system, i.e. the cancer stage at diagnosis,

the time between diagnosis and start of treatment, and

the effectiveness of all interventions.

2.2.1 Incidence

Incidence is the number of new cases (of cancer) occurring

in a defined population during a given time period.

It is generally expressed as a rate (number of new cases

per 100,000 inhabitants per year).

Given the impact of age on the risk of cancer, it is

imperative to take into account age when comparing

cancer rates between populations and over time. Direct

standardisation procedures are used to present standardised

rates; rates recalculated on the assumption that the

study population represents the age structure of a reference

population (e.g. standard population types defined

by the World Health Organisation – WHO). Except for

international comparison, in the present report the European

standard population is used.

In Switzerland, incidence is not collected throughout

the country, with the exception of data on children. In

fact, it is collected by registries which cover almost all of

French-speaking Switzerland and Ticino (Italian-speaking

Switzerland) and about half of German-speaking Switzerland.

This rate is determined separately by five‐year age

14

Cancer in Switzerland FSo 2011


Data and Methods

group, sex and cancer site. It is applied to the entire

region assuming homogeneity of data between the geographical

areas that are covered and those that are not

covered. The hypothetical number of cases of the total

area is obtained in proportion to populations. The Swiss

estimate published in this report is the sum of estimated

cases for each language region.

Some discontinuities in representativeness are worth

mentioning in detail. The fact that the registries began

operations progressively over time can have an effect on

the published trends, particularly for cancers such as

stomach cancer in mountain regions, which were insufficiently

covered in the early years and which present differences

in risk compared with the Swiss plateau regions.

Thus, the registries of Valais and Graubünden were introduced

in the 1988–1992 period, those of Glarus and

Ticino in 1993–1997, and that of Fribourg in 2006, i.e.

during the last period. Incorporating all available data

improves the representativeness over time in preference

to strict comparability of the periods. The motivating criterion

for providing an optimised Swiss estimate for

recent periods is that it is more useful for public health

bodies.

2.2.2 Mortality

Mortality is the frequency of death in a population

during a given time period. Mortality due to a specific

disease (e.g. cancer) measures the impact of the disease,

expressed either as the number of deaths or as the mortality

rate (deaths per 100,000 persons per year). As in

the case of incidence, the use of standardised rates is

indispensable for comparison between populations or

population groups.

2.2.3 Survival

There are several ways to express the survival rate and

different methods to calculate it depending on what one

wants to measure and on the size of the observed

population. Observed survival, or crude survival, is the

ratio between the number of deaths that occurred during

a period of time (one year, five years. etc.) and the

population suffering from a disease. Relative survival

measures the excess mortality due to the disease by taking

account of the probability of death (from all other

causes) in the general population at every age. Relative

survival is expressed as the ratio of the observed number

of survivors (numerator) after a specified time period

(usually five years) and the number of expected survivors

(denominator) based on the mortality rate of the

general population. This rate is also called net survival.

For a good comparison between two populations, it is

preferable to use relative survivals, especially if the populations

differ in their age structures and/or their health

care systems. In this case, it is necessary to have mortality

tables for each population which are as detailed as

possible (by age, sex, and for each calendar year).

For a given cancer site, the survival rate depends on

several factors: the stage of cancer at the time of diagnosis,

the time between onset of the disease and start of

treatment, and the effectiveness of the treatment. Survival

is used as an indicator of the health care system’s

quality of cancer care.

To calculate survival it is necessary to know whether,

at a given date, a person affected by cancer is alive or

dead. However, under data protection regulations, registries

may not disclose information indicating that a person

is suffering from cancer. Therefore, they have to collect

the data indicating whether people are deceased or

not in an indirect way. The first method is to go through

third parties (e.g. hospital or treating physician) to ask

the communes every year whether the persons in question

are still alive and, if not, the date of their death. It is

a cumbersome process for the communes. Another

method consists of obtaining from the FSO general mortality

data from which the registries retrieve (via anonymous

parameters) the information on the persons they

have registered. This method is more complex and less

accurate. Lastly, in the canton of Fribourg a system was

recently introduced whereby each commune transmits

once a year to the cancer registry the list of persons who

died or who moved away from the commune during the

previous year. Thus, the registry can complement the

information it already has, confidentially and without

any additional workload for the communes.

2.2.4 Prevalence

Cancer prevalence is the proportion of patients with a

diagnosis of cancer in a population at a given moment in

time. Like incidence, it is generally represented as a rate

(number of cases per 100,000 inhabitants, e.g. on 31.12

of a given year).

2011 FSO Cancer in Switzerland

15


Data and Methods

This indicator is very difficult to establish. It depends

on two parameters that vary significantly depending on

cancer sites: incidence and survival. However, while the

cancer registries allow a correct estimate of the incidence,

survival is more difficult to know precisely for the

reasons discussed above. Prevalence cannot be registered

continuously. Nonetheless, if a registry has been in

existence for a sufficient number of years, it is possible

to estimate the prevalence simply by counting the patients

who are registered and still alive. But to achieve

precision, this method requires a long observation period,

because patients who had cancer before the start

of registration are not counted. That is why the estimation

of prevalence is the subject of specific publications. 4

The estimates presented in this report are drawn from

Globocan, 5 and are essentially based on a mortality/incidence

ratio. e These estimates are approximate for Switzerland

and only take account of persons diagnosed over

the previous five years.

2.2.5 Stage at Diagnosis

The stage at diagnosis is the degree of spread of the

tumour at diagnosis. It is conventionally defined according

to four stages (I-IV): The cancer is localized (I), with

local invasion (II), with regional invasion (III) or advanced/metastatic

(IV). The most frequently used classification

system to determine the stage is ”TNM“, which

describes the situation according to the following indicators:

the size of the tumour (T0 to T4), lymphnode involvement

(N- or N+), and the presence of metastases

(M- or M+).

Information on the stage at diagnosis is of great interest

for studies of survival: in most cases, an earlier diagnosis

increases the chances of survival. The stage is a difficult

data item to collect on a routine basis, because it requires

access to medical records and consequently collaboration

with clinicians, as well as considerable infrastructure

and personnel and technical resources. For this reason,

certain Swiss cancer registries cannot provide information

on the stage at diagnosis.

e

The Globocan prevalence 2002 was estimated with incidence data

provided by the registries of Basel-Stadt and Basel-Landschaft (1996),

Geneva (1997–99), Graubünden and Glarus (1997– 99), St. Gallen-

Appenzell (1997–99), Ticino (1997–98) and Valais (1997–98) and survival

data from EUROCARE 3, taking account of the registries of

Basel-Stadt and Basel-Landschaft (1990–92) and Geneva (1990–94).

2.2.6 Effectiveness of Treatment

The effectiveness of treatment also depends on many

factors, such as the time gap between diagnosis and

start of treatment. These data are collected by all registries.

The effectiveness of treatment also depends on the

type of treatment as well as the multidisciplinary care of

the patient; the impact of which is more difficult to

quantify.

2.3 Quality of Data

The quality of data from a cancer registry is measured

on the basis of at least four criteria: the comparability,

completeness, validity, and accuracy of the information it

comprises and the results it produces. These criteria are

applied and regularly measured by each registry and by

NICER. In addition, the ongoing use of data makes it

possible to verify their quality by means of a series of

analyses.

2.3.1 Comparability

Comparability is based on a set of criteria to ensure

consistent coding and to estimate the reliability of a register.

These criteria are defined in the International Classification

of Diseases (ICD-10, ICD-O-3) 6 and by the

IARC. 7 They relate to the topography, morphology, and

behaviour of tumours, as well as to the registration process

(date of incidence, multiple tumours, and diagnostic

mode). All Swiss cancer registries follow international

recommendations in this regard.

2.3.2 Completeness

The indicator of completeness of the record is based

on the proportion of cases recorded in the registry, compared

with the estimated number of all cases occurring

in the observed population. A higher level of completeness

is obtained by combining multiple data sources

(cf. 2.1.1). Thus, the registries periodically check that all

cases of death from cancer are also found in their databases.

This procedure, combined with the systematic

search for duplicates, improves the completeness of the

registry and prevents the same case from being recorded

several times.

According to the latest assessments of the completeness

of registration, it is estimated that approximately

90% of cancers diagnosed are registered within the first

year after diagnosis.

16

Cancer in Switzerland FSo 2011


Data and Methods

2.3.3 Validity

To assess the validity of the data in the registries, two

dimensions are taken into account: internal and external

validity. Internal validity refers to the plausibility of the

information recorded for each case (i.e. the absence of

incompatibility in the data). Incompatibilities can be

found, for example, between the age of a patient and

the date of diagnosis of his or her cancer, between the

tumour type, the site and the sex of the patient, between

the site and histological type, etc.

External validity concerns the representativeness of

the information held by the registries in relation to the

general population. Validity is affected inter alia by an

uneven distribution of registries across the regions of

Switzerland. Thus, at the end of 2009, coverage was

91% for French- and Italian-speaking cantons, but only

47% for German-speaking Switzerland. f An optimal

external validity implies a lack of information bias

between the morbidity documented by the registry and

the actual morbidity in the reference population. Such

biases may result from patients spontaneously selecting

different types of care in the private or public sector,

depending on sites and treatments. This self-selection

phenomenon may vary from one canton to another.

Thus, not all registries have exactly the same index of

external validity. That said, in terms of international comparability,

all Swiss registries are in the group with very

good validity: the data they provide are very representative

of the population.

2.3.4 Accuracy

Accuracy is defined by the level of detail contained in

the information collected and its precision. For the calculation

of rates (e.g. incidence), it is essential to have

demographic data on the same periods as those used for

the registration of cases. To this end, data from population

censuses and intercensal data are used. For a

description of cases, all characteristics must be subject to

a systematic search for accuracy: site, histological type,

results of further laboratory tests, degree of spread of

cancer, number of lymph nodes assessed and number of

positive lymph nodes.

Based on these elements, the accuracy of the data

collected can be expressed by different indicators such as

the proportion of cases in which the record contains

poorly defined or unknown items, the proportion of

autopsies performed, and the proportion of cases

defined based on a histological investigation.

f

New registries are planned, which should improve coverage of Germanspeaking

Switzerland in the coming years.

2011 FSO Cancer in Switzerland

17


General Remarks about Cancer in Switzerland

3 General Remarks about Cancer

in Switzerland

3.1 Incidence and Risk of Cancer

During the 2003–2007 observation period, the estimated

number of new cases of invasive cancers a each

year was approximately 19,000 among men and approximately

16,000 among women. b Cancer can occur at

any age but risk increases with age. Thus, only 13% of

cancers occur before age 50 and 54% before age 70.

The risk of developing a cancer before the age of 70 years

is approximately 25% for men and 20% for women.

Compared with 40 European countries, in 2008 c Switzerland

ranked 16 th for men and 15 th for women in

terms of the frequency of new cases. d This places it in

the group of countries with high risk especially for following

cancer types:

– melanoma (rank 1–2206 cases per year: 1049 in men

and 1157 in women)

– breast cancer (rank 5–5900 cases per year) and

– prostate cancer (rank 8–5380 cases per year) 8

Lung cancer (30 th rank in Europe among men and

13 th among women) accounts, together with three other

cancer sites, for 53% of cancers among men (prostate

30%, lung 13%, colon-rectum 11%) and 51% of cancers

among women (breast 32%, colon-rectum 11%,

and lung 8%). The other cancers account for less than

6% each.

3.2 Deaths and Years of Life Lost

The number of cancer deaths amounts to approximately

16,000 per year: 9000 men and 7000 women. It is

important to note that the classification of the frequency

of cancer by mortality differs from the classification by

incidence. This difference is due to the prognosis for

each type of cancer. Lung cancer is the most frequent

cause of death from cancer among men in Switzerland.

With 2000 deaths per year (23%), it is followed by prostate

cancer, which accounts for 1300 deaths (15%), and

colorectal cancer with 860 deaths (10%). In the female

population, breast cancer is the leading cause of death,

with 1300 deaths each year (13%), followed by lung

cancer with 900 deaths (13%), and colorectal cancer

with 740 deaths (11%) (G 3.1).

However, the mortality rate says nothing about the

age at which death occurred. This information can be

provided by means of the ”years of potential life lost“.

This index is calculated from the difference between the

age of death and a theoretical life expectancy of 70 years

(in number of years). A high index can be obtained in

two ways: by a high mortality rate in an elderly population

or by an average mortality rate in younger age

groups. The proportion of years of life lost by premature

death due to cancer is estimated to be 29% among men

and 45% among women. 9

a

These are ”invasive“ cases which exclude ”in situ“ cancers diagnosed

very early (usually through screening) at a localised (precancerous) stage.

b

Incidence estimated based on cancer registry data, cf. 2.1.1 and 2.2.1

c

To estimate the incidence, Globocan projected the mortality in 1986–2005

(FSO Cause of Death Statistics) to the year 2008 and used the ratio incidence/mortality

taking into account the incidence observed in the cantonal

registries of Geneva, Graubünden and Glarus, Neuchâtel, St. Gallen-

Appenzell, Ticino, Valais and Vaud for the period 2000–02.

d

Incidence rates standardised to the world population, according to the

World Health Organisation (WHO)

18

Cancer in Switzerland FSo 2011


General Remarks about Cancer in Switzerland

Incidence 1 , mortality and years of potential life lost (YPLL) by cancer site, 2003–2007

G 3.1

Share by cancer site, in%

Share by cancer site, in%

Breast

Prostate

Colon-rectum

Lungs, bronchi, trachea

Lungs, bronchi, trachea

Skin melanoma

Corpus uteri

Non-Hodgkin

lymphoma

Ovary

Pancreas

Leukaemia

Thyroid

Colon-rectum

Skin melanoma

Bladder

Oral cavity and pharynx

Non-Hodgkin

lymphoma

Leukaemia

Kidney

Stomach

Pancreas

Oral cavity and pharynx

Stomach

Bladder

Liver

Kidney

Testis

Cervix uteri

Brain and central

nervous system

Multiple myeloma

Gallbladder and extrahepatic

bile ducts

Liver

Oesophagus

Hodgkin’s disease

Larynx

Oesophagus

Brain and central

nervous system

Multiple myeloma

Larynx

Gallbladder and extrahepatic

bile ducts

Pleura

Thyroid

Bones, joints, cartilage

Hodgkin’s disease

Pleura

Women

Bones, joints, cartilage

Men

0% 10% 20% 30% 40%

Incidence 1

Mortality YPLL before age 70

0% 10% 20% 30% 40%

Incidence 1

Mortality YPLL before age 70

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

19


General Remarks about Cancer in Switzerland

For cancer, the only survival data currently available for

Switzerland are those obtained for 34,000 patients diagnosed

between 1995 and 1999. They were subjected

to a specific follow-up procedure by seven cantonal registries:

Basel-Stadt and Landschaft, Geneva, Graubünden

and Glarus, St. Gallen-Appenzell, Ticino, Valais and

Zurich. The results have been published as part of the

European EUROCARE 4 study and are available on the

internet. 10 This study compared the survival of patients

from 23 European countries. Switzerland is often ranked

among the countries with the best survival rates. In Switzerland,

for all cancers combined, five‐year relative survival

rate is estimated at 48% for men and 57% for

women.

However, survival varies considerably between different

cancers. Thus, cancers of the liver, lung, pancreas,

brain, central nervous system, and acute leukaemia all

have a poor prognosis. In contrast, testicular cancer,

melanoma, thyroid cancer, Hodgkin’s disease, and breast

cancer have good prognoses.

Besides the evolutionary potential of the disease itself,

variations in survival may depend on the degree of

spread of the disease when it is detected. The degree of

spread may in turn depend on the availability of diagnostic

and treatment services as well as on their resources

and the effectiveness of their interventions. A better survival

is usually expected in early detection stages.

Estimating prevalence requires knowing the incidence

and survival over a very long period. At present, only

estimates for breast and colorectal cancer are available in

Switzerland. The most recent publications estimate the

prevalence of breast cancer at 72,000 women and colo-

3.4 Time Trends and Regional

3.3 Survival and Prevalence

rectal cancer at 32,000 men and women. 11 Comparisons

Cancer risk trends can be identified on the basis of mortality

because national data are available over a long

period of time. Nevertheless, mortality trends should be

interpreted and compared with caution, especially in

cancer cases characterised by changes in survival rate

over time. It is generally accepted that it is necessary to

consider incidence, mortality and survival within the

same time periods to understand the complex changes

that occur over a long period.

12, 13

For cancers with short survival times, mortality on

its own can be a reliable indicator of changes in risk.

Thus, lung cancer mortality has expressed the changing

smoking habits over successive generations (i.e. birth

cohorts). 14, 15 Among men, the decline in smoking was

followed some decades later and in the same generations

by a decline in the incidence of lung cancer (-8%

between 1998–2002 and 2003–2007) and subsequently

in mortality (-10%). Among women, smoking is more

recent and is increasing (incidence +16%), a fact that is

reflected by an increase in mortality due to lung cancer

(+15%) (G 3.2).

For cancers with longer survival times, time trends

reflect a complex mix of the effects of incidence (and its

determinants), early diagnosis, and recent advances in

therapy. In the case of breast cancer, the reduction in

mortality (-6% between the last two periods) is likely

due to these factors. It is, however, difficult to distinguish

between the impact of improved treatment and

that of early detection thanks to screening tests.

20

Cancer in Switzerland FSo 2011


General Remarks about Cancer in Switzerland

Trend of incidence 1 and mortality by cancer site between 1998–2002 and 2003–2007

G 3.2

Hodgkin’s disease

Bones, joints, cartilage

Thyroid

Gallbladder and extrahepatic

bile ducts

Stomach

Larynx

Non-Hodgkin

lymphoma

Kidney

Colon-rectum

Cervix uteri

Pleura

Breast

Corpus uteri

Leukaemia

Multiple myeloma

Bladder

Oesophagus

Oral cavity and pharynx

Brain and central

nervous system

Pancreas

Ovary

Skin melanoma

Lungs, bronchi, trachea

Liver

Change in incidence

Significant 2

Not significant 2

By increasing mortality

Women

-40% -30% -20% -10% 0% 10% 20% 30%

Change in mortality

Significant 2

Not significant 2

Testis

Stomach

Larynx

Hodgkin’s disease

Gallbladder and extrahepatic

bile ducts

Prostate

Bones, joints, cartilage

Lungs, bronchi, trachea

Oral cavity and pharynx

Colon-rectum

Non-Hodgkin

lymphoma

Kidney

Bladder

Thyroid

Pancreas

Oesophagus

Leukaemia

Brain and central

nervous system

Liver

Multiple myeloma

Skin melanoma

Pleura

Change in incidence

Significant 2

Not significant 2

By increasing mortality

Men

-40% -30% -20% -10% 0% 10% 20% 30%

Change in mortality

Significant 2

Not significant 2

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

2 Mantel-Haenszel ratio: increase (> 1) or decrease (< 1) since the previous period, with statistical significance of 95%

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

21


General Remarks about Cancer in Switzerland

The same applies to prostate cancer. It is, in fact, difficult

to determine which of the two factors, early diagnosis

or better treatment, is responsible for the recent decline

in mortality (-13%) (G 3.2), observed especially in

German-speaking Switzerland. After a steady increase in

prostate cancer mortality until the 1980s, a rapid increase

in incidence has been observed simultaneously in

many other Western countries. This increase in incidence

is largely due to the rapid spread in the use of the PSA

(Prostate specific antigen) test, which allows the detection

of a disease that is still latent.

Recent changes in mortality and incidence for the

other cancer sites are shown in graph G 3.2. These

trends, calculated for the whole of Switzerland, ignore

heterogeneities between linguistic regions or age groups.

Incidence is a better indicator of change in risk. The

use of incidence data, collected by cancer registries for

the period 1983–2007, makes it possible to identify

trends by age group and language region. e The sites

whose frequency has increased significantly over the

past 15 years are the lung among women, prostate

among men, melanoma and thyroid among both sexes.

– Lung cancer among women increased by approximately

3% per year, at an equal rate in Germanspeaking

and in French- and Italian-speaking Switzerland.

– Melanoma also increased by 3% per year on average

across Switzerland, but the increase was more significant

in French- and Italian-speaking Switzerland (4%

per year in men and 5% per year in women).

– Thyroid cancer increased by almost 6% per year

among men and by 4% per year among women in

French- and Italian-speaking Switzerland. It registered

a very small increase in German-speaking Switzerland.

In both language regions, the age group

that has been most affected by this increase is that of

20–49-year-olds.

– Prostate cancer increased by over 12% per year

among men under 50, and by 6% per year among

those aged 50–69.

The cancers that showed a decline in incidence

over the past 15 years are cancers of the cervix uteri,

pleura, and stomach.

– Cancer of the cervix uteri decreased by 5% per year,

in a uniform way for all ages and regions.

– Pleural cancer decreased by 10% per year among

women in French- and Italian-speaking Switzerland.

In the country as a whole, there was practically no

decrease, but it actually increased by 2% in Germanspeaking

Switzerland.

– Stomach cancer decreased by 4% per year among

men and 3% among women. The decline was

observed mainly in people over age 50 and was more

pronounced in German-speaking Switzerland.

These observations sometimes reflect a real change

in risk over time, sometimes the emergence of new diagnostic

methods, and other times the effects of exposure

to a factor whose impact has varied between birth

cohorts. Chapter 4 discusses this for the individual cancer

types.

3.5 Risk, Prevention and Treatment

Factors

In many cases, the causes of cancer are not known;

where they are known, the international scientific literature

often points to specific events, behaviours or prior

exposure to carcinogens such as tobacco, alcohol, asbestos,

some viruses and especially a combination of these

factors. Cancers related to genetic factors represent a

small minority of no more than 10% of cancers. But the

causes of many cancers remain unknown. Moreover,

the risk increases with age for most cancers.

Primary prevention measures such as health education

and promotion also have an influence on cancer risk. In

the case of some cancers, a better understanding of their

causes is increasingly making it possible to intervene

before the disease manifests. Thus, primary prevention

aims to avoid or at least to reduce exposure to risk, such

as smoking, obesity, excessive sun exposure, or the

excessive consumption of alcohol. Health promotion as

e

A table of annual trends between 1993 and 2007 is available at

www.tumours.bfs.admin.ch.

22

Cancer in Switzerland FSo 2011


General Remarks about Cancer in Switzerland

primary prevention encourages daily physical activity

and increased consumption of fruits and vegetables coupled

with a reduced intake of animal fat. 16

Technological advances improve the effectiveness of

secondary prevention, also called ”screening“. The aim

is to identify the disease at a very early stage when the

disease has not yet manifested itself with symptoms.

Such screening tests are available for cancers of the

breast, prostate, colon and cervix uteri.

Technological progress also enables greater efficacy

of care and treatments, especially thanks to innovations

in imaging, surgery, radiotherapy and chemotherapy.

All these methods have and will continue to offer certain

cancer patients a higher probability of cure.

In addition, advances in genetics and genetic epidemiology

are now opening new perspectives for diagnosis,

treatment and (soon) perhaps even prevention. The fight

against cancer is therefore based on the synchronisation

of programmes and services for primary prevention,

screening, diagnosis, treatment, and rehabilitation.

3.6 Swiss Specificities

Similarly to other European countries the incidence of

lung cancer in men, stomach cancer in both sexes, and

cancer of the cervix uteri in women is declining significantly

in Switzerland. f Conversely, as in other European

countries, the incidence of prostate cancer in men and

lung cancer in women is rising.

Compared with the rest of Europe, the mortality rate

for melanoma for both sexes in Switzerland is above the

average range. Men also have a higher mortality rate for

prostate cancer, multiple myeloma and non-Hodgkin

lymphomas. Women have a higher than average mortality

rate of lung and bladder cancer. Conversely, the mortality

rate for Swiss women is lower than the European

average for cancers of the cervix uteri and stomach.

Compared with other European countries, the survival

rate of people suffering from cancer is particularly high

in Switzerland. Survival rates indicate the capacity of the

health care system to diagnose cases early and to treat

them effectively.

By international comparison the incidence of cancers

of the breast, testis and prostate, melanoma, Hodgkin’s

disease and to lesser extent non-Hodgkin lymphomas is

high in Switzerland. The sharp increase in melanoma,

observed particularly among young women, underscores

the necessity of prevention measures.

Furthermore, some regional differences within Switzerland

should be highlighted. Lung cancer and ear, nose

and throat (ENT) cancers, g which are associated with the

consumption of tobacco and alcohol, are more common

in French- and Italian-speaking Switzerland. For breast

cancer, the incidence is higher in French- and Italianspeaking

Switzerland, while the mortality is higher in

German-speaking Switzerland. All cantons in Frenchspeaking

Switzerland have a breast-cancer screening by

mammography programme, compared with only one

German-speaking canton. Such a mammography programme

is expected to be introduced in the canton of

Ticino in 2011. As far as cancer of the cervix uteri is concerned,

the incidence rates are twice as high in the cantons

of Graubünden and Glarus as in the cantons of

Geneva and Fribourg. Lastly, it is worth noting that the

incidence of testicular cancer is very high in Switzerland,

particularly in Basel-Stadt and Basel-Landschaft. Specific

studies would be needed to identify potential causes. For

colorectal cancer there is currently no organised screening

in Switzerland. However, two screening methods are

available (cf. 4.2.6). The value of such screening would

be to allow early diagnosis.

f

International comparisons ought to be considered with caution, particularly

because of differences in cancer registration and between health

systems.

g

Also known as ORL cancers, i.e. cancers involving otorhinolaryngology.

2011 FSO Cancer in Switzerland

23


Cancer Sites

4 Cancer Sites

4.1 Stomach Cancer

4.1.1 General Observations

Approximately 800 stomach cancers are diagnosed each

year in Switzerland. a This cancer accounts for less than

3% of all new cancer cases in both sexes. It is about

twice as common in men than in women and risk increases

with age (G 4.1.1). The risk of developing this cancer

before the age of 70 is 0.6% in men and 0.3% in

women.

Stomach cancer, 2003–2007 G 4.1.1

Age-specific rate per 100,000 inhabitants

120

100

80

Stomach cancer is responsible for 536 deaths per year,

about 3.5% of all cancer deaths in both sexes. In terms

of mortality, its impact is somewhat more significant

because of its relatively low survival rate. 17 The five‐year

relative survival rate is 27%, slightly above the European

average. In 2002, it was estimated that 1200 men and

650 women diagnosed with stomach cancer during the

previous five years were living in Switzerland. 18

4.1.2 Trends

In Switzerland, as in many parts of the developed world,

a significant decrease in the incidence and mortality of

stomach cancer is being observed (G 4.1.2). This decrease

is more pronounced in men than in women. In

French- and Italian-speaking Switzerland, the incidence

among women appears to no longer be declining

(G 4.1.3).

60

40

20

0

Source: FSO: COD, NICER, CCR

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

Stomach cancer: Incidence 1 and mortality trend G 4.1.2

Rate per 100,000 inhabitants, European standard

25

Women

Men

20

15

10

5

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence women 1

Mortality women

Incidence men 1

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

a

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

24

Cancer in Switzerland FSo 2011


Cancer Sites

Stomach cancer: Incidence 1 and mortality trend by language region G 4.1.3

Rate per 100,000 inhabitants, European standard

25

Women

20

15

10

5

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

Stomach cancer: Incidence 1 and mortality trend by age group G 4.1.4

Crude rate per 100,000 inhabitants

160

Women

140

120

100

80

60

40

20

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years

© FSO

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

2011 FSO Cancer in Switzerland

25


Cancer Sites

4.1.3 Regional Comparisons

There are significant disparities in incidence in Switzerland.

This cancer is about twice as common in the cantons

of Ticino and Valais and in the region of Graubünden

and Glarus than in the canton of Neuchâtel and the

registry of Basel-Stadt and Basel-Landschaft, which registers

the lowest rates among men and women respectively

(G 4.1.5).

4.1.4 International Comparisons

Significant geographic variations in incidence are observed

(G 4.1.6). The risk is 10–12 times higher in East

Asia (Korea and Japan), which has the highest rates,

than in the United States, India and Pakistan, which have

the lowest ones. Relatively high rates are also observed

in South America, Russia and Eastern Europe, as well

as in Portugal. The Swiss incidence rate is within the low

average range in Europe.

4.1.5 Risk Factors

The spontaneous and significant decline in stomach

cancer in most countries, commonly called the ”unplanned

triumph“, is probably linked to the emergence

of refrigerators, which has changed the method of food

preservation.

Infection with Helicobacter pylori bacterium is known

as one of the main risk factors for this cancer. The inflammations

it causes (chronic atrophic gastritis) promote

the occurrence of precancerous lesions. A diet rich in

smoked, salted, dried and pickled food, as well as food

containing high levels of nitrates and nitrites, increases

the risk. Such a diet may be the cause of the higher rates

observed in the cantons in the Alpine Arc. In contrast,

the consumption of fruits and vegetables appears to decrease

the risk. Pernicious anaemia, blood type A, and a

family history are all associated with inreased risk. A family

history of stomach cancer is associated with an increased

risk of developing it. In particular, some genetic

Stomach cancer: Incidence 1 in regional comparison, 2003–2007

G 4.1.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

German-speaking Switzerland

French-speaking Switzerland and Ticino

Ticino

Graubünden and Glarus

Valais

Zurich

Fribourg

Vaud

Neuchâtel

Geneva

St. Gallen and Appenzell

Basel-Stadt and Basel-Landschaft

20 15 10 5 0 0 5 10 15 20

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

26

Cancer in Switzerland FSo 2011


Cancer Sites

Stomach cancer: Incidence 1 in international comparison, 1998–2002

G 4.1.6

Rate per 100,000 inhabitants, world standard

Korea

Japan e

Russia e

Portugal e

Latin America e

Baltic States

China e

Italy e

Balkan states e

Germany e

Sub-Saharan Africa e

Czech Rep. and Slovakia

Austria

Israel

Southeast Asia e

Spain e

Finland

USA, Blacks e

Poland e

Turkey e

French Polynesia

Netherlands

British Isles e

Belgium e

Switzerland e

Australia and New Zealand

Scandinavia

Pakistan e

France e

Canada e

USA, Whites e

India e

North Africa e

Women

0 10 20 30 40 50 60 70

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

Rate per 100,000 inhabitants, world standard

Korea

Japan e

Russia e

Latin America e

Portugal e

Baltic States

China e

Italy e

Balkan states e

Czech Rep. and Slovakia

Germany e

Poland e

Spain e

Austria

Israel

British Isles e

Netherlands

USA, Blacks e

Turkey e

Southeast Asia e

Finland

France e

Switzerland e

Belgium e

Australia and New Zealand

Canada e

Sub-Saharan Africa e

Scandinavia

French Polynesia

USA, Whites e

Pakistan e

India e

North Africa e

Men

0 10 20 30 40 50 60 70

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

predispositions associated with the occurrence of breast

or colorectal cancer may also predispose to stomach cancer.

It is worth noting that cancer of the upper stomach

(cardia), close to the oesophagus, has become more

common in some countries. This cancer has risk factors

similar to those of cancer of the oesophagus, such as

smoking, reflux oesophagitis and obesity.

4.1.6 Prevention and Screening

Avoiding excessive consumption of salty foods such as

dried or pickled meats and fish, and regularly consuming

fruits and vegetables, is recommended. The treatment of

any Helicobacter pylori infections is also recommended.

To prevent cancers of the cardia, smoking cessation, prevention

of gastric reflux (particularly by avoiding weight

gain), are recommended. In Asian countries at high risk

for stomach cancer, screening has been introduced. Such

screening is not envisaged in other regions of the world

where the risk is lower, such as Switzerland.

2011 FSO Cancer in Switzerland

27


Cancer Sites

4.2 Colorectal Cancer

4.2.1 General Observations

Colorectal cancer is the second most frequent cancer

among women and the third among men. Approximately

4000 patients are diagnosed each year, b and accounts

for 11% of all cancers in both sexes. It occurs

more often in men and risk increases with age (G 4.2.1).

The risk of developing colorectal cancer before the age

of 70 is 2.6% in men and 1.6% in women. Most often,

this cancer develops from a pre-existing benign polyp.

Colorectal cancer is the third leading cause of cancer

death, with approximately 1600 deaths per year in both

sexes. The five‐year relative survival rate is 60%.

Switzerland has the best survival rate in Europe. 19 It is

estimated that some 8300 men and 6200 women diagnosed

with colorectal cancer in the previous five years

lived in Switzerland in 2002. 20

Colorectal cancer, 2003–2007 G 4.2.1

Age-specific rate per 100,000 inhabitants

450

400

350

300

250

200

150

100

50

0

0–4

5–9

10–14

Source: FSO: COD, NICER, CCR

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

4.2.2 Trends

In Switzerland, a stabilisation of incidence (G 4.2.2) and

even a slight decline among the elderly, coupled with

reduced mortality after age 50 (G 4.2.4) are being observed.

The latter is attributed to the introduction of

screening and therapeutic advances for colorectal cancer.

Trends in incidence and mortality are similar in the two

language regions (G 4.2.3).

Colorectal cancer: Incidence 1 and mortality trend G 4.2.2

Rate per 100,000 inhabitants, European standard

60

Women

Men

50

40

30

20

10

0

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Mortality women

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence men 1

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

2003–2007

© FSO

b

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

28

Cancer in Switzerland FSo 2011


Cancer Sites

Colorectal cancer: Incidence 1 and mortality trend by language region G 4.2.3

Rate per 100,000 inhabitants, European standard

60

Women

50

40

30

20

10

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

Colorectal cancer: Incidence 1 and mortality trend by age group G 4.2.4

Crude rate per 100,000 inhabitants

400

Women

350

300

250

200

150

100

50

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

29


Cancer Sites

4.2.3 Regional Comparisons

The highest rates of colorectal cancer in Switzerland

are observed in Ticino among men and in Neuchâtel

among women. The lowest rates are observed in Zurich

among men and in Fribourg among women (G 4.2.5).

4.2.4 International Comparisons

Large geographic variations in incidence of colorectal

cancer rates – of a factor of 15 between high and low

risk areas – are observed (G 4.2.6). Among men as well

as women, the lowest rates are found in India. The highest

rates for men are in the Czech Republic and for women

in New Zealand. In general, the highest risks are

in Europe, North America and Oceania. In contrast,

the risks are lower in Asia, Africa and South America.

Colorectal cancer was until recently much more common

in developed countries, where rates have now stabilised

and/or declined. However, it is becoming much more

common in developing countries and in Japan, where

the risk was previously low. The incidence rate in Switzerland

is within the average range in Europe.

4.2.5 Risk Factors

A diet rich in red meat (e.g. beef, pork, veal, lamb)

or processed meat (e.g. hot dogs, ham, salami), alcohol

consumption (more than one to two glasses per day),

and long-term smoking (30 years and over) increase the

risk of colorectal cancer. In contrast, regular exercise,

maintaining normal weight, and to a lesser extent high

consumption of fruits and vegetables appear to decrease

incidence. Taking anti-inflammatory medication (such

as aspirin), the contraceptive pill, and hormone replacement

therapy (HRT) at menopause have also been associated

with a decreased risk of developing colorectal

cancer. People with inflammatory bowel disease (e.g.

ulcerative colitis or Crohn’s disease) have an appreciably

higher risk of developing colorectal cancer. People with

a close family member (e.g. parent, sibling) who has

developed the disease are also at higher risk. It is estimated

that approximately 10% of colorectal cancers

are hereditary. Some familial cancers occur in the context

of a familial disease characterised by the presence of

numerous intestinal polyps (familial polyposis).

Colorectal cancer: Incidence 1 in regional comparison, 2003–2007

G 4.2.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Ticino

Neuchâtel

Fribourg

Graubünden and Glarus

Vaud

St. Gallen and Appenzell

Valais

Geneva

Basel-Stadt and Basel-Landschaft

Zurich

70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

30

Cancer in Switzerland FSo 2011


Cancer Sites

Colorectal cancer: Incidence 1 in international comparison, 1998–2002

G 4.2.6

Rate per 100,000 inhabitants, world standard

Australia and New Zealand

Israel

USA, Blacks e

Czech Rep. and Slovakia

Canada e

Netherlands

USA, Whites e

Russia e

Italy e

Belgium e

Germany e

Scandinavia

Japan e

Portugal e

British Isles e

Austria

France e

Switzerland e

China e

Spain e

Balkan states e

Latin America e

Finland

Baltic States

Poland e

Southeast Asia e

Korea

Turkey e

French Polynesia

Sub-Saharan Africa e

North Africa e

Pakistan e

India e

Women

0 10 20 30 40 50 60

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

Rate per 100,000 inhabitants, world standard

Czech Rep. and Slovakia

Australia and New Zealand

Japan e

USA, Blacks e

Germany e

Canada e

Italy e

Israel

Austria

Belgium e

Portugal e

Netherlands

France e

USA, Whites e

Russia e

British Isles e

Spain e

Switzerland e

Scandinavia

Balkan states e

Poland e

Baltic States

Korea

China e

Finland

Latin America e

Southeast Asia e

French Polynesia

Turkey e

North Africa e

Sub-Saharan Africa e

Pakistan e

India e

Men

0 10 20 30 40 50 60

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

4.2.6 Prevention and Screening

Besides smoking cessation, it is recommended to moderate

the consumption of red and processed meat, and

alcohol, and to promote the consumption of fruits and

vegetables, physical activity and obesity prevention.

Undergoing regular screening tests is the best way

to reduce the risk of colorectal cancer by detecting and

removing polyps before they become cancerous. Two

major screening methods are available and are commonly

offered in most developed countries from the age

of 50: fecal occult blood test (FOBT; screening for occult

blood in the stool) every year, or colonoscopy (a flexible

tube inserted in the anus to examine the entire colon)

every five years. For persons with a high individual or

familial risk, screening should begin earlier and endoscopic

examination should be more frequent.

2011 FSO Cancer in Switzerland

31


Cancer Sites

4.3 Lung Cancer

4.3.1 General Observations

Approximately 2500 men and 1200 women get lung

cancer each year in Switzerland. c This cancer accounts

for 13% of cancers in men, among whom it ranks second,

and for 8% of cancers in women, among whom it

ranks third. The risk of developing lung cancer before

the age of 70 is 3.2% in men and 1.7% in women. Lung

cancer is about twice as common in men as in women

and risk increases with age until the age of 75 and

decreases thereafter (G 4.3.1).

In terms of mortality, lung cancer’s impact is sizable

because of its relatively low survival rate. In men, it

remains the leading cause of cancer deaths with 2000

deaths per year, representing 23% of cancer deaths. In

women, it is the second leading cause of cancer deaths,

with approximately 900 deaths per year, or 13% of all

cancer deaths.

The five‐year relative survival is 14%, placing Switzerland

at the top of the European ranking, with the highest

survival rate. 21 In 2002, it was estimated that 3000

men and 1300 women diagnosed with lung cancer during

the previous five years were living in Switzerland. 22

4.3.2 Trends

In Switzerland, as in many parts of the world, an important

decrease in incidence and mortality in men and an

important increase in women is being observed (G 4.3.2).

The number of women affected doubled between 1983

and 2007. These trends are observed in all regions

of Switzerland (G 4.3.3) and in all age groups (G 4.3.4).

Lung Cancer: Incidence 1 and mortality trend G 4.3.2

Rate per 100,000 inhabitants, European standard

90

80

Women

Men

70

60

50

40

30

20

10

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Incidence men 1

Mortality women

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

2003–2007

© FSO

Lung Cancer, 2003–2007 G 4.3.1

Age-specific rate per 100,000 inhabitants

450

400

350

300

250

200

150

100

50

0

0–4

5–9

10–14

Source: FSO: COD, NICER, CCR

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

c

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

32

Cancer in Switzerland FSo 2011


Cancer Sites

Lung Cancer: Incidence 1 and mortality trend by language region G 4.3.3

Rate per 100,000 inhabitants, European standard

100

Women

80

60

40

20

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

Lung Cancer: Incidence 1 and mortality trend by age group G 4.3.4

Crude rate per 100,000 inhabitants

450

Women

400

350

300

250

200

150

100

50

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

33


Cancer Sites

4.3.3 Regional Comparisons

The incidence is higher in French- and Italian-speaking

Switzerland than in German-speaking Switzerland

(G 4.3.3). It is about 50% higher in cantons where it is

high (Fribourg and Neuchâtel for men, Neuchâtel and

Vaud for women) than in regions where it is low (Zurich

and Basel-Stadt and Basel-Landschaft for men, St. Gallen-Appenzell

and Basel-Stadt and Basel-Landschaft for

women) (G 4.3.5).

4.3.4 International Comparisons

Just a few decades ago, the highest incidence rates of

lung cancer were observed in the United States and England,

where the smoking epidemic among both men and

women was the highest in the world. Due to preventive

measures against smoking, geographic differences have

substantially changed. Today, the risk is highest among

African-American men in the United States. Their lungcancer

rate remains approximately 10 times higher than

among men in Sub-Saharan Africa, who have the lowest

rate. In men, high rates are also found in Turkey, the

Baltic States, and Eastern Europe (G 4.3.6). The lowest

rates are observed in developing countries. In women,

the highest rates are observed in both the white and

black populations of the United States. The rates remain

high among women in the British Isles. Unlike men,

women register low rates in the Balkans and in Turkey.

The relatively high rates among women in Southeast

Asia are worth noting. The lung cancer incidence rate in

Switzerland falls within the low average range in Europe

among men and within the high range among women.

4.3.5 Risk Factors

Smoking is responsible for more than 80% of lung cancers.

The more cigarettes a person smokes per day and

the longer he or she smokes, the higher the risk of cancer.

Passive smoking is estimated to be responsible for

nearly one quarter of lung cancers occurring among

people who have never smoked. In men, approximately

10% of lung cancers are of occupational origin. Exposure

to high levels of environmental pollution (e.g. particulate

matter, hydrocarbons), asbestos dust, silica,

some metals (e.g. arsenic and cadmium), and radioactive

substances such as radon increases the risk of lung cancer.

Among women in Southeast Asia, exposure to

fumes when cooking is probably the cause of the excess

Lung Cancer: Incidence 1 in regional comparison, 2003–2007

G 4.3.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Fribourg

Neuchâtel

Ticino

Graubünden and Glarus

Vaud

Geneva

Valais

St. Gallen and Appenzell

Zurich

Basel-Stadt and Basel-Landschaft

100 80 60 40 20 0 0 20 40 60 80 100

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

34

Cancer in Switzerland FSo 2011


Cancer Sites

Lung cancer: Incidence 1 in international comparison, 1998–2002

G 4.3.6

Rate per 100,000 inhabitants, world standard

USA, Whites e

USA, Blacks e

Canada e

French Polynesia

British Isles e

China e

Scandinavia

Netherlands

Australia and New Zealand

Southeast Asia e

Poland e

Switzerland e

Austria

Japane

Korea

Germany e

Czech Rep. and Slovakia

Israel

Italy e

Balkan states e

Belgium e

Finland

Latin America e

France e

Baltic States

Russia e

Portugal e

Turkey e

Spain e

Sub-Saharan Africa e

Pakistan e

India e

North Africa e

Women

Source: NICER, CCR, CI-Five Vol.9

0 10 20 30 40 50 60 70 80

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Rate per 100,000 inhabitants, world standard

USA, Blacks e

Turkey e

Baltic States

Czech Rep. and Slovakia

French Polynesia

Poland e

Belgium e

Balkan states e

USA, Whites e

Italy e

Russia e

China e

Netherlands

Germany e

Korea

Spain e

France e

Canada e

British Isles e

Austria

Switzerland e

Japan e

Southeast Asia e

Australia and New Zealand

Finland

Israel

Portugal e

Scandinavia

Pakistan e

Latin America e

North Africa e

India e

Sub-Saharan Africa e

Men

0 10 20 30 40 50 60 70 80

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

risk. Air pollution also increases the risk of lung cancer;

the extent of this association is currently being scientifically

investigated. The protective role of fruits and vegetables,

especially those rich in beta-carotene, remains

disputed. Certain genetic factors may also increase the

risk of lung cancer, especially by interfering with the

metabolism of carcinogens contained in tobacco smoke.

4.3.6 Prevention and Screening

Smoking cessation is the single best prevention method.

But it is also necessary to protect individuals from exposure

to passive smoking, especially in public places, and

to take the necessary measures to reduce occupational

exposure to carcinogens. Prevention also involves pollution

control.

Screening for lung cancer through routine x-ray

examinations or by searching for cancerous cells in the

sputum of populations of smokers has not proven to be

effective.

2011 FSO Cancer in Switzerland

35


Cancer Sites

4.4 Melanoma

4.4.1 General Observations

Of three types of skin cancer, basal cell carcinoma, squamous

cell carcinoma and melanoma, only melanoma is

discussed in this chapter. d Each year, about 1900 melanomas

are detected in Switzerland. e Melanoma accounts

for 5% of new cancer cases among men and 6% among

women. Melanoma is as common in men as in women

up to the age of 60. From age 60 on, it affects men

about twice as frequently as women (G 4.4.4). The risk

increases progressively with age (G 4.4.1), but it is worth

stressing that this cancer is one of the most common in

young adults. Approximately 30% of melanomas occur

before the age of 50. The risk of developing one before

the age of 70 is 1.4% in both sexes.

Melanoma, 2003–2007 G 4.4.1

Age-specific rate per 100,000 inhabitants

120

4.4.2 Trends

In recent decades, melanoma has had the sharpest increase

in incidence of all cancers in Switzerland – a trend

that has also been observed in many other regions of the

world. The incidence rates, both for men and women,

more than doubled in Switzerland between 1983 and

2007 (G 4.4.2). This increase is larger in French- and

Italian-speaking Switzerland than in German-speaking

Switzerland (G 4.4.3). The increase in melanoma cases

affects all age groups but is particularly marked among

men aged 70 and older and women under 50 (G 4.4.4).

In terms of mortality, however, the rates have

remained relatively stable. The change in mortality by

age has been less positive among people aged over 70,

with a considerable increase in men between 1983 and

1992, followed by an increase in women between 1998

and 2007. In contrast, mortality declined in the young

population (under age 50) between 1993 and 2002,

in both men and women (G 4.4.4). Mortality is slightly

higher, but not significantly so, in German-speaking

Switzerland (G 4.4.3).

100

80

60

40

20

0

Source: FSO: COD, NICER, CCR

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

Melanoma is responsible for approximately 270 deaths

per year, i.e. less than 2% of all cancer deaths in both

sexes. It has one of the best prognoses, with a five‐year

relative survival of more than 89%. Survival in Switzerland

is among highest in Europe. 23 It has a better prognosis

in women than in men. In 2002, it was estimated

that 2600 men and 3900 women diagnosed with a

melanoma in the previous five years were living in Switzerland.

24

Melanoma: Incidence 1 and mortality trend G 4.4.2

Rate per 100,000 inhabitants, European standard

25

Women

Men

20

15

10

5

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Incidence men 1

Mortality women

Mortality men

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

d

e

Rare forms of melanoma which occur in organs other than the skin are

not included in this chapter.

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

36

Cancer in Switzerland FSo 2011


Cancer Sites

Melanoma: Incidence 1 and mortality trend by language region G 4.4.3

Rate per 100,000 inhabitants, European standard

30

Women

25

20

15

10

5

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

Melanoma: Incidence 1 and mortality trend by age group G 4.4.4

100

90

80

70

60

50

40

30

20

10

0

Crude rate per 100,000 inhabitants

Women

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Men

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

37


Cancer Sites

4.4.3 Regional Comparisons

Disparities in incidence are observed. In men, the highest

incidence rates are found in the cantons of Neuchâtel,

Vaud and Geneva. The lowest rates have been registered

by the registries of St. Gallen-Appenzell, Graubünden,

Glarus, Basel-Stadt and Basel-Landschaft. Among

women, the data are very similar, but the canton of Fribourg

has the highest incidence (G 4.4.5).

4.4.4 International Comparisons

Geographic disparities can be seen in Melanoma incidence

rates worldwide. It is virtually nonexistent in black

and Asian populations. The highest rates in the world are

found in Caucasians living in New Zealand and Australia.

The second highest rates are found in Switzerland,

although the values are half of what they are in the Austral

continent. The United States (white population

only), Scandinavia, and the Netherlands also have a particularly

high risk (G 4.4.6).

4.4.5 Risk Factors

The dramatic rise in melanoma in Switzerland and

around the world is mainly due to two phenomena: one

related to exposure to the sun for fashion and recreation,

and the other to better detection. More naevi (moles or

beauty marks/spots) are being systematically screened

and analysed by pathologists.

The main risk factor for melanoma is exposure to ultraviolet

radiation, particularly type B, whose main sources

are the sun, tanning lamps and solariums. Ultraviolet

rays cause damage to the DNA of the skin, especially

during acute exposure (sunburn) in childhood. The

lighter the skin, the more intense the exposure, the less

the skin is protected the greater the risk of melanoma.

It is therefore not surprising that the Swiss population,

which is fair-skinned is particularly at risk for this cancer.

Ethnicity and skin colour are significant risk factors.

White populations have on average a ten times higher

risk of developing cancer than black or mixed-race populations,

which are protected by a high concentration of

skin melanin (skin pigment). The presence of numerous

naevi, is a risk factor. The vast majority of naevi do not

develop into melanoma, but almost all melanomas

develop within a preexisting nevus.

Individuals with congenital naevi and particularly with

multiple dysplastic naevi are at higher risk. A history of

melanoma in one or more family members increases the

risk of developing it. Approximately 10% of melanomas

occur in a familial context. In some families at high risk

of melanoma, certain specific genes are mutated.

People who have been diagnosed with a first

melanoma are more likely to develop a second. The risk

is also higher in immunosuppressed populations, particularly

in organ transplant recipients. Lastly, it is worth

mentioning a rare genetic syndrome called xeroderma

pigmentosum, which consists of a genetic deficiency in

an enzyme responsible for repairing damaged DNA.

Patients with this syndrome are at high risk of developing

multiple skin tumours from childhood.

Melanoma: Incidence 1 in regional comparison, 2003–2007

G 4.4.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Neuchâtel

Vaud

Geneva

Fribourg

Zurich

Ticino

Valais

Basel-Stadt and Basel-Landschaft

Graubünden and Glarus

St. Gallen and Appenzell

40 30 20 10 0 0 10 20 30 40

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

38

Cancer in Switzerland FSo 2011


Cancer Sites

Melanoma: Incidence 1 in international comparison, 1998–2002

G 4.4.6

Rate per 100,000 inhabitants, world standard

Australia and New Zealand

Switzerland e

Scandinavia

Netherlands

USA, Whites e

Israel

France e

Canada e

British Isles e

Germany e

Belgium e

Italy e

Czech Rep. and Slovakia

Austria

Finland

Spain e

Baltic States

Russia e

French Polynesia

Poland e

Latin America e

Portugal e

Balkan states e

Sub-Saharan Africa e

Turkey e

USA, Blacks e

Japan e

Korea

China e

Southeast Asia e

Pakistan e

North Africa e

India e

Women

0 5 10 15 20 25 30 35 40

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

Australia and New Zealand

Switzerland e

USA, Whites e

Scandinavia

Israel

Canada e

Netherlands

Czech Rep. and Slovakia

Finland

Germany e

Austria

France e

Italy e

British Isles e

Belgium e

Spain e

Balkan states e

Latin America e

Poland e

Russia e

Baltic States

Portugal e

French Polynesia

Turkey e

Sub-Saharan Africa e

USA, Blacks e

Southeast Asia e

Pakistan e

Korea

China e

Japan e

North Africa e

India e

Rate per 100,000 inhabitants, world standard

Men

0 5 10 15 20 25 30 35 40

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

4.4.6 Prevention and Screening

To prevent melanoma, it is necessary to prevent sunburn,

particularly in childhood. It is recommended that

sun exposure be avoided between 10 a.m. and 4 p.m.

People ought to protect themselves by using sunscreen

with a sun protection factor (SPF) of 30 or more. An

even more effective method is to wear appropriate

clothing (e.g. T-shirt, shorts, hat, sunglasses with ultraviolet

absorption > 400nm). Solariums and tanning lamps

ought to be avoided.

The systematic removal of naevi is generally not recommended

except in special situations (e.g. congenital

naevi on areas subject to friction). In contrast, for early

detection of a melanoma, it is necessary to monitor

naevi and consult a physician in case of changes (e.g.

redness, hardness, changes in shape or pigmentation or

bleeding). If there are many naevi, it is recommended

that the patients be examined on a regular basis by a

dermatologist. Techniques for microscopic examination

of the skin have been developed to facilitate clinical

monitoring. Prevention campaigns and testing are regularly

organised by the Swiss Cancer League which also

provides informational brochures.

Persons who are members of a family at high risk

for melanoma can have specific genetic testing. But

such genetic testing only makes sense for few people.

2011 FSO Cancer in Switzerland

39


Cancer Sites

4.5 Breast Cancer

4.5.1 General Observations

Breast cancer is the most common cancer in women.

5250 women develop it each year in Switzerland, f which

represents 32% of new cancer cases in women. A woman’s

risk to develop breast cancer before the age of 70 is

7.6%. This cancer is very rare before the age of 25.

Approximately 20% of cases occur before age 50. Until

2002, the risk of breast cancer increased steadily with

age. Since then, a bell-shaped curve has been observed,

with an increase in rates until age 60, followed by a plateau

and a decrease from age 70 (G 4.5.1). As discussed

below (cf. 4.5.4 and 4.5.5), this decrease in the frequency

of cases is probably related to changes in the use

of hormone replacement therapy (HRT). Taken at menopause,

HRT may increase the risk of breast cancer. But it

also accelerates the growth of existing tumours, thus

reducing the age of diagnosis by several years.

Approximately 1350 women die from this cancer each

year in Switzerland which corresponds to 20% of all

cancer deaths in women. The impact of breast cancer

in terms of mortality is less significant than the impact in

terms of incidence because survival is often favourable.

Breast cancer, 2003–2007 G 4.5.1

Age-specific rate per 100,000 inhabitants

400

350

300

250

200

150

100

50

0

f

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

45–49

50–54

Incidence women 1 Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

55–59

60–64

65–69

70–74

75–79

80–84

85+

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

© FSO

With a five‐year relative survival of 82%, Switzerland

ranks among the countries with the best prognosis. 25 It is

estimated that in 2002, some 22,000 women diagnosed

with breast cancer in the previous five years were living

in Switzerland. 26

Breast cancer: Incidence 1 and mortality trend G 4.5.2

120

100

80

60

40

20

0

Rate per 100,000 inhabitants,

European standard

1983–1987

Women

1988–1992

1993–1997

4.5.2 Trends

1998–2002

2003–2007

Incidence women 1

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

In Switzerland, as in the United States and in several

European countries, the number of women affected by

breast cancer has recently declined after decades of

increase (G 4.5.2). This decrease involves post-menopausal

women aged 50–69. It is attributable to the decline

in the number of women taking HRT which occurred

after the publication (in 2002) of the results of a

large clinical study that showed that these hormones

increase the risk of breast cancer. 27 On the other hand,

there is an increased incidence rate in women under the

age of 50. The incidence is stable in women aged 70 and

older (G 4.5.4).

Mortality from breast cancer is decreasing. This decrease

is particularly pronounced among women aged

50 and older (-25% between 1983–1987 and 2003–

2007). A study conducted five years after the systematic

introduction of screening in Switzerland showed that the

decrease in mortality among women aged 55–74 occurred

earlier and was larger in French-speaking cantons

than in German-speaking cantons. 28 This is attributable

to disparities in screening mammography, which is much

more widespread in French-speaking than in Germanspeaking

Switzerland. 29

40

Cancer in Switzerland FSo 2011


Cancer Sites

Breast cancer: Incidence 1 and mortality trend

by language region G 4.5.3

Rate per 100,000 inhabitants, European standard

140 Women

120

100

80

60

40

20

0

1983–1987

1988–1992

1993–1997

Incidence 1

Mortality

German-speaking French-speaking Switzerland

Switzerland

and Ticino

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL,

1

GR, SG and ZH for German-speaking Switzerland and FR, GE, NE, TI and VS

for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

1998–2002

2003–2007

Crude rate per 100,000 inhabitants

350

Women

300

250

200

150

100

50

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

© FSO

Breast cancer: Incidence 1 and mortality trend

by age group G 4.5.4

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years

Incidence 1 Mortality

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

4.5.3 Regional Comparisons

Breast cancer is more common in French- and Italianspeaking

than in German-speaking Switzerland

(G 4.5.3). Until recently, the highest incidence rate in

Switzerland, and also among the highest in the world,

was in the canton of Geneva. Because of the recent and

large decline in the number of breast cancers in this canton,

Geneva is now preceded by the cantons of Vaud

and Fribourg. The lowest rates are found in the registries

of St. Gallen-Appenzell, Basel-Stadt and Basel-Landschaft.

The rates are approximately 50% higher in the

registries with high incidence than in those where it is

low (G 4.5.5).

Breast Cancer: Incidence 1 in regional comparison,

2003–2007

G 4.5.5

Rate per 100,000 inhabitants,

European standard

Switzerland

Women

German-speaking Switzerland

French-speaking Switzerland and Ticino

Vaud

Fribourg

Geneva

Neuchâtel

Ticino

Zurich

Valais

Graubünden and Glarus

Basel-Stadt and Basel-Landschaft

St. Gallen and Appenzell

0 20 40 60 80 100 120 140 160

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL,

1

GR, SG and ZH for German-speaking Switzerland and FR, GE, NE, TI and VS

1 for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: NICER, CCR

© FSO

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

41


Cancer Sites

4.5.4 International Comparisons

Considerable geographic variations exist throughout the

world. The United States, particularly the white population,

Canada, Belgium, and Switzerland have the highest

incidence rates. In contrast, Southeast Asia, China, India,

and North Africa, have the lowest rates. At the European

level, the lowest rates are observed in Eastern Europe,

Portugal, and Spain (G 4.5.6).

Breast cancer: Incidence 1 in international

comparison, 1998–2002

Rate per 100,000 inhabitants, world standard

Belgium e

USA, Whites e

Israel

Netherlands

France e

Italy e

Australia and New Zealand

Switzerland e

British Isles e

Canada e

Finland

USA, Blacks e

Scandinavia

French Polynesia

Germany e

Pakistan e

Austria

Latin America e

Spain e

Portugal e

Balkan states e

Czech Rep. and Slovakia

Poland e

Russia e

Baltic States

Southeast Asia e

Japan e

China e

North Africa e

Turkey e

India e

Korea

Sub-Saharan Africa e

Women

Source: NICER, CCR, CI-Five Vol.9

G 4.5.6

0 20 40 60 80 100 120

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

© FSO

4.5.5 Risk Factors

Breast cancer is linked to female hormones and factors

that modify them. In particular, the risk increases with

the lifetime number of menstrual cycles. Thus, an early

age at menarche and/or late age at menopause are associated

with an increased risk. On the other hand, an

early age at first childbirth, a large number of childbirths,

as well as breastfeeding protect against the occurrence

of breast cancer. High levels of endogenous hormones

such as oestrogen and testosterone increase the risk of

breast cancer after menopause. The role played by

endogenous hormones in breast cancer occurring before

menopause is less clear. Regarding exogenous hormones,

taking the pill and HRT for more than five years

increases the risk of breast cancer by approximately 20%

and 70%, respectively. This increased risk is temporary

and returns to normal five years after cessation of the pill

and/or HRT. The risk associated with HRT is higher for

therapies that include a combination of oestrogen and

progestin than for therapies containing oestrogen alone.

It also appears to be higher in thin women. Conversely,

anti-hormonal therapies reduce the risk of breast cancer.

Women with dense breast tissue have a higher risk of

developing breast cancer. The same applies to women

who have previously had breast cancer or have had previous

breast problems, such as proliferative lesions or

lesions with atypia.

Obesity (and to a lesser extent tallness) is a risk factor

for breast cancer but only after menopause. This is because

postmenopausal women transform oestrogen precursors

into oestrogen in proportion to their body fat.

Alcohol consumption, particularly among young

women, and physical inactivity are also risk factors for

breast cancer. A great deal of research has been done on

the relationship between diet and breast cancer. The

only correlation supported by current literature is that

eating foods rich in fat increases the risk of breast cancer.

Some studies show that working at night may

increase the risk of breast cancer, probably due to lower

secretion of melatonin, a hormone that can modify the

secretion of other hormones.

42

Cancer in Switzerland FSo 2011


Cancer Sites

Ionizing radiation is another established risk factor for

breast cancer. The younger the age at which a woman is

exposed the greater the risk. In particular, women who

have received radiation treatment for Hodgkin’s disease

(a type of lymphoma) have a higher risk of breast cancer.

The same applies, albeit with a lower risk, to women

who have had numerous chest x-rays (e.g. for tuberculosis

or a disease of the spinal column).

Also worth mentioning is the role of a family history.

Women who have a mother or sister with breast cancer

before age 50, or multiple women with breast cancer

in their immediate family, are at higher risk for breast

cancer. An estimated 5–10% of breast cancers are hereditary.

Two genes, BRCA1 and BRCA2, are responsible

for approximately half of the familial breast cancer cases.

These genes regulate the DNA repair system. Women carrying

a mutation on one of these genes have a 50–65%

risk of developing breast cancer before age 70. Women

with the BRCA1 mutation also have a higher risk of

ovarian cancer. Other rare familial syndromes associate

breast cancer with other cancers such as brain cancer,

sarcomas, leukaemia (Li Fraumeni syndrome), gastrointestinal

and thyroid tumours (Cowden syndrome), ovarian

cancer (Peutz-Jeghers syndrome), and Hodgkin’s disease

(Ataxia telangiectasia).

Other gene mutations increase only slightly the risk of

breast cancer. These include genes involved in hormone

metabolism or in the process of cellular repair.

4.5.6 Prevention and Screening

Few risk factors for breast cancer can be modified. A moderate

consumption of fat and alcohol, physical exercise,

breastfeeding, and the prevention of obesity after menopause

are recommended. Discussions about the possibility

of undergoing hormone therapy ought to take into

account the increased risk of breast cancer. If hormone

therapy is needed, it should be given for less than five

years. The same applies to the contraceptive pill, whose

benefits and risks should also be discussed.

A large scale clinical study showed that among

women with an increased risk of developing breast cancer,

anti-hormonal therapy (tamoxifen) resulted in a

50% decline in the risk of developing this cancer. This

preventive effect was accompanied, however, by significant

adverse effects, such as increased risk of cancer of

the corpus uteri (cancer of the body of the uterus). More

recently, another clinical study showed that raloxifene, a

selective modulator of oestrogen receptors, showed the

same efficacy with fewer adverse effects. At present in

Switzerland, women at high risk are only taking these

drugs within the framework of specific studies.

Genetic screening is available for women at high

familial risk through specialised genetic counselling. For

women with BRCA1 or BRCA2 mutations, a preventive

bilateral mastectomy (removal of both breasts), with or

without removal of the ovaries, can be proposed. An

alternative is careful monitoring with alternating MRI

(Magnetic resonance imaging) and ultrasound every six

months starting five years before the youngest age of

breast cancer diagnosis in the youngest member of the

family.

Biennial screening mammography reduces mortality

from breast cancer by about 30% after age 50. The

benefit/harm-cost ratio of mammography screening in

women under age 50 still has to be examined in more

detail. In Europe, routine screening mammography every

two years from age 50 on is recommended. For women

with dense breast tissue, the benefit of combining regular

mammography with ultrasound should be discussed.

Individual screening of younger women is left to the initiative

of the woman and her treating physician.

Several screening programmes have been available in

French-speaking Switzerland for several years. They

ensure that women are sent invitations to get screened,

that mammograms are read by two separate radiologists,

and that the quality is evaluated. The pilot phase

of the first screening programme in German-speaking

Switzerland was launched in 2010. In Ticino systematic

screening has been approved and should begin in 2011.

2011 FSO Cancer in Switzerland

43


Cancer Sites

4.6 Uterine Cancer

4.6.1 General Observations

The uterus has two distinct parts: the cervix (”neck of

the uterus“) and the corpus uteri (”body of the uterus“).

Cancers of the cervix (1.4% of cancers in women) and

of the corpus uteri (5.4% of cancers in women, often

called endometrial cancer), have different risk factors,

characteristics and prognoses.

Cancer of the cervix uteri (i.e. cervical cancer) develops

gradually and goes through stages of precancerous

lesions. These lesions are registered by some Swiss

tumour registries, but are not described herein. About

240 patients each year develop cervical cancer. g The risk

of developing it before age 70 is 0.4%. About half of all

cervical cancers occur before age 50, but is rare before

the age of 20. The incidence rates increase between the

ages of 20 and 35 years, and then stabilise and increase

again around age 70; reaching a peak around age 75

and declining thereafter (G 4.6.1).

With a five‐year relative survival of 68%for cervical

cancer, Switzerland ranks second among European

countries. 30 Approximately 90 women die each year

from this cancer, which accounts for 1.3% of cancer

deaths in women.

Uterine cancer, 2003–2007 G 4.6.1

Age-specific rate per 100,000 inhabitants

20

Cervix uteri

16

12

8

4

0

100

Corpus uteri

80

60

40

20

0

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

Incidence 1 Mortality

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

45–49

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

Cancer of the corpus uteri (i.e. uterine cancer) affects

about 900 women each year in Switzerland. g The risk of

developing it before the age of 70 is 1.2%. This cancer

affects older women, with nearly half of cases occurring

after age 70. The frequency of the cancer of the corpus

uteri increases with age until 75 years, and decreases

thereafter (G 4.6.1).

Survival after cancer of the corpus uteri is 79%,

slightly above the European average. 31 This cancer causes

about 200 deaths per year, or approximately 3% of all

cancer deaths in women.

It is estimated for 2002, that approximately 1500 women

diagnosed with cancer of the cervix uteri and

3500 with cancer of the corpus uteri in the previous five

years were living in Switzerland. 32

Uterine cancer: Incidence 1 and mortality trend

Rate per 100,000 inhabitants, European standard

25

Cervix uteri

Corpus uteri

20

15

10

5

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

1983–1987

1988–1992

1993–1997

1998–2002

G 4.6.2

2003–2007

© FSO

g

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

44

Cancer in Switzerland FSo 2011


Cancer Sites

Uterine cancer: Incidence 1 and mortality trend by language region G 4.6.3

Rate per 100,000 inhabitants, European standard

25

Cervix uteri

20

15

Corpus uteri

German-speaking Switzerland

French-speaking Switzerland

and Ticino

10

5

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

Uterine cancer: Incidence 1 and mortality trend by age group G 4.6.4

Crude rate per 100,000 inhabitants

90

Cervix uteri

80

70

60

50

40

30

20

10

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Corpus uteri

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

4.6.2 Trends

In Switzerland, as in all industrialised countries, the incidence

and mortality of cancer of the cervix uteri has

decreased markedly (G 4.6.2). Between 1980 and 2007,

the number of new cases per year fell from 440 to 210

and the number of deaths from 200 to 90. The decline

in incidence was higher among women over age 50 than

among younger women (G 4.6.4) and was somewhat

more pronounced in French- and Italian-speaking Switzerland

than in German-speaking Switzerland (G 4.6.3).

The incidence and mortality of cancer of the corpus

uteri have also declined, but much less markedly (G 4.6.2).

The decline in incidence was limited to women aged

50–59 and the decline in mortality to women aged 70

and over (G 4.6.4).

2011 FSO Cancer in Switzerland

45


Cancer Sites

4.6.3 Regional Comparisons

The incidence of cancer of the cervix uteri also shows

variations between regions, with rates about two times

higher in the region of Graubünden and Glarus than in

the cantons of Geneva and Fribourg (G 4.6.5).

In contrast, the incidence of cancer of the corpus

uteri, is relatively uniform across Switzerland. The highest

rates are observed in Fribourg and the lowest in

Ticino (G 4.6.5).

4.6.4 International Comparisons

Cancer of the cervix uteri is the second most common

cancer in women worldwide, with very large geographic

differences. Approximately 83% of these cancers occur

in developing countries. The incidence rates vary by a

factor 10 between the areas with the highest and the

lowest risk. Sub-Saharan Africa is the region of the world

most affected, followed by Latin America, South Asia,

and Southeast Asia. The Balkans and Eastern Europe also

have especially high rates compared with Western

Europe. The lowest rates are observed in Switzerland,

Israel, and Finland. Also worth noting are the particularly

low rates in North Africa (G 4.6.6).

Cancer of the corpus uteri, it is more common in

industrialised countries. The highest rates are found

among white women in certain regions of the United

States. High levels are also observed in Eastern Europe.

The lowest rates are in East Asia (Japan, China, Korea),

in India and in North Africa and Sub-Saharan Africa.

Switzerland is within the average range in Europe

(G 4.6.6).

Uterine cancer: Incidence 1 in regional comparison, 2003–2007

G 4.6.5

Rate per 100,000 inhabitants, European standard

Cervix

uteri

Switzerland

German-speaking Switzerland

French-speaking Switzerland and Ticino

Fribourg

St. Gallen and Appenzell

Basel-Stadt and Basel-Landschaft

Geneva

Neuchâtel

Valais

Vaud

Graubünden and Glarus

Zurich

Ticino

Corpus

uteri

30 25 20 15 10 5 0 0 5 10 15 20 25 30

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

46

Cancer in Switzerland FSo 2011


Cancer Sites

Uterine cancer: Incidence 1 in international comparison, 1998–2002

G 4.6.6

Sub-Saharan Africa e

Latin America e

India e

Balkan states e

Southeast Asia e

French Polynesia

Korea

Baltic States

Czech Rep. and Slovakia

Poland e

Portugal e

USA, Blacks e

Germany e

Russia e

Scandinavia

Belgium e

Austria

Pakistan e

British Isles e

France e

USA, Whites e

Canada e

Japan e

Australia and New Zealand

Spain e

Netherlands

Italy e

Switzerland e

China e

Israel

Turkey e

North Africa e

Finland

Rate per 100,000 inhabitants, world standard

Cervix uteri

0 5 10 15 20 25 30 35 40 45 50

Czech Rep. and Slovakia

USA, Whites e

Baltic States

French Polynesia

Canada e

Scandinavia

Balkan states e

Finland

Israel

Russia e

USA, Blacks e

Belgium e

Poland e

Switzerland e

Austria

Germany e

Italy e

Spain e

Netherlands

British Isles e

Australia and New Zealand

France e

Latin America e

Portugal e

China e

Southeast Asia e

Turkey e

Pakistan e

Japan e

Sub-Saharan Africa e

India e

Korea

North Africa e

Rate per 100,000 inhabitants, world standard

Corpus uteri

0 5 10 15 20 25 30 35 40 45 50

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

© FSO

2011 FSO Cancer in Switzerland

47


Cancer Sites

4.6.5 Risk Factors

The biggest risk factor for cancer of the cervix uteri is

infection with the human papillomavirus (HPV), which is

transmitted during sexual intercourse. There are a hundred

different HPV types, some of which are associated

with a high risk for cervical cancer. Specifically, types 16

and 18 are responsible for two thirds of cancer of the

cervix cases. Other types, such as 31 or 33, are more

related to precancerous cervical lesions. Factors promoting

cervical cancer are those that lead to infection by

HPV (e.g. early age at first intercourse, a significant

number of partners of the woman or her partner, and

multiple pregnancies). Condoms reduce the risk only

partially, because they do not cover the entire genital

area.

Among other risk factors worth mentioning is infection

with the human immunodeficiency virus (HIV)

which, by reducing immunity, increases the risk of cervical

cancer.

Taking oral contraceptives is associated with an

increased risk if they are taken for more than five years.

The risk returns to normal 10 years after cessation of oral

contraceptive use. It is difficult to know whether this is a

true risk factor or a confounding factor just indicating

the existence of sexual activity.

Long-term smoking increases the risk; a diet rich in

fruits and vegetables decreases it. Obesity increases the

risk of cervical cancer of a particular histological type

(Adenocarcinoma).

From a historical perspective, it is worth recalling that

taking diethylstilbestrol, which used to be prescribed

during pregnancy to prevent miscarriage, increases the

risk of a rare form of cervical cancer (Clear-cell adenocarcinoma).

Moreover, there is an increased risk among

women whose mother or sister has had cervical cancer,

but it has not been possible to prove a specific genetic

component.

The main risk factor for cancer of the corpus uteri is

exposure to oestrogen (which cause a proliferation of

the mucous membrane of the uterine wall, known as the

endometrium) when not counterbalanced by exposure

to progestins (which stop the proliferation of the

endometrium by maturing its cells). This risk is typically

due to taking oestrogen alone as hormone replacement

in menopause. This practice was discontinued in the

1980s (except for women who have no uterus) when

progesterone was systematically introduced in hormone

replacement therapy (HRT). Taking birth control pills

containing progesterone protects women from developing

this cancer.

Significant exposure to oestrogens also explains other

recognised risk factors, such as early age at menarche,

late menopause, nulliparity, endometrial hyperplasia, and

obesity. Obesity may be responsible for 40% of cancers

of the corpus uteri worldwide. After menopause, women

convert oestrogen precursors to active oestrogen molecules

in fat tissue. Obese women thus produce high levels

of endogenous oestrogen and are at higher risk of

endometrial cancer. Women with breast cancer who are

receiving certain types of anti-hormonal therapy (e.g.

tamoxifen) are at higher risk of cancer of the corpus

uteri.

Diabetes and hypertension are also risk factors for

cancer of the corpus uteri. Similarly, the rare disease

polycystic ovary syndrome, and a family history of cancer

of the corpus uteri increase the risk of developing this

cancer. Women with hereditary colorectal cancer (Lynch

syndrome) are also at higher risk of developing cancer

of the corpus uteri.

48

Cancer in Switzerland FSo 2011


Cancer Sites

4.6.6 Prevention and Screening

HPV vaccines for girls under 19 years are now available.

33 These vaccines ought to prevent 80% of cancer of

the cervix uteri, but they are not a substitution for pap

smear screening. The vaccination campaign began in

Switzerland in 2009. It will be necessary to assess its

acceptance, cost, and effectiveness.

The sharp decrease in the incidence and mortality of

cervical cancer is attributable to widespread screening in

developed countries. This screening makes it possible to

detect precancerous lesions and to treat them, thereby

preventing the cancer from developing. The pap smear

test for cervical cancer consists of taking a sample of

cells from the cervix to analyse them. After onset of initial

sexual activity, a pap smear is performed annually

during the first three years, and every three years thereafter.

Currently, screening tests can detect the infection

and HPV type. They therefore make it possible to identify

women at high or low risk and thus allow adjustment

in the frequency of screening.

For cancer of the corpus uteri, the primary means of

prevention is to prevent obesity, particularly after menopause.

Taking oestrogen alone should no longer be prescribed

as HRT. No screening is available for cancer of

the corpus uteri. Because the lining of the uterus is rich

in blood vessels, the most frequent symptom of this cancer

is bleeding after menopause. Women should consult

a doctor when these symptoms occur so that an early

diagnosis can be made.

2011 FSO Cancer in Switzerland

49


Cancer Sites

4.7 Prostate Cancer

4.7.2 Trends

4.7.1 General Observations

Prostate cancer is the most common cancer in men.

Approximately 5700 men are affected each year in Switzerland.

h This cancer accounts for 30% cancers diagnosed

in men. Until 2002, the risk increased linearly with

age. Since then, for the first time there has been a decrease

in incidence rates in men after the age of 70

(G 4.7.1). The risk that a man will develop prostate cancer

before the age of 70 is 7.8%. This cancer is very rare

before the age of 50. Approximately 50% of prostate

cancers occur between 50 and 70 years and half after 70.

The impact of prostate cancer mortality is less because

survival is often favourable. With a five‐year-relative survival

rate of 82%, Switzerland ranks first among the

countries with the best prognosis. 34 Nevertheless, this

cancer is the second leading cause of death in men, with

approximately 1300 deaths per year in Switzerland, and

it represents 15% of male deaths from cancer. In 2002,

the number of men living in Switzerland diagnosed with

prostate cancer during the previous five years was estimated

at about 19,000. 35

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

45–49

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

In Switzerland, as in many other parts of the world, a

large increase in the incidence of prostate cancer is observed

(G 4.7.2). This increase primarily involves men

aged 50–69, an age group targeted by screening with

the prostate specific antigen (PSA) test. Among this age

group, the incidence rate tripled between 1983 and

2007. In men over 70 years, rates rose between 1983

and 1997, but have steadily declined since then. The

decline in cases in men aged 70 and over is probably

related to PSA testing, which leads to diagnosis at a

younger age (G 4.7.4).

Incidence men 1 Mortality men

the United States and subsequently in other European

Prostate cancer: Incidence 1 and mortality trend G 4.7.2

Rate per 100,000 inhabitants,

European standard

140

Men

Incidence men 1

120

Mortality men

100

80

60

40

20

0

Prostate cancer, 2003–2007 G 4.7.1

1000

Age-specific rate per 100,000 inhabitants

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

800

600

400

200

0

In Switzerland, prostate cancer mortality rose annually

until 1993, and has fallen appreciably since. This drop,

involving all ages, was approximately 18% between

1993–1997 and 2003–2007. A significant decline in

mortality from prostate cancer was first observed in

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

countries.

The increase in incidence was particularly marked in

French- and Italian-speaking Switzerland. The rates were

lower in German-speaking Switzerland in the early

1980s, but are now similar rates in French- and Italianspeaking

Switzerland (G 4.7.3).

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

h

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

50

Cancer in Switzerland FSo 2011


Cancer Sites

Prostate cancer: Incidence 1 and mortality trend

by language region G 4.7.3

Rate per 100,000 inhabitants, European standard

160 Men

140

120

100

80

60

40

20

0

1983–1987

1988–1992

1993–1997

1998–2002

Incidence 1

Mortality

German-speaking French-speaking Switzerland

Switzerland

and Ticino

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL,

1

GR, SG and ZH for German-speaking Switzerland and FR, GE, NE, TI and VS

for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

2003–2007

Crude rate per 100,000 inhabitants

1000

Men

800

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

© FSO

Prostate cancer: Incidence 1 and mortality trend

by age group G 4.7.4

600

4.7.3 Regional Comparisons

Prostate cancer is approximately 50% more common

in the canton of Vaud, which has the highest incidence,

than in the canton of Ticino which has the lowest.

Among the other cantons, however, the differences in

incidence are relatively small (G 4.7.5).

Prostate cancer: Incidence 1 in regional comparison,

2003–2007

G 4.7.5

Rate per 100,000 inhabitants,

European standard

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Vaud

Zurich

Basel-Stadt and Basel-Landschaft

St. Gallen and Appenzell

Geneva

Valais

Neuchâtel

Fribourg

Graubünden and Glarus

Ticino

0 20 40 60 80 100 120 140 160 180

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL,

1

GR, SG and ZH for German-speaking Switzerland and FR, GE, NE, TI and VS

1 for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: NICER, CCR

© FSO

400

200

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years

Incidence 1 Mortality

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

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Cancer Sites

4.7.4 International Comparisons

There are significant geographic variations throughout

the world. The United States particularly the African-

American population, Canada, Belgium, and Switzerland

have the highest incidence rates in the world. In contrast,

Southeast Asia, China, India, and North Africa

have the lowest rates. At the European level, the lowest

rates are observed in Eastern Europe, Italy, and Spain

(G 4.7.6).

Prostate cancer: Incidence 1 in international

comparison, 1998–2002

G 4.7.6

Rate per 100,000 inhabitants, world standard

USA, Blacks e

USA, Whites e

Canada e

Belgium e

Switzerland e

Finland

Australia and New Zealand

France e

Austria

Latin America e

Scandinavia

French Polynesia

Germany e

Netherlands

British Isles e

Portugal e

Israel

Italy e

Spain e

Baltic States

Czech Rep. and Slovakia

Sub-Saharan Africa e

Poland e

Balkan states e

Russia e

Turkey e

Japan e

Southeast Asia e

Pakistan e

China e

North Africa e

Korea

India e

Men

0 20 40 60 80 100 120 140 160 180

4.7.5 Risk Factors

African-American men in the United States have a 20%

higher risk of developing this cancer than whites. Studies

of migrants from low risk areas (such as Japan) who

have settled in high-risk areas (such as the United States)

show that after one generation their risk catches up with

that of the host country. This demonstrates the important

role of the environment, including lifestyle in the occurrence

of this cancer. However, to date no specific risk

factors have been identified. No clear relationship between

diet and prostate cancer has been established despite

many studies. The protective effect of tomato consumption,

which is often mentioned, is far from proven.

Male hormones probably play an important role. It is

known, for example, that men with congenital hormone

deficiencies and individuals castrated at a young age do

not develop prostate cancer. However, studies have

failed to show any relationship between circulating levels

of male hormones (testosterone and specifically its active

derivative dihydrotestosterone) and the risk of prostate

cancer.

Having a first-degree relative who has had prostate

cancer increases the risk. It is estimated that approximately

5–10% of prostate cancers are linked to heredity.

36 As is the case in breast cancer, the BRCA1 and

BRCA2 genes, which are linked to the cellular repair

process, play a role in the occurrence of this cancer, albeit

a less pronounced one. Other genes, namely those

involved in the metabolism of hormones, may also play

a role.

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

© FSO

52

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Cancer Sites

4.7.6 Prevention and Screening

A Mediterranean type diet rich in olive oil, garlic, tomato,

and a moderate consumption of animal fat can

only be beneficial to men’s health in general. However,

the impact of such a diet on the prevention of prostate

cancer remains unquantifiable.

A large scale clinical study showed that taking a dietary

supplement of vitamin E did not reduce the risk of

developing prostate cancer. The same applies to taking a

folic acid supplement which may even be associated

with an increased risk. A clinical study is under way to

evaluate the preventive role of lycopene, the main antioxidant

found in tomatoes.

A recent study showed a 30% decline in the occurrence

of prostate cancer among men at high risk who

took anti-hormone drugs. But these drugs have side

effects and should not be prescribed as a preventive

measure without specific indication.

The effectiveness of screening by detecting PSA

in the blood, with or without a digital rectal examination

(DRE), is disputed. PSA screening allows diagnosis of

prostate cancer at an early stage. However, it is not

certain that this earlier detection makes it possible to

effectively change the natural course of the cancer and

reduce mortality. The decline in mortality observed in

industrialised countries, as well as that observed in a randomized

European study, point to the effectiveness of

screening. But the adverse effects of PSA screening are

not insignificant because it detects non-progressive cancers

that would not have surfaced clinically without

screening. This leads to potentially unnecessary treatments

(e.g. removal of the prostate, radiotherapy) that

result in subsequent clinical consequences (e.g. erectile

dysfunction, urinary incontinence). It is mainly the

adverse effects associated with such over-diagnosis and

over-treatment that constitute a major obstacle to the

implementation of routine PSA screening for prostate

cancer. It is therefore important to inform men both

about the benefits and risks of screening, so they can

make an informed decision about whether or not to be

screened. PSA screening can be performed annually from

the age of 50 (or earlier if a family member has been

diagnosed with prostate cancer or for high risk populations)

until age 75 or until the man has a life expectancy

of less than 10 years.

2011 FSO Cancer in Switzerland

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Cancer Sites

4.8 Thyroid Cancer

4.8.1 General Observations

With about 480 new cases each year, thyroid cancer

accounts for approximately 1% of cancers in men and

2% of cancers in women. i It is about twice as common

in women as in men. In men, the risk increases with age

until age 70. In women, the risk also increases with age

but stabilises at the age of 45 (G 4.8.1). The risk of

developing thyroid cancer before the age of 70 is 0.2%

in men and 0.6% in women. However, half the cases

occur before age 50 (46% for men and 49% for

women).

Because of its favourable prognosis, mortality from

thyroid cancer is low. With fewer than 70 deaths per

year, it accounts for less than 0.5% of cancer deaths in

both sexes. With a five‐year relative survival of 86%,

Switzerland is one of the European countries with the

highest survival rates. 37 It is estimated that 380 men and

930 women diagnosed with thyroid cancer during the

previous five years were living in Switzerland in 2002. 38

Thyroid cancer, 2003–2007 G 4.8.1

Age-specific rate per 100,000 inhabitants

18

16

14

12

10

8

6

4

2

0

0–4

5–9

10–14

Source: FSO: COD, NICER, CCR

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

4.8.2 Trends

In Switzerland, the incidence of thyroid cancer is increasing

among women and, to a lesser extent, among men

(G 4.8.2). An increase has also been observed throughout

the world, particularly in Europe and North America,

but also and especially in Belarus. j The increase in the

number of cases of thyroid cancer worldwide has been

largely attributed to the growing and now widespread

use of advanced diagnostic methods (e.g. ultrasound

and needle biopsies for removal of tissue samples) which

are carried out much more systematically during the

investigation of thyroid problems. Consequently, cancers

that previously went undetected are now being discovered.

Because benign thyroid disorders are much more

common in women, the increase in detection of thyroid

cancer is subsequently higher among women.

Thyroid cancer: Incidence 1 and mortality trend G 4.8.2

Rate per 100,000 inhabitants, European standard

9

8

Women

Men

7

6

5

4

3

2

1

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Incidence men 1

Mortality women

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

2003–2007

© FSO

i

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

j

This increase is attributable to the accident at the Chernobyl nuclear

power plant in April 1986.

54

Cancer in Switzerland FSo 2011


Cancer Sites

Thyroid cancer: Incidence 1 and mortality trend by language region G 4.8.3

Rate per 100,000 inhabitants, European standard

10

Women

9

8

7

6

5

4

3

2

1

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Source: FSO: COD, NICER, CCR

© FSO

Thyroid cancer: Incidence 1 and mortality trend by age group G 4.8.4

Crude rate per 100,000 inhabitants

18

Women

16

14

12

10

8

6

4

2

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

In Switzerland, the increase in both sexes is restricted

to persons under age 70. In contrast, after 70 there is a

decrease in incidence rates (G 4.8.4). The increase is

greater in French- and Italian-speaking Switzerland than

in German-speaking Switzerland (G 4.8.3).

Unlike incidence, mortality from thyroid cancer is

falling sharply, particularly among women. The very low

mortality rate among individuals under age 50 is also

worth noting (G 4.8.4).

2011 FSO Cancer in Switzerland

55


Cancer Sites

4.8.3 Regional Comparisons

The differences are greatest between the cantons of

French- and Italian-speaking Switzerland. Among men,

the highest incidence rates are found in Fribourg and

Geneva, the lowest in the cantons of Vaud and Ticino.

Among women, the cantons of Geneva and Ticino have

the highest rates, whereas the canton of Vaud and the

region of Graubünden and Glarus register the lowest

rates (G 4.8.5).

4.8.4 International Comparisons

In both sexes, the highest incidence rates in the world

are found in French Polynesia (cf. 4.8.5), where women

have rates five times higher than the European average.

The lowest rates are observed in India, Pakistan, and

Sub-Saharan Africa. Switzerland is within the world average,

with a relatively high rate among men and a relatively

low rate among women (G 4.8.6).

4.8.5 Risk Factors

As mentioned above (cf. 4.8.2), the increase in thyroid

cancer is probably due to better detection. However, a

greater frequency in the population of one or more risk

factors associated with this cancer cannot be excluded.

Established risk factors for thyroid cancer include exposure

to ionizing radiation, excessive or inadequate intake

of iodine, a history of goitre, and genetic factors.

The irradiated survivors of Hiroshima and Nagasaki k

have an increased risk of thyroid cancer. The same

applies to the population of Belarus after the Chernobyl

disaster in 1986. The younger people are when exposed,

the higher the risk. Studies evaluating the impact in

Europe of the radioactive cloud released by the Chernobyl

disaster on the occurrence of thyroid cancers are

generally relatively reassuring, in that they attribute the

observed increase to the development of improved diagnostic

methods not to radiation exposure. 39

The high rates of thyroid cancer in French Polynesia

are currently the subject of several studies attempting

to establish or exclude a link with the nuclear tests which

were carried out in the Mururoa Atoll in 1966–1996.

The risk of thyroid cancer also increases after radiation

treatment of the head and neck (e.g. for Hodgkin’s disease)

in children.

Populations living in regions with dietary iodine deficiency,

such as rural and mountainous areas, present an

excess of goitre and sometimes thyroid cancer (follicular

type). But a diet too rich in iodine may also increase the

risk of this cancer (papillary type).

Persons with a goitre or thyroid nodule have a slightly

higher risk of developing thyroid cancer. An association

between an overactive thyroid (hyperthyroidism) and

thyroid cancer has not been established.

Some types of thyroid cancer are hereditary. Several

types of familial syndromes associated with thyroid cancer

alone or with tumours of other glands (e.g. adrenal

and parathyroid glands) or of the intestine are known.

Thyroid cancer: Incidence 1 in regional comparison, 2003–2007

G 4.8.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Fribourg

Geneva

Neuchâtel

Valais

Graubünden and Glarus

Basel-Stadt and Basel-Landschaft

Zurich

St. Gallen and Appenzell

Vaud

Ticino

15 12 9 6 3 0 0 3 6 9 12 15

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

k

Atomic bombings of Hiroshima and Nagasaki in August 1945

56

Cancer in Switzerland FSo 2011


Cancer Sites

Thyroid cancer: Incidence 1 in international comparison, 1998–2002

G 4.8.6

Rate per 100,000 inhabitants, world standard

French Polynesia

Korea

Israel

Latin America e

Italy e

France e

Portugal e

Canada e

USA, Whites e

Finland

Southeast Asia e

Poland e

Austria

Australia and New Zealand

Spain e

Switzerland e

Japan e

Baltic States

China e

USA, Blacks e

Czech Rep. and Slovakia

Germany e

Balkan States e

Turkey e

Russia e

Scandinavia

Belgium e

Pakistan e

North Africa e

British Isles e

Netherlands

Sub-Saharan Africa e

India e

Women

Source: NICER, CCR, CI-Five Vol.9

0 2 4 6 8 10 12 14 36 38

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Rate per 100,000 inhabitants, world standard

French Polynesia

Italy e

Israel

USA, Whites e

France e

Canada e

Austria

Latin America e

Korea

Finland

Australia and New Zealand

Germany e

Switzerland e

Portugal e

Southeast Asia e

Spain e

USA, Blacks e

Czech Rep. and Slovakia

Japan e

China e

Poland e

Scandinavia

Balkan States e

Baltic States

Belgium e

North Africa e

Turkey e

Russia e

Netherlands

British Isles e

India e

Sub-Saharan Africa e

Pakistan e

Men

0 2 4 6 8 10 12 14

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

4.8.6 Prevention and Screening

There are few prevention or screening methods for thyroid

cancer. In Switzerland, iodine supplementation in

table salt has made it possible to combat iodine deficiency,

especially in mountain populations.

The exposure of children to radiation ought to be

avoided or kept as low as possible. Children exposed to

high doses should be monitored. Providing iodine supplementation

to irradiated populations could reduce the

risk of thyroid cancer.

Palpation of the thyroid to detect goitre or nodules is

part of the general clinical examination performed in

particular during an initial medical consultation. Further

investigations are only carried out if an anomaly is

detected. Genetic testing for familial cancers is now possible

as part of highly specialised consultations.

2011 FSO Cancer in Switzerland

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Cancer Sites

4.9 Hodgkin’s Disease

4.9.1 General Observations

Hodgkin’s disease is a type of lymphoma. Lymphomas

include various groups of cancers arising from the cells

of the lympho-hematopoietic system, which produces

the lymph fluid and blood cells. Hodgkin’s disease or

Hodgkin’s lymphoma accounts for approximately 12%

of all lymphomas and 0.6% of cancers in men and

women. Hodgkin’s disease is about 1.5 times more common

in men than in women. The distribution of incidence

is bimodal with a first and largest peak between

ages 15 and 35 and a second peak after age 60

(G 4.9.1).

Approximately 220 new cases of Hodgkin’s disease

are diagnosed annually. l The risk of developing this disease

before the age of 70 is 0.2% in both sexes.

Hodgkin’s lymphoma, 2003–2007 G 4.9.1

Age-specific rate per 100,000 inhabitants

9

8

7

6

5

4

3

2

1

0

0–4

5–9

10–14

Source: FSO: COD, NICER, CCR

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

4.9.2 Trends

An increased incidence was observed worldwide in the

late 1990s, but it was probably due to changes in the

pathological classification of lymphomas and leukaemias.

In Switzerland, the development of the rate of new cases

is uneven; the overall incidence remained relatively stable

in both sexes (G 4.9.2). The average annual number

of deaths in both sexes in Switzerland fell from 138 in

1983–1987 to 27 in 2003–2007 (G 4.9.2). The decrease

of 70% can partly, but not entirely, be attributed to a

break in the series following a coding rule change

between 1994 and 1995. m The very low mortality rate

among people under age 50 during the last period is

worth noting (G 4.9.4).

Hodgkin’s lymphoma: Incidence 1

and mortality trend G 4.9.2

Rate per 100,000 inhabitants, European standard

4,0

Women

Men

3,5

3,0

2,5

2,0

1,5

1,0

0,5

0,0

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Mortality women

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence men 1

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

2003–2007

© FSO

Mortality from Hodgkin’s disease is low because of

very good prognosis at least in adolescents and younger

adults. It accounts for fewer than 30 deaths per year, or

less than 0.2% of cancer deaths in both sexes. The

five‐year relative survival in Switzerland is 83%, which is

higher than the European average. 40 According to estimates,

in 2002 approximately 450 men and 330 women

diagnosed with Hodgkin’s disease over the previous five

years were living in Switzerland. 41

Mortality from Hodgkin’s disease is declining appreciably

in men and in women in all age groups (G 4.9.4).

The decline in mortality is similar in French- and Italianspeaking

Switzerland and in German-speaking Switzerland

(G 4.9.3). A similar decline in mortality is found in

most industrialised countries. It is attributable to significant

therapeutic advances.

l

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

m

For Hodgkin’s lymphoma it was not possible to calculate correction

factors because of the small number of cases (cf. 2.1.3).

58

Cancer in Switzerland FSo 2011


Cancer Sites

Hodgkin’s lymphoma: Incidence 1 and mortality trend by language region G 4.9.3

Rate per 100,000 inhabitants, European standard

4,0

Women

Men

3,5

3,0

2,5

2,0

1,5

1,0

0,5

0,0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Source: FSO: COD, NICER, CCR

© FSO

Hodgkin’s lymphoma: Incidence 1 and mortality trend by age group G 4.9.4

Crude rate per 100,000 inhabitants

9

Women

8

7

6

5

4

3

2

1

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

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Cancer Sites

4.9.3 Regional Comparisons

In men, rates are about twice as high in cantons with a

high incidence (Fribourg and Ticino) as in the canton

with a low incidence (Neuchâtel). In women, geographical

disparities exist but are less pronounced. The cantons

of Fribourg and Geneva have the highest risk, while the

canton of Valais as well as the Basel-Stadt and Basel-

Landschaft region have the lowest rates (G 4.9.5).

4.9.4 International Comparisons

For both sexes, the highest incidence rates in the world

are found in Israel, Italy, Switzerland, Finland, the United

States, and Canada. In women, high rates are observed

in Russia and the Baltic States. Hodgkin’s disease is rare

in China, Korea, Southeast Asia, and Japan with rates

8–10 times lower than regions with high incidence

(G 4.9.6).

4.9.5 Risk Factors

Risk factors for Hodgkin’s disease are age, sex, infections,

certain medical problems, and heredity.

Two age groups are at risk: young people aged

15–35, and people over age 60. The aetiology of cancers

in adolescents and young adults probably differs

from that of older adults.

It is unknown why this cancer is generally more common

in men than in women. Some evidence indicates

that children from large families or who have had contact

with other children in a childcare centre or kindergarten

have a lower risk, probably related to early

exposure to childhood infections which boosted their immunity.

Hodgkin’s disease is more common in people

who have been infected with the Epstein Barr virus (EBV).

This virus infects B lymphocytes and causes the disease

known as infectious mononucleosis. This antecedent

infection is found in 50% of patients with Hodgkin’s disease.

Carriers of hepatitis C are reported to be at higher

Hodgkin’s lymphoma: Incidence 1 in regional comparison, 2003–2007

G 4.9.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

German-speaking Switzerland

French-speaking Switzerland and Ticino

Ticino

Fribourg

Geneva

Zurich

Vaud

Valais

Graubünden and Glarus

Basel-Stadt and Basel-Landschaft

St. Gallen and Appenzell

Neuchâtel

10 8 6 4 2 0 0 2 4 6 8 10

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Men

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

60

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Cancer Sites

Hodgkin’s lymphoma: Incidence 1 in international comparison, 1998–2002

G 4.9.6

Rate per 100,000 inhabitants, world standard

Israel

Italy e

Switzerland e

Russia e

USA, Whites e

Baltic States

Finland

Canada e

Belgium e

Czech Rep. and Slovakia

Portugal e

Poland e

France e

Balkan states e

Netherlands

British Isles e

Spain e

Germany e

Australia and New Zealand

USA, Blacks e

Scandinavia

Latin America e

Austria

North Africa e

Pakistan e

Turkey e

French Polynesia

Sub-Saharan Africa e

India e

China e

Southeast Asia e

Japan e

Korea

Women

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

Rate per 100,000 inhabitants, world standard

Israel

Italy e

USA, Whites e

Switzerland e

Finland

Canada e

Balkan states e

British Isles e

Spain e

Poland e

Netherlands

Belgium e

USA, Blacks e

Russia e

Portugal e

France e

Czech Rep. and Slovakia

Germany e

North Africa e

Scandinavia

Australia and New Zealand

Baltic States

Austria

Latin America e

Pakistan e

Turkey e

French Polynesia

India e

Sub-Saharan Africa e

China e

Southeast Asia e

Japan e

Korea

Men

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

risk of developing the disease as well. Hodgkin’s disease

is also more common in individuals with reduced immunity,

particularly in the context of infection with the HIV,

of an autoimmune disease (e.g. rheumatoid arthritis,

lupus, thyroiditis), of hereditary immunodeficiency syndrome

(e.g. ataxia telangiectasia), or of an organ transplant

requiring immunosuppressive treatment.

A recent study reported an increased risk among

workers exposed to pesticides, though this link has yet

to be confirmed.

The risk is higher in individuals with a first-degree

relative diagnosed with Hodgkin’s disease or another

lymphoma or chronic lymphocytic leukaemia. However,

a family link is found in only about 5% of cases. It is

difficult to determine whether this family link is due to

a common exposure to environmental risk factors

(e.g. exposure to the Epstein Barr virus), to a genetic

predisposition, or to both factors. In the case of twins,

if one has Hodgkin’s disease, the probability that the second

twin will develop it is much higher in identical twins

(monozygotic) than in fraternal (dizygotic) twins. This

suggests that a genetic component exists. Some studies

have shown genetic changes in certain genes involved in

immune regulation among patients with Hodgkin’s disease.

4.9.6 Prevention and Screening

Currently no prevention method is known, except the

prevention of HIV infection. It is not possible to protect

oneself from exposure to the widespread EBV (more

than 80% of people infected before the age of 30). 42

No screening methods for Hodgkin’s disease are available.

2011 FSO Cancer in Switzerland

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Cancer Sites

4.10 Non-Hodgkin Lymphoma

4.10.1 General Observations

Lymphomas are cancers of the immune system. They are

broadly classified into two main types: Hodgkin’s disease

(cf. 4.9) and non-Hodgkin lymphoma (NHL). While the

majority of NHLs occur in the lymph nodes, a smaller

proportion (approximately 20%) occur elsewhere (e.g.

stomach, intestine, bone, and breast). NHLs account for

approximately 80% of all lymphomas.

Some 1400 new patients develop non-Hodgkin’s lymphoma

each year in Switzerland. n NHLs represent

approximately 4% of cancers in men and in women.

Their frequency increases gradually with age, with 83%

of cases occurring after age 50 (G 4.10.1). NHLs are

slightly more common in men than in women. The risk

of developing non-Hodgkin’s lymphoma before the age

of 70 is 1.0% in men and 0.8% in women.

Non-Hodgkin’s lymphoma, 2003–2007 G 4.10.1

Age-specific rate per 100,000 inhabitants

120

100

80

60

40

20

0

Source: FSO: COD, NICER, CCR

0–4

5–9

10–14

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

In Switzerland, approximately 500 patients die each

year of NHL. These NHL cases account for approximately

6.2% of cancer deaths in men and 3.7% in

women. The prognosis for NHL depends on age of onset

and cellular characteristics. Some NHLs have a very good

prognosis while others do not. The five‐year relative survival

in Switzerland is 56%, placing Switzerland within

the high average range in Europe. 43 In 2002, the number

of persons living in Switzerland diagnosed with NHL during

the previous five years was estimated at about 2200

men and 1800 women. 44

4.10.2 Trends

In Switzerland, as in other regions of the world, the incidence

of NHL has been rising for several decades both in

men and in women. This increase in incidence stabilised

after the 1993–1997 period, whereas mortality began

to decrease after the same period (G 4.10.2). The average

annual number of deaths from NHL has been

approximately 530 over the past 10 years. Given that

the elderly population is growing, this corresponds to an

actual decrease in mortality rates. This decrease is most

likely related to improvements in the effectiveness of

treatments. The rise in the incidence and the decline in

the mortality rate are similar in the two language regions

(G 4.10.3). These changes in incidence are observed in

all age groups (G 4.10.4).

Non-Hodgkin’s lymphoma: Incidence 1

and mortality trend G 4.10.2

Rate per 100,000 inhabitants, European standard

20

Women

Men

15

10

5

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence women 1

Mortality women

Incidence men 1

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Source: FSO: COD, NICER, CCR

© FSO

n

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

62

Cancer in Switzerland FSo 2011


Cancer Sites

Non-Hodgkin’s lymphoma: Incidence 1 and mortality trend

by language region G 4.10.3

Rate per 100,000 inhabitants, European standard

20

Women

18

16

14

12

10

8

6

4

2

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Incidence 1

Mortality

Incidence 1

Mortality

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Men

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Source: FSO: COD, NICER, CCR

© FSO

Non-Hodgkin’s lymphoma: Incidence 1 and mortality trend by age group G 4.10.4

Crude rate per 100,000 inhabitants

100

Women

80

60

40

Men

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

20

0

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

Source: FSO: COD, NICER, CCR

© FSO

2011 FSO Cancer in Switzerland

63


Cancer Sites

4.10.3 Regional Comparisons

In men, the incidence rates are approximately 60%

higher in the canton of Ticino than in the Basel-Stadt

and Basel-Landschaft region. Apart from these two regions,

the rates are relatively similar between the cantons.

In women, the cantons of Fribourg and Ticino have

the highest incidences, and the canton of Neuchâtel and

the Basel-Stadt and Basel-Landschaft region the lowest

(G 4.10.5).

4.10.4 International Comparisons

In both sexes, the highest incidence rates in the world

are found in Israel, the United States (white population),

Canada, Australia, New Zealand, and Italy. The lowest

rates are observed in India, Russia, Turkey, and Korea.

Unlike Hodgkin’s disease, low rates are observed in the

Balkans and Baltic States. Switzerland is within the high

average range in Europe and the world. The worldwide

rates are about three times higher in regions with high

incidence than in regions with low incidence (G 4.10.6).

4.10.5 Risk Factors

The risk factors for NHL vary depending on the subtypes

concerned. In general, risk of NHL increases with age

and is higher in men than in women.

The relationship between NHL and radiation has been

shown in survivors of Hiroshima and Nagasaki. o Occupational

exposure to radiation is also associated with an

increased risk. Occupational exposure to herbicides and

pesticides increases the risk of NHL. A relationship with

domestic exposure to these substances remains uncertain.

Some studies have shown an increased risk linked

to benzene based solvents (also associated with leukaemia

risk). A number of reviews have combined the

results of studies on the possible relationship between

NHL risk and use of hair dyes, but a relationship has not

been confirmed.

Cancer treatments may increase the risk of NHL many

years later. Patients who have received radiation treatment

for other cancers such as Hodgkin’s disease have a

slightly increased risk of developing NHL. The risk is

higher for patients who have received both chemotherapy

and radiotherapy.

People with immune deficiency have an increased risk

of NHL. This applies in particular to people with hereditary

immunodeficiency or to people who are receiving

immunosuppressive treatment (e.g. to prevent rejection

of transplanted organ). By altering immunity, the HIV

increases the risk of NHL. Part of the increased incidence

of lymphoma is probably related to the acquired immunodeficiency

syndrome (AIDS) epidemic related to the HIV

Non-Hodgkin’s lymphoma: Incidence 1 in regional comparison, 2003–2007

G 4.10.5

Rate per 100,000 inhabitants, European standard

Women

Switzerland

Men

German-speaking Switzerland

French-speaking Switzerland and Ticino

Ticino

Geneva

Vaud

Zurich

St. Gallen and Appenzell

Valais

Neuchâtel

Graubünden and Glarus

Fribourg

Basel-Stadt and Basel-Landschaft

25 20 15 10 5 0

0 5 10 15 20 25

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Source: NICER, CCR

© FSO

o

Atomic bombings of Hiroshima and Nagasaki in August 1945

64

Cancer in Switzerland FSo 2011


Cancer Sites

Non-Hodgkin’s lymphoma: Incidence 1 in international comparison, 1998–2002

G 4.10.6

Rate per 100,000 inhabitants, world standard

Israel

USA, Whites e

Canada e

Australia and New Zealand

Italy e

Finland

Switzerland e

British Isles e

USA, Blacks e

Belgium e

North Africa e

Spain e

Netherlands

France e

Latin America e

Scandinavia

Portugal e

Germany e

French Polynesia

Austria

Sub-Saharan Africa e

Czech Rep. and Slovakia

Pakistan e

Southeast Asia e

Japan e

Poland e

China e

Turkey e

Baltic States

Balkan states e

Korea

Russia e

India e

Women

0 5 10 15 20

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Source: NICER, CCR, CI-Five Vol.9

Rate per 100,000 inhabitants, world standard

Israel

USA, Whites e

Canada e

Australia and New Zealand

Italy e

Switzerland e

North Africa e

USA, Blacks e

Finland

British Isles e

Belgium e

France e

Netherlands

Spain e

Scandinavia

Portugal e

Latin America e

Germany e

Austria

French Polynesia

Pakistan e

Czech Rep. and Slovakia

Sub-Saharan Africa e

Southeast Asia e

Japan e

Poland e

China e

Baltic States

Korea

Balkan states e

Turkey e

Russia e

India e

Men

0 5 10 15 20

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

virus. Other viruses that can transform lymphocytes also

increase NHL risk. In particular, the Human T cell leukaemia/lymphoma

virus type 1 (HTLV-1) and the Epstein

Barr virus (EBV). HTLV-1 transmitted through sexual contact

or blood, is common in some parts of Japan and the

Caribbean. In certain regions of Africa, EBV associated

with a high prevalence of malaria causes a specific lymphoma

called Burkitt’s lymphoma.

In addition, certain chronic infections can boost

immunity and increase the risk of lymphoma. Infection

with hepatitis B has been associated with an increased

risk of NHL. Helicobacter pylori which causes chronic

stomach ulcers is also associated with the occurrence of

lymphoma of the stomach.

Autoimmune diseases (e.g. rheumatoid arthritis or

lupus erythematosus) are associated with increased NHL

risk. There is no increased risk of lymphoma in firstdegree

relatives of a person diagnosed with NHL.

4.10.6 Prevention and Screening

To prevent occupational risks, it is necessary to protect

workers exposed to radiation, herbicides/pesticides, and/

or benzene-based solvents associated with increased

NHL risk.

As for other forms of risk, the best method to prevent

NHL is to take appropriate measures to prevent HIV

infection. Importantly, treatment for HIV-infected persons

has decreased the risk of developing NHL. The prevention

of HTLV-1 infection in at-risk regions (Japan and

the Caribbean) is also recommended. Antibiotic treatment

of Helicobacter pylori is one means of preventing

the occurrence of lymphoma and stomach cancer.

There is no recommended screening, but regular

monitoring of people at risk may allow early diagnosis.

2011 FSO Cancer in Switzerland

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Cancer Sites

4.11 Leukaemias

4.11.1 General Observations

Leukaemias are cancers of white blood cells. They are

broadly classified into two types, with a further distinction

between acute and chronic characteristics: acute

lymphocytic leukaemia (ALL), chronic lymphocytic leukaemia

(CLL), and acute myeloid leukaemia (AML),

chronic myeloid leukaemia (CML).

Leukaemias are slightly more common in men than in

women. In Switzerland, approximately 900 people, (500

men and 400 women) develop leukaemia each year. p

Leukaemias account for slightly less than 3% of cancers

in men and slightly more than 2% of cancers in women.

The risk of leukaemia increases with age, after a peak

in childhood in the case of lymphocytic leukaemias

(G 4.11.1). The risk of developing a lymphocytic leukaemia

before the age of 70 is 0.9% in men and 0.4% in

women. Approximately 80% of leukaemia cases in children

are ALL, while 85% of cases after the age of 15 are AML.

In Switzerland, approximately 500 people a year die

from leukaemia. Leukaemias are responsible for 3.3%

of cancer deaths in both sexes. The prognosis for leukaemia

depends on age of onset and type of the disease.

The five‐year relative survival is 50%, ranking Switzerland

second among European countries. 45 There are,

however, large disparities between the different types of

leukaemia, ranging from 19% for AML to 75% for CLL.

In 2002, it was estimated that 1500 men and 1000

women diagnosed with leukaemia during the previous

five years were living in Switzerland. 46

4.11.2 Trends

The incidence of leukaemia is showing a slight decline in

Switzerland. The decrease in the number of leukaemias

is accompanied by an increase in certain types of lymphoma.

The decrease in incidence is probably linked

more to the change in the classification of these diseases

than to a reduction in exposure to risk factors. q In the

case of lymphocytic leukaemias, the decrease is observed

Leukaemias, 2003–2007 G 4.11.1

Leukaemias: Incidence 1 and mortality trend G 4.11.2

60

50

40

30

20

10

0

60

50

40

30

20

10

0

Age-specific rate per 100,000 inhabitants

Lymphocytic leukaemia

Myeloid leukaemia

0–4

5–9

10–14

Source: FSO: COD, NICER, CCR

15–19

20–24

25–29

30–34

35–39

40–44

45–49

Incidence men 1 Incidence women 1

Mortality men

Mortality women

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

50–54

55–59

60–64

65–69

70–74

75–79

80–84

85+

© FSO

Rate per 100,000 inhabitants, European standard

10

Lymphocytic leukaemia

Lymphocytic leukaemia

8

6

4

2

0

10

Myeloid leukaemia

Myeloid leukaemia

8

6

4

2

0

1983–1987

1988–1992

1993–1997

1998–2002

Incidence women 1

Mortality women

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

Incidence men 1

Mortality men

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

2003–2007

Source: FSO: COD, NICER, CCR

© FSO

p

Annual average 2003–2007, estimated based on cancer registry data,

cf. 2.1.1 and 2.2.1

q

For leukaemias it was not possible to calculate correction factors because

of the small number of cases (cf. 2.1.3).

66

Cancer in Switzerland FSo 2011


Cancer Sites

Leukaemias: Incidence 1 and mortality trend by language region G 4.11.3

10

Rate per 100,000 inhabitants, European standard

Lymphocytic leukaemia

8

Lymphocytic leukaemia

6

4

2

0

10

8

Myeloid leukaemia

Myeloid leukaemia

6

4

2

0

Incidence 1

Mortality

Incidence 1 Mortality

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Source: FSO: COD, NICER, CCR

© FSO

Leukaemias: Incidence 1 and mortality trend by age group G 4.11.4

Crude rate per 100,000 inhabitants

50

Lymphocytic leukaemia

40

30

20

10

0

50

40

30

20

10

0

Myeloid leukaemia

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1 Incidence estimate based on cancer-registry data; cf. 2.1.1 and 2.2.1

Lymphocytic leukaemia

Myeloid leukaemia

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

1998–2002

2003–2007

20–49 years 50–69 years 70+ years 20–49 years 50–69 years 70+ years

Women

Incidence 1

Mortality

Men

Incidence 1

Mortality

Source: FSO: COD, NICER, CCR

© FSO

among men in the age 70 over. For myeloid leukaemias,

the decline is seen in both sexes but is more pronounced

in men than in women and occurs primarily from the

age of 70 on (G 4.11.4). As in other regions of the world,

the decline is more significant in terms of mortality.

It was approximately 35% for lymphocytic leukaemias

between 1983 and 2007. In Switzerland, the average

annual number of deaths from lymphocytic leukaemias

was 195 between 2003 and 2007. The decline in mortality

is less pronounced for myeloid leukaemias at around

20% between 1983 and 2007 (G 4.11.2).

The decrease in mortality from lymphocytic and myeloid

leukaemias is similar in the two language regions.

It is considered to be associated with improved therapies

(G 4.11.3).

2011 FSO Cancer in Switzerland

67


Cancer Sites

4.11.3 Regional Comparisons

In men the highest incidence rates of lymphocytic leukaemias

are in the registries of Graubünden and Glarus,

and Fribourg, and the lowest in the registries of Vaud

and Neuchâtel. In women, the highest rates are found in

the same regions as men plus in the canton of Valais,

while the lowest rates are observed in the cantons of

Vaud and in the Basel-Stadt and Basel-Landschaft region.

In the case of myeloid leukaemias, the Basel-Stadt and

Basel-Landschaft region and the canton of Vaud have

the highest rates in men and the cantons of Valais and

Fribourg the lowest. In women, the highest rates are

observed in the registries of Graubünden and Glarus and

Geneva, while the lowest are found in the registries of

Neuchâtel and St. Gallen-Appenzell (G 4.11.5).

4.11.4 International Comparisons

Worldwide disparities are very similar for both sexes.

For lymphocytic leukaemias, Australia, New Zealand, and

Canada have the highest incidence rates in the world,

while Sub-Saharan Africa, Korea, India, Pakistan, and

Southeast Asia have the lowest. For myeloid leukaemias,

the highest rates are found in French Polynesia, Australia,

New Zealand, and in the white population in North

America. Very low rates are observed in Sub-Saharan

Africa and India. Incidence rates vary by a ratio of one to

five (myeloid leukaemias) and one to seven (lymphocytic

leukaemias) between regions with the lowest and the

highest risk. Switzerland is generally within the average

range within Europe (G 4.11.6).

Leukaemias: Incidence 1 in regional comparison, 2003–2007

G 4.11.5

Rate per 100,000 inhabitants, European standard

Lymphocytic

leukaemia

Switzerland

German-speaking Switzerland

French-speaking Switzerland and Ticino

Graubünden and Glarus

Fribourg

Geneva

Zurich

St. Gallen and Appenzell

Ticino

Valais

Basel-Stadt and Basel-Landschaft

Neuchâtel

Vaud

Lymphocytic

leukaemia

Women

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Men

German-speaking Switzerland

French-speaking Switzerland

and Ticino

Confidence interval 95%

Myeloid

leukaemia

Switzerland

German-speaking Switzerland

French-speaking Switzerland and Ticino

Basel-Stadt and Basel-Landschaft

Vaud

Zurich

Ticino

Neuchâtel

Geneva

St. Gallen and Appenzell

Graubünden and Glarus

Valais

Fribourg

Myeloid

leukaemia

14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14

1 Incidence estimated based on data from registries in the cantons of AI, AR, BL, BS, GL, GR, SG and ZH for German-speaking Switzerland

1 and FR, GE, NE, TI and VS for French- and Italian-speaking Switzerland; cf. 2.1.1 and 2.2.1

Source: NICER, CCR

© FSO

68

Cancer in Switzerland FSo 2011


Cancer Sites

Leukaemias: Incidence 1 in international comparison, 1998–2002

G 4.11.6

Australia and New Zealand

Canada e

Scandinavia

Italy e

Israel

USA, Whites e

France e

Poland e

Baltic States

Russia e

British Isles e

Finland

Belgium e

Czech Rep. and Slovakia

Switzerland e

Spain e

Germany e

Balkan States e

Netherlands

Austria

Latin America e

USA, Blacks e

Turkey e

Portugal e

Japan e

North Africa e

China e

Southeast Asia e

Pakistan e

French Polynesia

India e

Korea

Sub-Saharan Africa e

French Polynesia

Australia and New Zealand

USA, Whites e

Italy e

Israel

France e

USA, Blacks e

Canada e

Belgium e

Latin America e

Germany e

Scandinavia

British Isles e

Switzerland e

Netherlands

Baltic States

Czech Rep. and Slovakia

Austria

Pakistan e

Finland

Russia e

Spain e

Southeast Asia e

Portugal e

Poland e

Korea

Turkey e

Balkan States e

North Africa e

Japan e

China e

India e

Sub-Saharan Africa e

Source: NICER, CCR, CI-Five Vol.9

Rate per 100,000 inhabitants, world standard

Lymphocytic leukaemia

Myeloid leukaemia

0 1 2 3 4 5 6 7

Women

Europe

Coverage e < 10%

Other countries Coverage e < 10%

1 A list of all included cancer registries is presented in Annex 1

e Countries and regions with partial coverage: estimate based on registered regions

Australia and New Zealand

Canada e

Israel

Czech Rep. and Slovakia

France e

Italy e

USA, Whites e

Scandinavia

Switzerland e

Baltic States

British Isles e

Belgium e

Germany e

Finland

Netherlands

Russia e

Austria

Balkan States e

Spain e

French Polynesia

Poland e

USA, Blacks e

Latin America e

Portugal e

Turkey e

North Africa e

Japan e

Pakistan e

India e

China e

Southeast Asia e

Korea

Sub-Saharan Africa e

Australia and New Zealand

USA, Whites e

French Polynesia

Italy e

USA, Blacks e

Israel

France e

Canada e

Germany e

Switzerland e

British Isles e

Belgium e

Latin America e

Scandinavia

Netherlands

Baltic States

Austria

Japan e

Spain e

Czech Rep. and Slovakia

Finland

Russia e

Portugal e

Korea

Southeast Asia e

Balkan States e

China e

Turkey e

Poland e

Pakistan e

North Africa e

India e

Sub-Saharan Africa e

Rate per 100,000 inhabitants, world standard

Lymphocytic leukaemia

Myeloid leukaemia

0 1 2 3 4 5 6 7

Men

Europe

Coverage e < 10%

Other countries Coverage e < 10%

© FSO

2011 FSO Cancer in Switzerland

69


Cancer Sites

4.11.5 Risk Factors

Ionizing radiation is recognised as a primary cause of

certain leukaemias. The survivors of Hiroshima and

Nagasaki r have a higher risk of ALL, AML, and CML, but

not of CLL. Their increased risk began two years after

irradiation and is greater for persons who were near the

centre of the explosion. Radiation therapy, which was

used in the past for the treatment of ankylosing spondylitis

(a chronic inflammatory rheumatic disease with pain

and stiffness of joints), also increases the risk. Radiation

exposure during pregnancy increases the risk of childhood

leukaemia, particularly myeloid leukaemia.

Another risk factor for leukaemia (principally AML) is

cancer treatments, especially for Hodgkin’s disease, non-

Hodgkin lymphomas, childhood leukaemias, and breast

and ovarian cancers. The increased risk depends on the

type of chemotherapy. Alkylating agents and agents

containing epipodophyllotoxins are primarily responsible

for the increased risk. The risk is particularly high in

patients who were treated at a young age. Leukaemias

induced by cancer treatments often present an anomaly

induced by chromosome 11.

The Human T cell leukaemia/lymphoma virus type 1

(HTLV-1) (common in some parts of Japan and the Caribbean),

and the EBV (Epstein Barr virus) responsible for

infectious mononucleosis, transform lymphocytes and

thereby increase the risk of leukaemia. EBV in particular

increases the risk of ALL in the regions of Africa highly

endemic for malaria. (It also increases the risk of a particular

form of lymphoma: Burkitt’s lymphoma.)

Occupational exposure to benzene is associated with

increased risk of leukaemia, mainly AML. Benzene is

used as a solvent in the rubber, footwear, and dry cleaning

industries, as well as in laboratories and the chemical

industry (e.g. in paints, varnishes, printing inks, etc.)

Benzene is also contained in premium-grade unleaded

petrol. Tobacco, probably because of its high benzene

content, increases the risk of leukaemia, mainly AML.

Some genetic abnormalities such as Down syndrome

(Trisomy 21) increase the risk of leukaemia particularly

ALL. Fanconi anaemia and ataxia telangiectasia are associated

with an increased risk of both AML and ALL. An

increased risk of CLL has been observed in families with

a first-degree family member diagnosed with CLL. The

genetic component of other forms of leukaemia, notably

CML, is low.

The association between exposure in pregnancy to

marijuana smoke or to benzene and the occurrence of

childhood leukaemia is still being researched. As yet

unconfirmed other factors worth mentioning include

exposure to electromagnetic fields, diesel fuel, pesticides,

hair dye, and viruses that cause leukaemia in animals.

r

Atomic bombings of Hiroshima and Nagasaki in August 1945

70

Cancer in Switzerland FSo 2011


Cancer Sites

4.11.6 Prevention and Screening

The prevention of leukaemia is linked to radiation protection.

It is also necessary to take precautionary measures

to protect workers who are in contact with solvents

known to be associated with increased risk of leukaemia.

Protective measures against HTLV-1 infection are recommended

in areas at risk. Smoking cessation is in any case

a beneficial measure.

2011 FSO Cancer in Switzerland

71


Childhood Cancers

5 Childhood Cancers

5.1 General Observations

Cancers in children are rare. Only about 0.5% of all

tumours worldwide occur during childhood. In Switzerland

there are about 170 new cases of childhood cancer

every year.

Interdisciplinary therapy, mostly in the context of

international clinical trials, has steadily improved treatment

success. Currently the cure rate is 80%, which is

significantly higher than in adults (cf. 3.3). Nevertheless,

after accidents, cancers are the second leading cause

of death among children in Switzerland.

Childhood Tumour Types

Childhood cancers are different from adult forms of the disease.

Common cancers in adults are breast, lung, prostate,

and colorectal cancer. These are carcinomas (i.e. cancers that

spread from cells in the tissue that lines the skin or mucous

membranes called epithelium). In children, on the other

hand, tumours arise from a variety of tissue types and carcinomas

are rare. Therefore, childhood cancers are classified

according to their histology (tissue type), not according to

the site.

The International Classification of Childhood Cancer

(ICCC-3) 47 distinguishes 12 groups of cancers (G 5.1).

The most common are leukaemias (33% of all cancers),

followed by tumours of the central nervous system

(especially brain tumours) (21%), and lymphomas

(13%). Other cancers arise from embryonic tissue. These

include neuroblastomas (7%) from primitive neural tissue,

nephroblastomas (6%) from renal tissue, hepatoblastomas

(1%) in the liver, retinoblastomas (3%) from

cells of the retina, as well as germ cell tumours (3%).

The latter may arise in the gonads (ovaries and testes),

or in other sites, for example in the brain. In older children,

malignant bone tumours (5%) and soft tissue sarcomas

(7%), which arise from abnormal connective tissue,

are occurring with increasing frequency.

Furthermore, sometimes children also develop melanomas

and other rare tumours (2%).

An intermediate position is occupied by Langerhans

cell histiocytoses, which are not officially counted as

malignant diseases and are therefore not included in the

graphs below. But since they are treated similarly to cancer

and in rare cases also result in death, they are

recorded in the Swiss Childhood Cancer Registry. On

average, five such cases occur each year in Switzerland.

72

Cancer in Switzerland FSo 2011


Childhood Cancers

Cancer in children: diagnoses by age group, 1988–2007 G 5.1

100%

ICCC-3 diagnostic groups

I Leukaemias

II Lymphomas

III Central nervous system

neoplasms

IV Neuroblastomas

V Retinoblastomas

VI-VII Nephroblastomas

and hepatoblastomas

VIII Malignant bone

tumours

IX Soft tissue sarcomas

X Germ cell tumours

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: SCCR

< 1

1–4 5–9 10–14

© FSO

XI-XII Other malignant

tumours

The surfaces are proportional

to the number of cases.

Treatment

Most children who develop cancer in Switzerland are treated

in one of nine clinics specialising in paediatric oncology.

These are the departments of paediatric oncology in the

paediatric clinics in Aarau, Basel, Bern, Geneva, Lausanne,

Lucerne, St. Gallen, Zurich, and Ticino (until 2008 in

Locarno, since then in Bellinzona), which are summarised in

the website of the Swiss Paediatric Oncology Group (SPOG;

www.spog.ch). These clinics are working closely together to

provide the highest level of treatment. Where possible, all

children are included in international treatment studies. This

guarantees standardised therapy at the cutting edge of current

research. At the same time, the results can be evaluated

to improve knowledge about the tumours and to further

improve treatment. In addition to improved effectiveness,

the focus is on the reduction of short- and long-term side

effects.

For some tumours, surgical treatment is sufficient (e.g.

benign brain tumours or early-stage melanomas). Most

cases, however, require complex combination therapy consisting

of several cycles of chemotherapy, surgery and sometimes

radiation or bone marrow transplants. Therefore,

treatment often lasts one to two years, and after the children

are cured, they are followed up for several years. Even

children who suffer a relapse have a good chance of a complete

cure. But in such cases the therapy is adapted and

intensified.

Unless children or their parents avail themselves of their

veto power, information on the child’s tumour, treatment

and course of treatment are documented in the Swiss Childhood

Cancer Registry (www. childhoodcancerregistry.ch). 48

This allows for quality control and rapid feedback of results

to the treating hospitals.

2011 FSO Cancer in Switzerland

73


Childhood Cancers

5.2 Cancer Cases and Deaths

On average over the 1998–2007 period, 168 new childhood

cancer cases occurred each year in Switzerland

(14 new diagnoses per 100,000 children per year). Over

the same period on average 37 children died each year

(3 per 100,000). The annual number of new cancer cases

remained relatively stable from the early 1990s (G 5.2).

Mortality decreased slightly during the same period, from

5 per 100,000 per year (1983–87) to 3 per 100,000 per

year in the years 2003–2007 (G 5.2). Given the small

number of cases, slight variations from period to period

may also be due to chance.

Cancers occur in infants and children aged one to four

years more frequently than during early school age

(G 5.3). Among adolescents, the incidence increases

again slowly, and continues to rise into adulthood.

Practically all types of tumours occur more frequently

among boys than among girls, but sex differences are

less pronounced than later in life (G 5.4).

5.3 Cure and Survival Rates

Thanks to intensive treatment, the chances of cure for

children with cancer have improved dramatically over

the past 60 years and have now reached 80%, compared

with below 20% in 1950. All survival rates

improved significantly for all tumours, although marked

differences remain between the various diagnoses. 49 The

best results are obtained for Hodgkin lymphomas (over

95% cured), and are worse for acute myeloid leukaemia

and for brain tumours and sarcomas (G 5.5).

Cancer in children by age group, 1993–2007 G 5.3

Age-specific rate per 100,000 children

25

20

15

10

5

Cancer in children: incidence and mortality trend G 5.2

Crude rate per 100,000 children

18

16

Girls

Boys

14

12

10

8

6

4

2

0

1983–1987

1988–1992

1993–1997

Incidence

Mortality

Source: SCCR, FSO: COD

1998–2002

2003–2007

1983–1987

1988–1992

1993–1997

Incidence

Mortality

1998–2002

2003–2007

© FSO

0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Boys Incidence

Boys Mortality

Girls Incidence

Girls Mortality

Source: SCCR, FSO: COD

© FSO

In Switzerland, the 10-year survival rate was 72% for

children who were diagnosed in the 1980s, 76% for

those who were diagnosed in the 1990s and 82% for

children who were diagnosed in 2000–2009 (G 5.6).

With Germany, Austria and Finland, Switzerland is

among the countries with the best treatment results. 50

International studies show that survivors have a

higher risk of secondary tumours, for example breast

cancer after Hodgkin’s disease. Survivors also have an

increased risk of hormonal problems, cardiovascular diseases,

osteoporosis, and a slightly higher overall mortality.

Therefore, it is important that follow-up check-ups

continue long after the patient is cured. a

a

A national Swiss strategy to effectively organise such follow-ups is

currently being elaborated in collaboration among the Swiss Paediatric

Oncology Group (www.spog.ch), the “Kinderkrebshilfe Schweiz“

(www.kinderkrebshilfe.ch), the network childhood cancer survivors

(www.survivors.ch.vu) and the Swiss Childhood Cancer Registry.

74

Cancer in Switzerland FSo 2011


Childhood Cancers

Cancer in children by diagnosis, 1983–2007

G 5.4

Crude incidence and mortality rate, per 100,000 children

I Leukaemias

II Lymphomas

III Central nervous

system

IV Neuroblastomas

V Retinoblastomas

VI-VII Nephroblastomas

and hepatoblastomas

VIII Malignant bone

tumours

IX Soft tissue sarcomas

Girls

Boys

Incidence

Mortality

Incidence

Mortality

Girls

X Germ cell tumours

Boys

6 5 4 3 2 1 0 0 1 2 3 4 5 6

Source: SCCR, FSO: COD

© FSO

Cancer in children: five-year survival rates in Central Europe 1 , diagnosis years

1995–1999 G 5.5

Age-standardised 5-year survival rates, in percent

Ia Lymphoid leukaemias

Ib Acute myeloid leukaemias

IIa Hodgkin’s lymphoma

IIb Non-Hodgkin’s lymphomas

IIc Burkitt lymphoma

III Central nervous system

neoplasms

IVa Neuroblastomas

V Retinoblastomas

(only 0–4-year-olds)

VIa Nephroblastomas

VIIIa Osteosarcomas

(only 10–14-year-olds)

VIIIc Ewing sarcoma

IXa Rhabdomyosarcoma

Confidence interval 95%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1 Belgium, Germany, France, Netherlands, Austria, Switzerland; a list of the registries included is presented in Annex 2

Source: EUROCARE-4, European Journal of Cancer 45 (2009) 992–1005

© FSO

Survival over time by period of diagnosis

G 5.6

Survival rate adjusted for age at diagnosis, sex and tumour type (ICCC-3 classification)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

0 5 10 15 20 25 30

Time since diagnosis (year)

1980–1989

1990–1999

2000–2009

Source: SCCR

© FSO

2011 FSO Cancer in Switzerland

75


Childhood Cancers

Because of the high cure rates and the young age at

disease onset, quality of later life is very important for

children who have been cured. A national follow-up

study of long-term survivors was conducted for the first

time in Switzerland in the 1990s. 51 A second study is

currently under way. The findings of these two studies

show that most children who have been cured have

good physical and mental health and good quality of

life. There are nonetheless some young adults with

chronic illnesses or emotional problems. 52

5.4 International Comparisons

Within Europe, the incidence of cancer in children varies

between about 13 cases per 100,000 children per year in

Great Britain and 16 cases per 100,000 in Northern

Europe. 53 With 14 cases per 100,000, Switzerland is in

the mid-range (G 5.7). 54 Worldwide the differences are

even greater with a total variation of 7 to 16 cases per

100,000. 55 However, regional comparisons are made difficult

by differences in cancer registrations.

Cancer in children: incidence in international

comparison 1 , 1988–1997 G 5.7

Rate per 100,000 children, European standard

Finland

Italy e

Denmark

Belarus

Norway

Switzerland e

Malta

Spain e

Netherlands

France e

Estonia

Slovakia

Germany

Slovenia

Iceland

Ireland

United Kingdom

Hungary

Turkey e

0 2 4 6 8 10 12 14 16 18 20

Confidence interval 95%

1 A list of all included registries is found in Annex 3

e Countries with sub-national coverage: estimate based on the registered areas

Greater than the differences in the total number of

cancers are regional differences for certain cancer types.

For example, acute lymphocytic leukaemia (ALL) occurs

particularly frequently among fair-skinned peoples with a

Western lifestyle. Melanomas are most common in Oceania,

where strong sunlight, an ozone hole, and a lightskinned

population are found together. In Africa there

are many virus-associated tumours, such as Burkitt’s lymphoma,

Kaposi’s sarcoma, and nasopharyngeal cancer.

Data from Europe and North America but also from

within certain large countries (e.g. Great Britain) consistently

show a slight increase of childhood cancer over the

last three decades for all age groups (G 5.8 b ). 56 The

number of new cancers also appears to be increasing

slightly in the Swiss Childhood Cancer Registry (G 5.2).

But the numbers are small and not statistically significant,

and the increase may be at least partly attributable

to improved registration.

Cancer in children: incidence trend in Europe 1

by age group b

Crude rate per 100,000 children

25

20

15

10

5

0

1978–1982

1983–1987

1988–1992

1993–1997

1978–1982

1983–1987

1988–1992

1993–1997

1978–1982

1983–1987

1988–1992

1993–1997

G 5.8

1978–1982

1983–1987

1988–1992

1993–1997

0 1–4 5–9 10–14

1 A list of all included registries is found in Annex 4

Source: ACCIS, European Journal of Cancer 42 (2006) 1961–1971

© FSO

Source: ACCIS, European journal of Cancer 42 (2006) 1952–1960

© FSO

b

With thanks to Dr. Eva Steliarova-Foucher (IARC) and the ACCIS

Working Group

76

Cancer in Switzerland FSo 2011


Childhood Cancers

5.5 Causes and Risk Factors

Little is known about the causes of cancers in children.

Their aetiology is multifactorial. This means that they

have different causes and that both environmental influences

and a genetic predisposition play an important

role. Cancers in infants and young children are probably

caused by risk factors present before birth or even before

conception.

A series of familial and genetic syndromes are associated

with increased cancer incidence. These include

familial neoplastic syndromes such as familial retinoblastoma,

familial Wilms tumour, Li Fraumeni syndrome,

neurofibromatosis, and multiple endocrine neoplasia. An

increased risk of cancer is also found in children with

congenital immunodeficiency or bone marrow diseases,

and in children with genetic diseases or chromosomal

anomalies. Children with Down syndrome (Trisomy 21)

have an increased risk of acute leukaemia, but a reduced

risk for solid tumours.

Family members of children with cancer (siblings and

offspring) only have an increased cancer risk if they suffer

from one of the aforementioned familial syndromes

or from genetic diseases.

Increasing maternal age at birth is associated with a

slight increase in cancer risk among children, especially

for ALL. The data are less consistent regarding the

father’s age.

Although environmental factors certainly play a role in

the development of cancer in children, there is little definite

knowledge about this. Because of the extreme rarity

of childhood cancer and the relatively long latency

period between exposure and onset of the disease,

research in this area is much more difficult.

Ionizing (radioactive) radiation in higher doses promotes

the development of cancer. Consequently, in past

years, the routine x-ray examination of pregnant women

resulted in cancers in children. The increase in thyroid

cancers among children in Belarus after the Chernobyl

accident in 1996 is also well documented.

The effect of low doses of radiation (radon) and electromagnetic

radiation (power lines, mobile phones, radio

stations) is still unclear. There is also little clarity regarding

the effects of pesticides, benzene, or parents’ occupational

exposure to chemicals.

Certain viruses, particularly HIV, hepatitis B, Epstein

Barr virus (EBV), and HHV-8, contribute to international

variation in cancer incidence among children, especially

for lymphomas, nasopharyngeal carcinomas, liver carcinomas

and Kaposi’s sarcomas. On the other hand, there

are studies that indicate a possible protective effect of

early exposure to common cold viruses through contact

with older siblings or other children in childcare centres

or kindergartens.

Three studies are currently examining the effect of environmental

factors on the development of cancer in children

in Switzerland. A national study (www.canupis.ch)

is comparing the place of residence of children with cancer

with the place of residence of healthy children. The

aim is to investigate whether children with cancer live

closer to nuclear power plants, power lines, radio transmitters,

and/or main roads. A second international casecontrol

study with Switzerland’s participation (CEFALO)

examines risk factors for brain tumours in children.

A third study examines whether cancer risk and chances

of cure in Switzerland are affected by social class.

5.6 Prevention and Early Detection

As summarised above, to date there is little reliable

knowledge about preventable risk factors. A generally

healthy lifestyle is certainly a sensible measure. Some

tumours in infancy and early childhood (e.g. retinoblastoma)

can be detected during routine paediatric examinations.

However, except for families with hereditary syndromes,

specific screening tests are not a reasonable

measure. For example, a laboratory screening test for

neuroblastoma (concentration of certain substances in

the urine) has not proved useful. Such screening identified

a number of tumours that would have regressed

without treatment. As a result, some children were

unnecessarily subjected to such treatment, and for other

affected children with larger tumours the chances of survival

did not improve because of the earlier diagnosis.

2011 FSO Cancer in Switzerland

77


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of childhood cancer. Oncogene 23:6429-44.

56

Kaatsch P et al. (2000). Time trends of cancer incidence

in European children, 1978–1997. Report

from the Automated Childhood Cancer Information

System project. Eur J Cancer 42(13):1961-71.

82

Cancer in Switzerland FSo 2011


Annex

Annex


Annex

Annex 1: List of registries for international comparison graphs (chap. 4)

Australia and New Zealand

Austria

Baltic States

Belgium

British Isles

Canada

China

Czech Republic and Slovakia

Finland

France

French Polynesia

Germany

India

Israel

Italy

Japan

Korea

Latin America

Netherlands

Australia: New South Wales, Northern Territory, Queensland, South, Tasmania,

Victoria, Western, Capital Territory; New Zealand

Austria

Estonia; Latvia; Lithuania

Flanders

Ireland; United Kingdom: East of England, Merseyside and Cheshire,

North Western, Northern and Yorkshire, Oxford Region, South and Western,

Thames, Trent, West Midlands, Northern Ireland, Scotland

Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador,

Northwest Territories, Nova Scotia, Ontario, Prince Edward Island, Saskatchewan

Guangzhou, Hong Kong, Jiashan, Harbin, Shangha, Zhongshan

Czech Republic; Slovak Republic

Finland

Bas-Rhin, Calvados, Doubs, Haut-Rhin, Hérault, Isère, Loire-Atlantique,

Manche, Somme, Tarn, Vendée

French Polynesia

Brandenburg, Saxony, Hamburg, Mecklenburg-Western Pomerania, Munich,

Munster, Saarland

Chennai, New Delhi, Karunagappally, Mumbai, Nagpur, Poona, Trivandrum

Israel

Biella, Brescia, Ferrara, Florence and Prato, Genoa, Macerata, Milan, Modena,

Naples, Parma, Ragusa, Reggio Emilia, Romagna, Salerno, Sassari, Syracuse,

Sondrio, Torino, Umbria, Varese, Veneto

Aichi, Fukui, Hiroshima, Miyagi, Nagasaki, Osaka, Yamagata

South Korea

Argentina: Bahia Blanca; Brazil: Brasilia, Cuiaba, Goiania, Sao Paulo;

Chile: Valdivia; Colombia: Cali; Costa Rica; Ecuador: Quito; France: La Martinique;

Peru: Trujillo

Netherlands

84

Cancer in Switzerland FSo 2011


Annex

North Africa

Pakistan

Poland

Portugal

Russia

Scandinavia

Southeast Asia

Spain

Sub-Saharan Africa

Switzerland

Balkan States

Turkey

USA, Blacks, USA, Whites

Algeria: Setif; Egypt: Gharbiah; Tunisia: Sousse

Karachi South

Cracow, Kielce, Warsaw City

Porto, South

Saint Petersburg

Denmark; Norway; Sweden

Malaysia: Penang, Sarawak; Philippines: Manila; Singapore (Chinese, Indian

and Malaysian population); Thailand: Chiang Mai, Lampang, Songkhla

Albacete, Asturias, Basque Country, Canary Islands, Cuenca, Girona, Granada,

Murcia, Navarra, Tarragona, Zaragoza

Uganda: Kyadondo; Zimbabwe: Harare (African population)

Basel-Stadt and Basel-Landschaft, Geneva, Graubünden and Glarus, Neuchâtel,

St. Gallen-Appenzell, Ticino, Valais, Vaud, Zurich

Bulgaria; Croatia; Serbia; Slovenia

Antalya, Izmir

Alabama, Alaska, Arizona, California, Colorado, District of Columbia, Florida,

Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Massachusetts,

Michigan, Missouri, Montana, New Jersey, New York, Ohio, Oklahoma, Oregon,

Pennsylvania, Rhode Island, South Carolina, Texas, Vermont, Washington,

West Virginia, Wisconsin

Annex 2: List of registries for Central Europe (G 5.5)

Austria

Belgium

France

Germany

Netherlands

Switzerland

Austria

Flanders

Bas-Rhin, Brittany, Calvados, Côte d’Or (hematologic), Doubs, Haut-Rhin,

Hérault, Isère, Lorraine, Manche, Somme, Tarn

German childhood cancer registry (in German: Deutsches Kinderkrebsregister)

Amsterdam, Eindhoven, North Holland

Basel-Stadt and Basel-Landschaft, Geneva, St. Gallen-Appenzell, Ticino, Valais

2011 FSO Cancer in Switzerland

85


Annex

Annex 3: List of registries and period covered a (G 5.7)

Belarus Belarus (since 1989)

Denmark

Estonia

Finland

Denmark

Estonia

Finland

France Bas-Rhin (until 1996), Brittany (since 1991), PACA and Corsica (until 1996),

Doubs (until 1996), Haut-Rhin ,Hérault, Lorraine, Manche (1994 to 1996),

Rhône-Alpes, Somme (until 1996), Tarn

Germany

Hungary

Iceland

NCR: National Cancer Registry (national cancer registry of the former

East Germany) until 1989; GCCR: German Childhood Cancer Registry

(childhood cancer registry of the former West Germany) from 1983 until 1990;

GCCR (East and West) since 1991

Hungary

Iceland

Ireland Ireland (since 1994)

Italy

Piedmont paediatric registry, Marches (since 1990), Ferrara (1991 to 1995), Latina,

Liguria (until 1995), Lombardy, Umbria (1994 to 1996), Parma (until 1995),

Ragusa, Sassari (1992 to 1995), Tuscany, Veneto (1990 to 1996)

Malta Malta (since 1991)

Netherlands

Norway

Slovakia

Slovenia

Spain

Netherlands (1989 to 1995; except for leukaemias) DCOG: Dutch Childhood

Oncology Group (only for leukaemias)

Norway

Slovakia

Slovenia

Spain (1990 to 1995): when periods overlap, only records from this registry

are used, Albacete (since 1991), Asturias, Canary Islands (1993 to 1996),

Girona (since 1994), Granada, Mallorca (until 1995), Navarra (until 1996),

Tarragona, Basque country (until 1994), Zaragoza (until 1996)

Switzerland Basel-Stadt and Basel-Landschaft, Geneva, Graubünden and Glarus (since 1989),

St. Gallen-Appenzell, Valais (since 1989)

Turkey Izmir (1993 to 1996)

United Kingdom England and Wales (until 1995), Scotland, Northern Ireland (1993 to 1996)

a

The coverage period is only indicated if the registry does not cover

the entire 1988–1997 period.

86

Cancer in Switzerland FSo 2011


Annex

Annex 4: List of registries and period covered a (G 5.8)

Denmark

Estonia

Finland

Denmark

Estonia

Finland

France Lorraine (since 1983), PACA and Corsica (1984 to 1996), Doubs (until 1996),

Isère (since 1979), Bas-Rhin (until 1996), Somme (1983 to 1996) Tarn (since 1983)

Germany

Hungary

Iceland

NCR: National Cancer Registry (national cancer registry of the former

East Germany) until 1989; GCCR: German Childhood Cancer Registry (childhood

cancer registry of the former West Germany) from 1983 to 1990;

GCCR (East and West) since 1991

Hungary

Iceland

Italy Piedmont paediatric registry, Latina (since 1983), Lombardy, Parma (until 1995),

Ragusa (since 1983)

Netherlands

Norway

Slovakia

Slovenia

DCOG: Dutch Childhood Oncology Group (only for leukaemias),

Eindhoven (for other cancers)

Norway

Slovakia

Slovenia

Spain Asturias (since 1983), Navarra (until 1996), Tarragona (since 1983),

zaragoza (until 1996)

Switzerland

United Kingdom

Basel-Stadt and Basel-Landschaft (since 1983), Geneva,

St. Gallen-Appenzell (since 1983)

England and Wales (until 1995), Scotland

a

The coverage period is only indicated if the registry does not cover

the entire 1978–1997 period.

2011 FSO Cancer in Switzerland

87


Glossary

Glossary


Glossary

Adenocarcinoma

Benign polyp

Biopsy

Birth cohort

BRCA1 and BRCA2

Cancer site

Carcinogen

Carcinoma

Colonoscopy

Congenital naevus (or mole)

Dysplastic naevus

(also called atypical mole)

Endometrium

Goitre

Health education

Health promotion

Helicobacter pylori

Histological investigation

Histological type

Hormone replacement therapy

(HRT)

Human papillomavirus (HPV)

Hyperplasia

In situ

Incidence

International Classification of

Childhood Cancer (ICCC)

A cancer of epithelia originating in glandular tissue.

A non-malignant growth that protrudes from a mucous membrane.

The removal of cells or tissues for microscopic examination by a pathologist.

A group of people born on a particular day or during a particular period or year

who are followed up over time.

Human gene that belongs to a class of genes known as tumour suppressors.

Women with a mutation of the BRCA1 or BRCA2 gene have a higher risk

of breast cancer.

Site or organ affected by cancer.

Substances or exposures in the environment that may cause cancer.

A malignant new growth of epithelial cells that begins in skin or tissues that line

the inside or cover the outside of internal organs.

A procedure that allows visual observation of the large intestine

(rectum and colon) with a flexible probe.

Naevus present at birth.

Naevus with birth or developmental abnormalities which occurred during

the embryonic period or after birth.

The inner lining of the uterus (womb).

Enlargement of the thyroid.

The process of teaching people about and how to improve their health and to give

them the means to control it more effectively.

Actions to improve the health of the population (cf. health education).

The bacteria responsible for most ulcers and many cases of stomach inflammation

(chronic gastritis).

The study of the form of structures of tissue seen under the microscope.

Classification of cancers according to their cellular characteristics.

Treatment generally used to limit troubles associated with menopause.

There are different types of sexually transmitted viruses, some of which are

associated with cancer and precancerous lesions of the cervix uteri.

Increase in the number of cells in a tissue.

A cancer that has remained within the tissue in which it originated (i.e. localised

or non-invasive cancer that has not begun to spread).

Frequency of new cases of a disease in a defined population during a given period.

The incidence of cancer is often expressed as annual rates over 100,000 inhabitants

(cf. 2.2).

The classification system for childhood cancers based on tumour morphology and

primary site with emphasis on morphology rather than the emphasis on primary site.

90

Cancer in Switzerland FSo 2011


Glossary

International Classification

of Diseases (ICD)

International Classification

of Diseases for Oncology

(ICDO)

Invasive cancer

Major regions

Mammography

Mastectomy

Melanin

Melatonin

Metastasis

Morbidity

Mortality

Naevus

Nodule

Occult blood

Over-diagnosis

Pap smear

Precancerous lesion

The classification used to code and classify diseases. Uniformly revised

and published by the World Health Organisation (WHO) since the19 th century;

the tenth revision has been in use since 1994.

A classification system that extends the ICD and is used principally in tumour or

cancer registries for coding the site (topography) and the histology (morphology)

of neoplasms. The 3 rd revision is currently in force.

A cancer spread beyond the layer of tissue in which it originated and growing into

surrounding healthy tissue.

– Lake Geneva region: Vaud (VD), Valais (VS), Geneva (GE)

– Espace Mittelland: Bern (BE), Fribourg (FR), Solothurn (SO), Neuchâtel (NE),

Jura (JU)

– Northwest Switzerland: Basel-Stadt (BS), Basel-Landschaft (BL), Aargau (AG)

– Zurich: Zurich (ZH)

– Eastern Switzerland: Glarus (GL), Schaffhausen (SH), Appenzell Ausserrhoden (AR),

Appenzell Innerrhoden (AI), St. Gallen (SG), Graubünden (GR), Thurgau (TG)

– Central Switzerland: Lucerne (LU), Uri (UR), Schwyz (SZ), Obwalden (OW),

Nidwalden (NW), Zug (ZG)

– Ticino: Ticino (TI)

An x-ray imaging test performed to examine breast tissue and detect breast cancer.

Partial or total surgical removal of the breast.

The pigment that gives skin colour.

”Sleep“ hormone that regulates biological rhythms.

The spread of cancer from the primary site (place where it started) to other places

in the body via blood or lymphatic vessels.

The frequency or rate at which (an) illness occurs in a particular area or population

during a specific period (includes prevalent and incident disease).

The frequency or rate at which death occurs in a particular population during

a specific period. Cancer mortality is often expressed as annual rates over

100,000 inhabitants (cf. Chapter 2).

Mole or beauty mark/spot.

A growth or lump that may be malignant (cancerous) or benign (noncancerous)

and that develops in or under the skin.

Blood present in the stool which is not visible to the naked eye.

Detection of an asymptomatic disease that would not have spontaneously

presented symptoms and that would not have had consequences during the

patient’s lifetime.

A screening test based on microscopic examination of cervical cells to detect cancer

of the cervix uteri.

Abnormal cells characterised by a disruption of the mechanisms of cell renewal.

At this stage, the risk that a cancer will develop is higher.

2011 FSO Cancer in Switzerland

91


Glossary

Prevalence

Prevention

Primary Prevention

Prostate specific antigen (PSA)

Relative survival rate

Risk factor

Risk

Sarcoma

Screening

Secondary prevention

Stage

Standardised rate

Survival rate

Ulcer

Years of Potential Life Lost

(YPLL)

The frequency of cases of a disease in a given population at a specific time

(can be expressed by a number, proportion or rate). The prevalence is sometimes

limited to a particular period of time after diagnosis, for example the prevalence

at age 5 (cf. Chapter 2).

Measures to limit the impact of a disease by avoiding its occurrence

(primary prevention) or by limiting its consequences (secondary prevention).

Strategies performed to decrease the chance of getting a disease or condition such

as cancer (e.g. exposure to tobacco for lung cancer).

A protein produced by cells of the prostate gland. The PSA test measures the level

of PSA in the blood to help detect prostate cancer.

Survival rate estimated by taking into account the deaths occurring in the general

population at each age.

Any characteristic of a person or a person’s environment or life style that increases

the likelihood that the person will eventually develop a disease.

The probability of an event occurring such as developing or dying from a disease

in a population or subpopulation.

A cancer of the bone, cartilage, fat, muscle, blood vessels, or other connective

or supportive tissue.

Procedures which can help find diseases (at an early stage) before symptoms

appear and which can be widely applied to an entire ”target population“ in good

health.

Strategies performed that focus on early diagnosis, symptoms, and treatment to

minimise and/or stop the progress of diseases such as cancer.

Degree of spread of cancer at the time of diagnosis: the cancer is localized (I), with

local invasion (II), with regional invasion (III) or advanced/metastatic (IV) (cf. 2.2).

The standardised rate is a rate recalculated on the assumption that the study population

presents the age structure of a standard population. The standardised rate

makes it possible to compare the incidence or mortality between populations, while

controlling for differences due to age structure. The standard populations generally

used correspond to a European or world average.

The percentage of people who are alive for a certain period of time after they were

diagnosed with a disease such as cancer.

A break on the skin, in the lining of an organ, or on the surface of a tissue

(e.g. in skin, eyes, or mucous membrane) which sometimes appears not to heal.

The sum of the differences between the age of death and a theoretically defined

”acceptable“ age limit; in the existing report age 70 years. YPLL is a measure of

premature mortality and can also be expressed as a rate.

Sources

FSO, IARC, Swiss Cancer League (www.liguecancer.ch)

Gutzwiller F, Paccaud F (2009). Médecine sociale et préventive – santé publique. 3 rd edition, entirely revised.

Bern: Huber.

92

Cancer in Switzerland FSo 2011


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Published by Oxford University Press on behalf of the International Epidemiological Association

ß The Author 2011; all rights reserved.

International Journal of Epidemiology 2011;1–14

doi:10.1093/ije/dyr115

Childhood cancer and nuclear power plants

in Switzerland: a census-based cohort study

Ben D Spycher, 1,2y Martin Feller, 1y Marcel Zwahlen, 1 Martin Röösli, 3,4 Nicolas X von der Weid, 5

Heinz Hengartner, 6 Matthias Egger, 1,2 Claudia E Kuehni, 1 * for the Swiss Paediatric Oncology Group z

5 and the Swiss National Cohort Study Group z

1 Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern,

Switzerland, 2 School of Social and Community Medicine, University of Bristol, Bristol, UK, 3 Swiss Tropical and Public Health

Institute, Basel, Switzerland, 4 University of Basel, Switzerland, 5 Paediatric Haematology-Oncology Unit, Centre Hospitalier

Universitaire Vaudois, Service de Pédiatrie, Lausanne-CHUV, Switzerland and 6 Ostschweizer Kinderspital, St Gallen, Switzerland

10 *Corresponding author. Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM),

Finkenhubelweg 11, CH-3012 Bern, Switzerland. E-mail: kuehni@ispm.unibe.ch

yThese authors contributed equally to this work.

zSee Acknowledgements for a list of the members of the Swiss Paediatric Oncology Group and the Swiss National Cohort

Study Group.

15

Accepted 28 June 2011

Background Previous studies on childhood cancer and nuclear power plants

(NPPs) produced conflicting results. We used a cohort approach

to examine whether residence near NPPs was associated with leukaemia

or any childhood cancer in Switzerland.

20 Methods We computed person-years at risk for children aged 0–15 years born

in Switzerland from 1985 to 2009, based on the Swiss censuses

1990 and 2000 and identified cancer cases from the Swiss

Childhood Cancer Registry. We geo-coded place of residence at

birth and calculated incidence rate ratios (IRRs) with 95% confi-

25 dence intervals (CIs) comparing the risk of cancer in children born


2 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Introduction

Since Black reported a cluster of children with leukaemia

near Sellafield in 1984, 1 numerous studies

investigated cancer incidence near nuclear power

5 plants (NPP), with conflicting results. Some found

an increased risk also at places where NPPs were

planned but not built, concluding that factors other

than radiation might be responsible. 2,3 A recent case–

control study from Germany, which reported odds

10 ratios (ORs) of 1.61 for all cancers and 2.19 for leukaemia

in 0–4 year olds living


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 3

Figure 1 Maps showing sites of nuclear facilities and population density in Switzerland. Locations of NPPs, research

facilities, the interim storage facility and sites where NPPs were planned but never built (upper map) and population

density in 2000 in quintiles (lower map)

NPP, nuclear power plant; EPFL, École Polytechnique Fédérale de Lausanne; Uni, University; PSI, Paul Scherrer Institute


4 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TV transmitters (from an area exposure model),

multi-track railways and high voltage (5200 kV)

power lines (indexed by distance to nearest installation);

(iii) carcinogens related to traffic exhaust (dis-

5 tance to major roads); (iv) agricultural pesticides

(distance to the nearest land use plot with fruit

trees, vineyards and golf courses); (v) socio-economic

status measured at community level based on income,

education and job position (Sotomo Index); 23 (vi)

10 population mixing and exposure to childhood infections

(indexed by average number of children per

household in the community and degree of urbanization).

We also adjusted for distance to the nearest

paediatric cancer centre, which may have affected

15 the probability of registration in the SCCR.

Details on data sources and variable definitions

are given in Supplementary Appendix 1, available as

Supplementary data at IJE online.

Statistical analysis

20 We used Poisson regression to estimate incidence rate

ratios (IRRs) and 95% CIs, comparing children living


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 5

Box 1 Description of sensitivity analyses and additional analyses

Analysis Stronger associations in this analysis compared with the main analysis would

Description Background and rationale

Sensitivity analyses

1 Account for airborne emissions by redefining the exposure as

average duration of slow winds (


6 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Figure 2 Flow chart of selection of children with childhood cancer

and Figure 3). IRRs (95% CI) for leukaemia diagnosed

in 0–4 and 0–15 year olds, comparing children in this

inner circle with children living 415 km away, were

1.20 (0.60–2.41) and 1.05 (0.60–1.86), respectively.

5 The corresponding IRRs for any cancer were 0.97

(0.61–1.54) and 0.89 (0.63–1.27). In the 5–10 km

zone, IRRs tended to be


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 7

Table 1 Characteristics of childhood cancer cases included in birth and resident cohorts

Birth cohort n (%) Resident cohort n (%)

Included

Excluded

Included

Excluded

0–4 years 0–15 years 0–15 years 0–4 years 0–15 years 0–15 years

1618 (100.0) 2925 (100.0) 1250 (100.0) 1830 (100.0) 4090 (100.0) 85 (100.0)

Diagnosis (ICCC3) 20

I Leukaemias, myeloproliferative diseases and

myelodysplastic diseases

573 (35.4) 953 (32.6) 413 (33.0) 680 (37.2) 1345 (32.9) 21 (24.7)

II Lymphomas and reticuloendothelial neoplasms 72 (4.4) 303 (10.4) 242 (19.4) 88 (4.8) 530 (13.0) 15 (17.6)

III CNS and miscellaneous intracranial and intraspinal

neoplasms

IV Neuroblastoma and other peripheral nervous

cell tumours

252 (15.6) 594 (20.3) 228 (18.2) 273 (14.9) 796 (19.5) 26 (30.6)

227 (14.0) 242 (8.3) 33 (2.6) 245 (13.4) 274 (6.7) 1 (1.2)

V Retinoblastoma 88 (5.4) 92 (3.1) 10 (0.8) 93 (5.1) 101 (2.5) 1 (1.2)

VI Renal tumours 143 (8.8) 182 (6.2) 52 (4.2) 166 (9.1) 232 (5.7) 2 (2.4)

VII Hepatic tumours 28 (1.7) 37 (1.3) 7 (0.6) 28 (1.5) 43 (1.1) 1 (1.2)

VIII Malignant bone tumours 11 (0.7) 115 (3.9) 83 (6.6) 13 (0.7) 195 (4.8) 3 (3.5)

IX Soft tissue and other extra-osseous sarcomas 96 (5.9) 184 (6.3) 77 (6.2) 106 (5.8) 255 (6.2) 6 (7.1)

X Germ cell tumours, trophoblastic tumours and

neoplasms of gonads

XI and XII Other malignant epithelial neoplasms and

malignant melanomas or unspecified

malignant neoplasms

38 (2.3) 68 (2.3) 41 (3.3) 40 (2.2) 104 (2.5) 5 (5.9)

13 (0.8) 44 (1.5) 27 (2.2) 14 (0.8) 70 (1.7) 1 (1.2)

Langerhans cell histiocytosis 77 (4.8) 111 (3.8) 37 (3.0) 84 (4.6) 145 (3.5) 3 (3.5)

Gender

Male 894 (55.3) 1621 (55.4) 711 (56.9) 1007 (55.0) 2278 (55.7) 54 (63.5)

Female 724 (44.7) 1304 (44.6) 539 (43.1) 823 (45.0) 1812 (44.3) 31 (36.5)

Median age at diagnosis in years (interquartile range) 2.2 (1.0–3.4) 4.3 (2.0–8.6) 10.4 (6.0–13.5) 2.3 (1.2–3.5) 5.8 (2.6–11.2) 7.6 (3.5–12.3)

ICCC3, International Classification of Childhood Cancer, third edition; CNS, central nervous system.


8 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Table 2 Incidence of childhood cancer in birth cohort according to distance to nuclear power plant, any nuclear facility and

NPPs that were planned but never built

Cases

PY at risk in

100 years

Age 0–4 years

IR per

100 000 PY

IRR

(95% CI) a Cases

PY at risk in

100 years

Age 0–15 years

IR per

100 000 PY

IRR

(95% CI) a

Distance to nearest NPP (km)

Leukaemias

0–5 8 1000 8.00 1.20 (0.60–2.41) 12 2548 4.71 1.05 (0.60–1.86)

5–10 12 3011 3.99 0.60 (0.34–1.06) 25 7631 3.28 0.73 (0.49–1.09)

10–15 31 4194 7.39 1.10 (0.77–1.58) 47 10487 4.48 0.99 (0.74–1.33)

415 522 77 375 6.75 1 869 190 509 4.56 1

All cancers

0–5 18 1000 17.99 0.97 (0.61–1.54) 31 2548 12.17 0.89 (0.63–1.27)

5–10 43 3011 14.28 0.77 (0.57–1.04) 89 7631 11.66 0.85 (0.69–1.05)

10–15 92 4194 21.94 1.17 (0.95–1.44) 156 10 487 14.88 1.08 (0.92–1.27)

415 1465 77 375 18.93 1 2649 190 509 13.91 1

Distance to nearest nuclear facility (NPP, research, or storage) (km)

Leukaemias

0–5 39 5034 7.75 1.15 (0.83–1.59) 65 12 184 5.34 1.16 (0.90–1.50)

5–10 32 6013 5.32 0.79 (0.55–1.13) 57 14 624 3.90 0.85 (0.65–1.12)

10–15 41 5858 7.00 1.05 (0.76–1.44) 62 14 547 4.26 0.95 (0.73–1.22)

415 461 68 674 6.71 1 769 169 821 4.53 1

All cancers

0–5 94 5034 18.67 0.98 (0.80–1.21) 180 12 184 14.77 1.07 (0.92–1.24)

5–10 103 6013 17.13 0.90 (0.74–1.11) 200 14 624 13.68 0.99 (0.86–1.14)

10–15 130 5858 22.19 1.18 (0.99–1.42) 217 14 547 14.92 1.09 (0.95–1.25)

415 1291 68 674 18.80 1 2328 169 821 13.71 1

Distance to nearest planned NPP (km)

Leukaemias

0–5 5 1387 3.60 0.54 (0.22–1.31) 13 3443 3.78 0.85 (0.49–1.47)

5–10 53 6627 8.00 1.20 (0.90–1.60) 79 16 102 4.91 1.09 (0.87–1.38)

10–15 55 8126 6.77 1.01 (0.77–1.34) 97 19 557 4.96 1.10 (0.89–1.36)

415 460 69 439 6.62 1 764 172 073 4.44 1

All cancers

0–5 26 1387 18.74 0.98 (0.67–1.45) 48 3443 13.94 1.00 (0.75–1.33)

5–10 127 6627 19.16 1.00 (0.83–1.20) 223 16 102 13.85 0.98 (0.86–1.13)

10–15 145 8126 17.84 0.93 (0.78–1.10) 260 19 557 13.30 0.94 (0.83–1.07)

415 1320 69 439 19.01 1 2394 172 073 13.91 1

a Adjusted for sex, age and calendar year at diagnosis.

PY, person-year; IR, incidence rate; IRR, incidence rate ratio; NPP, nuclear power plant.

Adjustment for confounders and sensitivity

analyses

Results were closely similar when adjusting, one at

a time, for potential confounders (Figures E1–E30

5 of Supplementary Appendix 2, available as Supplementary

data at IJE online). As shown in Figure 5,

the results from the sensitivity analyses were closely

similar to the main analysis (detailed results are

shown in Figures E31–E48 of Supplementary

Appendix 2, available as Supplementary data at IJE

online). In the analyses using 1/(distance in km), estimated

IRRs were close to 1 for the birth cohort and

41 for the resident cohort, with 95% CIs including 1

(Figure E49 in Supplementary Appendix 2, available

as Supplementary data at IJE online). The results of

the direct comparison of distances to nearest NPP

10

15


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 9

Figure 3 Results for birth cohort. Incidence rate ratios adjusted for sex, age and year at diagnosis and 95% CIs comparing

children living in the inner 5 km, 5–10 km and 10–15 km zones with children outside the 15 km zone. Results for nuclear

power plants (NPPs); any nuclear facility including NPPs, research and storage facilities; and sites of planned but not built

NPPs are shown

between childhood cancer cases and the population at

risk are shown in Table E2 in Supplementary

Appendix 2, available as Supplementary data at IJE

online. Among infants living


10 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Table 3 Incidence of childhood cancer in resident cohort according to distance to nuclear power plant, any nuclear facility

and NPPs that were planned but never built

Cases

PY at risk in

100 years

Age 0–4 years

IR per

100 000 PY

IRR

(95% CI) a Cases

PY at risk in

100 years

Age 0–15 years

IR per

100 000 PY

IRR

(95% CI) a

Distance to nearest NPP (km)

Leukaemias

0–5 11 1094 10.06 1.41 (0.78–2.55) 20 3784 5.29 1.24 (0.80–1.94)

5–10 20 3297 6.07 0.85 (0.54–1.32) 35 11 255 3.11 0.73 (0.52–1.02)

10–15 34 4542 7.49 1.05 (0.74–1.48) 66 15 039 4.39 1.02 (0.80–1.31)

415 615 85 579 7.19 1 1224 282 721 4.33 1

All cancers

0–5 23 1094 21.03 1.11 (0.74–1.67) 50 3784 13.21 1.03 (0.78–1.36)

5–10 57 3297 17.29 0.91 (0.70–1.18) 133 11 255 11.82 0.92 (0.77–1.10)

10–15 105 4542 23.12 1.21 (0.99–1.47) 222 15 039 14.76 1.14 (0.99–1.30)

415 1645 85 579 19.22 1 3685 282 721 13.03 1

Distance to nearest nuclear facility (NPP, research, or storage) (km)

Leukaemias

0–5 47 5389 8.72 1.21 (0.90–1.62) 90 17 244 5.22 1.19 (0.96–1.48)

5–10 42 6687 6.28 0.86 (0.63–1.18) 74 22 367 3.31 0.76 (0.60–0.97)

10–15 39 6480 6.02 0.83 (0.60–1.15) 91 21 545 4.22 0.98 (0.79–1.21)

415 552 75 955 7.27 1 1090 251 643 4.33 1

All cancers

0–5 104 5389 19.30 0.99 (0.81–1.21) 254 17 244 14.73 1.13 (0.99–1.28)

5–10 125 6687 18.69 0.96 (0.80–1.16) 286 22 367 12.79 0.99 (0.87–1.11)

10–15 139 6480 21.45 1.12 (0.94–1.33) 312 21 545 14.48 1.13 (1.00–1.26)

415 1462 75 955 19.25 1 3238 251 643 12.87 1

Distance to nearest planned NPP (km)

Leukaemias

0–5 12 1563 7.68 1.07 (0.60–1.89) 24 5222 4.60 1.09 (0.72–1.63)

5–10 58 7270 7.98 1.11 (0.85–1.46) 112 23 555 4.76 1.11 (0.92–1.35)

10–15 60 8950 6.70 0.93 (0.71–1.22) 130 29 322 4.43 1.04 (0.87–1.24)

415 550 76 728 7.17 1 1079 254 700 4.24 1

All cancers

0–5 35 1563 22.39 1.15 (0.82–1.61) 70 5222 13.40 1.03 (0.81–1.31)

5–10 141 7270 19.39 0.99 (0.83–1.18) 323 23 555 13.71 1.04 (0.93–1.16)

10–15 159 8950 17.77 0.90 (0.77–1.06) 370 29 322 12.62 0.95 (0.86–1.06)

415 1495 76 728 19.48 1 3327 254 700 13.06 1

a Adjusted for sex, age and calendar year at diagnosis.

PY, person-year; IR, incidence rate; IRR, incidence rate ratio; NPP, nuclear power plant.

is a latency between exposure and development of

cancer; 15 and young families tend to move.

Therefore, studies based on residence at diagnosis

might suffer from exposure misclassification, and ad-

5 dress at birth will be a better proxy for the place of

residence during pregnancy. Whereas most previous

studies were ecological using community mid-points

to determine the distance to the nearest NPP, our

study used precise (


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 11

Figure 4 Results for resident cohort. Incidence rate ratios adjusted for sex, age and year at diagnosis and 95% CIs

comparing children living in the inner 5 km, 5–10 km and 10–15 km zones with children outside the 15 km zone. Results

for nuclear power plants (NPPs); any nuclear facility including NPPs, research and storage facilities; and sites of planned

but not built NPPs are shown

Figure 5 Comparison of results of main and sensitivity analyses. Incidence rate ratios adjusted for sex, age and year at

diagnosis and 95% CIs comparing children living


12 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

close to NPPs, resulting in large CIs around estimated

IRRs. Second, we could not adjust for some potential

individual or family level confounders, such as health

behaviours, diet, infections, medical radiation or

5 medications. However, with the exception of high

dose radiation treatment, these exposures are all

weak risk factors (if at all) and thus unlikely to be

strong confounders. 22 Another methodological limitation

of our and other studies 14,24 was the need to

10 compute person-years from census data. We accounted

for non-linear population fluctuations at

the aggregate level, but internal migration was only

accounted for by linear inter-/extrapolation of

person-years between and around census years.

15 Finally, the birth cohort did not include cases who

had emigrated before diagnosis. However, data from

the Swiss National Cohort show that only 2% (4%) of


CHILDHOOD CANCER AND NUCLEAR POWER PLANTS IN SWITZERLAND 13

Bucher from the Swiss Federal Nuclear Safety

Inspectorate (ENSI), René Vogt from the Federal

Office of Communications (BAKOM), Raffael Bovier

from the Federal Office of Topography (Swisstopo),

5 Thomas Schlegel from the Federal Office of

Meteorology and Climatology (MeteoSwiss), Urs

Huber from the Federal Inspectorate for Heavy

Current Installations (ESTI), Hubert Gerhardinger

from the Institute of Geography, University of Bern

10 and Adrian Spoerri from the Institute of Social and

Preventive Medicine, University of Bern. Finally, we

thank Anke Huss for advice in the early stages of the

project and Aysel Güler for her great help with the

geo-coding of addresses.

15 Swiss Paediatric Oncology Group (SPOG):

R. Angst, Aarau; M. Paulussen, Basel; T. Kuehne,

Basel; P. Brazzola, Bellinzona; A. Hirt, K.

Leibundgut, Bern; A. H. Ozsahin, Geneva; M. Beck

Popovic, Lausanne; NX. von der Weid, Lausanne;

L. Nobile Buetti, Locarno; J. Rischewski, Lucerne;

U. Caflisch, Lucerne; J. Greiner, St. Gallen;

H. Hengartner, St. Gallen; M. Grotzer, Zürich; F.

Niggli, Zürich.

Swiss National Cohort Study Group: F. Gutzwiller

(Chairman of the Executive Board), M. Bopp and D.

Faeh, Zurich; M. Egger (Chairman of the Scientific

Board), K. Clough-Gorr, K. Schmidlin, A. Spoerri,

M. Sturdy (Data Manager), and M. Zwahlen, Bern;

N. Künzli, Basel; F. Paccaud, Lausanne; and M.

Oris, Geneva.

Conflict of interest: None declared.

20

25

30

KEY MESSAGES

This large-scale study examined the association between childhood cancer and residence near nuclear

power plants at birth and at diagnosis.

35 The study found little evidence of an association, either for residence at birth or residence at diagnosis,

but the number of exposed cases was small and confidence intervals wide.

Results remained consistent after adjustment for potential confounders and in a number of sensitivity

analyses.

A major strength of this study was the nationwide cohort approach, leaving little room for selection

40 bias.

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