Cancer in Australia: Actual incidence data from 1982 to 2013 and mortality data from 1982 to 2014 with projections to 2017

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1 Received: 2 May 2017 Accepted: 13 July 2017 Published on: 20 September 2017 DOI: /ajco REVIEW ARTICLE Cancer in Australia: Actual incidence data from 1982 to 2013 and mortality data from 1982 to 2014 with projections to 2017 Australian Institute of Health and Welfare Australian Institute of Health and Welfare, Fern Hill Park, Bruce, Australia Correspondence Digital and Media Communications Unit, Australian Institute of Health and Welfare info@aihw.gov.au Abstract Cancer is a major cause of illness in Australia and therefore ongoing monitoring of cancer in Australia is important. This study sources data from the Australian Institute of Health and Welfare (AIHW) and reports actual number of cases diagnosed and deaths, for all cancers combined and selected cancers, from 1982 to 2013 for incidence and from 1982 to 2014 for mortality, with projections to 2017 for both. It is estimated that new cases of cancer (excluding basal and squamous cell carcinomas of the skin) will be diagnosed in The number of new cancer cases more than doubled from in Prostate cancer is estimated to be the most commonly diagnosed cancer in males in 2017, whereas breast cancer is estimated to be the most commonly diagnosed cancer in females. It is estimated that there will be deaths from cancer in Australia in Although the mortality rate decreased, the number of people who died in Australia from cancer almost doubled from in Lung cancer was the most common cause of cancer death in both males and females. In 2011, cancer was the leading cause of disease burden in Australia. KEYWORDS Australia, burden of disease, early detection of cancer, incidence, mortality, neoplasm, screening 1 INTRODUCTION Cancer is a major cause of illness in Australia and has a substantial social and economic impact on individuals, families and the community. On average, one in two Australians will be diagnosed with cancer and one in five will die from it before the age of 85. This article provides an overview of statistics on cancer in Australia, focusing on incidence and mortality estimates for The information presented has been extracted from the biennial publication Cancer in Australia 2017, 1 produced by the Australian Institute of Health and Welfare (AIHW) in collaboration with the Australasian Association of Cancer Registries (AACR). Further information on Australian cancer statistics can be found in this publication. 2 METHODS 2.1 Data sources Registration of all cancers, excluding basal and squamous cell carcinomas of the skin (BCC and SCC, respectively), is required by law in each Australian state and territory, where the data are collated by cancer registries. Registration of SCC and BCC of the skin are not required, and most cases are treated in doctors surgeries with techniques that preclude histological confirmation. Data on newly diagnosed cancers are supplied to the AIHW on an annual basis. The AIHW assembles the information into the Australian Cancer Database (ACD), which currently holds information on Australian cancer cases (excluding SCC and BCC of the skin) diagnosed between 1982 and As the 2013 data files for New South Wales were not available for inclusion in the ACD, 2013 incidence data for New South Wales were estimated by the AIHW, based on available data, in consultation with the New South Wales cancer registry. Further, actual data for the Australian Capital Territory in 2013 do not include death-certificate-only cases. All cancer incidence cases held in the ACD are coded by both morphology and topography according to the third edition of the International Classification of Diseases for Oncology (ICD-O). Data from the ACD were used to present data on cancer incidence, prevalence and survival. Mortality data from 1982 to 2014 in Australia were extracted from the National Mortality Database (NMD). Information on deaths in Australia is registered with the relevant state and territory Registrar of Births, Deaths and Marriages. Deaths are coded by the Australian Bureau of Statistics (ABS) to reflect the underlying cause of death, according to rules set forward in various versions of the International Asia-Pac J Clin Oncol. 2018;14:5 15. wileyonlinelibrary.com/journal/ajco c 2017 John Wiley & Sons Australia, Ltd 5

2 6 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE Classification of Diseases (ICD-8, ICD-9, ICD-10). The data are consolidated at the AIHW to form the NMD. Data sourced from the NMD contain deaths where the underlying cause was a primary cancer, and include BCC and SCC. Hospitalization and palliative care data for the financial year were extracted from the National Hospital Morbidity Database (NHMD). This annual collection of demographic, diagnostic, procedural and duration of stay information on episodes of care is compiled and maintained by the AIHW using data supplied by state and territory health authorities. There are two different types of diagnoses recorded in the NHMD: principal diagnosis and additonal diagnoses. Both are coded using International statistical classification of diseases and related health problems, tenth revision, Australian Modification (ICD-10- AM), 7th edition. The principal diagnosis is the diagnosis listed in hospital records to describe the problem that was chiefly responsible for the patient s episode of care in hospital. Additional diagnoses are conditions or complaints either coexisting with the principal diagnosis or arising during the episode of care. Population screening programs are available for breast, cervical and bowel cancers; they are BreastScreen Australia, the National Cervical Screening Program and the National Bowel Cancer Screening Program. Data on cancer screening in Australia were obtained from these national screening programs. Information on the number of Medicare-subsidized breast imaging (female only), prostate-specific antigen (PSA) testing (male only) and radiotherapy numbers were extracted from AIHW s Medicare Benefits Schedule (MBS) claims database. Information is collected about patients, providers, the type of service provided and the amount of benefit paid. Information on cancer burden was extracted from the Australian Burden of Disease Study (ABDS) The ABDS 2011 provides Australia-specific burden of disease estimates for the 2011 reference year. Population data used to derive cancer incidence and mortality rates were sourced from the ABS. The estimated resident populations derived by the ABS were based on the 2011 Census of Population and Housing data. For Indigenous comparisons, Indigenous experimental estimated resident populations based on the 2011 Census of Population and Housing were used. 2 obtained from the Australian Cancer Incidence and Mortality (ACIM) books published in Estimation of 2013 cancer incidence data for New South Wales Estimation of 2013 cancer incidence for New South Wales was undertaken using site- and age-specific least squares regression models over the most recently available 10 years of data for New South Wales, extrapolated to 2013 populations. A full description of the methodology is included in Cancer in Australia estimated incidence and mortality The estimated 2017 incidence data were derived from least square regression models using site-specific cancer incidence data from 2004 to The estimated 2017 mortality data were derived by applying an ordinary least square regression model to site-specific mortality data from 1968 to These incidence and mortality estimates should be interpreted as only indicative of future trends and do not allow for future changes in cancer detection methods, changes in cancer risk factors or for nondemographic factors (such as government policy changes). Further details of the models are provided in Cancer in Australia Data by population groups Data by population groups are presented for five years from 2008 to 2012 for incidence and from 2010 to 2014 for mortality to reduce random variation in the rates Survival methodology Relative survival is a measure of the survival of people with cancer compared with that of the general population. The period method was used to calculate the survival estimates presented, 4 in which estimates are based on the survival experience during a given at-risk or follow-up period. The main follow-up period used for the survival estimates was the 5-year period A full description of the methodology is included in Cancer in Australia Statistical analysis The following methods were used in the statistical analyses. A full description of these methods is available in Cancer in Australia Age-standardized rates Information on the number of cancer cases and deaths is presented together with age-standardized rates. To enable meaningful comparisons within Australian population subgroups, rates have been directly standardized to the Australian population at 30 June 2001 using 5-year age ranges to 85 years. They are generally expressed per people. For international comparisons, incidence rates standardized to the World Health Organization world population can be Prevalence methodology Prevalence refers to the number of people alive who have previously been diagnosed with cancer. Five-year prevalence is presented as at the end of That is, the number of living people who were diagnosed in the past 5 years to 31 December A full description of the methodology is included in Cancer in Australia Burden of disease methodology The overall burden is expressed as diasability-adjusted life years (DALY) and is the sum of years of life lost from premature mortality and years lived with disability. A full description of the methodology is included in Australian Burden of Disease Study 2011: methods and supplementary material. 5

3 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 7 3 RESULTS 3.1 Surveillance and early detection National cancer screening programs In Australia, there are three national population-based screening programs BreastScreen Australia, the National Cervical Screening Program and the National Bowel Cancer Screening Program that aim to reduce illness and death from these cancers through early detection of cancer and precancerous abnormalities and effective follow-up treatment. More information about these programs can be found at Breast screen Australia In the two years , over 1.7 million women (54% of women in the recently expanded target age group of years) had a screening mammogram through BreastScreen Australia. 1 In 2014, there were 108 invasive breast cancers and 24 ductal carcinomas in situ (DCIS) detected for every women in the target age group (50 69 years) screened for the first time. A high proportion (50% at the initial screen and 59% of those attending subsequent screening rounds) of the cancers diagnosed were classified as small. 7 Small breast cancers are associated with increased treatment options and improved survival. 8, National cervical screening program In the two years , more than 3.8 million women (57% of women in the target age group of years) participated in the National Cervical Screening Program. 10 In 2014, the National Cervical Screening Program detected eight high-grade abnormalities for every 1,000 women screened, providing an opportunity for treatment before possible progression to cervical cancer National bowel cancer screening program Of the eligible people invited in , over a million people participated in the National Bowel Cancer Screening Program, giving an overall Australia-wide participation rate of 39%. 1 Participation was higher among women (41%) than men (37%) and higher in older age groups. In 2014, about 35,000 participants returned a positive screening test, giving a 7% screening positivity rate. Of the participants who had a diagnostic assessment, one in 32 were diagnosed with a confirmed or suspected cancer and one in seven were diagnosed with an adenoma Medicare-subsidized surveillance, detection and monitoring tests Cancer surveillance and detection regularly occurs outside of screening programs and could be provided under Medicare or privately. In 2014, 579,844 women had a Medicare-subsidized breast imaging test (either breast ultrasound, mammogram or breast magnetic resonance imaging) and 1,337,033 men received a Medicare-subsidized PSA test. 3.2 Incidence of cancer in Australia All cancer combined It is estimated that new cases of cancer (excluding BCCs and SCCs) will be diagnosed in Australia in Of these, (54%) are expected to be diagnosed in males and (46%) in females. The male incidence rate is 1.2 times the female rate (526 per and 423 per , respectively). In 2017, the age-specific incidence rate for all cancers combined increased with age, with the highest incidence rates observed in the age group 85 years and over for both males and females (Figure 1). For those aged under 30, the age-specific incidence rate was similar in males and females. Between the ages of 25 and 54, females had FIGURE 1 Estimated incidence and mortality rates of all cancers combined by age at diagnosis or death and sex, Australia, 2017 Males Incidence Females Incidence Persons Incidence Males Mortality Females Mortality Persons Mortality Notes: All cancers combined includes cancers coded in the ICD-10 as C00 C97, D45, D46, D47.1 and D47.3 D47.5. Those C44 codes that indicate a basal or squamous cell carcinoma are not included in incidence data. Source: AIHW ACD 2013, AIHW National Mortality Database. [Colour figure can be viewed at wileyonlinelibrary.com]

4 8 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE slightly higher incidence rates than males, but this trend was reversed for those aged 55 years and over, where males had higher incidence rates than females. The number of new cancer cases estimated to be diagnosed in 2017 is 2.8 times as high as in 1982 increasing from in 1982 to in The age-standardized incidence rate for all cancers increased from 383 cases per persons in 1982 to a peak of 504 per persons in 2008, before decreasing to 483 per persons in 2013 and an expected 470 per persons in 2017 (Figure 2). For information on trends by sex, see Cancer in Australia Most commonly diagnosed cancers In 2017, the most commonly diagnosed cancers in males were estimated to be prostate cancer ( new cases), colorectal cancer (9 127) and melanoma of the skin (8 392). These three cancers accounted for 47% of all newly diagnosed cancers in males, with prostate cancer alone accounting for 23% (Table 1). In 2017, the most commonly diagnosed cancers in females were estimated to be breast cancer ( new cases), colorectal cancer (7 555) and melanoma of the skin (5 549), with these three cancers accounting for 49% of all cancer cases in females. Breast cancer alone accounted for 28% of all new cancer cases in females. Between 1982 and 2017, thyroid cancer showed the greatest percentage increase in the age-standardized incidence rate, increasing by 351% (from 2.7 to 12 per persons; Figure 3). This was followed by liver cancer with an increase of 310% (from 1.8 to 7.5 per ) then mesothelioma with an increase of 123% (from 1.2 to 2.7 per ). In contrast, cancer of unknown primary site showed the greatest percentage decrease in incidence rate with a decrease of 53% (from 18 to 8.5 per ). Incidence rates decreased by more than 40% for cervical cancer (from 14 to 7.1 per females), stomach cancer (from 16 to 7.9 per persons), laryngeal cancer (from 4.3 to 2.2 per ) and bladder cancer (from 18 to 10 per ). 3.3 Mortality from cancer in Australia All cancers combined It is estimated that in 2017, cancer will account for 29% of all deaths registered in Australia. Of these cancer deaths, (57%) were in males, and (43%) in females (Table 1). The age-specific mortality rate in 2017 increased sharply with age (Figure 1). It is estimated that 88% of all cancer deaths in males and 85% of all cancer deaths in females will occur in people aged 60 and over. The age-specific mortality rate was similar for males and females for those aged under 50. The mortality rate increased more steeply for males than females after age 55. From 1982 to 2017, it is estimated that the number of deaths from cancer increased by 92% from to deaths. In contrast, between 1982 and 2017 the age-standardized mortality rate for cancer decreased by 23%, from 209 to 161 deaths per persons (Figure 2). This decline in age-standardized mortality rates occurred in both males and females; however the rate was consistently lower for females Most common causes of death from cancer Lung cancer is estimated to be the leading cause of cancer death in 2017 for both males and females, with 5179 and 3842 deaths, respectively. Prostate cancer was the second leading cause of cancer death in males (3452 deaths), followed by colorectal cancer (2136). These three leading causes of cancer death accounted for around 40% of all cancer deaths in males. Breast cancer was the second leading cause of cancer death in females (3087 deaths), followed by colorectal cancer (1978). These three leading causes of cancer death accounted for around 43% of all cancer deaths in females. From 1982 to 2017, cancers with a greater than 50% decrease in mortality rate included testicular cancer (from 0.5 to 0.0 per males), Hodgkin lymphoma (0.9 to 0.1 per persons), lip cancer (0.1 to 0.0 persons), stomach cancer (12 to 3.7 per persons), gallbladder cancer (2.6 to 0.9 per persons), cervical cancer (5.2 to 1.8 per females) and colorectal cancer (32 to 14 per persons; Figure 4). Cancer of other digestive organs showed the greatest percentage increase in mortality rates, increasing by 377% (from 1.1 to 5.1 per persons). This was followed by liver cancer (2.3 to 6.8 per persons) and melanoma of the skin (4.7 to 6.3 per ). 3.4 Focus on key population groups Aboriginal and Torres Strait Islander people The term Indigenous refers to a person of Aboriginal and/or Torres Strait Islander descent who identifies as an Aboriginal and/or Torres Strait Islander and is accepted as such by the community with which he or she is associated. Around 3% of Australians identify as Aboriginal or Torres Strait Islander. 2 Indigenous identification in cancer incidence data for was considered of sufficient quality for national reporting for the following five jurisdictions: New South Wales, Victoria, Queensland, Western Australia and Northern Territory. Indigenous identification in mortality data for was considered of sufficient quality for the following five jurisdictions: New South Wales, Queensland, Western Australia, South Australia and Northern Territory. Between 2008 and 2012, an average of 1,189 Indigenous Australians were diagnosed with cancer each year, comprising 1.1% of all cancer cases diagnosed in that period. Between 2008 and 2012, the age-standardized incidence rate of all cancers combined was higher for Indigenous Australians than for their non-indigenous counterparts (484 and 439 per persons, respectively (Table 2). This finding, while contrasting with the 2014 edition of the Cancer in Australia report, which found that the incidence rate for Indigenous Australians was slightly lower than for non-indigenous Australians, 11,12 is similar to previous editions of the report. 13,14 The change in trend may be partially attributable to changes in the ABS estimated population for Indigenous Australians.

5 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 9 FIGURE 2 Trends in incidence and mortality of all cancers combined, by sex, Australia, 1982 to 2017 Males Incidence Females Incidence Persons Incidence Males Mortality Females Mortality Persons Mortality Notes: 1. All cancers combined includes cancers coded in the ICD-10 as C00 C97, D45, D46, D47.1 and D47.3 D47.5. Those C44 codes that indicate a basal or squamous cell carcinoma are not included in incidence data. 2. The rates were age standardized to the 2001 Australian Standard Population and are expressed per 100,000 population. 3. Deaths registered in 2012 and earlier are based on the final version of cause of death data; deaths registered in 2013 and 2014 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. 4. Actual mortality data from 1982 to 2013 are based on the year of occurrence of the death, and data for 2014 are based on the year of registration of the death. 5. Incidence data are projections from 2014 to 2017 and mortality data are projections from 2015 to Source: AIHW ACD 2013, AIHW National Mortality Database [Colour figure can be viewed at wileyonlinelibrary.com] The age-standardized incidence rate was higher for Indigenous than for non-indigenous Australians for liver cancer (2.8 times as high), cervical cancer (2.2), lung cancer (2.0), cancer of unknown primary site (1.9), uterine cancer (1.7) and pancreatic cancer (1.4). In contrast, the age-standardized incidence rates were lower for Indigenous than for non-indigenous Australians for colorectal cancer, breast cancer in females (both rate ratio of 0.9), non-hodgkin lymphoma (0.8) and prostate cancer (0.7). Between 2010 and 2014, Indigenous Australians accounted for an annual average of 512 cancer deaths (1.6% of all deaths due to cancer). The age-standardized mortality rate of all cancers combined was significantly higher for Indigenous Australians than for their non- Indigenous counterparts (221 and 171 per , respectively). The age-standardized mortality rate was higher for Indigenous than for non-indigenous Australians for cervical cancer (3.8 times as high), liver cancer (2.5), lung cancer (1.8), uterine cancer and cancer of unknown primary site (both 1.6), and pancreatic cancer (1.3). (71%), 18% live in inner regional areas, 8.9% in outer regional, 1.4% in remote areas and 0.9% in very remote areas. 15 Between 2008 to 2012, the age-standardized incidence rate for all cancers combined was highest in inner regional areas (516 cases per persons) and lowest in very remote areas (462 per ). People living in inner regional areas of Australia had the highest agestandardized incidence rate for prostate cancer (186 per ), and melanoma of the skin (59 per ). Very remote areas accounted for the highest age-standardized incidence rate for lung cancer (65 per ). In contrast, between 2010 and 2014, the age-standardized mortality rate for all cancers combined was 16% higher in very remote (188 deaths per persons) than in major cities (162 per ). People living in very remote areas had the highest age-standardized mortality rate for lung cancer (44 per ), cancer of unknown primary site (15 per ), bladder cancer (5.1 per ) and cervical cancer (4.8 per females) Remoteness areas The remoteness areas (RAs) divide Australia into broad geographic regions that share common characteristics of remoteness for statistical purposes. The Remoteness Structure divides each state and territory into several regions on the basis of their relative access to services. More information about the RAs classification is available in Cancer in Australia Incidence and mortality rates are presented by five categories: major cities, inner regional, outer regional, remote and very remote. The majority of the Australian population lives in major cities Socioeconomic disadvantage The Index of Relative Socioeconomic Disadvantage (IRSD) is used to indicate socioeconomic status. The IRSD scores each area by summarising attributes of the population, such as low income, low educational attainment, high unemployment and jobs in relatively unskilled occupations. The first socioeconomic status group corresponds to geographical areas containing the 20% of the population living in the area with the lowest socioeconomic status according to the IRSD, and the fifth group to the 20% of the population living in areas with the highest

6 10 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE TABLE 1 Estimated 10 most commonly diagnosed cancers, and 10 most common causes of cancer death, Australia, 2017 Males Females Cancer site/type (ICD-10 codes) Cases ASR Risk to 85 Cancer site/type (ICD-10 codes) Cases ASR Risk to 85 New cases Prostate (C61) in7 Breast (C50) in8 Colorectal (C18 C20) in 11 Colorectal (C18 C20) in 15 Melanoma of the skin (C43) in13 Melanoma of the skin (C43) in23 Lung (C33 C34) in 14 Lung (C33 C34) in 21 Head and Neck (C00 C14, C30 C32) in32 Uterine (C54 C55) in42 Lymphoma (C81 C86) in 30 Lymphoma (C81 C86) in 45 Leukemia (C91-C95) in46 Thyroid (C73) in62 Bladder (C67) in 42 Ovary (C56) in 77 Kidney (C64) in49 Pancreas (C25) in73 Pancreas (C25) in 57 Leukemia (C91 C95) in 79 All cancers combined in2 All cancers combined in2 Deaths Lung (C33 C34) in18 Lung (C33 C34) in29 Prostate (C61) in 30 Breast (C50) in 41 Colorectal (C18 C20) in47 Colorectal (C18 C20) in63 Pancreas (C25) in 64 Unknown primary (C77 C80, C97) in 84 Unknown primary (C77 C80, C97) in75 Pancreas (C25) in80 Liver (C22) in 74 Ovary (C56) in 112 Melanoma of the skin (C43) in77 Leukemia (C91 C95) in 164 Leukemia (C91 C95) in 86 Other digestive (C26) in 178 Esophagus (C15) in96 Liver (C22) in 172 Lymphoma (C81 C86) in 114 Lymphoma (C81 C86) in 196 All cancers combined in4 All cancers combined in6 Notes: 1. The rates were age standardized to the 2001 Australian Standard Population and are expressed per population. 2. All cancers combined includes cancers coded in the ICD-10 as C00 C97, D45, D46, D47.1 and D47.3 D47.5. Source: AIHW ACD 2013, AIHW National Mortality Database. socioeconomic status. More information about the IRSD is available in Cancer in Australia Between 2008 and 2012, the age-standardized incidence rate for all cancers combined was highest among those living in the two lowest socioeconomic group areas (509 and 508 cases per persons, respectively) and lowest for those living in the two highest socioeconomic group areas (both 488 per ). Those living in the lowest socioeconomic group areas accounted for the highest age-standardized incidence rate for colorectal cancer (65 per persons), lung cancer (54 per ), cancer of unknown primary site (12 per ), pancreatic cancer (12 per ), bladder cancer (11 per ) and cervical cancer (8.5 per females). Between 2010 and 2014, the age-standardized mortality rate for all cancers combined was highest among those living in the lowest socioeconomic group areas (190 deaths per persons) and lowest among those living in the highest socioeconomic group areas (143 per ). Those living in the lowest socioeconomic group areas had the highest age-standardized mortality rate for lung cancer (40 per persons), breast cancer (22 per females), colorectal cancer (17 per persons), cancer of unknown primary site (12 per persons), pancreatic cancer (11 per persons), kidney cancer (4.0 per persons), and cervical cancer (2.6 per females). 3.5 Survival after a diagnosis of cancer in Australia In , 5-year relative survival for all cancers combined was 68%. Females had slightly higher survival than males, at 69% compared to 68% for males. For all cancers combined, 5-year relative survival was highest for those aged (91%); survival then decreased with age and was lowest for those aged 75 and over (50%). For males, 5-year relative survival was highest for testicular cancer (98%), prostate cancer (95%), and thyroid and lip cancer (both 93%). For females, 5-year relative survival was highest for thyroid cancer (97%), lip cancer (94%) and melanoma of the skin (93%). For males, mesothelioma (5%) and pancreatic cancer (8%) had the lowest survival. For females, pancreatic cancer (8%) and mesothelioma (8%) had the lowest survival.

7 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 11 FIGURE 3 Estimated percentage change in age-standardized incidence rates between 1982 and 2017, Australia *The incidence rate of colorectal cancer decreased by 0.5%. Notes: 1. The bars indicate the estimated percentage change in incidence rates between 1982 and The percentage change between 1982 and 2017 is a summary measure that allows the use of a single number to describe the change over a period of multiple years. However, it is not always reasonable to expect that a single measure can accurately describe the trend over the entire period. 2. The rates were age standardized to the 2001 Australian Standard Population and are expressed per 100,000 population. Source: AIHW ACD [Colour figure can be viewed at wileyonlinelibrary.com] 3.6 Prevalence of cancer in Australia At the end of 2012, people were alive who had been diagnosed with cancer in the previous 5 years, representing 1.8% of the Australian population. Five-year prevalence was higher for males at (56% of five-year prevalent cases) than for females at (44%). At the end of 2012, 7% of all Australians aged 75 and over had a diagnosis of cancer within the previous 5 years. The 5-year prevalence rate was highest for those aged and and lowest for those under 14. For males, 5-year prevalence was highest for prostate cancer (94 114), followed by melanoma of the skin (29 567) and colorectal cancer (29 049). Among females, 5-year prevalence was highest for breast cancer (65 489), followed by colorectal cancer (23 581) and melanoma of the skin (22 130). Prevalence data for less common cancers are available in Cancer in Australia Burden of disease In 2011, cancer was the leading cause of disease burden. Australians lost 833,250 DALY due to premature death from cancer or from living with cancer. This burden was almost entirely due to dying prematurely (94%), with only 6% of this burden due to living with cancer. Lung cancer was associated with the highest proportion of the cancer burden, followed by colorectal cancer and breast cancer Treatment for cancer in Australia Cancer-related hospitalizations In , there were cancer-related hospitalizations, accounting for 1 in 10 hospitalizations in Australia. In , cancer-related hospitalizations were more common among older age groups. In , of all hospitalizations that involved palliative care, 58% (37 825) were cancer-related.

8 12 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE FIGURE 4 Estimated percentage change in age-standardized mortality rates between 1982 and 2017, Australia. All cancers combined Other cancers (by individual site) *The mortality rate of pancreatic cancer increased by 0.6%. **The mortality rate of brain cancer decreased by 1.2%. Notes: 1. The bars indicate the percentage change in mortality rates between 1982 and The percentage change between 1982 and 2017 is a summary measure that allows the use of a single number to describe the change over a period of multiple years. However, it is not always reasonable to expect that a single measure can accurately describe the trend over the entire period. 2. The rates were age standardized to the 2001 Australian Standard Population and are expressed per 100,000 population. Source: AIHW National Mortality Database. [Colour figure can be viewed at wileyonlinelibrary.com] Seven in ten (70%) cancer-related hospitalizations were for same day care, where a patient was admitted and separated on the same day. The average length of stay for overnight cancer-related hospitalizations was 7.8 days. Between and , the total number of cancerrelated hospitalizations increased by 57%, from to Much of this can be attributed to a 77% increase in the number of same-day hospitalizations, from in to in In the same period, the age-standardized cancer-related hospitalization rate increased by 12% from 357 per to 401 per Nonmelanoma skin cancer was the most common cancer type recorded as principal diagnosis, accounting for 25% ( ) of all hospitalizations in (Table 3) Hospitalization for chemotherapy In , there were chemotherapy hospitalizations. For these hospitalizations, breast cancer (20%) was the most common cancer diagnosis associated with a chemotherapy hospitalization (additional diagnosis), followed by colorectal cancer (15%) and cancer of a secondary site (10%) Radiotherapy In 2014, people received about 1.8 million Medicare-subsidized radiotherapy services. During that year, patients had, on average, 30 radiotherapy services and the Australian Government contributed on average, $5322 per patient. 4 DISCUSSION These results show that cancer is the leading cause of disease burden in Australia. It is estimated that in 2017, new cases will be diagnosed and people will die from cancer in Australia. Australians lost DALY in 2011 due to premature death from cancer or from living with cancer.

9 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 13 TABLE 2 All cancers combined, incidence and mortality, by selected population groups, persons, Australia Incidence Mortality Number Average number ASR Number Average number ASR Indigenous status Indigenous Non-Indigenous Total Remoteness area Major cities Inner regional Outer regional Remote Very remote Total Socioeconomic status 1 (lowest) (highest) Total Notes: 1. Data pertain to cancers coded in the ICD-10 as C00 C97, D45, D46, D47.1 and D47.3 D47.5. For incidence data, C44 codes that indicate a BCC or SCC were excluded. 2. The rates were age-standardized to the Australian Standard Population and are expressed per 100,000 population. 3. Some states and territories use an imputation method to determine Indigenous cancers, which may lead to differences between these data and those shown in jurisdictional cancer incidence reports. 4. Incidence data by Indigenous status pertain to New South Wales, Victoria, Queensland, Western Australia and the Northern Territory. Mortality data by Indigenous status pertain to New South Wales, Queensland, Western Australia, South Australia and the Northern Territory. 5. Geography is based on area of usual residence (Statistical Local Area Level 2) at time of diagnosis/death. The area of usual residence was then classified according to Remoteness Area 2011 (see Appendix H of Cancer in Australia ). Incidence and mortality cells may not sum to the total due to nonconcordance of some remoteness categories. 6. Socioeconomic status was classified using the ABS Index of Relative Socio-Economic Disadvantage (see Appendix H of Cancer in Australia ). Source: AIHW Australian Cancer Database 2013; AIHW National Mortality Database. These results show that the number of new cancer cases diagnosed increased over time, whereas the cancer incidence rate increased between 1982 and 2008, before a decrease between 2009 to 2013 and a further expected decrease to This suggests that the increase in the absolute number of cancer cases diagnosed over the years could only be partly explained by the ageing and increasing size of the Australian population. The increase in trend in the early years can be attributed to the rise in the number of breast cancers in females and prostate cancers diagnosed, as well as improved diagnoses through population screening programs and improvements in technologies used to identify and diagnose cancer. For example, the increase in thyroid cancer may be due to an increase in medical surveillance and the introduction of new diagnostic techniques, such as neck ultrasonography. 16 The decrease in cancer incidence rates in the last few years has mainly been observed in males. Trends in cancer incidence rates for males are strongly influenced by changes in the incidence rate of prostate cancer which accounts for around one in four cases in males. Incidence rates of prostate cancer have fluctuated considerably over time due to the effect of PSA testing. 17 The clinical practice guidelines for PSA and the early management of test-dected prostate cancer were endorsed by the National Health and Medicare Research Council in November Although for females, trends were heavily influenced by trends in the incidence rates of breast cancer which accounts for more than one in four cancer cases in females. Between 1982 and 2017, there has been a decrease in cancer mortality rates. The overall decrease in mortality rates in males can be largely attributed to declines in mortality rates for lung cancer, prostate cancer and colorectal cancer. The decline in the mortality rate for females was largely due to declines in the mortality rates of breast and colorectal cancer. Although the mortality rate from cancer is decreasing, the number of people dying from cancer is increasing due to the ageing and increasing Australian population, and is expected to continue to increase. This has implications for service provision, as the results show cancer patients comprise the majority of hospitalizations involving palliative care. The results highlight important differences in cancer incidence and mortality rates among Indigenous and non-indigenous Australians. The higher incidence rates for liver, lung and cervical cancer in Indigenous

10 14 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE TABLE 3 Ten most common cancers as principal diagnosis, by sex, Australia, Males Females Principal diagnosis (ICD 10-AM codes) Number Percent Principal diagnosis (ICD 10-AM codes) Number Percent Nonmelanoma skin cancer (C44) Nonmelanoma skin cancer (C44) Prostate cancer (C61) Breast cancer (C50) Secondary site (C77 C79) Secondary site (C77 C79) Colorectal cancer (C18 C20) Colorectal cancer (C18 C20) Leukemia (C91 C96) Lymphoma (C81 C86) Lymphoma (C81 C86) Leukemia (C91 C96) Lung cancer (C33 C34) Lung cancer (C33 C34) Bladder cancer (C67) Myelodysplastic syndromes (D46) Myelodysplastic syndromes (D46) Melanoma of the skin (C43) Melanoma of the skin (C43) Uterine cancer (C54 C55) Total hospitalizations with a principal diagnosis of cancer Total hospitalizations with a principal diagnosis of cancer Notes: 1. The rates were age standardized to the 2001 Australian Standard Population and are expressed per 100,000 population. 2. All cancers combined includes cancers coded in the ICD-10 as C00 C97, D45, D46, D47.1 and D47.3 D47.5, except those C44 codes that indicate a basal or squamous cell carcinoma. Source: AIHW ACD Australias may be related to high prevalence of cancer-related modifiable risk fators. The higher mortality rate for Indigenous Australians may be partly explained by their greater likelihood of being diagnosed with cancer at an advanced stage due to lower participation rates in national population screening programs which may delay earlier diagnoses, as well as less access to timely adequate treatment. 15,19 The results show differences in cancer incidence and mortality rates for those living in different RAs in Australia. Although the overall age-standardized incidence rate was lowest in very remote areas, the overall mortality rate was highest in Very remote and Remote areas. People living in remote areas of Australia may be disadvantaged in relation to access to primary health-care services, educational and employment opportunities, and income. Further, they are more likely to have higher rates of risky health behaviours, such as smoking, heavy alcohol use and poor nutrition. 15 This may partially explain why mortality rates were highest for those living in remote and very remote areas. The results also showed differences in cancer incidence and mortality rates across different socioeconomic groups in Australia. The overall age-standardized incidence rate for all cancers combined was slightly higher for those living in the two lowest socioeconomic group areas compared with those living in the highest socioeconomic group areas. Similarly, the age-standardized mortality rate for all cancers combined was highest among those living in the lowest socioeconomic group areas and lowest among those living in the highest socioeconomic group areas. This may be partially explained by the population attributes for people living in disadvantaged areas, such as low income, low educational attainment and high unemployment. Differences in incidence and mortality by key population groups may be interlinked, as there is overlap between these groups. For example, Indigenous Australians are more likely to live in remote areas of Australia than non-indigenous Australians. Information on survival from cancer provides an indication of cancer prognosis and the effectiveness of treatments available. The results indicated that females had a slightly higher 5-year relative survival rate than males. Survival rates decreased with age. Pancreatic cancer and mesothelioma had the lowest 5-year relative survival rates for both males and females. The combined effect of several factors increasing incidence rates, decreasing mortality rates, improving survival, and developments in treatment is leading to an increase in the prevalence of cancer. The results showed that 5-year cancer prevalence was higher for males than females. Prostate cancer had the highest prevalence for males, and breast cancer had the highest prevalence for females. The extent of hospitalization for cancer is an important indicator of the impact of cancer on the Australian population. The results show the high proportion of cancer-related hospitalizations in Australia. The likelihood of being hospitalized for a cancer-related condition increased with age. Nonmelanoma skin cancer was the most common cancer type recorded as principal diagnosis. The results showed an increase in the total number and rate of cancer-related hospitalizations over time, much of which can be attributed to an increase in the number and rate of same-day hospitalizations. Changes in the rate of same-day hospitalizations may reflect changes in admission practices in some jurisdictions. 5 LIMITATIONS The most recent national data available at the time of analysis was 2013 for cancer incidence and 2014 for mortality data. Estimates of cancer incidence and mortality for 2017 are based on projections of these data available up to Basal and squamous cell carcinomas of the skin are by far the most common cancers diagnosed in Australia, 20 but, unlike other invasive cancers, these cancers are not reportable by law to cancer registries. As a result, data on these cancers are not included in the ACD, and therefore are not included in the incidence statistics presented here.

11 AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE 15 Thus, the precise number of total cancer cases diagnosed in Australia each year is unknown. Virtually all reportable cancer cases and cancer deaths in Australia are registered. However, the Indigenous status of the cases or deaths is not always known. Such cases and deaths are not included in the numerators in the calculation of incidence and mortality rates by Indigenous status. Therefore the rates reported here for both Indigenous and non-indigenous Australians are less than the true rates. The analysis by Indigenous status is limited to those jurisdictions with the most complete coverage of Indigenous cancer cases and deaths. However, even within the jurisdictions with data of acceptable quality, data on Indigenous cancer cases and deaths vary in their completeness. Thus, differences between Indigenous and non-indigenous incidence and mortality rates may also be influenced by jurisdictional differences in data quality. 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Cancer in Australia: Actual incidence data from 1982 to 2013 and mortality data from 1982 to 2014 with projections to Asia-Pac J Clin Oncol. 2018;14: