Incidence and Mortality Report 2008

Transcription

1 CANCER IN NEW SOUTH WALES: Incidence and Mortality Report 28 Elizabeth Tracey, Tara Kerr, Ariana Dobrovic, David Currow

2 Cancer Institute NSW catalogue number: ER-21-2 National Library of Australia Cataloguing-in-Publication data: Cancer in New South Wales: Incidence and Mortality Report 28 SHPN (CI) 1235 ISSN Key words: cancer incidence, cancer mortality, trends, risk factors, cancer survival, New South Wales, Australia. Suggested citation: Tracey E, Kerr T, Dobrovic A, Currow D. Cancer In NSW: Incidence and Mortality Report 28. Sydney: Cancer Institute NSW, August 21. Published by the Cancer Institute NSW, August 21 New South Wales Department of Health, August 21 New South Wales Central Cancer Registry Cancer Institute NSW Locked Mail Bag 1 Kings Cross NSW 134 Telephone (2) Facsimile (2) ccr@cancerinstitute.org.au Homepage cancerinstitute.org.au Online cancer statistics NSW Central Cancer Registry Staff Senior Epidemiologist Elizabeth Tracey Manager, NSW Central Cancer Registry Narelle Grayson Coding Manager Analyst, Data and reporting systems Manager, Monitoring Evaluation & Research Unit Cancer Services Reporting Manager Analyst/Programmer Medical Advisor Administrative and Data officer Maria Arcorace Tara Kerr Deborah Baker Ariana Dobrovic David Wyndham Russell Cameron Claire Cooke- Yarborough Celia Ching Medical Coders Cancer Notifications Manager Data Quality Assistant Data Quality Officers Medical Coding Coordinator Anne Pelquest-Hunt Basil Goonewardene Bruna Corti Clementina Squadrito Haining Xie Janet Lee Dale Matthews Sharon Pettigrew Heather Byrne Jacki Luker Kathryn Farrar Aisling Raftery Teresa Butylewicz Denise Bradfield Brenda Potter Lisa Barry Lilian Scafaro Michelle Emanuels Vijay Gounder Serina Faraji

3 Contents Tables 2 Figures 4 Acknowledgements 6 Chief Cancer Offi cer s report 7 Executive Summary 9 Key Findings 15 Introduction 16 Overview of cancer incidence in Overview of cancer mortality in 28 2 Incidence of cancer by age and sex 23 Age-specifi c incidence and mortality rates 26 Trends in incidence and mortality rates 34 All cancer 36 Bladder cancer 38 Bowel cancer 4 Brain cancer 42 Breast cancer 44 Cancer unknown primary (CUP) 46 Cervical cancer 48 Melanoma 66 Mesothelioma 68 Multiple myeloma 7 Non-Hodgkin s lymphoma 72 Oesophageal cancer 74 Ovarian cancer 76 Pancreatic cancer 78 Prostate cancer 8 Rectal cancer 82 Stomach cancer 84 Testicular cancer 86 Thyroid cancer 88 Uterine cancer 9 Regional variation in incidence rates 92 Regional variation in localised incidence rates 93 Regional variation in mortality rates 94 References: risk factors section 95 Age and sex-specifi c tables by cancer type 14 Appendixes 137 Childhood cancer 5 Colon cancer 52 Head and neck cancer 54 Kidney cancer 56 Leukaemia 58 Lip cancer 6 Liver cancer 62 Lung cancer 64 1

4 Cancer in New South Wales: Incidence and Mortality Report 28 Tables Table 1a Most common cancers in people by age category Table 1b Most common cause of cancer death by age category 11 Table 2 New cancers, all people, NSW, Table 3 New cancers,males, NSW, Table 4 New cancers, females, NSW, Table 5 New cancers, clinical groupings, all people, NSW, Table 6 New cancers, clinical groupings, males, NSW, Table 7 New cancers, clinical groupings, females, NSW, Table 8 Cancer deaths, all people, NSW, 28 2 Table 9 Cancer deaths, males, NSW, 28 2 Table 1 Cancer deaths, females, NSW, Table 11 Cancer deaths, clinical groupings, all people, NSW, Table 12 Cancer deaths, clinical groupings, males, NSW, Table 13 Cancer deaths, clinical groupings, females, NSW, Table 14 Changes in incidence and mortality rates, NSW, Table 15 Numbers of new cases of cancer by age group, Table 16 Numbers of new cases of bladder cancer by age group, Table 17 Numbers of new cases of bowel cancer by age group, Table 18 Numbers of new cases of brain cancer by age group, Table 19 Numbers of new cases of breast cancer by age group, Table 2 Numbers of new cases of cancer unknown primary (CUP) by age group, Table 21 Numbers of new cases of cervical cancer by age group, Table 22 Childhood cancers, NSW, Table 23 Numbers of new cases of colon cancer by age group, Table 24 Numbers of new cases of head and neck cancer by age group, Table 25 Numbers of new cases of kidney cancer by age group, Table 26 Numbers of new cases of leukaemia by age group, Table 27 Numbers of new cases of lip cancer by age group, Table 28 Numbers of new cases of liver cancer by age group,

5 Table 29 Numbers of new cases of lung cancer by age group, Table 3 Numbers of new cases of melanoma by age group, Table 31 Numbers of new cases of mesothelioma by age group, Table 32 Numbers of new cases of multiple myeloma by age group, Table 33 Numbers of new cases of non-hodgkin s lymphoma by age group, Table 34 Numbers of new cases of oesophageal cancer by age group, Table 35 Numbers of new cases of ovarian cancer by age group, Table 36 Numbers of new cases of pancreatic cancer by age group, Table 37 Numbers of new cases of prostate cancer by age group, Table 38 Numbers of new cases of rectal cancer by age group, Table 39 Numbers of new cases of stomach cancer by age group, Table 41 Numbers of new cases of thyroid cancer by age group, Table 42 Numbers of new cases of uterine cancer by age group, Table 43 Regional variation in incidence rates, NSW Area Health Services, Table 44 Regional variation in incidence rates for localised cancers, NSW Area Health Services, Table 45 Regional variation in mortality rates, NSW Area Health Services, Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, Table 48 Summary of age standardised cancer incidence, crude and cumulative incidence rates, NSW, Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, Table 51 Summary of age standardised cancer mortality, crude and cumulative mortality rates, NSW, Table 4 Numbers of new cases of testicular cancer by age group,

6 Cancer in New South Wales: Incidence and Mortality Report 28 Figures Figure 1 New cases of cancer, all people, NSW, 28 9 Figure 2 Cancer deaths, all people, NSW, 28 1 Figure 3 Percentage change in incidence rates in males and females, NSW, Figure 4 Percentage change in mortality rates in males and females, NSW, Figure 5 Relative survival in NSW 22 to 26 followed to the end of Figure 6 Most common cancers by age and sex, NSW, Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, Figure 8 All cancer 37 Figure 9 Bladder cancer 39 Figure 1 Bowel cancer 41 Figure 11 Brain cancer 43 Figure 12 Breast cancer 45 Figure 13 Cancer unknown primary (CUP) 47 Figure 14 Cervical cancer 49 Figure 15 Childhood cancer incidence (<15 years), NSW, Figure 16 Trends in age-standardised incidence rates of childhood cancers by sex (age<15), NSW, Figure 17 Colon cancer 53 Figure 18 Head and neck cancer 55 Figure 19 Kidney cancer 57 Figure 2 Leukaemia 59 Figure 21 Lip cancer 61 Figure 22 Liver cancer 63 Figure 23 Lung cancer 65 Figure 24 Melanoma 67 Figure 25 Mesothelioma 69 Figure 26 Multiple myeloma 71 Figure 27 Non-Hodgkin s lymphoma 73 Figure 28 Oesophageal cancer 75 Figure 29 Ovarian cancer 77 Figure 3 Pancreatic cancer 79 Figure 31 Prostate cancer 81 4

7 Figure 32 Rectal cancer 83 Figure 33 Stomach cancer 85 Figure 34 Testicular cancer 87 Figure 35 Thyroid cancer 89 Figure 36 Uterine cancer 91 5

8 Cancer in New South Wales: Incidence and Mortality Report 28 Acknowledgements Professor David Roder, Cancer Council SA Hui You, Cancer Institute NSW Narelle Grayson and staff of the NSW Central Cancer Registry, Cancer Institute NSW Adrian Grundy, Cancer Institute NSW NSW Health (Epidemiology Branch) NSW medical records personnel, statutory notifi ers, clinicians and pathologists Principal Registrar Births, Deaths and Marriages (NSW) Australian Bureau of Statistics The NSW Central Cancer Registry is managed and funded by the Cancer Institute NSW under a Memorandum of Understanding with the NSW Department of Health. This report is dedicated to Dr Joyce Ford, the founding Director of the NSW Central Cancer Registry who sadly passed away on May 6 th 21. Joyce established the registry in 1971 which was subsequently included under the Public Health Act. Joyce was always interested in the progress of the registry and maintained friendships with many of the staff that she employed that still continue to work at the registry. We would like to express our deep gratitude and appreciation for Joyce s signifi cant contribution towards cancer control in NSW.

9 Chief Cancer Offi cer s report Cancer is a major public health problem in NSW and Australia and many parts of the world. If a person lives to 85 years of age there is a one is two chance that they will have a diagnosis of cancer in their lifetime if they are male and a one in three chance if they are female. The absolute number of cases of cancer is increasing as our population ages and grows, and because of the lifestyle choices we make. Cancer in New South Wales: Incidence and Mortality 28 is the most up-to-date overview of cancer published for NSW. The report provides new information for incidence, mortality and survival from cancer in NSW. The number of men and women diagnosed with cancer has increased to 36,611 new cases. Incidence rates have increased in men by 11 per cent over the past 1 years. There is a signifi cant downward trend in incidence rates of cancer in women for the most recent seven-year period. This downward trend in incidence observed in NSW is consistent with fi ndings in the USA. Prostate cancer, our most common cancer overall, increased from 18 per cent in 27 to 19 percent of total cancers in 28 or 33 percent of all cancers in men. The lifetime risk of prostate cancer is now one in four if a man lives to the age of 85 years. The most recent fi ve year survival is 9 per cent for males diagnosed between 22 and 26 and followed to the end of 27. Australia has the highest rates of melanoma in the world and this has continued to increase over the last 1 years by 15 per cent in males and 11 per cent in females. Most of the increase in melanoma is seen in older people with no increases in those aged less than fi fty years. Mortality rates from all causes of cancer death have declined in NSW since 1989 in males and females. In the last ten years mortality rates declined by 13.2 per cent in males and 7.8 per cent in females. Cancer is still responsible for 28 per cent of all deaths in NSW i and is the leading cause in people aged between 35 and 84 years in 28. There has been a more rapid decline in mortality rates in NSW since 25 in males and 24 in females. The decline in overall mortality rates in males is most infl uenced by declines in lung, bowel and prostate cancer mortality rates. The most likely explanation for more rapid reduction in mortality rates in NSW in women since 24 is the decline in breast and bowel cancer mortality rates. Unfortunately, lung cancer and pancreatic cancer mortality rates continue to increase in women. Reductions in mortality rates for the majority of cancer sites are considered to result from a combination of earlier detection, changes in risk factors and improved treatments. Of concern is the statistically signifi cant 11 per cent increase in male mortality rates from melanoma for the most recent ten year period. This is the fi rst time a statistically signifi cant increase in mortality from melanoma is reported in NSW. Increasing mortality from melanoma has also been reported in the USA, UK, Canada and Nordic countries. Melanoma is treatable if diagnosed early. Mortality rates also continue to increase for liver cancer in males. Overall, the cancer survival in NSW are as good as or better than anywhere in the world. Around 65 percent of people diagnosed with cancer in NSW are alive fi ve years later. It is particularly pleasing that survival has increased by two percent for males from 61 per cent to 63 since the last time survival was measured between 1999 to 23 and has remained at 66 per cent for women. Cancers with 8 per cent or better survival fi ve years after the diagnosis include prostate, breast, melanoma and lymphoma. The most prevalent cancer with a fi ve year survival of between 3 per cent and 7 per cent is bowel cancer. Bowel cancer survival will be expected to improve as bowel cancer screening becomes more established, given the evidence from large Australian pilot studies and the success of established screening programs like breast and cervical cancer. i. Australian Bureau of Statistics. Causes of Death, Australia. 28 Cat No March 21. 7

10 Cancer in New South Wales: Incidence and Mortality Report 28 Cancers with 2 per cent or worse survival at fi ve years include lung cancer, brain, oesophagus, liver and pancreas cancers and mesothelioma. Cancers with less than 2 per cent survival fi ve years after a diagnosis require additional focus, new research and better methods of early diagnosis as well as a better understanding of the molecular nature of the cancer leading to more specifi c and targetted therapies. Cancer control programs depend on quality data. I would like to acknowledge the signifi cant contribution that Dr Joyce Ford has made to cancer contol in NSW by establishing the NSW Central Cancer Registry in Joyce died in May this year. Many of the notifi cation, coding and registration practices developed by Joyce continue today. Her legacy of excellent cancer data in NSW continues today through the work of staff at the Cancer Institute NSW which provides unparalled information on how best to minimise the impacts of cancer across our community. Professor David Currow Chief Cancer Offi cer and CEO, Cancer Institute NSW 8

11 » executive summary Executive Summary New cases in 28 All people: 36,611 Males: 2,873 Females: 15,738 Excludes non-melanoma (basal and squamous cell) skin cancers, which are estimated to account for 154,693 cases in 28. Most common cancers in 28 Rank All People Males Females Cancer Number % of total Cancer Number % of total Cancer Number % of total 1 Prostate 6,95 19% Prostate 6,95 33% Breast 4,376 28% 2 Bowel ii 4,741 13% Bowel 2,66 12% Bowel 2,135 14% 3 Breast 4,418 12% Melanoma 2,127 1% Melanoma 1,464 9% 4 Melanoma iii 3,591 1% Lung 1,96 9% Lung 1,354 9% 5 Lung 3,26 9% NHL * 758 4% NHL 633 4% *Non-Hodgkin s lymphoma Figure 1 New cases of cancer, all people, NSW, 28 Prostate 6,95 Bowel 4,741 Breast 4,418 Melanoma 3,591 Lung 3,26 Colon 3,71 Rectum 1,67 Non-Hodgkin's lymphoma 1,391 Cancer unknown primary 1,65 Kidney 1,2 Leukaemia 91 Pancreas 858 Thyroid 78 Bladder 713 Stomach 667 Uterine 625 Brain 5 Myelodysplasia 466 Liver 46 Oesophagus » 36,611 people (2,873 males and 15,738 females) were diagnosed with invasive cancer in NSW.» Cancers of the prostate, bowel, breast, melanoma and lung cancer were the most common and were responsible for 63 per cent of all new cases.» Males were 1.5 times more likely to be diagnosed with cancer than females.» Prostate cancer as a proportion of all cancer increased by 1 per cent compared to 27.» Bowel cancer as a proportion of all cancer declined by 1 per cent compared with 27.» There were 3 additional cases of prostate cancer in 28 compared with 27.» Breast and lung cancer in females increased by 1 per cent compared to the proportional representation in 27. ii. iii. Cancers of the colon and rectum are presented separately to allow comparison with other epidemiological publications and also presented together as bowel cancer. Melanoma refers to melanoma of the skin only. 9

12 Cancer in New South Wales: Incidence and Mortality Report 28» executive summary Cancer deaths in 28 All people: 13,213 Males: 7,391 Females: 5,822 Most common causes of cancer death in 28 Rank All People Males Females Cancer Deaths % of total Cancer Deaths % of total Cancer Deaths % of total 1 Lung 2,664 2% Lung 1,666 23% Lung % 2 Bowel 1,716 13% Bowel % Breast 94 16% 3 Prostate 93 7% Prostate 93 13% Bowel % 4 Breast 99 7% Pancreas 381 5% CUP iv 384 7% 5 Pancreas 749 6% CUP iv 364 5% Pancreas 368 6% Figure 2 Cancer deaths, all people, NSW, 28 Lung 2,664 Bowel 1,716 Colon Prostate Breast Pancreas Cancer unknown primary Rectum Non-Hodgkin's lymphoma Melanoma Stomach Leukaemia Brain Oesophagus Liver Kidney Bladder Ovary Multiple myeloma Myelodysplasia Mesothelioma 1, » There were 14 fewer cancer deaths than reported in 27.» Cancer represented 28 per cent of all NSW deaths and 29 per cent of all deaths in Australia in 28 v.» Cancer was the leading cause of death in NSW people aged 35 to 84 years.» The top fi ve cancers caused 53 per cent of all cancer deaths in 28.» In males, lung cancer as a proportion of total cancer deaths increased by 2 per cent compared to 27. iv. Cancer unknown primary v. Australian Bureau of Statistics. Causes of Death, Australia. 28 Cat No March 21. 1

13 » executive summary Differences by age New cases by age group in 28 Age group Number of cases % of total Less than 15 years 172.5% 15 to 29 years % 3 to 64 years 14, % 65 years and older 2, %» The risk or likelihood of being diagnosed with cancer increases with age.» 7 per cent of lung cancers, 66 per cent of bowel cancers, 63 per cent of prostate cancers and 38 per cent of breast cancers were diagnosed in people aged 65 years and older.» 49 per cent of all melanomas were found in males and females aged 3 years to 64 years.» One half of female breast cancer cases (2,247) were aged between the BreastScreen target age range of 5 and 69 years of age at diagnosis. Table 1a Most common cancers in people by age category 28 to to 29 3 to 49 5 to plus All Ages Leukaemia Melanoma Breast Prostate Prostate Prostate Brain Testicular Melanoma Breast Bowel Bowel Other endocrine Hodgkin s lymphoma Thyroid Bowel Lung Breast Cancer unknown primary Thyroid Bowel Melanoma Melanoma Melanoma Kidney Leukaemia NHL Lung Breast Lung Table 1b Most common cause of cancer death by age category to 49 5 to All Ages Breast Lung Lung Lung Lung Bowel Bowel Bowel Bowel Breast Prostate Prostate Melanoma Pancreas CUP Breast Brain Prostate Pancreas Cancer unknown primary 11

14 Cancer in New South Wales: Incidence and Mortality Report 28» executive summary Trends Trends in overall cancer incidence 1999 to 28 Figure 3 Percentage change in incidence rates in males and females, NSW, Males M Females F 8 Liver 52.5 M 77.7 F Thyroid 78.8 M 71.3 F 6 Prostate Lung 29.2 F 2 All Cancers 11.2 Melanoma 14.9 M 11.2 F Leukaemia M F Bladder M F Uterus 19.1 Oesophagus F Pancreas 18.7 M -2-4 Lung M Stomach M -1.9 F Head & Neck -1.1 M -1.1 F Cancer unknown primary M F Cervix Lip M F -6» Prostate cancer is responsible for a third of all new cases in males (33 per cent), therefore changes in the rates of all cancer in males will be most infl uenced by changes in prostate cancer rates.» Rates for all cancer in males were also infl uenced by changes in rates of the high volume cancers of bowel, melanoma and lung. Bowel cancer incidence rates have remained stable, melanoma rates have continued to increase and lung cancer rates continued to decrease.» Incidence rates were stable for breast and bowel cancer in females.» Lung, melanoma, liver and thyroid cancer in females increased.» Head and neck, oesophagus, stomach and cervix cancer rates in females declined.» Compared with the previous 1-year period the percentage change in incidence rates of pancreatic cancer is no longer statistically signifi cant.» There was no statistically signifi cant change in female cancer incidence rates over the 1 year period. However, there was a signifi cant decline in incidence rates for the most recent seven year period. 12

15 »» executive summary Trends in overall cancer mortality 1999 to 28 Figure 4 Percentage change in mortality rates in males and females, NSW, Males M Females F 1 Liver 47.9 M 95.4 F Lung 22.1 F 2 All Cancers M -7.8 F Bowel M F Rectum M F Breast -11. F NHL M F Leukaemia M -3.9 F Bladder -2.3 M Kidney F Pancreas 16.3 M Lung M Colon M F Prostate -2.3 M Brain F Stomach M Head & Neck M F Cancer unknown primary M F Cervix F Testis M Lip F -8»» During the period age standardised mortality rates for all cancers declined by 13.2 per cent in males and 7.8 per cent in females. The rate of decline in mortality rates is steeper from 25 in males and 24 in females.»» Mortality rates declined for the majority of cancer sites including bowel cancers, non-hodgkin s lymphoma, head and neck cancers, leukaemia and cancer of unknown primary (CUP).»» Mortality rates increased for liver cancer (males and females), pancreatic cancer and melanoma in males and lung cancer in females.»» All other mortality rate differences were similar in the period to those reported in the previous ten year period. 13

16 Cancer in New South Wales: Incidence and Mortality Report 28» executive summary Survival Figure 5 Relative survival in NSW 22 to 26 followed to the end of 27 Testis 96 Thyroid 96 Lip Melanoma Prostate Breast Hodgkin's lymphoma Uterus Cervix 73 Kidney Rectum Bowel Colon Non-Hodgkin s lymphoma All Cancers Head and Neck Bladder Leukaemia Myelodysplasia Multiple myeloma Ovary Stomach 31 Brain Cancer unknown primary Oesophagus Liver Lung Mesothelioma 1 Pancreas » Five-year relative survival from cancer in NSW improved to 64 per cent in 22 26, from 63 per cent in » Relative survival for males increased to 63 per cent from 61 percent and survival in females remained at 66 per cent.» For males diagnosed with prostate cancer, the fi ve-year relative survival was 9 per cent up from 88 per cent.» The fi ve-year relative survival was 65 per cent for males and 66 per cent for females diagnosed with bowel cancer.» For females diagnosed with breast cancer, the fi ve-year relative survival was 88 per cent in both periods.» The fi ve-year relative survival was 89 per cent for males and 93 per cent for females diagnosed with melanoma in both periods.» Relative survival fi ve-years after diagnosis exceeded 8 per cent for cancers of the uterus, and was greater than 95 per cent for cancers of the thyroid, testis, and lip.» Five-year relative survival was less than 22 per cent for, stomach, lung and brain cancer; and less than 1 per cent for the poor prognosis cancers of mesothelioma and pancreatic cancer.» Once confi dence limits were considered there was a statistically signifi cantly higher relative survival from all cancer and cancer unknown primary.» Bladder cancer relative survival was statistically signifi cantly lower in males compared to the earlier period » All other cancer sites were not statistically signifi cantly different between the two time periods.» Relative survival was signifi cantly higher in females than males for most cancer sites. 14

17 » key fi ndings Key Findings Incidence Incidence rates in males increased by 11 per cent for the most recent 1-year period but declined in females for the most recent seven-year period. Prostate cancer increased as a proportion of total cancers from 18 per cent in 27 to 19 per cent in 28 and for males from 32 per cent to 33 percent for the same time period. Lung cancer incidence rates in females continue to increase at a more rapid rate with a 29 per cent increase compared with a 23 per cent increase for the previous 1 year period. Uterine cancer incidence rates increased by 19 per cent compared to 17 per cent in the previous 1 year period. In all people, incidence rates for head and neck cancer fell by 1 per cent and mortality rates fell by 23 per cent. Pancreatic cancer incidence in all people and mortality rates in males continue to increase. As survival is poor for pancreatic cancer trends in incidence and mortality rate mirror one another. Mortality Lung cancer was responsible for 23 per cent of deaths in males in 28 accounting for an increase in the proportion of total cancer deaths in males from 21 per cent in 27. Mortality rates in males have been declining since the 198s. However, the rate of the decline has slowed in the last four years. Death rates in males and females have declined since 1989 but have dropped more steeply from 25 and 24 respectively to 28. Mortality rate declines in females for all cancer are most infl uenced by changes in breast cancer mortality rates. Mortality rates for melanoma in males increased for the fi rst time by 12 percent in the most recent ten year period. Cervical cancer mortality rates increased in 28. This increase is mainly in females aged 8 years and older and those aged 5 to 55 years compared to earlier time periods. Investigation by country of birth group shows similar patterns over time, indicating that the increase in death rates is not related to a particular migrant group. Further monitoring of mortality is required to determine the signifi cance of this change. Survival Five-year relative survival was 64% in 22 26, compared to 63% in This was a statistically signifi cant improvement. Survival increased in males from 61 per cent to 63 per cent and remained higher in females at 66 per cent. 15

18 Cancer in New South Wales: Incidence and Mortality Report 28» introduction Introduction The NSW Central Cancer Registry The Central Cancer Registry receives notifi cations of cancer in NSW. It is managed by the Cancer Institute NSW for the NSW Department of Health (NSW Health), and operates under the authority of the Public Health Act of The Registry maintains a record of all invasive cases of cancer diagnosed in NSW residents since 1972 with the exception of non melanoma skin cancers. The information collected about people with cancer includes name and address, date of birth, country of birth, clinical details about the cancer, the notifying institution, treating doctor and general practitioner. Personal details, such as name and address are needed to ensure that accurate information is recorded for each person and that each new cancer is only counted once in the statistics. All information sent to the Registry is kept confi dential under tight security and is protected by the Public Health Act and the Health Records Information Privacy Act. Notifi cation of cancer in NSW Notifi cation of malignant neoplasms is a statutory requirement for all notifying institutions. These are public and private hospitals, departments of radiation oncology, nursing homes, pathology laboratories, outpatient departments and day procedure centres. When cliniciians at any of these institutions diagnose or treat someone with cancer, they are required by law to notify the NSW Central Cancer Registry. Notifi cations of cancer in NSW residents are also received from cancer registries in other states and territories. Further details of the notifi cation procedure can be found in Appendix 1. Purpose of the Registry The Registry contributes to the prevention, control and treatment of cancer in the population of NSW. The aims of the NSW Central Cancer Registry are to: assist in planning and monitoring services for the control of cancer and the care of people with cancer in NSW. monitor the number of new cases of cancer, deaths and survival from cancer in NSW. make the data available for use by health providers, planners, educators and research scientists, including epidemiologists and clinicians. produce regular reports about cancer incidence and mortality, and contribute to the national and international reporting of cancer. evaluate the continuing benefi ts of screening programs. Demography of NSW NSW is the most populous state of Australia with 6,984,172 residents in 28. According to the Australian Bureau of Statistics publication of the Estimated Resident Population in June 28 for NSW the population increased by 96,158 people between 27 and 28. NSW is situated between latitudes 28 S and 38 S and longitudes 141 E and 154 E. Two-thirds (63 per cent) of the population live in the capital city, Sydney. 16

19 » overview of cancer incidence Overview of cancer incidence in 28 Table 2 New cancers, all people, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World # Aust 21 All cancers 36, Prostate 6, Bowel 4, Breast 4, Melanoma 3, Lung 3, Colon 3, Rectum 1, Non-Hodgkin's lymphoma 1, Cancer unknown primary 1, Kidney 1, Leukaemia Pancreas Thyroid Bladder Stomach Uterine Brain Myelodysplasia Liver Oesophagus Ovary Other 3,44 9 # the World population is 196 SEGI. Table 3 New cancers,males, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World Aust 21 All cancers 2, Prostate 6, Bowel 2, Melanoma 2, Lung 1, Colon 1, Rectum 1, Non-Hodgkin's lymphoma Kidney Cancer unknown primary Bladder Leukaemia Pancreas Stomach Liver Oesophagus Brain Myelodysplasia Multiple myeloma Testis Thyroid Mesothelioma Other 1,

20 Cancer in New South Wales: Incidence and Mortality Report 28» overview of cancer incidence Table 4 New cancers, females, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World Aust 21 All cancers 15, Breast 4, Bowel 2, Colon 1, Melanoma 1, Lung 1, Rectum Non-Hodgkin's lymphoma Uterus Thyroid Cancer unknown primary Ovary Pancreas Leukaemia Kidney Stomach Cervix Myelodysplasia Brain Bladder Multiple myeloma Other female genital Other 1,45 7 Table 5 New cancers, clinical groupings, all people, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World Aust 21 All cancers 36, Urogenital 8, Bowel 4, Breast 4, Skin 3, Respiratory 3, Haematopoietic 2, Upper GI 2, Gynaecological 1, Cancer unknown primary 1, Head and neck Thyroid and other endocrine Neurological Myelodysplasia Bone and connective tissue Eye

21 » overview of cancer incidence Table 6 New cancers, clinical groupings, males, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World Aust 21 All cancers 2, Urogenital 8, Bowel 2, Skin 2, Respiratory 2, Upper GI 1, Haematopoietic 1, Head and neck Cancer unknown primary Neurological Myelodysplasia Thyroid and other endocrine Bone and connective tissue Eye Breast Table 7 New cancers, clinical groupings, females, NSW, 28 Cancer type Cases per cent Crude incidence rate Standardised incidence Risk to age 75 Risk to age 85 World Aust 21 All cancers 15, Breast 4, Bowel 2, Skin 1, Gynaecological 1, Respiratory 1, Haematopoietic 1, Upper GI 1, Thyroid and other endocrine Urogenital Cancer unknown primary Head and neck Neurological Myelodysplasia Bone and connective tissue Eye

22 Cancer in New South Wales: Incidence and Mortality Report 28» overview of cancer mortality Overview of cancer mortality in 28 Table 8 Cancer deaths, all people, NSW, 28 Cancer type Deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 13, Lung 2, Bowel 1, Colon 1, Prostate Breast Pancreas Cancer unknown primary Rectum Non-Hodgkin's lymphoma Melanoma Stomach Leukaemia Oesophagus Brain Liver Kidney Bladder Ovary Multiple myeloma Myelodysplasia Mesothelioma Other 1,9 88 Table 9 Cancer deaths, males, NSW, 28 Cancer type Deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 7, Lung 1, Bowel Prostate Colon Rectum Pancreas Cancer unknown primary Melanoma Stomach Non-Hodgkin's lymphoma Leukaemia Oesophagus Liver Bladder Brain Kidney Mesothelioma Multiple myeloma Myelodysplasia Gallbladder Larynx Other

23 » overview of cancer mortality Table 1 Cancer deaths, females, NSW, 28 Cancer type Deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 5, Lung Breast Bowel Colon Cancer unknown primary Pancreas Ovary Non-Hodgkin's lymphoma Rectum Stomach Leukaemia Melanoma Brain Oesophagus Kidney Multiple myeloma Body of uterus Myelodysplasia Cervix Liver Bladder Other Table 11 Cancer deaths, clinical groupings, all people, NSW, 28 Cancer type Deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 13, Respiratory 2, Upper GI 2, Bowel 1, Urological 1, Haematopoeitic 1, Breast Cancer unknown primary Gynaecological Skin Head and neck Neurological Myelodysplasia Bone and Connective tissue Thyroid and other endocrine Eye

24 Cancer in New South Wales: Incidence and Mortality Report 28» overview of cancer mortality Table 12 Cancer deaths, clinical groupings, males, NSW, 28 Cancer type Deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 7, Respiratory 1, Urogenital 1, Upper GI 1, Bowel Lymphohaematopoetic Cancer unknown primary Skin Head and neck Neurological Myelodysplasia Bone and connective tissue Thyroid and other endocrine Eye Table 13 Cancer deaths, clinical groupings, females, NSW, 28 Cancer type deaths per cent Crude mortality rate Standardised mortality Risk to age 75 Risk to age 85 World Aust 21 All cancers 5, Respiratory 1, Breast Upper GI Bowel Gynaecological Haemopoetic Cancer unknown primary Urological Neurological Skin Myelodysplasia Head and neck Bone and Connective tissue Thyroid and other endocrine Eye

25 » incidence by age and sex Incidence of cancer by age and sex Most common cancers by age and sex Leukaemia, brain and other endocrine cancers were the most common cancers in children aged 14 years. Testicular cancer in males and melanoma in females were the most common cancers in the year age group. They were followed by Hodgkin s lymphoma (males), thyroid (females), melanoma of the skin (males), Hodgkin s lymphoma (females), leukaemia (males) and breast cancer (females). Breast cancer was the leading cancer for females from age 3 79 years, followed by cancer of the large bowel and melanoma. While for males in the same age groups, the leading cancers were melanoma (aged 3 49 years) and prostate cancer (5 years and over). Prostate and bowel cancers were the top two cancers in males aged 65 years and over. While for the women in the same age group, breast and bowel were the major cancer sites. Differences by cancer Of the major cancers, 7 per cent of lung cancers, 66 per cent of bowel cancers, 63 per cent of prostate cancers and 38 per cent of breast cancers were diagnosed in people aged 65 years and older. Forty-nine percent of all melanomas were found in males and females aged 3 to 64 years. One half of female breast cancer cases (2,225) were aged between 5 and 69 years of age at diagnosis. Thirty-eight per cent of all cervical cancer cases and 54 per cent of all testicular cancers were diagnosed in those aged 3 to 49 years. Twenty-four per cent of all bone cancers, 33 per cent of all testicular cancers and 42 per cent of all Hodgkin s lymphomas were found in people aged 15 to 29 years. Differences by age years (adolescent and young adult) 555 cancers diagnosed (289 males and 266 females). 1.5 per cent of all new cases in NSW. Melanoma was the most common cancer with 85 cases, or 15 per cent of cases for both sexes combined, followed by testicular cancer with 69 cases or 12 per cent and Hodgkin s lymphoma with 67 cases or 12 per cent years 4,36 cancers diagnosed (1,613 males and 2,423 females). 11 per cent of all new cases in NSW. Breast cancer was the most common cancer, with 1,4 cases or 25 per cent of cases in this age range. Melanoma of the skin with 638 cases was the next most common cancer in this age category. 23

26 Cancer in New South Wales: Incidence and Mortality Report 28» incidence by age and sex 5 64 years 1,892 cancers diagnosed (6,271 males and 4,621 females). 3 per cent of all new cases in NSW. Prostate cancer was the most common cancer, with just over a fi fth of all cases, followed by breast, bowel, melanoma and lung cancer. Collectively these cancers were responsible for 68 per cent of cases in this age range. 65 years and older 2,956 cancers diagnosed (12,611 males and 8,345 females) per cent of all new cases in NSW. Prostate cancer (4,321) was responsible for a fi fth of all cases in this age range, followed by bowel, lung, melanoma and breast. In those age 8 years and older, bowel cancer was the most commonly diagnosed cancer, followed by prostate, lung and melanoma. Differences by sex Males were 1.5 times more likely to be diagnosed with cancer. Age-standardised incidence rates were higher in males than in females for the majority of cancers. The male to female ratios were: mesothelioma and cancer of the larynx (6:1);kaposi s sarcoma (5:1); bladder cancer (4:1); head and neck, liver, oesophageal and lip (3.1); and stomach, kidney (2:1). There were four times as many thyroid cancers in females compared to males. There are 97 times more cases of breast cancer in females than in males. Figure 6 Most common cancers by age and sex, NSW, 28 Males aged to 14 years Females aged to 14 years All leukaemia 35 All leukaemia 38 Brain 8 Brain 11 Other endocrine 7 Eye 4 Connective tissue 6 Kidney, etc Number of cases Number of cases Males aged 15 to 29 years Females aged 15 to 29 years Testis 69 Melanoma 5 Hodgkin's disease 39 Thyroid 46 Melanoma 35 Hodgkin's disease 28 All leukaemia 29 Breast Number of cases Number of cases 24

27 » incidence by age and sex Figure 6 Most common cancers by age and sex, NSW, 28 (cont d) Males aged 3 to 49 years Females aged 3 to 49 years Melanoma 322 Breast 12 Prostate 164 Melanoma 316 Testis 114 Thyroid 244 Head and neck 11 Bowel Number of cases Number of cases Males aged 5 to 64 years Females aged 5 to 64 years Prostate 2,42 Breast 1,718 Bowel 785 Bowel 59 Melanoma 644 Melanoma 465 Bronchus, lung 449 Bronchus, lung Number of cases Number of cases Males aged 65 to 79 years Females aged 65 to 79 years Prostate 3,388 Breast 1,174 Bowel 1,163 Bowel 88 Bronchus, lung 973 Bronchus, lung 596 Melanoma 733 Melanoma Number of cases Number of cases Males aged 8 years and over Females aged 8 years and over Prostate 933 Bowel 66 Bowel 49 Breast 461 Bronchus, lung 45 Bronchus, lung 316 Melanoma 393 Other & unspecified sites Number of cases Number of cases 25

28 Cancer in New South Wales: Incidence and Mortality Report 28» age-specifi c rates Age-specifi c incidence and mortality rates Age-specifi c incidence rates In most cancer types, age-specifi c incidence rates increased rapidly with age. There were some exceptions: - Childhood cancers - Thyroid cancer which increased from age 15 years (rapidly in females and more moderately in males) - Melanoma, which increased after age 2 years - Brain cancer, which increased from age 25 years - Breast cancer, which increased sharply after age 25 years - Testicular cancer peaked at age 3 34 years - Head and neck cancer, which increased from age 35 years. Generally, age-specifi c incidence rates were consistently higher in males than females. There were some exceptions: - Breast and thyroid cancer was higher in females - Bowel cancer, cancers of the gallbladder, pancreas and central nervous system were higher in females in some age groups. All cancer age-specifi c incidence rates were higher in females than in males aged years due to the incidence of breast cancer. From age 55 years and older, age-specifi c incidences rates were higher and climbed more sharply in males than in females. Bowel cancer rates peaked at age 85+ years. Melanoma gradually increased with age and peaked at aged 8 84 years. Lung cancer rates peaked at aged 8 84 years. Age-specifi c mortality rates All cancer age-specifi c mortality rates were higher in females than in males aged 3 49 years due to the impact of breast cancer. From age 5 years and older, age-specifi c mortality rates were higher and climbed more sharply in males. Lung cancer mortality rates peaked at 8 84 years in all people, although rose more sharply in males after age 4 years. Breast cancer mortality rates climbed gradually between the ages of 25 and 74 years, then sharply after 75 years and peaked after 85 years. Bowel cancer increased in all people from age 4 44 years and peaked in those aged 85 years and over. Mortality rates were consistently higher in males than females. Prostate cancer mortality rates increased gradually between 4 and 64 years, then sharply from 65 years and peaked after age 85 years. 26

29 » age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, Age-specifi c incidence rates Age-specifi c mortality rates 4 4 7a 35 7b Rate per 1, Rate per 1, Age Age All sites male All sites female All sites male All sites female 4 4 7c 35 7d Rate per 1, Rate per 1, Age Age Melanoma male Melanoma female Lip male Lip female Kaposi's sarcoma male Kaposi's sarcoma female Melanoma male Melanoma female Lip male Lip female Kaposi's sarcoma male Kaposi's sarcoma female 27

30 Cancer in New South Wales: Incidence and Mortality Report 28» age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates 7e 45 7f Rate per 1, Rate per 1, Age Age Lung male Lung female Mesothelioma male Mesothelioma female Lung male Lung female Mesothelioma male Mesothelioma female 1 1 7g 7h 8 8 Rate per 1, 6 4 Rate per 1, Age Age Head & neck male Head & neck female Oesophagus male Oesophagus female Head & neck male Head & neck female Oesophagus male Oesophagus female 28

31 » age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates 7i j Rate per 1, Rate per 1, Age Age Bowel male Bowel female Stomach male Stomach female Bowel male Bowel female Stomach male Stomach female 2 2 7k 7l Rate per 1, 1 Rate per 1, Age Age All leukaemias males All leukaemias females Myeloproliferative disorders males Myeloproliferative disorders females All leukaemias males All leukaemias females Myeloproliferative disorders males Myeloproliferative disorders females 29

32 Cancer in New South Wales: Incidence and Mortality Report 28» age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates 2 2 7m 7n Rate per 1, 1 Rate per 1, Age Age Non-Hodgkin's lymphoma male Non-Hodgkin's lymphoma female Multiple myeloma male Multiple myeloma female Hodgkin's disease male Hodgkin's disease female Non-Hodgkin's lymphoma male Non-Hodgkin's lymphoma female Multiple myeloma male Multiple myeloma female Hodgkin's disease male Hodgkin's disease female o 7p Rate per 1, 3 Rate per 1, Age Age Brain male Brain female Eye male Eye female Central nervous system male Central nervous system female Brain male Brain female Eye male Eye female Central nervous system male Central nervous system female 3

33 » age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates 7q 25 7r Rate per 1, 15 1 Rate per 1, Age Bladder male Bladder female Kidney male Kidney female Age Bladder male Bladder female Kidney male Kidney female 7s t Rate per 1, Rate per 1, Age Age Prostate Testicular Other male genital organs Prostate Testicular Other male genital organs 31

34 Cancer in New South Wales: Incidence and Mortality Report 28» age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates u 4 7v Rate per 1, Rate per 1, Age Age Breast Cervix Other female genital organs Ovary Uterus, Body & NOS Breast Cervix Other female genital organs Ovary Uterus, Body & NOS 7w 12 7x Rate per 1, 8 6 Rate per 1, Age Age Pancreas male Liver male Gallbladder male Pancreas female Liver female Gallbladder female Pancreas male Liver male Gallbladder male Pancreas female Liver female Gallbladder female 32

35 » age-specifi c rates Figure 7 Age-specifi c incidence and mortality rates by cancer site, males and females, NSW, (cont d) Age-specifi c incidence rates Age-specifi c mortality rates 7y 3 7z Rate per 1, 2 15 Rate per 1, Age Age Thyroid male Thyroid female Other endocrine glands male Other endocrine glands female Thyroid male Thyroid female Other endocrine glands male Other endocrine glands female 5 5 7aa 45 7ab Rate per 1, Rate per 1, Age Age Cancer unknown primary male Cancer unknown primary female Cancer unknown primary male Cancer unknown primary female 33

36 Cancer in New South Wales: Incidence and Mortality Report 28» trends Trends in incidence and mortality rates Table 14 Changes in incidence and mortality rates, NSW, Incidence Mortality Cancer site Average annual change males Average annual change females Average annual change males Average annual change females Lip Head and Neck Oesophagus Stomach Colon Rectum Bowel Liver Pancreas Lung Melanoma Mesothelioma Breast Cervix Uterus Ovarian Prostate Testes Kidney Bladder Brain Thyroid Non-Hodgkin s lymphoma Multiple myeloma Leukaemia Cancer unknown Primary All Cancers Green downward arrow: there has been a statistically signifi cant (p<.5) percentage decrease Red upward arrow: there has been a statistically signifi cant (p<.5) percentage increase

37 » trends Change in annual incidence and mortality rates Between 1999 and 28, the number of newly diagnosed cancers in males and females increased by an average of 912 new cases (622 male, 29 female) a year. Deaths have increased on average by 155 deaths (77 in males and 78 in females) per year. These additional cases and deaths are due to the ageing and growth of the population in NSW and are consistent with the number of cases and deaths expected in cancer population projections. Incidence rates for all cancers increased by 11 per cent in males and there was no statistically signifi cant change for females. However, there was a signifi cant decline in incidence rates in females for the last seven years by.61 per cent. Age-standardised mortality rates for all cancers declined by 13.2 per cent in males and 7.8 per cent in females. There was a more rapid decline from 25 to 28 (2.8 per cent per annum) in males and from 24 to 28 in females (2. per cent per annum). Incidence Males» Lung cancer incidence rates declined 15.1 per cent, declining at a slower rate over time.» Melanoma incidence rates increased 14.9 per cent.» Head and neck cancer incidence rates declined 1.1 per cent.» Bladder cancer incidence rates declined 34.9 per cent.» Stomach cancer incidence rates declined 22.1 per cent.» Cancer unknown primary incidence rates declined 24.7 per cent.» Liver cancer incidence rates increased 52.6 per cent.» Thyroid cancer incidence rates increased 78.8 per cent.» Prostate cancer incidence rates increased 61 per cent.» Pancreatic cancer incidence rates increased 18.7 per cent. Females» Lung cancer incidence rates increased 29.9 per cent, increasing at a steeper rate over time.» Melanoma increased 11.2 per cent.» Head and neck cancer declined 1.1 per cent.» Bladder cancer incidence rates declined 38.1 per cent.» Stomach cancer incidence rates declined 1.9 per cent.» Cancer unknown primary incidence rates decline 27.4 per cent.» Liver cancer incidence rates increased 77.7 per cent.» Thyroid cancer incidence rates increased 71.3 per cent.» Uterine cancer incidence rates increased 19.1 per cent.» Cervical cancer incidence rates declined 25.1 per cent. Mortality Males» Lung cancer mortality rates declined 16.2 per cent.» Bowel cancer mortality rates declined 16.3 per cent.» Cancer unknown primary mortality rates declined 38.2 per cent.» Non-Hodgkin s lymphoma mortality rates declined 19.5 per cent.» Leukaemia mortality rates declined 23.7 per cent.» Liver cancer mortality rates increased 47.9 per cent.» Head and neck cancer mortality rates declined 22.5 per cent.» Prostate cancer mortality rates declined 2.3 per cent.» Stomach cancer mortality rates declined 24.2 per cent.» Bladder cancer mortality rates declined 21.3 per cent.» Testicular cancer mortality rates declined 56.3 per cent.» Pancreatic cancer mortality rates increased 16.3 per cent.» Melanoma mortality rates increased for the fi rst time by 11.9 per cent. Females» Lung cancer mortality rates increased 22.1 per cent. Rates have increased steeply since 23 by 4 per cent per annum.» Bowel cancer mortality rates declined 14.9 per cent.» Cancer unknown primary mortality rates declined 35.7 per cent.» Non-Hodgkin s lymphoma mortality rates declined 32.2 per cent.» Leukaemia mortality rates declined 3.9 per cent.» Liver cancer mortality rates increased 95.4 per cent.» Head and neck mortality rates declined 23.4 per cent.» Breast cancer mortality rates declined 11 per cent.» Cervical cancer mortality rates declined 21.6 per cent.» Kidney cancer mortality rates declined 32.5 per cent.» Brain cancer mortality rates declined 19 per cent. 35

38 Cancer in New South Wales: Incidence and Mortality Report 28» all cancer All cancer Incidence MALES FEMALES ALL PEOPLE New cases: 2,873 15,738 36,611 Age-standardised vi rate per 1,: year trend (rates ): 11.2% Crude rate per 1,: Risk of diagnosis by age 75 years: 1 in 3 1 in 4 1 in 3 Risk of diagnosis by age 85 years: 1 in 2 1 in 3 1 in 2 Median age at diagnosis: Mortality Total deaths: 7,391 5,822 13,213 Age-standardised rate per 1,: year trend (rates ): 13.2% 7.8% Crude rate per 1,: » Incidence rates in males increased by 11 per cent in the last 1 years refl ecting an increased incidence of prostate cancer in 22.» The change in female incidence rates over ten years was not statistically signifi cant, but there was a statistically signifi cant decline in the most recent seven year period.» Mortality rates declined by 13.7 per cent in males and 7.8 per cent in females in the past 1 years.» The likelihood or risk of developing cancer is one in two in males and one in three in females by the age of 85 years. Risk of death by age 75 years: 1 in 9 1 in 12 1 in 1 Risk of death by age 85 years: 1 in 4 1 in 6 1 in 5 Median age at death: Survival Relative fi ve-year 22 26: 63% 66% Change from : Change was not statistically signifi cant 2% unchanged Allowing for differences in age, males were 1.5 times as likely to be diagnosed with cancer as females and 1.6 times as likely to die from cancer. The majority of new cases were in people aged 65 years and older: 6 per cent for males and 53 per cent for females. Incidence rates increased with age in both sexes. vi. Unless otherwise stated rates are age standardised to the 21 Australian population. 36

39 » all cancer Figure 8 All cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 4 3 Rate per 1, Males Females Table 15 Numbers of new cases of cancer by age group, 28 Age (yr) plus Total Males 1,991 6,271 8,921 3,69 2,873 Females 2,772 4,621 5,112 3,233 15,738 Risk factors Tobacco smoking is the most common risk factor, associated with cancers of the lung, bladder, cervix, head and neck, lip, pancreas, oesophagus, bowel and kidney. Melanoma is strongly related to ultraviolet radiation exposure. Exposure to ionising radiation has been linked to cancers of the brain, lung, leukaemia, multiple myeloma and thyroid. Other risk factors include alcohol, diet and obesity; and reproductive factors in females such as number of children or age at fi r s t birth which affect the risk of both breast and ovarian cancer. There is convincing evidence that greater body fatness is a cause of adenocarcinoma of the eosophagus and pancreas, breast (post menopausal), uterus and kidney cancers. There is convincing evidence that greater abdominal fatness is a cause of bowel cancer. 37

40 Cancer in New South Wales: Incidence and Mortality Report 28» bladder cancer Bladder cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 2.6% 1.1% 1.9% Rank against all cancer: 9 th 18 th 14 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in in in 188 Risk of diagnosis by age 85 years: 1 in 44 1 in in 74 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 2.8% 1.6% 2.3%» Mortality rates from bladder cancer declined in males by 21.3 per cent, with no statistically signifi cant change in females.» After allowing for differences in age, males were 4. times more likely than females to be diagnosed with bladder cancer and 3.2 times more likely to die from it.» The fi ve-year relative survival 22 to 26 was 57 per cent for males and 5 per cent for females.» Age at diagnosis is the main contributing factor to variations in survival from bladder cancer. Rank against all cancer deaths: 13 th 19 th 17 th Age-standardised rate per 1,: year trend (rates ): 21.3 Risk of death by age 75 years: 1 in in 1,975 1 in 748 Risk of death by age 85 years: 1 in in in 187 Median age at death: Survival Relative fi ve-year 22 26: 57% 5% Change from : 6% 2% Change was not statistically signifi cant After allowing for differences in age, males were 4 times more likely than females to be diagnosed with bladder cancer and 3.2 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 8 per cent for males and 81 per cent for females. Incidence and mortality rates of bladder cancer increased rapidly with age. The increase in rates was greater in males than females aged 6 years and over. The decline in incidence from bladder cancer is partly artefactual due to changes in coding practices from 26 onwards to better ensure that only cases of invasive bladder cancer are counted. The decline in male survival was statistically signifi cant due to an increase in the median age at diagnosis and therefore an increase in risk of death. Over time, the median age at diagnosis and death is increasing in males, accounting for the six per cent decline in survival between the most recent and earlier time periods. 38

41 » bladder cancer Figure 9 Bladder cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 2 Rate per 1, Males Females Table 16 Numbers of new cases of bladder cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Tobacco smoking accounts for 5 6 per cent of bladder cancer in males and 2 3 per cent in females. Smokers are more likely to develop bladder cancer than non-smokers 1. Occupational exposure to aromatic amines, often used in dyes, may also be a risk factor 2 7. Males are more likely to develop bladder cancer than females 6,8. Those with a family history of bladder cancer (in a father/mother or brother/sister) are at higher risk People with diabetes are at increased risk of bladder cancer

42 Cancer in New South Wales: Incidence and Mortality Report 28» bowel cancer Bowel cancer vii Incidence MALES FEMALES ALL PEOPLE New cases: 2,66 2,135 4,741 Percentage of all cancer: 12.5% 13.6% 12.9% Rank against all cancer: 2 nd 2 nd 2 nd Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 18 1 in 27 1 in 22 Risk of diagnosis by age 85 years: 1 in 1 1 in 15 1 in 12 Median age at diagnosis: Mortality Total deaths: ,716 Percentage of all cancer deaths: 12.7% 13.4% 13.% Rank against all cancer deaths: 3 rd 3 rd 2 nd Age-standardised rate per 1,: year trend (rates ): 16.3% 14.9%» Bowel cancer was the most common cancer diagnosed.» Bowel cancer ranked second in incidence after prostate cancer in males and breast cancer in females.» Mortality ranked second overall and ranked third for males and females.» One in 1 males and one in 15 females would develop bowel cancer by the age of 85 years.» Mortality rates fell by 16.7 per cent in males and 14.9 per cent in females between 1999 and 28 and are expected to continue to decline.» Five year relative survival for was 65 percent for males and 66 per cent for females. Risk of death by age 75 years: 1 in 64 1 in 92 1 in 76 Risk of death by age 85 years: 1 in 27 1 in 43 1 in 34 Median age at death: Survival Relative fi ve-year 22 26: 65% 66% Change from : unchanged 1% Change was not statistically signifi cant After allowing for differences in age, males were 1.4 times more likely than females to be diagnosed with bowel cancer and 1.5 times more likely to die from it The majority of new cases were in people aged 65 years and older: 63.4 per cent for males and 69.6 per cent for females Incidence and mortality rates increased with age. They were higher in males than females aged years and was the second most common cancer in males and the most common in females aged 75 years and older. vii. Bowel cancer refers to cancers of the large bowel. Cancers of the colon and rectum are combined. 4

43 » bowel cancer Figure 1 Bowel cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 5 4 Rate per 1, Males Females Table 17 Numbers of new cases of bowel cancer by age group, 28 Age (yr) plus Total Males , ,66 Females ,135 Risk factors The risk of bowel cancer with age; those aged over 5 years are at higher risk 12,13. People with a family history of bowel cancer are at greater risk People with personal history of adenomatous polyposis or hereditary non polyposis colon cancer, polyps, or infl ammatory bowel disease are at greater risk 12, Crohn s disease and diabetes increase the greater risk 2,21. Obesity, a sedentary lifestyle and those with a diet high in animal fats and processed meats are at greater risk 12, Tobacco consumption or heavy alcohol consumption may also increase the risk 22,

44 Cancer in New South Wales: Incidence and Mortality Report 28» brain cancer Brain cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 1.4% 1.3% 1.4% Rank against all cancer: 15 th 17 th 18 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in in in 183 Risk of diagnosis by age 85 years: 1 in 96 1 in in 123 Median age at diagnosis: Mortality» Mortality rates declined in females for the most recent 1 year period by 19 per cent.» The fi ve-year relative survival experienced in 22 to 26 in NSW was 21 per cent for males and 24 per cent for females diagnosed with brain cancer.» Survival from brain cancer varies by cell type of cancer ranging from 37 per cent for males and 45 per cent with low grade astrocytoma to 4 per cent in NSW males and 2.7 per cent in NSW females for glioblastoma. Total deaths: Percentage of all cancer deaths: 2.7% 2.4% 2.6% Rank against all cancer deaths: 14 th 12 th 15 th Age-standardised rate per 1,: year trend (rates ): 19.2% Risk of death by age 75 years: 1 in in in 269 Risk of death by age 85 years: 1 in in in 168 Median age at death: Survival Relative fi ve-year 22 26: 21% 24% Change from : Change was not statistically signifi cant 2% 3% After allowing for differences in age, males were 1.6 times more likely than females to be diagnosed with brain cancer and 1.6 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 45 per cent for males and 54 per cent for females. Since 1972 there has been no signifi cant change in brain cancer incidence rates in males and females. There has been a downward trend in mortality rates since 1994 in males and 1991 in females. 42

45 » brain cancer Figure 11 Brain cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 6 4 Rate per 1, Males Females Table 18 Numbers of new cases of brain cancer by age group, 28 Age (yr) plus Total Males Females Risk factors There are very few known risk factors for brain tumours. Exposure to ionising radiation to the head, usually received for treatment of other cancers, is an established risk factor 3,31. Risk increases with age; brain cancer is most common in people older than 65. Children younger than 14 years of age appear to be at a higher risk for brain tumours than older children 31. People with impaired immune systems due to congenital abnormalities, side effects from cancer treatment, immunosuppressive therapy or HIV infection are also at increased risk

46 Cancer in New South Wales: Incidence and Mortality Report 28» breast cancer Breast cancer Incidence MALES FEMALES ALL PEOPLE New cases: 42 4,376 4,418 Percentage of all cancer:.2% 27.8% 12.1% Rank against all cancer: 4 th 1 st 3 rd Age-standardised rate per 1,: year trend (rates ): -- Risk of diagnosis by age 75 years: 1 in in 11 1 in 21 Risk of diagnosis by age 85 years: 1 in in 9 1 in 16 Median age at diagnosis: -- 6 Mortality Total deaths: Percentage of all cancer deaths:.1% 15.5% 6.9% Rank against all cancer deaths: 46 th 2 nd 5 th Age-standardised rate per 1,: » In 28 there were 4,418 cases of breast cancer.» Breast cancer ranked fi rst in females for incidence and its mortality ranked second.» Breast cancer was the most common cancer in females aged 3 to 74 years.» Incidence rates have remained constant since 1995.» Mortality rates declined by 11 per cent over the most recent 1 year period.» The fi ve-year relative survival in NSW was 88 per cent for females diagnosed with breast cancer. This is exactly the same as survival for the earlier time period year trend (rates ): -- 11% Risk of death by age 75 years: 1 in 8,347 1 in 65 1 in 126 Risk of death by age 85 years: 1 in 5,635 1 in 39 1 in 72 Median age at death: Survival Relative fi ve-year 22 26: -- 88% Change from : -- unchanged Change was not statistically signifi cant Allowing for differences in age, females were 96.5 times more likely to be diagnosed with breast cancer than males and more likely to die from breast cancer. In 28, 63 new breast cancers were diagnosed in women who had a previous or simultaneous breast cancer (since January 1972). These additional primary cancers were not included in the tabulations in this report. 63 per cent of new cases in females were in those aged less than 65 years. Incidence and mortality rates of breast cancer increased with age, beginning earlier (2 24 years) than for most other cancers. Breast cancer was the most common in females aged 3 to 74 years. 44

47 » breast cancer Figure 12 Breast cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 75 5 Rate per 1, Males Females Table 19 Numbers of new cases of breast cancer by age group, 28 Age (yr) plus Total Females 1,23 1,718 1, ,376 Risk factors The risk of breast cancer increases with age 32,33. Reproductive factors such as not having children or having them after the age of 3 years, early onset of menarche or late onset of menopause and no or limited breast feeding may also increase the risk of breast cancer 34,35. Family history, especially when diagnosed in a mother, daughter or sister. There is increase if breast cancer is in two or more relatives, or diagnosed in a relative before the age of 5 years, or if there are relatives with breast and ovarian cancer. Five to 1 per cent of breast cancer cases are hereditary due to mutations in the BRCA1 and BRCA2 genes. Women of Ashkenazi Jewish origin are at 32, higher risk, possibly due to an increased rates of BRCA1 and BRCA2 gene mutation found in this ethnic group. Excessive alcohol consumption and obesity increase the risk of breast cancer 42,43. Hormone replacement therapy (HRT) may increase the risk and recurrence of breast cancer

48 Cancer in New South Wales: Incidence and Mortality Report 28» cancer unknown primary Cancer unknown primary (CUP) Incidence MALES FEMALES ALL PEOPLE New cases: ,65 Percentage of all cancer: 2.6% 3.3% 2.9% Rank against all cancer: 8 th 9 th 9 th Age-standardised rate per 1,: year trend (rates ): 24.7% 27.4% Risk of diagnosis by age 75 years: 1 in 18 1 in in 127 Risk of diagnosis by age 85 years: 1 in 48 1 in 69 1 in 57 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 4.9% 6.6% 5.7%» There were 1,65 new cases of CUP in NSW in 28.» Mortality rates fell by 38.2 per cent in males and 35.7 per cent in females for the period 1999 to 28.» CUP was the sixth most common cause of cancer death in males and the fourth in females.» The fi ve-year relative survival experienced in 22 to 26 in NSW was 2 per cent for males and 17 per cent for females diagnosed with CUP.» Survival from CUP varies by cell type. Rank against all cancer deaths: 6 th 4 th 7 th Age-standardised rate per 1,: year trend (rates ): 38.2% 35.7% Risk of death by age 75 years: 1 in in in 21 Risk of death by age 85 years: 1 in 71 1 in 96 1 in 82 Median age at death: Survival Relative fi ve-year 22 26: 2% 17% Change from : Change was not statistically signifi cant 4% 3% This category includes cancers of other and ill-defi ned sites of digestive tract (ICD-1 C26), within respiratory system and intrathoracic organs (C39), retroperitoneum and peritoneum (C48), ill-defi ned sites (C76) and unknown primary site (C8). After allowing for differences in age, males were 1.4 times more likely than females to be diagnosed with CUP and 1.3 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 7 per cent for males and 81 per cent for females. Males had higher incidence and mortality than females. Incidence and mortality increased sharply from age 5 years. Survival from CUP varies by cell type. Five-year relative survival from adenocarcinoma of CUP was 6.5 per cent in males and 11.2 per cent in females. Survival from squamous cell carcinoma of CUP was 5.2 per cent in males and 5 per cent in NSW females viii. viii. Tracey E, Ling L, Baker D, Dobrovic A, Bishop J. Cancer In NSW: Incidence and Mortality 27. Sydney: Cancer Institute NSW, December

49 » cancer unknown primary Figure 13 Cancer unknown primary (CUP) Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 2 15 Rate per 1, Males Females Table 2 Numbers of new cases of cancer unknown primary (CUP) by age group, 28 Age (yr) plus Total Males Females Risk factors Since the exact organ of origin of a CUP is not known, it is diffi cult to identify the risk factors. Smoking may be an important risk factor as more than half of CUP patients have a history of smoking. Age, diet, alcohol, and obesity common risk factors for many cancers may also be risk factors for CUP. 47

50 Cancer in New South Wales: Incidence and Mortality Report 28» cervical cancer Cervical cancer Incidence FEMALES New cases: 248 Percentage of all cancer: 1.6% Rank against all cancer: 15 th Age-standardised rate per 1,: year trend (rates ): 25.1% Risk of diagnosis by age 75 years: 1 in 24 Risk of diagnosis by age 85 years: 1 in 16 Median age at diagnosis: 53 Mortality Total deaths: 11 Percentage of all cancer deaths: 1.7%» There were 248 new cases of cervical cancer in 28 compared to 28 in 27.» Between 26 and 28 there has been an additional 8 new cases compared to an average number of new cases of 22 in 26. The most likely explanation for this increase is because of television campaigns held in 27 encouraging screening participation.» Although the incidence rate of cervical cancer has been decreasing throughout the period from 1972 to 28, the decline in the trend was most marked between 1992 and 22 with an average annual decline of fi ve per cent per annum largely due the introduction of population screening.» The number of cervical cancer deaths has increased from 69 deaths in 27 to 11 deaths in 28.» Of the 11 deaths from cervical cancer in 28, 64 were diagnosed in 26, 27, or 28.» The fi ve-year relative survival experienced in 22 to 26 in NSW was 73 per cent. Rank against all cancer deaths: 18 th Age-standardised rate per 1,: year trend (rates ): 21.6% Risk of death by age 75 years: 1 in 587 Risk of death by age 85 years: 1 in 351 Median age at death: 64 Survival Relative fi ve-year 22 26: 73% Change from : unchanged Change was not statistically signifi cant The number of cervical cancer deaths has increased from 69 deaths in 27 to 11 deaths in 28. Of the 11 deaths from cervical cancer in 28, 64 were in females diagnosed from 26 onwards. The increase in mortality in 28 is mainly in females aged 8 years and older and those aged 5 55 years, compared to the earlier time period of per cent of new cases were in those aged 64 years or younger. Unlike most cancers, incidence rates for cervical cancer increased rapidly between 2 24 and years of age, but remained relatively constant thereafter. Incidence rates increased since 26 and mortality rates increased in

51 » cervical cancer Figure 14 Cervical cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 1 Rate per 1, Males Females Table 21 Numbers of new cases of cervical cancer by age group, 28 Age (yr) plus Total Females Risk factors Infection with human papillomavirus (HPV) is the well-established risk factor for cervical cancer. HPV is most likely contracted by having multiple sexual partners, having sex at an early age, or sex with uncircumcised males. HPV infections are mostly asymptomatic and occur mainly in young women and are less common in women over A family history of cervical cancer in a fi rst-degree relative is a risk factor 51. Tobacco smoking increases the risk, and is independent of HPV infection Smoking may also increase the risk of developing high-grade lesions in women with atypical or low grade lesions but normal colposcopy Infection with chlamydia or HIV, multiple pregnancies, or long-term oral contraceptive use increase the risk Obesity may also increase the cervical cancer risk

52 Cancer in New South Wales: Incidence and Mortality Report 28» childhood cancer Childhood cancer The classifi cation for cancer in children ( 14 years) used in this report is based on morphology. ix In 28 there were 173 childhood cancers diagnosed (89 males, 84 females). Leukaemias accounted for 42.8 per cent of all new cancers, 11.6 per cent were central nervous system tumours (CNS), 9.2 per cent were neuroblastomas and 5.8 per cent were lymphoma : there were 94 new childhood cancers (58 in males, 432 in females). more than half of childhood cancer were leukaemia and cancers of the brain and central nervous system. Trends in childhood cancer In the period the age-standardised incidence rates were 14. new cases per 1, in males and 12.3 per 1, in females. This increased in to 15.4 per 1, in males and 14. per 1, in females. There has been an increase in the incidence rates of.3 per cent per annum in males and.5 per cent per annum in females. Incidence rates of childhood leukaemia increased from 4.8 per 1, (all children) in to 7.7 per 1, in males and 7.2 per 1, in females in Incidence rates of childhood leukaemia increased.5 per cent per annum in both sexes. Incidence rates of childhood central nervous system tumours were 2.7 per 1, in males and 2.3 per 1, in females in , showing little change by with 2.4 per 1, in males and 2. per 1, in females. Incidence rate trends of cancer of the brain and central nervous system showed a decline of.9 per cent per cent per annum in females and but no statistically signifi cant change in males. Figure 15 Childhood cancer incidence (<15 years), NSW, Leukaemia Central nervous system Other Lymphoma Neuroblastoma Soft tissue sarcomas Wilm's tumour Bone tumour Retinoblastoma Melanoma Males Females Numbers of new cases Figure 16 Trends in age-standardised incidence rates of childhood cancers by sex (age<15), NSW, Rate per 1, Period of diagnosis All cancer Males All Leukaemia Males CNS Males All cancer Females All Leukaemia Females CNS Females ix. Kramarova E, Stiller CA, Ferlay J et al. International Classifi cation of Childhood Cancer IARC Technical Report No. 29. Lyon: International Agency for Research on Cancer,

53 » childhood cancer Table 22 Childhood cancers, NSW, Cancer Type Sex -4 yrs 5-9 yrs 1-14 yrs -14 yrs Cum% No. Rate x No. Rate No. Rate No. SI xi Lymphoid leukaemia M F Other acute leukaemia M Other and unspecifi ed leukaemia F M F Hodgkin s disease M F Non-Hodgkin s lymphoma M F Ependymoma M F Astrocytoma xii M Primitive neuroectodermal tumours Other malignant central nervous system tumours Neuroblastoma and ganglioneuroblastoma F M F M F M F Retinoblastoma M F Wilms tumour M F Ewing s sarcoma M F Rhabdomyosarcoma M Other unspecifi ed soft tissue sarcomas F M F Malignant melanoma M F Other xiii M F All Cancers M F x. Rates are numbers of cases per 1, persons per annum classifi ed according to Kramarova et al. xi. SI: Standardised incidence rate using the world population as standard. xii. Pilocytic astrocytomas are no longer considered malignant in ICD-3. xiii. Includes malignant epithelial neoplasms (11 cases), non-gonadal germ cell tumours (8), osteosarcoma (11), gonadal germ cell tumours (4), hepatoblastoma (6), other (18) in males and malignant epithelial neoplasms (14 cases), non-gonadal germ cell tumours (4), osteosarcoma (6), gonadal germ cell tumours (1), hepatoblastoma (5), unspecifi ed lymphoma (1), other (2) in females. 51

54 Cancer in New South Wales: Incidence and Mortality Report 28» colon cancer Colon cancer Incidence MALES FEMALES ALL PEOPLE New cases: 1,59 1,481 3,71 Percentage of all cancer: 7.6% 9.4% 8.4% Rank against all cancer: 4 th 2 nd 6 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 31 1 in 4 1 in 35 Risk of diagnosis by age 85 years: 1 in 16 1 in 2 1 in 18 Median age at diagnosis: 71 73» There were 3,71 new cases of colon cancer in NSW in 28.» Incidence rates have remained stable in the most recent 1-year period and mortality rates fell by 15.2 per cent in males and 11.8 per cent in females.» Obesity, including abdominal obesity, is a risk factor for colon cancer.» The fi ve-year relative survival in NSW was 65 per cent. Mortality Total deaths: ,15 Percentage of all cancer deaths: 7.5% 9.5% 8.4% Rank against all cancer deaths: 3 rd 3 rd 3 rd Age-standardised rate per 1,: year trend (rates ): 15.2% 11.8% Risk of death by age 75 years: 1 in 18 1 in in 123 Risk of death by age 85 years: 1 in 46 1 in 61 1 in 53 Median age at death: Survival Relative fi ve-year 22 26: 65% 65% Change from : Change was not statistically signifi cant 1% 2% After allowing for differences in age, males were 1.3 times more likely than females to be diagnosed with and die from colon cancer. The majority of new cases were in people aged 65 years and older: 69 per cent for males and 74 per cent for females. Incidence and mortality rates increased with age. They were higher in males than females from years of age and older. 52

55 » colon cancer Figure 17 Colon cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 3 2 Rate per 1, Males Females Table 23 Numbers of new cases of colon cancer by age group, 28 Age (yr) plus Total Males ,59 Females ,481 Risk factors Obesity, including abdominal obesity, is an established risk factor for colon cancer 24,65,66. Diets high in processed meat and alcohol increase the risk of colon cancer

56 Cancer in New South Wales: Incidence and Mortality Report 28» head and neck cancer Head and neck cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 3.4% 1.6% 2.6% Age-standardised rate per 1,: year trend (rates ): 1.1% 1.1% Risk of diagnosis by age 75 years: 1 in 63 1 in 22 1 in 97 Risk of diagnosis by age 85 years: 1 in 43 1 in in 66 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 3.5% 1.6% 2.6% Age-standardised rate per 1,: year trend (rates ): 22.5% 23.4% Risk of death by age 75 years: 1 in in in 34 Risk of death by age 85 years: 1 in 19 1 in in 173 Median age at death: 68 73» There were 957 new cases of head and neck cancer in NSW in 28: 72 in males and 255 in females or 3.4 per cent of all cancers in males and 1.6 per cent in females.» Incidence rates fell by 1 per cent in males and females and mortality rates fell by 22.5 per cent in males and 23.4 per cent in females.» The fi ve-year relative survival was 58 per cent for males and 64 per cent for females diagnosed with head and neck cancer.» Survival is infl uenced by the cell type of cancer which is predominantly squamous cell carcinoma.» Tobacco and alcohol consumption are the known risk factors for head and neck cancer. Survival Relative fi ve-year 22 26: 58% 64% Change from : 2% 8% Change was not statistically signifi cant Cancers included in this section are oral (tongue, mouth, salivary glands), pharynx, larynx and nose, sinuses, etc (ICD-1 codes C1-C14, C3-C32). After allowing for differences in age, males were 3.1 times more likely than females to be diagnosed with head and neck cancer and 3.4 times more likely to die from it. The majority of new cases were in people aged 65 years or older: 47 per cent for males and 56 per cent for females. Incidence and mortality rates increased with age, though incidence rates were lower in the oldest age groups. Incidence rates were much higher in males than females at all ages. This difference peaked in the 45 to 54 age range where the male to female ratio was 4:1. Squamous cell carcinoma was responsible for 82 per cent of all head and neck cancers in 27 and has a fi ve-year relative survival of 54 per cent in males and 5 per cent in females. Adenocarcinoma, with 9 per cent of head and neck cancers, has a fi ve-year relative survival of 74 per cent in males and 77 per cent in females. xiv xiv. Tracey E, Ling L, Baker D, Dobrovic A, Bishop J. Cancer In NSW: Incidence and Mortality 27. Sydney: Cancer Institute NSW, December

57 » head and neck cancer Figure 18 Head and neck cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, Rate per 1, Males Females Table 24 Numbers of new cases of head and neck cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Tobacco smoking and alcohol consumption are established risk factors for head and neck cancer, and the risk is multiplied when alcohol and tobacco use are combined 24,35,98,99. Family history of head and neck squamous cell carcinoma (HNSCC) leads to an increased risk of developing oropharyngeal cancer 29,69. Genetic alterations may be responsible in some cases of HNSC 29. Human papillomavirus and Epstein-Barr virus are associated with head and neck cancer 7,71. Poor oral hygiene, mechanical irritation from poorly fi tting dentures, and some industrial exposures such as wood and nickel dust inhalation are risk factors 29,72,73. 55

58 Cancer in New South Wales: Incidence and Mortality Report 28» kidney cancer Kidney cancer Incidence MALES FEMALES ALL PEOPLE New cases: ,2 Percentage of all cancer: 3% 2.4% 2.7% Rank against all cancer: 7 th 13 th 1 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 76 1 in in 98 Risk of diagnosis by age 85 years: 1 in 45 1 in 81 1 in 59 Median age at diagnosis: Mortality» Males are twice as likely to be diagnosed with and die from kidney cancer as females.» Mortality rates fell by 32.5 per cent in females and showed no statistically signifi cant change for males over the same time period.» The fi ve-year relative survival in NSW was 66 per cent for males and 65 per cent for females.» Obesity and smoking usage have been suggested to be risk factors for kidney cancer. Total deaths: Percentage of all cancer deaths: 2.5% 2.% 2.3% Rank against all cancer deaths: 15 th 14 th 16 th Age-standardised rate per 1,: year trend (rates ): 32.5% Risk of death by age 75 years: 1 in 36 1 in in 424 Risk of death by age 85 years: 1 in in in 18 Median age at death: Survival Relative fi ve-year 22 26: 66% 65% Change from : unchanged 4% Change was not statistically signifi cant After allowing for differences in age, males were 1.9 times more likely than females to be diagnosed with kidney cancer and 2. times more likely to die from it. The majority of new cases were in people aged 65 years and older: 51 per cent for males and 59 per cent for females. Incidence and mortality rates increased with age. Kidney cancer was the third most common cancer in children age 4 years, however, the majority of cases occurred 4 years of age and older. Rates were higher in males compared to females at all ages. 56

59 » kidney cancer Figure 19 Kidney cancer Age-standardised incidence, NSW Age-standardised mortality, NSW 2 2 Rate per 1, 1 Rate per 1, Males Females Table 25 Numbers of new cases of kidney cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Kidney cancer is strongly associated with tobacco smoking 29,52. Increased body fatness is a cause of kidney cancer 24. Family history of kidney cancer, particularly in a brother or sister, increases the risk 74. High blood pressure, advanced kidney disease and certain inherited diseases increase the risk. Exposure to high levels of an industrial solvent, trichloroethylene, is a risk factor 75. There is evidence of risk through exposures to cadmium, asbestos and industrial exposure among leather tanners and shoe manufacturing 76,77. 57

60 Cancer in New South Wales: Incidence and Mortality Report 28» leukaemia Leukaemia Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 2.5% 2.5% 2.5% Rank against all cancer: 1 th 12 th 11 th Age-standardised rate per 1,: year trend (rates ): 14.9% 13.3% Risk of diagnosis by age 75 years: 1 in 99 1 in 16 1 in 123 Risk of diagnosis by age 85 years: 1 in 56 1 in 86 1 in 68 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 3.5% 2.8% 3.2% Rank against all cancer deaths: 1 th 1 th 12 th Age-standardised rate per 1,: year trend (rates ): 23.7% 3.9%» There were 91 new cases of leukaemia in NSW in 28: 521 in males and 389 in females.» Among children, leukaemia was the most common cancer in boys and girls aged less than 15 years.» Leukaemia incidence rates have declined since 2 but more steeply since 24. Some of this decline is coding related because myelodysplasia is now registered as malignant. Prior to 24 it was considered as a preleukaemic condition.» Mortality rates fell by 23.7 per cent in males and 3.9 per cent in females for all aged combined.» The fi ve-year relative survival in NSW was 49 per cent for males and 48 per cent for females. Risk of death by age 75 years: 1 in in in 343 Risk of death by age 85 years: 1 in 13 1 in in 137 Median age at death: Survival Relative fi ve-year 22 26: 49% 48% Change from : 2% 3% Change was not statistically signifi cant After allowing for differences in age, males were 1.6 times more likely than females to be diagnosed with leukaemia and 2.1 times more likely to die from it. Reported leukaemias included 44 per cent acute (11 per cent lymphoid, 33 per cent myeloid) 49 per cent chronic (33 per cent lymphoid, 17 per cent myeloid) and 7 per cent other and unspecifi ed. The majority of new cases were in people aged 65 years and older: 53 per cent for males and 64 per cent for females. Among children, leukamia was the most common cancer aged 5 years. From about years, incidence and mortality rates for leukaemias increased rapidly with age. Incidence rates for males were double those of females from 6 years and older. The decline in incidence rates of leukaemia is partially due to changes in coding practices. Myelodysplasia a pre-leukaemic condition was only considered an invasive cancer after

61 » leukaemia Figure 2 Leukaemia Age-standardised incidence, NSW Age-standardised mortality, NSW 2 2 Rate per 1, 1 Rate per 1, Males Females Table 26 Numbers of new cases of leukaemia by age group, 28 Age (yr) plus Total Males Females Risk factors Exposure to ionising radiation and certain chemicals such as benzene, petroleum products, paint, ethylene oxide and some pesticides are the main risk factors for leukaemia Occupational exposure to formaldehyde is a risk factor 78. There is greater risk in people with pre-existing blood disorders or particular genetic disorders such as Down syndrome, Klinefelter s syndrome, Patau syndrome and other genetic disorders such as Bloom syndrome and Fanconi s anaemia 79,8. Drugs used in cancer treatment (chemotherapy) such as alkylating agents and topoisomerase II inhibitors may induce treatmentassociated acute myeloid leukaemia 8. 59

62 Cancer in New South Wales: Incidence and Mortality Report 28» lip cancer Lip cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer:.8%.5%.6% Rank against all cancer: 22 nd 25 th 24 th Age-standardised rate per 1,: year trend (rates ): 23.9% 16.3% Risk of diagnosis by age 75 years: 1 in 37 1 in in 442 Risk of diagnosis by age 85 years: 1 in 18 1 in in 277» Lip cancer is a low-incidence cancer.» The primary risk factor for lip cancer is exposure to tobacco smoke and sun.» There are few deaths from lip cancer.» The fi ve-year relative survival in NSW was 91 per cent. Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths:.1%.%.1% Rank against all cancer deaths: 36 th 43 rd 45 th Age-standardised rate per 1,: year trend (rates ): 66.1% Risk of death by age 75 years: 1 in 21, in 43,557 Risk of death by age 85 years: 1 in 4,778 1 in 17,64 1 in 7,986 Median age at death: 8 84 Survival Relative fi ve-year 22 26: 91% 91% Change from : unchanged 4% Change was not statistically signifi cant After allowing for differences in age, males were 2.6 times more likely than females to be diagnosed with lip cancer and 8.8 times more likely to die from it. The majority of new cases were in people aged 65 years and older: with 48 per cent for males and 52 per cent for females. Incidence rates increased from 4-44 years and older and were three times higher in males compared to females. The small number of deaths from lip cancer in both males and females give rise to unstable rates with large confi dence limits. 6

63 » lip cancer Figure 21 Lip cancer Age-standardised incidence, NSW Age-standardised mortality, NSW 2 2 Rate per 1, 1 Rate per 1, Males Females Table 27 Numbers of new cases of lip cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Tobacco smoking is the primary risk factor particularly in those who smoke a pipe, or leave a cigarette on the lip 52. Various high risk mucosal and cutaneous human papillomavirus (HPV) are associated with pathogenesis (verrucous carcinoma 81. Occupational exposure to benzene is also considered a risk factor for lip cancer 82. Excessive alcohol consumption is a risk factor for lip cancer 24. Risk may be increased in people with lighter eye colour, sun exposure early in life and cumulative sun exposure during outdoor work. Renal-transplant recipients are at increased risk of lip cancer, as are other people who receive immunosuppressive therapy

64 Cancer in New South Wales: Incidence and Mortality Report 28» liver cancer Liver cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 1.6%.8% 1.3% Rank against all cancer: 13 th 22 nd 19 th Age-standardised rate per 1,: year trend (rates ): 52.6% 77.7% Risk of diagnosis by age 75 years: 1 in 15 1 in in 223 Risk of diagnosis by age 85 years: 1 in 81 1 in in 127 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 3% 1.6% 2.4%» Between the incidence rates for liver cancer increased by 52.6 per cent in males and 77.7 per cent in females.» Mortality rates increased by 47.9 per cent in males and 95.4 per cent in females. Mortality rates mirror incidence largely because of poor survival.» The fi ve-year relative survival in NSW was 17 per cent for males and 15 per cent for females.» The most important risk factors are infection with the hepatitis B and C virus and alcohol consumption. Rank against all cancer deaths: 12 th 19 th 15 th Age-standardised rate per 1,: year trend (rates ): 47.9% 95.4% Risk of death by age 75 years: 1 in in in 357 Risk of death by age 85 years: 1 in in in 18 Median age at death: Survival Relative fi ve-year 22 26: 17% 15% Change from : 2% unchanged Change was not statistically signifi cant After allowing for differences in age, males were 3. times more likely than females to be diagnosed with and die from liver cancer. The majority of new cases were in people aged 65 years and older: 55 per cent for males and 67 per cent for females. Liver cancer rates increased rapidly in males aged 5 54 and 7 74 years. Rates for males were at least three times those for females from 4 44 years, peaking to six and fi ve times those in females aged years. Incidence and mortality rates refl ect a similar pattern consistent with a cancer that is continuing to increase and has poor survival. There is a higher prevalence in overseas-born males who have a higher frequency of hepatitis B infection. Immunisation against hepatitis B at birth is recommended NSW policy for high-risk populations. 62

65 » liver cancer Figure 22 Liver cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 6 4 Rate per 1, Males Females Table 28 Numbers of new cases of liver cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Infection with chronic hepatitis B or C viruses substantially increases the risk of liver cancer Cirrhosis of the liver, which can be caused by, among other things, excessive alcohol consumption or the progression of hepatitis C virus, increases the risk of liver cancer Risk increases with age. Males are at greater risk than females. People with diabetes are at increased risk

66 Cancer in New South Wales: Incidence and Mortality Report 28» lung cancer Lung cancer Incidence MALES FEMALES ALL PEOPLE New cases: 1,96 1,354 3,26 Percentage of all cancer: 9.1% 8.6% 8.9% Rank against all cancer: 3 rd 4 th 5 th Age-standardised rate per 1,: year trend (rates ): 15.1% 29.2% Risk of diagnosis by age 75 years: 1 in 27 1 in 4 1 in 32» Lung cancer mortality ranked fi rst in males and females.» Incidence rates are increasing steeply in females with a 29.2 per cent increase in incidence rates » Incidence and mortality rate declines have slowed in males since 22. Risk of diagnosis by age 85 years: 1 in 13 1 in 22 1 in 17 Median age at diagnosis: Mortality Total deaths: 1, ,664 Percentage of all cancer deaths: 22.5% 17.1% 2.2% Rank against all cancer deaths: 1 st 1 st 1 st Age-standardised rate per 1,: year trend (rates ): 16.2% 22.1% Risk of death by age 75 years: 1 in 34 1 in 59 1 in 43 Risk of death by age 85 years: 1 in 14 1 in 29 1 in 2 Median age at death: Survival Relative fi ve-year 22 26: 14% 18% Change from : 1% 3% Change was not statistically signifi cant After allowing for differences in age, males were 1.6 times more likely than females to be diagnosed with lung cancer and twice as likely to die from it. The majority of new cases were in people aged 65 years and older: 72 per cent for males and 68 per cent for females. Incidence and mortality rates increased with age. From years rates in males exceeded those in females, the male to female ratio increasing with age for both incidence and mortality. Rates in males were double those of females from years and older. Incidence rates have been declining in males and increasing steadily in females since the 198s. 64

67 » lung cancer Figure 23 Lung cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 6 4 Rate per 1, Males Females Table 29 Numbers of new cases of lung cancer by age group, 28 Age (yr) plus Total Males ,96 Females ,354 Risk factors Tobacco smoking and exposure to tobacco smoke is the major risk factor for lung cancer 52. Risk increases with duration and quantity of smoking 117,118. Alcohol consumption and smoking may increase the risk 119. Exposure to asbestos and silica fi bres increases the risk 12. There is convincing evidence that beta-carotene supplements (in smokers only) are a cause of lung cancer 121. Chronic lung disease, chronic obstructive pulmonary disease, interstitial lung disease, scleroderma, rheumatoid disease, sarcoidosis or tuberculosis may increase the risk of lung cancer

68 Cancer in New South Wales: Incidence and Mortality Report 28» melanoma Melanoma Incidence MALES FEMALES ALL PEOPLE New cases: 2,127 1,464 3,591 Percentage of all cancer: 1.2% 9.3% 9.8% Rank against all cancer: 2 nd 3 rd 4 th Age-standardised rate per 1,: year trend (rates ): 14.9% 11.2% Risk of diagnosis by age 75 years: 1 in 24 1 in 34 1 in 28 Risk of diagnosis by age 85 years: 1 in 13 1 in 24 1 in 18 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 4.6% 2.5% 3.7% Rank against all cancer deaths: 7 th 11 th 1 th Age-standardised rate per 1,: year trend (rates ): 11.9% Risk of death by age 75 years: 1 in in in 258 Risk of death by age 85 years: 1 in 75 1 in in 12» There were 3,591 new cases of melanoma in NSW in 28.» Incidence rates have increased in NSW since 1972.» Melanoma age-specifi c incidence rates in Australia are the highest in the world and increase from the southern coastal regions of Australia to the most northern state of Queensland, largely due to the outdoor coastal lifestyle of Australians.» Age-specifi c mortality rates increased by 11.9 per cent in males and showed no signifi cant trend in females.» This is the fi rst time that mortality rates have shown a statistically signifi cant increase in males in NSW.» The fi ve-year relative survival was 88 per cent for males and 93 per cent for females. Median age at death: Survival Relative fi ve-year 22 26: 88% 93% Change from : unchanged unchanged Change was not statistically signifi cant Refers to melanoma of the skin only. After allowing for differences in age, males were 1.6 times more likely than females to be diagnosed with melanoma and 2.9 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 53 per cent for males and 43 per cent for females. Melanoma was the most common cancer in males aged 25 to 54 and in females aged 15 to 29. It was the second most common cancer in females aged 3 to 54 years of age. Age-specifi c incidence increased slowly from aged 2 24 years when rates were higher in females compared to males, and were higher in females until the age of Incidence in males were double females in the age of years and older. Age-specifi c mortality was double in males compared to females from years. Mortality was four times higher in males than females aged years and three times higher than females in 69+ years. 66

69 » melanoma Figure 24 Melanoma Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 6 4 Rate per 1, Males Females Table 3 Numbers of new cases of melanoma by age group, 28 Age (yr) plus Total Males ,127 Females ,464 Risk factors Over exposure to ultraviolet (UV) radiation and sun burn are the main risk factors for melanoma 123. Risk is higher in people who have freckles and skin that burns easily, more moles, blue eyes and red hair 124. Melanoma is more likely to occur in older people and men are at increased risk 125. Risk is greater in people who are immunosuppressed 126. People with a family history of melanoma are at higher risk

70 Cancer in New South Wales: Incidence and Mortality Report 28» mesothelioma Mesothelioma Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer:.8%.2%.6% Rank against all cancer: 2 th 31 st 25 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in in 1,686 1 in 55 Risk of diagnosis by age 85 years: 1 in in 82 1 in 241 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 2.1%.6% 1.5% Rank against all cancer deaths: 16 th 23 rd 21 st Age-standardised rate per 1,: year trend (rates ):» Males are six times more likely than females to be diagnosed with mesothelioma and fi ve times more likely to die from it.» In Australia mesothelioma incidence rates are not expected to peak until 217 and 215 in NSW.» The fi ve-year relative survival in NSW was 8 per cent for males and 18 per cent for females.» Exposure to asbestos fi bres is the primary cause of malignant mesothelioma.» People involved in certain occupational settings such as manufacturing in cements, textile products, shipyard and mining industries are at increased risk of mesothelioma. Risk of death by age 75 years: 1 in in 1,412 1 in 648 Risk of death by age 85 years: 1 in in in 262 Median age at death: Survival Relative fi ve-year 22 26: 8% 18% Change from : Change was not statistically signifi cant 2% 12% After allowing for differences in age, males were six times more likely than females to be diagnosed with mesothelioma and fi ve times more likely to die from it. The majority of new cases were in people aged 65 years and older: 83 per cent for males and 73 per cent for females. Age-specifi c mesothelioma incidence rates were four times higher in males than females aged years and ten times higher in males aged years and older. 68

71 » mesothelioma Figure 25 Mesothelioma Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, Rate per 1, Males Females Table 31 Numbers of new cases of mesothelioma by age group, 28 Age (yr) plus Total Males Females Risk factors Exposure to asbestos fi bres is the primary cause of malignant mesothelioma 128,129. Exposure to other mineral fi bres can cause the disease 13. Occupational exposure through manufacturing in cements, textile products, shipyard and mining industries increases the risk 13. There is some evidence that genetic predisposition may be important in determining individual susceptibility to mineral fi bre carcinogenesis and to the development of mesothelioma

72 Cancer in New South Wales: Incidence and Mortality Report 28» multiple myeloma Multiple myeloma Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 1.1% 1.% 1.1% Rank against all cancer: 17 th 19 th 22 nd Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in in in 268 Risk of diagnosis by age 85 years: 1 in 11 1 in 29 1 in 148 Median age at diagnosis: 7 7» There were 4 new cases and 261 deaths in NSW in 28.» In the most recent 1 year period mortality rates fell by 14.2 per cent in females.» The fi ve-year relative survival in NSW was 43 per cent for males and 45 per cent for females.» Exposure to ionising radiation is the strongest single factor linked to an increased risk of multiple myeloma. Mortality Total deaths: Percentage of all cancer deaths: 2.% 2.% 2.% Rank against all cancer deaths: 17 th 14 th 19 th Age-standardised rate per 1,: year trend (rates ): 14.2% Risk of death by age 75 years: 1 in in in 517 Risk of death by age 85 years: 1 in in in 199 Median age at death: Survival Relative fi ve-year 22 26: 43% 45% Change from : Change was not statistically signifi cant 3% 1% After allowing for differences in age, males were 1.7 times more likely than females to be diagnosed with multiple myeloma and 1.6 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 62 per cent for males and 69 per cent for females. 7

73 » multiple myeloma Figure 26 Multiple myeloma Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 15 1 Rate per 1, Males Females Table 32 Numbers of new cases of multiple myeloma by age group, 28 Age (yr) plus Total Males Females Risk factors Exposure to ionising radiation is the strongest single factor linked to an increased risk of multiple myeloma 131. Exposures to nickel, agricultural chemicals, benzene and petroleum products, other aromatic hydrocarbons, silicon and various industrial dusts are potential risk factors 132,133. Being overweight or obese increases a person s risk of developing myeloma1. First-degree relatives of people with multiple myeloma patient are at signifi cantly greater 134. Chromosomal abnormalities may be associated with the disease

74 Cancer in New South Wales: Incidence and Mortality Report 28» non-hodgkin s lymphoma Non-Hodgkin s lymphoma Incidence MALES FEMALES ALL PEOPLE New cases: ,391 Percentage of all cancer: 3.6% 4.% 3.8% Rank against all cancer: 6 th 6 th 8 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 65 1 in 87 1 in 75 Risk of diagnosis by age 85 years: 1 in 36 1 in 49 1 in 42 Median age at diagnosis: 66 7 Mortality Total deaths: Percentage of all cancer deaths: 4.% 4.1% 4.%» In 28, there were 1,391 new cases of non-hodgkin s lymphoma in NSW.» Between 1999 and 28 mortality rates fell by 19.5 per cent in males and 32.2 per cent in females.» The fi ve-year relative survival was 63 per cent for males and 66 per cent for females.» Immune defi ciency is the most well described risk factor for non Hodgkin s lymphoma (NHL), associated with either immunosuppressive therapy following organ transplant, HIV or autoimmune diseases. Rank against all cancer deaths: 9 th 7 th 9 th Age-standardised rate per 1,: year trend (rates ): 19.5% 32.2% Risk of death by age 75 years: 1 in in in 295 Risk of death by age 85 years: 1 in 89 1 in in 111 Median age at death: Survival Relative fi ve-year 22 26: 63% 66% Change from : Change was not statistically signifi cant 2% 5% After allowing for differences in age, males were 1.4 times more likely than females to be diagnosed with non-hodgkin s lymphoma and 1.7 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 54 per cent for males and 62 per cent for females. Mortality rates in males declined 2.7 per cent per annum since Mortality rates in females declined 3.3 per cent per annum in females since

75 » non-hodgkin s lymphoma Figure 27 Non-Hodgkin s lymphoma Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 15 1 Rate per 1, Males Females Table 33 Numbers of new cases of non-hodgkin s lymphoma by age group, 28 Age (yr) plus Total Males Females Risk factors Immune defi ciency is a well described risk factor for non Hodgkin s lymphoma often associated with either immunosuppressive therapy following organ transplant infection with, human immunodefi ciency virus (HIV) or autoimmune diseases 136. There is some evidence of higher risk of non Hodgkin s lymphoma in siblings or fi rst-degree relatives of people with lymphoma or other hematologic malignancies 137. An increased risk of NHL is also associated with previous cancer treatment, exposure to infectious agents such as Epstein Barr virus, human T cell lymphotrophic virus (HTLVI), HIV, hepatitis C, Helicobacter pylori and human herpes virus 8, autoimmuine disease, and exposure to agricultural chemicals such as pesticides and herbicides, and occupational exposure to arsenic compounds, chlorophenols, diesel fuel, nitrites/nitrates/nitrosamines, and organic dusts

76 Cancer in New South Wales: Incidence and Mortality Report 28» oesophageal cancer Oesophageal cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 1.4%.8% 1.2% Rank against all cancer: 14 th 21 st 2 th Age-standardised rate per 1,: year trend (rates ): 24.1% Risk of diagnosis by age 75 years: 1 in in in 248 Risk of diagnosis by age 85 years: 1 in 86 1 in in 13 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 3.% 2.% 2.6% Rank against all cancer deaths: 11 th 13 th 13 th Age-standardised rate per 1,: year trend (rates ): Risk of death by age 75 years: 1 in in in 359» Between the incidence rates for oesophageal cancer fell by 24.1 per cent in females and showed no statistically signifi cant change for males.» Mortality rates mirrored incidence rates because survival is poor.» The fi ve-year relative survival in NSW was 15 per cent for males and 2 per cent for females.» Tobacco smoking and alcohol consumption are the major contributing factors in the development of oesophageal cancer and their effects are multiplicative.» There is convincing evidence that greater body fatness is a cause of adenocarcinoma of the oesophagus. Risk of death by age 85 years: 1 in in in 16 Median age at death: 7 81 Survival Relative fi ve-year 22 26: 15% 2% Change from : Change was not statistically signifi cant 2% 4% After allowing for differences in age, males were 2.7 times more likely than females to be diagnosed with oesophageal cancer and 2.5 times more likely to die from it. The majority of new cases were in people aged 65 years and older: 62 per cent for males and 82 per cent for females. Incidence and mortality rates increased with age with higher rates in males compared to females aged years and older. Between and incidence rates were between four and six times higher in males. 74

77 » oesophageal cancer Figure 28 Oesophageal cancer Age-standardised incidence, NSW Age-standardised mortality, NSW 1 1 Rate per 1, 5 Rate per 1, Males Females Table 34 Numbers of new cases of oesophageal cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Tobacco smoking and alcohol consumption are the major risk factor in oesophageal cancer and their effects are multiplicative Body fatness is a risk factor People with Barrett s oesophagus, gastroesophageal refl ux disease, tylosis and achalasia are at greater risk. Barrett s esophagus is a condition in which the tissue lining the esophagus is replaced by tissue that is similar to the lining of the intestine. it is commonly found in people with gastroesophageal refl ux disease (GERD)

78 Cancer in New South Wales: Incidence and Mortality Report 28» ovarian cancer Ovarian cancer Incidence FEMALES New cases: 426 Percentage of all cancer: 2.7% Rank against all cancer: 1 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 117 Risk of diagnosis by age 85 years: 1 in 78 Median age at diagnosis: 64» There were 426 new cases of ovarian cancer in 28 and 285 deaths.» In 28 the median age at diagnosis of ovarian cancer was 64 and the median age at death was 73.» The fi ve-year relative survival in NSW was 44 per cent.» Reproductive factors such as early menarche, late menopause, having no children, or having children after the age of 3, oestrogen-only hormone replacement therapy or treatment with fertility drugs. Mortality Total deaths: 285 Percentage of all cancer deaths: 4.9% Rank against all cancer deaths: Age-standardised rate per 1,: year trend (rates ): Risk of death by age 75 years: 1 in 218 Risk of death by age 85 years: 1 in 17 Median age at death: 73 6 th Survival Relative fi ve-year 22 26: 44% Change from : Change was not statistically signifi cant 2% 49 per cent of new cases were in females aged 65 years or older. Age-specifi c incidence and mortality rates from ovarian cancer increased steadily from ages 35 years and older. 76

79 » ovarian cancer Figure 29 Ovarian cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 1 8 Rate per 1, Males Females Table 35 Numbers of new cases of ovarian cancer by age group, 28 Age (yr) plus Total Females Risk factors Reproductive factors such as early menarche, late menopause, having no children, or having children after the age of 3 years, oestrogen-only hormone replacement therapy can increase the risk of ovarian cancer 15,151. Ovarian cancer is associated with a family history of ovarian, breast or colon cancer, or a personal history of breast cancer 15,152. The breast ovarian cancer syndrome accounts for approximately 9 per cent of all hereditary ovarian cancer cases and is most frequently associated with mutations in the BRCA1 or BRCA2 genes 153,154. Genetic factors (inherited and somatic) as well as hormonal and environmental exposures all contribute to the development of ovarian cancer. Five to 1 per cent of patients are likely to have inherited a genetic predisposition to the disease 15. There is inconsistent evidence that obesity increases the risk of ovarian cancer

80 Cancer in New South Wales: Incidence and Mortality Report 28» pancreatic cancer Pancreatic cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 2.1% 2.6% 2.3% Rank against all cancer: 11 th 11 th 12 th Age-standardised rate per 1,: year trend (rates ): 18.7% Risk of diagnosis by age 75 years: 1 in in in 145 Risk of diagnosis by age 85 years: 1 in 54 1 in 75 1 in 64 Median age at diagnosis: Mortality» Between 1999 and 28 the incidence rates for pancreatic cancer in males increased by 18.7 per cent and mortality rates increased by 16.3 per cent.» The fi ve-year relative survival in NSW was 6 per cent for males and 8 per cent females.» Tobacco smoking is strongly associated with pancreatic cancer incidence such that smokers are two to three times more likely to develop this cancer than non smokers. Total deaths: Percentage of all cancer deaths: 5.2% 6.3% 5.7% Rank against all cancer deaths: 4 th 5 th 6 th Age-standardised rate per 1,: year trend (rates ): 16.3% Risk of death by age 75 years: 1 in in in 172 Risk of death by age 85 years: 1 in 64 1 in 88 1 in 75 Median age at death: Survival Relative fi ve-year 22 26: 6% 6% Change from : unchanged 2% Change was not statistically signifi cant After allowing for differences in age, males were 1.3 times more likely than females to be diagnosed with pancreatic cancer and die from pancreatic cancer. The majority of new cases were in people aged 65 years and older: 71 per cent for males and 81 per cent for females. Incidence and mortality rates increased with age. Rates for males were double those for females aged years to 6 64 years. Incidence and mortality rates were similar due to poor survival from this cancer. 78

81 » pancreatic cancer Figure 3 Pancreatic cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, Rate per 1, Males Females Table 36 Numbers of new cases of pancreatic cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Tobacco smoking is strongly associated with pancreatic cancer 24,162. Diabetes, chronic cirrhosis, pancreatitis and prior cholecystectomy increases the risk 163. High alcohol consumption is associated with a moderately increased risk 164. Obesity, increased height and abdominal fatness increases the risk of pancreatic cancer 165. Occupational exposure to chlorinated solvents and other aromatic hydrocarbons, nickel, chromium compounds, silica dust, and aliphatic solvents increase the risk 166. Genetic predisposition plays a small but signifi cant role in pancreatic cancer risk for a small number of people 167. Sporadic cancers of the pancreas are frequently associated with the activation of an oncogene, K-ras, and the inactivation of multiple tumour suppressor genes, including p53, DPC4, p16, and BRCA2. 79

82 Cancer in New South Wales: Incidence and Mortality Report 28» prostate cancer Prostate cancer Incidence MALES New cases: 6,95 Percentage of all cancer: 33.1% Rank against all cancer: Age-standardised rate per 1,: year trend (rates ): 61% Risk of diagnosis by age 75 years: 1 in 7 Risk of diagnosis by age 85 years: 1 in 4 1 st» There were 6,95 new cases of prostate cancer in NSW in 28.» Prostate cancer was the most common cancer in NSW overall and in males with 33 per cent of all new cases in males.» Between 1999 and 28 the incidence rates of prostate cancer increased by 61 per cent.» The fi ve-year relative survival in NSW was 9 per cent for males diagnosed with prostate cancer.» Family history is considered as the strongest risk factor for prostate cancer. Median age at diagnosis: 68 Mortality Total deaths: 93 Percentage of all cancer deaths: 12.6% Rank against all cancer deaths: 2 nd Age-standardised rate per 1,: year trend (rates ): 2.3% Risk of death by age 75 years: 1 in 114 Risk of death by age 85 years: 1 in 27 Median age at death: 8 Survival Relative fi ve-year 22 26: 9% Change from : 2% Change was not statistically signifi cant 63 per cent of new cases were in males aged 65 years and older. Incidence and mortality increased with age. Prostate cancer was the most common cancer overall in people aged 55 to 85 years and the most common cancer in males from age 5 years and older. Prostate cancer mortality rates increased by.8 per cent per annum until 1993 and declined thereafter at a rate of 1.9 per cent per annum. The most likely reason for the increase in prostate cancer incidence is increased awareness and participation of PSA testing. Twentyseven per cent of Australian men aged 5 years and over had at least one PSA test in 1995 or 1996; 33 per cent of men had a PSA in this period. In NSW the number of PSA tests per quarter was highly correlated with the number of new cases of prostate cancer (R 2 =.92). xv The current Australian policy is to not recommend population based screening for prostate cancer. xv. Smith DP, Armstrong B, Prostate specifi c antigen testing in Australia and association with prostate cancer incidence in NSW, MJA 1988, 169:

83 » prostate cancer Figure 31 Prostate cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 1 Rate per 1, Males Females Table 37 Numbers of new cases of prostate cancer by age group, 28 Age (yr) plus Total Males 164 2,42 3, ,95 Risk factors Age is an established risk factor for prostate cancer with the risk increasing with advancing age 168,169. Family history is considered a strong risk factor for prostate cancer. The risk is higher among men who have a fi rst-degree relative (father or brother) with the disease Among men with early onset prostate cancer, hereditary susceptibility is predominant, and may account for as much as 3 per cent to 4 per cent of cases High intake of foods from animal sources that contain high levels of saturated fat and foods that are refi ned carbohydrate have been identifi ed as increasing the risk for prostate cancer

84 Cancer in New South Wales: Incidence and Mortality Report 28» rectal cancer Rectal cancer Incidence MALES FEMALES ALL PEOPLE New cases: 1, ,67 Percentage of all cancer: 4.9% 4.2% 4.6% Rank against all cancer: 5 th 5 th 7 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 44 1 in 83 1 in 58 Risk of diagnosis by age 85 years: 1 in 27 1 in 49 1 in 35 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths: 5.2% 4.% 4.6% Rank against all cancer deaths: 4 th 8 th 8 th Age-standardised rate per 1,: year trend (rates ): 17.9% 21.2% Risk of death by age 75 years: 1 in in in 195 Risk of death by age 85 years: 1 in 66 1 in in 94 Median age at death: 74 73» Allowing for differences in age, males are two times more likely to be diagnosed with and die from rectal cancer than females.» Mortality rates fell by 17.9 per cent in males and by 21.2 per cent in females between 1999 and 28.» The majority of new cases with 54 per cent for males and 6 per cent for females were aged 65 years or older at diagnosis.» The fi ve-year relative survival in NSW was 64 per cent for males and 67 per cent for females.» There is convincing evidence that greater abdominal fatness is a cause of bowel cancer.» High intake of processed meat increases the risk of rectal cancer. There is consistent evidence that increased consumption of alcohol also increases the risk. Survival Relative fi ve-year 22 26: 64% 67% Change from : 2% 1% Change was not statistically signifi cant After allowing for differences in age, males were 1.8 times more likely than females to be diagnosed with rectal cancer and 2. times more likely to die from it. The majority of new cases were in people aged 65 years and older: 54 per cent for males and 6 per cent for females. Incidence and mortality rates increased with age. They were higher in males than females aged years and older. 82

85 » rectal cancer Figure 32 Rectal cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 25 2 Rate per 1, Males Females Table 38 Numbers of new cases of rectal cancer by age group, 28 Age (yr) plus Total Males ,16 Females Risk factors High intake of processed meat increases the risk of rectal cancer 182. Consumption of alcohol increases the risk of rectal cancer Greater abdominal fatness is a cause of bowel cancer. There is limited evidence that higher consumption of food containing iron, foods containing animal fats, sugar and cheese increase the risk of rectal cancer 186. There is some evidence that the risk of colorectal cancer is increased among tobacco smokers. However, the association has not been established as being causal

86 Cancer in New South Wales: Incidence and Mortality Report 28» stomach cancer Stomach cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 2.% 1.6% 1.8% Rank against all cancer: 12 th 14 th 15 th Age-standardised rate per 1,: year trend (rates ): 22.1% 1.9% Risk of diagnosis by age 75 years: 1 in in in 168 Risk of diagnosis by age 85 years: 1 in 61 1 in in 83 Median age at diagnosis: 7 75 Mortality Total deaths: » Males are twice as likely to be diagnosed with and die from stomach cancer as females.» The majority of new cases with 67 per cent for males and 71 per cent for females were aged 65 years or older at diagnosis.» Stomach cancer mortality rates fell by 24.2 per cent in males from 1999 to 28.» The fi ve-year relative survival in NSW was 31 per cent.» There has been a steady decline in both incidence and mortality rates since Percentage of all cancer deaths: 4.% 3.1% 3.6% Rank against all cancer deaths: 8 th 9 th 11 th Age-standardised rate per 1,: year trend (rates ): 24.2% Risk of death by age 75 years: 1 in in 38 1 in 257 Risk of death by age 85 years: 1 in 84 1 in in 12 Median age at death: Survival Relative fi ve-year 22 26: 31% 31% Change from : Change was not statistically signifi cant 1% unchanged After allowing for differences in age, males were 2. times more likely than females to be diagnosed with and die from stomach cancer. The majority of new cases were in people aged 65 years and older: 67 per cent for males and 71 per cent for females. Incidence and mortality rates increased with age. From ages 45 to 84 years, incidence in males was more than double females. There has been a steady fall in both incidence and mortality since data collection began in 1972 when stomach cancer was the fourth most common cancer in males and the third most common cause of cancer death in males and females. 84

87 » stomach cancer Figure 33 Stomach cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 15 Rate per 1, Males Females Table 39 Numbers of new cases of stomach cancer by age group, 28 Age (yr) plus Total Males Females Risk factors A common stomach bacteria (H. pylori) that can cause low-grade infection in the stomach, is a strong risk factor 24,19. Tobacco smoking is strongly associated with stomach cancer191,192. Diets high in salt, foods that are smoked, or that consists of frequent consumption of red or processed meat, heavily grilled or barbecued meats, or whose food is poorly refrigerated, increase the risk. Obesity and high caloric consumption increase the risk. Gastric (stomach) ulcer disease may increase the risk. Exposure to nuclear radiation, especially at a young age, has been shown to produce a high risk of stomach cancer

88 Cancer in New South Wales: Incidence and Mortality Report 28» testicular cancer Testicular cancer Incidence MALES New cases: 212 Percentage of all cancer: 1% Rank against all cancer: 18 th Age-standardised rate per 1,: year trend (rates ): Risk of diagnosis by age 75 years: 1 in 227 Risk of diagnosis by age 85 years: 1 in 224 Median age at diagnosis: 34» Most cases are diagnosed in males aged less than 5 years with a median age of 34 years at diagnosis.» Mortality is low mainly due to platinum-based drugs introduced in the 198s.» Unlike most cancers, the incidence and mortality of testicular cancer peaked at years.» Mortality was very low at all ages.» The fi ve-year relative survival in NSW was 96 per cent. Mortality Total deaths: 3 Percentage of all cancer deaths:.% Rank against all cancer deaths: 4 th Age-standardised rate per 1,:.1 1 year trend (rates ): 56.4% Risk of death by age 75 years: 1 in 22,634 Risk of death by age 85 years: 1 in 22,634 Median age at death: 52 Survival Relative fi ve-year 22 26: 96 Change from : Change was not statistically signifi cant unchanged Incidence and mortality of testicular cancer peaked at years. Mortality was very low at all ages. Mortality rates have consistently declined due to effective platinum based treatments introduced in the 198s. 86

89 » testicular cancer Figure 34 Testicular cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 4 Rate per 1, Males Females Table 4 Numbers of new cases of testicular cancer by age group, 28 Age (yr) plus Total Males Risk factors Cryptorchidism (undescended testis) is a risk factor 194. Klinefelter s syndrome, a disease of chromosome abnormality is a risk factor 194. Infertility increases the risk Age (2 to 35 years) and a family history of testicular cancer are risks

90 Cancer in New South Wales: Incidence and Mortality Report 28» thyroid cancer Thyroid cancer Incidence MALES FEMALES ALL PEOPLE New cases: Percentage of all cancer: 1.% 3.7% 2.1% Rank against all cancer: 19 th 8 th 13 th Age-standardised rate per 1,: year trend (rates ): 78.8% 71.3% Risk of diagnosis by age 75 years: 1 in 28 1 in 79 1 in 114 Risk of diagnosis by age 85 years: 1 in in 68 1 in 96 Median age at diagnosis: Mortality Total deaths: Percentage of all cancer deaths:.1%.3%.2% Rank against all cancer deaths: 32 nd 27 th 32 nd Age-standardised rate per 1,: year trend (rates ): Risk of death by age 75 years: 1 in 4,38 1 in 2,956 1 in 3,392» Incidence numbers and rates are four times higher in females than in males.» Almost half of all new cases occurred in people aged less than 5 years» Between incidence rates increased by 78.8 per cent in males and 71.3 per cent in females.» Most of the increase is due to an increased detection of papillary thyroid cancer.» The fi ve-year relative survival in NSW was 91 per cent for males and 97 per cent for females.» Increased risk of thyroid cancer has been shown to be associated with working in wood processing, pulp and paper making, industries with exposure to solvents. Risk of death by age 85 years: 1 in 2,25 1 in 1,471 1 in 1,729 Median age at death: 7 76 Survival Relative fi ve-year 22 26: 91% 97% Change from : Change was not statistically signifi cant 1% 2% After allowing for differences in age, females were four times more likely than males to be diagnosed with thyroid cancer and seven times more likely to die from it. The majority of new cases were in people aged less than 64 years: 75 per cent for males and 79 per cent for females. In females incidence rates increased steeply in ages 1 39 years and then plateaued. From age 6 years incidence rates fell with increasing age. In males rates increased more uniformly with age but at a slower rate than in females. Rates in females are triple those in males aged 5 54 years increasing to six times those in males aged years. 88

91 » thyroid cancer Figure 35 Thyroid cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, Rate per 1, Males Females Table 41 Numbers of new cases of thyroid cancer by age group, 28 Age (yr) plus Total Males Females Risk factors Iodine defi ciency and iodine excess may contribute to the risk of thyroid cancer 24. Internal and external exposure of the thyroid to radiation increases the risk 21,22. Females, people over the age of 35 and those with a fi rst-degree relative with thyroid cancer are at increased risk 22,23. Genetic mutations involving BRAF and RAS genes cause papillary thyroid carcinoma, the most common type of thyroid cancer, and genetic disorder causes medullary thyroid carcinoma 24,25. Incidence of other cancers, including oesophageal, stomach, liver, bone, brain, pancreatic and colorectal cancer increases the risk 26. Exposure to solvents and occupation exposure in wood processing, pulp and paper making, increases the risk 27,28. 89

92 Cancer in New South Wales: Incidence and Mortality Report 28» uterine cancer Uterine cancer Incidence FEMALES New cases: 625 Percentage of all cancer: 4% Rank against all cancer: Age-standardised rate per 1,: year trend (rates ): 19.1% Risk of diagnosis by age 75 years: 1 in 73 Risk of diagnosis by age 85 years: 1 in 52 Median age at diagnosis: 63 Mortality 7 th» Uterine cancer accounted for four per cent of all cancers in females and ranked seventh for incidence in females in 28.» Between the incidence rates for uterine cancer increased by 19.1 per and there was no statistically signifi cant change in mortality rates.» The fi ve-year relative survival was 8 per cent.» The well-documented risk factors for the development of uterine cancer are chronic oestrogen exposure including oral intake of oestrogen, extended periods of anovulation, early menarche, and late menopause.» Being overweight, especially with higher abdominal fatness, are important risk factors for uterine cancer. Other risk factors are physical inactivity, high caloric intake, high blood pressure and high blood glucose concentrations. Total deaths: 126 Percentage of all cancer deaths: 2.2% Rank against all cancer deaths: 16 th Age-standardised rate per 1,: year trend (rates ): Risk of death by age 75 years: 1 in 598 Risk of death by age 85 years: 1 in 258 Median age at death: 75 Survival Relative fi ve-year 22 26: 8% Change from : unchanged Change was not statistically signifi cant 53 per cent of new cases were in women aged less than 64 years. Age specifi c incidence rates increased in ages years, but were lower in those aged 85 years and over. Age specifi c mortality rates increased steadily from age 5 years and older. Thirty-four per cent of endometrial cancers have been attributed to obesity in the United States between 1988 and 1994 and 4 per cent between 1999 and 2. In later metanalysis 4 per cent of cases of uterine cancer were considered to be due to overweight or obesity in developed countries. 9

93 » uterine cancer Figure 36 Uterine cancer Age-standardised incidence, NSW Age-standardised mortality, NSW Rate per 1, 1 Rate per 1, Males Females Table 42 Numbers of new cases of uterine cancer by age group, 28 Age (yr) plus Total Females Risk factors Chronic oestrogen exposure including oral intake of oestrogen, extended periods of anovulation, early menarche, and late menopause are risk factors 29,21. Breast cancer, ovarian tumours or polycystic ovary syndrome, gallbladder disease, oestrogen-producing tumours, diabetes and hypertension may increase the risk of uterine cancer Women with a family history of uterine cancer or hereditary non-polyposis colorectal cancer are at increased risk of uterine cancer 21. Excessive consumption of fat and being overweight, especially with higher abdominal fatness, are important risk factors for uterine cancer 24,21. Physical inactivity, high caloric intake, high blood pressure and high blood glucose concentrations increase the risk 212,

94 Cancer in New South Wales: Incidence and Mortality Report 28» regional variation Regional variation in incidence rates, NSW Area Health Services, Table 43 Regional variation in incidence rates, NSW Area Health Services, This chart shows new Area Health Services that have signifi cantly (p<.1) higher or lower age-standardised incidence rates of cancer when compared to NSW as a whole. Sydney South West South Eastern Sydney & Illawarra Sydney West Northern Sydney & Central Coast Hunter & New England North Coast Greater Southern Greater Western M F M F M F M F M F M F M F M F All cancers Breast Bowel Kaposi s Sarcoma Lip Liver Lung, bronchus Melanoma Non-Hodgkin s Lymphoma Prostate Stomach Rectal Thyroid Myeloproliferative disorders Cancer unknown primary HIGH LOW NOT SIGNIFICANTLY DIFFERENT FROM WHOLE STATE The following cancer types showed no signifi cant geographical variation across Area Health Services within NSW: bladder, brain, colon, cervical, gallbladder, head and neck, Hodgkin s lymphoma, kidney, leukaemia, mesothelioma, multiple myeloma, oesophageal, ovarian, pancreas, small intestine, uterine, testicular. 92

95 » regional variation Regional variation in localised incidence rates, NSW Area Health Services, Table 44 Regional variation in incidence rates for localised cancers, NSW Area Health Services, This chart shows new Area Health Services that have signifi cantly (p<.1) higher or lower age-standardised incidence rates of localised cancers when compared to NSW as a whole. Sydney South West South Eastern Sydney & Illawarra Sydney West Northern Sydney & Central Coast Hunter & New England North Coast Greater Southern Greater Western M F M F M F M F M F M F M F M F All cancers Breast Colon Bowel Lip Liver Lung, bronchus Melanoma Prostate Rectal Thyroid HIGH LOW NOT SIGNIFICANTLY DIFFERENT FROM WHOLE STATE The following cancer types showed no signifi cant geographical variation across Area Health Services within NSW: bladder, bowel, brain, cervical, gallbladder, head and neck, Hodgkin s lymphoma, Kaposi s sarcoma, kidney, leukaemia, mesothelioma, multiple myeloma, non- Hodgkin s lymphoma, oesophageal, ovarian, pancreas, small intestine, stomach, testicular, uterine, myeloproliferative disorders and cancer unknown primary. 93

96 Cancer in New South Wales: Incidence and Mortality Report 28 Regional variation in mortality rates, NSW Area Health Services, Table 45 Regional variation in mortality rates, NSW Area Health Services, This chart shows new Area Health Services that have signifi cantly (p<.1) higher or lower age-standardised mortality rates of cancer when compared to NSW as a whole. Sydney South West South Eastern Sydney & Illawarra Sydney West Northern Sydney & Central Coast Hunter & New England North Coast Greater Southern Greater Western M F M F M F M F M F M F M F M F All cancers Liver Lung, bronchus Melanoma Mesothelioma Prostate Cancer unknown primary HIGH LOW NOT SIGNIFICANTLY DIFFERENT FROM WHOLE STATE The following cancer types showed no signifi cant geographical variation across Area Health Services within NSW: bladder, bowel, brain, breast, cervical, colon, gallbladder, head and neck, Hodgkin s lymphoma, Kaposi s sarcoma, kidney, lip, leukaemia, multiple myeloma, non-hodgkin s lymphoma, oesophageal, ovarian, pancreas, rectal, small intestine, stomach, testicular, thyroid, uterine and myeloproliferative disorders. 94

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106 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Age and sex-specifi c tables by cancer type Description of tables The following tables, three for new cases and a corresponding three for deaths are grouped as follows: Tables 46 to 49 provide a breakdown of new cases and deaths for fi ve-year age groups from 4 years to 95 years and older, the total numbers of cases and deaths and the percentage of all cases for the same sex. Tables 47 and 5 include age specifi c incidence and mortality rates, the crude rate, cumulative rate to age 75 years, cumulative risk expressed as one in to age 75 and 85 and rates directly standardised to the age distribution of the standard world population and the population of Australia in 21. The crude and age-standardised rates are expressed per 1, populations. The cumulative rate is a percentage as well as lifetime risk to 75 years and to 85 years. Tables 48 and 51 have two directly age-standardised rates with 95 per cent confi dence intervals. Grouping of cancer sites and deaths All tables include results for the three groups of cancers: head and neck, colorectal (bowel) and all leukaemias. Note that head and neck includes cancers of oral cavity (mouth (C1-C6), salivary glands (C7-C8), pharynx (C9-C14)) and upper respiratory tract (nose, sinuses, etc (C3-C31) and larynx (C32)). It does not include lip cancer (C). The total number of cancers is referred to as All sites except non-melanocytic skin cancers. As well as melanocytic skin cancers, the total includes Kaposi s sarcoma of the skin and cutaneous lymphomas. Other rare non-melanocytic skin cancers such as Merkel cell tumours are tabulated by site. Basal and squamous cell carcinomas of the skin are not registered and not included. Since the introduction of ICD-3 myelodysplasia and myeloproliferative disorders are now considered invasive. Historically, these have been considered pre-leukaemic and not notifi ed to the registry. 14

107 » age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 Cancer type (ICD-1) Sex All ages % C Lip M F T C1-2 Tongue M F T C3-6 Mouth M F T C7-8 Salivary gland M F T C9-1 Oropharynx M F T C11 Nasopharynx M F T C12-13 Hypopharynx M F T C14 Pharynx unspecifi ed M F T C1-C14, C3-C32 Head and neck M F T

108 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C15 Oesophagus M F T C16 Stomach M F T C17 Small intestine M F T C18 Colon M , F , T , C19-21 Rectum etc. M , F T , C18-21 Bowel M , F , T , C22 Liver M F T C23-24 Gallbladder etc. M F T C25 Pancreas M F T

109 » age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C3-31 Nose, sinuses, etc. M F T C32 Larynx M F T C33-34 Bronchus, lung M , F , T , C37-38 Other thoracic organs M F T C4-41 Bone M F T C43 Melanoma M , F , T , C45 Mesothelioma M F T C46 Kaposi s sarcoma M F T C47,C49 Connective tissue, peripheral nerves M F T

110 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C5 Breast M F , T , C53 Cervix F T C545 Uterus, Body & NOS F T C56-57 Ovary, etc F T C58 Placenta F T C51-2 Other female genital F T C61 Prostate M , T , C62 Testis M T C6,C63 Other male genital M T C64-6,8 Kidney, etc M F T ,2 2.7 C67 Bladder M F T C69 Eye M F T

111 » age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C71 Brain M F T C7,C72 Central nervous system M F T C73 Thyroid M F T C74,C75 Other endocrine M F T C81 Hodgkin s lymphoma M F T C82-C85 Non-Hodgkin s lymphoma M F T , C88-C9, Multiple myeloma M F T C91. Acute lymphoid leukaemia M F T C Other lymphoid leukaemia M F T

112 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 46 New cases of cancer - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C92. Acute myeloid leukaemia M F T C Other myeloid leukaemia M F T C93-C95 Other and unspecifi ed leukaemias M F T C91-C95 All leukaemia M F T C26,C39, C48, C76,C8 Other & unspecifi ed sites M F T , M95 Myelodysplasia M F T C-C96 All sites except NMSC M ,269 2,13 2,899 3,134 2,918 2,869 2,28 1, ,873 1 F ,61 1,35 1,566 1,75 1,734 1,685 1,693 1,61 1, ,738 1 T ,76 1,836 2,574 3,669 4,649 4,868 4,63 4,562 3,818 2, ,

113 » age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 1 Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C Lip M F T C1-2 Tongue M F T C3-6 Mouth M F T C7-8 Salivary gland M F T C9-1 Oropharynx M F T C11 Nasopharynx M F T C12-13 Hypopharynx M F T C14 Pharynx unspecifi ed M F T C1-C14, C3-C32 Head and neck M F T Crude incidence rate, cumulative incidence rate and risk to age 85, and directly standardised rates using World and Australia, 21 as standard populations 111

114 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C15 Oesophagus M F T C16 Stomach M F T C17 Small intestine M F T C18 Colon M F T C19-21 Rectum etc. M F T C18-21 Bowel M F T C22 Liver M F T C23-24 Gallbladder etc. M F T C25 Pancreas M F T

115 » age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C3-31 Nose, sinuses, etc. M F T C32 Larynx M F T C33-34 Bronchus, lung M F T C37-38 Other thoracic organs M F T C4-41 Bone M F T C43 Melanoma M F T C45 Mesothelioma M F T C46 Kaposi s sarcoma M F T C47,C49 Connective tissue, peripheral nerves M F T

116 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C5 Breast M F T C53 Cervix F T C545 Uterus, Body & NOS F T C56-57 Ovary, etc F T C58 Placenta F T C51-2 Other female genital F T C51-8 All gynae cological F T C61 Prostate M T C62 Testis M T C6,C63 Other male genital M T C64-6,8 Kidney, etc M F T C67 Bladder M F T

117 » age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C69 Eye M F T C71 Brain M F T C7,C72 Central nervous system M F T C73 Thyroid M F T C74,C75 Other endocrine M F T C81 Hodgkin s lymphoma M F T C82-C85 Non-Hodgkin s lymphoma M F T C88-C9, Multiple myeloma M F T

118 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust C91. Acute lymphoid leukaemia M F T C Other lymphoid leukaemia M F T C92. Acute myeloid leukaemias M F T C Other myeloid leukaemias M F T C93-C95 Other and unspecifi ed leukaemia M F T C91-C95 All leukaemia M F T C81-C96 All haemato poietic M F T C26,C39, C48, C76,C8 Other & unspecifi ed sites M F T

119 » age- and sex-specifc tables Table 47 Age-specifi c incidence rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised Per cent World Aust M95 Myelodysplasia M F T C-C96 All sites except NMSC M F T

120 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 48 Summary of age standardised cancer incidence, crude and cumulative incidence rates, NSW, 28 1 MALES FEMALES PERSONS Cancer type (ICD-1) No. % Standardised Incidence rates per 1, No. % Standardised Incidence rates per 1, No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C Lip ( ) 4.7 ( ) ( ) 1.8 ( ) C3-6 Mouth ( ) 2.9 ( ) ( ) 1.8 ( ) C7-8 Salivary gland ( ) 1.5 ( ) ( ).8 ( ) 86.2 C9-1 Oropharynx ( ) 2.9 ( ) ( ).8 ( ) C11 Nasopharynx ( ) 1.1 ( ) ( ).3 ( ) 47.1 C12-13 Hypopharynx ( ) 1 ( ) (. -.3 ).2 ( ) 43.1 C14 Pharynx unspecifi ed ( ).5 ( ) (. -.2 ).2 ( ) 22.1 C1-C14, C3-C32 Head and neck ( ) 19.6 ( ) ( ) 6.4 ( ) C15 Oesophagus ( ) 8.2 ( ) ( ) 3 ( ) C16 Stomach ( ) 11.7 ( ) ( ) 5.9 ( ) C17 Small intestine ( ) 2.2 ( ) ( ) 1.2 ( ) 13.4 C18 Colon ( ) 44.8 ( ) ( ) 35.2 ( ) C19-21 Rectum etc ( ) 28.1 ( ) ( ) 15.8 ( ) C18-21 Bowel ( ) 73 ( ) ( ) 51 ( ) C22 Liver ( ) 9.3 ( ) ( ) 3.1 ( ) C23-24 Gallbladder etc ( ) 2.3 ( ) ( ) 2.5 ( ) 19.5 C25 Pancreas ( ) 12.6 ( ) ( ) 9.5 ( ) C3-31 Nose, sinuses, etc ( ) 1.2 ( ) ( ).5 ( ) 6.2 C32 Larynx ( ) 4.6 ( ) ( ).8 ( ) C33-34 Bronchus, lung ( ) 54.1 ( ) ( ) 32.9 ( ) C37-38 Other thoracic organs ( ).6 ( ) ( ).4 ( ) 34.1 C4-41 Bone ( ).9 ( ) ( ).5 ( ) 49.1 C43 Melanoma ( ) 59.9 ( ) ( ) 37.4 ( ) C45 Mesothelioma ( ) 5 ( ) ( ).9 ( ) Numbers and percentage of all cancers, crude incidence rate, cumulative incidence rate and directly standardised incidence rates using World and Australia, 21 as standard populations (including 95% confi dence intervals). 118

121 » age- and sex-specifc tables Table 48 Summary of age standardised cancer incidence, crude and cumulative incidence rates, NSW, 28 (cont d) MALES FEMALES PERSONS Cancer type (ICD-1) No. % Standardised Incidence rates per 1, No. % Standardised Incidence rates per 1, No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C47,C49 Connective tissue, peripheral nerves ( ) 2.8 ( ) ( ) 2.3 ( ) C5 Breast (.5-1. ) 1.2 ( ) ( ) ( ) C53 Cervix n.a ( ) 6.7 ( ) C545 Uterus, Body & NOS n.a ( ) 15.6 ( ) C56-57 Ovary, etc n.a ( ) 1.7 ( ) C58 Placenta n.a (. -.3 ).1 (. -.3 ) 3 C51-2 Other female genital n.a ( ) 3.8 ( ) C61 Prostate ( ) ( ) n.a C62 Testis ( ) 6.2 ( ) n.a C6,C63 Other male genital ( ) 1.4 ( ) n.a. 5.1 C64-6,8 Kidney, etc ( ) 17.5 ( ) ( ) 9.4 ( ) C67 Bladder ( ) 15.6 ( ) ( ) 3.9 ( ) C69 Eye ( ) 1.6 ( ) ( ) 1 ( ) 96.3 C71 Brain ( ) 8.3 ( ) ( ) 5.3 ( ) C7,C72 Central nervous system ( ).3 ( ) ( ).3 ( ) 23.1 C73 Thyroid ( ) 5.7 ( ) ( ) 15.8 ( ) C74,C75 Other endocrine ( ).6 (.4-1. ) ( ).4 ( ) 38.1 C81 Hodgkin s lymphoma ( ) 2.8 ( ) ( ) 1.8 ( ) C82-C85 Non-Hodgkin s lymphoma ( ) 21.3 ( ) ( ) 15.5 ( ) C88-C9, Multiple myeloma ( ) 6.6 ( ) ( ) 3.8 ( )

122 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 48 Summary of age standardised cancer incidence, crude and cumulative incidence rates, NSW, 28 (cont d) MALES FEMALES PERSONS Cancer type (ICD-1) No. % Standardised Incidence rates per 1, No. % Standardised Incidence rates per 1, No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C91. Acute lymphoid leukaemia ( ) 1.7 ( ) ( ) 1.3 ( ) 11.3 C Other lymphoid leukaemia ( ) 5 ( ) ( ) 2.7 ( ) C92. Acute myeloid leukaemia ( ) 4.5 ( ) ( ) 3.4 ( ) C Other myeloid leukaemia ( ) 2.5 ( ) ( ) 1.5 ( ) C93-C95 Other and unspecifi ed leukaemias ( ) 1.3 ( ) ( ).5 ( ) 69.2 C91-C95 All leukaemia ( ) 14.9 ( ) ( ) 9.4 ( ) C26,C39 Other & unspecifi ed sites ( ) 15.6 ( ) ( ) 11.5 ( ) M95 Myelosysplasia ( ) 7.5 ( ) ( ) 4.8 ( ) C-C96 All sites except NMSC ( ) ( ) ( ) 391.3( )

123 » age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 Cancer type (ICD-1) Sex All ages % C Lip M F 1 1. T C1-2 Tongue M F T C3-6 Mouth M F T C7-8 Salivary gland M F T C9-1 Oropharynx M F T C11 Nasopharynx M F T C12-13 Hypopharynx M F T C14 Pharynx unspecifi ed M F T C1-C14, C3-C32 Head and neck M F T

124 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C15 Oesophagus M F T C16 Stomach M F T C17 Small intestine M F T C18 Colon M F T C19-21 Rectum etc. M F T C18-21 Bowel M F T C22 Liver M F T C23-24 Gallbladder etc. M F T C25 Pancreas M F T

125 » age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C3-31 Nose, sinuses, etc. M F T C32 Larynx M F T C33-34 Bronchus, lung M F T C37-38 Other thoracic organs M F T C4-41 Bone M F T C43 Melanoma M F T C45 Mesothelioma M F T C46 Kaposi s sarcoma M 1 1. F. T 1 1. C47,C49 Connective tissue, peripheral nerves M F T

126 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C5 Breast M F T C53 Cervix M F T C54 Body of uterus M F T C55 Uterus unspecifi ed M F T C56-57 Ovary, etc M F T C51-2 Other female genital M F T C61 Prostate M F T C62 Testis M F T C6,C63 Other male genital M F T

127 » age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C64-6,8 Kidney, etc M F T C67 Bladder M F T C69 Eye M F T C71 Brain M F T C7,C72 Central nervous system M 1 1. F T C73 Thyroid M F T C74,C75 Other endocrine M F T C81 Hodgkin s lymphoma M F T C82-C85 Non-Hodgkin s lymphoma M F T

128 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % C88-C9, Multiple myeloma M F T C91. Acute lymphoid leukaemia M F T C Other lymphoid leukaemia M F T C92. Acute myeloid leukaemia M F T C Other myeloid leukaemia M F T C93-C95 Other and unspecifi ed leukaemias M F T C91-C95 All leukaemia M F T C26,C39, C48, C76,C8 Other & unspecifi ed sites M F T

129 » age- and sex-specifc tables Table 49 Cancer deaths - numbers and percentages of all cancers by type, age and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex All ages % M95 Myelodysplasia M F T C-C96 All sites except NMSC M F T

130 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 1 Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C Lip M F T C1-2 Tongue M F T C3-6 Mouth M F T C7-8 Salivary gland M F T C9-1 Oropharynx M F T C11 Nasopharynx M F T C12-13 Hypopharynx M F T C14 Pharynx unspecifi ed M F T C1-C14, C3-C32 Head and neck M F T Crude mortality rate, cumulative mortality rate and risk to age 85, and directly standardised rates using World and Australia, 21 as standard populations. 128

131 » age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C15 Oesophagus M F T C16 Stomach M F T C17 Small intestine M F T C18 Colon M F T C19-21 Rectum etc. M F T C18-21 Bowel M F T C22 Liver M F T C23-24 Gallbladder etc. M F T C25 Pancreas M F T

132 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C3-31 Nose, sinuses, etc. M F T C32 Larynx M F T C33-34 Bronchus, lung M F T C37-38 Other thoracic organs M F T C4-41 Bone M F T C43 Melanoma M F T C45 Mesothelioma M F T C46 Kaposi s sarcoma M F T C47,C49 Connective tissue, peripheral nerves M F T

133 » age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C5 Breast M F T C53 Cervix F T C54 Body of uterus F T C55 Uterus unspecifi ed F T C56-57 Ovary, etc F T C51-2 Other female genital F T C51-8 All gynaecological F T C61 Prostate M T C62 Testis M T C6,C63 Other male M T C64-6,8 Kidney, etc M F T C67 Bladder M F T

134 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C69 Eye M F T C71 Brain M F T C7,C72 Central nervous system M F T C73 Thyroid M F T C74,C75 Other endocrine M F T C81 Hodgkin s lymphoma M F T C82-C85 Non-Hodgkin s lymphoma M F T C88-C9, Multiple myeloma M F T C91. Acute lymphoid leukaemia M F T

135 » age- and sex-specifc tables Table 5 Age-specifi c mortality rates per 1, population by type and sex, NSW, 28 (cont d) Cancer type (ICD-1) Sex Crude Risk Risk Risk Standardised % 1-in- 1-in- World Aust C Other lymphoid leukaemia M F T C92. Acute myeloid leukaemia M F T C Other myeloid leukaemia M F T C93-C95 Other and unspecifi ed leukaemias M F T C91-C95 All leukaemia M F T C81-C96 All haematopoietic M F T C26,C39, C48, C76,C8 Other & unspecifi ed sites M F T M95 Myelodysplasia M F T C-C96 All sites except NMSC M F T

136 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 51 Summary of age standardised cancer mortality, crude and cumulative mortality rates, NSW, 28 1 MALES FEMALES PERSONS Cancer type ICD-1 No. % Standardised Mortality rates per 1, Standardised Mortality rates per 1, No. % No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C Lip (. -.2 ).2 ( ) 1 (. -. ) (. -.1 ) 7.1 C1-2 Tongue ( ) 1.4 ( ) ( ).3 ( ) 65.5 C3-6 Mouth (.5-1. ) 1.1 ( ) ( ).6 ( ) 64.5 C7-8 Salivary gland ( ).4 ( ) ( ).3 ( ) 26.2 C9-1 Oropharynx ( ).8 ( ) ( ).3 ( ) 4.3 C11 Nasopharynx ( ).5 ( ) ( ).2 ( ) 24.2 C12-13 Hypopharynx ( ).7 (.4-1. ) (. -.1 ).1 (. -.2 ) 28.2 C14 Pharynx unspecifi ed (. -.3 ).2 ( ) (. -.1 ).1 (. -.2 ) 11.1 C1-C14, C3-C32 Head and neck ( ) 7.2 ( ) ( ) 2.1 ( ) C15 Oesophagus ( ) 6.2 ( ) ( ) 2.5 ( ) C16 Stomach ( ) 8.5 ( ) ( ) 4.1 ( ) C17 Small intestine ( ).8 ( ) ( ).6 ( ) 51.4 C18 Colon ( ) 16 ( ) ( ) 12.3 ( ) C19-21 Rectum etc ( ) 1.9 ( ) ( ) 5.4 ( ) C18-21 Bowel ( ) 26.9 ( ) ( ) 17.7 ( ) C22 Liver ( ) 6.2 ( ) ( ) 2.1 ( ) C23-24 Gallbladder etc ( ) 1.8 ( ) ( ) 1.9 ( ) C25 Pancreas ( ) 1.8 ( ) ( ) 8.2 ( ) C3-31 Nose, sinuses, etc ( ).4 ( ) (. -.2 ).1 ( ) 19.1 C32 Larynx ( ) 2.1 ( ) (. -.2 ).2 ( ) 79.6 C33-34 Bronchus, lung ( ) 47 ( ) ( ) 24.6 ( ) C37-38 Other thoracic organs (. -.3 ).2 ( ) (. -.2 ).1 (. -.3 ) Numbers and percentage of all cancers, crude mortality rate, cumulative mortality rate and directly standardised mortality rates using World and Australia, 21 as standard populations (including 95% confi dence intervals). 134

137 » age- and sex-specifc tables Table 51 Summary of age standardised cancer mortality, crude and cumulative mortality rates, NSW, 28 (cont d) MALES FEMALES PERSONS Cancer type ICD-1 No. % Standardised Mortality rates per 1, Standardised Mortality rates per 1, No. % No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C4-41 Bone ( ).5 ( ) (. -.2 ).2 ( ) 24.2 C43 Melanoma ( ) 9.8 ( ) ( ) 3.4 ( ) C45 Mesothelioma ( ) 4.5 ( ) ( ).9 ( ) C46 Kaposi s sarcoma 1 (. -.1 ) (. -.2 ) (. -. ) (. -. ) 1 C47,C49 Connective tissue, peripheral nerves ( ).8 ( ) ( ).6 ( ) 51.4 C5 Breast (. -.2 ).1 (. -.3 ) ( ) 21.6 ( ) C53 Cervix n.a ( ) 2.5 ( ) 11.8 C55 Uterus unspecifi ed n.a ( ).4 ( ) 16.1 C56-57 Ovary, etc n.a ( ) 6.8 ( ) C51-2 Other female genital n.a ( ) 1 ( ) 45.3 C61 Prostate ( ) 27.8 ( ) n.a. 93 C62 Testis (. -.3 ).1 (. -.3 ) n.a. 3 C6,C63 Other male genital (. -.2 ).2 ( ) n.a. 6 C64-6,8 Kidney, etc ( ) 5.3 ( ) ( ) 2.7 ( ) C67 Bladder ( ) 6.2 ( ) (.6-1. ) 1.9 ( ) C69 Eye ( ).3 ( ) ( ).3 ( ) 24.2 C71 Brain ( ) 5.6 ( ) ( ) 3.5 ( ) C7,C72 Central nervous system 1 (. -.1 ) (. -.2 ) (. -.3 ).2 ( ) 8.1 C73 Thyroid ( ).3 ( ) ( ).5 ( ) 31.2 C74,C75 Other endocrine ( ).3 ( ) (. -.3 ).2 ( ) 18.1 C81 Hodgkin s lymphoma (. -.2 ).2 ( ) (. -.3 ).2 ( ) 15.1 C82-C85 Non-Hodgkin s lymphoma ( ) 8.5 ( ) ( ) 5.1 ( ) C88-C9, Multiple myeloma ( ) 4.1 ( ) ( ) 2.6 ( ) C91. Acute lymphoid leukaemia ( ).6 ( ) ( ).4 ( )

138 Cancer in New South Wales: Incidence and Mortality Report 28» age- and sex-specifc tables Table 51 Summary of age standardised cancer mortality, crude and cumulative mortality rates, NSW, 28 (cont d) MALES FEMALES PERSONS Cancer type ICD-1 No. % Standardised Mortality rates per 1, Standardised Mortality rates per 1, No. % No. % Crude Cum World Aust 21 Crude Cum World Aust 21 C Other lymphoid leukaemia ( ) 2 ( ) ( ).8 ( ) 15.8 C92. Acute myeloid leukaemia ( ) 3.2 ( ) ( ) 1.9 ( ) C Other myeloid leukaemia ( ) 1.2 ( ) ( ).5 ( ) 64.5 C93-C95 Other and unspecifi ed leukaemias ( ).5 ( ) (. -.1 ).1 (. -.2 ) 24.2 C91-C95 All leukaemia ( ) 7.6 ( ) ( ) 3.7 ( ) C26,C39, C48, C76,C8 Other & unspecifi ed sites ( ) 1.5 ( ) ( ) 8.2 ( ) M95 Myelodysplasia ( ) 3.9 ( ) ( ) 2.1 ( ) C-C96 All sites except NMSC ( ) ( ) ( ) ( )

139 » appendixes Appendixes Appendix One Cancer registration in New South Wales 124 Appendix Two Specifi c classifi cation and coding practices 127 Appendix Three Clinical Groupings used in this report 129 Appendix Four Survival methodology 13 Appendix Five Join point regression analysis 131 Appendix Six Trends in numbers of new cases 132 Appendix Seven Indices of data quality 135 Appendix Eight Trends in data quality indices, NSW, Appendix Nine Demography of New South Wales 14 Appendix Ten Statistical concepts and their use 143 Appendix Eleven Worked example of the main statistical calculations 147 Appendix Twelve Glossary 15 Appendix Thirteen Publications 1996 to

140 Cancer in New South Wales: Incidence and Mortality Report 28» appendixes Appendix One Cancer registration in New South Wales The NSW Central Cancer Registry was established in 1971 as a population-based register of all cancers in NSW residents. Currently notifi cation of malignant neoplasms is a statutory requirement for public and private hospitals, departments of radiation oncology, nursing homes, pathology laboratories, outpatient departments and day procedure centres. Data collected include identifying and demographic information, brief medical details describing the cancer and a record of at least one episode of care from each notifi er. Similar details are supplied electronically by many hospitals. The data are supplemented by pathology reports and death certifi cates. The fl ow chart summarises the process. For breast cancer and cutaneous melanoma additional prognostic factors are coded from pathology reports and in situ lesions are registered. Classifi cation and coding Primary site of cancer (topography) and cell type (morphology) are coded according to the International Classifi cation of Diseases for Oncology, Third edition (ICD-O-3) i. Hospitals in NSW code disease in ICD-1 AM (Australian modifi cation) ii, and are required to notify the following invasive codes: C-C76 and C8-C96. Notifi cation of basal and squamous cell carcinoma of skin is not required (C44, M85-M811). Routine quality control measures include: 1. Monitoring of notifi cation rates for each notifi er. 2. Extensive data entry validation and checks of consistency with other data items. 3. Routine periodic checks of the accuracy and reliability of coding and data entry. 4. Reconciliation of information from multiple sources. 5. Ongoing computerised scrutiny for multiple registrations of the same person. 6. Correction of inaccuracies found when data are used. 7. Maintenance of consistency of coding through regular internal coding meetings and resolution diffi culties in collaboration with medical experts and other cancer registries. 8. International Association of Cancer Registries check program used quarterly. 9. Use of conventions published by the International Association of Cancer Registries iii. Data available from the Registry. Data are available from the Registry in a number of formats: Published data: Registry publications are listed. The most recent report is available on the Cancer Institute NSW web site cancerinstitute.org.au Web Based reporting module: Ad hoc summary information: Special tabulations are available at an hourly charge. Identifi ed data: Notifi ers can request the Registry to supply follow-up data on notifi ed patients. Identifi ed data are available for scientifi c research after approval of a formal protocol submitted to the Cancer Institute NSW Ethics Committee. i. Percy C, Van Holten V, Muir C (eds). ICD-O International Classifi cation of Diseases for Oncology, 3nd edition. Geneva: WHO, 199. ii. National Centre for Classifi cation in Health. International Statistical Classifi cation of Diseases and Related Health Problems, 1th Revision, Australian Modifi cation (ICD-1-AM). Sydney: NCCH, iii. Parkin DM, Chen VW, Ferlay J et al. Comparability and Quality Control in Cancer Registration. IARC Technical Report No. 19. Lyon: International Agency for Research on Cancer,

141 » appendixes Figure A1 NSW Central Cancer Registry: Inputs, processes and outputs Person diagnosed with cancer EVENT Pathology result diagnosing cancer Hospital inpatient care for cancer Outpatient radiotherapy or chemotherapy Death NOTIFICATION Copy of pathology report Notification by medical records Notification by radiation oncology or outpatient departments Notification by NSW Principal Registrar of Births, Deaths and Marriages DATABASE NSW Central Cancer Registry Yes Reconcile and add extra information Is person already registered No Validate and register new cancer Cancer database Information about cancer OUTPUT Evaluation of Research Planning Education health programs National & international data sets OUTCOME Better cancer control 139

142 Cancer in New South Wales: Incidence and Mortality Report 28» appendixes Figure A2 Cancer notifi cation form V1/6 NSW CENTRAL CANCER REGISTRY Public Health Act, 1991 Please only notify admissions for which cancer is a principal or additional diagnosis. PLEASE PRINT CLEARLY 1. Name of Hospital 2. Unit Record No. 3. Family Name 4. Given Names Patient ID label may be used 5. Former Name(s)/Pseudonym(s) family, maiden, AKA, etc. 6. Sex M F 7. Residential Address 8. Postcode 9. Date of Birth Day Month Year 1. Age 11. Aboriginal Both Aboriginal & Torres Strait Islander 12. Country of Birth Torres Strait Islander Neither A nor Torres Strait Islander 13. Medicare Number 14. (a) Doctor in Charge of Case (full name) (b) GP or Referring Doctor if GP not known (full name) 15. Address of General Practitioner or Referring Doctor (if GP not known) 16. Date of Admission Day Month Year 17. Date of Separation Day Month Year 18. Status at Separation Alive Dead 19. More than one Primary Cancer Y N Different primary cancers in the one patient should be notified on separateforms 2. Date of Diagnosis of this Cancer (NOT onset of symptoms) 21. Was this person a resident of NSW or ACT at diagnosis? Month Year Not known NSW ACT Elsewhere (please state) Not known 22. Primary Site of Cancer 23. Laterality of Cancer Left Right Not applicable or not known 24. Morphological Type of Cancer 25. Name of Pathology Laboratory 26. Best Basis for Diagnosis at this Admission (a) Histology (b) Cytology (including blood or bone marrow smear) (c) Other (clinical, imaging, biochemical, etc) 27. Degree of Spread of Cancer at this Admission (a) Localised to organ of origin (b) Invasion of adjacent tissue or organs (c) Regional lymph nodes (d) Distant (e) Not known (f) Not applicable 28. Main Procedures for Cancer at this Admission (a) Principal Procedure (b) Other Procedure 29. For Coronial Inquiry Purposes Only Date of Death Day Month Year 3. Y N Signature Date 14

143 » appendixes Appendix Two Specifi c classifi cation and coding practices Classifi cation and coding Prior to July 1999, primary site of cancer was coded according to the International Classifi cation of Diseases, 9th revision (ICD-9) iv. Morphology was coded using SNOMED II morphology codes which is equivalent to ICD-O-1. Cases registered more recently were coded according to the International Classifi cation of Diseases for Oncology, 3rd edition (ICD-O-3) v. Though recorded when notifi ed, in situ cancers for breast and melanoma, and second primary cancers with the same three-digit topography code and related morphologies for all sites, are not tabulated in this report. However, data include cancers notifi ed only by death certifi cate (1.3 per cent males and 1.6 per cent females in 26) recorded as diagnosed at the time of death. Multiple primary cancers in the same person are counted according to the rules set out by the International Association of Cancer Registries vi. For tabulation in this report equivalent ICD-1 codes are used: Mesothelioma, Kaposi s sarcoma, lymphoma and other neoplasms of haematopoietic and reticuloendothelial systems are tabulated as separate entities, and cases are not included in statistics for the organs in which these diseases were diagnosed. Some sites have been grouped for comparability with previous reports. The following classifi c a t io ns should be noted. C Lip excludes skin of lip. C18 Colon carcinoid tumours of the appendix are assumed to be non-invasive unless the contrary is stated. All other carcinoid tumours with no further information are assumed to be invasive. C22 Liver includes only cancers specifi ed as primary. C48 Retroperitoneum and peritoneum cancers of these sites other than mesothelioma have been included with other and unspecifi ed primary sites. C43 Melanoma of skin excludes melanoma with no dermal invasion. C44 Skin apart from squamous cell carcinoma of lip, vulva, penis, scrotum and anus, basal and squamous cell carcinomas of skin are not registered. C45 Mesothelioma defi ned by morphology whatever the site of origin. C46 C53 C56 C67 Kaposi s sarcoma for any site of origin. Cervix includes microinvasive carcinomas but not CIN III or carcinoma-in-situ. Ovary tumours of uncertain behaviour are not included. Uterine adnexa (C57.-C57.7) are included. Bladder papillomata with no malignant change and in situ cancers are excluded. Invasive disease is assumed where behaviour cannot be established. C71 Brain benign tumours are not included. M95 Myelodysplasia and myeloproliferative disorders have only been considered invasive since the introduction of ICDO3 in June 24. iv. World Health Organization. Manual of the International Statistical Classifi cation of Diseases, Injuries, and Causes of Death Ninth Revision. Geneva: WHO, v. Percy C, Van Holten V, Muir C (eds). ICD-O International Classifi cation of Diseases for Oncology, 3nd edition. Geneva: WHO, 199. vi. Parkin DM, Chen VW, Ferlay J et al. Comparability and Quality Control in Cancer Registration. IARC Technical Report No. 19. Lyon: International Agency for Research on Cancer, vii. World Health Organization. Manual of the International Statistical Classifi cation of Diseases, Injuries, and Causes of Death Tenth Revision. Geneva: WHO,

144 Cancer in New South Wales: Incidence and Mortality Report 28» appendixes ICD-9, ICD-1 and code groups used in this report In annual reports before 1995 data were based on the ICD-9 viii topography codes for cancer type. All topography codes on the Cancer Registry database were translated to the International Classifi cation of Diseases for Oncology, 3rd edition. (ICD-O-3) viii in July In June 24, a third revision ICD-O-3 included myeloproliferative disorders and myelodysplastic syndromes as invasive cancers. These cancers moved from uncertain behaviour to invasive cancers. Currently this specialist oncology classifi cation is only used in cancer registries in Australia. Hospitals in NSW, which code inpatient data, and the Australian Bureau of Statistics, which codes deaths, moved from ICD-9 to ICD-1 in ICD-O-3 codes are readily mapped to ICD-1. The present report is based on ICD-1 ix topography codes tabulated in the same groups as for the 1995 to 1998 reports of cancer incidence and mortality in New South Wales. The special reporting category is to ensure continuity for trends. The following table shows the numbers of cases affected by changing tabulation practice. Note that Kaposi s sarcoma of the skin would have been excluded before Table A1 Topography codes classifi ed differently in ICD-9, ICD-1 and grouping used in this report Cancer site ICD-9 Code No. ICD-1 Code No. Report Code No. Mouth C3 31 C3 - C C C5,C6 95 Rectum including anus C19,C2 165 C19 - C C21 87 Other thoracic organs C37 19 C37 - C C38 19 Mesothelioma (in ICD-9 in C45 2 C45 2 included in primary site) in Kaposi s sarcoma in C46 24 C46 24 (included in primary site in ICD-9) in Connective and other soft tissue (including peripheral nerves) C47 9 C47, C C Ovary C C56, C57. - C C57 (part) 7 Other female genital organs C51 12 C51, C52, C C C52 28 C57 (part) 9 Other male genital organs C6 42 C6, C63 53 C63 11 Kidney C C64 - C66, C C65 87 C66 48 C68 13 Ill-defi ned and unknown primary sites C48 55 C26, C48, C76, C C C C8 125 viii. ix. See references. Mesothelioma and Kaposi s sarcoma are tabulated with the site of origin in ICD-9 but separately in ICD

145 » appendixes Appendix Three Clinical Groupings used in this report Clinical groupings are cancers that have been categorised based on treatment categories. For example a urologist would commonly treat cancers of the prostate, testis, bladder, kidney and other male genital organs. Similarly a gynaecologist would normally treat cancers of the cervix, uterus, ovary, placenta and other female genital organs. These groupings were developed with advice from Professor Jim Bishop and presented by the author for discussion and endorsement at the Annual Association of Cancer Registers Annual General Meeting in December 24. Minor modifi cations of these groupings were requested with the outcome that the AACR have adopted these groupings for clinical and planning purposes and where appropriate as normal inclusions in state and national incidence and mortality reports. Table A2 Topography codes classifi ed into clinical grouping categories Clinical Group Report Code (topotab) ICD-1 Skin C, C43,C46 Lip (ICD-O-3 C), Melanoma of skin (ICD-O-3 C44 and M872-M879), Kaposi s sarcoma (M914) Head and Neck C1,C2,C3-C6,C7,C8,C9,C1,C11,C14,C12,C13,C3,C31,C32 Tongue (ICD-O-3 C1,C2), Mouth (ICD-O-3 C3-C6) Salivary glands (ICD-O-3 C7,C8), Oropharynx (ICD-O-3 C9,C1), Nasopharynx (ICD-O-3 C11),Hypopharynx (ICD-O-3 C12,C13), Other oral cavity & pharynx (ICD-O-3 C14),Nose, sinuses, etc (ICD-O-3 C3, C31), Larynx (ICD-O-3 C32) Upper Gastrointestinal C15, C16, C17, C22,C23, C24, C25. Oesophagus (ICD-O-3 C15), Stomach (ICD-O-3 C16), Small intestine (ICD-O-3 C17), Liver (ICD-O-3 C22), Gallbladder(ICD-O-3 C23,C24), Pancreas (ICD-O-3 C25) Colorectal C18, C19, C2, C21 Colon (ICD-O-3 C18), Rectum, rectosigmoid, anus (ICD-O-3 C19-C21) Respiratory C33,34,C37, C38, C45 x Lung (ICD-O-3 C33,C34), Other thoracic organs (ICD-O-3 C37,C38), Mesothelioma (M95) Bone and other connective tissue C4, C41, C47, C49 Bone (ICD-O-3 C4,C41), Connective tissue, peripheral nerves (ICD-O-3 C47,C49) Breast C5 Breast (ICD-O-3 C5) Urogenital C6, C61, C62, C63, C64, C66, C67,C68 Prostate(ICD-O-3 C61), Testis (ICD-O-3 C62), Other male genital organs (ICD-O-3 C6,C63), Kidney (ICD-O-3 C64-C66,C68),Bladder (ICD-O-3 C67) Gynecological C53, C54, C55, C56, C57, C58, C59 Cervix (ICD-O-3 C53), Uterus, Body & NOS (ICD-O-3 C54,C55), Ovary (ICD-O-3 C56,C57.-7), Placenta (ICD-O-3 C58), Other female genital organs (ICD-O-3 C51,C52,C57.8-9) Eye C69 (ICD-O-3 C69) Neurological C7, C71, C72 C71 Brain (ICD-O-3 C71), C72 Central nervous system (ICD-O-3 C7,C72) Thyroid and other endocrine C73, C74, C75 Thyroid (ICD-O-3 C73), Other endocrine glands (ICD-O-3 C74,C75) Lymphohaematopoeitic C81, C82, C88, C9, C91, C92, C95 Hodgkin s disease (M965-M966), Non-Hodgkin s lymphoma (M959,M967- M972,M974), Multiple myeloma (M973,M976), Acute lymphoblastic leukaemia (M9821), Other lymphoid leukaemias (M982,M9822- M9827,M994), Acute myeloid leukaemia (M9861), Other myeloid leukaemia (M986,M9862-8,M987-M988,M993,M9987), Other specifi ed leukaemias (M984,M985,M989-M993), Unspecifi ed leukaemias (M98), Myeloproliferative disordera, Myelodysplasia (this has been grouped separately but should be included in this category in the future) Ill-defi ned and unknown primary sites C26, C39, C48, C76, C8 Other and ill defi ned digestive organs (ICD-O-3 C26), Other and ill defi ned respiratory (ICD-O-3 C39), Retroperitoneum and peritoneum (ICD-O-3 C48), Other and ill defi ned sites (ICD-O-3 C76), Unknown primary site (ICD-O-3 C8) x. All mesothelioma is included here even the small proportion less than 5 per cent that have peritoneum as the primary site. 143

146 Cancer in New South Wales: Incidence and Mortality Report 28» appendixes Appendix Four Survival methodology Monitoring of long term survival rates is now routinely performed by many cancer registries throughout the world. The most commonly reported measures of long term survival reported by population-based cancer registries are 5- and 1-year survival rates. Survival rates are typically monitored and reported for patients diagnosed within defi ned calendar years by traditional relative survival methods. NSW incidence cases diagnosed between 1999 and 23 and followed up to the end of 24 were used to calculate survival. The program used in this report is the cohort method relative survival SAS program developed by Brenner xi and the NSW life table from the Australian Bureau of statistics for the time period xii. Both absolute and relative survival rates are obtained. Relative survival rates refl ect the net mortality of patients in the hypothetical situation in which cancer is the only cause of death. Relative survival rates are derived as the ratios of the observed survival rates to the expected rates of people in the general population with respect to sex, age and calendar period of observation. The following information is required for each patient in the analysis; age (years), sex, month and year of diagnosis, month and year of follow-up, and vital status at the end of follow-up in years of each case. Conditional one-year survival rates by age and sex of the general population for the calendar period are included in the analysis. Other specifi cations that need to be made include the length of follow-up in years eg., fi ve years and the fi rst and last calendar year of the period of interest. To ensure consistency in sub setting cases for survival analysis advice was obtained from Timo Hakulinen from the Finnish Cancer Registry and then discussed at the Australian Association of Cancer Registers meeting. All Australian registries have agreed to the following criteria: Records fl agged as death certifi cate only and autopsy should be excluded. Records for persons 1 years of age and older should be excluded or grouped as aged 1 years. Records of living people with a survival less than one month which are not death certifi cate only shall be included, even if there is zero survival time. Where a nominal day of diagnosis has been recorded (15 th of the month), and death occurs within that month, an average survival time of two weeks will be imputed. This should make no difference to results which are normally reported in terms of 1-year, 5-year, 1-year, 15-year etc survival. Where a person has multiple cancers, eg. a breast cancer and a lung cancer, the person will be included in multiple sets for survival analysis, ie. one for breast cancer and one for lung cancer. xiii xi. Brenner H, Gefeller O, Hakulinen T A computer program for period analysis of cancer patient survival (in press). xii. Australian Bureau of Statistics Life tables, New South Wales, cat. no xiii. Australian Association of Cancer Registries Annual General Meeting November

147 » appendixes Appendix Five Join point regression analysis Join point regression analysis has been used in this report on incidence and mortality trends over thirty six years for all cancer sites. Similar to the least squares regression method,the joinpoint program which was developed by Statistical Research and Applications Branch of the National Cancer Institute uses an algorithm that tests whether a multi-segmented line is a signifi cantly better fi t then a straight or less-segmented line. Line segments are joined at points called joinpoints. Each joinpoint denotes a statistically signifi cant (P =.5) change in trend. One way to characterize trends in cancer rates over time is in terms of an Annual Percent Change (APC). This means that the cancer rates are assumed to change at a constant percentage of the rate of the previous year. In the prostate cancer example, to calculate the average annual percentage change from 1994 to 23, we note that the annual percentage change of 1.7 runs for one year (with a slope coeffi cient of.113), while in the next segment the annual percentage change of.7 runs for 8 years (with a slope coeffi cient of.7).therefore the average annual percentage change is calculated as: {Exp( ( 1 x ) / 9 ) 1 } 1 =.6 The average annual percentage change in rates was a decline of.6 per cent per annum. In this case it is not statistically signifi cantly different from. The average percentage change for each joinpoint segment provides better understanding of changes in the trend over time. For incidence it may indicate either the introduction of a new screening test as is the case below with the introduction of PSA test in NSW and the US. Or a steeper decline in incidence and mortality rates in NSW since the early 9s as with a result of the introduction of the of the Cervical Screening Program. Another advantage is that comparisons using joinpoint analysis of trends in NSW can be made with joinpoint trends in the US. Joinpoint analyses for all major cancer sites for US SEER registries can be obtained through published fact sheets xiv. Figure A3 Prostate incidence, males, all races, xiv