Invasive cancer of the cervix is considered a preventable disease because it has a long pre

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1 Focused Issue of This Month Epidemiology of Cervical Cancer Kyu Wan Lee, MDJae Yun Song, MD Department of Obstetrics and Gynecology, Korea University College of Medicine pumplee@kumc.or.kryuni105@yahoo.co.kr J Korean Med Assoc 2007; 50(9): Abstract Invasive cancer of the cervix is considered a preventable disease because it has a long pre invasive state, cervical cytology screening programs are currently available, and the treatment of preinvasive lesions is effective. Cancer of the cervix is the second most common cancer among women worldwide, with an estimated 493,000 new cases and 274,000 deaths in The highest incidence rates are observed in subsaharan Africa, Melanesia, Latin America and the Caribbean, SouthCentral Asia, and South East Asia. In Korea, cervical cancer is the fifth most common cancer among women with over 3,000 new cases every year. Agestandardized incidence rate (ASR) is 15.5 per 100,000, which is lower than those in developing countries but higher than in western countries such as Europe and North America. The patients mean parity is 2.59, and the range of age in peak incidence is 40~49 years (29.8%), followed by 50~59 years (21.9%). As the age goes on, more advanced stage cancer is frequent. Squamous cell carcinoma is the most common cell type, and adenocarcinoma is more frequent among those under 60 years old. Operation (56.0%) is the major treatment modality under stage IIa, and concurrent chemoradiation (31.6%) is the major treatment over stage IIb. The 5year survival rate is 73.9%. It is generally thought that human papillomavirus (HPV) test and HPV vaccine might play an important role in lowering the incidence of cervical cancer, and continuous epidemiologic studies will support its usefulness and efficacy. Keywords : Epidemiology; Cervical cancer; Incidence; Human papillomavirus 762

2 Epidemiology of Cervical Cancer Major Steps in Cervical Carcinogenesis Normal Cervix Infection Clearance HPV Infected Cervix Persistence (1 to 10 years) CIN-3/ Infection Pre- Regressiion Cancers CANCER Mild Cytologic Abnormalities Figure 1. An epidemiologic model of cervical carcinogenesis. The major steps in cervical carcinogenesis are human papillomavirus (HPV) infection (balanced by viral clearance), progression to precancer (partly offset by regression of precancer), and invasion. The persistence of oncogenic HPV types is necessary for progression and invasion. HPV infection is frequently but not necessarily associated with cytologic and histologic abnormalities(3). Age standardized (world) rate (per 100,000) Figure 2. Agestandardized (world) incidence of cervical cancer in 2002(4). 763

3 Lee KYSong JY Zimbabwe, Harare: African Uganda, Kyadondo County Brazil, Goiania Viet Nam, Ho Chi Minh City Thailand, Chiang Mai Ecuador, Quito India, Bangalore USA, California, LA: Hispanic White Slovakia Singapare: Chinese Poland, Lower Silesia Estonia Denmark Algeria, Algiers UK, Scotland USA, SEER: Black Australia, New South Wales Canada Switzerland, Zurich USA, SEER: White The Netherlands Italy, Varese Province Spain, Navarra China, Beijing Israel, non-jews ASR per 100, Squamous Adenocarcinoma Other 56.9 Figure 3. Agestandardized (world) incidence of cervical cancer by histological subtypes in selected cancer registries circa 1993~1997(5). 764

4 Epidemiology of Cervical Cancer Eastern Africa Southern Africa Melanesia Caribbean Central America Western Africa South America Middle Africa South Central Asia Micro/Polynesia South-Eastern Asia Eastern Europe Northern Africa Southern Europe Western Europe Northern Europe Japan Northern America Australia/New Zealand China Western Asia Incidence Mortality Age standardized per 100,000 Figure 4. Agestandardized incidence and mortality rate(10). 765

5 Lee KYSong JY pancreas 2.3% hematopoietic 2.5% ovary 3.6% liver 6.0% lung 5.6% others 17.6% cervix 9.1% thyroid 9.5% breast 16.8% colon 10.7% Figure 5. Annual report of the Korea Central Cancer Registry. (2002.1~ ). stomach 15.3% 766

6 Epidemiology of Cervical Cancer Figure 6. A) The incidence of cervical cancer by year, B) The stage distribution of cervical cancer by year(13). 11. Bosch FX, de Sanjose S. Chapter 1: Human papillomavirus and cervical cancerburden and assessment of causality. J Natl Cancer Inst Monogr 2003; Snijders PJ, Steenbergen RD, Heideman DA, Meijer CJ. HPV mediated cervical carcinogenesis: concepts and clinical implications. J Pathol 2006; 208: Schiffman M, Kjaer SK. Chapter 2: Natural history of anogenital human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr 2003: Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, CA Cancer J Clin 2005; 55: Parkin DM WS, Ferlay J, Teppo L, Thomas DB, eds. Cancer incidence in five continents, vol. VIII. Lyon. IARC Scientific Publications, 2002: Handbooks of Cancer Prevention, vol 9. Cervix Cancer Screening. Lyon: IARC Press, Ries LAG EM, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Feuer EJ, Edwards BK, eds. SEER Cancer Statistics Review, Bethesda, MD [cited; Available from: /] 18. Sant M, Aareleid T, Berrino F, Bielska Lasota M, Carli PM, Faivre J, Sant M, Aareleid T, Berrino F, Bielska Lasota M, Carli PM, Faivre J, Grosclaude P, Hédelin G, Matsuda T, Møller H, Möller T, Verdecchia A, Capocaccia R, Gatta G, Micheli A, Santaquilani M, Roazzi P, Lisi D; EUROCARE Working Group. EUROCARE3: survival of cancer patients diagnosed results and commentary. Ann Oncol 2003; 14(S5): Gondos A, Chokunonga E, Brenner H, Parkin DM, Sankila R, Borok MZ, Gondos A, Chokunonga E, Brenner H, Parkin DM, Sankila R, Borok MZ, Chirenje ZM, Nyakabau AM, Bassett MT. Cancer survival in a southern African urban population. Int J Cancer 2004; 112:

7 Lee KYSong JY 10. Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol 2006; 24: Chung HH, Jang MJ, Jung KW, Won YJ, Shin HR, Kim JW, Lee HP; Members for Gynecologic Oncology Committee of Korean Society of Obstetrics and Gynecology. Cervical cancer incidence and survival in Korea: Int J Gynecol Cancer 2006; 16: Shin HJK, Won YJ, Park JG Annual report of the Korea Central Cancer Registry: based on registered from 139 hospitals: Korea Cancer Res Treat; Korean Society of Obstetrics and Gynecology. Annual Report of Gynecologic Cancer Registry Program in Korea for 2004 (Jan. 1st, 2004 Dec. 31st, 2004). Korean Journal of Obstetrics and Gynecology 2007; 50: Jay N, Moscicki AB. Human papillomavirus infections in women with HIV disease: prevalence, risk, and management. AIDS Read 2000; 10: Peer Reviewer Commentary 768