Cancer in Australia: Actual incidence data from 1991 to 2009 and mortality data from 1991 to 2010 with projections to 2012

bs_bs_banner Asia-Pacific Journal of Clinical Oncology 2013; 9: 199 213 doi: 10.1111/ajco.12127 ORIGINAL ARTICLE Cancer in Australia: Actual incidence data from 1991 to 2009 and mortality data from 1991 to 2010 with projections to 2012 Australian Institute of Health and Welfare Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia Abstract Aims: The Australian Institute of Health and Welfare (AIHW) is a major national agency established by the Australian government to provide information and statistics on Australia s health and welfare. The AIHW and the Australasian Association of Cancer Registries collaborate every year to provide updated information on cancer occurrences and trends in Australia. Method: Actual number of cases and deaths is presented together with age-standardized rates for all cancers combined and selected cancer sites from 1991 to 2009 for incidence and from 1991 to 2010 for mortality, with projections to 2012. Differences in incidence and mortality rates according to age, Indigenous status and remoteness areas are also provided. In addition, information on hospitalizations due to cancer, palliative care and participation in Australia s national screening programs for breast, cervical and bowel cancer is presented. Results: In 2012, it was estimated that 120 710 new cases of cancer (excluding basal and squamous cell carcinoma of the skin) were diagnosed. Prostate cancer was estimated to be the most commonly diagnosed cancer in males, while breast cancer was estimated to be the most commonly diagnosed cancer in females. In 2010, more than 42 800 deaths from cancer occurred in Australia. Lung cancer was by far the most common cause of cancer death in both males and females. Conclusion: In the last decade, cancer incidence rates increased in males and stabilized in females, while mortality rates decreased steadily. The overall incidence and mortality rates of cancer for Indigenous Australians were higher than for non-indigenous Australians. Key words: Australia, early detection of cancer, incidence, mortality, neoplasm, screening. INTRODUCTION Cancer has a greater overall impact on the health of Australians than any other disease group. 1 On average, one in two Australians will develop cancer and one in five will die from it before the age of 85. This article provides an overview of statistics on cancer in Australia, focusing on incidence, mortality, hospitalization, burden Correspondence: Communications, Media and Marketing Unit, Australian Institute of Health and Welfare, GPO Box 570, Canberra, ACT 2601, Australia. Email: info@aihw.gov.au Conflict of interest: none Accepted for publication 10 July 2013. of disease and participation in national cancer screening programs. The information presented was extracted from the biennial publication Cancer in Australia: an overview, 2012, 2 produced by the Australian Institute of Health and Welfare (AIHW) in collaboration with the Australasian Association of Cancer Registries (AACR). Further information on Australian cancer statistics can be found in this publication. METHODS Data sources Registration of all cancers, excluding basal and squamous cell carcinomas of the skin (BCC and SCC, respectively), is required by law in each of the Australian

200 Australian Institute of Health and Welfare states and territories, where the data are collated by cancer registries. SCC and BCC of the skin are not registered as most cases are treated in doctor s surgeries with techniques that preclude histological confirmation. Information on newly diagnosed invasive cancers is supplied to the AIHW on an annual basis. The AIHW assembles the information into the Australian Cancer Database (ACD), which currently holds information on Australian cancer cases (excluding SCC and BCC of the skin) diagnosed between 1982 and 2009. As the 1982 2009 data files for New South Wales and the Australian Capital Territory were not available for inclusion in the ACD, 2009 incidence data for these two jurisdictions were estimated by the AIHW in consultation with the jurisdictional cancer registries. All cancer incidence cases held in the ACD are coded by both morphology and topography according to the third edition of the International Classification of Diseases for Oncology (ICD-O). Data from the ACD were used to present data on cancer incidence and survival. Mortality data from 1982 to 2010 in Australia were extracted from the National Mortality Database (NMD). Information on deaths in Australia is registered with the relevant state and territory registrar of births, deaths and marriages. Deaths are coded by the Australian Bureau of Statistics (ABS) to reflect the underlying cause of death, according to rules set forward in various versions of the International Classification of Diseases (ICD-8, ICD-9, ICD-10). The data are consolidated at the AIHW to form the NMD. Hospitalization data for the 2010 2011 financial year and palliative care for the 2009 2010 financial year were extracted from the National Hospital Morbidity Database (NHMD). This annual collection of demographic, diagnostic, procedural and duration of stay information on episode of care is complied and maintained by the AIHW using data supplied by state and territory health authorities. There are two different types of diagnoses recorded in the NHMD: principal diagnosis and additional diagnoses. Both were coded using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification, 7th edition. Population screening programs are available for breast, cervical and bowel cancers; they are BreastScreen Australia, the National Cervical Screening Program and the National Bowel Cancer Screening Program. Data on the level of cancer screening that occurs in Australia were obtained from these national screening programs. Population data used to derive cancer incidence and mortality rates were sourced from the ABS. The estimated resident populations derived by the ABS were based on the 2006 Census of Population and Housing data. For Indigenous comparisons, Indigenous experimental estimated resident populations based on the 2006 Census of Population and Housing were used. 3 Statistical analysis The following methods were used in the statistical analyses. A full description of these methods is available in Cancer in Australia: an overview, 2012. 2 Age-standardized rates Information on the number of cancer cases and deaths is presented together with age-standardized rates. To enable meaningful comparisons within Australian population subgroups, rates have been directly standardized to the Australian population at June 30, 2001 using 5-year age ranges to 85 years. They are generally expressed per 100 000 people. For international comparisons, incidence rates standardized to the World Health Organization world population can be obtained from the Australian Cancer Incidence and Mortality workbooks published in 2012. 4 Confidence intervals Confidence intervals (at the 95% level) based on a weighted sum of Poisson parameters are shown in tables. Where confidence intervals do not overlap, the difference between rates may be greater than would readily be attributable to chance. While such differences may be regarded as significant in statistical terms, they may or may not be significant from a practical or clinical perspective. Estimation of 2009 cancer incidence data Estimation of 2009 cancer incidence for New South Wales and the Australian Capital Territory was undertaken using site- and age-specific least squares regression models over the most recently available 10 years of data for these two jurisdictions, extrapolated to 2009 populations. A full description of the methodology is included in Cancer in Australia: an overview, 2012. 2 2012 estimated incidence and mortality The estimated 2012 incidence data were derived from least squares regression models using site-specific cancer incidence data from 2000 to 2009. Because of unavailability of 2009 data for New South Wales and the Australian Capital Territory, the estimated 2009 incidence for these two jurisdictions was derived using 1999 2008 data. The estimate for prostate cancer Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 201 incidence was supplemented by data on prostate specific antigen (PSA) testing data from Medicare Australia. The estimated 2012 mortality data were derived from least squares regression models using site-specific mortality data from 2001 to 2010. Further details of the projection models are provided in Cancer in Australia: an overview, 2012. 2 Estimation of prostate cancer incidence Least squares linear regression of time trends in services of Medicare Benefits Schedule (MBS) item 66655 (PSA test for screening in a 12-month period) showed an age-specific relationship between the level of PSA testing for screening purposes and prostate cancer incidence. Year-to-date prostate cancer incidence counts were estimated by applying the estimated ratios to the number of services recorded to May 2012 for item 66655. Further details of the estimation models are provided in Cancer in Australia: an overview, 2012. 2 Risk to age 85 years Risk to age 85 years refers to the probability that an individual will be diagnosed with or die from cancer before the age of 85 years, assuming that the age-specific risks observed in 2009 for diagnosis and 2010 for death remained throughout life. It was based on a mathematical relationship with the cumulative rate. Data by population groups Data by population groups are presented for 5 years from 2004 to 2008 for incidence and from 2006 to 2010 for mortality to reduce random variation in the rates. RESULTS Incidence of cancer in Australia Estimated new cancer cases in 2012 In 2012, it was estimated that a total of 120 710 new cases of cancer were diagnosed in Australia (excluding BCCs and SCCs). Of these, 67 260 were expected to be diagnosed in males and 53 460 in females. The estimated male incidence rate was 1.4 times the female rate (558 vs 405 per 100 000). The 10 most common cancers expected to be diagnosed in males and females in 2012 are shown in Table 1. These estimates should be interpreted as only indicative of future trends. The most commonly diagnosed cancers in males in 2012 were expected to be prostate cancer, bowel cancer and melanoma of the skin. These three cancers accounted for 52% of all newly diagnosed cancers in males, with prostate cancer alone accounting for 28% of the incidence cases. The most commonly diagnosed cancers in females in 2012 were expected to be breast cancer, bowel cancer and melanoma of the skin, accounting for 50% of all cancer cases in females. Breast cancer alone accounted for 27% of all new cancer cases in females. Incidence data for less common cancers are available in Cancer in Australia: an overview, 2012. 2 Incidence by age In 2012, the age-specific incidence rate for all cancers combined was estimated to increase with age, with the Table 1 Estimated 10 most commonly diagnosed cancers by sex, Australia, 2012 Males Females Site/type (ICD-10) Cases ASR Site/type (ICD-10) Cases ASR Prostate (C61) 18 560 147.9 Breast (C50) 14 560 113.2 Bowel (C18 C20) 8 760 72.8 Bowel (C18 C20) 7 080 51.5 Melanoma of skin (C43) 7 440 62.7 Melanoma of skin (C43) 5 070 39.9 Lung (C33 C34) 6 620 55.8 Lung (C33 C34) 4 650 34.1 Non-Hodgkin lymphoma (C82 C85) 2 620 22.0 Uterus (C54 C55) 2 270 17.1 Kidney (C64) 2 000 16.6 Non-Hodgkin lymphoma (C82 C85) 2 070 15.6 Bladder (C67) 1 800 15.3 Thyroid (C73) 1 830 15.4 Unknown primary site (C80) 1 490 12.7 Ovary (C56) 1 410 10.7 Pancreas (C25) 1 450 12.1 Unknown primary site (C80) 1 360 9.2 Stomach (C16) 1 420 11.9 Pancreas (C25) 1 290 9.1 All cancers 67 260 557.9 All cancers 53 460 404.5 2012 estimates are based on 2000 2009 incidence data. The estimates are rounded to the nearest 10. Rates were age standardized to the Australian population as of June 30, 2001 and are expressed per 100 000 population. Includes cancers coded in ICD-10 as C00 C97, D45, D46, D47.1 and D47.3. ASR, age-standardized rate. (Source: AIHW Australian Cancer Database 2009.) Asia-Pac J Clin Oncol 2013; 9: 199 213

202 Australian Institute of Health and Welfare Table 2 Estimated risk of being diagnosed with cancer (2009) and risk of dying from cancer (2010) before the age 85 years, Australia Males Females Site/type (ICD-10) Risk of being diagnosed Risk of dying Risk of being diagnosed Risk of dying Prostate (C61) 1 in 5 1 in 25 Breast cancer in women (C50) 1 in 8 1 in 39 Bowel (C18 C20) 1 in 10 1 in 37 1 in 15 1 in 57 Melanoma of the skin (C43) 1 in 14 1 in 85 1 in 23 1 in 226 Lung (C33 C34) 1 in 13 1 in 16 1 in 22 1 in 29 Non-Hodgkin lymphoma (C82 C85) 1 in 35 1 in 100 1 in 51 1 in 175 Pancreas (C25) 1 in 60 1 in 64 1 in 77 1 in 76 Unknown primary (C77 C80) 1 in 53 1 in 66 1 in 72 1 in 98 All cancers 1in2 1in4 1in3 1in6 Includes cancers coded in ICD-10 as C00 C97 (except C44), D45, D46, D47.1 and D47.3. Mortality data for 2010 are preliminary and are subject to further revision. (Source: AIHW Australian Cancer Database 2009; AIHW National Mortality Database.) estimated risk of diagnosis before aged 85 for males was prostate cancer (1 in 5), while for females it was breast cancer (1 in 8). Figure 1 Estimated age-specific incidence rates for all cancers combined, Australia, 2012., males;, females;, persons. highest incidence rates observed in the age group 85 and over for both males and females (Fig. 1). Between the ages of 30 and 54, females were expected to have slightly higher incidence rates of cancer than males, but this trend was reversed after the age of 55 where males were expected to have higher incidence rates of cancer than females. Risk of cancer In Australia, in 2009, it was estimated that the risk of being diagnosed with cancer (excluding BCC and SCC) before the age of 85 was 1 in 2 for males and 1 in 3 for females (Table 2). The cancer with the greatest Trends Figure 2 shows the actual number of new cancer cases in males and females, together with the corresponding agestandardized rates from 1991 to 2009 and estimates for 2010 2012. The number of new cancer cases diagnosed each year almost doubled over the 19-year period from 1991 to 2009 for both males and females and was estimated to increase for the next 3 years. In males, the overall age-standardized incidence rate of cancer rose steadily until 1994. This was followed by a decline in rates until the late 1990s, after which the rates began to rise again until 2008. This trend was strongly influenced by changes in the incidence rate of prostate cancer, the leading type of cancer in males. Rates from 2008 to 2012 were expected to remain below the 2008 level. In females, the overall cancer incidence rate rose during the early 1990s, after which the rate remained relatively stable. The trend was expected to continue to 2012 and was strongly influenced by the trend in the incidence rate of breast cancer. Figure 3 shows long-term trends in age-standardized incidence rates for prostate cancer, breast cancer in females and lung cancer. The incidence rate of prostate cancer increased sharply in the early 1990s reaching a peak in 1994. This was followed by a sharp decline in rates from 1995 to 1997. After this time, the rate remained stable until the early 2000s when the incidence rate began to increase again, with rates in 2008 almost reaching the same level as the peak in 1994. The rate Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 203 Figure 2 Incidence of all cancers combined, Australia, 1991 2009, with estimates to 2012., males;, females. Figure 3 Incidence of prostate cancer, breast cancer in women and lung cancer, Australia, 1991 2009, with estimates to 2012., prostate cancer;, breast cancer in females;, lung cancer in males;, lung cancer in females. then declined from 2008 to 2009. Supplementary MBS data on PSA tests to 2012 from Medicare Australia suggested that this decline will remain below the 2008 level to 2012. The age-standardized incidence rate of breast cancer in females increased between 1991 and 1995. After this, the rates were fairly stable, ranging from 110 to 118 per 100 000. This trend was expected to continue to 2012. The age-standardized incidence rate of lung cancer decreased in males from 75 per 100 000 in 1991 to 56 per 100 000 in 2009; however, this trend was expected to stabilize to 2012. Unlike males, the age-standardized rate increased for females from 1991 to 2009. This trend was also expected to continue to 2012. Although these cancers account for a substantial proportion of cancer incidence over the past two decades, there has been significant acceleration in other cancers that should be noted. In particular, between 1991 and 2009, thyroid cancer has experienced a 160% percentage-point increase in age-standardized rates (from 3.5 to 9.1 per 100 000), while age-standardized rates of liver cancer have increased by 120% (from 2.5 to 5.5 per 100 000). There have also been significant decreases in the agestandardized rates of some cancers in this same time period: cervical cancer has decreased by 48% (from 13 to 6.7 per 100 000) and lip cancer by 41% (from 6.3 to 3.7 per 100 000). Significant decreases have also been observed in cancer of unknown primary site, decreasing from 19 to 12 per 100 000 (37%). Mortality from cancer in Australia Number of cancer deaths in 2010 Cancer accounted for 30% of all deaths registered in Australia in 2010. A total of 42 844 Australians died from cancer in 2010, of which 24 328 were males and 18 516 were females. The age-standardized mortality rate for males was 1.6 times that for females (222 vs 138 per 100 000). The 10 most common causes of death from cancer are shown in Table 3. Lung cancer, prostate cancer and Asia-Pac J Clin Oncol 2013; 9: 199 213

204 Australian Institute of Health and Welfare Table 3 The 10 most common causes of death from cancer by sex, Australia, actual (2010) and estimated (2012) Males Females Site/type (ICD-10) Deaths ASR 2012 Site/type (ICD-10) Deaths ASR 2012 Estimated Estimated Lung (C33 C34) 4 934 44.6 5 070 Lung (C33 C34) 3 165 24.2 3 340 Prostate (C61) 3 235 30.6 3 410 Breast (C50) 2 840 21.6 2 920 Bowel (C18 C20) 2 205 20.1 2 200 Bowel (C18 C20) 1 777 13.0 1 760 Pancreas (C25) 1 233 11.1 1 300 Pancreas (C25) 1 201 8.9 1 200 Unknown primary (C77 C80) 1 167 10.7 1 380 Unknown primary (C77 C80) 1 113 7.8 1 170 Melanoma of the skin (C43) 933 8.9 1 070 Ovary (C56) 912 7.0 975 Liver (C22) 890 7.9 975 Other digestive organs (C26) 641 4.4 835 Oesophagus (C15) 879 7.8 960 Non-Hodgkin lymphoma (C82 C85) 557 4.0 640 Non-Hodgkin lymphoma 781 7.1 800 Brain (C71) 512 4.1 520 (C82 C85) Bladder (C67) 736 6.9 795 Melanoma of the skin (C43) 459 3.5 495 All cancers 24 328 221.7 25 860 All cancers 18 516 137.6 19 650 Mortality data for 2010 are preliminary and are subject to further revision, 2012 estimates were based on mortality data for 2006 2010. Rates were standardized to the Australian population as of June 30, 2001 and are expressed per 100 000 population. Includes cancers coded in ICD-10 as C00 C97, D45, D46, D47.1 and D47.3. ASR, age-standardized rate. (Source: AIHW National Mortality Database.) bowel cancer were the most common causes of cancer deaths in males, while lung cancer, breast cancer and bowel cancer were the most common in females. The three most common causes of cancer deaths accounted for 43% and 42% of the total cancer deaths among males and females, respectively. Mortality data for less common causes of cancer deaths are available in Cancer in Australia: an overview, 2012. 2 Mortality by age Figure 4 shows that the age-specific mortality rate in 2010 increased sharply with age. The mortality rates for males were higher than the rates for females after the age of 50. Risk to 85 years The risk of dying from cancer before the age of 85 is shown in Table 2. In 2010, the risk of dying from cancer before the age of 85 was 1 in 4 for males and 1 in 6 for females. The risk of dying from lung cancer, the most common cause of death from cancer in both males and females, before the age of 85 was relatively high for both males and females, at 1 in 16 for males and 1 in 29 for females. Trends Figure 5 illustrates that the number of deaths from cancer has increased steadily over time in both males and females. Despite the increase in numbers, however, the age-standardized mortality rates for cancer overall have Figure 4 Age-specific mortality rates for all cancers combined, Australia, 2010., males;, females;, persons. fallen steadily and substantially by 22% from 1994 to 2010 in males and by 16% from 1993 to 2010 in females. Figure 6 shows long-term trends in the mortality rates from lung cancer, prostate cancer and breast cancer in females. The mortality rates of lung cancer for males decreased steadily between 1991 and 2010. In contrast, the rate for females increased gradually over the same period. Over the entire 20-year period, the mortality rate of lung cancer for males was consistently higher than that for females; however, the gap has narrowed considerably over the last decade. Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 205 Figure 5 Mortality from all cancers combined, Australia, 1991 2010., males;, females. increased significantly from 2.8 to 5.5 deaths per 100 000 (96%) between 1991 and 2010. Estimated number of cancer deaths in 2012 Table 3 shows the 2012 mortality estimates for the 10 leading causes of cancer deaths in males and females. As for the 2012 incidence estimates, these estimates should be interpreted as only indicative of future trends. It was estimated that the number of cancer deaths in 2012 was around 25 860 for males and 19 650 for females, which was a 6% increase for males and for females in 2010. Lung cancer was expected to continue to be the leading cause of cancer deaths in 2012 for both males and females. Figure 6 Mortality from prostate cancer, breast cancer in women and lung cancer, Australia, 1991 2010., prostate cancer;, breast cancer in females;, lung cancer in males;, lung cancer in females. The mortality rate of prostate cancer peaked in 1993, after which the rate declined, with the decline in rates sharper in the 1990s than in the following decade. The mortality rates from breast cancer in females remained relatively stable in the early 1990s, after which there was an appreciable decline in mortality rates from 1994 to 2010 (a fall of 30%). While mortality rates have generally declined for most cancers, age-standardized rates for liver cancer have Differences in incidence and mortality by population groups Cancer incidence and mortality data are presented according to Aboriginal and Torres Strait Islander status and remoteness from urban centers. Observed differences may result from a number or combination of factors, including variations in population characteristics, such as the proportion of Indigenous people living in remote areas; prevalence of risk and/or protective factors, such as tobacco consumption; and the availability and usage of diagnostic and screening services. Indigenous status Table 4 presents cancer incidence and mortality statistics by Indigenous status. The term Indigenous refers to a person of Aboriginal and/or Torres Strait Islander Asia-Pac J Clin Oncol 2013; 9: 199 213

206 Australian Institute of Health and Welfare Table 4 Incidence (2004 2008) and mortality (2006 2010) of selected cancers by Indigenous status, Australia Indigenous status Number ASR 95% CI Number ASR 95% CI Incidence Mortality All cancers Indigenous 3 875 460.8 443.8 478.2 2 120 249.1 236.8 261.8 Non-Indigenous 292 949 434.4 432.8 436.0 142 075 173.9 173.0 174.8 Not stated 40 494 1 147 Total 337 318 494.1 492.4 495.8 145 342 176.3 175.4 177.3 Prostate cancer (C61) Indigenous 291 105.2 91.5 120.2 70 30.2 22.6 39.3 Non-Indigenous 47 404 147.6 146.2 148.9 10 521 30.3 29.8 30.9 Not stated 9 379 85 Total 57 074 176.1 174.7 177.6 10 676 30.6 30.0 31.2 Bowel cancer (C18 C20) Indigenous 348 47.8 42.1 53.9 128 14.5 11.7 17.7 Non-Indigenous 39 725 58.8 58.2 59.4 13 485 16.5 16.2 16.7 Not stated 2 369 135 Total 42 442 62.1 61.6 62.7 13 748 16.6 16.4 16.9 Breast cancer in females (C50) Indigenous 438 82.1 73.8 91.0 137 27.4 22.3 33.1 Non-Indigenous 35 851 103.6 102.5 104.7 9 407 21.6 21.2 22.0 Not stated 3 469 84 Total 39 758 112.9 111.8 114.0 9 628 21.9 21.4 22.3 Melanoma of the skin (C43) Indigenous 60 8.5 6.0 11.4 19 2.4 1.3 3.9 Non-Indigenous 21 328 31.8 31.4 32.3 5 045 6.2 6.1 6.4 Not stated 15 058 46 Total 36 446 53.7 53.1 54.2 5 110 6.3 6.1 6.4 Lung cancer (C33 C34) Indigenous 603 79.8 72.7 87.2 518 61.3 55.4 67.6 Non-Indigenous 28 998 43.0 42.5 43.5 27 118 33.5 33.1 33.9 Not stated 792 208 Total 30 393 44.6 44.1 45.1 27 844 34.0 33.6 34.4 Cervical cancer (C53) Indigenous 121 18.0 14.5 22.0 57 8.3 6.1 11.0 Non-Indigenous 2 185 6.5 6.3 6.8 792 1.9 1.7 2.0 Not stated 188 7 Total 2 494 7.3 7.0 7.6 856 2.0 1.9 2.1 Non-Hodgkin lymphoma (C82 C85) Indigenous 125 14.2 11.3 17.5 43 5.1 3.5 7.2 Non-Indigenous 10 945 16.3 16.0 16.6 4 773 5.8 5.6 6.0 Not stated 1 156 27 Total 12 226 17.9 17.6 18.3 4 843 5.8 5.7 6.0 Pancreas (C25) Indigenous 110 15.2 12.1 18.8 109 12.8 10.2 15.8 Non-Indigenous 7 046 10.4 10.1 10.6 7 772 9.5 9.3 9.7 Not stated 132 55 Total 7 288 10.6 10.4 10.9 7 936 9.6 9.4 9.8 Unknown primary site (C80) Indigenous 167 23.6 19.6 28.2 134 16.7 13.6 20.3 Non-Indigenous 8 329 12.2 12.0 12.5 8 290 10.1 9.8 10.3 Not stated 559 67 Total 9 055 13.2 12.9 13.5 8 491 10.2 10.0 10.4 Data from New South Wales, Queensland, Western Australia and the Northern Territory were used to examine the incidence of cancer by Indigenous status, whereas data from New South Wales, Queensland, Western Australia, South Australia and the Northern Territory were used to examine the mortality from cancer by Indigenous status. The total number of cases over the 5-year period from 2004 to 2008 or deaths over the 5-year period from 2006 to 2010. Rates were age standardized to the Australian population as of June 30, 2001 and are expressed per 100 000 people. ASR, age-standardized rate. (Source: AIHW Australian Cancer Database 2009; AIHW National Mortality Database.) Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 207 descent who identifies as an Aboriginal and/or Torres Strait Islander and is accepted as such by the community with which he or she is associated. 5 Indigenous identification in cancer incidence data for 2004 2008 was considered of sufficient quality for national reporting for four jurisdictions (New South Wales, Queensland, Western Australia and Northern Territory), while Indigenous identification in mortality data for 2006 2010 was considered of sufficient quality for five jurisdictions (New South Wales, Queensland, Western Australia, South Australia and Northern Territory). In the period 2004 2008, there were 3875 cancers diagnosed among Indigenous Australians, comprising 1% of all cancer cases diagnosed in that period. The age-standardized incidence rate among Indigenous Australians was significantly higher than non-indigenous Australians (461 vs 434 per 100 000 people). This contrasts with the findings in the 2010 edition of Cancer in Australia, an overview. 6 However, the data are not directly comparable as different jurisdictions were used to calculate Indigenous rates. Incidence rates were higher in Indigenous than in non-indigenous Australians for cervical cancer, pancreatic cancer, lung cancer and cancer of unknown primary site. There were 2120 cancer deaths for Indigenous Australians in the period 2006 2010. Similar to incidence, the mortality rate from cancer was also higher (1.4 times) in Indigenous than in non-indigenous Australians (249 vs 174 per 100 000 population). The mortality rate of cervical cancer, pancreatic cancer, lung cancer, breast cancer in females and cancer of unknown primary site was higher in Indigenous than in non-indigenous Australians. Remoteness areas The Australian Standard Geographical Classification Remoteness Areas classification was used to assign areas across Australia to a remoteness category. 7 The classification allocates one of five remoteness categories to areas depending on their distance from urban centers, where the population size of the urban center was considered to govern the range of type of services available. Areas are classified as major cities, inner regional, outer regional, remote and very remote. The categories of remote and very remote have been collapsed due to the small number of cases and deaths in these two subgroups. Table 5 presents age-standardized rates for incidence and mortality for 2004 2008 by remoteness for selected cancers. In the period 2004 2008, the age-standardized incidence rate of all cancers combined was significantly higher for people living in inner regional areas of Australia than other areas. Incidence rates also varied by geographical region of residence for some individual cancers, although in a different pattern from all cancers combined. The incidence rates of breast cancer in females and non-hodgkin lymphoma decreased with remoteness, with people living in remote and very remote areas 0.8 0.9 times as likely as their city counterparts to be diagnosed with these two types of cancer. Conversely, the incidence rates of cervical cancer, cancer of unknown primary site and lung cancer increased with remoteness, with people living in remote and very remote areas having 1.4 times the rate of cervical cancer and cancer of unknown primary site and 1.3 times the rate of lung cancer than their counterparts in major cities. People living outside major cities had significantly higher mortality rates for all cancers combined (1.1 times) than their city counterparts in the period 2006 2010. Mortality rates of cervical cancer, cancer of unknown primary site, breast cancer in females and lung cancer increased with remoteness. For prostate cancer, bowel cancer and melanoma of the skin, particularly high mortality rates were observed for people living in inner and outer regional areas. Burden of disease Cancer is estimated to be the leading cause of the burden of disease in Australia in 2012 (19% of total disabilityadjusted life years (DALYs)), followed by cardiovascular disease (16%). In males, lung, prostate and bowel cancers are expected to be the leading causes of the burden of disease due to cancer accounting for 48% of the total burden of disease due to cancer, and 9% of all male burden of disease. In females, breast, lung and bowel cancers are expected to account for about 53% of the total burden of disease due to cancer in females, and for about 10% of all female burden of disease. Table 6 presents the estimated leading cancer causes of burden of disease in Australia. Hospitalizations for cancer The extent of hospitalization for cancer is an important indicator of the burden of cancer on the Australian population. In the 2010 2011 financial year, there were 880 432 cancer-related hospitalizations, meaning cancer was responsible for 1 in 10 hospitalizations in Australia. Three quarters (75%) of the total number of hospitalizations for cancer were same-day hospitalization where a patient was admitted and separated on the same day. Asia-Pac J Clin Oncol 2013; 9: 199 213

208 Australian Institute of Health and Welfare Table 5 Incidence (2004 2008) and mortality (2006 2010) of selected cancers by remoteness area, Australia Remoteness area ASR 95% CI ASR 95% CI Incidence Mortality All cancers Major cities 480.0 478.4 481.6 170.5 169.6 171.4 Inner regional 503.6 500.8 506.5 185.4 183.8 187.1 Outer regional 494.8 490.5 499.0 192.8 190.2 195.4 Remote and very remote 474.3 464.5 484.3 195.7 189.2 202.3 Prostate cancer (C61) Major cities 173.3 171.9 174.7 29.1 28.5 29.7 Inner regional 186.6 184.1 189.1 34.6 33.5 35.7 Outer regional 178.5 174.9 182.2 35.3 33.6 37.0 Remote and very remote 150.8 142.9 159.0 33.0 28.9 37.6 Bowel cancer (C18 C20) Major cities 60.7 60.2 61.3 16.6 16.3 16.9 Inner regional 66.4 65.4 67.4 18.0 17.5 18.5 Outer regional 65.7 64.2 67.2 18.2 17.4 19.0 Remote and very remote 59.0 55.5 62.7 15.6 13.8 17.6 Breast cancer in females (C50) Major cities 114.2 113.1 115.3 21.9 21.4 22.3 Inner regional 111.9 110.0 113.8 22.6 21.8 23.4 Outer regional 106.3 103.5 109.1 21.9 20.7 23.2 Remote and very remote 94.3 88.4 100.6 28.2 24.3 32.5 Melanoma of the skin (C43) Major cities 45.6 45.1 46.1 5.7 5.5 5.9 Inner regional 57.1 56.1 58.1 6.6 6.3 7.0 Outer regional 52.8 51.4 54.2 6.0 5.5 6.4 Remote and very remote 42.8 40.0 45.8 4.9 3.9 6.0 Lung cancer (C33 C34) Major cities 43.1 42.6 43.5 32.4 32.0 32.8 Inner regional 44.7 43.8 45.5 34.6 33.9 35.4 Outer regional 47.3 46.0 48.6 37.8 36.6 38.9 Remote and very remote 54.8 51.4 58.3 41.8 38.9 44.9 Cervical cancer (C53) Major cities 6.9 6.6 7.1 1.8 1.7 2.0 Inner regional 6.4 5.9 6.9 1.7 1.5 2.0 Outer regional 7.2 6.5 8.0 2.2 1.8 2.6 Remote and very remote 9.6 7.8 11.7 5.7 4.0 7.7 Non-Hodgkin lymphoma (C82 C85) Major cities 18.8 18.5 19.2 5.8 5.6 6.0 Inner regional 18.0 17.5 18.6 6.1 5.8 6.4 Outer regional 16.8 16.0 17.6 5.5 5.1 6.0 Remote and very remote 16.3 14.5 18.2 5.3 4.3 6.5 Pancreas (C25) Major cities 10.8 10.5 11.0 9.7 9.5 9.9 Inner regional 10.2 9.8 10.6 9.5 9.1 9.9 Outer regional 10.3 9.7 10.9 9.8 9.2 10.4 Remote and very remote 11.2 9.7 12.9 8.8 7.5 10.3 Unknown primary site (C80) Major cities 12.3 12.0 12.5 9.5 9.3 9.7 Inner regional 13.4 12.9 13.8 10.3 9.9 10.7 Outer regional 13.8 13.1 14.5 12.2 11.6 12.9 Remote and very remote 16.8 14.9 18.8 13.1 11.5 15.0 Remoteness was classified according to the 2006 Australian Standard Geographical Classification Remoteness Areas. Rates were age standardized to the Australian population as of June 30, 2001 and are expressed per 100 000 people. ASR, age-standardized rate. (Source: AIHW Australian Cancer Database 2009; AIHW National Mortality Database.) Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 209 Table 6 Estimated leading cancer causes of burden of disease, Australia, 2012 Site/type DALYs Males % of cancer burden Females % of total % of cancer burden Rank Site/type DALYs burden % of total burden Lung 57 300 19 4 4 Breast 61 300 24 4 6 Prostate 44 300 15 3 8 Lung 43 400 17 3 7 Bowel 38 800 13 3 11 Bowel 30 700 12 2 10 Melanoma 15 700 5 1 23 Ovary 13 200 5 1 26 Lymphoma 14 700 5 1 25 Pancreas 12 700 5 1 28 Leukemia 13 000 4 1 30 Lymphoma 12 600 5 1 29 Pancreas 12 800 4 1 32 Leukemia 9 300 4 1 34 Brain 12 600 4 1 33 Brain 9 000 4 1 36 Esophagus 10 600 4 1 38 Melanoma 7 100 3 1 44 Kidney 8 900 3 1 43 Kidney 5 500 2 0 56 All cancers 294 400 100 20 All cancers 256 900 100 18 All causes 1 497 600 100 All causes 1 413 000 100 The estimates are projected from a 2003 baseline. The estimates are rounded to the nearest 100. Includes cancers coded in ICD-10 as C00 C96. DALY, disability-adjusted life years. (Source: AIHW Burden of Disease Database.) Rank Table 7 Most common hospitalizations with a principal diagnosis of cancer or other cancer-related hospitalizations, Australia, 2010 2011 financial year Principal diagnosis (ICD-10-AM) Same day Overnight Total Principal diagnosis of cancer Non-melanoma skin (C44) 80 122 15 190 95 312 Secondary site (C77 C79) 6 347 34 880 41 227 Prostate (C61) 18 241 16 935 35 176 Bowel (C18 C20) 8 504 20 759 29 263 Breast (C50) 4 917 19 100 24 017 Non-Hodgkin lymphoma (C82 C85) 8 759 10 238 18 997 Lung (C33 C34) 3 887 13 845 17 732 Bladder (C67) 6 771 7 784 14 555 Myelodysplastic syndrome (D46) 10 729 2 629 13 358 Melanoma skin (C43) 7 026 3 431 10 457 Cancer as principal diagnosis 195 767 210 837 406 604 Other cancer-related hospitalization Chemotherapy session (Z51.1) 352 704 168 352 872 Special screening examination (Z12) 53 177 517 53 694 Follow-up after surgery for cancer (Z08.0) 38 331 2 100 40 431 Follow-up after multiple treatment (Z08.7 Z08.9) 8 397 409 8 806 Adjustment and management of infusion pumps and vascular device (Z45.1, Z45.2) 7 082 233 7 321 Other cancer-related hospitalizations 468 789 5 039 473 828 All cancer-related hospitalizations 664 556 215 876 880 432 Hospitalizations in which (i) the principal diagnosis is cancer (ICD-10-AM codes C00 C97, D45, D47.1 and D47.3); or (ii) the principal diagnosis is a health service or treatment that may be related to treatment of cancer. (Source: AIHW National Hospital Morbidity Database.) Cancer-related hospitalizations were dominated by chemotherapy sessions, which accounted for 40% of all cancer-related hospitalizations in 2010 2011 financial year. Because of the way hospital morbidity data were coded, not all hospitalizations can be classified by specific cancer type. Non-melanoma of skin cancer was the most common cause of hospitalizations (11% of all cancer-related hospitalizations) where cancer was recorded as the principal diagnosis. Table 7 presents the most common cancer-related hospitalizations. Asia-Pac J Clin Oncol 2013; 9: 199 213

210 Australian Institute of Health and Welfare Figure 7 Age-specific rates for all cancer-related hospitalizations, Australia, 2010 2011 financial year., males;, females;, persons. Hospitalizations by age The cancer-related hospitalization rate in 2010 2011 financial year was relatively low in the younger age groups and increased with age, with the highest rate of 1644 per 10 000 for those aged 75 79. The cancerrelated hospitalization rate followed a similar pattern as that of incidence of cancer, where females had slightly higher hospitalization rates than males between the ages of 30 and 59, but this trend was reversed after the age of 60 where males had higher hospitalization rates than females (Fig. 7). In the 2009 2010 financial year, there were 55 983 palliative care hospitalizations recorded in Australia among which 33 278 (59%) were cancer related. The most common type of cancer recorded for palliative care separations was secondary site cancer, which accounted for 15% of all cancer-related palliative care separations. National cancer screening programs In Australia, there are national population screening programs for breast, cervical and bowel cancers. Their goals are to reduce illness and death from these cancers through early detection of cancer and precancerous abnormalities and effective follow-up treatment. These programs are BreastScreen Australia, the National Cervical Screening Program and National Bowel Cancer Screening Program. More information about these programs can be found at http://www.cancerscreening.gov.au. 8 Annual monitoring of outcomes of individuals who participate in these programs is undertaken by the AIHW, but because out-of-program screening may occur for breast and bowel cancers, the data presented underestimate the total level of breast and bowel screening in Australia. In the 2 years 2010 2011, over 1.7 million women (59% of women in the target age group of 50 69 years) had a screening mammogram through BreastScreen Australia and nearly 3.8 million women (57% of women in the target age group of 20 69 years) participated in the National Cervical Screening Program. 9,10 In 2010, 2414 women were diagnosed with breast cancer through BreastScreen Australia. A high proportion (47% in women at the initial screen and 63% of those attending subsequent screening rounds) of the cancers diagnosed was classified as small. 11 Small breast cancers are associated with increased treatment options and improved survival. 12,13 In 2011, the National Cervical Screening Program detected eight high-grade abnormalities for every 1000 women screened, providing an opportunity for treatment before possible progression to cervical cancer. 14 More than 325 000 people (35% of those invited) participated in the National Bowel Cancer Screening Program between July 2011 and June 2012, with females more likely to participate than males (37.5% vs 32.5%). Around 7% of those who returned the properly completed fecal occult blood test had a positive result which required further investigation. Three percent of those who had a colonoscopy to follow up the positive fecal occult blood test were found to have suspected or confirmed cancer. In addition, 11% had adenomas detected, 40% had polyps detected and the remaining 46% was found to have no cancer or adenoma. 15 DISCUSSION These results show increases in incidence rates and decreases in mortality rates in Australia from all cancers combined among both males and females. However, trends in incidence rates and mortality rates varied by cancer type and sex. Trends in cancer incidence rates for males were heavily influenced by trends in prostate cancer which accounts for almost 1 in 3 cases in males, while for females, trends were heavily influenced by trends in the incidence rates of breast cancer which accounts for 1 in 4 cases in females. The overall decrease in mortality rates in males has been heavily influenced by declines in mortality rates for lung, prostate and bowel cancers which account for most of the total decrease between 1994 and 2010, Asia-Pac J Clin Oncol 2013; 9: 199 213

Cancer in Australia 2012 211 while the decline in the mortality rate for females was largely due to declines in the mortality rates of breast and bowel cancers. Trends in prostate cancer incidence and mortality rates are of special note, as prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in males. Prostate cancer incidence rates fluctuated between 1991 and 2009, reflecting similar changes in the uptake of PSA testing. Substantial reductions in prostate cancer mortality rates occurred from 1993 to 2010, which may be related to declines in diagnosis at an advanced stage due to early detection of prostate cancer cases by PSA testing or improvements in treatment. 16 19 Lung cancer incidence rates have declined in males but increased in females between 1991 and 2009 and, similarly, mortality rates have declined in males but increased in females between 1991 and 2010. These sex differences in lung cancer trends are likely to have been affected by different histories of tobacco smoking. As overall tobacco consumption began to decline in males in the second half of the 20th century, the incidence and mortality rates followed, with a time lag of two to three decades. Cigarette smoking in females peaked later than in males, which may explain the fact that the lung cancer incidence and mortality rates for females are still rising. 20,21 Trends in age-standardized incidence rates of breast cancer in females have varied over time. The most notable change in incidence rates was the rapid increase between 1991 and 1995, which was most likely due to greater use of mammography screening, with organized mammographic screening programs commencing in each Australian state and territory between 1989 and 1994. The recent decline in breast cancer incidence rates since 2002 was possibly due to reduced use of long-term hormone replacement therapy (HRT) following the publication of results of the Women s Health Initiative randomized trial in 2002, which indicated that long-term HRT was linked to increased risk of breast cancer. 22,23 The decline in the mortality rates of breast cancer in females since the early 1990s was believed to be due to the early detection of breast cancers through mammography and more effective treatments. 24 The results have also highlighted important differences in cancer incidence and mortality rates among Indigenous and non-indigenous Australians. The overall age-standardized incidence rate of cancer among Indigenous Australians was 1.1 times the rate for non- Indigenous Australians. The higher incidence rate of cervical cancer in Indigenous Australians was likely to reflect the lower participation in cervical screening and higher rates of infection with human papilloma virus, 25 27 while the higher incidence of lung cancer may be explained, at least in part, by the fact that Indigenous adults are more than twice as likely to be current daily smokers as non-indigenous adults. 5 The higher incidence of cancer of unknown primary site in Indigenous Australians may be related to late diagnosis. 28,29 Similar to incidence, this report found that the overall age-standardized mortality rate from cancer was higher in Indigenous than in non-indigenous Australians, which was most likely due to the higher mortality from cervical cancer, pancreatic cancer, cancer of unknown primary site, breast cancer in females and lung cancer. Diagnosis at an advance stage, lesser uptake of cancer treatment and a greater number of comorbidities may also contribute to the higher overall mortality in Indigenous Australians. 25,27,30,31 Although the mortality rate from cancer is decreasing, the number of people dying from cancer is increasing due to the increasing Australian population and is expected to continue with Australia s ageing population. This has implications for service provision as cancer patients comprise the majority of those using palliative care services in admitted patient settings. 32 This may be due to the recognized disease pathway and prognosis of decline for cancer patients compared to non-cancer patients. 33 LIMITATIONS The most recent national data available at the time of analysis were 2009 for cancer incidence and 2010 for mortality data. Estimates for 2012 are based on projections of these data. BCC and SCC of the skin are by far the most common cancer diagnosed in Australia, 34 but, unlike other invasive cancers, these cancers are not reportable by law to cancer registries. As a result, data on these cancers are not included in the ACD, and therefore are not included in the incidence statistics presented here. Thus, the precise number of cancer cases diagnosed in Australia each year is unknown. Almost all reportable cancer cases and cancer deaths in Australia are registered. However, the Indigenous status of the cases or deaths is not always recorded correctly. The incompleteness of Indigenous identification means the number of cases and deaths registered as Indigenous is an underestimation of the cases and deaths occurring in the Aboriginal and Torres Strait Islander population. As a result, the observed difference between Indigenous and Asia-Pac J Clin Oncol 2013; 9: 199 213

212 Australian Institute of Health and Welfare non-indigenous in incidence and mortality rates may be underestimates of the true differences. In this report, the analysis by Indigenous status is limited to those jurisdictions with the most complete coverage of Indigenous cancer cases and deaths. However, even within the jurisdictions with data of acceptable quality, data on Indigenous cancer cases and deaths vary in their completeness. Thus, differences between Indigenous and non-indigenous incidence and mortality rates may also be influenced by jurisdictional differences in data quality. It should also be noted that data presented for the jurisdictions with data of acceptable quality for analysis are not necessarily representative of the jurisdictions excluded. The most recent national burden of disease analysis, based on 2003 data, was conducted by the AIHW and the University of Queensland. 1 Since then, no updates have been made to the national data. However, projections that were calculated as part of the 2003 study provide estimates of national burden of disease. Although sophisticated statistical methods were used to produce the projected results, uncertainties about how incidence, mortality and other factors change over time may affect these estimates. Over the last decade, the number of public hospitals in New South Wales, South Australia and the Australian Capital Territory changed their admission practices so that not all patients who receive same-day chemotherapy treatment were admitted to hospital but are treated on an outpatient (non-admitted patient) basis. This change must be taken into account when interpreting numbers and rates for hospitalizations. ACKNOWLEDGMENTS Staff in the Cancer and Screening Unit of the AIHW prepared this article and conducted analyses. The support of the AACR in producing the report Cancer in Australia: an overview 2012 2 is gratefully acknowledged. The AACR assisted the AIHW through provision of data, resolution of coding and tabulation issues, and checking of the tabulated data. REFERENCES 1 Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez A. The burden of disease and injury in Australia. Cat. No. PHE 82. Australian Institute of Health and Welfare, Canberra 2007. 2 Australian Institute of Health and Welfare, Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2012. Cancer Series No. 74. Cat. No. CAN 70. Australian Institute of Health and Welfare, Canberra 2012. 3 Australian Bureau of Statistics. Experimental Estimates and Projections: Aboriginal and Torres Strait Islander Australians, 1991 to 2021. Australian Bureau of Statistics, Canberra 2009. 4 Australian Institute of Health and Welfare. Australian Cancer Incidence and Mortality (ACIM) Workbooks. 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