Incidence a mortalita nádorových onemocnění v České republice
Česká republika patří mezi onkologicky nejzatíženější státy v evropském i celosvětovém měřítku. Cílem této studie je shrnout dlouhodobé trendy v epidemiologii nádorů, včetně nových odhadů incidence a mortality za rok 2007.
Materiál a metody: Český národní onkologický registr (NOR) byl založen v roce 1977 a zpřístupňuje informace o epidemiologii nádorů za 30 let při 100% pokrytí onkologických diagnóz a české populace. Analýza epidemiologie nádorů se dále opírá o demografická data a o data Registru zemřelých ČR. Epidemiologická data jsou dostupná on‑line na portálu www.svod.cz.
Výsledky: Hrubá incidence zhoubných nádorů (včetně jiných nádorů kůže) dosáhla v roce 2007 hodnoty 736/ 100 000 mužů a 648/ 100 000 žen. Roční hrubá mortalita přesáhla 263 úmrtí / 100 000 obyvatel; každoročně umírá z příčiny zhoubného nádoru více než 27 000 osob. Celková incidence nádorových onemocnění setrvale roste, růstový index dosáhl za období 1997– 2007 hodnoty + 26,4 %. Naopak mortalita je ve stejném období stabilizována (růstový index – 2,5 %). Důsledkem rostoucí incidence a stabilizované mortality je růst prevalence, která v roce 2007 přesáhla 400 000 osob. K růstu populační zátěže přispívá kromě demografického stárnutí populace také rostoucí incidence vícečetných primárních nádorů u téhož pacienta (v recentním období více než 11 % z celkové incidence). Mezi nejčastější malignity české populace patří nádory kolorekta, prsu, plic a prostaty. Ačkoli je řada onkologických diagnóz stale častěji zachytávána v méně pokročilých stadiích (např. stadium I + II u nádorů prsu: 71,9 %, u zhoubného melanomu: 81,3 %), celkově je včasná diagnostika zhoubných v ČR nedostatečná. To se týká i velmi častých typů nádorových onemocnění, jako je kolorektální karcinom (pouze 43,2 % nově diagnostikovaných pacientů ve stadiu I + II).
Závěr: Česká republika je vybavena kvalitním a funkčním zázemím pro sběr a analýzu onkologických populačních dat. Dostupná data napomáhají definovat priority organizace onkologické péče, kterými jsou jednoznačně posílení záchytu časných stadií onkologických onemocnění a redukce existujících rozdílů mezi regiony ČR.
Klíčová slova: epidemiologie nádorových onemocnění – incidence – mortalita – Česká republika
L. Dušek1; J. Mužík1; E. Gelnarová1; J. Fínek2; R. Vyzula3; J. Abrahámová4
Authors place of work:
Institute of Biostatistics and Analyses, Faculty of Medicine and Faculty of Science, Masaryk University, Brno, Czech Republic1; Department of Oncology and Radiotherapy, University Hospital, Plzeň, Czech Republic2; Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic3; Department of Oncology, Thomayer University Hospital, Prague, Czech Republic4
Published in the journal:
Klin Onkol 2010; 23(5): 311-324
Backgrounds: The Czech Republic is ranked among those countries with the highest cancer burden in Europe and worldwide. The purpose of this study is to summarize long-term trends in the cancer burden and to provide up-to-date estimates of incidence and mortality rates from 2007.
Material and Methods: The Czech National Cancer Registry (CNCR) was instituted in 1977 and contains information over a 30-year period of standardized registration covering 100% of cancer diagnoses and the entire Czech population. The analysis of CNCR is supported by demographic data of the Czech Republic and by the Death Records Database as civil registration systems. The epidemiology of malignant tumours in the Czech population is available online at www.svod.cz.
Results: All neoplasms, including non-melanoma skin cancer, reached a crude incidence rate of almost 736 cases per 100,000 men and 648 cases per 100,000 women in 2007. The annual mortality rate exceeded 263 deaths per 100,000 population; each year, more than 27,000 persons die of cancer. The overall incidence of malignancies has increased during the last decade with growth index + 26.4% (1997–2007) while the mortality rate has stabilized over this time span (growth index in 1977–2007: –2.5%). Consequently, the prevalence has significantly increased in the registration period and in 2007 it exceeded 400,000 cases. In addition to the demographic ageing of the Czech population, the cancer burden is increased by the growing incidence of multiple primary tumours (recently more than 11% of the total incidence). The most frequent diagnoses include colorectal cancer, lung cancer, breast cancer and prostate cancer. Although some neoplasms are increasingly diagnosed at an early stage (e.g. proportion of stage I + II in female breast cancer: 71.9%, skin melanoma: 81.3%), in general early diagnostics is insufficient in the Czech Republic. This is the case even for highly prevalent colorectal carcinoma (only 43.2% of incident cases recently diagnosed at stage I or II).
Conclusion: The Czech Republic is well equipped with high-quality and functional facilities for collecting and analysing population-based data on malignant tumours. The data survey has enabled the priorities of cancer management in the Czech Republic to be defined. This will undoubtedly lead to a sustained reduction in late diagnosed cases and a reduction in the remarkable regional differences in diagnostic efficiency.
of the Czech National Cancer Registry and population based
monitoring of cancer disparities are supported by grant “Addressing
Cancer Disparities in Central and Eastern Europe” Bristol Myers
Squibb Foundation, 2009– 2011 (Project:
National Information System for the Assessment and Communication of
Cancer Care Results and Quality in the Czech Republic). The authors
also greatly acknowledge professional support of data managers of the
Czech National Cancer Registry, as well as excellent
collaboration with the Institute of Health Information and Statistics
of the Czech Republic (IHIS).
epidemiology is of an ever growing importance due to the high
incidence rates of malignant tumors [1,2]. In recent years, several
comprehensive worldwide and European summaries of cancer incidence
and prevalence have been published [3– 5].
These reports are unambiguous data based evidence of a rapid
increase of cancer incidence in most of European countries. According
to Ferlay et al  there were 3,191,000 diagnosed cancer cases
(excluding nonmelanoma skin cancer) and 1,703,000 deaths from
cancer in Europe in 2006. The same authors concluded that the total
number of new cases of cancer in Europe appears to have increased by
300,000 since 2004. Therefore, the cancer is an important public
health problem in Europe with only partially effective measures how
to diminish the continuous growth of burden. The Czech Republic
represents no exception in this respect; quite the opposite, the
Czech population ranks among the most burdened countries worldwide
The current role of epidemiology
is not purely descriptive. Knowledge on age specific
or stage specific
trends is necessary to evaluate effectiveness of diagnostic
processes, to identify weak points in the management of cancer care
or to analyze associations with therapeutic outcomes . Among all
health care end points of population based cancer
registries, survival occupies dominant position. Recently, a series
of excellent articles summarizing cancer related survival in
European countries has been published [8– 11].
Although significant improvement in reached survival rates have been
reported for most of the European countries, there are still apparent
regional differences, mostly associated with late diagnosis of
advanced disease stage and with more o less specific care
disparities. Based on current epidemiological trends, it seems that
promising modern research technologies and onset of personalized
medicine have not yet been effectively translated into cancer
control. Epidemiologic data can thus strategically contribute to the
management of this field of medicine .
Relevant epidemiologic analyses
supporting control and planning of cancer prevention, diagnostics and
therapy require population data rich in available parameters.
Particularly records identifying morphology and clinical stage of
tumors are important. Such clinical registries enable monitoring of
early detection of cancer which is currently major area of interest
in Europe , closely related to survival of cancer patients.
Cancer population registries form an indispensable component of
functional information systems for monitoring of organized screening
However, not all national cancer
registries can provide such complex information and therefore many
epidemiologic summaries covering large geographic areas cannot
address the health care topics adequately. International
epidemiologic surveys also often suffer from partially inconsistent
data from participating countries or from interruption in time as it
was the case of the Europe Against Cancer Programme of the European
Commission . Therefore separate processing of national databases
leading to extraction of clinically relevant knowledge is still of
a great value. That is why we prepared this overview of recent
cancer epidemiology in the Czech Republic. This article presents
cancer incidence and mortality in the Czech population, utilizing
more than 30 years experience with nationwide cancer data
collection. Up to date
estimates of incidence and mortality rates from period 2006– 2007 are
presented in the context of long term trends. We take not only
general descriptive approach, detailed stage specific
trends and regional differences are discussed as well.
a standard part of population
monitoring, the Czech Statistical Office administrates data on the
demographic structure of the Czech population and makes it available
on its website [16,17]. This fully consolidated data source describes
the main demographic characteristics of the Czech population, such as
the total population, the age structure, life expectancy, as well as
predictions up to 2050. Basic demographic characteristics of the
Czech population are summarized in Tab. 1.
Cancer Registry (CNCR)
CNCR has been maintained since 1977 when it was instituted as
database covering 100% of cancer diagnoses and the entire Czech
population. The most recent validated outcomes are from 2007 and
the CNCR database contains more than 1.6 million records. The
registration of malignant neoplasms is stipulated by the legislation
and is obligatory. The CNCR is a part of the National Health
Information System (NHIS) and is administered by the Institute of
Health Information and Statistics of the Czech Republic . The
CNCR is accepted as a key database component of the Czech
National Cancer Control Programme, designated to report regular and
timely estimates of the cancer burden in the Czech population. For
the purpose, automated analytic tools with outputs in the final form
were developed. The CNCR is equipped with an information system
which, among others, provides free accessible an analytical web
portal (www.svod.cz) .
data and associated
CNCR contains personal data on patients,
data describing malignant tumors and diagnostic details (including
morphology classification and stage), data on patients‘ treatment,
as well as data on post treatment follow ups. The
registration of a new incident case begins with the cancer
diagnosis, its morphological verification and an accurate staging.
Subsequently, basic records on primary therapy (employed modalities),
reasoning of therapeutic strategy, follow up data and/ or
deaths are transferred into the registration forms. The forms are
directly linked to the database on the basis of standardized data
model and data processing rules . Malignant neoplasms were
recorded according to the International Classification of Diseases
for Oncology (ICD O,
tenth revision) . Tumours are staged on the basis of TNM
classification system . For the purposes of this article, all
cases recorded in the CNCR, including DCO records, were included
among incident cases. Identification of multiple cancers in the same
person was accurately controlled in the CNCR database, based on
strict recognition of individual code of a patient, date of the
diagnosis and diagnostic typology of multiple cancers.
Czech legislation requires all deaths in the Czech Republic to be
registered in the Death Records Database, a civil registration
system . For this purpose, standardized Death Certificates
(internationally recommended by WHO, ) are designed to collect
precise data on the cause of death in each individual, typically
performed and proved by general practitioner. The causes of death are
classified according to the International Classification of Diseases
which provides standardized nomenclature in this field . This
system ensures comparability of official Czech mortality data 
with common international reporting. The coding of underlying cause
of death can be controlled against independently and timely filled
National Cancer Registry. The CNCR serves as another source of
mortality data in the Czech Republic. Here, the individual records on
the cause of death according to the Death Certificate are directly
linked to diagnostic data on decedents, which can be used to code
mortality with respect to different cancer diagnoses. Death of
a given person from malignant tumour is accurately indexed with
respect to the main cancer diagnosis in accord with the immediate or
the primary cause of death. So the Czech system allows the data
managers to code distinct cancer entities and the records on causes
of death are finally kept separately in two information systems. The
system makes it possible to check the correctness of CNCR data
retrospectively, and to verify the validity of mortality data on
cancer patients according to internationally accepted rules [24,25],
as discussed in .
epidemiologic measures as crude incidence and mortality rates, age
standardized rates and lifetime cumulative cancer rates were
calculated according to widely accepted international guidelines
[26,27]. Cumulative risk is expressed as the probability that an
individual will develop the given cancer type during age span
0– 74 years,
in the absence of other competing causes of death. Annual incidence
and mortality rates per 100,000 population (crude incidence)
were calculated by gender and related to the Czech population
structure in 2007 . Age standardized
rates adjusted for the World and European population were calculated
using age standards according to Waterhouse et al .
Republic belongs to the group of countries with the highest cancer
burden, mortality from cancer contributes to the overall population
mortality by 26.5% (Tab. 1). The highest relative proportion of
mortality from cancer in relation to the other competing causes of
death is registered in age group 50– 64 years
(Tab. 2). Male population is ranked worldwide in the 7th
position in cancer incidence and in the 18th position in cancer
mortality, women population occupies 15th place in worldwide
statistics of incidence and 36th position in mortality ranking
(Tab. 3). In 2007, there were 71 757 (691.2 per
100 000 people) new incident cases of all cancers including
skin neoplasms (C00– C97).
In total, 27 359 cancer deaths were registered in
2007 (263.5 per 100 000 population) (Tab. 3).
Crude incidence rate continuously increases with the growth
index in the last decade 26.4 %
while the crude mortality rate was stabilized in late 1990s and
recently it has become to decrease with growth index –5.4%
over time range 1997– 2007 (Fig.
1, Tab. 3– 4).
Growing incidence and stabilized mortality necessarily increase
prevalence which exceeded 400,000 of cases in 2007 (Tab. 3).
The age standardized
rates (World and European age standard) as well as crude incidence
and mortality rates are presented in Tab. 5– 6 by
sex and for all main cancer diagnostic groups. Following types of
cancer are most frequent in men population (absolute number in 2007):
prostate cancer (5,094), followed by nearly equally incident
colorectal cancer (4,638) and lung cancer (4,630). In women, the
breast cancer is significantly most frequently diagnosed
(6,500 incident cases in 2007), followed by colorectal cancer
(3,188), uterus cancer (1,771) and lung cancer (1,762). The highest
value of lifetime cumulative risk (0– 74 years)
was observed in breast cancer (women: 7.75), prostate cancer (men:
7.31), lung cancer (men: 6.82) and colorectal cancer (men: 6.44).
In addition to demographic ageing
of the Czech population, the cancer burden is increased by growing
incidence of multiple primary tumors. Data in Tab. 7 documents
significantly growing contribution of multiple incident cases (both
synchronous and metachronous) to the overall incidence. In most
prevalent cancers, the rate of multiple diagnoses in the same
patients forms more than 11% of the overall incidence (1998– 2007).
The database of CNCR offers
accurate stratification of newly diagnosed cases according to
clinical stage (Fig. 2, Tab. 8). It is evident that early
detection of the disease is a weak point of the Czech cancer
management, particularly in the following diagnoses: cancer of
oesophagus, liver, gallbladder and pancreas. Relatively low
proportion of early detected cases can also be observed in highly
prevalent cancers like colorectal cancer (stage I + II: 43.2%)
and lung cancer (stage I + II: 14.6 %).
Furthermore, in all mentioned diagnoses there is no signal of
improving situation over a wide time span 1998– 2007 (Fig.
2). On the other hand, our survey revealed also prevalent cancers
with continuous increase of early diagnosed cases. It is the case of
female breast cancer, male testicular and prostate cancer and bladder
cancer in both sexes; all these diagnoses have recently exceeded 70 %
of incident cases in stage I or II (Tab. 8, Fig. 2).
Problems with accessibility of
early diagnostics in cancer management are indicated also in regional
survey presented in Tab. 9. Significant regional heterogeneity
in early detection rate was found in nearly all listed diagnoses,
including most prevalent colorectal cancer (inter regional range in
proportion of early diagnosed cases: 37.4%– 53.0%),
prostate cancer (41.4%– 74.3%)
or bladder cancer (62.1%– 89.6%).
It should be emphasized here, that even generally calculated cancer
burden significantly differs among regions of the Czech Republic.
Crude incidence estimated in 2007 regionally ranges from
444.5 to 604.9 and crude mortality ranges from 236.7 to
301.4 (Tab. 9). Such heterogeneity cannot be explained only
by different population structure of the regions. In selected types
of cancer the regional distribution of age standardized
incidence rather indicates potential influence of some external,
environmental factors (Fig. 3).
cancer burden of the Czech population
ranks among the highest worldwide and has been growing continuously
[4,6]. During 1990s and 2000s, the incidence of all major cancers was
constantly increasing in the Czech population  and the growth
dynamic was consistent with recently published international data
Also relative profile of most prevalent cancer types (breast cancer
in women, prostate cancer in men, colorectal and lung cancer in both
sexes) corresponds to the outcomes of most recent European
epidemiology summaries . In agreement with international reports,
lung cancer is the most frequent cause of death from cancer. In the
Czech male and female population it means 4,032 and
The growing trend in cancer
burden can be generally attributed to widely known risk factors, like
apparent demographic ageing of the Czech population, life style
factors or more specifically, to changes in reproductive behavior
(female breast cancer) .
Further growth in cancer
incidence can be expected also in future, due to the demographic
structure and ageing of the Czech population. In 1995, the average
age was 35.6 years for men and 38.9 years for women. Within
twelve years, these values shifted to 38.8 years for men and
41.8 years for women (data from 2007). During the period
the proportion of inhabitants aged over 50 years increased by
The increasing trend in incidence
is remarkable also in preventable cancers, particularly in breast and
colorectal carcinoma. Latest IARC database  even shows the Czech
Republic to have the highest male colorectal cancer incidence
worldwide. The growing incidence of colorectal cancer (growth index
6.8%) is accompanied with relatively weak early detection of the
disease (only 43.2% of incident cases in stage I or II).
Furthermore, the relative rate of early detected cases greatly varied
among regions (37.4– 53.0%)
which indicates some disparities in the cancer control. These facts
are challengeable for the Czech programme of colorectal screening
which has well documented history [30,31].
International trials promise
decrease in CRC mortality by more than 30% due to organized screening
based on annual guaiac faecal occult blood test (gFOBT) [32,33].
However, recent Czech data indicates only 16% coverage of target
adult population by gFOBT screening which is insufficient to initiate
The recent situation in
epidemiology of breast cancer in the Czech women population is better
than in colorectal cancer. Although the incidence of breast carcinoma
is significantly increasing (growth index 1997– 2007:
41.4%), it is accompanied with continuous increase of early diagnosed
cases (recently 72% of incident cases diagnosed in stage I or II).
These positive changes are due to increasing power of the Czech
national screening for breast cancer which already reached more than
50% coverage of target women population (> 45 years).
Similarly, as a consequence of widely used PSA test, we can
observe growing incidence of early detected prostate cancer (Tab. 8,
Fig. 2) although no organized screening for this type of cancer
exists in the Czech Republic.
The cancer burden in the Czech
Republic has also been increasing due to growing incidence rate of
multiple primary malignancies, diagnosed in the same patient.
Although the registration of multiple tumors was discussed in
literature as rather complicated topic , it is not the case of
the Czech cancer registry. The CNCR database makes it possible to
identify a specific patient; therefore, recurring malignancy in
the same person can be accurately identified, whether it is in the
same location or another. The chronological order of recurring
malignancies can also be measured. Tab. 7 sums up the
overall data, showing that multiple malignancies are relatively
common, although they differ markedly among diagnoses. If
non melanoma skin cancers (C44) and malignant neoplasms of
uncertain behavior (D37– D48)
are not taken into account, the relative frequency of recurring
malignancies ranges from 12 to 14%, the overwhelming majority
(96%) of recurring malignancies belonging to other diagnostic group
than the primary tumor. Recurring malignancy of the same diagnostic
group is more common in breast cancer (C50), bladder cancer (C67) and
partly in testicular cancer (C62). This field is very compelling
because of it offers a new dimension for cancer burden
causation. Additionally, it represents an opportunity for prevention
and for better targeting of already diagnosed and treated cancer
In addition to insufficient early
detection of many cancers and related disparity in cancer
diagnostics, the Czech cancer care is faced with high regional
variability in epidemiologic measures. Although we cannot exclude the
influence of under registration
in some regions, its real impact is highly probably limited,
particularly in recent period since 2000. This assumption is based on
the regional profiles of mortality rates which fully correspond to
that observed for the incidence profiles. Mortality estimates are
double controlled in the Czech Republic using two independent sources
of information on death events, i.e. cancer registry and Death
Records Database [17,18]. Furthermore, the CNCR management closely
respects the administrative division of the country into 14 regions
and is collected with the same operation in each of them. Moreover,
observed regional differences in cancer burden are different for
various cancers and do not reveal any consistent pattern (Fig. 3).
Therefore, in view of regional
differences (Tab. 9, Fig. 3), we cannot neglect influence of
environmental factors, although their contribution to aetiology of
human cancer is disputably discussed in literature [37,38]. Czech
adults who come to risk age categories 50– 60 years
or older were probably at least partially exposed with environmental
pollutants including DDT, PCBs, PAHs and pesticides in 1960s– 1970s
. This hypothesis however cannot be exactly quantified due to the
lack of environmental data from the period of communist government
before 1989. Although we cannot address the role of environment in
cancer causation, some birth cohort
effects should be studied as indirect population indicator of some
unspecified harmful effect in past. This information should be
translated into well designed future studies focused on space
variability of cancer epidemiology in the Czech Republic.
This work is based on 30 year
experience of a nationwide, fully representative cancer
registry. It supports the idea that cancer registries can be accepted
as one of the main strategies for improving our understanding of
cancer and its causation. Representative registries may reveal
factors underlying trends in cancer incidence; moreover, they can
detect significant changes over time in the main diagnostic measures
(such as morphology and staging). This information is necessary to
promote prevention which might ultimately lead to better control of
the disease. The Czech National Cancer Registry contains complete and
comprehensive records on the clinical stage at the time of diagnosis,
including detailed records on individual components of TNM
classification. The overall CNCR assessment has revealed only 5.8% of
records which unfoundedly miss information on both TNM classification
and clinical stage (Fig. 2). The completeness of CNCR data increases
in time and the most recent period provides high quality data.
The CNCR is equipped by web based analytic tool which allows the
user to perform comprehensive analyses in user friendly
environment . We regard the CNCR database and associated software
as one of the most influential product of the Czech National Cancer
Control Program. These products also support wider international
collaboration which is preferred also by other, similarly equipped
cancer control programs .
data accessible, the cancer burden in the Czech Republic can be
assessed throughout the population and for individual regions. The
proportion of clinical stages as well as the success rate of early
detection can be analyzed, and the time trends can then be drawn from
all assembled data. The most impressive aspect of our study is the
accessibility of information over a 30 year period of
continuous and standardized registration covering 100% of cancer
diagnoses and the entire Czech population; also available in an
on line working, interactive tool . The main challenge for
the future is to achieve the unaccomplished objective of lowering
cancer mortality, particularly by sustained reduction of late
diagnosed cases and of remarkable regional differences in diagnostic
authors declare they have no potential conflicts of interest
concerning drugs, pruducts, or services
used in the study. Autoři
deklarují, že v souvislosti s předmětem studie nemají
žádné komerční zájmy.
Editorial Board declares that the manuscript met the ICMJE “uniform
requirements” for biomedical papers. Redakční
rada potvrzuje, že rukopis práce splnil ICMJE kritéria pro
publikace zasílané do biomedicínských časopisů.
Prof. MUDr. Ladislav Dušek, Ph.D. Institute
of Biostatistics and Analyses Faculty
of Medicine and Faculty of
University in Brno Kamenice
00 Brno Czech
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