0964~1947l9255.00 + 0.00 0 1992 Pergmnm Prerr Lid

EurJ Cnncpr, Vol. ZSA, No. 12,~~. 202M049,1992. Pnnred m Great Btioin

Patterns of Childhood Cancer Incidence and Mortality in Europe Fabio Levi, Carlo La Vecchia, Franca Lucchini, Eva Negri and Peter Boyle Histograms including age-standardised (O-14 years, world standard) incidence and mortality rates from selected childhood cancers are presented for 21 European cancer registration areas and 24 countries. The overall range of variation in all childhood cancer incidence rates across various cancer registration areas in Europe was around a factor 1.5, with highest rates in Spain, Italy, Sweden and France, and lowest rates in Poland, Hungary, UK, Germany and Yugoslavia. For most single cancer sites, however, the observed pattern is essentially attributable to random variation alone. A clearer pattern, however, emerged with reference to mortality. The overall range of variation, in fact, was around a factor two in both sexes, with highest rates in Bulgaria, Portugal, Hungary, Czechoslovakia and Poland, and the lowest rates in Austria, UK, Germany, The Netherlands and Finland. Trends in mortality from childhood cancers between 1950 and 1989 were also presented. Recent declines were observed for total childhood cancer mortality, leukaemias, kidney cancer (Wiis’ tumours), Hodgkin’s disease and other lymphomas in most European countries. These declines, however, were generally earlier and larger in northern as compared with southern and, mostly, with eastern European countries. This pattern of trends likely reflects the different adoption and impact of newer efficacious therapies of childhood cancer, and hence, confirms that there is ample scope for further reduction in childhood cancer mortality in several eastern and some southern European countries. EurJ Cancer, Vol. 28A, No. 12, pp. 202&2049,1992.

INTRODUCTION THE AIM of this report is to provide, in a standard format, figures

of incidence and mortality from main childhood cancer sites in various European cancer registration areas and countries. This work offers general baseline documentation and description of the overall picture of childhood cancer incidence and mortality in Europe, and could constitute a basis for potential inferences on determinants of differences in childhood cancer rates. Further, since several childhood cancers are now amenable to treatment, variation in certified mortality and comparisons between pattern of incidence and mortality and comparative analysis of trends in mortality over the last few decades may provide useful clues towards the differential utilisation and impact of newer treatments in various European geographical areas. MATERIALS AND METHODS

Age-standardised (on the world standard population) [l] incidence rates from 0 to 14 years for selected cancers or groups of cancers in 21 European cancer registration areas were abstracted from the volume of Znrernarional Incidence of Childhood Cancer published by the International Agency for Research on Cancer [2]. A total of 11 cancers or groups of cancers, plus total cancer mortality, were abstracted, using the

Correspondence to F. Levi at the Registre vaudois des tumeurs. F. Levi and F. Lucchini are at the Registre vaudois des tumeurs, Institut universitaire de medecine sociale et prkventive, CHLJV-Falaises 1,lOll Lausanne, Switzerland; F. Levi, C. La Vecchia and F. Lucchini are at the Institut universitaire de mkdecine sociale et preventive, Bugnon 17, 1005 Lausanne, Switzerland; C. La Vecchia and E. Negri are at the Istituto di Ricerche Farmacologiche “Mario Negri”, Via Eritrea 62, 20157 Milano, Italy; and I’. Boyle is at the Istituto Europe0 di Oncologia, Division of Epidemiology and Biostatistics, Via Ripamonti 332/10,20141 Milano, Italy. Received 16 Apr. 1992; accepted 5 May 1992.

same histo-pathologic classification adopted in that volume [2]. Table 1 gives the list of cancer registration regions, the calendar period, and the average annual population. Childhood cancer mortality rates (age-standardised O-14 years, world standard) for 24 European countries (excluding the former Soviet Union and a few small countries such as Iceland, Liechtenstein, Malta, etc.) were computed for the period 1950-1989 on the basis of the official death certification data provided by the World Health Organization (WHO) database. The corresponding average annual population is given in Table 2. Death certification data allowed separate analysis of six cancer sites: all leukaemias, Hodgkin’s disease, all non-Hodgkin lymphomas, malignant bone neoplasms, kidney cancer (Wilms’ tumour), eye (retinoblastoma), plus total cancer mortality. During the calendar period considered, four different revisions of the International Classification of Diseases (ICD) [3-61 were in operation. Nonetheless, there were no major changes in the classification or coding of these cancers or groups of cancers between the sixth and the ninth revisions of the ICD. It was impossible, however, to obtain meaningful death certification data for neoplasms of the nervous system on account of difficulties in histopathological classification and of changes in the classification of neuroblastoma, which is coded in part to the organ affected (chiefly, the adrenal gland, i.e. with cancers of the endocrine organs), in part to connective and soft tissue sarcomas, and in part to the nervous system. Incidence and mortality rates are graphically presented in two groups of histograms, including the most recent available incidence (Fig. 1) and (whenever available) mortality rates (Fig. 2) for each sex, respectively. Figure 3 gives trends in agestandardised (O-14 years; world standard) mortality rates from 1950 to 1989 for all childhood cancers and each separate cancer or group of cancers considered.

2028

Childhood

Cancer Incidence

Table 1. Average annual population (age O-14) in 21 European cancer registry regions

Cancer registry region Czechoslovakia, Slovakia Denmark Finland France, Bas-Rhin France, Lorraine, Provence-AlpesC&e d’Azur and Corse (L-PACA-C) GDR (197680) FRG, Co-operative Register (CR) FRG, Saarland Hungary Italy, Province of Torino Netherlands, Dutch Childhood Leukaetnia Study Group (DCLSG)* Netherlands, South-East Registry (SOOZ), Eindhoven Norway Poland, Warsaw City Spain, Zaragoza Sweden Switzerland, Three Western Cantons of Geneva, Neuchatel and Vaud (TWC) UK, England and Wales UK, Manchester UK, Scotland Yugoslavia, Slovenia

Calendar period

Males

1970-1979 1978-1982 1970-1979 1975-1984 1983-1985

631099 550496 531516 102 141 687993

603 599 525 278 509555 98 105 656439

19761980 1982-1984 1967-1982 1975-1984 1967-1981 1973-1982

1744 100 5 097 995 121 189 1171851 256 739 1703 583

1658 500 4 864 396 116040 1107396 243 595 1632 143

1973-1983

98 227

94117

1970-1979 1970-1979 1973-1982 1970-1982 1974-1983

484 158 167014 96113 853734 96 482

460 082 159287 90 245 811164 92 448

Females

1971-1980 5 707 800 5 407900 1971-1983 484 161 459 534 1971-1980 644800 611900 1971-1980 217897 206512

*Incidence data provided only for leukaemias.

Table 2. Average annual population (age O-14) in 24 selected European countries (1985-1989) Country Austria Belgium Bulgaria Czechoslovakia Denmark Finland France Germany, GDR Germany, FRG Greece Hungary Ireland Italy Netherlands Norway Poland Portugal Romania Spain Sweden Switzerland UK, England and Wales UK, Scotland Yugoslavia

Males 688 500 930 400 965 800 1906 900 469 200 487 300 5 749 200 1645 900 4 660 700 1047 700 1 147 900 522 000 5411700 1409 700 417 100 4921800 1175 900 3 397 800 4531700 773 100 578 300 4 843 800 497 900 2 828 600

Females 658 100 886 800 916 500 1822 600 449 300 465 600 5 466 700 1566 900 4 436 100 979 000 1091000 495 100 5 135400 1348 200 397 700 4 694 600 1116300 3 119000 4 256 800 735 700 552 000 4 594 000 473 200 2 665 900

and Mortality

in Europe

2029

RESULTS AND DISCUSSION This report has mainly a descriptive value, and is therefore not directly intended to draw inferences. A few general comments are, nonetheless, useful for supporting data interpretation. First, problems of random variability for most childhood cancers are substantial, and are clearly greater in relation to incidence data (often based on smaller populations) and more rare cancers. A simple comparison between male and female incidence figures indicates that, for several cancer sites, the

apparent variability is essentially attributable to random variation alone, since there are substantial differences in the figures for the two sexes. Thus, the true variability is probably limited [7]. Clearer patterns, however, were distinguishable for some cancer sites: for instance, incidence rates from brain and nervous system neoplasms tended to be systematically elevated in Sweden and other Nordic countries, France and Italy (Turin), and low in Germany and surrounding countries, UK and most eastern European cancer registration areas. Incidence rates from Hodgkin’s disease and other lymphomas tended to be higher in Italy, Yugoslavia, Czechoslovakia and Spain, and low in Nordic countries, Poland and Hungary. Leukaemias were again elevated in Spain and Italy, but also in Norway, Finland and Sweden, and showed low incidence in most eastern European areas. Thus, the overall range of variation in all cancer incidence rates across various cancer registration areas in Europe was around a factor 1.5 in both sexes, with higher rates in Spain, Italy, Sweden and France, and low rates in Poland, Hungary, UK, Germany and Yugoslavia. With reference to mortality, the pattern of rates was confused and probably largely influenced by random variation for bone and kidney (Wilms’ tumour), but clear and systematic pictures emerged for other sites, and particularly for lymphomas and leukaemias, since higher mortality rates were observed in eastern and southern European countries, and were 50-100% higher as compared with those of most northern European countries. Thus, the range of variation in total childhood cancer mortality was around a factor two in both sexes, with higher rates in Bulgaria, Portugal, Hungary, Czechoslovakia and Poland, and the lower rates in Austria, UK, Germany, The Netherlands and Finland. Trends in mortality for selected childhood cancers between 1950 and 1989 are graphically presented in Fig. 3. Declines were observed for total childhood cancer mortality, leukaemias, kidney cancer (Wilms’ tumour), Hodgkin’s disease and other lymphomas in most European countries, particularly from the late 1960s onwards. These declines, however, were generally earlier and larger in northern as compared with southern and, mostly, with eastern European countries. Steady falls in childhood cancer mortality were still evident over the most recent calendar periods, indicating that these favourable trends are likely to continue in the near future and that there is scope for further improvement in the management of and survival from childhood cancer. Trends in mortality are more difficult to interpret for eye cancer (retinoblastoma), particularly due to the low absolute numbers of deaths, and for bone neoplasms (Ewing’s sarcomas), possibly because the impact of newer conservative treatment is not clear [9]. Overall, during the last three decades, childhood cancer mortality has declined by an average 40% in western European countries, but only by approximately 20% in Eastern Europe [8]. This pattern of trends most likely reflects the different adoption and impact of newer therapies of childhood cancer in

2030

F. Levi et al.

various European geographical areas. These improvements have heea due to the availability and adoption of effective multidrug

chemotherapy, together with the introduction of improved diagnostic techniques, of various supportive measures to overcome toxicity and the availability of megavoltage radiation [%13]. Thus, the distribution of rates of childhood cancer mortality in various European countries, and the corresponding trends over time, together with the absence of systematic patterns for incidence, again con6rms that there is ample scope for further reduction in childhood cancer mortality, particularly in several eastern (and also some southern) European countries, which may be obtained through better availability and introduction of currently available treatments [II].

1. Doll R, Smith PG. Comparisonbetween registries:age-standardized rates. In Waterhouse JAH, Muir C, Shanmugarstnam K, et al., eds. Cancer Incdence in Five Continents, Vol. IV, IARC Scientific Publication No. 42. Lyon, International Agency for Research on Cancer, 1982,671475. 2. Parkin DM, Stiller CA, Draper GJ, Bieber CA, Terra&i B, Young JL (eds). Inremarional Incidenceof Childhood Cancer. IARC Scientific Publication No. 87. Lyon, International Agency for Research oncanCer, 1988. 3. World Health Organization. ZnrernationalClassificati of Diseases: 6th Revision. World Health Organization, Geneva, 1950.

4. World Health Organization. Intemational Classificationof Diseases: 7th Revision. World Health Organization. Geneva, 1957. 5. World Health Organization. I&rnationa~Classir;chtia of Diseases: 8th Revision. World Health Organization, Geneva, 1967. 6. World Health Organization. International Classijkarion of Diseases: 9th Revision. World Health Organization, Geneva, 1977. 7. Parkin M, Nectoux J, Stiller C, Draper G. L’incidence des cancers de I’enfant dans le monde. Pbdianie 1989,44,725-736. 8. La Vecchia C, Levi F, Lucchini F, Garattini S. Progress of anticancer drugs in reducing mortality from selected cancers in Europe: an assessment. Anti-Cancer Drugs 1991,2,215-221. 9. Stiller CA, Bunch KJ. Trend in survival for childhood cancer in Britain diagnosed 1971-1985. BrJ Cancer 1990,62,80&815. 10. Birch JM, Marsden HB, Morris Jones PH, et al. Improvements in survival from childhood cancer: results of a population based survey over 30 years. Br MedJ 1988,296,1372-1376. 11. Craft AW, Pearson ADJ. Three decades of chemotherapy for childhood cancers: from cure ‘at any cost’ to cure at ‘least cost’. CancerSurveys 1989,8,605-629. 12. La Vecchia C, Decarli A. Decline in childhood cancer mortality in Italy, 1955-1980. Oncology 1988,45,93-97. 13. Levi F, La Vecchia C. Childhood cancer in Switzerland: mortality from 1951 to 1984. Oncology 1988,45,313-317. Acknowledgements-This study has been made possible by a core grant of the Swiss (Aargau and St-Gall) League against cancer. Supports were also received by tbe Italian Association for Cancer Research and the Italian League against Cancer. This study was conducted within the framework of the CNR (Italian National Research Council) Applied Project “Clinical Application of Oncological Research” and of the “Europe Against Cancer” Programme of the Commission of the European Communities.

2031

Childhood Cancer Incidence and Mortality in Europe

Bone, females

Bone, males 16

0

-I sph m S4vbhnd.w FRO. Smtk”d GDR Finland ltdy, TOd”0 Nonmy wad.” N9lhub”dD. SOOZ Ebdlwb” FRG. CR UK. E”&md nd W6ba czwhoabukb, aour* DMmrt Yugoabvia. Sbw”b Fmna. Bm-Rhh Frmc.. LP&xC UK Mnchnw HuwV -. wrm ChY UK, smtbnd

16

FRO.

Smlmd NV, Tab0 SOOZ Ebdhuw” Fmnm. Bn.Rhb swadm Dwllmlt Q~hoabwkb. slcruJ;b GDR Fmna, L-PXAX UK. MaUK.soobnd Finlmd FRO. CR Spd”. Lmwa UK. E”gb”dmldWaba swkabnd.TWC Pobnd. wanm City Nomy Hunpy Y”pebti. sbmlb

Soft tissue sarcomas , males 6

Soft tissue sarcomas, females

16 I 13.4 N.thwimd~.SOOZEbdh Spin. x

10

Fr.nc.. L-P&XC spin. m SwiQedmd. ‘Iwc GDR LwlmrL YUgoabvb. sbw”b I-V, Totho Fmnc., Bn.Rhh FRG, CR Suodm Finbnd UK. En#mdmdWaln wwrrwcl(y N.thmlm&. SOOZ Eindhova HWWY RG. Saahnd UK, smtbnd Czeoho&a&b, Sbukh Uk MmMr NwmY

0

6

10

16 I 11.0

P&de Swodm FRO. Sahnd Fblald MY, Torn0 swiQ*h”d, TWC YU(p&+ia, Sbvmb UK. En@utdandWJw FM-. L-PMXC Fmo. Mhh Ulisoor*nd FRG, CR Q.chabv&b. Shv.km HUnW UK. Mandmtiw Dbnnnrk

Kidney, 0 Fm”a. Mhin Finlmd cachoeknkii. SMk Nom, svndn Spain. Zw3~= Pobwd, Wanm CiIY FRG. Srdad mnmrk Yugmbvb. sbwn* UIcsmt*nd FRG. CR Neth.hn&, SOOZ Eiihawn HU”VV UK. En&end and Waba My, Torbo UK. t.!ac&wtw GDR Fmnce. L-F’ACAC Swiuw!am(. TWC

males

Kidney, females

6

10

16

I

I

I

0

6

10

16.4

11.6 10.2 9.4 0.1 9.0 6.6 6.6 6.6 8.4 8.1 7.6 7.4 7.3 7.1 7.1 6.8 (la 6.0 6.6

S.wiQ.da”d. TVK Dulmrl; Swadm Hnkd PObnd, wmw uy FRG. CR GMI Franc., Em-Mb Czachoabtmkh SbutL MY. Torino UI; En&d and Waba UK Mmohwtw Now UK. smt*“d FRG. Seahnd YU!poJav*. sbwnb HU”lJV Fmno. LPAc*c swim. twoza Nathe da”&. SOOZ Eindhown

Germ cell and gonads, females

Germ cell and gonads, males 8

10

_I N.therbn&.

SOOZ Eindhown NOtMY S+rtz.rb”d. IWC svudm Fiibnd UK. M.wlohmtN GDR Czbchosbnkii, Sbvakb +b”wY UK. Englandand Wab. France,@a,Rhb Frann. L-PACA-C YUgwbv*. sbwnb lm)y. Torbo FRO. Sarbnd FRO, CR Dwlrrwk UK Swtbnd Il.4 SPai”. zanpou 0 Pobnd. Wemaw Cm, 0

Age-standardised

10

Nath&.“d.,

0

Fig. 1 (a-d).

6

0

2

4

6

8

10

GDR

UK. Mmchrtr MY. Twi”a Fmnu. L-PACAC Czedlodo~kb. sbwkb Yugoabvb. sbwnia SW&ml Pobnd. Wemaw City Fhhnd Nwmy Fnnor. B=-Rhh UK. Smtbnd UK. E”6bnd and W.bm HUWnl Donmfk 6pai”. 2am6oza Swiaadand, lWC FRO. CR FRG, Sa.h”d Neth.r!.a”d~,SOOZ Eindho”.”

O-14 years (on the world standard population) incidence rates of selected European cancer registry regions, mostly circa 1975.

childhood

cancers

in

various

2032

F. Levi et al.

Retincblastoma, 0

2

4

males 6

Retinoblastoma,

8

0

2

4

females 6

8

10

wb*,SOOZEindhua Swiebhnd. TWC

UK Mnchmr FRG, smrhd France, SawRhin Huwry Yutp~sbvulii Nuhedand.. SOGZ Eindwbvn Sv.iE*dmd.Twc 0 w.M 0

2.2

P 2.1

13 1.2 1.1 0.9

Brain and spinal, males

0 swmlm

10 I

20 I

30 I

40 I

Brain and spinal, females EO I

37.0

Frana.

L-PkcAc mnn FMmd spin. hItat6 T&to

POblldW~lWWci(y

Sympathetic

nervous system, males

0

Sympathetic

20 I

Fma. LPACAC

finbnd

Neth-.

N.xwx SOOZ Eindwn~

30

40

60

nervous system, females

0

Hodgkin’s disease, males

Yuoosbva. sbvonii Cz.choslonkb, Sb&dn MY, Tadno SPdn. M GDR FRG.CR U& Scotbnd Hwlw UK Engbnd and Ml.. UK h4mwhut.r Swa&n Fimm. L-FVCAC Twc mnrmlk hurr.Gm.Rhin FAG, Sambnd ~-CRY

20

10

20 I

France, LPKA-C Rab, Torim, FROCR Caulwk Sv&mhnd TWC Fbbnd H%l=Y swwdm FRG. Saarhnd N.therbnds. SOOZ Ekknn UK. Manchemu Spin. 2amgoz4 GDR Normy Franc., Sa.Rhln UK. Scatbnd UK. Engbndand Walr Czechosbnkii, Sbwki. Yugoslavia.Sbnnb Poland,Wamaw Cm,

Frmes. Mhh SwiQubnd,TvK IMy. Twkw spin. Lw-4 H”“plY FRG.CR swodm Dennut GDR Pdand. Warsaw CRY UKscotlnd Finlnd UhEnglutdandWaba _Y N~hu*nd., SCOZ Eiktdw..n UK Menchn¶u Yugwbbia, Skmb FRG. Smdmd Czechabakia. sbukin

0

10

Sdn Franca,SeRhb Fkkbnd mnnwk Switwbml lwC UK Mandmnw It&y. Torkw GDR Nomy UI( En&wd and Waba Pobnd Wamaw Cm, FRG, Sahnd UK Scotland Cz.&o~bvd;i~. Sbv.ki France,L-PACAC Spin. hmpozl HunOny YugAlvim. Sbnnb FRG. CR Nelherbnd.. SOOZ Eindhonn -rag

33.9 33.8 33.7 3g.S 30.4 M.2 27.0 27.2 21.8 2S.4 26.7 21.0 24.1 32.0 2o.S 20.3 16 17.1

% Yugslnc. Stennh utt Mallemstu UK E&ndutdWAa CzmdK9bvJj.S~ Fma, BmTthm FRG, Smlbnd UKseoc*nd NwJmMda, SCXIZ Ehdwn HwPw

0

2 I

4

6 I

8 I 9.2 8.8 SA 0.2 7.8

S.7 S.4 (1.1 6.1) 1.2 6.2 4.9 4.5 4.3 4.0 3.9 3.S 3.2 3.0 2.9

Hodgkin’s disease, females 10 I

0

hair. Torbo GDR YUgwtiia, storm* Czechoab~kh. Sbvakii cwinw-k Swinwbnd, TWC FRGSR France,L-PAC.&C Nrthwbnb. SOOZ Eindhown FRG. Sadand Pobnd. Warn... Cm, UK Engbnd end Walu UK Scofbnd spin. zamgzza NOfWOY Hunwnl UK. Manc!l@9tar Finbnd France. Ba%Rhin SW&n

Fig. 1 (e-h).

2

4

6

8 I

10 I

Childhood Cancer Incidence and Mortality in Europe Non-Hodgkin’s 0

lymphomas,

Non-Hodgkin’s

males

10

2033 lymphomas,

0

20

1 19.2 Nethehnda.SOOZ

females

10

20

I

I

Eindhovsn

Yu!p&Nb. sbnni Etqbnd and Wab.

“I;

Czedwebvakb. Sbnku Fmcu, LPACA-C S.wQwlr,nd. TVK Pobnd, Wanaw Clo, Franc., L-P&XC Pobnd. Wamaw Cii

Acute lymphocytic 0

10 I

Swhhd,1WC Nethw!ands,

leukaemias. males

20 I

30 I

40 I 42.3 38.1 36.8 Y.1

FRO. CR UK Mac-anw SOOZ Eindhovu, Italy, T&no

*b. NeUwfb+

33.8

Nethwbnds.

33.7 33.8 33.0 32.2 Jo.9 30.2 28.2 26.3 24.7 24.2 24.4

Fnno,

L-PACA-C Huww Fin*cd GDR France. Br-Rhin spein,zgz

Caoho&-.mkii Sbwkm FRG. Sau&nd Yu@bti, Sbwnb Pohnd. Warsew City

0

m DCLSG

My.Torino N.therb,,ds,

40 I

0.7

All leukaemias, females 50 I

60

0

J

Ei”dho,.n NoMY Spab. LRODU Fhlnd FRG, CR

swirzubnd, TWC SFRG. Saar*nd Dulmuk UK, MarKdlntw UK. En(lbndand W&a UK scabnd Neth*rbndn. DCLSG czu+iwbv&*. sbx.ukb Hungq France. L-PACK PObnd. waruw tin, Fmncr, &&hi! GDR Yugos!nvb. Sbmnb

a.2 36.1

lwf.

Po*nd.

HunOnl Warsaw CItq

I

30

llS.6 119.1 ,143 113.6 107.6

I

50

I

60

1

29.3 24.7

0 .svadDn

16s.9 167.0 1w.4 149.9 146.6 143.6 141.0 136.2 138.1 136.4 136.0 132.8 126.0 122.0 120.2

40

I

Total, all sites, females 200 I

Tmilw

UICEm$.ndandW.b. UK, bbnchatr UK swdwd

20

34:: 33.8 33.7 32.9 52.1 32.1

Huww Poland, W.MW Gin,

100 I

Finbred swuhn Fmna. LPACA-C DMnwk Nethorbnd#. SOOZ Eindhovm Czochoevakii. Qaukb brwy Franc+. &eRRhk swiuwbnd. TWC GDR Y”gc&via. sbnnia FRG. Smdmd FRO. CR

I

43.8 43.0 42.7 41.8 41.1 3s7 39.6 38.0 38.1 m.4 34.8 34.2

Total, al! sites, males 0 Swn.bmgw

10

64.2 Spin. zsnooa 62.0 ttal~, Torino 60.2 sv.udM 48.1 France, LPAC&C 18.0 Swi‘zwbnd. TWC 47.1 Fmna, F@-Rhk 46.3 FRG. CR 46.6 N0fW6Y 44.4 Czechoslonkin. Sbuakii Fiiti a.1 42.6 FRG. Sadand Nech.tbna. DCLSG 41 .B 41.6 UK. Scatid 40.9 mnmmlt 38.6 UK, Manohww 38.1 Nethetbnd8. SOOZ Eindhown U& Engbnd and Wab. 98.9 30.8 Y”!p!avii. Sbwnb GDR al.8

SOOZ

50 I

20.3 18.2 18.1

All leukaemias, males 30 I

40 I

2e.s 28.0 27.6 w.9 m.0 26.8 26.7 26.6 26.2 24.4 22.7 22.3 22.4

SCOZ Eindhown France, Bae-flhin UK. Manchntw Dsnnnrk

Normy FRG. Saatbnd Y”Qoenvii. Sbve”b Pobnd. WOMW City

0

20 I

30 I

36.3 33.6 324 30.4

UK Scotland swdnn and Wab. naiy, Torn0 H”“W GDR Cze&osb,&m, Sbvakb Fiibnd

24.2 22.8

10 I

leukaemias, females

20 I

UK. E”&,nd

17.4

0

10 I

France. LPACA-C FRG, CR swillubnd. Twc

33.8

Dsnlmh U& Engbnd and W&a N.th&a&. OCLSG UK. saltbnd

Acute lymphocytic

50 I

Itaiy, Twin0 Fmna. Br-Rhin Finland Fmnca. LPACA-C swttmr*nd. 5wc GDR Cznhwlovslds. SbwL;i mnnnrl; NOmy Ur; Msnchhut., FRG. Samb”d Spain. zlraoou N&lwb~. SOOZ. Eindhown FAG, CR UK E&end md Wab* UK, Scatland Pob”d, Wa”.w Cky Y”go.bvim. Sbwnb HUww

Fig. 1 (i-l).

100 I 128.9 124.8 123.6 118.1 116.2 114.4 139.8 111.4 110.8 106,s 103.0 102.6 101.9 101.1

87.2 06.8 M.2 66.6 a6.6 82.2

200 I

2034

F. Levi et al. Bone, males 12 I

0 "r;Nonhem lnbnd

I

3 I

4 I 4.0

BUlga

5 I

3.0

%z POItUO#l 3wad.n spin w B*!gium Polnd czedK&wk*

3.6 3.5 3.0 2.8 2.8 2.7 2.7 2.0 2.4

Kidney, males 12

0

3

Kidney, females 4

49

i

5

0

1

2

3

4

5

.a

r

Pobnd 0 Bal@m 0

IrelandlO

Eye, females

Eye, males 0

Poland Inland wlblld0 Dwlmrk 04&m

0.5

1.0

1.5

0

5

0

0.5

1.0

1.5

0 0 0 0

Hodgkin’s disease, males 12

0

3

4

Hodgkin’s disease, females 12

3

4

5

UK

SpaIn Alma* Grm*

c ii 0.3

0.2 0.2

Fm-lm NM02 UK smt*nd 0

Fig. 2 (a-d).

Age-standardised

O-14 years (on the world standard population) various European countries,

death certification 1985-1989.

rates from selected

childhood

cancers in

2035

Childhood Cancer Incidence and Mortality in Europe Non-Hodgkin’s lymphomas, females

Non-Hodgkin’s lymphomas, males 0

2

4

6

I

I

I

Cmchombwki 3

0

10

6.7 6.6 4.86.3

ItA%

GumnY. G anlmdl

4.6 4.6 4.4 4.2 4.2 3.8

GM

4

6 J

8

I

10

-I

m2.1

-2

4.6 4.7

GM Fmna

2

02 0.6

7.4

Hw9fY Donnnk 6gzlz

YGwmv,

8

6zz

Anbnd Gumny. b

2.4 2.4 2.0 2.0 1 .s

L c

RIO Imzarvl

_...

1.6 1.4 1.3

1.1

UK

Pobnd ) 0

Leukaemias, females

Leukaemias, males 0

10

0

20

Total, all sites, males 20

I

40

80

I

I

30

40

50

Total, all sites, females

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60

80

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2036

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Fig. 3 (a). Trends

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O-14 years (on the world standard population) death certification cancers in various European countries, 195tL1989.

rates from selected

childhood

2037

Childhood Cancer Incidence and Mortality in Europe

lb) Bone Itaty 1.0 L

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Fig. 3 (b).

1980 1985 1990 I

F. Levi et al.

2038

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Fig. 3 (c).

I 1980 1985 1990

2039

Childhood Cancer Incidence and Mortality in Europe

(d) Kidney Netherlands

Italy

Males 0-l 4 0 Females &14 #-J_-_-_~--_-~

n

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F. Levi et al.

2040 (e) Eye Austria

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2041

Childhood Cancer Incidence and Mortality in Europe (REve Italy

Netherlands

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2042

F. Levi et al.

(g) Hodgkin’s disease Austria

Belgium

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Calendar years Fig. 3 (g).

1980 1986 1990

Childhood

Cancer

Incidence

and Mortality

2043

in Europe

(h) Hodgkin’s disease Netherlands

Italy

Males O-l 4 0 Females O-l 4 D--_-f-J--_-~

1950

1955 1980

1985

1970

1975

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Norway

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n

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3 (h).

1990 1986 1990

2044

F.

Levi et al.

0)All other lymphomas

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Belgium

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8

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Childhood Cancer Incidence and Mortality in Europe

2045

(j)Allother lymphomas Netherlands

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-‘o

1980 I 1985 I 1990 I

F. Levi et al.

2046

(k) Leukaemias Belgium

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Calendar years

Fig. 3 (k).

1960 1966 199U

Calendar years

1960 I 1966 I 1990 I

2047

Childhood Cancer Incidence and Mortality in Europe

(I) Leukaemias ItalY

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Fig. 3 (1).

1 I I 1980 1985 1990

F. Levi et al.

2048

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Belgium

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