Site- and gender-specific time trend analyses of the incidence of skin melanomas in the former German Democratic Republic (GDR) including 19351 cases

Epidemiology and genetic susceptibility of malignant melanoma in North Sardinia, Italy

The aim of this report was to study the descriptive and genetic epidemiology of malignant melanoma in North Sardinia, Italy, in the period 1992-2011. Epidemiological data were obtained from the local tumor registry, which is part of the Italian Association for Tumor Registries. Among patients included in the North Sardinia tumor registry, 316 patients first evaluated for familial recurrence of melanoma were submitted to mutation analysis in CDKN2A and CDK4 genes. The overall number of cases registered was 532. The male-to-female ratio was 1 : 1 and the mean age was 56 years for men and 55 years for women. The standardized incidence rates were 4.9/100 000 and 4.4/100 000 and the standardized mortality rates were 1.7/100 000 and 1.3/100 000 for men and women, respectively. The relative 5-year survival was 77% for men and 79% for women. In our series, 24/316 (7.6%) patients had a familial occurrence of melanoma (presence of at least one additional family member affected). Among these, one variant (Gly23Asp), reported previously as a low-frequency disease-causing mutation, was detected by mutational screening in the p16 gene only. With the exception of polymorphisms, none of either the sporadic melanoma patients or healthy controls presented a germline mutation in candidate genes. An increase in incidence and a decrease in mortality rates of malignant melanoma were registered in North Sardinia, from 1992 to 2011, whereas survival was similar to that reported in recent international reports. The high-penetrance melanoma susceptibility genes (CDKN2A and CDK4) are not involved in predisposition to melanoma in North Sardinia.

Changes in the site distribution of common melanoma subtypes in Queensland, Australia over time: implications for public health campaigns

BACKGROUND

An examination of melanoma incidence according to anatomical region may be one method of monitoring the impact of public health initiatives.

OBJECTIVES

  To examine melanoma incidence trends by body site, sex and age at diagnosis or body site and morphology in a population at high risk.

MATERIALS AND METHODS

  Population-based data on invasive melanoma cases (n = 51473) diagnosed between 1982 and 2008 were extracted from the Queensland Cancer Registry. Age-standardized incidence rates were calculated using the direct method (2000 world standard population) and joinpoint regression models were used to fit trend lines.

RESULTS

  Significantly decreasing trends for melanomas on the trunk and upper limbs/shoulders were observed during recent years for both sexes under the age of 40 years and among males aged 40-59years. However, in the 60 and over age group, the incidence of melanoma is continuing to increase at all sites (apart from the trunk) for males and on the scalp/neck and upper limbs/shoulders for females. Rates of nodular melanoma are currently decreasing on the trunk and lower limbs. In contrast, superficial spreading melanoma is significantly increasing on the scalp/neck and lower limbs, along with substantial increases in lentigo maligna melanoma since the late 1990s at all sites apart from the lower limbs.

CONCLUSIONS

  In this large study we have observed significant decreases in rates of invasive melanoma in the younger age groups on less frequently exposed body sites. These results may provide some indirect evidence of the impact of long-running primary prevention campaigns.

Malignant eyelid tumors in Hong Kong 1997-2009

PURPOSE

To determine the epidemiologic and clinical characteristics of patients with malignant eyelid tumors in Hong Kong.

METHODS

A computerized retrieval system was used to identify all patients with histologically confirmed malignant eyelid tumors residing in Western Kowloon and the Southern New Territories, Hong Kong, during the 13-year period from 1997 to 2009. The patients' medical records were reviewed for clinical and demographic data.

RESULTS

A total of 36 patients were identified; all were Chinese. The mean age at diagnosis was 73.4 ± 11.5 years. Women were more commonly affected. Each patient had 1 tumor. Tumors developed more commonly on the lower eyelid (n = 19; 52.8%) than on the upper eyelid (n = 11; 30.6%). The right eye was more often involved (n = 20; 55.6%). With regard to the type of tumor, 27 were basal cell carcinoma (BCC) (75%), 4 sebaceous gland carcinoma (11.1%), 2 squamous cell carcinoma (5.6%), 1 mucinous eccrine carcinoma (2.8%), 1 verrucous carcinoma (2.8%), and 1 metastatic carcinoma (2.8%). Most were treated by frozen section-guided excision and eyelid reconstruction. Recurrence occurred in 1 case only. Incidence was low until approximately 45 years of age, after which it rose sharply. The incidence continued to increase until above the age of 85 years. There was an overall increase in incidence from 0.6 per million in 1997 to 2.3 per million in 2009.

CONCLUSION

Increasing incidence of malignant eyelid tumors was noticed in Hong Kong from 1997 to 2009, with BCC dominating the incidence trend. Recurrence after complete surgical excision was uncommon.

Micrographic surgery of skin cancer in German hospitals 2005-2006

BACKGROUND/OBJECTIVE

Surgical therapy of skin cancer includes conventional wide excision and micrographic surgery (MS). Little is known about the population-wide spread of MS for the treatment of skin cancer. The aim was to estimate the in-hospital use of MS for the treatment of skin cancer in Germany.

METHODS

We used nationwide DRG data from 2005 through 2006. We identified hospitalizations with a main diagnosis of cutaneous malignant melanoma (CMM) (ICD-10: C43) or non-melanoma skin cancer (NMSC) (ICD-10: C44). MS was identified by OPS procedure codes including 5-895.1, 5-895.3, 5-212.1, 5-181.1, 5-181.4, 5-181.6, 5-182.1, 5-091.1, or 5-091.3.

RESULTS

We identified 52 660 and 98 484 hospitalizations with a primary diagnosis of CMM and NMSC respectively; 54.6% and 36.5% of NMSC and CMM-related admissions with local skin cancer treatment included MS. The relative frequency of MS varied by anatomic subsite of the skin cancer and by region of the hospital. Local infections were the most frequent complications after MS with 3.2-4.0% for NMSC and 2.3-2.9% for CMM followed by haemorrhages. Dehiscence of the operation wound is a rare event with risks ranging between 0.1% and 0.3%.

CONCLUSIONS

Micrographic surgery is frequently used for the local treatment of NMSC and varies considerably across Federal States of Germany. It is difficult to speculate how many MS might be performed in private or ambulatory settings in Germany. As MS requires surgical expertise, technical support and dermatopathology, we speculate that MS is much less frequently undertaken in private practices in Germany.

Inpatient management of patients with skin cancer in Germany: an analysis of the nationwide DRG-statistic 2005-2006

BACKGROUND

In 2004, Germany introduced a nationwide DRG (Diagnosis Related Groups) based recompensation system for hospitals. The aim of this study was to provide nationwide quantitative information about the in-hospital management of skin cancer patients in Germany based on the DRG statistic of the years 2005 through 2006.

METHODS

We analysed the DRG statistic of the years 2005 and 2006. For each hospitalisation, diagnoses and procedures codes were analysed. The unit of analysis was the hospital admission with a diagnosis of skin melanoma (MEL) or nonmelanoma skin cancer (NMSC) including 151.144 hospitalisations.

RESULTS

In 60% and 28% of all MEL- and NMSC-related hospitalisations respectively, skin cancers were surgically excised. Local therapies other than surgical excision were more prevalent among hospitalisations for NMSC than for MEL (9% vs. 4%). 22% and 1% of all MEL-related and NMSC-related hospitalisations respectively included a systemic chemotherapy. Plastic surgery was more common among NMSC-related hospitalisations (56%) than among MEL-related hospitalisations (30%). Native CT or MRI scans were coded in 11% and 2% of all MEL- and NMSC-related hospitalisations respectively. Age-standardized hospitalisation rates for MEL and NMSC varied considerably across the 16 Federal States of Germany. However, these rates were neither associated with the number of dermatology hospital beds or number of registered dermatologists.

DISCUSSION

We provide for the first time nationwide quantitative data on the in-hospital management of skin cancer patients. The observed differences in the management of MEL and NMSC most likely reflect differences of the biology, epidemiology and therapeutic modalities of these cancers.

Late recurrence (10 years or more) of malignant melanoma in south-east Germany (Saxony). A single-centre analysis of 1881 patients with a follow-up of 10 years or more

BACKGROUND

Late recurrent melanoma (MM) is rare.

OBJECTIVE

In the present study, we analysed the frequency of late recurrent MM in south-eastern Germany.

PATIENTS AND METHODS

In our centre, 2314 MM patients were documented (1972-2001). A total of 1881 patients in stage I or II (AJCC) with a follow-up of > or = 10 years were selected and screened for late recurrence (> or = 10 years after diagnosis).

RESULTS

Twenty patients were identified (1.1%), 13 women and 7 men, median age 44 years (age range 30-74 years). Nineteen suffered from cutaneous MM and one had a uveal MM (excluded from further analysis). The primary cutaneous MM occurred on the trunk (6), on the upper limb/shoulder (4), or on the lower limb (9). MM type was superficial spreading (13), nodular (2), acrolentiginous (1), lentigo maligna-type (1) or unclassified (2). Tumour thickness varied from 0.33 mm to 9.5 mm (median 2.0 mm). Ulceration was seen in four, and spontaneous regression in two MM patients. Invasiveness into blood or lymphatic vessels occurred in seven MM patients. The largest period from primary diagnosis to recurrence was 25.1 years with a median of 13.9 years. Metastatic spread was loco-regional (12 patients) or distant (7). Four patients were survivors and three of these had in-transit metastases only. Overall survival was 14.7 +/- 6.6 years. Statistical analysis could not identify factors significantly associated with late recurrence.

CONCLUSIONS

Late recurrence is a clinical sign of melanoma dormancy. We conclude that late recurrences argue for a lifelong follow-up of melanoma patients.

Time trends in tumour thickness vary in subgroups: analysis of 6475 patients by age, tumour site and melanoma subtype

An elevated tumour thickness is strongly associated with an increased risk of mortality in melanoma patients. In the last few decades, an overall decrease of the tumour thickness to prognostically more favourable levels has been observed in several countries. Nevertheless, it is not clear whether this positive time trend occurred uniformly in specific subgroups of melanoma patients. Therefore, we aimed to assess time trends of tumour thickness by age group, tumour site and melanoma subtype. The study population consisted of 6475 patients with histologically proven primary invasive cutaneous melanomas seen at the Department of Dermatology and Allergology at the Ludwig-Maximilian-University Munich between 1977 and 2000. Age-adjusted time trends were assessed using linear and logistic regression analysis. Overall, a positive time trend with a decreasing tumour thickness was observed during the observation period in most subgroups. However, no significant time trend was observed in patients with a melanoma on the feet or with a nodular or acrolentiginous melanoma. The almost constant high tumour thickness of these patients might be caused by underaddressing the specific traits of these melanomas in earlier prevention campaigns. An important goal for the upcoming years should consist of a positive time trend with a decreasing tumour thickness in these subgroups.

Cutaneous Melanomas of the Eyelid

Cutaneous eyelid melanomas are very rare lesions. The lentiginous subtypes are the most frequent melanocytic lesions of the eyelid and can be likened to conjunctival melanocytic lesions like PAM, PAM with atypia and conjunctival melanoma. Compared to melanomas elsewhere on the body, eyelid melanomas have special considerations. Eyelid skin is very thin, the mucocutaneous junction at the lid margin can affect prognosis, the lymphatic drainage pattern is very variable and there is an inherent difficulty to excise wide margins without sacrificing important structures. A customized excision approach, using tissue-sparing "Slow-Mohs" technique, is suggested. Sentinel lymph node dissection has an evolving therapeutic role but remains controversial.

Body-site distribution of common acquired melanocytic nevi associated with severe sunburns among children in Lithuania

BACKGROUND

The aim of this cross-sectional study is to provide information on subsite-specific densities of melanocytic nevi by age, sex, and in relation to the history of severe sunburns.

MATERIALS AND METHODS

This study was conducted in Kaunas, Lithuania, on a sample of 484 children aged 1-2 years, 4-5 years, 9-10 years, and 14-15 years. The questionnaire provided information about the history of severe sunburns since birth. Site-specific numbers and densities of melanocytic nevi of all sizes and nevi 2 mm or greater were studied. We used log-linear and Poisson regression models to estimate the effects of age, sex, and severe sunburns on the nevus density.

RESULTS

The predicted total body density of nevi shows a considerable increase up to the age of roughly 10 years. Thereafter, the density increase tapered off. Median densities of nevi were highest on the face. The median density of nevi on the upper arms is higher than on the forearms. Similarly, the median density of nevi on the thighs is higher than on the lower legs. Estimates of the relative nevus densities related to the history of severe sunburns tend to be small with the exception of the legs for nevi 2 mm or greater (relative nevus density = 2.09, 95% CI 1.49-2.93).

CONCLUSION

Nevus densities are highest on maximally or intermittently sun-exposed skin areas. With the exception of the legs among women, the subsite-specific ranking of nevus densities among adolescents follows a similar ranking as the skin melanoma incidence in Lithuania.

Do sex and site matter? Different age distribution in melanoma of the trunk among Swedish men and women

BACKGROUND

Recent research on cutaneous malignant melanoma (CMM) points to the coexistence of several biological pathways linked to the anatomical site of the lesion, which could lead to this neoplasm. Although the different anatomical distribution of CMM by sex is usually attributed to gender-specific patterns of sun exposure, it has been suggested that an alternative explanation might lie in gender-specific site susceptibility.

OBJECTIVES

This paper aimed at analysing the age distribution of CMM by site and sex to gain in-depth knowledge of differences between the sexes.

METHODS

Using a large Swedish cohort comprising 2 992 166 workers, Poisson models were fitted to estimate age-specific incidence rates by site and sex, duly adjusted for several factors that might account for changes in environmental exposures (period, birth cohort, socioeconomic level, latitude and rurality).

RESULTS

Incidence rates were 17.4 cases per 100 000 person-years in men and 16.5 in women. Sex differences were particularly striking for CMM of the trunk, where both crude and adjusted incidence rates displayed a steady increase with age in men, but reached a plateau in women at around four cases per 100 000 person-years from the 40-45-year age group (perimenopausal period) upwards. There was an almost fivefold increase in the sex ratio for this body site between the younger and older age groups, a difference which could not be attributed to period or cohort effects.

CONCLUSIONS

If different aetiological pathways can be assumed to lead to melanoma, then disparities between men and women, particularly in CMM of the trunk, suggest that a possible interaction between site and sex should be borne in mind.

Socio-economic class, rurality and risk of cutaneous melanoma by site and gender in Sweden

Background

Cutaneous melanoma (CM) is a cancer usually associated with high socio-economic level in the literature. Few studies have, however, assessed this relationship by gender and site or the association between CM and rurality.

Methods

A major-sized historical occupational Swedish cohort comprising 2,992,166 workers was used to estimate relative risk of cutaneous melanoma, broken down by gender and anatomical site, for occupational sectors (as a proxy of socio-economic class) and rurality. To this end, Poisson models were fitted for each site in men and women, including occupational sector and town size, with adjustment for age, period of diagnosis and geographical area as possible confounding factors.

Results

White collar workers presented a marked increased of risk in men in all melanoma cases, as well as in trunk, upper and lower limbs. This pattern was less clear for women, in which some heterogeneity appeared, as low risks in lower socioeconomic sectors in trunk, or risk excesses in white collar workers in lower limbs did not achieve statistical significance. Males also showed significant differences in risk by rural/urban distribution, but in women this association was limited to CM of lower limb. Risk of CM of head/neck did not vary by occupational sector or town size, thus depicting a specific epidemiological profile, which proved common to both sexes.

Conclusion

While differences in risk between men and women could suggest greater homogeneity in UV-exposure behaviour among women, the uniform risk pattern in head and neck melanoma, present in both sexes, might support the coexistence of different aetiological pathways, related to anatomical site.

Malignant melanoma and nonmelanoma skin cancers in Northrhine-Westphalia, Germany: a patient- vs. diagnosis-based incidence approach

BACKGROUND

Dermatologists have repeatedly criticized that the public health importance of nonmelanoma skin cancers is not appropriately reflected by the patient-based cancer incidence rates of population-based cancer registries. The aims of this study were to estimate the patient incidence rates of squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and skin melanoma, and to study the effect of multiple primary skin tumors on the incidence rates.

METHODS

We used a network of physicians covering a population of about 75,000 individuals to register all newly diagnosed invasive skin cancers (996 diagnoses in 796 patients), including BCC, SCC, and skin melanoma, from July 1998 to June 2003. We calculated age-standardized (world standard population) incidence rates (cases per 100,000 person-years) for the first diagnoses (called "patient incidence") and for any diagnoses of BCC, SCC, and skin melanoma (called "case incidence").

RESULTS

The patient incidence rates of BCC were 63.6 in men and 54.0 in women, and the case incidence rates of BCC were 82.7 and 71.1, respectively. The patient incidence rates of SCC were 17.4 in men and 9.7 in women, and the case incidence rates were 20.4 and 10.2, respectively. The patient and case incidence rates of skin melanoma were about the same at 13.6 in men and 18.5 in women. Twenty-five per cent of the BCC patients and 14% of the SCC patients suffered from more than one BCC and SCC, respectively, during the 5-year period.

CONCLUSIONS

Patient incidence rates of BCC and SCC substantially underestimate the burden of nonmelanoma skin cancer in the population.

Clinical epidemiology of invasive cutaneous malignant melanoma in the Austrian province Styria in the years 2001-2003 and its relationship with local geographical, meteorological and economic data

BACKGROUND

Melanoma incidence rates vary within Europe. The highest incidences are reported in Scandinavia, the lowest in the southern parts, but incidences themselves also vary within the different countries.

OBJECTIVE

We investigated the incidence of invasive cutaneous melanoma in Styria, a province of Austria, in the years 2001-2003.

METHODS

Data from 1,082 patients, 511 males and 571 females (mean age 58.2 years) with primary melanoma were collected. For each patient, information regarding residence was available, and therefore the geographic distribution of melanoma on district level was investigated with particular reference to the mean number of sun hours, mean altitude, number of companies with more than 200 employees and median income.

RESULTS

The mean annual incidence (age-standardized rate) was 24.5 per 100,000 (95% CI: 22.4-26.6), lifetime risk 1 in 52. Districts with a higher number of sun hours and higher altitude showed lower melanoma incidences. Higher median income was associated with higher melanoma incidence (p<0.001).

CONCLUSION

The high incidence of invasive melanoma in Styria is unclear and a causal relationship between higher income and melanoma incidence remains speculative. Further investigations, especially concerning lifestyle and environmental factors, may unravel additional causative factors.

Melanoma in Children and Teenagers: An Analysis of Patients From the National Cancer Data Base

Purpose

This study examines the demographics, presentation, and outcomes of children and teenagers with melanoma using a US hospital-based oncology database.

Patients and Methods

Data from the National Cancer Data Base from 1985 through 2003 were examined for demographics, presentation, and survival of patients aged 1 to 19 years, as well as a comparison group of patients aged 20 to 24 years. Two-sided linear and Pearson χ2 tests were calculated to examine associations. Proportions were compared using two-sided z tests. Five-year overall observed survival was evaluated using the Kaplan-Meier method and the log-rank test. Cox proportional hazards regression was used to estimate risk of mortality.

Results

Of 3,158 patients aged 1 to 19 years, 96.3% had cutaneous melanoma, 3.0% had ocular melanoma, and 0.7% had an unknown primary tumor. Cutaneous melanoma in patients aged 1 to 19 years was more common in girls (55.5%) and patients older than 10 years (90.5%). The demographics and presentation of cutaneous melanoma were age related; younger children were significantly more likely to be nonwhite and male and more likely to present with a head and neck primary tumors and with regional or distant metastases (linear χ2, P < .001 for sex, race, and extent of disease). Poorer survival was associated with higher stage and younger age. In contrast to patients aged 20 to 24 years, survival was not related to thickness in patients aged 1 to 19 years with localized invasive melanoma.

Conclusion

Melanoma in children and teenagers differs from melanoma in young adults in demographics, presentation, and survival. Further investigation is warranted to elucidate possible biologic correlates of the unique aspects of melanoma in children and teenagers.

Incidence of Eyelid Cancers in Taiwan

PURPOSE

To describe the epidemiologic characteristics and incidence trends of primary eyelid cancers in the Chinese population in Taiwan between 1979 and 1999.

DESIGN

Retrospective population-based cancer registry data review.

PARTICIPANTS

A total of 1166 primary eyelid cancers coded to International Classification of Diseases 8 or 9, site 172.1 (malignant melanoma of eyelid) and 173.1 (other malignant neoplasm of eyelid) were retrieved from the Taiwan National Cancer Registry between January 1979 and December 1999. Of these, 1121 (96.1%) were histopathologically verified and were used for analysis.

METHODS

Age- and gender-specific incidence rates were calculated and were age-adjusted to the 2000 world standard population. Trends in incidence rates were estimated by calculating the annual percentage change. We further examined the effects of age, period of diagnosis, and birth cohort on incidence trends using age-period-cohort analysis.

MAIN OUTCOME MEASURE

Age-standardized incidence rate.

RESULTS

The mean age at diagnosis of eyelid cancers was 62.6+/-14.1 years. The average annual age-standardized incidence rate was 3.2 per million during the study period. There was an overall increase of incidence rates from 1.5 per million in 1979 to 5.1 per million in 1999, with an annual percentage change of 4.63% (P<0.001). The most common eyelid malignancy was basal cell carcinoma (BCC; 65.1%), followed by squamous cell carcinoma (12.6%), and sebaceous cell carcinoma (7.9%). The increasing rates were mainly driven by an increase in the incidence of BCC. Cohort effects were found to play a major role in terms of model fit for the incidence trends of BCC.

CONCLUSIONS

These national data reveal a rapidly increasing incidence of eyelid cancers from 1979 to 1999 in Taiwan. Basal cell carcinoma dominates the incidence trends, and the significant cohort effects give a warning of increasing risk of BCC in younger birth cohorts.

Time trend analysis of the skin melanoma incidence of Finland from 1953 through 2003 including 16,414 cases

Site-specific analyses of the skin melanoma incidence show marked differences between men and women by site and over time. The aim of our study was to analyze long-term population-based incidence time trends of skin melanoma in Finland over a period of more than 50 years, with special emphasis on sex- and subsite-specific changes over time. We analyzed incidence data of the Finnish Cancer Registry from 1953 through 2003 including overall 16,414 cases. We calculated age-standardized incidence rates per 100,000 person years using the European Standard Population. From 1953 through 2003, the incidence of skin melanoma increased from 1.5 to 12.8 per 100,000 among men and from 1.8 to 10.4 per 100,000 among women. Incidence rates showed a constant increase from 1953 through the mid of the 1980s. Thereafter, the rate of increase leveled off. The highest relative incidence increases occurred on the trunk among men and on the legs and hips among women. Within the skin area of the head, melanoma of the ear showed the highest relative increase among both men and women. Subsite-specific sex differences in the early registration period tended to become more pronounced in the most recent period. The highest body surface adjusted incidence rates occurred on the head. Only skin melanoma of the head showed an exponential age-specific incidence pattern and the aetiology of these skin melanomas may differ from skin melanoma on other subsites.

Population-based incidence rates of malignant melanoma of the vulva in Germany

OBJECTIVES

Only few population-based incidence analyses of vulvar melanoma including the United States and Sweden are currently available. We studied the incidence of vulvar melanoma in a large population-based cancer registry of East Germany and compared our findings with the United States and Sweden.

METHODS

We extracted vulvar melanoma registered between 1976 and 1989 in the former National Cancer Registry of the German Democratic Republic (GDR) and of three new East German cancer registries of the federal states of Sachsen, Brandenburg, and Mecklenburg-Vorpommern of the period 1998 to 2002. We calculated age-specific and age-standardized incidence rates using the World Standard Population.

RESULTS

One hundred two cases (1976-1989, former GDR) and twenty-five cases of vulvar melanoma (1998-2002, three new federal states) were registered. The age-standardized incidence rate (World Standard Population) remained constant over the period from 1976 to 1989 and ranged between 0.26 and 0.52 cases per million. From 1998 to 2002, the incidence rate was 0.48 per million. The ratio of registered vulvar melanoma to skin melanoma was 1:71, and the ratio of vaginal melanoma to skin melanoma was 1:314. Age at diagnosis during the period 1976 to 1989 was lower among women with vulvar melanoma (median age 70 years) compared to women with vulvar tumors other than melanoma (median age 73 years).

CONCLUSIONS

The risk of vulvar melanoma was considerably lower in East Germany than in the United States and Sweden. Due to the rarity of vulvar melanoma, population-based cancer registries are hampered to study this tumor in detail.

Nonmelanoma skin cancer in the Federal State of Saarland, Germany, 1995-1999

We analysed incidence data of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin from the Cancer Registry Saarland, Germany. During 1995-1999, the age-standardised incidence rates (world standard population) of BCC and SCC were 43.7 and 11.2 per 100000 among men and 31.7 and 4.4 per 100000 among women.