Recent trends in incidence of and mortality from breast, ovarian and endometrial cancers in England and Wales and their relation to changing fertility and oral contraceptive use

Contraceptive strategies for reducing the risk of reproductive cancers

Reproductive cancers, encompassing various malignancies like endometrial, ovarian, cervical cancer, and gestational trophoblastic neoplasia, pose a significant global health burden. Understanding their patterns is vital for effective prevention and management. Contraceptives show a protective effect against some of these cancers. This clinical guidance document aims to elucidate the disease burden of reproductive cancers and the evidence supporting contraceptive methods in prevention and management. Regional disparities in incidence and mortality highlight the urgent need for targeted interventions, particularly in low-resource settings. Healthcare providers must weigh individual risk profiles and medical eligibility criteria when discussing contraceptive options. Enhanced health literacy through direct patient education is essential for leveraging low-cost behavioral interventions to mitigate reproductive cancer risks.

Mortality due to breast cancer in a region of high socioeconomic vulnerability in Brazil: Analysis of the effect of age-period and cohort

INTRODUCTION

Breast cancer is an important public health problem worldwide, with important disparities in incidence, mortality, and survival rates between developed and developing countries due to inequalities regarding access to measures for the prevention and treatment of the disease. In Brazil, there are higher rates of incidence and a downward trend in mortality in regions of greater socioeconomic development.

OBJECTIVE

To evaluate the effect of age, period, and birth cohort on breast cancer mortality in women aged 20 years and older in the states of the Northeast Region of Brazil, an area of high socioeconomic vulnerability, from 1980 to 2019.

METHODS

The death records were extracted from the DATASUS Mortality Information System website (Department of National Health Informatics) from the Ministry of Health of Brazil. Estimable functions were used to estimate the age-period and cohort models (APC) using the Epi library from the R statistical software version 6.4.1.

RESULTS

The average breast cancer mortality rate for the period was 20.45 deaths per 100,000 women. The highest coefficients per 100,000 women were observed in the states of Pernambuco (21.09 deaths) and Ceará (20.85 deaths), and the lowest in Maranhão (13.58 deaths) and Piauí (15.43 deaths). In all of the locations, there was a progressive increase in mortality rates in individuals over 40 years of age, with higher rates in the last five-year period (2015-2019). There was an increase in the risk of death for the five-year period of the 2000s in relation to the reference period (1995-1999) in the Northeast region and in the states of Alagoas, Bahia, Maranhão, Paraíba, and Piauí. In addition, there was an increased risk of death for women born after the 1950s in all locations.

CONCLUSION

The highest mortality rates in all five-year periods analyzed were observed in states with greater socioeconomic development, with an increase in mortality rates in the 2000s, and a higher risk of death in the younger cohorts.

[Effects of age-period and cohort on mortality due to ovarian cancer in Brazil and its regions]

This article sought to evaluate the effects of age, period and birth cohort (APC) on the temporal evolution of mortality due to ovarian cancer in Brazil and its regions from 1980 to 2014. This is an ecological, time-trend study using APC models with a Baysean approach and INLA (Integrated Nested Laplace Approximations) deterministic method for parameter inference. Mortality data and population data were obtained from the Brazilian Health Informatics Department. Rates of mortality due to ovarian cancer, according to geographical region, were standardized using the direct method, after correcting deaths for undefined causes and incomplete cancer diagnosis. In the period we studied, Brazil had 4.91 deaths due to ovarian cancer per 100,000 women, the Southern (5.66) and Southeastern regions (5.70) had higher rates per 100,000 women and the Northern region had the lowest rate (3.13/100,000 women). In all regions, there was a progressive increase in mortality as ages advanced. The multivariate best fit APC model showed positive risk of death in the Central and Northeast between 2010-2014 and, beginning in 1995-1999, in the South. We also observed a positive and significant risk of death for older cohorts in the South and Southeast and a reduced risk for younger cohorts. The inverse was opposed in the Northern and Northeastern regions. The data shows a heterogeneous pattern in the temporal evolution of mortality due to ovarian cancer in the Brazilian geographical regions, which may be related to the distinct demographic and epidemiological transition processes experienced in these regions.

International patterns and trends in ovarian cancer incidence, overall and by histologic subtype

Internationally, ovarian cancer is the 7th leading cancer diagnosis and 8th leading cause of cancer mortality among women. Ovarian cancer incidence varies by region, particularly when comparing high vs. low-income countries. Temporal changes in reproductive factors coupled with shifts in diagnostic criteria may have influenced incidence trends of ovarian cancer and relative rates by histologic subtype. Accordingly, we evaluated trends in ovarian cancer incidence overall (1973-1977 to 2003-2007) and by histologic subtype (1988-1992 to 2003-2007) using volumes IV-IX of the Cancer Incidence in Five Continents database (CI5plus) and CI5X (volume X) database. Annual percent changes were calculated for ovarian cancer incidence trends, and rates of histologic subtypes for individual countries were compared to overall international incidence. Ovarian cancer incidence rates were stable across regions, although there were notable increases in Eastern/Southern Europe (e.g., Poland: Annual Percent Change (APC) 1.6%, p = 0.02) and Asia (e.g., Japan: APC 1.7%, p = 0.01) and decreases in Northern Europe (e.g., Denmark: APC -0.7%, p = 0.01) and North America (e.g., US Whites: APC -0.9%, p < 0.01). Relative proportions of histologic subtypes were similar across countries, except for Asian nations, where clear cell and endometrioid carcinomas comprised a higher proportion of the rate and serous carcinomas comprised a lower proportion of the rate than the worldwide distribution. Geographic variation in temporal trends of ovarian cancer incidence and differences in the distribution of histologic subtype may be partially explained by reproductive and genetic factors. Thus, histology-specific ovarian cancer should continue to be monitored to further understand the etiology of this neoplasm.

Gynaecological cancer mortality in Serbia, 1991-2010: a joinpoint regression analysis

This descriptive epidemiological study aimed to analyse the mortality trends from gynaecological cancer in Serbia. Average annual percentage of change (AAPC) and the corresponding 95% confidence intervals (CIs) were computed for trend using joinpoint regression analysis. Nearly 25,000 gynaecological cancer deaths occurred in Serbia during the 1991-2010 period, with the average annual age-standardised mortality rate being 17.2 per 100,000 women. Increase of mortality was observed for cancer of the vulva and vagina (AAPC=+1.3%, 95% CI=0.1 to 2.6), ovarian cancer (AAPC=+0.8%, 95% CI=0.4-1.3) and for cervical cancer (AAPC=+0.7%, 95% CI=0.3 to 1.1). Mortality rates for gynaecological cancer overall declined in women aged 30-39 years, but mortality was increased in middle-aged women (for cervical cancer) and in the elderly (for ovarian cancer). Improvements to and implementation of the national cervical cancer screening programme conducted in 2013 and expected to be finalised in the following years throughout Serbia should contribute to improvement.

Higher incidence of premenopausal breast cancer in less developed countries; myth or truth?

Background

Fundamental etiologic differences have been suggested to cause earlier onset of breast cancer in less developed countries (LDCs) than in more developed countries (MDCs). We explored this hypothesis using world-wide breast cancer incidence data.

Methods

We compared international age-standardized incidence rates (ASR) of pre- (<50 years) and postmenopausal (≥50 years) breast cancers as well as temporal trends in ASRs of pre-and postmenopausal breast cancer among selected countries during 1975–2008. We used joinpoint log-linear regression analysis to estimate annual percent changes (APC) for premenopausal and postmenopausal breast cancer in the northern Europe and in Black and White women population in the US.

Results

Premenopausal breast cancers comprised a substantially higher proportion of all incident breast cancers in LDCs (average 47.3%) compared to MDCs (average 18.5%). However, the ASR of premenopausal breast cancer was consistently higher in MDCs (29.4/100,000) than LDCs (12.8/100,000). The ASR of postmenopausal cancer was about five-fold higher in the MDCs (307.6/100,000) than the LDCs (65.4/100,000). The APC of breast cancer in Denmark was substantially higher in postmenopausal (1.33%) than premenopausal cancer (0.98%). Higher incidence of breast cancer among the white than black women in the US was pertained only to the postmenopausal cancer.

Conclusion

The substantial and consistent lower age-specific incidence of breast cancer in LDCs than in MDCs contradicts the theory of earlier onset. Demographic differences with fewer old women in LDCs and lower prevalence of risk factors of postmenopausal cancer are the most likely explanation to the lower mean age at diagnosis in these countries.

Ovarian cancer in younger vs older women: a population-based analysis

To compare the clinico-pathologic prognostic factors and survival of younger vs older women diagnosed with epithelial ovarian cancer. Demographic, clinico-pathologic, treatment, and surgery information were obtained from patients with ovarian cancer from the Surveillance, Epidemiology, and End Results Program from 1988 to 2001 and analysed using Kaplan–Meier estimates. Of 28 165 patients, 400 were <30 years (very young), 11 601 were 30–60 (young), and 16 164 were >60 (older) years of age. Of the very young, young, and older patients, 261 (65.3%), 4664 (40.2%), and 3643 (22.5%) had stage I–II disease, respectively (P<0.001). Across all stages, very young women had a significant survival advantage over the young and older groups with 5-year disease-specific survival estimates at 78.8% vs 58.8 and 35.3%, respectively (P<0.001). This survival difference between the age groups persists even after adjusting for race, stage, grade, and surgical treatment. Reproductive age (16–40 years) women with stage I–II epithelial ovarian cancer who received uterine-sparing procedures had similar survivals compared to those who underwent standard surgery (93.3% vs 91.5%, P=0.26). Younger women with epithelial ovarian cancer have a survival advantage compared to older patients.

Oral contraceptives and ovarian cancer: an update, 1998-2004

Over the last two decades, ovarian cancer incidence and mortality for younger generations have been declining in most developed countries, and the decline has been greatest in countries where oral contraceptive (OC) use had spread earlier. The overall estimated protection from cohort and case-control studies is approximately 30% for ever OC users, and increases with duration of use by approximately 5% per year of use to about 50% for long-term (> or =10 years) users. The favourable effect of OC against ovarian cancer risk persists for at least 20 years after OC use has ceased, and it is not confined to any particular type of OC formulation. The reduced risk among OC users is observed in women without or with family history or genetic predisposition to ovarian cancer, and for most histological types of epithelial ovarian cancer, although the pattern of risk is less consistent for mucinous than for other types. The protection of OC on ovarian cancer risk, also in view of its long-term persistence, corresponds to the avoidance of 3000-5000 ovarian cancers (and 2000-3000 deaths) per year in Europe, and a similar figure in North America.

A decreasing incidence of ovarian carcinoma in Israel

The aim of the present study was to assess the incidence trend of invasive epithelial ovarian carcinoma in Israel. We assessed the incidence rate of invasive epithelial ovarian cancer in Israeli Jewish women during the 10-year period from 1993 to 2002 based on data obtained from the population-based Israel National Cancer Registry. There was a gradual significant decrease in the incidence of ovarian cancer from 9.64 in 1993 to 6.55 in 2002. The decrease in incidence was evident in all ethnic groups except those born in Asia and in all the age groups older than 35 years. The decrease in incidence of ovarian carcinoma is gratifying, but its reason remains obscure.

An ovarian cancer diagnosis-seeking process: unraveling the diagnostic delay problem

PURPOSE/OBJECTIVES

To propose a conceptualization that identifies when diagnostic delays occur and suggests a delay-reduction strategy for the diagnosis of ovarian cancer.

DATA SOURCES

Findings and extrapolations from published national and international research studies, research reviews, books, Internet sources, and a family-functioning research project.

DATA SYNTHESIS

Three phases of diagnosis seeking were identified. Self-care was characterized by self-diagnosis, self-interpretation of symptoms, and self-management. Primary provider care was characterized by misdiagnosis and ineffective symptom management. Specialist care was characterized by specialized examinations, tests, and definitive diagnoses. Diagnostic delays were associated with extended periods of self-care and the misinterpretation of symptoms in primary care.

CONCLUSIONS

Periods of opportunity for early diagnosis occurred in the early symptom stages, when self- and primary care were dominant.

IMPLICATIONS FOR NURSING

Women must be taught to self-monitor for early ovarian cancer symptoms. Primary care providers should be urged to attend frequent state-of-the-science updates that regard early symptoms as manifestations of ovarian cancer.

Abnormal expression of period 1 (PER1) in endometrial carcinoma

The development of endometrial carcinoma (EC) is a multiple-step process, which includes inactivation of tumour suppressor genes, activation of oncogenes, and disturbance of cancer-related genes. Recent studies have shown that the circadian cycle may influence cancer development and prognosis. In this study, the expression of a circadian gene, PER1, was examined in 35 ECs and paired non-tumour tissues by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Expression levels of PER1 were significantly decreased in EC, and mutational analysis of the coding regions, together with methylation analysis of cytosine-phosphate guanosine (CpG) sites in the promoter area, was performed to investigate the possible mechanisms. The analyses detected four single nucleotide polymorphisms in both tumour and non-tumour tissues, which had no relationship with the expression of PER1. In the promoter area of the PER1 gene, the CpG sites were methylated in 31.4% of ECs, but in 11.4% of paired non-tumour tissues (p < 0.05). These results suggest that the down-regulation of PER1 expression in EC was partly due to inactivation of the PER1 gene by DNA methylation of the promoter and partly due to other factors. Analysis of the relationships between the expression of PER1, P53, c-MYC, cyclin A, cyclin B, and cyclin D1 showed no definite relationship. These results suggest that down-regulation of the PER1 gene disrupts the circadian rhythm, which may favour the survival of endometrial cancer cells.

Endometrial Cancer Incidence Trends in Europe: Underlying Determinants and Prospects for Prevention

More than one in 20 female cancers in Europe are of the endometrium. Surveillance of incidence rates is imperative given the rapidly changing profile in the prevalence and distribution of the underlying determinants. This study presents an analysis of observed and age-period-cohort-modeled trends in 13 European countries. There were increasing trends among postmenopausal women in many Northern and Western countries. Denmark and possibly France and Switzerland were exceptions, with decreasing trends in postmenopausal women. In premenopausal and perimenopausal women, declines were observed in Northern and Western Europe, most evidently in Denmark, Sweden, and the United Kingdom, affecting consecutive generations born after 1925. These contrast with the increasing trends regardless of menopausal age in some Southern and Eastern European countries, particularly Slovakia and Slovenia. These observations provide evidence of changes in several established risk factors over time and have implications for possible primary prevention strategies. In postmenopausal women, changes in reproductive behavior and prevalence of overweight and obesity may partially account for the observed increases, as well as hormone replacement therapy use in certain countries. Combined oral contraceptive use may be responsible for the declines observed among women aged <55 years. Whereas there are some prospects for chemoprevention in premenopausal women as oral contraceptive use becomes more widespread in Europe, increases in obesity and decreases in fertility imply that endometrial cancer in postmenopausal women will become a more substantial public health problem in the future.

Geographic and temporal variations in cancer of the corpus uteri: Incidence and mortality in pre- and postmenopausal women in Europe

Corpus uteri cancer is the fourth most common neoplasm in women in Europe and the tenth most common cause of cancer death. We examined geographic and temporal variations in corpus uteri cancer incidence and mortality rates in the age groups 25-49 and 50-74 in 22 European countries. The disease is considerably less common in premenopausal women, with incidence and mortality rates decreasing throughout Europe and mortality declines more marked in western and southern European countries. Incidence rates among postmenopausal women are highest in the Czech Republic, Slovakia, Sweden and Slovenia and lowest in France and the United Kingdom. Increasing incidence trends in this age group are observed in the Nordic countries (except Denmark) and in the United Kingdom. Some increases are also seen in eastern (Slovakia) and southern Europe (Spain and Slovenia), while relatively stable or modestly decreasing trends are observed in Italy and most western European countries. Postmenopausal mortality rates are systematically higher in eastern Europe, with death rates in the Ukraine, Latvia, Czech Republic, Russia and Belarus 2-3 times those seen in western Europe. Declining mortality trends are seen in most populations, though in certain Eastern European countries, the declines began rather recently, during the 1980s. In Belarus and Russia, recent postmenopausal death rates are stable or increasing. The rates are adjusted for misclassification of uterine cancer deaths but remain unadjusted for hysterectomy, and where there is an apparent levelling off of incidence or mortality rates recently, rising prevalence of hysterectomy cannot be discounted as an explanation. However, the trends by age group can be viewed in light of several established risk factors for endometrial cancer that are highly prevalent and most likely changing with time. These are discussed, as are the prospects for preventing the disease.

Trends in incidence of and mortality from cancer in The Netherlands in the period 1989-1998

This paper summarises the population-based major trends in cancer incidence and mortality in the period 1989-1998 in The Netherlands. Trends of the European age-adjusted incidence and mortality rates were estimated by the Estimated Annual Percentage Change (EAPC) method. Increases in incidence were found for cancer of the breast and lung for females. For males, an increase was observed for cancer of the prostate, colon, rectum and testis. In both groups, oesophageal and pharyngeal cancer increased, but that of stomach and gallbladder cancer decreased. The main increases in mortality were found for pharyngeal cancer in males, lung in females and oesophageal cancer in both sexes. Decreases were shown for stomach cancer for both sexes and lung cancer for males. Trends in incidence may be a result of changes in behaviour, smoking habits in preceding decades are related to the increase in lung cancer for females, and early detection, screening programmes increased the incidence for breast and prostate cancers. Decreases in mortality may be related to more successful treatment of leukaemia, Hodgkin's lymphoma, colorectal and testicular cancers. Primary prevention of cancer remains important.

Breast cancer incidence and mortality trends in 16 European countries

Trends in the incidence of and mortality from breast cancer result from a variety of influences including screening programmes, such as those introduced in several European countries in the late 1980s. Incidence and mortality rates for 16 European countries are analysed. Incidence increased in all countries. The estimated annual percent change (EAPC) varied from 0.8 to 2.8% in prescreening years in 6 'screened' countries and from 1.2 to 3.0% in 10 'non-screened' countries. Screening related temporary increases were visible. Earlier mortality trends were maintained in the most recent decade in Estonia (EAPC +1.8%) and Sweden (-1.2%). In other countries, previously increasing trends changed. Trends flattened in Finland, Denmark, France, Italy and Norway (EAPC 0.0 to -0.3%), while they declined in England and Wales (-3.1%), Scotland (-2.0%), and The Netherlands (-1.0%), all of which have national screening programmes, and in Slovakia (-1.1%), Spain (-0.7%), and Switzerland (-1.1%). In some countries with screening programmes, declines in mortality started before screening was introduced, and declines also occurred in non-screened age groups and in some countries without national screening programmes. This suggests that the major determinants of the observed trends vary among the countries and may include earlier detection through screening in countries where this has been introduced, but also improvements in therapy, in countries with or without screening.

Long-term trends in cancer mortality in the United States, 1930-1998

BACKGROUND

Progress against cancer can be examined by analyzing long-term trends in cancer incidence and mortality. The recent directive from the U.S. Department of Health and Human Services to adopt the 2000 U.S. standard population for the age adjustment of death rates prompted the American Cancer Society to update historical cancer mortality statistics using the new standard.

METHODS

Mortality data were abstracted by race, gender, year, and age at death for 1930 through 1959 from annual volumes of Vital Statistics of the United States. For 1960 through 1998, these data were obtained from data tapes provided by the National Center for Health Statistics. Two U.S. standard million populations (1970 and 2000) were used to calculate age-adjusted rates. Average annual percent change was estimated for each decade by site, gender, and age, and the statistical significance of the change was assessed at p < 0.05.

RESULTS

After long-term increases or mostly level trends that date from the 1930s for some sites, death rates for cancers of the lung (in males), prostate, female breast, colon-rectum, pancreas, leukemia, and ovary were decreasing in the 1990s. Liver cancer death rates were increasing in the 1990s. Throughout the study period, death rates for female lung cancer increased, while death rates for stomach and uterine cancers declined.

CONCLUSIONS

The trends of decreasing cancer death rates for the leading cancer sites in the 1990s are encouraging. However, surveillance researchers must continue to monitor these declines to assess whether the progress seen in this decade persists. Efforts also must be made to study the sites with increasing trends and identify potential underlying causes.

Ovarian cancer incidence and survival by histologic type in Osaka, Japan

The incidence of ovarian cancer among Japanese has increased since the 1970s. Histologic diversity is a characteristic of this cancer. However, there has been no population-based study made on the incidence and survival by histologic type. Osaka Cancer Registry's data was used for incidence and survival analyses of ovarian cancer by histologic type in this study. Seven thousand one hundred sixty-seven incident cases were registered during the period 1975 to 1998. According to the IARC's histologic classification, types of ovarian cancer were classified into five categories. Survival analysis was restricted to the reported 2431 cases who lived in Osaka Prefecture (except for Osaka City) and were diagnosed in 1975-1994, since active follow-up data on vital status 5 years after the diagnosis were available. The age-standardized incidence rate of ovarian cancer increased from 4.0 to 5.4 per 100,000 women (standard: world population) in Osaka during the period 1975-1998. Carcinoma, the major histologic category, also increased (from 3.4 to 4.8 per 100,000 women), while sex cord-stromal tumors decreased after 1980 and germ cell tumors remained stable. The 5-year relative survival was 36.4% for ovarian cancer patients diagnosed in 1975-1994. The survival for carcinoma was 38.3%, which was lower than that in sex cord-stromal tumors or germ cell tumors (55.3% and 58.6%, respectively). The increase in the incidence of ovarian cancer was caused by the increase in carcinoma. The relative 5-year survival of ovarian cancer improved over the period, but was different by histologic type.

Incidence patterns of invasive and borderline ovarian tumors among white women and black women in the United States. Results from the SEER Program, 1978-1998

BACKGROUND

Malignant tumors of the ovary are the leading cause of death from gynecologic malignancies in the United States. Population-based incidence data for these neoplasms by histopathologic type and race are limited. Variation in rates may provide clues for future etiologic studies.

METHODS

The authors performed a detailed, population-based analysis of U.S. incidence rates by histologic type, race, and age for invasive ovarian tumors that were diagnosed during 1978-1998 and for borderline ovarian tumors that were diagnosed during 1992-1998 using data from the U.S. Surveillance, Epidemiology, and End Results (SEER) Program.

RESULTS

White women had significantly higher rates compared with black women of all types of epithelial tumors, with the white:black rate ratios ranging from 1.23 to 2.56. Black women had higher rates of gonadal stromal tumors. Among both white women and black women, total carcinoma rates did not change greatly from 1978-1982 to 1995-1998. Among white women, the reported incidence rates for invasive serous, endometrioid, and clear cell tumors increased during 1978-1998, whereas the rates of mucinous; papillary, not otherwise specified (NOS); and other epithelial tumors declined. Among black women, the reported rates of papillary, NOS tumors decreased significantly, whereas the rates of other tumor types fluctuated. Incidence rates of borderline ovarian tumors were higher among white women compared with black women and did not change significantly during 1992-1998. Serous and mucinous tumors were the predominant tumors reported for women age < 45 years, whereas serous; papillary, NOS; and other epithelial tumors predominated among older women.

CONCLUSIONS

Incidence rates for malignant ovarian tumors have remained relatively stable, with higher rates for white women compared with black women. The reported rates for some specific histopathologic tumor types have changed over time, in part reflecting more specific pathologic classification. The possible effect of shifting exposure prevalence on incidence patterns warrants further study.

Oral contraceptives and cancer: an update

Most up-to-date information on oral contraceptives (OCs) and breast cancer risk comes from a collaborative re-analysis of individual data on 53297 cases and 100239 controls. It is now established that there is a moderately increased breast cancer risk among current OC users, which tends to level off in the few years after stopping use. With regard to cervical cancer, OC use has been found to be associated with increased risk in human papilloma virus-positive women. With reference to the well known protective effects of OCs against endometrial carcinogenesis, additional information has suggested a consistent protection across types of OCs used. Further data on ovarian cancer confirm that the protection of OCs is long lasting, and may well be observed 15 to 20 years after stopping use. Several studies have suggested an inverse relationship between use of OCs and risk of colorectal cancer, and in a meta-analysis of published data the pooled relative risk of colorectal cancer for DC ever-use was 0.82 (95% confidence interval 0.74 to 0.97). There was no association with duration of use. The increased risk for hepatocellular carcinoma in the absence of hepatitis B viruses is the only established evidence of a direct association between OC use and cancer risk, which led an International Agency for Research on Cancer Working Group to classify OCs as carcinogenic to humans in 1998.

Trends in the mortality (1950-1997) and incidence (1975-1993) of malignant ovarian neoplasm among Japanese women: analyses by age, time, and birth cohort

OBJECTIVE

The purpose of this study was to explore epidemiological features of malignant ovarian neoplasm in Japan.

METHODS

The number of deaths from malignant ovarian neoplasm was obtained from the national vital statistics. Estimated incidence rates, based on several cancer registries, were also used for analyses. We divided the subjects into two age groups (0-29 and 30+ years) and examined secular trends in mortality (1950-1997) and incidence (1975-1993) by age, time, and birth cohort.

RESULTS

The age-adjusted mortality rate has increased approximately 4-fold (from 0.9 to 3.6 per 100,000 women) from 1950 to 1997. Age-specific mortality rates showed a rising pattern in the elderly, whereas mortality in the younger people tended to increase in the 1950s and 1960s, but then decreased in the 1970s and afterward. In analyses using a mathematical model, the time effect in the population aged 0-29 years increased with advancing period up to 1970, and then decreased. The cohort effects had positive values, which indicate higher than additive influence from age/time effect, for birth cohorts from 1900 to 1935. The age-adjusted incidence rate increased approximately 1.5-fold (from 3.6 to 5.7) from 1975 to 1993. The rate increased in the early 1980s, but has remained stable since the late 1980s. Age-specific incidence rates in older age groups increased steadily up to 1985, and have remained stable since, while the rates in younger women have remained almost unchanged.

CONCLUSION

The major effects on malignant ovarian neoplasm in Japan are supposed to be due to declining parity and therapeutic improvements.

Diverging breast cancer mortality rates in relation to screening? A comparison of Nijmegen to Arnhem and the Netherlands, 1969-1997

Age-standardised breast cancer mortality rates have been stable for decades. However, rates have started to decline in several Western countries. In countries where population-based screening programmes for breast cancer were introduced in the late 1980s or early 1990s, the key question now is to what extent screening is responsible for the reported declines in mortality. This study compares breast cancer mortality rates in Nijmegen, where a screening programme for breast cancer was introduced in 1975, to a control city, Arnhem, and to the Netherlands as a whole over a 20-year period. Age-standardised breast cancer mortality rates as well as age-standardised mortality ratios were calculated for successive calendar years from 1969 to 1997. Further, a tailor-made period-cohort-group Poisson regression model was fitted. Figures displaying age-standardised mortality rates and ratios showed inconclusive patterns with regard to the expected impact of screening. Depending on when mortality rates were allowed to deviate between populations, the period-cohort-group analysis indicated a non-significant 6% to 16% reduction in breast cancer mortality after 2 decades in favour of the Nijmegen female population. Possible explanations are discussed as to why the mortality reductions reported by randomised trials might not be observed in a public health screening programme, such as the Nijmegen programme, evaluated by comparisons of geographical trends.

Chien-Tien Hsu Memorial Lecture. Fertility and gynaecologic malignancies

Fertility and gynaecological malignancies have an important relationship. A clear inverse relationship exists between family size and the incidence of ovarian and endometrial cancer. Current methods of fertility control have an influence on subsequent development of various gynaecological malignancies. A slightly increased risk of breast cancer has been reported in current users and those who had used hormonal contraceptives (OCs) within 10 years; this risk declined with time and disappeared after 10 years. Women who started OC before age 20 had a higher relative risk; the disease did not spread beyond the breast in the majority. Most studies found OC to reduce the risk of ovarian and endometrial cancer. The relative risks of squamous cell carcinoma and adenomatous carcinoma of the cervix have been reported to be 1.3 and 1.5, respectively in ever-users of OCs; however, the aetiology of cervical cancer is multifactoral. Several reports suggest the beneficial effect of tubal ligation and breast feeding in reducing the risk of ovarian cancer. Therapy of gynaecological malignancies may have an influence on subsequent fertility. Amenorrhoea developing after treatment of hydatidiform mole may be due to choriocarcinoma, recurrent mole or a normal pregnancy. Choriocarcinoma can also develop after a partial mole. The risk of fetal teratogenicity from chemotherapy is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTD including cerebral metastases. In the young patient with gynaecological malignancy preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian epithelial cancers and even in advanced germ cell tumours. Recently, the fertility-sparing surgery of radical trachelectomy and pelvic lymphadenectomy has been carried out for early invasive cervical cancer in young women. Gynaecological cancer occurring in pregnancy is uncommon; it presents the clinician with a difficult situation to manage. In most instances the cancer is treated as though the patient is not pregnant; the timing and mode of delivery needs individualization. The overall prognosis for breast cancer complicating pregnancy is poor. Survival in cervical cancers diagnosed antepartum is similar to the non-pregnant patient. Ovarian cancer in pregnancy has a good prognosis because of the early stage at diagnosis.

Breast cancer incidence rates in Slovenia 1971-1993

BACKGROUND

Analyses of time trends in breast cancer incidence and mortality have generally revealed cohort-based changes in the rates. These have been linked to cohort-based changes in lifestyle factors. The effect of the changes in the reproductive risk factors on the changes in the rates, and the relative importance of the reproductive characteristics in Slovenia, a country which has not had much breast cancer screening, are investigated.

METHODS

Data on breast cancer incidence for 1971-1993 were obtained from the Cancer Registry of Slovenia (Registry). The Registry covers the whole population of the Republic of Slovenia (1.99 million on 30 June 1993). The statistical analysis uses parametric age-period-cohort models.

RESULTS

Breast cancer incidence has increased by 70% in Slovenia from 1971 to 1993, These changes are dominated by cohort effects and the cohorts born in 1907-1922 have the greatest increase in incidence. Period effects on changes in incidence were modest. The percentage of nulliparous women in the cohort and the average family size in the cohort explained 38% of the variation in the cohort effects.

CONCLUSIONS

The percentage of nulliparous women in the cohort is the most important reproductive variable associated with the trends in the rates, with breast cancer risk predicted to be higher in cohorts with a larger percentage of nulliparous women. As the cohorts born 1932-1946 have a more favourable reproductive pattern as regards breast cancer risk, compared to the 1907-1922 cohorts, age-specific incidence rates in Slovenia would be predicted to decline in the future in the absence of changes in the other risk factors.

Receipt of preventive health care services by lesbians

BACKGROUND

We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services.

METHODS

A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U. S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged > or= 50, receipt of a mammogram within the past 1 and 2 years.

RESULTS

Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged > or = 50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms.

CONCLUSIONS

It is important for providers to identify their lesbian patients' unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.

Patterns in the incidence of age-related ovarian cancer in South East England 1967-1996

OBJECTIVE

To study the age-related trends in the incidence rates of ovarian cancer in South East England between 1967 and 1996.

DESIGN

A retrospective review of systematically collected data on ovarian cancer in South East England.

METHODS

Data were obtained from the Thames Cancer Registry on the numbers and rates per 100,000 population of ovarian cancer per five-year age group (0-85+) in the 30-year period from 1967 to 1996 from the 26 health authorities in the Thames region. Linear regression was performed to determine the changes in incidence rates of ovarian cancer per age group over time.

MAIN OUTCOME MEASURES

The change in overall incidence of ovarian cancer in South East England, as well as the change in incidence of ovarian cancer in each five-year age groups (20-85+) in the 30-year study period.

RESULTS

There was a strong positive correlation between ovarian cancer rates and year of diagnosis in women aged > or = 70 years, and this was particularly marked in women > 85 years of age. There was a negative correlation between rates and year of diagnosis in women aged 45-59 years. The analysis did not demonstrate a significant correlation between ovarian cancer rates and year of diagnosis in women < 44 years of age or women aged 60-69 years.

CONCLUSIONS

There have been significant changes in the pattern of ovarian cancer incidence in South East England during the 30-year period studied. The observed changes in ovarian cancer incidence in younger women may, in part, be explained by known reproductive factors. The rise in ovarian cancer rates among the older age group is difficult to explain, but has important implications for the future planning and provision of cancer services.

Time trends in ovarian cancer mortality in Europe (1955-1993): effect of age, birth cohort and period of death

The time trend in ovarian cancer mortality in the European Union over the period 1955-1993, and the age, period-of-death and birth cohort components underlying the trend's evolution were analysed using log-linear Poisson models to quantify risk of dying from ovarian cancer in the different countries and regions of Europe, and ascertain the relative annual trend for each country. Furthermore, age-period-cohort models were fitted for each country in order to ascertain the effect on time trend exerted by the respective age, period-of-death and birth cohort components. Ovarian cancer mortality proved 2.77-fold (95% confidence interval (CI) 2.60-2.95) higher in northern versus southern Europe over the period 1955-1993. Denmark registered the highest adjusted rates, namely, 14.3 per 100000 person-years for the 1989-1993 5-year period, the last studied, with Portugal (4.5 per 100000) and Greece (4.5 per 100000) being the countries with the lowest rates. Spain and Greece, with annual rises of 5.8% (95% CI 5.3-6.3) and 5.1% (95% CI 4.2-6.0) respectively, were the countries that displayed the greatest increase in ovarian cancer mortality. Risk of death associated with the birth cohort effect declined in all northern countries from 1920 to 1930. In the south, Italy and France recorded a decline in risk from 1930. Women in Spain and Greece registered an increase in birth cohort-associated mortality, which became less pronounced after 1930. Ovarian cancer mortality in Europe evinces a south-north distribution pattern. The mortality risk for women cohorts born in northern Europe witnessed a gradual decline from 1920 to 1930. In the southern region: (1) Italy and France display a cohort effect of decreased risk from 1930; and (2) Greece and Spain show a cohort effect of increased risk among the different generations of women, though this became less pronounced from 1930 onwards.

Current management of epithelial ovarian carcinoma: a review

Epithelial carcinoma of the ovary is the most lethal of gynaecological malignancies and it affects about one in 70 women in developed countries. Over 75% of women with the disease have tumour spread beyond the pelvis at the time of diagnosis, and their treatment requires the appropriate use of surgery and chemotherapy. The strategies used in the treatment of ovarian cancer are constantly evolving. An overview of current treatment regimens and their evolution is provided, with particular emphasis on the interdependence of surgery and chemotherapy in the optimal management of the disease.

The prevalence of BRCA1 mutations in Chinese patients with early onset breast cancer and affected relatives

The purpose of this study was to determine the prevalence of BRCA1 mutations in Chinese breast cancer patients in Singapore. BRCA1 analysis was conducted in consecutive patients with breast cancer before the age of 40 years (76 women), or whose relatives had breast or ovarian cancer (16 women). Ten patients had both early onset breast cancer and affected relatives. Genomic DNA from peripheral mononuclear blood cells was studied by using the protein transcription-translation assay (exon 11) and single-strand conformational polymorphism, with subsequent DNA sequencing. All six disease-causing mutations occurred in women under 40 years (8.6%) with three occurring in patients under 35 years (three out of 22 patients, 13.6%). Mis-sense mutations of unknown significance were found in three patients. Two of the ten women with affected relatives under 40 years had BRCA1 mutations. The prevalence of BRCA1 mutations in Chinese patients with early onset breast cancer is similar to that observed in Caucasian women. Most Chinese patients with affected relatives were not carriers of BRCA1 mutations.

Decision making about prophylactic oophorectomy among at-risk women: psychological influences and implications

OBJECTIVE

Women with a family history of ovarian cancer are confronted with difficult decisions regarding the management of their risk status. Currently, the main preventive option available is prophylactic oophorectomy. The objective of the present paper is to review research and theory on psychological factors that influence decision making about preventive surgery and discuss the implications for patient management.

METHODS

Guided by a cognitive-social framework, the literature on decision making about preventive surgery is reviewed and integrated.

RESULTS

The available studies show that women are more likely to opt for surgery if they feel more vulnerable to cancer, believe that surgery will prevent cancer, and are worried about developing cancer. Further, the response to ovarian risk is influenced by the individual's characteristic psychological style: monitors (who typically scan for and amplify threatening cues) tend to feel more vulnerable to cancer and more distressed about their cancer risk than blunters (who typically distract from threatening cues) do.

CONCLUSION

On the basis of prior research, monitors may be more likely to choose surgical intervention to reduce their distress, without fully anticipating the psychological and medical consequences of that decision. In order to facilitate informed decision making, counseling protocols should be designed to enable the patient to understand and take account of the psychological consequences of the available medical options. Future studies are needed to systematically extend and explore the proposed theory-based relationships.

Ovarian cancer histology-specific incidence trends in Canada 1969-1993: age-period-cohort analyses

This study examined histology-specific incidence trends of ovarian cancer in Canada, 1969-1993. The impact of age, period and cohort effects on these trends were studied by means of age-period-cohort analysis. Age-standardized incidence rates of serous, endometrioid, clear cell and germ cell tumours increased significantly and the rates of sex cord-stromal and other classified epithelial ovarian tumours decreased considerably. The rates of mucinous and NOS/unclassified tumours remained unchanged. Cohort effect has a major impact on incidence trends of serous, endometrioid, germ cell, sex cord-stromal and other classified epithelial ovarian tumours but no meaningful impact on trends of mucinous, clear cell, or NOS/unclassified ovarian tumours. Various cohort patterns by histology subtypes were observed: the risk of developing serious tumours increased markedly among birth cohorts of 1895-1930, stabilized thereafter and decreased among young cohorts of 1950-1960; the risk of germ cell tumours increased significantly among young cohorts of 1965-1980; and the risk of sex cord-stromal tumours dropped constantly among cohorts 1910-1950. Various period patterns by histology subtypes observed in this study suggested changes in histology classification criteria over the period. Further studies need to consider the various etiologies and the classification criteria changes according to histology subtypes.

p53 expression, p21 expression and the apoptotic index in endometrioid endometrial adenocarcinoma

AIMS

Although several genetic abnormalities are known to occur in endometrial cancer, including tp53 gene mutation, the pathogenesis of this common malignancy remains poorly defined. We investigated the relationship between overexpression of p53 protein, p21 protein expression and apoptosis in endometrial carcinoma.

METHODS AND RESULTS

Sixteen cases of endometrial carcinoma in which polymerase chain reaction analysis had demonstrated the absence of a tp53 gene mutation were selected on the basis of p53 protein expression; p21 protein expression and the apoptotic index were then determined for each case. The proportion of cells in each case expressing p53 and p21 protein immunoreactivity was compared with the apoptotic index. Overall, no significant correlation was demonstrated between p53 and p21 immunoreactivity, or between either p53 or p21 and the apoptotic index.

CONCLUSIONS

Factors other than p53 are involved in the regulation of p21 expression and apoptosis in endometrioid endometrial adenocarcinomas without p53 mutations. Despite the small numbers used in this study, the data suggest a correlation between low levels of p53 immunoreactivity and apoptosis. We postulate that high levels of p53 immunoreactivity may be due to abnormal stabilization of the p53 protein. Follow-up studies are needed with a larger data set.

Recent advances in the histopathology and molecular pathology of carcinoma of the endometrium

Endometrial carcinoma is the commonest malignancy of the female genital tract. The pathogenesis is complex and at least three pathogenetic subtypes exist with different prognostic implications. The molecular events involved remain poorly defined but several genes are involved and mutations of tp53, WAF1/CIP1, PTEN, bcl-2 and c-erbB-2 have been implicated. Although care is needed in interpreting the results, the majority of these mutations can be detected immunohistochemically and therefore have the potential to aid the pathologist and surgeon in assessing the prognosis of a tumour. However, for the time being, no molecular marker is as valuable in determining prognosis as conventional parameters such as tumour type, grade and vascular space involvement.

Breast cancer mortality trends in Australia: 1921 to 1994

OBJECTIVE

To analyse breast cancer mortality trends in Australia and to see if mammographic screening has yet led to a reduction in mortality.

DESIGN

Retrospective analysis of trends in mortality rates from breast cancer in Australian women between 1921 and 1994, and in potentially explanatory variables such as fertility, body size, age at menarche, and screening.

RESULTS

Changes in breast cancer mortality in Australian women could not be explained by chance variation alone. Mortality rose steadily (average annual increase, 1.0%) to 1940-1944, fell to the 1960s and early 1970s, and rose (average annual increase, 0.3%) to the late 1980s. Between 1985-1989 and 1990-1994, breast cancer mortality fell by 3.2% in women 50-69 years of age (the target age group for mammographic screening) and by 4.2% in women 25-49 years of age. There was almost on change (-0.2%) in breast cancer mortality in older women in this period. The proportion of women screened in all age groups increased substantially between 1988 and 1994; nearly 65% of women in the target age group had had at least one mammogram by 1994. Decreases in fertility were followed by increases in mortality, and vice versa.

CONCLUSIONS

Trends in breast cancer mortality have probably been influenced by changing fertility, nutrition and body-size increases among Australian women. Improvements in stage at diagnosis and treatment have probably moderated the upwards pressure on mortality caused by an increasing incidence. Recent falls in mortality could be expected to continue as more women participate in the mammographic screening program. This trend should be more clearly evident in the second half of the 1990s.

Trends in cancer incidence and mortality in Scotland: description and possible explanations

Secular and cohort trends in mortality from cancer in Scotland during 1953-93, and incidence during 1960-90, were analysed using individual records from the national mortality and registration files. For certain cancer sites, the secular analyses of mortality were extended back to 1911 by use of published data. Mortality from cancer at older ages in Scotland has increased over the last 40 years. In each sex, this trend has been dominated by the effects of smoking: all-cancer rates and rates of lung cancer, now the most common fatal cancer in men and in women in Scotland, reached a peak in the cohort of men born at the turn of the century and the cohort of women born in the 1920s. For much of the period, the Scottish all-age rates of lung cancer were the highest reported in the world; they are now decreasing on a secular basis in men, but are still increasing in women. There have also been large increases at older ages in the incidence and mortality rates for cancer of the prostate in recent years. bladder cancer, nervous system cancer, non-Hodgkin's lymphoma, myeloma and leukaemia; for each there is likely to be a considerable artefactual element to the increase, with differing degrees of possibility that there may in addition be an element of real increase. Substantial decreases in mortality at all ages have occurred for stomach and colorectal cancers and substantial increases at all ages for pleural cancer and melanoma. Rates of mortality from breast cancer, the most common cancer in women in Scotland, have generally increased over the past 80 years; a temporary cessation in this upward trend occurred in the years during and after the Second World War, and recently rates have turned downward, probably at least in part because of better treatment. Mortality from ovarian cancer, the second most common reproductive-related female tumour in Scotland, has also increased at older ages. At younger ages, mortality from cancer in Scotland has decreased, especially in men, whereas incidence has not. This divergence, which has been a consequence of better treatment, has occurred especially for cancers of the testis and ovary, Hodgkin's disease and leukaemia. There have been increases at young adult ages, however, in both mortality from and incidence of oral and pharyngeal, oesophageal and laryngeal cancers in men, and melanoma and non-Hodgkin's lymphoma in each sex. Cervical cancer rates at young ages also increased, but this trend has reversed for incidence in the most recent birth cohorts. Incidence rates have also increased for testicular cancer in young adults and leukaemia in children. With the possible exceptions of non-Hodgkin's lymphoma and childhood leukaemia, the increasing rates are likely largely to reflect real rises in incidence, and they highlight the need for investigation of the causes of these cancers, and, when causes are known, for preventive action.

Breast cancer: aetiological factors and associations (a possible protective role of phytoestrogens)

BACKGROUND

In spite of many known and suspected factors associated with the risk of breast cancer there has until recently been no explanation for its continuing increase in women of Western societies over recent decades or why there has not been an equivalent increase in women of most Asian and other less Westernized societies. It has long been suspected that a significant factor has been an increasing change of diet in Western societies from one predominantly vegetarian to one with a high content of meat and dairy products as well as 'refined' foods. Although diet has long been suspected there has otherwise been no real explanation as to the mechanism of the change in incidence of breast cancer.

METHODS

A comprehensive literature review has been made of aetiological factors and associations concerning breast cancer to determine whether any consistent trend can explain the rising incidence in Western societies.

RESULTS

There are a number of likely contributory factors but there is now accumulating evidence that the single most important difference is that people having a vegetarian diet have a high intake of legumes and other plant foods containing a variety of lignans and isoflavonoids. These appear to have an important role as nature's sex hormone modulators. These agents appear to be biologically active in a number of ways not yet completely understood but they do have both a weak oestrogenic effect and an anti-oestrogenic competitive effect, thus reducing the potential carcinogenic action of prolonged oestrogen activity. A probable additional benefit of such diets could be the role of dietary fibre.

CONCLUSIONS

A major problem of Western diets may not be the presence of meat or dairy products in the diet but the absence of desirable ingredients of vegetarian diets, namely dietary fibre and certain plant lignans and isoflavonoids. A modification of diet to include a greater proportion of fibre and soy or other leguminous plant food should be studied. Alternatively addition of more fibre and lignans and especially isoflavonoids to traditional Western diets would seem worthy of serious investigation. Such influences appear to have their greatest impact early in life and therefore could be especially important for girls and young women in Western societies.

Cancer incidence and mortality in the European Union: cancer registry data and estimates of national incidence for 1990

Members of the European Network of Cancer Registries (ENCR) provide population-based data on cancer incidence for some countries and regions of Europe. These were supplemented by estimates in order to provide comparable information on cancer incidence and mortality in the 15 member states of the European Union (EU). The estimated numbers of new cases of cancer (excluding nonmelanoma skin cancer) in 1990 were approximately 706,900 in men and 644,200 in women. Approximately 497,500 men and 398,200 women died of cancer in the same year. The main sites of incident cases in men were lung (21%), large bowel (13%), prostate (12%), bladder (7%) and stomach (7%). For women, the predominant sites were breast (28%), large bowel (15%), lung (6%), uterine corpus (5%) and stomach (5%). The overall incidence rates for males were highest in continental Western Europe (France, The Netherlands, Austria, Luxembourg, Belgium, Germany and Italy) while the rates of Greece, Portugal, Sweden, Ireland, Spain, Finland, the U.K. and Denmark were below the average value for the EC. Rates for females were highest in Northern and Western Europe, with the exception of France, which had a relatively low rate for females, in common with Greece, Spain and Portugal. The geographical variations in incidence of the major cancers are discussed in relation to risk factors. The estimates show the substantial burden of cancer in European Union populations, but there are also indications of effects of past preventive measures and there is scope for further intervention. Cancer registries are an important source of information for cancer control since they provide population-based incidence and survival statistics. These, along with mortality data, are required to obtain a full picture of the frequency of cancer and its effects at the population level. Some 44% of the EU population is covered by registries. The European Network of Cancer Registries aims to standardise the information provided by existing registries and to provide practical assistance to those in development.

Sex differences in time trends of colorectal cancer in England and Wales: the possible effect of female hormonal factors

Differences between the sexes in time trends of colorectal cancer incidence 1962-87 and mortality 1960-91 in England and Wales are examined in relation to changes in female hormonal factors. There was a trend in the sex ratio of this tumour, particularly marked for the descending colon, whereby the female excess in risk at young ages has almost disappeared but the male excess at older ages has increased. This trend started for cohorts born since the 1920s and coincided with the increase in the use of oral contraceptives and, to a lesser extent, with increases in fertility. The decline has been particularly pronounced for women at young ages born since 1935-39, coinciding with the spread of oral contraceptive use to younger age groups. These results are consistent with the hypothesis that female hormonal factors may play a role in the aetiology of colorectal cancer and with the possibility that oral contraceptive use might exert a protective effect in the descending colon.

Changes in incidence of and mortality from breast cancer in England and Wales since introduction of screening. United Kingdom Association of Cancer Registries

OBJECTIVE

To assess the impact of the NHS breast screening programme on the incidence of and mortality from breast cancer.

DESIGN

Comparison of age specific incidence and mortality before and after the introduction of screening in the late 1980s.

SETTING

England and Wales.

SUBJECTS

Women aged over 30 years.

RESULTS

In 1992 the age standardised incidence of breast cancer was 40% higher than in 1979. After the introduction of screening in 1988 recorded incidence rates rose steeply in the screened age group (50-64 year olds) but not in others. In 1992 the rates levelled off at about 25% higher than in 1987. Total mortality from breast cancer has increased steadily since the 1950s; the rates increased earlier in the younger age groups. By the mid-1980s rates had begun to fall in the younger age groups; but total mortality was still among the highest in the world. Age standardised mortality in the 55-69 age group changed little during the first three years of screening but then fell steeply and in 1994 was 12% lower than in 1987.

CONCLUSIONS

Since the introduction of screening there have been pronounced increases in recorded incidence in the screened age group. Cancer registries have an essential role in assessing screening programmes and cancer services. The steep decrease in mortality in 55-69 year olds which began three years after screening started is unlikely to be due to screening. The widespread adoption of treatment with tamoxifen during this period may be important. With the reduction in mortality already observed and the expected additional benefits from screening, the Health of the Nation target should be achieved.