Download Cancer in Finland

Cancer in Finland
Eero Pukkala
Matti Rautalahti
Publications from the Cancer Society of Finland 2013
Cancer in Finland
Eero Pukkala and Matti Rautalahti
Cancer in Finland
First edition in English
ISBN 978-952-5815-16-0
ISBN 978-952-5815-17-7 (pdf)
Cancer Society of Finland Publication No. 86
Translation from Finnish Luanne Siliämaa
Layout and graphics Hannu Rinne and Jaana Viitakangas Atelier GraGra
Publisher Cancer Society of Finland
Printed by Erweko, Helsinki 2013
This book is based on the original edition published in Finnish Pukkala E, Rautalahti M, Sankila R. Syöpä Suomessa 2011.
Suomen Syöpäyhdistyksen julkaisuja nro 82. Cancer Society of Finland, Helsinki 2011.
To the readers
Cancer in Finland aims to give a balanced overview of cancer incidence, prevalence, and mortality
in Finland. The report also presents current information on the causes of cancer and the possibilities for cancer prevention. The Finnish Cancer Registry, an institute for epidemiological and
statistical cancer research, was founded in 1952. At first, reporting of cancer cases was voluntary,
but in 1961 the National Board of Health issued a by-law making reporting compulsory for all
physicians, hospitals and other relevant institutions. Primary medical care in Finland is provided
to the entire population at only a nominal fee. Every cancer patient receives adequate and modern
treatment as required. Most of the information presented in this book is based on the comprehensive, high quality registration of cancers over the last 60 years and on the extensive epidemiological
research done in Finland.
Trends in cancer incidence have been studied in Finland for an exceptionally long time period.
With the help of information from the registry files, many studies are done at the Finnish Cancer
Registry on risk factors for cancer, prevention, and early diagnosis. The efficacy of the health care
system has been followed using survival statistics of cancer patients.
There are outstanding possibilities in Finland and in the other Nordic Countries for cancer research due to comprehensive data of high quality and the availability of data for research purposes.
Employing and safeguarding these can be considered an important international obligation.
Helsinki, June 2013
Nea Malila
Professor, Director of the Finnish Cancer Registry
Contents
Introduction
6
The Finnish Cancer Registry
Cancer Registration 7
Acknowledgements 7
6
Risk factors for cancer and their effect
8
Internal factors 8
Environmental exposures 10
Lifestyle 16
Socio-economic position 21
Cancer and other illnesses 23
Attributable fractions of risk factors 24
Possibilities for cancer prevention 24
Frequency of cancer in Finland
26
Changes in cancer frequency 26
Cancer and gender 35
Cancer and age 35
Differences between generations 40
Regional variation 40
Cancer screening
50
Cervical cancer screening 50
Screening for breast cancer 52
Colorectal cancer screening 53
Screening for prostate cancer 54
Screening for other cancers 54
Treatments
55
Survival
56
Factors contributing to survival
Years of life lost
59
Cancer in the future
References
57
62
69
How to find information about cancer on the Internet
76
6
| Cancer in Finland
Introduction
This publication deals with the occurrence of
cancer in Finland. The goal is to distribute information related to cancer to those who have
something to do with cancer in their work or
studies, or to those who are otherwise interested
in the topic. The publication describes the frequency of cancer among different population
groups, risk factors for cancer, treatments for
cancer, the detection of cancer in pre-malignant
and early stages through mass screening, the
survival of cancer patients as well as projections
of cancer occurrence in the future.
The publication is based for the most part on
the data and results from the research work of
the Finnish Cancer Registry.
The Finnish Cancer Registry
The Finnish Cancer Registry is an institute for
statistical and epidemiological cancer research
founded in 1952. In 2013 there were some 30
permanent employees in the Cancer Registry:
administrative personnel as well as experts in
medicine, epidemiology, and statistics. In addi-
tion, there are a number of researchers working
on project-based funding.
The Finnish Cancer Registry
• produces descriptive information on the inci-
dence, prevalence and mortality of cancer as
well as changes and predicted changes in the
situation;
• produces countrywide and regional estimates
of cancer patient survival;
• acts as a specialist organization in questions
related to cancer epidemiology and in the
planning and evaluation of mass-screening
programmes and other actions against cancer,
and
•researches the causes of cancer and the ef-
fectiveness of treatments using epidemiology and statistics, provides data to outside
researchers and helps them in the planning
and execution of their studies.
Introduction |
Cancer Registration
The registration of cancers began countrywide
in Finland in 1953. The National Board of
Health requested at that time all doctors, hospitals and laboratories in Finland to report all
information about cancer cases to the cancer
registry that was overseen by the Finnish Cancer Registry. Notification of cancer cases has
been compulsory since 1961.
Notifications from doctors, hospital and laboratories, as well as death certificate information
from Statistics Finland, are built into a database
that is suitable for statistical use, and which
produces graphs and other summaries. These
research materials are published as reports of
the Cancer Registry and as part of the official
statistics for Finland and the European Union.
The Registry covers over 99 percent newly diagnosed cancers and deaths from cancer in Finland since 1953 (Teppo et al 1994).
Comprehensive statistical and epidemiological research is done on the basis of the Registry
1
2
7
database and various other study materials collected for the purpose of research. During the
existence of the Cancer Registry about 2000
scientific articles1 and some 200 doctoral dissertations2 have been published in which Cancer
Registry researchers or its data have had a central role. Research related to the countrywide
mass screening programmes is performed in the
Mass Screening Registry, which is part of the
Finnish Cancer Registry.
Acknowledgements
We thank Prof. Lauri Aaltonen from the
­University of Helsinki and from the Center of
Excellence on Cancer Genetics – in which ”Team
Pukkala” from the Finnish Cancer Registry is
one of the five partners (Kaasinen et al. 2013)
– and Prof. Jaakko Kaprio from the University
of Helsinki for updating the text on heritability
with the most recent references on this topic.
We also thank Dr. Harry Comber from the
Irish National Cancer Registry for valuable
comments.
stats.cancerregistry.fi/Publications/publications.html
www.cancer.fi/syoparekisteri/en/general/doctoral-student-education
8
| Cancer in Finland
Risk factors for cancer
and their effect
Factors associated with a person’s lifestyle and
environment are significant in the development
of many cancers but for some cancers genetic
characteristics may also be an important factor.
In order to prevent cancer, it is crucially important to know those factors which influence the
probability of developing cancer.
Risk factors for cancer can be roughly divided
into the following groups:
• biological or internal factors such as age, gen-
der, the metabolism of foreign substances in
the body, inherited genetic faults and skin
type
• environmental exposures such as radon and
ultraviolet radiation, as well as fine particles
• work-related exposures such as chemicals, ra-
dioactive materials and asbestos
cause symptoms. A single cause cannot be identified for the majority of cancer cases.
Cancer is a complex group of diseases whose
causes, development, symptoms and treatment
can differ greatly from one to another.
Internal factors
Age. The majority of cancer cases are related to
the process of aging. During a long life, there is
more time for exposure to the risk factors that
cause the cell mutations related to the development of cancer. The longer a person lives, the
more probable it is that his or her cells will accumulate cancer-causing damage. Aging also
weakens the cell’s ability to prevent and repair
this damage.
Gender. Gender-related characteristics (such as
hormones) also influence the risk of cancers
other than those of the reproductive organs.
• lifestyle related factors such as physical activ-
ity and diet
The development of cancer is a series of events
occurring over many years, where the DNA of
a normal, healthy cell is damaged. The cells
change, through many stages, into malignant
cells which grow independently of the normal
regulatory systems of the tissues and finally
A cancerous tumour or cell is not
contagious, nor is it passed from parent to child.
As cancer is a common disease, approximately
every third Finn will fall ill from cancer during his or her lifetime. Thus it is normal that
in nearly every family there will be some cancer patients, but this results from both genetic
and environmental influences. Susceptibility to
Heritability.
Risk factors for cancer and their effect |
Figure
9
1
Cancer begins as a result of genetic mutations lasting many years after complicated series of events
that are influenced by numerous different environmental risks.
g
Normal
cell
g
g
Mutated
cell
g
Stage 1 cancer
/ cancer’s first
stage
g
Cancerous
tumour
Confirmed
cancer
Exposure risk factors for cancer such as chemicals,
viruses or radiation.
g
Cell level change
cancer (an increased risk of developing cancer)
can be inherited. This means that one or more
inherited gene defects relevant to the development of cancer are already in place in all of the
person’s cells, and they can be passed on to offspring through the germ line.
While in rare cases a single gene defect may lead
to a greatly increased risk of cancer, it is much
more common that there are multiple gene defects, each contributing a minor increase in risk.
Depending on the inherited combination of
such genes, inherited susceptibility may be larger or smaller. In addition to such defects, environmental risk factors are also required to cause
the additional changes in the cells necessary for
the development of a malignant tumour.
For cancers where there are only a single or few
gene defects it is typical that cancer of the same
organ presents in several affected family members. Young age at onset, and the occurrence
of multiple primary tumours, are also features
suggestive of hereditary predisposition. Dominantly inherited susceptibility is passed on to
an average of every second offspring. If a member of a family with hereditary susceptibility
has not inherited the faulty gene(s), his or her
children do not have an increased risk of cancer.
These types of cancer are rare and account for
only a small fraction of all cancers.
However, most common cancers have some
hereditary component, including breast and
intestinal cancers, thyroid cancer, uterine and
ovarian cancers as well as prostate cancer, based
on analyses of large twin cohorts (Lichtenstein
et al 2000). In the past five years, genome-wide
studies have discovered tens of genetic loci associated with increased risk of common ­cancers
10
| Cancer in Finland
such as prostate (Amin et al 2012, Eeles et al
2013) and breast cancer (Pylkäs et al 2012,
­Solyom et al 2012, Bojesen et al 2013, French et
al 2013, Garcia-Closas et al 2013, Michailidou
et al 2013).
Cell level changes in cancers related to hereditary predisposition have begun to be better understood through molecular genetic research.
Finland offers excellent possibilities for research
on hereditary susceptibility, and because of this
many internationally recognised research projects have been carried out here (Peltomäki et
al 1993, Aaltonen et al 1998, Hemminki et al
1998, Aarnio et al 1999, Matikainen et al 2000,
Olsen et al 2001, Eerola et al 2001, Tomlinson et
al 2002, Vierimaa et al 2006, Erkko et al 2006,
Georgitsi et al 2007, Alhopuro et al 2008, Tuupanen et al 2009, Sur et al 2012).
Genetic tests have been developed for diagnosing hereditary susceptibility. Some of these are
still only in research use while others have been
implemented for clinical use. There remain a
number of unsolved problems with regard to
the relevance of genetic testing, interpretation
of the results and counselling of at-risk individuals. The identification of multiple genes, each
having a small effect on risk, poses particular
challenges for clinical use.
The Cancer Society’s advisory services (also
website www.neuvontahoitaja.fi, in Finnish)
offer advice to persons concerned about hereditary susceptibility to cancer. For many of
the hereditary cancer syndromes management
strategies for prevention and early detection are
available, and cancer incidence and mortality
can be reduced in at-risk individuals.
Environmental exposures
Impurities in the air and
emissions from nearby industry and traffic increase, to some extent, the risk of lung cancer.
Differences in the incidence of cancer in different parts of Helsinki, however, are not connected to sulphur or nitrogen oxide emissions,
nor to traffic volumes (Pönkä et al 1993). Lung
cancer in men appears most frequently in those
parts of Finland where the air is clean. Thus,
air pollutants are insignificant risk factors compared to tobacco.
Residential pollution.
In the production of drinking water, the chlorination of surface water produces compounds
that can cause mutations which may slightly
increase the risk of bladder cancer, for example
(Koivusalo et al 1997). Arsenic in drilled wells
appears to have the same kind of effect (Kurttio
et al 1999). In a village in Southern Finland,
chlorophenol in the ground water was estimated to have caused approximately one additional
cancer case every two years (Lampi et al 1992)
during 1972–1986; there was no excess risk
following closure of the old water intake plant
(Lampi et al 2008). Another study is investigating, among other things, whether dioxins from
a river in south-eastern Finland increase the risk
of cancer for people who eat fish containing dioxins from that river (Verkasalo et al 2004).
Another target of investigation in environmental health have been residents of buildings constructed over the garbage dump in a residential
area of Helsinki. According to the first results,
slightly more cancer and asthma were diagnosed
in the residents than in residents of comparable
buildings (Pukkala and Pönkä 2001), but based
Risk factors for cancer and their effect |
on the latest research, the people who lived in
those – now demolished – buildings have not
had any more cancers than others in Helsinki
after 1999.
In recent years, there have been more measure­
ments of the environmental situation, and with
their help, we can better evaluate the association between environmental pollutants and
cancer risk.
The influence of workrelated hazards, such as chemicals, on the risk
of cancer has been identified in hundreds of
different studies. The web page of the Finnish Institute for Occupational Health (www.
occuphealth.fi) has good information about
cancer risks resulting from occupational environment hazards and about their measurement.
Occupational hazards.
In the Cancer Registry, research has been done
over many decades on the risk of cancer, among
others, for healthcare personnel, workers in
the chemical wood processing industry and
sawmill industry, employees in the printing
industry, shipyard workers and machinists, oil
refinery employees, glass and glass fibre workers, shipping personnel, airline personnel, train
engineers, farmers, bush insecticide sprayers,
hairdressers as well as employees exposed to
asbestos, styrene, trichloroethylene, formaldehyde, PCB, lead, nickel and other metals. Many
of these worker cohorts are still being followed.
Asbestos is considered to be an important factor in increasing the risk of cancer in the working environment, and that is why, for example,
clear regulations have been given for the repair
and demolition of older houses. The regula-
11
tions are intended to ensure that the exposure
of workers to asbestos remains as small as possible. Despite this, for those who have done
asbestos spraying work, the risk of developing
mesothelioma and lung cancer is still greater
than for the rest of the population (Oksa et
al 1997). Tobacco has, however, proven to be
many times more important as a cause of cancer than asbestos. The risk of lung cancer for a
non-smoking asbestos worker is only 1.4 times
that of a non-smoker not exposed to asbestos.
However, a smoker not exposed to asbestos has
a 14-times greater risk, and a smoker exposed
to asbestos has a 17-times greater risk, of lung
cancer. Almost all mesotheliomas are caused by
asbestos (Meurman et al 1994).
Exposures considered to be relatively safe in
the working environment may change into
significant risk factors, if they occur together,
for example, with tobacco use. The Finnish Job
Exposure Matrix (FINJEM), developed by the
Finnish Institute of Occupational Health, helps
to estimate exposures to different chemicals and
other factors for workers in different occupations. With its help, we can estimate quantitative amounts of exposure to carcinogenic factors
for every person in the population (Pukkala et
al 2005). Currently, comparable estimates can
be made for the populations of all Nordic countries (Kauppinen et al 2009).
Large variations in cancer risk in different occupational categories have been demonstrated
in the large Nordic Occupational Cancer Study,
NOCCA (astra.cancer.fi/nocca) which studied
the risks for cancers associated with different
occupations.
12
| Cancer in Finland
Figure
2
Occupations with the lowest and highest incidence of cancers in men in the Nordic countries
1961–2005 (Pukkala et al 2009).
Mesothelioma
Farmers
Plumbers
Pharynx cancer
Farmers
Waiters
Oral cancer
Farmers
Waiters
Liver cancer
Farmers
Waiters
Tongue cancer
Farmers
Waiters
Lip cancer
Doctors
Fishermen
Laryngeal cancer
Farmers
Waiters
Oesophageal cancer
Doctors
Waiters
Lung cancer
Nurses
Waiters
Nasal cancer
Military workers
Wood workers
Skin melanoma
Fishermen
Dentists
Gastric cancer
Dentists
Fishermen
Skin, squamous cell carcinoma
Forestry workers
Nurses
Bladder cancer
Farmers
Waiters
Gallbladder cancer
Farmers
Laundry service
Testicular cancer
Forestry workers
Doctors
Pancreatic cancer
Farmers
Beverage workers
Non-Hodgkin lymphoma
Chimneysweeps
Tobacco industry
Kidney cancer
Nurses
Tobacco industry
Colon cancer
Forestry workers
Chimneysweeps
Prostate cancer
Domestic assistants
Dentists
Rectal cancer
Nurses
Waiters
Central nervous system cancer
Chimneysweeps
0.3
0.5
0.7
1.0
Standardized incidence ratio
Physicians
2.0
3.0
5.0
Risk factors for cancer and their effect |
Table
13
1
Occupations with the highest and lowest cancer incidence in Finland 1971–2005: Standardized incidence ratios (SIR) that are statistically significantly increased in relation to the mean in the population
(SIR = 1.00) are highlighted in red and those which are decreased in green (Pukkala et al 2009).
N = number of cancers.
MEN
WOMEN
Occupational categoryN
Tobacco industry work SIR
Occupational categoryN
SIR
26
1.30
Military work 20
1.36
Mine work 1 398
1.28
Security work 175
1.27
Seafarers 1 742
1.19
Dentists 440
1.22
251
1.15
Physicians 438
1.19
10 939
1.14
Traffic work 677
1.17
Waiters Construction work 38
1.12
Directors 1 507
1.14
Plumbers 2 488
1.11
Journalists 434
1.12
Packers 5 670
1.11
Building hands 897
1.12
252
1.10
Technical, scientific, etc. work 1 651
1.11
Teachers Assistant nurses Cooks and head waiters 8 093
1.11
Chemists and laboratory assistants 894
1.10
Nurses 4 543
1.10
26 565
1.10
95
1.10
Farmers 6 526
0.90
Drivers 262
0.89
Office work Tobacco industry work Fishermen and hunters Wood work Welders 38 820
0.90
Gardeners Gardeners 5 174
0.87
Mine work Teachers 4 914
0.84
Beverage industry Dentists Farmers 42
0.88
1 803
0.88
78
0.87
18 024
0.86
31
0.81
120
0.79
132
0.78
Seafarers 9
0.71
Barbers, hairdressers 54
0.78
Bricklayers 17
0.60
Domestic assistants 4
0.24
Forestry work 50
0.53
14
| Cancer in Finland
The NOCCA study confirms known connections between occupational factors and cancer,
but points in addition to the influence of lifestyle related choices such as use of tobacco and
alcohol. The increase in office work reduces
work-related physical activity, which would
protect against cancer. Shift work is now also
seen to be a probable cancer risk factor (Straif
et al 2009). Ultraviolet rays from sunlight are a
significant risk for certain occupations: for example lip cancer is found particularly often in
fishermen and farmers, while the risk of skin
melanoma is greatest for indoor workers whose
skin is not accustomed to the sun and burns
easily on holiday.
The greatest cancer risk for Finnish men is in the
tobacco industry and in mining work (Table 1).
The occurrence of cancer for those working in
these areas is about thirty percent more than
the average for Finnish men.
The biggest cancer risk for Finnish women is
in military and security work, which also includes women working as police officers or as
security guards. Next on the list are dentists and
doctors. There is a significantly less-than-average cancer risk, for example, for women forest
workers and bricklayers.
Ionizing radiation is ubiquitous, because radiation is produced, for example, by
natural radioactive materials in the Earth’s crust.
Ionizing radiation has been estimated to cause
1–3 percent of all cancers. X-rays were found to
cause cancer in the early 1900s. Strong scientific proof that small doses increase the impact
of radiation risk was obtained from research on
survivors of the Hiroshima and Nagasaki nucle-
Radiation.
ar bombs in the 1950s. Radiation particularly
increases the risk of leukaemia, thyroid cancer,
breast cancer, lung cancer and bladder cancer.
The most important source of radiation among
the Finnish population is radon in indoor air,
with a dose averaging 2 mSv received annually, which is about half of the total radiation
received by Finns. Alpha radiation produced by
radon does not penetrate material deeply, and
therefore inhaled radon results in radiation exposure only to the lung. The only clearly established health impact of radon is increased lung
cancer risk. In an extensive European study, also
involving Finnish researchers, the proportionate
increase in lung cancer risk was 8 percent (Darby et al 2005) at a concentration close to the average in Finnish houses (100 Bq/m3). Radon in
indoor air is estimated to cause about ten percent of lung cancer among Finns or about two
hundred lung cancer cases every year, which is
far less than that attributable to smoking but
comparable to the burden from e.g. environmental tobacco smoke.
In diagnostic radiology the benefits of investigations using x-rays need to be considered
relative to the small risk caused by radiation
exposure. Occupational groups exposed to radiation include, for example, radiologists, x-ray
technicians or nurses and nuclear power plant
workers. The radiation doses received by these
groups nowadays are generally rather small. No
increased cancer risk has been shown among
Finnish nuclear power station workers or physicians occupationally exposed to radiation
(Auvinen et al 2002, Jartti et al 2006). The production of nuclear energy in normal circumstances causes radiation exposure, in practice,
Risk factors for cancer and their effect |
only to workers, and no excess of cancer has
been found around nuclear power stations in
Finland (Heinävaara et al 2010). The nuclear
power station disaster in Chernobyl in 1986 resulted in some additional radiation to nearly all
Finns. The dose, even at its largest, was only the
same as that received annually from other natural sources (about 1 mSv). Leukaemia among
children or thyroid cancers did not increase after the accident (Auvinen 1994, But 2006), nor
did the fallout from atmospheric nuclear tests
in the 1960s result in a detectable excess of cancer in the most heavily exposed population of
Northern Finland (Figure 3, Kurttio et al 2010).
Cancer patients receiving radiation therapy are
exposed to very high radiation doses, and in addition to the tumour, the surrounding tissues
are also affected. Patients treated with radiation
therapy involving substantial doses to the bone
marrow have an increased risk of leukaemia and
other cancers (Travis et al 2000, Worrillow et al
2003, Hill et al 2005, Salminen et al 2006 and
2007), but the benefits of treatment clearly outweigh the risks.
Figure
15
3
Doses of radiation among reindeer herders and
other people in northern Finland in 1950–2005.
Those who had eaten the most reindeer meat
did not have more cancer than others (Kurttio et
al 2010).
µGy
2.0
Reindeer herder
1.5
1.0
0.5
Other
0
Cosmic radiation is sparse at sea level, but increases with altitude. Exposure to cosmic radiation is considerable in air travel, but the increased breast and skin cancer risk among pilots
and flight attendants is not related to the radiation dose (Pukkala et al 1995, 2002 and 2012).
Non-ionizing radiation does not have sufficient
energy to remove electrons from an atom. It includes ultraviolet radiation as well magnetic and
electric fields. Ultraviolet radiation is received
from the sun and solarium and causes skin cancer. The most important cause of melanoma is
1950
1960
1970
1980
1990
2000
2010
Year
16
| Cancer in Finland
intensive UV-radiation to skin unaccustomed
to this, causing burning of the skin, particularly
in children and adolescents. In particular, light
skinned, blue-eyed people and those who burn
easily and tan poorly are at risk. Some melanomas occur in moles, and having a large number
of moles (over 100 pigmented naevi) increases
melanoma risk.
Power lines and electrical appliances generate
low frequency magnetic fields (50–60 Hz).
The impact on cancer risk, and particularly on
childhood leukaemia, has been studied extensively, and increased risk estimates for childhood leukaemia, related to very high exposure
levels, have been shown in several studies. For
other cancers, no clear indication of excess risk
has been demonstrated. According to Finnish
research series covering the entire population,
children and adults do not have an increased
cancer risk related to proximity to power lines
(Verkasalo et al 1993 and 1996). Occupational
exposure to electromagnetic fields occurs in
many workplaces, but there is no indication of
cancer risk as a result of such exposures.
Radar, radio transmitters, mobile phones and
base stations, among others, generate radiofrequency electromagnetic fields (in the megahertz
range). Radiofrequency fields do not cause genetic changes, and have not increased cancers
in animal tests. In epidemiologic research, the
use of mobile phones has been linked to an
increased cancer risk (Interphone Study Group
2010), but problems with this research include
a fairly short ten-year follow-up period and the
unreliability of information on mobile phone
use based on questionnaires. More reliable evidence is expected from follow-up studies ongo-
ing in Finland, Sweden, Denmark, Great Britain and the Netherlands.
Lifestyle
The use of tobacco products is the
most important single factor that increases cancer risk. The risk from tobacco is based on a
large amount of carcinogenic (cancer-causing)
compounds, which are already in tobacco products or are formed during the burning process.
Tobacco.
It has been estimated that tobacco products
cause one third of all cancers. The impact of
smoking on lung cancer is the best known. The
probability of getting lung cancer is greater the
younger a person starts smoking, the more the
person smokes daily and the longer the smoking continues (Hakulinen and Pukkala 1981). If
a person has smoked 20 cigarettes daily for 50
years, his or her risk of getting lung cancer is 50
times higher than that of non-smokers. After
stopping smoking, the danger of lung cancer
quite rapidly approaches the lung cancer risk of
a non-smoker of the same age, but never drops
to the same level. Those who have smoked for a
long time will still benefit the most from stopping smoking.
Smoking is a significant cause of laryngeal cancer, and is also linked to cancers of the mouth,
throat, kidney, pancreas, oesophagus, uterus
and bladder. Smoking may also increase the risk
of breast cancer (Xue et al 2011).
In 2009, 22 percent of Finnish men and 16 percent of Finnish women smoked daily (Helakorpi 2010). In addition, about 8 percent of adults
smoked occasionally. Smoking among men
Risk factors for cancer and their effect |
has been decreasing for decades, but smoking
among women has begun to reduce slightly
only in the last few years. There are major differences between social groups in the frequency
of smoking, and these differences continue to
grow. Fifteen percent of men with a higher level
of education, but 37 percent of men with the
lowest level of education, are smokers. At least
two out of three smokers have attempted to
stop smoking.
Figure
17
4
Age-adjusted (world) incidence of lung cancer
in Finland and Norway 1953–2009.
Incidence/100 000
90
80
70
Snus is being used daily by 1.7 percent of Finnish men and 0.1 percent of women (Helakorpi
et al 2011). Recent research has indicated a
clear cancer risk resulting from using snus. The
danger of cancers of the mouth, throat, pancreas, stomach as well as oesophagus is much
greater in those using snus than those not using
tobacco products (Luo et al 2007, Roosaar et al
2008, Zendehdel et al 2008).
The prevalence of lung cancer in Finland’s
male population has been among the highest
in the world, and 20 years ago it was five times
higher than that in Norwegians. This big diffe­
rence was explained by different smoking habits
some decades ago (Hakulinen et al 1987). Lung
cancer develops only decades after the smoking
started, and therefore lung cancer incidence reflects the smoking habits of 20–50 years ago.
Nowadays Norwegians have more lung cancer
than Finns (Figure 4).
Exposure to cigarette smoke in the environment
increases the risk of lung cancer. It has been estimated that involuntary smoking causes 10–50
new lung cancers every year in Finland. Involuntary smoking in previous decades may be one
of the explanations for the fact that restaurant
60
50
40
30
20
10
0
1950
1960
1970
men
• Norway:
• Finland: men
1980
1990
2000
women
• Norway:
• Finland: women
2010
Year
18
| Cancer in Finland
workers have the highest cancer risk of all occupations in the Nordic countries (Pukkala et
al 2009).
Cancer risk often increases significantly through
the combined impact of smoking and some
other factor. Smoking and outdoor work together increase increase for instance the risk of
lip cancer by 15-fold, although outdoor work
alone or smoking increases lip cancer risk only
by two-fold (Lindqvist 1979). Correspondingly,
smoking increases the impact of asbestos and
many such materials used in the working environment, which alone are not particularly
dangerous.
Alcohol. There is a clear causal relation between
the use of alcohol and several cancers. There is
convincing evidence that the use of alcohol increases cancers of the mouth, throat, larynx,
oesophagus and liver (Baan et al 2007, www.
dietandcancerreport.org).
Four daily servings of alcohol (50 g ethanol), for
example, increase the risk of mouth and pharynx cancers by two-fold. Other factors may increase the impact of alcohol. Drinking alcohol
and smoking together very strongly increase the
risk of cancers of the mouth, throat and larynx.
With regard to breast cancer, there is no safe
amount of alcohol intake, but rather the
risk of cancer increases directly in relation to
the amount of alcohol consumed. Moderate
amounts of alcohol taken infrequently are not
significant. On the other hand, excessive use of
alcohol increases the cancer risk and causes other clear health problems regardless of whether
drinking alcohol is infrequent or regular. The
cancer risk does not differ significantly with
the type of alcohol drink consumed. The most
important risk factor is the amount of ethanol
consumed.
Alcohol, or ethanol, may cause cancer through
several possible mechanisms. The most significant is probably that, in the body, alcohol
breaks down into acetaldehydes, which are
capable of causing DNA damage (Salopuro
2009). In addition, the breakdown of alcohol
blocks the body’s removal of toxins and makes
it possible for the other cancer risk factors to accumulate in tissues. Alcohol is also an efficient
solvent, which may harm mucous membranes
from the mouth to the stomach and, therefore,
make it possible for other substances to have an
influence.
The effects of diet on cancer
have been researched intensively for decades.
Thirty years ago it was estimated that diet was
the most important modifiable cause of cancer.
Diet is a complex mix of components in which
combined and contradictory effects are difficult
to understand.
Dietary factors.
Diet has been considered to have the strongest
influence on the risk of cancer of the stomach,
colon, rectum, as well as the oesophagus, kidney,
bladder, prostate, lung, breast and corpus uteri.
These are common cancers in Finland and other
countries with western diets. Dietary factors can
cause cell transformations in many ways:
• Some dietary factors can in themselves cause
cancer (for example alcohol).
• Cancer causing substances can be found in
Risk factors for cancer and their effect |
food which is spoiled or not clean (for example aflatoxin of certain moulds).
• In some methods of preparing food, cancer-
causing substances are formed (for example
polycyclic aromatic hydrocarbons when grilling).
19
Many of these vitamins are important antioxidants in the body. They prevent oxidation of
fatty acids and protect the body from harmful
substances arising from oxidation. Low levels of
vitamin D seem to be linked to an increased
risk of some cancers, but high levels of vitamin
D are also linked to a higher than usual cancer
risk (Tuohimaa et al 2007).
•Certain dietary factors can become cancer-
causing in the body (nitrites).
• The lack of dietary factors which are protec-
tive against cancer (for example a lack of vitamins and minerals) increase the risk of getting disease.
A diet that has an excessive energy content, or
the resulting excess in body weight, increases
the risk of many cancers. Based on many animal experiments, it has been found that fat
in the diet increases the risk of cancers of the
breast, colon and pancreas. Information concerning humans is not yet so convincing that
dependable conclusions could be drawn on
the impact of fat in the diet on the cancer risk.
Cancer tissue also needs energy and minerals,
and therefore, dietary factors can – as well as
causing cancer – also influence the growth of
cancer.
Dietary fibre probably protects against colon
cancer (Bingham 2003). Hence root vegetables
and rye bread, which belong to the traditional
Finnish diet, are also healthy in this regard.
Vitamins are one of the most important areas
of research concerning links between food and
cancer. The greatest interest has been in carotenoids, A, E, C and D vitamins and folates.
Several studies have indicated that a diet rich in
vegetables and fruit decreases the risk of many
cancers. Vitamin products have been also researched in cancer prevention experiments, but
none have so far been proven to prevent cancer
alone or in combination (ATBC 1994). It is
probable that from the point of cancer prevention, a balanced totality, not single nutrient factors, is the most crucial aspect of diet.
Among the minerals, selenium has been the
most researched. It is estimated that a lack of
selenium increases cancer risk. The selenium
content of Finnish food is nowadays sufficient;
therefore additional selenium products are not
needed.
Some food preparation methods cause chemical changes that lead to cancer-causing factors.
Smoking and grilling fatty food on an open
fire or otherwise at a high temperature creates
small amounts of polycyclic aromatic hydrocarbons (PAH) on the surface of the food, which
increase the cancer risk. Acrylamide in potato
chips, French-fries and hard bread is classified
as a possible cancer risk compound, but eating
food containing acrylamide has not been found
to have a connection to cancers (Mucci et al
2003). Excessive use of food preserved by salt
increases the risk of gastric cancer.
20
| Cancer in Finland
A link between exercise and cancer risk has been observed in several studies. Scientific proof has been collected
of the protective effects of exercise, particularly
concerning cancers of the breast, colon, uterus
and prostate (www.dietandcancerreport.org).
Exercise and weight control.
Moderate exercise changes the metabolism of
certain hormones and strengthens the functioning of the body’s general protective mechanisms. Exercise reduces the amount of fat
tissue, and the amounts of different growth
factors become more balanced. The diet of an
actively exercising person often includes more
components that protect from cancer.
According to the latest research, the benefits of
exercise are generally achieved by about an hour
of daily exercise, such as walking or cycling to
work or to the shops, going up the stairs or raking the yard. For weight control, it is sufficient
to have half an hour of exercise three times a
week. Those doing office work in particular
should exercise regularly in order to avoid being
overweight. Brisk exercise several times a week
can give an extra benefit in preventing cancer
(Latikka et al 1998).
Exercise is also beneficial when rehabilitating
from cancer or in preventing a relapse (Knols
et al 2005). Finnish BREX study concerning
this issue started in 2005 (Penttinen et al 2009).
While nothing can yet be said of the cancer
prevention potential of exercise, this 12-month
aerobic jumping and circuit training intervention completely prevented femoral neck bone
loss in premenopausal breast cancer patients
(Saarto et al 2012).
Reproduction and hormones. Cancer of women’s reproductive organs and breast cancer are
clearly linked to sexual and reproductive behaviour. If a woman herself – or her sexual partner
– has had several partners, she is more likely
than other women to get cervical cancer. The
explanation for this is that sexually transmitted
viruses are important factors in cervical cancer
(see Infections).
Giving birth at a young age and having many
children protect from breast cancer. The protective impact is increased if a woman has many
children (Hinkula et al 2001). Not having children is also a risk factor for cancers of the ovary
and corpus uteri, and early sexual maturity and
late menopause increase the number of a woman’s menstrual cycles and increase the risks of
the above-mentioned cancers.
Modern contraceptive pills protect against cancers of the ovary and corpus uteri. During menopause, women who have undergone lengthy
hormone therapy are, on the other hand, diagnosed with more cancers of the breast, endometrium and ovary than women who do not use
hormone therapy (Jaakkola et al 2009, Lyytinen
et al 2010, Koskela-Niska et al 2013). Linking
the progesterone hormone to estrogen replacement therapy increases the risk of breast cancer,
but protects against cancer of the uterus. The
benefits of hormonal therapy during menopause must be considered individually in relation to the cancer risk.
Some viral infections increase cancer risk. Infections caused by some bacteria
may also increase risks of certain cancers. For
example, Helicobacter pylori increases the risk
Infections.
Risk factors for cancer and their effect |
of gastric cancer (Rehnberg-Laiho et al 2001).
Some tropical parasitic diseases also increase the
cancer risk, but they are very unusual in Finland.
Human papilloma viruses (HPV) are the most
researched virus family of those which cause cancer. Some cause chronic infection and, through
this, cervical cancer (Lehtinen et al 1996). Papilloma viruses may also cause other cancers, such
as pharyngeal cancer (Mork et al 2001).
Vaccines aimed at preventing infections caused
by papilloma viruses have been on the market
for some years. Vaccine efficacies against lowgrade cervical intraepithelial neoplasia (CIN)
have been defined for both licensed vaccines
(Lehtinen et al 2013). Ongoing studies with
long-term follow-up will by 2015 and 2022
find out if HPV-vaccines also prevent higher
grades of CIN3 and invasive cervical cancer,
respectively (Lehtinen et al 2006, Rana et al
2012).
An increased risk of liver cancer is also linked to
chronic liver infection (hepatitis B and C viral
infections). The Hepatitis B virus (HBV) vaccination campaign that began in Taiwan in 1984
led first to a reduction in HBV incidence and
then to a significant reduction in liver cancer
incidence in the age groups vaccinated (Chang
2011).
HIV infection and AIDS are linked to an increased risk of lymphoma and Kaposi sarcoma,
which would otherwise be a very rare disease
(Kaasinen et al 2013). These cancers are not
caused directly by cancer-causing features of the
HIV virus, but by the collapse of general im-
21
mune defence linked to the illness. In this situation, the HHV8 virus can cause Kaposi sarcoma.
Socio-economic position
The overall cancer incidence for working aged
men in the lowest social class is about one third
higher than in the highest class. On the other
hand, the cancer incidence for women is highest in the highest social class. Typical cancers in
the lower class are those of the lip, stomach and
nose as well as throat and laryngeal cancer (Figure 5). In the lower classes, there are also more
cervical cancers and vaginal cancers in women
and lung cancers in men. Cancers linked to a
high standard of living are cancers of colon,
breast and testis as well as melanoma of skin
on the trunk and limbs. Differences in cancer
incidence between social classes may be as great
as five-fold.
Differences between social classes have increased
rather than decreased (Pukkala and Weiderpass
1999 and 2002). The socio-economic pattern
can also change: for example, lung cancer in
women changed very rapidly from an illness related to a high standard of living to one related
to a low standard of living at the turn of 1980s.
Socio-economic position impacts on cancer risk
through lifestyle and work-related factors. In
most cancers in the lower social classes, smoking is an important cancer risk factor. Smoking
among men and young women in Finland is
most common in the lower social classes. For
more than three decades, smoking differences
have been accepted as explaining almost all of
the differences in the frequency of lung cancer and many other cancers between the social
22
| Cancer in Finland
Figure
5
Connection of socio-economic position to cancer incidence in Finland 1971–2005. The graph is based
on information from NOCCA study (Pukkala et al 2009) and it shows standardized incidence ratios
(SIR) in relation to the population mean (1.0).
MEN
SIR
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
Lip cancer
Oesophageal
cancer
Gastric
cancer
Colon cancer
Nose cancer
Laryngeal
cancer
Lung cancer
Skin melanoma
WOMEN
SIR
level clerical employees
• Higher
level clerical employees
• Lower
Skilled workers
•Unskilled
workers
•
•Farmers
• Economically inactive
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
Laryngeal
cancer
Lung cancer
Breast cancer
Cervical
cancer
Skin melanoma
Risk factors for cancer and their effect |
classes (Pukkala et al 1983). Dietary differences
have been suggested to be related to social class
differences in cancer risk (Pukkala and Teppo
1986).
Cancer and other illnesses
Generally, cancer risk is independent of that
for other illnesses. For example, cancer risk
does not increase in those with injuries from
accidents or in those receiving treatment for
heart ailments. Although lung cancer risk is
increased for people suffering from asthma
(Vesterinen et al 1993), the risk is not caused
by asthma but by smoking, which causes both
illnesses.
Depression, anxiety, grief and work-related
stress have little impact on cancer risk. Finnish
schizophrenics have less cancer than the population average (Lichtermann et al 2001). Hip or
knee prostheses (Visuri et al 2010, Mäkelä et al
2012) and silicone breast implants (Pukkala et
al 2002 a) do not lead to an increased cancer
risk.
Normal everyday ailments of the working age
population, such as headache, tiredness, diarrhoea, weak spells or anaemia connected to the
menstrual cycle, are not normally associated
with cancer, although they can sometimes be
symptoms of cancer. Epilepsy does not increase
the risk of cancer, but epilepsy can be a symptom of a hidden brain tumour (Lamminpää et
al 2002).
Medicines are tested in clinical research before
they are used. Research and development work
is stopped if there are even small indications
23
that the medicine being developed could cause
cancer. The side effects of medicines that are already on the market are monitored closely, and
manufacturers remove products readily from
the market. However, it is unlikely that medicines already in use nowadays or those which
are newly introduced new medicines have significant cancer risks. For example the risks of
cancer associated with the use of antibiotics and
statins have been researched in Finland (Kilkkinen et al 2008, Haukka et al 2010). At the moment, diabetes medicines are being researched
for any possible impact on cancer risk. Preliminary results suggest that, although diabetics
have an increased risk of getting cancer, there
is no connection between diabetic medication
and cancer.
Relatively toxic medicines and other treatments
which are used for treating complex illnesses are
a different matter. For example, radiation therapy for cancer, and some medical treatments,
may increase the risk of getting cancer later
(Kumpulainen et al 1998, Salminen et al 1999,
Metayer et al 2000, Travis et al 1999, 2002,
2003, Dores et al 2002, Pukkala et al 2002 c,
Gilbert et al 2003, Worrillow et al 2008, Jakobsson et al 2011, Morton et al 2011). However, the
benefits of these types of cancer treatment have
been estimated to be greater than their adverse
effects.
The body’s immune system must be suppressed
for organ transplants, so that the transplanted
organ will not be rejected. Because the immune
system protects against cancer, the cancer risk
for people who have received kidney or liver
transplants, for example, is above average (Birkeland et al 1995, Åberg et al 2008). The virus
24
| Cancer in Finland
causing HIV infection and AIDS suppresses
the immune system and increases the risk of
cancer. The body’s disturbed immune system
in rheumatic illnesses (Kauppi et al 1997, Hill
et al 2001), in certain intestinal tract and skin
ailments (Collin et al 1996) as well as in cartilage-hair hypoplasia (Mäkitie et al 1999) also
increase the cancer risk.
Many genetic syndromes also include cancers
as one aspect, sometimes giving rise to several
tumours in different organs. For some inherited
illnesses, the cancer risk is increased, although
cancer itself does not belong to the group of
symptoms. For example Down syndrome is
linked to an increased risk of leukaemia (Patja
et al 2006).
Getting one cancer does not protect against
other cancers. Cancer patients can develop new
cancers just like healthy people. According to
the data of the Finnish Cancer Registry, among
those who have recovered from the first cancer
about one in ten gets a new cancer (Sankila et al
1995). The factors causing the first cancer can
also increase the risk of the second cancer: for
example patients with laryngeal cancer have an
increased risk of getting lung cancer (Teppo et
al 1985).
Attributable fractions
of risk factors
There have been attempts to put the population
attributable fractions of different cancer-related
factors in order of importance. The most wellknown estimate of the contribution of environmental and other causes to the risk of cancer is
the study of Doll and Peto in 1981, according
to which tobacco and diet were both responsible for one third of cancer deaths in the United
States (Doll and Peto 1981). According to Nordic estimates (Olsen et al 1997) tobacco causes
only about 15 percent of new Finnish cancer
cases. The difference is explained, among other
things, by the fact that lung cancer is a disease
with a poor prognosis and its proportionate
share of cancer deaths is therefore bigger than
its share of cancer incidence. The significance
of various factors also differs according to regional and local circumstances, health behaviour and socio-economic situation.
Possibilities for cancer
prevention
It is in principle possible to attempt to prevent
cancer at different phases of the chain of events
leading to the disease. We may affect the factors
that begin the process, or its progression, by
helping the body to correct early changes or by
treating early stages of disease before the actual
cancer has developed.
The possibility of preventing cancer depend on
whether it is possible to change cancer risk factors related to environment and lifestyle. It was
estimated in 1980 that the annual number of
lung cancer cases in men would decrease from
2000 cases, at that time, to a few hundred if all
Finns stopped smoking immediately (Hakuli­
nen and Pukkala 1981). Smoking did not stop
completely, but has decreased so much that the
age-adjusted incidence of lung cancer has fallen
to less than half of the highest level in 1970s.
According to estimates, the incidence of lung
cancer will continue to decrease up to the year
2020 (see page 65).
Risk factors for cancer and their effect |
Finland was the first country to add tobacco
smoke to the list of carcinogenic substances
and, in its legislation, states that tobacco smoke
causes cancer. The aim of the tobacco law of
2010 is to stop smoking in Finland by the year
2040. If this happened, it would have a great
impact on the incidence of lung and other cancers.
The potential of reducing other risk factors
does not look as promising. For example, the
cancer-causing and cancer-protective characteristics of food products are not well enough
known for cancer risk to be reduced through
specific changes in eating habits. The knowledge of many other risk factors is equally insufficient and inaccurate.
Recently, many have begun to consider increasing exercise as a significant method of cancer
prevention. For example, the European recommendations on cancer prevention (Boyle et
al 2003) list avoiding obesity and taking daily
exercise as the second most important practical steps in cancer prevention. Only refraining
from smoking is more important. The World
Cancer Research Fund and the American Cancer Society published in 2007 the recommendations of an extensive group of experts on
reducing the risk of cancer through diet and
exercise. The recommendations and justifications can be found on the Internet (www.dietandcancerreport.org). The messages of most
dietary recommendations are similar: they underline the importance of staying as slim as possible, as long as weight remains within normal
limits. Exercise should be taken every day. Diet
should be mainly of vegetable origin. Intake of
high-energy foods, red meat, meat products,
25
alcohol, salt and mouldy products should be
limited. Artificial dietary supplements should
not be used.
The development of cancer normally requires
a long time. Any current changes in exposure
will mainly impact on cancer risk after the
2020s. Although significant changes in cancer
incidence cannot be expected in the coming
decades, deaths from cancer can be reduced
through the development of methods for early
cancer detection and improvement in treatments, amongst others. An excellent example
of cancer prevention is the systematic screening
of cell changes in the cervix by the Pap test and
the treatment of these cell changes, which has
dramatically reduced cervical cancer in Finland
(see page 50).
There are excellent conditions in Finland for
carrying out epidemiologic research on cancer
risk factors. A well-functioning personal identity code system makes it possible for information
collected from different sources to be combined
reliably (Pukkala 2011). In addition, Finnish
legislation allows the combination of information from different registries, for scientific studies that will benefit society and individuals. For
example, research on dietary factors, the risks
of living in certain areas, working environments, heritable factors and the inequality of
social groups have all been based on combining
information from registries. It is of the utmost
importance that the possibility of doing high
quality epidemiologic research is safeguarded
when cancer research becomes more and more
complex and requires detailed information.
Then the co-operation of several information
providers is needed even more than before.
26
| Cancer in Finland
Frequency of cancer in Finland
Currently in our country there are 250 000
people who have had cancer at some point in
their lives. Some of them are fully recovered;
some of them have a problem or side-effect
caused by the disease or its treatment. The
number of prevalent cancer patients is continuously increasing.
In 2011 more than 30 000 new cancer cases
were diagnosed in Finland. The most common
cancer in women was breast cancer and in men
prostate cancer. Nearly 4 900 women got breast
cancer and over 4 700 men got prostate cancer
(Figure 6). More than 3 000 intestinal tract cancers were found for men and women combined.
Only 656 cases of gastric cancer, which was the
most common cancer for both men and women in the 1950s, were detected. Statistics on the
amount of cancer cases and cancer deaths are
given by age group and health districts on the
website of the Finnish Cancer Registry (www.
cancerregistry.fi, section Statistics).
About 11 700 Finns die of cancer annually,
making cancer the main cause of every fifth
Finnish death. The number of cancer deaths
has remained quite stable for a long time. The
commonest cause of cancer death is lung cancer
(Figure 7).
Changes in cancer frequency
Cancer is a disease which becomes more common with increasing age (Figure 8). Although
Stomach 1 189
Other 661
Kidney 70
Leukaemia 83
Central nervous system 84
Rectum 91
Bladder 92
Colon 94
Pancreas 96
Larynx 99
Lip 132
Oesophagus 150
Prostate 204
MEN
1953
Lungs 903
Stomach 1 000
Other 833
Skin, non-melanoma 73
Pancreas 82
WOMEN
Leukaemia 84
1953
Lung 87
Central nervous system 97
Rectum 110
Breast 613
Ovary 150
Colon 150
Oesophagus 153
Cervix 318
Uterus 243
Frequency of cancer in Finland |
Figure
6
Number of cancer cases for men and women in 1953 and 2011. The surface area of the circle
describes the total number of cancer cases.
Other 1 147
Larynx 104
Pharynx 108
Soft tissues 109
Testis 134
Thyroid 137
Oesophagus 196
Multiple myeloma 197
Liver 292
Prostate 4 719
Leukaemia 312
Stomach 376
Central nervous system 400
MEN
Pancreas 473
2011
Kidney 563
Rectum 623
Lung 1 570
Non-Hodgkin lymphoma 651
Skin melanoma 655
Colon 876
Skin, non-melanoma 808
Bladder 731
Other 1 265
Soft tissues 129
Gallbladder 132
Liver 156
Cervix 168
Multiple myeloma 171
Bladder 215
Stomach 280
Breast 4 865
Leukaemia 285
Thyroid 314
Kidney 417
WOMEN
Ovary 433
2011
Rectum 436
Non-Hodgkin lymphoma 533
Pancreas 540
Colon 874
Central nervous system 600
Skin melanoma 664
Skin, non-melanoma 791
Uterus 859
Lung 824
27
28
| Cancer in Finland
Figure
7
Number of deaths caused by cancer in Finland in 2011.
Other 1 602
Lung 2 100
Gallbladder 220
Skin melanoma 223
Oesophagus 231
Multiple myeloma 258
Colon and rectum 1 152
Bladder 283
Leukaemia 328
Ovary 360
Liver 74
Pancreas 1008
Central nervous system 399
Kidney 420
Prostate 886
Non-Hodgkin lymphoma 476
Stomach 499
Breast 844
Frequency of cancer in Finland |
Figure
8
Cancer incidence and mortality
per 100 000 person-years by age group
in Finland in 2005–2011.
29
/100 000
5 000
incidence
• Men,
• Men, mortality
4 000
3 000
2 000
incidence
• Women,
• Women, mortality
1 000
Figure
9
Trends of annual numbers in new cancer cases
and cancer deaths in Finland in 1953–2011.
0
0
20
40
60
80
Number of cases
16 000
• Men, new cases
• Women, new cases
14 000
12 000
10 000
8 000
• Men, cancer deaths
• Women, cancer deaths
6 000
4 000
2 000
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Year
100 Age
30
| Cancer in Finland
the number of those getting cancer annually
has increased over three-fold in 50 years (Figure
9), this increase does not describe changes in
the risk of getting cancer. Population increase,
particularly in older age groups, also has an impact on the growth in case numbers.
Cancer risks at different time periods, in different
regions and populations, can be made comparable using age-standardization. Figure 10 shows
trends in the age-standardized cancer incidence
and mortality rate for all cancers over the years.
In the absence of population aging, the annual
number of cancers would have stayed approximately the same, if breast cancers detected by
screening and prostate cancers detected by PSA
tests were excluded from the figures. The agestandardized cancer mortality is now only onehalf the rate of the peak years.
Gastric cancer, which was the most common
cancer in men and women up to the 1950s, has
decreased during the whole period of cancer
registration (Figure 11). Since the 1950s, lung
cancer in men has increased dramatically, as
men had started smoking during the war in the
early 1940s. Thereafter, smoking among men
has decreased, which can be seen as a reduced
lung cancer risk. The risk of prostate cancer has
increased steadily since the early 1990s. Since
then, PSA testing, used in the early diagnosis of
prostate cancer, has become increasingly common. This has increased the detection rate of
prostate cancer so strongly up to the year 2005
(Figure 11)), that it has produced an overall increase in the incidence of all cancers (Figure 10).
Of the more rare cancers among Finnish men,
for example, the incidence of bladder cancer
increased at first and then reduced as smoking
declined. The same phenomenon is seen, but
slightly less marked, in the incidence of pancreatic cancer (Figure 12). Developing lymphoma
is linked, among other things, to the reduced
functioning of the immune system. This happens, for example, when many serious illnesses
are treated successfully. This phenomenon may
explain the increasing risk for lymphoma at the
population level. The incidence of lip cancer
has decreased heavily, reflecting the fact that
Finns have moved to indoor work and that their
exposure to sunlight and tobacco has reduced.
The risk of breast cancer in women has increased continuously, and breast cancer is now
the most common cancer among women (Figure 11). The occurrence of breast cancer increased by about one-tenth in 1987, when the
national mammographic screening programme
for breast cancer began (see page 52). More
than one thousand breast cancers are detected
annually through screening, most of which are
asymptomatic. Another significant reason for
the increase in breast cancers is hormone treatment of menopause (Jaakkola et al 2009, Lyyti­
nen et al 2010). The reduction of lengthy hormone therapy at the beginning of 2000s is seen
clearly in a decrease in breast cancer incidence
in Norway and Sweden, with a smaller decrease
in Finland (Hemminki et al 2008).
The increase in the risk of cancer of corpus
uteri ended in the 2000s (Figure 11). This phenomenon is partly explained by the fact that
the uterus has been removed from nearly onethird of all 70-year old women, and that there
is no longer a risk of cervical cancer (Luoto et
al 2004). No clear reasons have been found for
Frequency of cancer in Finland |
31
Figure 10
Age-standardized cancer incidence and mortality in Finland 1953–2011.
Incidence/100 000
350
• Men, age-standardized incidence
300
• Women, age-standardized incidence
250
200
150
• Men, age-standardized mortality
100
• Women, age-standardized mortality
50
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Year
32
| Cancer in Finland
Figure 11
Age-standardized incidence of the most common cancers in Finland 1953–2011.
MEN
Incidence/100 000
120
100
• Prostate cancer
80
60
40
cancer
• Lung
• Colorectal cancer
20
• Gastric cancer
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Year
Frequency of cancer in Finland |
WOMEN
Incidence/100 000
100
• Breast cancer
80
60
40
20
• Colorectal cancer
• Endometrial cancer
• Gastric cancer
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year
33
Figure 12
Age-standardized incidence rates for selected cancers in men in Finland 1957–2011
in five-year periods.
Incidence/100 000
16
cancer
• Bladder
• Non-Hodgkin lymphoma
• Skin melanoma
• Pancreatic cancer
12
8
4
• Lip cancer
0
1957– 1962– 1967– 1972– 1977– 1982– 1987– 1992– 1997– 2002– 2007– Year
1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011–
Figure 13
Age-standardized incidence rates for selected cancers in women in Finland 1957–2011
in five-year periods.
Incidence/100 000
16
12
8
4
• Cancer of central nervous system
cancer
• Lung
• Skin melanoma
•Ovary cancer
• Cervical cancer
•Oesophageal cancer
0
1957– 1962– 1967– 1972– 1977– 1982– 1987– 1992– 1997– 2002– 2007– Year
1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011–
Frequency of cancer in Finland |
35
the changes in the incidence of ovarian cancer
(Figure 13). In other Nordic countries ovarian
cancer risk has decreased even more than in
Finland, which might suggest a role of decreasing use of lengthy hormone therapies (KoskelaNiska et al 2013). The incidence of female lung
cancer has increased continuously as smoking
among women has become more common.
cancer frequency. The age-standardized rate of
laryngeal cancer for men is ten times that for
women. For lung and lip cancers, the difference
is currently about three times, but in the 1950s
the risk was 15 times greater. This phenomenon
is mainly explained by the fact that smoking
habits among men and women have developed
different manners in recent decades.
Tumours of the central nervous system, and
especially benign tumours of brain membranes
(meningiomas) in women have become more
common. This is linked to more advanced imaging techniques, through which symptomless
tumours inside the skull are found, for example, in connection with the examination of the
blood circulation in the brain.
Bladder cancer risk is four times greater, and
gastric cancer risk nearly two times greater for
men than for women, and many other cancers
are more common in men. On the other hand,
thyroid cancer is over three times more common in women than in men.
Cancer and age
Cancer and gender
Cancer is typically an illness of elderly people.
People aged under 40 get cancer only rarely,
but after that the probability of getting cancer
grows rapidly with increasing age (Figure 8).
For some cancers, the dependency of incidence
on age differs from the average (Figure 15).
For instance, at the start of the 1960s cervical
cancer was the most common cancer among
women aged 50-54 years, and the disease risk
was relatively high even for 40-year old women. Nowadays the cancer is most common in
70-year old women. For the middle-aged and
younger, disease risk has reduced considerably
because of mass screening.
Of the new female cancers detected in 2011,
44 percent were in the breast or the reproductive organs (Figure 14). Prostate cancer made
up 31 percent of all cancers in men. Apart
from gender-based cancers, there are other
clear differences between men and women in
Lung cancer is most common among people
in their eighties, but quite rare in even older
age groups (Figure 15). Smoking increases mortality rates for causes other than lung cancer,
which is why there are fewer long-term smokers
among people over 80 years. For men over 50
Skin melanoma is one of the increasingly common cancer types in both women and men.
This is linked to travel to the south, the popularity of sun tanning and repeated sunburning. Skin melanomas are found mostly among
clerical workers in towns and much less in those
who work outside and whose skin, being used
to sun, does not burn (Pukkala et al 1995). On
the other hand the most important cause of
the other main types of skin cancer, basal cell
carcinoma and squamous cell carcinoma, is the
cumulative lifespan dose of UV-radiation.
36
| Cancer in Finland
Figure 14
Age-standardized incidence of cancer by gender in 2011.
MEN
WOMEN
Prostate cancer
Breast cancer
Lung cancer
Colon cancer
Skin melanoma
Non-Hodgkin lymphoma
Cancer of central nervous system
Skin cancer, non-melanoma
Rectum cancer
Bladder cancer
Kidney cancer
Pancreatic cancer
Leukaemia
Cervical cancer
Gastric cancer
Thyroid cancer
Ovary cancer
Liver cancer
100
50
0
Incidence/100 000
50
100
Frequency of cancer in Finland |
37
Figure 15
Incidence of some cancers by to age in 2005–2009. The age distribution for 1959–1962
(before starting systematic screening) is shown for cervical cancer, and for prostate cancer
in 1985–1989 (before PSA-testing became common).
Cervical cancer
Prostate cancer
Incidence/100 000
Incidence/100 000
60
1 200
2005–2009
1958–1962
40
800
20
400
1985–1989
2005–2009
0
0
0
10
20
30
40
50
60
70
80
90 Age
0 10 20 30 40 50 60 70 80 90 100 Age
Lung cancer
Juvenile cancer
Incidence/100 000
Incidence/100 000
500
20
Leukaemia
Testicular cancer
400
15
Men
300
10
200
Women
Hodgkin
lymphoma
5
100
0
0
0 10 20 30 40 50 60 70 80 90 100 Age
0
10
20
30
40
50
60
70
80
90 Age
38
| Cancer in Finland
Table
2
Average annual cancer cases for children under 15 years old in Finland 2005–2009.
Number of cases Proportion of all childhood cancers (%)
Leukaemia 53
36
Brain tumours 34
23
Lymphomas 15
10
Neuroblastoma 9
6
Soft tissue sarcomas 8
5
Kidney tumours 7
5
Germ cell tumours 5
3
Bone sarcomas 4
3
Liver tumours 3
2
Retinoblastoma 2
1
Others 8
5
148
100
Total years of age, prostate cancer, which is very rare
for men under 45, is clearly the most common
cancer. Before PSA screening, prostate cancer
was mostly detected in even older age groups
than nowadays (Figure 15).
About 150 young Finns, under the age of 15
years, develop cancer each year. The portion
of childhood cancer is therefore about half a
percent of the total population cancer cases.
Childhood cancer can differ from adult cancer,
among other ways, in the cell type and in its
biological behaviour. The most common childhood cancers are leukaemia and brain tumours,
the combined number of which comprises over
half the cancers for those under 15 years (Table
2). The different cancer types are almost equal
in number for boys and girls. The frequency of
childhood cancers has not changed significantly
over the past decades.
The incidence of brain and nervous system tumours and leukaemia (Figure 15), on the other
hand, is quite high among children. Testicular
cancer and Hodgkin lymphoma are typical malignancies of young adults (Figure 15).
The likelihood of an individual getting cancer can be estimated from the age-specific incidence figures. For example, about one in 15
women will develop breast cancer before reaching retirement age, and more than every tenth
woman during her entire life span (Figure 16).
Almost every third Finn has been diagnosed
with cancer by the age of 85 years.
Frequency of cancer in Finland |
39
Figure 16
Probability of getting cancer up to each age. Calculation is based on the incidence of cancer
2005–2009.
%
MEN
• All cancers
30
20
• Cancers of reproductive organs
10
of digestive system organs
• Cancers
of respiratory organs
• Cancers
of urinary tract organs
• Cancers
• Cancers of blood and lymph cells
0
30
40
50
60
70
80
90
Age
%
WOMEN
30
• All cancers
20
• Breast cancer
10
of digestive system organs
• Cancers
of reproductive organs
• Cancers
of blood and lymph cells
• Cancers
• Cancers of urinary tract organs
0
30
40
50
60
70
80
90
Age
40
| Cancer in Finland
Differences between generations
Time factor changes in incidence result mainly
from the different exposures of each generation
to cancer risk factors. Smoking among men
was most common during the first two decades
of the 1900s, and as a result the incidence of
lung cancer for men is highest for those born in
1900–1924. However, smoking by women has
increased continually from one age group to the
next so the incidence of lung cancer for women
is systematically higher for those women born
later.
Skin melanoma is one of the most rapidly increasing cancers. For women born in 1950,
the risk of getting melanoma by the age of 30
was as great as the risk of developing it by the
age of 65 for those born around 1900 (Figure
17). The probability of getting gastric cancer,
by contrast, is smaller for those born later. For
those born in the 1940s, gastric cancer risk at
each age is about one-tenth the risk of those
born in 1900 (Figure 17).
Regional variation
The risk to Finns of getting cancer is close to
the average of the countries in the European
Union (Figure 18).
Changes in cancer incidence in Finland reflect
the improving standard of living. Gastric cancer was the most common cancer in Finland
in the 1950s, but has become rarer in all western countries (Figure 19). Comparison of the
frequency of colorectal cancer in the Nordic
countries shows clearly the impact of changes
in the standard of living (Figure 19). The recent
wealth of Norway has changed the nutritional
and other habits of its population, shown as a
much greater increase in colorectal cancer than
in Finland.
Cervical cancer incidence decreased drastically
when organised mass screening started in the
1960s (see page 50). In comparing Nordic
countries, it can be clearly seen that the risk
of cervical cancer in Denmark has always been
greater than in other countries (Figure 20). In
other Nordic countries, the decline in cervical cancer risk started earlier than in Norway,
where the organization of screening was improved later than elsewhere.
The incidence of skin melanoma in the Nordic countries decreases towards the north, and
people living in the same latitude in different
countries do not differ much in their incidence
of melanoma (Figure 21). On the other hand,
the map of lung cancer in women (Figure 22)
shows that although female lung cancer is one
of the most rapidly increasing diseases in Finland, the risk in Finnish women is still far from
the high figures for Denmark and Norway. In
Iceland the prevalence of lung cancer is the
same for men and women.
Municipalities are such small units that it is
very seldom possible to draw reliable conclusions from cancer incidence for an individual
municipality. In a typical Finnish municipality
of 10 000 people, normally only about eight
cases of cancer are diagnosed annually for each
of the most common cancers – prostate cancer
in men and breast cancer in women. More reliable information can be deduced about cancer
incidence in different regions when informa-
Frequency of cancer in Finland |
Figure 17
Incidence of gastric cancer in men and melanoma of skin in women by birth year and age
in 1955–2009.
Incidence/100 000
MEN, gastric cancer
1 000
Birth year 1880
500
200
1900
100
50
1940
20
1920
10
1960
5
2
1
35
40
45
50
55
60
65
70
75
80
85+
Age
Incidence/100 000
WOMEN, skin melanoma
100
Birth year 1915
1930
50
1950
20
1970
10
5
1880
1900
2
1
20 25 30 35 40 45 50 55 60 65 70 75 80 85+
Age
41
42
| Cancer in Finland
Figure 18
Variations in incidence of some cancers in EU countries 2008 (Ferlay et al 2010).
BREAST CANCER, women
PROSTATE CANCER
EU
EU
Belgium
Denmark
Finland
Sweden
Ireland
Norway
Finland
Holland
Italy
Estonia
Spain
Estonia
0
50
100
150
200
0
20
40
60
Incidence/100 000
LUNG CANCER, women
Incidence/100 000
LUNG CANCER, men
EU
EU
Denmark
Great-Britain
Sweden
Hungary
Poland
Estonia
Finland
Estonia
Spain
Finland
Portugal
Sweden
0
10
20
30
40
0
20
40
Incidence/100 000
SKIN MELANOMA, women
100
EU
Norway
Denmark
Finland
Italy
Estonia
Spain
Sweden
Finland
Estonia
Spain
10
80
TESTICULAR CANCER
Denmark
Switzerland
5
60
Incidence/100 000
EU
0
80 100 120 140
15
20
25
Incidence/100 000
0
5
10
15
Incidence/100 000
Frequency of cancer in Finland |
43
Figure 19
Age-standardized incidence in Nordic countries 1943–2009 for gastric cancer in men and
colorectal cancer in women.
Incidence/100 000
MEN, gastric cancer
70
60
50
40
30
20
•Finland
•Denmark
•Norway
•Sweden
10
0
1940
1950
1960
1970
1980
1990
2000
2010 Year
Incidence/100 000
WOMEN, colorectal cancer
40
•Norway
•Denmark
35
30
•Sweden
25
20
•Finland
15
10
5
0
1940
1950
1960
1970
1980
1990
2000
2010 Year
44
| Cancer in Finland
Figure 20
Age-standardized incidence of cervical cancer in 1943–2009.
Incidence/100 000
35
30
25
20
15
•Denmark
•Norway
•Sweden
•Finland
10
5
0
1940
1950
1960
1970
1980
tion from neighbouring municipalities is combined, for example as shown in Figures 23 and
24.
The cancer risk for women living in towns in
southern Finland has been consistently about
one and a half times greater than that for
women in the north-east of Finland, whose in-
1990
2000
2010 Year
cidence has been the lowest in the country (Figure 24). For example, lung and breast cancer
are most common for women living in Helsinki
and the surrounding areas. A benign papillary
form of thyroid cancer has been diagnosed
mostly around Oulu, which probably derives
from different regional diagnostic practices for
thyroid masses.
Frequency of cancer in Finland |
Regional variations in overall cancer incidence
among men are small. In the 1950s the incidence in coastal towns was slightly above average, and from there the higher incidence spread
to other towns, until regional variations disappeared entirely in the 1980s (Pukkala and Patama 2010). Prostate cancer, which became more
common in the 1990s, increased the number
of cancer cases firstly mainly in the capital city
area but in more recent years also in the Tampere area in southern mid-Finland (Figure 23).
The cancer burden is lowest in the most northern part of Finland, due to an exceptionally low
cancer incidence rate among the Sami population: the Sami people have fewer cancers of any
kind than other people living in the same area
(Soininen et al 2002). This difference is not explained by known variations in lifestyle.
The geographical variation in most cancers
has remained relatively constant, although the
overall incidence level has changed in the whole
country. Changes in the factors causing cancer
can however little by little alter the regional
emphasis in cancer incidence. The different development of smoking habits in different parts
of Finland has shifted the main focus of lung
cancer in men from southern Finland to the
east-central part of Finland, where lung cancer
incidence was least common in the 1950s. On
the other hand, prostate cancer was diagnosed
in the 1990s mostly in the Tornio area in the
southwest part of Lapland, then in the capital
area and Tampere, and in the 2000s in South
Ostrobothnia in western Finland. The webpage
of the Cancer Registry has illustrative map ani-
45
mations on this subject (see for example astra.
cancer.fi/cancermaps/suomi5308/fi).
Most cancer types are more common in towns
than in rural areas. For many cancers this difference has declined over the decades, but the
incidence of lung cancer in women is still about
two times higher in bigger towns than in rural
towns. Lip cancer is the only type that is found
more frequently in rural areas than in towns.
Similar differences have been found when municipalities are classified according to average
income or family size of the population, because the income of those living in rural areas
is lower and there are more children in families
than in those living in industrialized communities (Teppo et al 1980).
The impact on cancer incidence of the environment in which people live can be studied,
for example, through the quality of soil, air or
drinking water. This can be studied when good
background information about the environment is available. The excellent Finnish population registry system makes this kind of research
possible for very small area units – even for a
250 meter square map grid (Kokki et al 2002).
Comparing differences in regional incidence
and their trends can indicate possible causes of
cancer. More accurate clarification of causal relations, however, requires studies in which large
numbers of people, who are exposed in different ways, are compared using individual-level
information.
46
| Cancer in Finland
Figure 21
Incidence of skin melanoma in men in the Nordic countries 2004–2010.
21.0
19.1
17.4
15.8
14.3
13.0
11.9
10.8
9.80
8.91
8.10
7.36
6.69
6.08
5.53
5.03
4.57
4.15
Frequency of cancer in Finland |
Figure 22
Incidence of lung cancer in women in the Nordic countries 2004–2010.
42.0
38.2
34.7
31.6
28.7
26.1
23.7
21.6
19.6
17.8
16.2
14.7
13.4
12.2
11.1
10.1
9.14
8.31
47
48
| Cancer in Finland
Figure 23
Variation in incidence of some cancer types among men in Finland 2000–2009.
Average in Finland = 1.00.
2.00
All cancers
1.33
Lung cancer
1.00
0.75
0.50
Prostate cancer
Lip cancer
Oesophageal cancer
Frequency of cancer in Finland |
Figure 24
Variation in incidence of some cancer types among women in Finland 2000–2009.
Average in Finland = 1.00.
2.00
All cancers
1.33
Lung cancer
1.00
0.75
0.50
Breast cancer
Thyroid cancer
Cervical cancer
49
50
| Cancer in Finland
Cancer screening
The objective of cancer screening is to detect
pre-clinical disease in its early stages, when cancer can still be cured. The main aim is to reduce
mortality from cancer, and also sometimes its incidence. The latter is possible if the progression
of pre-cancerous lesions to cancer can be prevented by treating them in the precursor phase.
Municipalities in Finland are obliged to organise free cancer screening for their population.
The Health Care Act (1326/2010) and the
Government Decree on Screening (339/2011)
regulate this area. According to the Decree on
Screenings, screening for cervical cancer should
be offered to women aged 30–60 years every 5
years and breast cancer screening to those aged
50–69 at 20–26 month intervals. The obligation to organise breast cancer screening for
women over 60 years concerns women born
in 1947 and later. In addition to these mandatory screening programmes, some municipalities have voluntarily started colorectal cancer
screening for men and women aged 60–69
years every two years.
Cervical cancer screening
Cervical cancer best fulfils the conditions for
screening. It has a microscopically identifiable
early pre-malignant stage, which can be detected from a smear sample taken from the uterine cervix. When early stage cancer has been
detected, it can be treated and thus prevented
from progressing to invasive cancer.
Cervical cancer screening began in Finland at
the initiative of the Cancer Society of Finland
at the beginning of the 1960s. Based on the
decree on screening, about 250 000 women
between the ages of 30–60 years are screened
annually. All women belonging to the target
age group are invited for smear taking every
five years. Certain high risk women are referred
for testing more often than the normal five year
interval. This improves early detection of cancer cases (Hakama and Pukkala 1977, Hakama
et al 1979).
Cervical cancer screening is carried out using
cells from the cervix, the so-called Papanicolau
test. Since 1999 new screening techniques have
also been studied, such as automated PAPNET
screening (Anttila et al 2006) and HPV-based
screening test to indicate the presence of the
human papilloma virus (Kotaniemi-Talonen et
al 2005). In addition to these, screening samples taken at home have been tried for those
women who have not participated in regular
screening (Virtanen et al 2011).
The number of cervical cancer cases began to
decrease rapidly when screening for cervical
cancer had almost reached its full extent at the
end of the 1960s. The number of new cases in
the most completely screened age group (35–
59 years) decreased from 300 to 40 annually.
On the other hand, the number of cancer cases
in unscreened women remained largely the
same or even increased (Figure 25). The same
Cancer screening |
51
Figure 25
Number of new cervical cancers annually 1953–2009, by age group.
Number of cases
300
250
35–59 years
200
150
100
60–69 years
50
70–89 years
20–34 years
0
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
has happened in other Nordic countries when
screening for cervical cancer has become part of
the healthcare system (Figure 20).
Since the start of screening, cervical cancer
has become rarer, and the mortality rate has
Year
decreased. Annually detected new cases in the
population and the mortality rate from cancer
of uterine cervix have reduced to a fifth from
the starting point. It has been estimated that
screening averts over 200 deaths from cervical
cancer annually.
52
| Cancer in Finland
Figure 26
Change in age distribution of breast cancer in
the periods before and after starting organised
mammography screening programme.
Incidence/100 000
400
2005–2009
300
200
1978–1982
100
0
0
10
20
30
40
50
60
70
80
90
100
Age
Screening for breast cancer
Breast cancer has been the most common
cancer among women since the 1960s. The
incidence of cancer starts to increase from 40
years of age. Breast cancer screening is based
on mammographic tests or x-ray examination
of the breasts, in which an x-ray is taken from
one or more directions. If the mammography
finding is abnormal, the woman is invited for
further investigation. This further investigation may include additional mammograms,
ultrasound examination or fine or core needle
biopsies. If the possibility of cancer cannot be
excluded, investigation will continue in hospital, and a biopsy sample is taken from the
breast in order to determine the tumour type.
The national mammographic screening for
breast cancer started in Finland at the beginning of 1987, the first of its kind in the world
(Elovainio et al 1989). Nearly 90 percent of
the invited age groups participate in screening.
About three percent of screened women are
invited for supplementary examination, and
breast cancer is detected about in one out of
three hundred. Mass screening has led to a reduction in breast cancer mortality by one quarter for 50–59-year-old women, which means
averting one death against every 10 000 examinations (Hakama et al 1997). Breast cancer
incidence has strongly increased in age groups
participating in screening (Figure 26).
Research has been carried out on screening
which was implemented by the units of the
Cancer Society of Finland from the 1990s to
the start of the 2000s. The activity of these units
was of good quality and met the European Un-
Cancer screening |
ion quality specifications. Breast cancer mortality for 50–69-year-old women was 22 percent
lower in those invited for screening than the
estimated rate without screening. Breast cancer
mortality was reduced by 28 percent in screening participants (Hakama et al 1997, Sarkeala et
al 2005, Sarkeala 2008).
Colorectal cancer screening
Cancer of the colon and rectum are the third
most common cancers of Finns, after prostate
cancer and breast cancer. The primary treatment of these cancers is surgery. In most cases
the patient will be cured if the cancer is limited to the bowel wall. If the cancer has spread
into regional lymph nodes or further within
the body, chemotherapy and possibly radiation
therapy are given as additional treatments.
In Finland, almost half of all colorectal cancers
have already spread beyond the bowel wall in
patients seeking treatment based on symptoms.
Early detection is difficult, because symptoms
of cancer in the abdominal area are often unclear or there are no symptoms at all.
In randomized screening studies carried out
abroad, it has been observed that screening can
reduce the mortality rate for colorectal cancer
by about 16 percent (Hewitson 2007). Colorectal cancer is screened using a test indicating
faecal blood. The screening sample is taken at
home and is returned by mail to the screening
centre. Those with faecal blood detected are referred for follow-up examination by colonoscopy. Two to three persons of every hundred have
occult faecal blood. For most, the occult blood
is caused by something else than cancer, such as
53
haemorrhoids, infection of the intestinal tract
or benign polyps.
Screening of men and women aged 60–69 for
colorectal cancer has begun in Finland since
2004 in municipalities that were willing to start
the screening program. In 2010, 45 percent of
60–69-year-old people were living in municipalities taking part in the screening program.
Screening begins with those aged 60–64 years,
and expands gradually to include the entire
60–69-year-old age group in the screening program within five years. In the implementation
phase, only half of this age group is screened
and the other half remains as a control group,
as the benefit-risk ratio is not yet clear.
In Finland, the screening program for colorectal cancer works well, and population participation in screening is extremely high. About 70
percent of those invited participate in screening
(Malila et al 2008, 2011). Follow-up investigations associated with the screening program
have also been effective, and it has been possible to do colonoscopies with very short waiting times. Colorectal cancer or neoplastic early
stages have been detected as predicted, i.e.
about in every tenth of those sent for a colonoscopy.
Colorectal cancer can also be screened by colonoscopy, but screening carried out this way
is expensive, and serious harm may be caused
by the procedure. The use of colonoscopy as a
screening method is currently being studied in
Europe and the United States. In Finland colonoscopy screening is used only if a person has
an increased risk of getting bowel cancer, for
example, in patients suffering from adenomas
54
| Cancer in Finland
or in close relatives of those with an inherited
susceptibility to colorectal cancer.
Screening for prostate cancer
Prostate cancer is the most common cancer
in men in Finland. Finland has been participating in the European Randomised Prostate
Cancer Screening (ERPSC) trial, the results of
which indicate that PSA testing reduced deaths
from prostate cancer by one fifth (Schroder
et al 2009). These findings are based on the
screening of 262 000 people during a nineyear period. Altogether 80 000 men from Finland were randomised, of whom 30 000 were
screened with PSA-testing at age 55–71 years
2–3 times at four-year intervals. The remaining men formed the control group. Men from
the area surrounding Tampere and from the
Helsinki capital area were invited for screening.
The actual screening stage was concluded at the
end of 2007.
Screening can detect cancer at an early stage,
when it can still be cured. However, many more
prostate cancers were detected in the screened
group than in the control group in the ERSPC.
This could mean that not all early stage tumours
would have ever advanced to harmful cancer.
Based on the results, it is not certain if screening causes more benefit or harm. The most
important disadvantage of screening for prostate cancer is the detection of indolent ­cases,
i.e. cancers that would not have been found
without screening and would not have caused
any harm during the man’s lifetime. It is not
possible to differentiate the detectable small,
histologically malignant but clinically benign,
prostate cancers from those aggressive cancers
that would spread and cause death eventually.
Screening for other cancers
Other cancers considered for screening are, for
example, oral cancer, especially in developing
countries, ovarian cancer, stomach or gastric
cancer, and lung cancer. It is not yet known if
screening would reduce mortality for these cancers in the population, but the issue is being
investigated in randomised studies. Of these,
the results of the effects of a screening for lung
cancer directed towards smokers and based on
low dose spiral computer tomography were
published in 2011 (The National Lung Screening Trial Research Team 2011).
Treatments |
55
Treatments
Surgery, radiation therapy, chemotherapy, hormone treatment and biologic treatments (for
example interferon treatment) are used in treating cancer. Different treatment methods are often combined, in order to get the best possible
result.
The selection of treatment methods is based
on cancer type and stage, the general condition
and age of the patient, among other things. Experts from different areas of medicine take part
in the selection of the treatment method. The
newest treatments are targeted drugs, which affect only the cancer. They cause fewer side effects for the patient than cytotoxic drugs and
hormonal treatments. The treatment of each
patient is planned individually, and so patients
with the same cancer may have different treatments. Some cancers can progress so slowly that
the situation can be followed up for some time
before selecting a treatment method.
After cancer is suspected and detected, a diagnosis is made and the stage is defined. In these
investigations, ultrasound, x-ray and magnetic
resonance imaging are used in addition to laboratory tests. Pathologists also identify the can-
cer grade in order to determine the most appropriate treatment combination for each cancer.
Breast cancer, for example, may be treated either by removal of the whole breast or by local
removal of the tumour, sparing the breast. It
is often necessary to also remove lymph nodes
from the armpit. The patient is generally given
radiation therapy and chemotherapy in addition to surgery in order to secure the destruction of all tumour cells. Long-term hormonal
treatment can be given as follow-up treatment
in order to prevent a relapse of the cancer. In
some cases, a surgically removed breast can be
replaced with a silicon prosthesis or with the
patient’s own tissue. If the cancer has spread,
the patient’s symptoms can often be relieved
with additional surgery or radiation therapy.
Combinations of medical treatment may be
changed if one combination begins to lose effect. If the cancer has spread and death gets
closer, the focus changes to relieving pain and
symptoms so that the patient’s quality of life
remains as good as possible. A cancer patient’s
final treatment stage is called hospice care.
56
| Cancer in Finland
Survival
Cancer treatments have progressed considerably in the last decades. Nowadays a large number of cancer patients live a normal life after the
detection and treatment of cancer and eventually die from causes other than cancer.
The relative survival ratio is used as an indirect
measure of recovery from cancer. It indicates
the proportion of cancer patients that live for
a certain period after diagnosis, compared to
the rest of the population of the same age during the same period. If the annual relative survival ratio is less than 100 percent, cancer has
caused additional deaths. Five years is generally
considered the statistical limit of recovery, although for some cancers there are a small number of extra deaths after that limit, and in some
cases statistical recovery may be reached earlier
(Dickman et al 1999).
The five-year relative survival ratio is 62 percent
for men and 65 percent for women for Finnish
patients who developed cancer in 2007–2009
(Table 3). This calculation does not take into
consideration basal cell carcinomas, which
cause almost no additional deaths. The higher
survival ratio for women is largely a result of
the considerably better prognosis for breast
cancer, the most common cancer for women,
compared to lung cancer, the most common for
men.
The five-year survival ratio is 89 percent for
those Finns who got breast cancer in 2007–
2009. Correspondingly, for those with prostate
cancer the five-year survival ratio is predicted to
be 93 percent, but this figure is distorted by the
many good prognosis prostate cancers discovered through PSA testing. Many of the cancers
discovered by PSA testing are such that they do
not have an impact on life span and these men
will die of other diseases. The five-year relative
survival ratio for testicular cancer has improved
considerably due to improved treatment and
nowadays exceeds 95 percent (Figure 27). The
notorious skin melanoma is discovered nowadays mainly in the form of a thin local tumour,
for which surgery is almost always curative (Table 3).
The most common cancer types of recent decades, gastric cancer and lung cancer, are cancers
with a poor prognosis. However, as the proportion of these cancers of the overall cancer burden is decreasing, and the prognosis for other
cancers is improving, the overall reputation of
cancer as a killing disease is slowly changing.
Some cancers remain difficult to cure. Among
these are cancers of the liver, gallbladder and
pancreas. Less than three percent of those suffering from pancreatic cancer will survive five
years from the date of diagnosis. However,
with modern treatments, even cancer that has
already spread can be controlled for some time
and survival ratios improve, although the patient finally dies of cancer.
Survival |
Factors contributing to survival
Survival ratios of cancer patients vary considerably depending on how far the cancer has
spread when it is detected. The prognosis for
those patients whose cancer has been detected
while local is best, because it is often possible
to remove the entire tumour at surgery. For example, for men whose local skin melanoma was
diagnosed in the 2000s, the five-year relative
survival ratio was 94 percent, but the survival
ratio was only 9 percent if the skin melanoma
had already spread. Although gastric cancer patients have a relatively poor prognosis on average, the five-year relative survival ratio was over
60 percent when the cancer was detected at the
local stage.
Table
57
3
Projected relative five-year survival ratios for
cancer patients in 2007–2009 (%).
Cancer type Men Women
Testicular cancer 96
Prostate cancer 93
Thyroid cancer 90
93
Hodgkin lymphoma 91
92
Skin cancer, non-melanoma 89
91
Breast cancer 89
83
88
Cancer of corpus uteri Skin melanoma 82
Cervical cancer 68
Bladder cancer 71
62
Breast cancer is an example of a disease where,
although the disease has already spread, the patient may have a long survival due to effective
treatment. For those with a local breast cancer
in the 2000s, the five-year relative survival ratio
was as much as 98 percent. If the disease had
spread only to the lymph nodes in the armpit,
the figure was 88 percent. Even when the disease had spread further, the relative survival ratio at five years was 42 percent.
Non-Hodgkin lymphoma 64
64
Myeloma 33
30
Young patients recover from almost all cancers
better than elderly ones. In the past leukaemia
was an exception; in the early 1970s the relative
survival ratio for patients under five years of age
was less than 10 percent, while for those aged
45 years or more it was over 20 percent. This
is because children are more likely than adults
to get leukaemia in the acute form. Survival ratios for children with leukaemia have, however,
improved enormously in recent years: since the
Gastric cancer 23
25
Oesophageal cancer 10
9
8
13
All cancers 62
65
Rectum cancer 62
65
Cancer of central nervous system 57
69
Kidney cancer 61
63
Colon cancer 60
61
Leukaemia 51
48
Ovary cancer 49
Lung cancer Gallbladder cancer 9
6
Liver cancer 7
3
Pancreatic cancer
3
3
58
| Cancer in Finland
Figure 27
Trends in relative five-year survival ratio for cancer patients in 1955–2009.
%
100
cancer
• Testicular
cancer
• Prostate
• Breast cancer, women
• Childhood leukaemia
80
• All cancers
60
40
20
• Lung cancer
• Pancreatic cancer
0
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
Survival |
59
1990s more than four patients out of five are
still alive five years after the disease was detected
(Figure 27). The average five-year survival ratio
for all cancer patients has increased by nearly 10
percent units in ten years.
countries are often due to differences in patients. In international comparisons, the survival ratios of Finnish patients are at the top
level both in Europe and worldwide (Sant et al
2009).
There generally are no major differences between sexes in the survival ratios of the same
cancer. The prognosis for women with skin
melanoma is better than for men, which is explained largely by the fact that most melanoma
in the men is on the trunk, where the prognosis
is worst, while most of the melanomas in women are located on the limbs. The social status
of the patient has some impact on the patient’s
prognosis: the well-to-do and well-educated recover from nearly all cancers a little better than
those belonging to a lower social group or with
a low level of education (Auvinen et al 1995,
Pokhrel et al 2010).
Years of life lost
There are large differences in the survival ratios of patients treated with different methods,
but it is not possible to draw direct conclusions
whether one method is better than another.
Extensive treatments that give the best results
are most suited to patients who are most likely
to be cured. The condition of these patients
must also be adequate to tolerate the strain
of treatment. The best prognosis, for localised
cancers treated with extensive surgery, was a
100 percent relative survival already at the end
of the 1960s, for example, for cervical cancer
(Hakulinen et al 1981).
Sizable variations in the survival ratios for different treatment institutions and in different
When estimating the significance of different
cancers to national health, attention should be
paid to the years of life lost because of different cancers, as well as to the number of cancer
cases and survival rates of cancer patients. The
quality of additional years of life also has significance, and should influence the selection of
the treatment method.
In Figures 28–29 the average age of detection,
duration of illness and estimated years of life
lost due to cancer are described for different
types of cancer. The target of comparison is the
remaining years of life for the population of the
same age. The average age at diagnosis varies
from 35 years for those with testicular cancer to
77 years for women with squamous cell carcinoma of the skin.
The relative survival ratios do not tell how
much a life is shortened because of cancer. Although in 2002–2009 the relative survival rate
for men with a brain tumour was 57 percent
and for those who had lung cancer it was 8 percent, the brain tumour patients lost more years
of life on average than the lung cancer patients,
who were older.
60
| Cancer in Finland
Figure 28
Average cancer detection age for men and number of life years lost due to cancer.
Cancers detected in 1998–2007.
30
40
50
60
70
80
90 Age
80
90 Age
Skin, non-melanoma
Lip
Bladder
500 cases/year
Average age of
getting disease
Lost years of life
caused by cancer
Prostate
Lung
Myeloma
Liver
Stomach
Colon
Pancreas
Rectum
Oesophagus
Kidney
Larynx
Non-Hodgkin lymphoma
Skin melanoma
Leukaemia
Soft tissue
Thyroid
Central nervous system
Hodgkin lymphoma
Testicle
30
40
50
60
70
Survival |
61
Figure 29
Average cancer detection age for women and number of life years lost due to cancer.
Cancers detected in 1998–2007.
30
40
50
60
70
80
90 Age
80
90 Age
Skin, non-melanoma
Oesophagus
Gall bladder
500 cases/year
Pancreas
Bladder
Liver
Average
age of
Lost years of life
Myeloma
getting
disease
caused by cancer
Stomach
Colon
Rectum
Lung
Kidney
Non-Hodgkin lymphoma
Corpus uteri
Ovary
Soft tissue
Leukaemia
Breast
Skin melanoma
Central nervous system
Cervix uteri
Thyroid
Hodgkin
lymphoma
30
40
50
60
70
62
| Cancer in Finland
Cancer in the future
Predictions of future developments in cancer
incidence are needed when planning hospital
beds, equipment and number of staff needed
for cancer treatment. Predictions are also beneficial because, using them, actions can be targeted at cancer prevention and early detection
as well as estimating the outcome of different
cancer prevention methods.
will remain at the 2007–2009 level (Figure 30)
for all age groups. The assumption is that the
incidence for prostate cancer was at its peak in
2004–2005 and that prostate cancer incidence
will return close to the trend seen before the use
of PSA testing increased. This kind of change
has been observed in the United States (Oliver
et at 2001) and in Sweden (Engholm et al 2011).
In the Finnish Cancer Registry, predictions of
cancer incidence have been developed on several occasions, and there is a lot of experience
concerning the accuracy of different methods.
According to a prediction made in 2009 (Finnish Cancer Registry 2009) age-standardized cancer incidence in men will reduce noticeably in
the coming years, and the cancer incidence for
women will also reduce slightly (Table 4). Although the age-standardized incidence will fall
as predicted, in 2020 about 3 000 more cancers will be detected than in 2011. According
to the prediction, about 17 700 cancer cases
will be detected among Finnish men in 2020
and about 16 100 cases among women. This
increase in case numbers is due to the fact that
the average life span for Finns is longer and the
more populous age groups born after World
War II will move into the ages in which cancer
incidence is the highest.
Future trends for most cancer types will follow
the previously observed directions (Figures 30–
31). Intestinal cancer will probably become still
more common, and will probably be the second most common cancer of men and women
from 2015 onwards. Lung cancer among men
will become rarer, but the age-standardized incidence for lung cancer in women is projected
to continue to increase. In 2020 there will be
over 900 cases of lung cancer detected among
women, which would be only about 40% less
than for men.
The prediction of cancer incidence for men is
affected largely by what will happen with regard
to prostate cancer. A prediction model for this
book assumes that prostate cancer incidence
The increase in case numbers means that cancer will require more health care resources than
today. Cancer types with a poor prognosis, for
example lung cancer, gastric cancer and cancer
of oesophagus will reduce in numbers. A larger
portion of cancers will be cured. Treatments
will develop, although in most cases in small
increments. From the perspective of treatment
results, it will be important that, in the future,
cancer is detected in an early enough stage and
that the cancer patient can get the best possible
treatment without delay.
Cancer in the future |
Table
63
4
Age-standardized incidence of most common cancers per 100 000 people in 2009 and
prognosis for 2020 (Finnish Cancer Registry 2009).
MEN
Number of casesAgestandardized
incidence
Number of casesAgestandardized
incidence
2009
2020
All cancers 14 863
304.9
All cancers 17 659
282.3
1 Prostate cancer 4 595
89.5
1 Prostate cancer 5 872
85.8
2 Lung cancer 1 676
32.0
2 Colorectal cancer 1 980
30.7
3 Colorectal cancer 1 391
27.5
3 Skin cancer 1 844
27.2
4 Skin cancer 1 550
22.3
774
13.5
1 344
26.8
4 Lung cancer 5 Non-Hodgkin lymphoma 650
14.6
5 Non-Hodgkin lymphoma 6 Cancer of bladder 708
13.6
6 Cancer of bladder 715
9.9
7 Pancreatic cancer 698
10.7
8 Cancer of
central nervous system 493
13.3
9.9
9 Leukaemia 432
10.2
9.2
10Kidney cancer 385
6.4
7 Cancer of
central nervous system 409
11.3
8 Kidney cancer 500
10.4
9 Pancreatic cancer 506
10Leukaemia 360
WOMEN
Number of casesAgestandardized
incidence
Number of casesAgestandardized
incidence
2009
2020
All cancers 13 946
254.3
All cancers 16 052
252.1
1 Breast cancer 4 469
92.1
1 Breast cancer 5 119
90.2
2 Skin cancer 1 200
18.8
2 Colorectal cancer 1 528
22.3
3 Colorectal cancer 1 255
18.4
3 Skin cancer 1 421
18.5
4 Cancer of corpus uteri 808
14.0
5 Cancer of
central nervous system 4 Cancer of
central nervous system 749
16.2
591
13.9
5 Cancer of corpus uteri 1 015
13.6
6 Lung cancer 691
11.0
6 Lung cancer 908
12.7
10.1
7 Non-Hodgkin lymphoma 559
9.7
7 Non-Hodgkin lymphoma 655
8Ovary cancer 435
8.2
8Ovary cancer 495
8.6
9 Thyroid cancer 298
8.2
9 Pancreatic cancer 770
8.3
10Kidney cancer 399
6.9
10Thyroid cancer 266
7.0
64
| Cancer in Finland
Figure 30
Number of new cases detected annually for men in 1982–2009 and projected number of cases
until 2027. Projection of prostate cancer has been made separately; others are carried out with
the NORDCAN spreadsheet tool (Engholm et al 2011).
Number of cases
7 000
Projected period
• Prostate cancer
6 000
5 000
4 000
3 000
• Colorectal cancer
• Lung cancer
2 000
melanoma
• Skin
lymphoma
• Non-Hodgkin
of bladder
• Cancer
• Gastric cancer
1 000
0
1980
1990
2000
2010
2020
2030 Year
Cancer in the future |
Figure 31
Number of new cases detected annually for women in 1982–2009 and projected number of
cases until 2027. Projection of breast cancer is made separately; others are carried out with the
NORDCAN spreadsheet tool (Engholm et al 2011).
Number of cases
7 000
Projected period
6 000
• Breast cancer
5 000
4 000
3 000
2 000
• Colorectal cancer
cancer
• Lung
of corpus uteri
• Cancer
melanoma
• Skin
lymphoma
• Non-Hodgkin
• Gastric cancer
1 000
0
1980
1990
2000
2010
2020
2030 Year
65
66
| Cancer in Finland
Figure 32
Age-standardized cancer mortality rate for men in 1982–2009 and projected rate until 2027.
Projections are made with the NORDCAN spreadsheet tool (Engholm et al 2011).
Age-standardized death rate/100 000
30
Projected period
25
• Lung cancer
20
15
cancer
• Prostate
• Colorectal cancer
10
cancer
• Gastric
of bladder
• Cancer
lymphoma
• Non-Hodgkin
cancer
• Kidney
• Skin melanoma
5
0
1980
1990
2000
2010
2020
2030 Year
Cancer in the future |
Figure 33
Age-standardized cancer mortality rate for women in 1982–2009 and projected rate until 2027.
Projection is made with the NORDCAN spreadsheet tool (Engholm et al 2011).
Age-standardized death rate/100 000
18
Projected period
16
14
12
cancer
• Breast
• Lung cancer
10
8
• Colorectal cancer
6
4
cancer
• Gastric
of corpus uteri
• Cancer
Non-Hodgkin lymphoma
•Leukaemia
• Cervical cancer
•
2
0
1980
1990
2000
2010
2020
2030 Year
67
68
| Cancer in Finland
Results presented in this book indicate that
cancer is closely linked to the individual’s lifestyle, behavioural habits and environmental aspects. Some cancers can be prevented, and it
is possible to change the future trends in the
cancer incidence.
The main challenges for cancer research for the
coming decades have not changed: it is still important to find the causes of cancer and to develop appropriate methods for detecting cancer
in an early stage. It is left as a challenge to decision-makers in society to find means by which
the living environment can be made safer and
which can support the population to change
their lifestyle habits to encourage better health.
Cancer is a very common group of diseases,
and is familiar to every family. However, cancer
deaths are becoming fewer (Figures 32–33). In
a Gallup poll held in May 2006, every fourth
Finn considered cancer a very scary disease, but
in the future this fear is likely to lessen. Already
the well-educated population fears cancer the
least: correct knowledge reduces pain.
References |
69
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How to find information about cancer
on the internet
Cancer frequency (incidence, mortality
and prevalence) in the whole of Finland
or by municipality
Go the Cancer Registry’s web page (www.cancer.fi)
and click on the word ”Statistics”. Choose the link
”Cancer Statistics”. Choose an area of your interest
and then a table. The selection of tables includes
figures on the incidence, mortality and prevalence as
numbers of cases and as rates. The table’s essential
figures can be highlighted and copied, for example
into Excel, from which presentation graphics can be
made. Ready-made graphic presentations exist in the
Statistics section link ”Graphics about Cancer Frequencies” (www.cancer.fi/syoparekisteri/en/statistics/
graphics-about-cancer-frequencie/), but these graphic
images are not regularly updated.
Cancer frequency
in an out of the ordinary way
The Cancer registry can chart cancers in ways
exceptional to the traditional categories, among others, according to topographical sub-categories (i.e.,
cardia), morphology (i.e. adenocarsinoma), staging
(local, spread to regional lymph nodes, or spread
further) and the method of detection (for example,
microscopically confirmed), if the tables are for a
justified need. Requests for tables should be sent to
[email protected].
Cancer frequency by municipality
The frequency of cancer can also be charted according to justified need by municipality, but there may be
questions of privacy protection connected to limited
population based tables. Requests for these tables
should also be sent to [email protected].
If you want to compare the cancer situation between residential areas, it can easily be done by using
the presentation materials in map format. That can be
found through the link in Cancer Registry’s Statistics
section “Graphics about Cancer Frequencies” (including
the links “Spatial and Temporal change in relation, Finland animations” and “Nordic countries’ map animations”
(http://astra.cancer.fi/cancermaps/Nord124/pub/).
Cancer frequency in Finland and other
Nordic countries in tables and graphs
Go to the Nordic Countries’ Cancer Registry
(ANCR) website (www.ancr.nu) and choose the link
NORDCAN - on the Web. Choose the language by
clicking on the flag. If the basic information package is
enough for you, choose the desired cancer and country from the selection “Cancer Fact Sheets” and click
on “Go” (generate fact sheet). If you need other kinds
of tables, they can easily be done through the link “Online Analysis”. Graphics that can be easily copied and
pasted into a PowerPoint presentation, for example,
appear within a few seconds. With the easy-to-use
tool of NORDCAN, the user can make predictions
about cancer frequency in the future.
Cancer Frequency in other countries
Estimation data about cancer incidence and mortality
in the whole world can be found from the WHO’s
international cancer research center’s (International
Agency for Research on Cancer) GLOBOCAN data
bank, which can be accessed through the website
www-dep-iarc.fi. It can be navigated in the same way
as the above-mentioned NORDCAN information database. Cancer data from the United States is related
on the page seer.cancer.gov/.
Cancer Frequency according to
occupation in Finland and
other Nordic Countries
Thanks to broad Nordic countries’ cooperative
­NOCCA study (Nordic Occupational Cancer Study),
plenty of informational tables about the number of
cancer cases and the risk for cancer according to
occupation categories (Pukkala, et al. 2009) are available. They are found on the website through the link
astra.cancer.fi/NOCCA. For English language tables,
click on the link “Table downloads”. After that, you can
choose tables according to the cancer type (more
than 80 alternatives) or the occupation (54 occupation categories). Word tables can be edited and
sorted in the normal way or transferred, for example,
to Excel.
Cancer patient survival
The Cancer Registry calculates at least every other
year patients’ survival ratios, which are always a part
of the published English language yearly statistics.
Electronic versions of the statistics can be accessed
by clicking on the book cover icons on the web page
www.cancerregistry.fi => ”Statistics”. Tables concerning the survival ratios for cancer patients from all of
the Nordic countries can be found in NORDCAN.
Finnish Cancer Registry
Institute for Statistical and Epidemiological Cancer Research
Pieni Roobertinkatu 9
FI-00130 Helsinki
Tel. +358 9 135 331 (switchboard)
[email protected]
www.cancerregistry.fi
Cancer Society of Finland
Pieni Roobertinkatu 9
FI-00130 Helsinki
Tel. +358 9 135 331 (switchboard)
[email protected]
www.cancer.fi
How common are cancers in Finland now and in the future? What do
we know about the risk factors for cancer? How can cancer best
be ­prevented? Should non-symptomatic cancers be screened from
the whole population? How will cancer patients survive?
This book is based on solid data including hundreds of c­ ancer studies
collected over time and the Finnish Cancer Registry’s data c­ ollected in
over 60 years time. The Cancer in Finland books have for over 30 years
provided credible and up-to-date information about what kind of disease
cancer is in the Finnish setting. This is the first edition in English.
The book is meant to be suitable for all who are interested in cancer,
not only for health care professionals.
Cancer Society of Finland
Pieni Roobertinkatu 9, FIN-00130 Helsinki
www.cancer.fi/en