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Cancer Trends No 9. Cancers of colon, rectosigmoid junction and rectum May 2011 Figure 2. Colorectal cancer incidence rates by site, females, 1994-2009 Cancer Trends Cancers of colon and rectum Anatomical sites 1 Sigmoid colon was the commonest site of colon cancers for both sexes (Figure 1). The distribution of cancers within the colon and rectosigmoid was similar for men and women, but rectal cancers were relatively more common in men. There was no change in the relative proportions of left- and right-sided colon cancers between 1994-1997 and 2006-2009. Figure 1. Anatomical site of colorectal cancers, 2005-2009: number and % of cases 300 caecum 200 number of cases per year 2005‐2009 100 0 100 200 300 400 12% 17% appendix 2% ascending colon hepatic flexure of colon 7% 3% 5% 2% descending colon 3% 2% 4% 21% 20% colon, not specified 8% 9% rectosigmoid junction rectum 3% 5% splenic flexure of colon sigmoid colon 1% 9% transverse colon 500 8% 7% 31% 22% female male Time trends There has been very little change in the incidence rate for cancers of the colon, rectosigmoid or rectum since 1994 (Figures 2 and 3). The incidence rate for cancer of the colon has risen by 1.2% annually for women and 2.5% annually for men since 2003. However, there have been falls of a similar magnitude in rectosigmoid and rectal cancers over the same period, so this may be a result of improving anatomical localisation through endoscopy and imaging. 50 40 30 20 10 colon rectosigmoid 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 0 1994 An annual average of 1445 colon cancers, 657 (45%) in females and 797 (55%) in males, 166 rectosigmoid cancers, 63 (38%) in females and 103 (62%) in males) and 606 rectal cancers, 209 (34%) in females and 398 (66%) in males, was registered between 2005 and 2009. Figure 3. Colorectal cancer incidence rates by site, males, 1994-2009 age‐standardised incidence rate per 100,000 per year As the aetiology, presentation and clinical course of cancers of the colon, rectosigmoid junction and rectum are quite similar, cancers of these three sites have been combined in this report. Anal cancers, which are comparatively rare, and constitute a separate entity both aetiologically and morphologically, are not included. rectum International variation in incidence Within Europe in 2008, the highest incidence of colorectal cancer for men was in Hungary, Slovakia and the Czech Republic and for women in Denmark and Norway (Figure 3).1 The lowest incidence, for both sexes, was in Cyprus and Greece. Apart from these, there was relatively little variation in colorectal cancer incidence across Europe. Figure 4. Estimated incidence of colorectal cancer, 2008 (world age-standardised rate)1 Hungary Czech Republic Slovakia Denmark Norway Italy Slovenia The Netherlands Germany Ireland Belgium Luxembourg Portugal Spain France United Kingdom Iceland Austria Bulgaria Sweden Estonia Lithuania Switzerland Malta Poland Latvia Finland Romania Cyprus Greece 60 40 20 0 20 40 60 80 100 120 age‐standardised incidence rate per 100,000 (world standard population) female male Histological types 93% of cancers were adenocarcinoma, almost all of the remainder being of unspecified type. Just over 1% (24 cases More information on cancer is available on our website www.ncri.ie © National Cancer Registry 2011. Cancer Trends No 9. Cancers of colon, rectosigmoid junction and rectum annually) were classified neuroendocrine tumours. as carcinoid or other May 2011 cancers were at stage I or II in 2008 (Table 1) while 48% of Surgery for rectosigmoid and rectal surgery followed a similar pattern to that for colon (Figure 8), but there was a larger increase between 1994-1998 and 2004-2008 in the percentage having chemotherapy (from 27% to 51%) and a much higher percentage (increasing from 26% to 41%) having radiotherapy. colon and 50% of rectal/rectosigmoid cancer were at stages Figure 7.Treatment for colon cancer, 1994-20082 Stage at diagnosis 38% of colon cancers and 31% of rectal/rectosigmoid III or IV. number of cases Table 1. Percentage of cases by stage 2008 0 I II III IV unknown colon 10% 28% 26% 22% 14% rectum/rectosigmoid 14% 19% 31% 19% 17% The percentage of stage III (Dukes C) colon cancers increased by 2% annually and stage IV cancers by 1% between 1994 and 20082, while the percentage of stage I cancers (Dukes A) fell by 2% and that of stage II cancers (Dukes B) by 1% (Figure 5). Figure 5. Colon cancer, percentage of cases by stage, 199420082 1000 2000 3000 4000 5000 6000 77% 76% surgery 79% 1994‐1998 1999‐2003 25% chemotherapy 2004‐2008 35% 39% 7% 7% 5% radiotherapy Figure 8. Treatment for rectosigmoid and rectal cancer, 1994-20082 35% number of cases percentageof cases 30% 2 0 1,000 2,000 3,000 4,000 25% 20% I 15% II 77% 74% 75% surgery 1994‐1998 III 10% IV 5% 1999‐2003 27% chemotherapy 51% 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 0% 1994 2004‐2008 44% unknown 26% radiotherapy 39% 41% year of incidence Over the same period, the percentage of stage III rectosigmoid and rectal cancers increased by 3% annually and of stage IV cancers by 1% annually (Figure 6), while the percentage of stage I cancers fell by 3% annually, and of stage II cancers by 2%. Survival This increase in later stage colorectal cancers may be partly attributable to more thorough staging. Figure 9. Cause-specific five-year survival for cancers diagnosed 1994-2005 Cause-specific survival for cases of colon cancer diagnosed in 1994-2005 was 51% (95% confidence interval 50%-52%) at five years, for rectosigmoid cancer 48% (46%-51%) and for rectal cancer 50% (48%-51%) (Figure 9). Figure 6. Rectosigmoid and rectal cancer, percentage of cases by stage, 1994-20082 0% 20% 30% 40% 50% 60% 70% 1994‐1997 colon 35% 30% 1998‐2001 2002‐2005 20% I 15% II III 10% rectosigmoid 25% IV 5% unknown year of incidence Treatment2 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 0% female 1994‐1997 male 1998‐2001 2002‐2005 1994‐1997 rectum percentageof cases 10% 1998‐2001 2002‐2005 There was an improvement in survival for all colorectal cancers for both sexes between 1994-1997 and 20022005; the increases for colon cancer were statistically significant, but those for rectal and rectosigmoid cancer, either separately or combined, were not. Survival from colon and rectal cancer (but not rectosigmoid) in the period 19942005 was significantly better for women. Almost 80% of patients with colon cancer had surgery and this changed little with time (Figure 7). The percentage having chemotherapy increased from 25% to 39% between 1994-1998 and 2004-20082, and the percentage having radiotherapy fell slightly, from 7% to 5%, in the same period. More information on cancer is available on our website www.ncri.ie © National Cancer Registry 2011. Cancer Trends No 9. Cancers of colon, rectosigmoid junction and rectum International variation in survival International variation in mortality Across Europe, five-year relative survival from colorectal cancer for patients diagnosed in 2000-2002 ranged from 45% in the Czech Republic to 64% in Switzerland (Figure 10).3 Survival in Ireland was similar to that in the UK, and, at 54%, below the European median. The highest colorectal cancer mortality in Europe for both men and women was in Hungary (Figure 12)1 and the lowest in Greece and Cyprus. Mortality for Ireland was close to the European median. Figure 10. Five year relative survival for colorectal cancer diagnosed 2000—20023 Switzerland Spain Germany Belgium France Sweden Norway Italy Finland Austria Iceland Netherlands Northern Ireland Ireland Scotland Wales England Malta Slovenia Poland Czech Republic 0% 10% 20% 30% 40% 50% 60% 70% five‐year relative survival Figure 12. Estimated mortality from colorectal cancer, 2008 (world age- standardised rate)1 Hungary Slovakia Czech Republic Slovenia Denmark Norway Latvia Portugal Lithuania Estonia Poland The Netherlands Malta Spain Ireland Bulgaria Germany Romania Austria Belgium Italy France United Kingdom Sweden Luxembourg Iceland Switzerland Finland Greece Cyprus 30 Mortality 20 10 0 10 20 30 40 50 60 age‐standardised mortality rate per 100,000 (world standard population) Age-standardised mortality rates from colorectal cancer for women have been falling by 2% annually since 1970 (Figure 11).4 Although male and female mortality rates were similar up to 1970, this fall in female rates was not initially matched by a similar fall for males. However, male mortality began to fall in about 1989, and has been falling by 1% annually since then. The male mortality rate in 2008 was 75% greater than the female rate. females males Figure 11. Age-standardised mortality rate (world standard population) for colorectal cancer 1950-20084 References and notes 30 25 1. European Cancer Observatory (ECO) http://eu-cancer.iarc.fr/ 2. Stage and treatment data is incomplete for 2009 and is not reported on here. 3. Recent cancer survival in Europe: a 2000-02 period analysis of EUROCARE-4 data. Verdecchia A, Francisci S, Brenner H, Gatta G, Micheli A, Mangone L, Kunkler I; EUROCARE-4 Working Group. Lancet Oncol. 2007 Sep;8(9):784-96. 4. WHO mortality database http://www-dep.iarc.fr/WHOdb/WHOdb.htm 20 15 males 10 females 5 2006 2003 2000 1997 1994 1991 1988 1985 1982 1979 1976 1973 1970 1967 1964 1961 1958 0 1955 age‐standardised mortality rate per 100,000 per year 3 May 2011 year of death More information on cancer is available on our website www.ncri.ie © National Cancer Registry 2011.