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Recent advances in the management of colorectal cancer Vilnius, May 6-7
Epidemiology of colorectal cancer:
what we can learn from Lithuania
Juozas Kurtinaitis
phD, Public health
Colorectal cancer
• Is the fourth most common cancer in the world accounting for 8,5 % of all new cancers
• The developed world accounts for over 63 % of all cases
• Colon cancer is more common in developed countries exhibiting Westernized lifestyle practices
• Lithuania is moving to market economy and is facing the westernized life style practices
Colorectal cancer around the world
Incidence Mortality
RegionMale Female Male Female
World 20,1 14,6 8,9 7,6
More developed
regions 40,0 26,6 27,5 12,3
Less developed regions 10,2 7,7 4,6 4,7
Based on world experience, what we expect in future?
Lithuania 26,5 16,8 18,0 11,3Based on the figures, we are targeting the more developed regions and need to pay attention on the western countries experience. Colorectal cancer is not only geography.
Colorectal cancer – Northern Europe 1997-1999 - MALE
Area Incidence Mortality Incidence/mortality ratio
Northern Europe 37,5 17,6 2,1
Denmark 41,0 23,3 1,8
Estonia 31,7 17,9 1,8
Finland 25,5 11,5 2,2
Iceland 34,0 12,8 2,7
Ireland 43,1 23,6 1,8
Latvia 24,2 18,0 1,3
Lithuania 26,5 18,0 1,5
Norway 43,4 20,1 2,2
Sweden 33,4 14,9 2,2
UK 39,2 17,5 2,2
Colorectal cancer – Northern Europe 1997-1999 - FEMALE
Area Incidence Mortality Incidence/mortality ratio
Northern Europe 26,4 12,7 2,1
Denmark 33,0 19,2 1,7
Estonia 23,2 12,6 1,8
Finland 21,1 9,8 2,2
Iceland 27,0 13,2 2,0
Ireland 27,0 13,7 2,0
Latvia 17,9 12,3 1,5
Lithuania 16,8 11,3 1,5
Norway 37,1 16,8 2,2
Sweden 26,2 11,1 2,4
United Kingdom 26,5 12,4 2,1
Incidence / mortality ratio -what the figures stand for?
• Male 26,5 18,0 1,5• Female 16,8 11,3 1,5
Lithuanian figures tell us unexpected high mortality compared to incidence
Questions:- do we have more advanced stages, compared to other countries in the region?- is the cases management according to
best clinical practice? - what is the rank of colorectal cancer in the country?
The figure we expect should be around 2
Colorectal cancer in Lithuania - 2004 - male
706 new cases(8,6% male
malignancies)
1655
233
274
394
398
590
706
718
1300
1910
0 500 1000 1500 2000 2500
Other
Pancreas
Oral cavity
Bladder
Kidney
Stomach
Colorectal
skin
Lung
ProstateMale
Site % of cancer death
Prostate 9,6
Lung 28,6
Colorectal 10,4
Stomach 10,2
Based on mortality distribution figures, colorectal cancer for males is the second ranking place of importance
Colorectal cancer in Lithuania 2004 - female
2052
259
263
387
404
508
570
735
1276
1308
0 500 1000 1500 2000 2500
Other
Lung
Kidney
Stomach
Ovary
Corpus uteri
Cervical
Colorectal
Skin
BreastFemale
736 new cases
(9,5% female malignancies)
Site % of cancer death
Breast 17,4
Colorectal 12,6
Ginecological 19,0
Stomach 9,5
Based on mortality distribution figures, colorectal cancer for females is the third ranking place of importance
Colorectal cancer in Lithuania 1978-2002number of the new cases
Population size was stable but total number of
cases has doubled
Ageing of population is the most important contributor of increasing of colorectal cancer.
Woman at elderly make higher proportion of cases
0
500
1000
1500
2000
2500
3000
3500
4000
1978-1982 1983-1987 1988-1992 1993-1997 1998-2002
Male
Female
Number of the new cases
0
5
10
15
20
1977 1982 1987 1992 1997 2002
Inci
denc
e ra
te p
er 1
0000
0 (W
orld
stan
dard
pop
ulat
ion)
male
female
COLON - MORTALITY
0
5
10
15
20
1977 1982 1987 1992 1997 2002
Inci
denc
e ra
te p
er 1
0000
0 (W
orld
stan
dard
pop
ulat
ion) male
femaleCOLON - INCIDENCE
Colon – age adjusted incidence and mortality trends
Sex Rate, incidence/mortality, cases per 100000, world
1978 2002
Male 6,0 / 4,8 15,6 / 8,3
Female 5,6 / 4,8 10,5 / 5,6
0
5
10
15
20
1977 1982 1987 1992 1997 2002
Inci
denc
e ra
te p
er 1
0000
0 (W
orld
stan
dard
pop
ulat
ion) male
femaleRECTAL - INCIDENCE
0
5
10
15
20
1977 1982 1987 1992 1997 2002
Inci
denc
e ra
te p
er 1
0000
0 (W
orld
stan
dard
pop
ulat
ion)
male
female
RECTAL - MORTALITY
Rectum – age adjusted incidence and mortality trends
Sex Rate, incidence/mortality, cases per 100000, world
1978 2002
Male 7,9 / 5,5 18,0 / 9,9
Female 6,4 / 4,8 8,6 / 5,1
Lithuania – can we see a progress in control and management?
Based on these figures – suggestion can been made that diagnostic and clinical management has improved over last decades. Is the progress strong enough?
Rectum Rate, incidence/mortality, cases per 100000, world
1978 2002
Male 7,9 / 5,5 18,0 / 9,9
Female 6,4 / 4,8 8,6 / 5,1
Colon Rate, incidence/mortality, cases per 100000, world
1978 2002
Male 6,0 / 4,8 15,6 / 8,3
Female 5,6 / 4,8 10,5 / 5,6
0
40
80
120
160
200
00-0
4
10-1
4
20-2
4
30-3
4
40-4
4
50-5
4
60-6
4
70-7
4
80-8
4
85+
Age
-spe
cific
inci
denc
e ra
te p
er 1
0000
0
1978-1982
1983-1987
1988-1992
1993-1997
1998-2002
0
40
80
120
160
200
00-0
4
10-1
4
20-2
4
30-3
4
40-4
4
50-5
4
60-6
4
70-7
4
80-8
4
85+
Age
-spe
cific
inci
denc
e ra
te p
er 1
0000
0
1978-1982
1983-1987
1988-1992
1993-1997
1998-2002
0
40
80
120
160
200
00-0
4
10-1
4
20-2
4
30-3
4
40-4
4
50-5
4
60-6
4
70-7
4
80-8
4
85+
Age
-spe
cifi
c in
cide
nce
rate
per
100
000
1988-1992
1993-1997
1998-2002
Female
0
40
80
120
160
200
00-0
4
10-1
4
20-2
4
30-3
4
40-4
4
50-5
4
60-6
4
70-7
4
80-8
4
85+
Age
-spe
cifi
c in
cide
nce
rate
per
100
000
1988-1992
1993-1997
1998-2002
Male
Lithuania colon & rectum by age – lacking power for incidence cases at elderly
Colon – stage distribution 1998-2002
Prediction – based on Finland experience 50% patients should survive
Stage distribution is comparable to Finland in the period of 1985-1994
1998-2002. C18, C19. Male
Stage I-II; 31%
Stage III; 29%
Stage IV; 32%
Unknown stage; 8%
1998-2002. C18, C19. Female
Stage I-II; 30%
Stage III; 32%
Stage IV; 29%
Unknown stage; 9%
Stage IV - percentage of new cases by subsite
Large number of cases still remains diagnosed late – new
clinical implications are needed to change to the positive trend
0
15
30
45
60
93-97 98-02 03-04
RightLeftrectum
Percent
MALE0
15
30
45
60
93-97 98-02 03-04
RightLeftrectum
Percent
FEMALE
Colorectal cancer stage I-II by age and place of residence
Diagnostic services should be improved for rural population
0
10
20
30
40
50
60
iki 55 55-64 65-74 75+
%
Large cities Other urban Rural% of new cases
Colorectal cancer
• Do we have enough power on diagnostics?
Sporadic and hereditary
cancer service
DiagnosisConsultingTreatment (reaserch only)
Oncology Institute
Cancer Registry
Regional Oncology Hospitals
HumanGeneticCenter DNA Isolation
DNA analysis
Public health
Follow-up
University hospitals
Colorectal cancer in Lithuania by subsite
Subsite: right side
Lithuania 1998-2002, %
Other sources,
%Male Female
Apendix 0,2 0,1 0,5
Caecum 6,2 8,8 8
Ascending 2,5 2,4 3
Hepatic flexsure 5,3 7,5 8
Transverse colon 4,8 6,1 6
Splenic flexsure 2,1 1,9 2
Total 21,1 26,8 27,5
Number of new cases at right side almost tripled
0
100
200
300
400
500
600
700
1978-1982 1983-1987 1988-1992 1993-1997 1998-2002
Male
Female
Number of the new cases
C18.0 - C18.3
Colorectal cancer in Lithuania by subsite
Lithuania 1998-2002, %
Other sources,
%Subsite Male Female
Descending colon
8,6 8,7 10
Sigmoid colon 19,6 22,2 20
Total 28,4 30,9 30
Number of new cases at left side almost doubled0
200
400
600
800
1000
1200
1978-1982 1983-1987 1988-1992 1993-1997 1998-2002
Male
Female
Number of the new cases
C18.5 - C18.7 + C19
Colorectal cancer in Lithuania by subsiteLithuania 1998-
2002, %Other
sources, %Subsite Male Female
Rectum 46,6 37,1 38
Anus 1,1 1,4 3
Total 47,7 38,5 41
Number of new cases has slowdown for females0
200
400
600
800
1000
1200
1400
1600
1800
1978-1982 1983-1987 1988-1992 1993-1997 1998-2002
Male
Female
Number of the new cases
C20 - C21
Male
Survival of cancer patients – Lithuania (1990-
1992) and Europe
(Eurocare2)
Colon and rectum:Lithuania is below the European average
0 20 40 60 80
Lung
Stomach
All sites
Prostate
Rectum
Colon
Kidney
Larynx
LithuaniaEurope
Female
Survival of cancer patients – Lithuania (1990-
1992) and Europe
(Eurocare2)
Colon and rectum:Lithuania is below the European average
0 20 40 60 80 100
Lung
Stomach
Rectum
Ovary
Colon
All sites
Cervix utrei
Breast
Kidney
Larynx
Corpus uteri
LithuaniaEurope
Survival of colorectal cancer in Lithuania:
1990-92 1993-95 1996-98 1999-01
Male 25,56 27,74 32,32 37,85
Female 29,35 30,60 37,65 40,56
20
30
40
50
60
70
1990-19921993-19951996-19981999-20012002-2004
1 year 2 year3 year 4 year5 year
20
30
40
50
60
70
1990-19921993-19951996-19981999-20012002-2004
1 year 2 year3 year 4 year5 year
Survival started to improve
Survival of colorectal cancer
stage III
1990-1992
1993-1995
1996-1998
1999-2001
Male 26,91 30,59 32,55 38,78
Female 32,31 32,97 39,52 43,61
Raising figures: Important
improvements in clinical applications
20
35
50
65
80
1990-1992 1993-1995 1996-1998 1999-2001 2002-2004
1 year 2 year
3 year 4 year5 year
20
35
50
65
80
1990-1992 1993-1995 1996-1998 1999-2001 2002-2004
1 year 2 year
3 year 4 year5 year
Colorectal cancer – what we can learn
• Based on mortality ranking, the importance of improvement clinical management of colorectal cancer in Lithuania is undervalued
• Increasing number of cases at right colon indicate on the needs of more extensive colonoscopy examination
• Incidence not high, there are reasonable resources, bur the survival is to low – clear indication on improvement of clinical management of cases
0
5
10
15
20
25
30
35
40
45
50
1990 1995 1996 1997 1998 1999 2000 2001
Sugar (kg)
Oil (kg)
100
150
200
250
300
350
400
450
500
1990 1995 1996 1997 1998 1999 2000 2001
Milk (kg)
Eggs (units)
20
30
40
50
60
70
80
90
100
1990 1995 1996 1997 1998 1999 2000 2001
Vegetables (kg)
Fruits (kg)
0
10
20
30
40
50
60
70
80
90
100
1990 1995 1996 1997 1998 1999 2000 2001
Meat (kg)
Fish (kg)
100
110
120
130
140
150
160
1990 1995 1996 1997 1998 1999 2000 2001
Potatoes (kg)
Grain (kg)
Positive Positive changes in changes in nutritional nutritional pattern pattern during last during last 10 years10 years
Lithuania population - nutrition
Lithuania – population – selected features• Total population 3,4 million• Urban - 67% , rural 33% • Income level (GNP) – 5200 USD• Average size of family – 3,18• Meat consumption - 50 kg per capita per year (137
g/day) • Alcohol consumption – 9,2 ltr per capita year • Life expectancy
– Male - 67 yr Female – 72 yr
• Cars – 1 million (one car per family)• Mobile phones – 3,4 million (one per capita)
What the message provide these figures for us?
Lithuania – population – selected features• Total population 3,4 million• Urban - 67% , rural 33%
• Income level (GNP) – 5200 USD• Average size of family – 3,18
• Meat consumption - 50 kg per capita per year (137 g/day)
• Alcohol consumption – 9,2 ltr per capita a year
• Life expectancy – Male - 67 yr female – 72 yr
• Cars – 1 million (one car per family)• Mobile phones – 3,4 million
There is a money but not for health or healthy life style
Lithuania: – we looking forward
optimistically expecting on
advanced clinical
management of colorectal
cancer
… and song festivals
Thank You
