Cancer incidence and mortality in people aged less than 75 years: Changes in Australia over the period 1987–2007

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CANEP-635; No. of Pages 8
Cancer Epidemiology xxx (2013) xxx–xxx

Contents lists available at ScienceDirect

Cancer Epidemiology
The International Journal of Cancer Epidemiology, Detection, and Prevention
journal homepage: www.cancerepidemiology.net

Cancer incidence and mortality in people aged less than 75 years:
Changes in Australia over the period 1987–2007
Freddy Sitas a,b,c,*, Alison Gibberd a, Clare Kahn a, Marianne F. Weber a, May Chiew a,d,
Rajah Supramaniam a, Louiza Velentzis a, Carolyn Nickson a,e, David P. Smith a,f,
Dianne O’Connell a,b,c,g, Megan A. Smith a,1, Katie Armstrong a, Xue Qin Yu a,b,
Karen Canfell a,b,1, Monica Robotin a,b, Eleonora Feletto a, Andrew Penman a
a

Cancer Council NSW, Australia
University of Sydney, School of Public Health, Australia
c
University of NSW, School of Public Health and Community Medicine, Australia
d
Australian National University, National Centre for Epidemiology and Population Health, Australia
e
Melbourne School of Population and Global Health, University of Melbourne, Australia
f
Griffith Health Institute, Griffith University, Australia
g
University of Newcastle, School of Medicine and Public Health, Australia
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 13 May 2013
Received in revised form 10 September 2013
Accepted 12 September 2013
Available online xxx

Background: Australia has one of the highest rates of cancer incidence worldwide and, despite improving
survival, cancer continues to be a major public health problem. Our aim was to provide simple summary
measures of changes in cancer mortality and incidence in Australia so that progress and areas for
improvement in cancer control can be identified.
Methods: We used national data on cancer deaths and newly registered cancer cases and compared
expected and observed numbers of deaths and cases diagnosed in 2007. The expected numbers were
obtained by applying 1987 age–sex specific rates (average of 1986–1988) directly to the 2007
population. The observed numbers of deaths and incident cases were calculated for 2007 (average of
2006–2008). We limited the analyses to people aged less than 75 years.
Results: There was a 28% fall in cancer mortality (7827 fewer deaths in 2007 vs. 1987) and a 21% increase
in new cancer diagnoses (13,012 more diagnosed cases in 2007). The greatest reductions in deaths were
for cancers of the lung in males (À2259), bowel (À1797), breast (À773) and stomach (À577). Other
notable falls were for cancers of the prostate (À295), cervix (À242) and non-Hodgkin lymphoma (À240).
Only small or no changes occurred in mortality for cancers of the lung (female only), pancreas, brain and
related, oesophagus and thyroid, with an increase in liver cancer (267). Cancer types that showed the
greatest increase in incident cases were cancers of the prostate (10,245), breast (2736), other cancers
(1353), melanoma (1138) and thyroid (1107), while falls were seen for cancers of the lung (À1705),
bladder (À1110) and unknown primary (À904).
Conclusions: The reduction in mortality indicates that prevention strategies, improvements in cancer
treatment, and screening programmes have made significant contributions to cancer control in Australia
since 1987. The rise in incidence is partly due to diagnoses being brought forward by technological
improvements and increased coverage of screening and early diagnostic testing.
ß 2013 Elsevier Ltd. All rights reserved.

Keywords:
Australia
Incidence
Mortality
Cancer

1. Introduction
Cancer is a significant health concern in Australia. While
survival data show some substantial improvements in outcomes
over the past few decades [1], the rate of cancer incidence in

* Corresponding author at: Cancer Council NSW, Australia. Tel.: +61 293341860.
E-mail address: freddys@nswcc.org.au (F. Sitas).
1
Current address: University of NSW, Lowy Cancer Research Centre, Australia.

Australia is still amongst the highest in the world [2]. This high
incidence ranking may give the impression that little progress in
cancer control is being made in Australia [3], while in fact there
have been many cancer related public health programmes
introduced since the late 1980s. These programmes have
addressed early diagnosis, exposure to modifiable risk factors
and improvements in clinical guidelines and treatment protocols.
While it is difficult to accurately assess any specific role these
programmes may have played in changing cancer mortality and
incidence, by investigating changes over the past few decades for

1877-7821/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.canep.2013.09.010

Please cite this article in press as: Sitas F, et al. Cancer incidence and mortality in people aged less than 75 years: Changes in Australia
over the period 1987–2007. Cancer Epidemiology (2013), http://dx.doi.org/10.1016/j.canep.2013.09.010

G Model

2

F. Sitas et al. / Cancer Epidemiology xxx (2013) xxx–xxx

individual cancer types it is possible to identify some of the
possible relationships and areas that warrant further attention.
Rather than reviewing yearly trends in cancer incidence and
mortality across all ages, which has been aptly done by others [1],
our aim was to provide simple summary measures of changes in
cancer mortality and incidence in Australia over a 20 year period.
We focused on the differences in cancer deaths and newly
diagnosed cases of cancer between two time periods, 1987 and
2007, for people under 75 years of age. People aged 75 and over
were excluded from the analysis because (1) older age groups
comprise those who have survived premature mortality from other
chronic disease making cancer a more prevalent cause of death by
default, (2) causes of death and diagnoses are less reliable at older
ages, (3) screening programmes stop at approximately 70 years of
age, and (4) treatments tend to be less aggressive in older patients
[4,5]. Australian mortality data are regarded as accurate and
complete [6], so we focused on mortality in the first instance, then
augmented this information with data on newly diagnosed cases.
2. Methods
Annual numbers of deaths from 1986 to 2008 for each major
cancer type, by age group and sex, were obtained from the
Australian Bureau of Statistics (ABS), which compiles yearly
national mortality statistics. To protect the identity of individuals,
data were grouped into 0–14 years, 15–34 years and 5-year age
groups from 35 to 74 years, with the exception of Hodgkin’s
lymphoma (0–14, 15–49, 50–64 and 65–74 years). However, as the
ABS does not provide cells with counts between 1 and 4, we
imputed values using data from the surrounding years and the
total number of deaths for the cancer site, sex and year.
Counts of cancer cases diagnosed from 1986 to 2008, by sex and
5-year age group, were obtained from the Australian Institute of
Health and Welfare (AIHW), which compiles cancer registration
data from each Australian State and Territory [7]. Age groups were
collapsed to match ABS groupings. For simplicity we refer to
diagnosed cases as incident cases, while acknowledging that
changes may be caused by diagnoses being brought forward by
improvements in screening, diagnostic methods or changes in
cancer registration.
The age- and sex-specific rates in 1987 and 2007 were
estimated by averaging the observed rates from 1986 to 1988
and 2006 to 2008, respectively. These rates were applied to the
2007 age and sex-specific population estimates from the ABS [8], to
calculate the expected and observed numbers of deaths and
incident cases (i.e. events) for 2007. Finally, the observed numbers
were compared to the 2007 expected numbers of events. The same
methods were used to calculate observed and expected events for
each year between 1987 and 2007 to determine the cumulative
total of events over the entire period.
To ensure disease groups were standard, where possible any
changes between ICD-9 and ICD-10 were accounted for with
bridging codes provided by the ABS. Mesothelioma was affected by
these changes and was therefore excluded. A few cancer types
(noted in the tabulations) were grouped differently by ABS and
AIHW.
To estimate trends over time, annual age- and sex-standardised
rates for each cancer type and all cancer types combined were
obtained by the method of direct standardisation, with the 1997
Australian population as the reference population [8]. The analysis
covered the years 1986–2008 for mortality and incidence, but the
average annual percent changes (AAPCs) were calculated for 1987–
2007. AAPCs were calculated using joinpoint regression models
and were fitted to annual age- and sex-standardised logarithmic
rates. Options chosen included calculating AAPCs for the period of
interest only (1987–2007), allowing 0–4 joinpoints, inputting

standard errors, and using the permutation method to determine
the optimal number of joinpoints. Data were analysed using R
2.15.1 [9] and Joinpoint 3.5.4 [10].
3. Results
Tables 1 and 2 show the numbers of deaths and incident cases
observed in 2007 compared to those expected using 1987 rates,
and AAPCs estimated from the age-standardised mortality and
incidence rates.
3.1. Changes in cancer mortality
Overall, 7827 (28%) fewer cancer deaths occurred in 2007 than
would have been expected based on mortality in 1987, and over
the entire period, 1987–2007, there were 61,190 fewer cancer
deaths than expected had the 1987 death rates remained constant.
The greatest reductions in deaths from 1987 to 2007 were for
cancers of the lung in males (À2259, À46%), bowel (À1797, À47%),
breast (À773, À31%), stomach (À577, À50%), and head and neck
(À478, À46%). Improvements in mortality for these five cancer types
(including only lung in males) accounted for 75% (n = 5884) of all the
net decrease in deaths. Other notable changes in mortality were for
cancers of the prostate (À295, À27%), cervix (À242, À62%), nonHodgkin lymphoma (NHL) (À240, À28%), melanoma (À89, À11%)
and all cancers for children 0–14 (À64, À43%). Negligible changes
occurred in mortality for cancers of the lung in females, pancreas,
brain and related, oesophagus and thyroid. A large increase in
mortality from liver cancer was observed (267, 70%) (Table 1).
3.2. Changes in cancer incidence
There were 13,012 (21%) more cases of cancer diagnosed in
2007 than would have been expected based on rates from 1987.
Prostate cancer had the largest increase, by 276% (10,245),
accounting for 79% of the rise in incident cases. Excluding prostate
cancer, the highest incident increases were in cancers of the breast
(2736, 34%), other cancers (1353, 18%), melanoma (1138, 17%) and
thyroid (1107, 198%). Liver (465, 132%) and kidney (excluding
renal pelvis and ureter) (676, 55%) cancers and NHL (584, 27%) also
recorded a higher number of cases than expected in 2007 (Table 2).
Several cancer types recorded fewer cases than expected in 2007
including cancers of the cervix (À690, À52%), bladder (À1110,
À51%), unknown primary (À904, À41%), stomach (À578, À34%),
head and neck (À562, À27%), and lung (À1705, À22%).
4. Discussion
By comparing the number of observed and expected events for
2007 in Australia, we estimate a 28% fall in mortality and a 21%
increase in incidence. AIHW estimates of age standardised
mortality (for all ages) were 212.1/100,000 in 1987 and 176.1/
100,000 in 2007, which is a 17% reduction in mortality [7]. For the
same period AIHW found that incidence rates rose from 408.2/
100,000 in 1987 to 490.1/100,000 in 2007, a 20% increase [7]. The
dominant reason for this fall in cancer mortality is due to the
inclusion of only people under the age of 75 years in our analysis.
Since the late 1980s, many key interventions for the cancer
prevention, screening and treatment have been introduced in
Australia with growing coverage (see Box 1). Over this same period,
there have been marked improvements in cancer mortality and
survival in Australia [7]. Although we are cautious of claiming any
direct causal link between specific programmes and changes in
cancer mortality and incidence, our analysis can provide some
insight into possible outcomes of some key interventions
implemented during the period 1987–2007.


Observed deaths in
2007 (O)
Male

Lung (C33-34)
Bowel (C18-20)
Breast (female) (C50)
Stomach (C16)
Head and Neck (C00-C14, C30-C32)
Unknown primary (C77-80)
Prostate (C61)
Cervix (C53)
Non-Hodgkin lymphoma (C82-C85)
Bladder (C67)
Kidney (C64)
Ovary (C56)
Brain and related (C69-72)
Myeloid leukaemia (C92)
Melanoma (C43)
Lymphoid leukaemia (C91)
Hodgkin lymphoma (C81)
Pancreas (C25)
Oesophagus (C15)
Uterus (C54-55)
Thyroid (C73)
Liver (C22)
Other cancers
All cancers (C00-C97, D45-46, D47.1, D47.3)
0–14 years (All cancers)
a
b

2668
1197
–
368
450
594
799
–
394
218
299
–
535
275
506
126
22
678
506
–
29
460
1410
11,535
46

Female
1555
791
1691
203
109
422
–
152
220
68
139
487
334
174
252
60
14
442
112
176
30
189
951
8569
41

Expected deaths in
2007 (E)
Total
4223
1988
1691
572
560
1017
799
152
614
286
438
487
869
450
759
185
36
1120
618
176
59
649
2361
20,104
87

Male
4927
2205
–
809
843
891
1094
–
504
400
402
–
607
341
556
184
76
698
504
–
26
265
1233
16,566
86

Female
1450
1580
2464
340
196
573
–
394
350
120
265
690
411
241
292
90
44
491
178
220
37
117
823
11,365
65

Difference O-E
Total
6377
3785
2464
1149
1038
1465
1094
394
854
520
668
690
1017
582
848
274
120
1189
682
220
63
382
2057
27,931
151

Male
-2259
À1008
–
À441
À393
À297
À295
–
À110
À182
À103
–
À72
À66
À50
À58
À54
À20
2
–
3
195
177
À5031
À40

Female
105
À789
À773
À137
À87
À151
–
À242
À130
À52
À126
À203
À77
À67
À40
À30
À30
À49
À66
À44
À7
72
128
À2796
À24

Change in deaths (%)
(O-E)/E
Total
À2154
À1797
À773
À577
À478
À448
À295
À242
À240
À234
À230
À203
À148
À132
À89
À89
À84
À69
À64
À44
À4
267
304
À7827
À64

Average annual percentage change (95% CI)

Male

Male

À46
À46
–
À54
À47
À33
À27
–
À22
À46
À26
–
À12
À19
À9
À32
À71
À3
0
–
12
73
14
À30
À47

Female
7
À50
À31
À40
À44
À26
–
À62
À37
À43
À48
À30
À19
À28
À14
À34
À68
À10
À37
À20
À19
62
16
À25
À37

Total
À34
À47
À31
À50
À46
À31
À27
À62
À28
À45
À34
À30
À15
À23
À11
À32
À70
À6
À9
À20
À6
70
15
À28
À43

À3.0
À2.9
–
À3.8
À3.0
À1.9
À1.5
–
À1.3
À2.6
À1.5
–
À0.7
À1.4
À0.5
À1.6
À5.7
À0.3
À0.1
–
0.1
2.3
0.6
À1.8
À2.9

Female
(À3.3,À2.7)
(À3.3,À2.5)
(À4.5,À3.1)
(À3.5,À2.4)
(À3.5,À0.3)
(À2.1,À1.0)
(À2.1,À0.4)
(À3.0,À2.2)
(À1.9,À1.1)
(À1.2,À0.2)
(À1.9,À0.9)
(À0.8,À0.1)
(À2.9,À0.4)
(À7.0,À4.5)
(À0.7,0.1)a
(À0.4,0.2)a
(À1.4,1.7)a
(1.9,2.7)
(0.3,0.9)
(À1.9,À1.6)
(À4.5,À1.2)

0.2
À3.3
À1.8
À2.8
À2.7
À1.5
–
À5.2
À1.8
À2.4
À3.0
À1.8
À0.8
À1.5
À0.9
À1.8
À5.2
À0.4
À1.8
À1.0
À0.9
2.7
0.6
À1.4
À2.3

Total
a

(À0.1,0.4)
(À4.4,À2.2)
(À2.2,À1.5)
(À3.3,À2.3)
(À3.4,À2.0)
(À2.4,À0.5)
(À5.8,À4.6)
(À2.5,À1.0)
(À3.1,À1.7)
(À3.6,À2.4)
(À2.2,À1.5)
(À1.6,À0.0)a
(À2.1,À1.0)
(À1.5,À0.4)
(À3.5,À0.1)
(À6.3,À4.1)
(À0.8,0.0)a
(À2.5,À1.1)
(À2.4,0.4)a
(À2.4,0.6)a
(2.0,3.3)
(À0.2,1.4)a
(À1.5,À1.2)
(À3.0,À1.5)

À2.1
À3.0
À1.8
À3.4
À2.9
À1.8
À1.5
À5.2
À1.5
À2.6
À1.9
À1.8
À0.6
À1.2
À0.6
À1.9
À5.6
À0.4
À0.3
À1.0
À0.3
2.4
0.7
À1.6
À2.7

(À2.3,À1.8)
(À3.4,À2.7)
(À2.2,À1.5)
(À3.6,À3.2)
(À3.5,À2.3)
(À3.1,À0.5)
(À2.1,À1.0)
(À5.8,À4.6)
(À2.0,À1.0)
(À2.9,À2.2)
(À2.4,À1.4)
(À2.2,À1.5)
(À1.2,À0.1)
(À1.9,À0.6)
(À0.9,À0.4)
(À2.8,À0.9)
(À6.4,À4.8)
(À0.9,0.1)a
(À1.0,0.3)a
(À2.4,0.4)a
(À1.3,0.7)a
(2.1,2.7)
(0.4,1.0)
(À1.7,À1.5)
(À3.8,À1.5)

Trend is not statistically signiﬁcant
All ﬁgures have been rounded

G Model


Cancer type



Table 1
Changes in cancer mortality in Australia from 1987 to 2007 for people under 75 years.b

3

b
c
d
e

Female

Total

Male

Female

Total

Male

Female

3612
5121
–
765
1209
748
13,961
–
1617
844
1285
–
704
4569
267
781
573
–
408
622
5611
42,698
321

2302
3653
10,681
365
307
532
–
649
1168
218
620
910
459
3446
213
527
161
1521
1258
194
3371
32,554
271

5915
8774
10,681
1131
1517
1281
13,961
649
2785
1062
1904
910
1162
8015
479
1308
734
1521
1666
816
8982
75,252
592

5786
4921
–
1201
1735
1303
3716
–
1253
1633
789
–
739
3635
226
730
524
–
147
264
4899
33,502
294

1834
3680
7945
508
344
882
–
1339
948
539
439
1077
490
3242
157
540
235
1311
412
87
2729
28,738
245

7620
8600
7945
1709
2079
2185
3716
1339
2201
2172
1228
1077
1229
6877
384
1269
759
1311
559
351
7629
62,240
538

À2174
200
–
À436
À526
À555
10,245
–
364
À789
496
–
À35
934
41
51
49
–
261
358
712
9196
27

468
À27
2736
À143
À37
À350
–
À690
220
À321
181
À167
À31
204
56
À13
À74
210
846
107
642
3816
26

Trend is not statistically signiﬁcant.
All ﬁgures have been rounded.
Data on leukaemias were not available for full time period.
Only incidence data on brain cancer were available.
Only incidence data on lip, tongue and pharyngeal cancers were available.

Difference O-E

Change in incidence
(%) (O-E)/E

Average Annual Percentage Change (95% CI)

Total

Male

Female

Total

Male

À1705
174
2736
À578
À562
À904
10,245
À690
584
À1110
676
À167
À67
1138
95
39
À25
210
1107
465
1353
13,012
54

À38
4
–
À36
À30
À43
276
–
29
À48
63
–
À5
26
18
7
9
–
177
135
15
27
9

26
À1
34
À28
À11
À40
–
À52
23
À60
41
À16
À6
6
35
À2
À32
16
205
122
24
13
11

À22
2
34
À34
À27
À41
276
À52
27
À51
55
À16
À5
17
25
3
À3
16
198
132
18
21
10

À2.4
0.2
–
À2.2
À1.8
À2.5
6.6
–
1.3
À3.2
2.1
–
À0.1
1.3
1.1
0.2
0.3
–
5.1
4.0
0.8
1.2
0.3

Female
(À2.6,À2.2)
(À0.1,0.4)a
(À2.5,À2.0)
(À2.5,À1.0)
(À3.2,À1.7)
(3.7,9.6)
(0.9,1.8)
(À3.4,À2.9)
(1.8,2.4)
(À0.4,0.2)a
(0.7,1.9)
(0.7,1.5)
(À0.2,0.6)a
(0.0,0.6)
(4.6,5.5)
(3.6,4.3)
(0.5,1.0)
(0.7,1.7)
(À0.2,0.9)a

Total

1.1
À0.1
1.5
À1.6
À0.5
À2.7
–
À3.6
1.1
À4.2
1.6
À1.1
À0.4
0.6
1.8
0.1
À1.7
0.9
5.8
4.5
1.0
0.7
0.5

À1.3
0.1
1.5
À2.0
À1.5
À2.6
6.6
À3.6
1.2
À3.3
2.2
À1.1
À0.3
0.9
1.4
0.1
À0.2
0.9
5.6
4.1
0.8
0.9
0.3

(0.9,1.3)
(À0.3,0.1)a
(1.1,1.9)
(À2.0,À1.3)
(À1.3,0.3)a
(À3.5,À1.9)
(À4.3,À2.8)
(0.7,1.5)
(À5.3,À3.1)
(1.3,2.0)
(À1.4,À0.8)
(À1.5,0.8)a
(0.2,0.9)
(1.3,2.3)
(À0.4,0.5)a
(À2.3,À1.1)
(0.6,1.1)
(5.4,6.1)
(3.9,5.1)
(0.7,1.3)
(0.5,0.8)
(0.1,0.9)

(À1.5,À1.1)
(À0.2,0.4)a
(1.1,1.9)
(À2.2,À1.8)
(À2.1,À0.8)
(À3.1,À2.2)
(3.7,9.6)
(À4.3,À2.8)
(0.7,1.6)
(À3.5,À3.0)
(1.6,2.7)
(À1.4,À0.8)
(À1.6,1.0)a
(0.6,1.2)
(1.0,1.7)
(À0.2,0.4)a
(À0.5,0.1)a
(0.6,1.1)
(5.3,5.9)
(3.8,4.4)
(0.6,1.0)
(0.5,1.4)
(0.1,0.6)


a

Expected incidence
in 2007 (E)

Male
Lung (C33-34)
Bowel (C18-20)
Breast (female) (C50)
Stomach (C16)
Head and neck (C00-C02,32)e
Unknown primary (C77-80)
Prostate (C61)
Cervix (C53)
Non-Hodgkin lymphoma (C82-C85)
Bladder (C67)
Kidney (C64)
Ovary (C56)
Brain and related (C71)d
Melanoma (C43)
Hodgkin lymphoma (C81)
Pancreas (C25)
Oesophagus (C15)
Uterus (C54-55)
Thyroid (C73)
Liver (C22)
Other cancers
All cancers (C00-C97, D45-46, D47.1, D47.3)
0–14 years (All cancers)

Observed incidence in
2007 (O)

G Model

Cancer Typec


4


Table 2
Changes in cancer incidence in Australia from 1987 to 2007 for people under 75 years.b

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5

Box 1. Selected cancer control interventions in Australia.
Intervention

Status – late 1980s

Status – around 2010

Smoking
Cervical screening 2-year participation
Breast screening
Breast cancer management guidelines

1987: 34% in males, 28% in females [12,90]
1992: Western Australia 37% [91]
1996/7: 51% coverage [93]
1995: Clinical practice guidelines for the
management of early breast cancer [95]
2000: 18% 50 yrs and over
1995/6: 24/1000 colonoscopies in 65–69 year
olds [23]
1999: Guidelines for prevention, early detection
and management released [24]
Introduced in 1988 ($0%)
1987: 18 RT Units [97]
1981: ‘‘Slip! Slop! Slap!’’ campaign introduced
1989: Campaign extended to ‘‘Slip! Slop! Slap!
Seek! Slide!’’ [68]

2010: 16% in males, 14% in females [12,90]
2009/10: National 57% [92]
2008/9: 55% [94] a
2001: Clinical practice guidelines for the management of
early breast cancer 2nd Edition [95]
2008–2011: 38.4% [96]
2005/6: 50/1000 colonoscopies in 65–69 year olds [23]

Bowel screening

Bowel cancer management guidelines
PSA testing
Radiotherapy
Sun Protection

2005: Guidelines for prevention, early detection and
management updated [28]
56% in NSW men over 45 Years [48]
2011: 56 RT Units (approximately 150 linear accelerators) [98]
2012: NSW Skin Cancer Prevention Strategy 2012–15 [7,99]

a

AIHW report excludes women screened for breast cancer in the private sector. Participation could be higher, up to 68% in NSW [48].

4.1. Cancers with a mortality improvement
Lung cancer in males showed the largest fall in the total
number of cancer deaths. A large proportion of lung cancer cases in
Australia are due to smoking, so it is likely that the fall in lung
cancer can be largely attributed to changes in tobacco consumption. In 1987, adult smoking prevalence was 28% in females and
34% in males [11], and anti-smoking campaigns were in their
infancy [12,13]. While overall smoking rates in men have declined,
smoking became popular with women later in the 20th century
and only started to decline in the 1980s [14]. This has resulted in no
decline of lung cancer mortality and incidence in women during
the study period. The relative contribution to lung cancer rates of
exposures other than tobacco is unclear. Head and neck cancer
has a complex aetiology. Smoking is the primary factor responsible
[15], along with alcohol and, in some cases, human papillomavirus
(HPV) infection [16], including a growing proportion of oropharyngeal cancers [17]. In contrast to lung cancer, similar declines in
mortality were observed for both sexes.
Bowel cancer mortality fell by 47%, but incidence did not
change significantly. The National Bowel Cancer Screening
Programme (NBCSP), offering a one-off faecal occult blood test
(FOBT), was piloted in 2002 and the full programme launched in
2006, so far only targeting Australians turning 50, 55, 60 and 65
years of age [18]. Participation in the programme dropped from
45% during the pilot programme to 40% when rolled out
nationally [19,20]. Screening trials have shown that biennial
FOBTs in people aged 50 years and over could reduce mortality by
15–30% [21,22]. The Australian Government recently announced
the inclusion of additional age groups, with full implementation
scheduled for 2034 [18]. In people aged 65–69 years, colonoscopies performed increased from 24/1000 in 1995/6 to almost 50/
1000 in 2005/6 [23]. The reduction in mortality could be
attributed to improved treatment and adherence to national
management guidelines [24–28], and potentially a result of the
increase in colonoscopies [23] while the full benefits of the
NBCSP have yet to be realised.
Smoking is an important behavioural risk factor associated with
stomach cancer [29], in addition to chronic infection with
Helicobacter pylori [30], the latter being associated with poor
living standards and overcrowding [31,32]. The observed 50% fall
in mortality and 34% fall in incidence reflects improvements in
living standards from the 1920s, when the prevalence of H. pylori
began to fall [33,34]. The continuing decline in smoking rates and
lower prevalence of H. pylori in younger adult groups [32], suggest
future reductions in stomach cancer mortality and incidence.

The 31% fall in female breast cancer mortality is likely to be
due to a combination of reduced population risk, earlier detection,
and improved treatment. After hormone replacement therapy
was linked to an increase in breast cancer risk in 2001 its use
dropped dramatically, corresponding with a concomitant 6.7% fall
in breast cancer incidence in Australian women aged 50 years and
over by 2003 [35]. Australia’s mammographic screening programme, established in 1990, has been estimated to reduce the
risk of breast cancer mortality among participants by about half
[36]. The management of early breast cancer has improved
through therapeutic innovations, and greater consistency was
achieved through the introduction of clinical practice guidelines
in 1995 that resulted in increased use of adjuvant radiotherapy,
chemotherapy and hormone therapy [37,38]. While mortality
decreased over this period, breast cancer incidence increased
overall by 34%. This was partly due to earlier detection by
screening (including some cases that would never have been
diagnosed) and changes in lifestyle factors [39]. Breast cancer
screening programmes have been clouded by conflicting expert
opinion on their benefit, with overdiagnosis being a growing
concern [40–44]. Measuring overdiagnosis is fraught with
methodological difficulties, however, in recent international
reviews of screening programmes it was thought that ecological
studies are the least informative [45].
Prostate cancer mortality began to fall in Australia from the
mid-1990s. Early detection from prostate-specific antigen (PSA)
testing has contributed to a significant increase in diagnosis and
treatment, a reduction in advanced stage disease and potentially,
more recently, mortality [46]. PSA testing, first identified as a
marker for prostate cancer progression in 1987 [47], has been
widely used in screening for prostate cancer in asymptomatic men
from 2001. In Australia PSA testing has now reached population
coverage of other established screening programmes [46,48]. The
27% fall in prostate cancer deaths is consistent with the decrease
observed internationally [49–51]. Improved surgical and radiotherapy techniques in primary treatment appears to explain up to
one-third of the mortality decline in the USA [52], which may be
applicable in Australia and is consistent with our data. Very few
lifestyle or other risk factors have been identified for prostate
cancer, so it is likely that PSA testing is largely responsible for the
276% increase in the number of cases diagnosed [53]. There has
been conflicting evidence from randomised controlled trials to
support population based screening programmes for prostate
cancer [54,55]. However, the increasing coverage of PSA testing in
some countries has seen a large increase in prostate cancer
incidence rates, which, when combined with post treatment


G Model

6


co-morbidities [56], cast significant doubt around the benefits of
screening being greater than the harm caused [57].
Falls in cervical cancer mortality and diagnosis occurred after
the introduction of the National Cervical Screening Programme in
1991, predominantly achieved over the first ten years of the
programme [7]. A 62% fall in mortality is similar to reported
reductions in other developed countries following the introduction
of organised screening programmes [58–61]. The reductions are
largely for squamous cell carcinomas, with comparatively little
reduction in glandular cancers since 1991 [62,63]. Other cases of
cervical cancer are thought to comprise women who are
unscreened or underscreened and women with glandular abnormalities that are difficult to detect or interpret using cytological
screening [63]. The programme is currently undergoing a review to
ensure access for all women and advocate best clinical practice
[64]. Recent work shows that the current biennial programme can
be safely extended to a triennial programme in keeping with
international recommendations [65]. The implementation of the
National HPV (quadrivalent) Vaccination Programme in girls aged
12–13 years is anticipated to further reduce incidence and
mortality over the long term and genital warts in the shorter
term [66]. The HPV vaccine was extended to boys aged 12–13 years
in February 2013, with a two year catch-up for boys aged 14–15
years [67]. It is anticipated that some male genital, oropharyngeal
and other HPV-related cancers (and male genital warts) may be
reduced in the future, and that there may be further benefits in
females, due to herd immunity [66].
Melanoma, often referred to as Australia’s national cancer, is
mainly caused by ultraviolet/sun exposure. Significant effort has
gone into sun protection: national campaigns, ‘‘Slip! Slop! Slap!’’
introduced in 1981 evolved into ‘‘Slip! Slop! Slap! Seek! Slide!’’ in
1989, recommending the public wear long sleeved clothes,
sunscreen, sunglasses and a hat, and seek shade [68] and the
‘‘Mole Patrol’’ campaign [69] started through the Melanoma
Foundation. Considering the extensive sun protection campaigns,
we observed a 17% increase in melanoma and an 11% decline in
mortality over the study period, which seems low. Survival from
melanoma has improved but much of the gain has been due to
improvements in the treatment of thin melanomas. In NSW,
survival from thick melanomas (>1 mm) remained unchanged
between 1994 and 2002 [70]. A detailed age specific incidence
analysis found a fall in incidence in younger age cohorts,
suggesting positive behavioural changes in sun protection [71].
Given the improvements, sun protection campaigns play an
important role in prevention and should be enhanced [69,72].
Bladder cancer incidence and mortality rates both fell, mainly
due to a fall in registration of non-invasive tumours of the bladder
since the late 1980s [73]. Despite the increasing numbers
diagnosed, mortality has fallen for lymphomas, specifically NHL,
probably explained by improvements in NHL treatment, such as the
introduction of monoclonal antibody therapy in 1998 [74].
4.2. Cancers with little or no improvement in mortality
There were only small or non-significant reductions in deaths
from cancers of the thyroid, uterus, brain and related, oesophagus and pancreas. Currently there is limited scope for the
prevention of cancers with unknown or predominantly unmodifiable risk factors. In these cases placing greater emphasis on the
improvement of detection and treatment should be a growing
priority. Although thyroid cancer mortality was stable over time, a
significant increase in incidence was observed, due to increased
use of imaging technologies to diagnose related conditions,
although it is possible that some of the increase is real and due
to other unknown risk factors [75]. Cancers of unknown primary
showed a decline in mortality, potentially caused by changes in

coding between ICD-9 and ICD-10, better differentiation or
improved diagnosis of cancers previously of unknown origin to
specific sites [76].
4.3. Cancers which show increased cases and deaths
We found a 70% increase in mortality and 132% increase in
diagnosed cases of primary liver cancer, similar to previously
reported changes [77]. While alcoholic liver disease was the main
aetiological factor in the 1970s, this was supplanted by Hepatitis B
and C infection in the following decades [78,79]. Australian
immigrants from Southeast Asia, Italy and some other parts of the
world have an increased risk of liver cancer compared to Australian
born residents [80]. The substantial burden of undiagnosed chronic
Hepatitis B infections in some of Australians immigrants, coupled
with the natural history of chronic Hepatitis B infection in
populations where the infection is acquired early in life [81,82]
contributes to about half of the increasing mortality and incidence
in Australia [83].
4.4. Cancers in population subgroups
Although not a key element of the analysis, it is important to
acknowledge Australia’s diverse ethnic composition affects cancer
incidence and mortality rates [84,85]. Since 2008 efforts to
quantify the effects of ethnicity on incidence and mortality have
lead to improvements in recording Aboriginal and Torres Strait
Islander status on pathology, hospital admission, outpatients
forms and the death certificate [86]. Similar improvements are
needed in country of birth registration to improve reporting for
immigrants. Finally, the inclusion of smoking status on the death
certificate, found useful in other nations, could result in more
accurate information on the largest cause of preventable deaths,
including cancers, and help monitor the benefits of quitting
smoking [87–89].
5. Conclusion
This analysis shows that in Australians under 75 years of age,
cancer mortality has decreased by 28% over the period 1987 to
2007. Prevention, improvements in treatment, and screening
programmes, all appear to have an important role in reducing
cancer mortality, and remain important elements of cancer
control. Cancer incidence, however, has increased by 21%, largely
due to diagnoses brought forward by the use of more modern
diagnostic technologies and the increased coverage of screening
and testing programmes. The changes highlighted by our analysis,
however, can only partially explain the observed effect of cancer
control efforts. This type of analysis provides a useful tool for
tracking changes in cancer incidence and mortality over time, and
can help to identify areas requiring further research.
Conflict of interest
The authors of this paper declare no conflict of interest.
Acknowledgements
We would like to thank Mark Short at AIHW and Julia Fitzgerald
from ABS for compiling the tables for us, and for providing
invaluable advice on ICD changes and conversion codes.
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