Articles

Platinum Priority – Prostate Cancer
Editorial by James W.F. Catto on pp. 16–18 of this issue

Trends in Mortality From Urologic Cancers in Europe, 1970–2008

By: Cristina Bosettia lowast , Paola Bertuccioa b, Liliane Chatenouda, Eva Negria, Carlo La Vecchiaa b and Fabio Levic

European Urology, Volume 60 Issue 1, July 2011, Pages 1-15

Published online: 01 July 2011

Keywords: Bladder cancer, Europe, Kidney, Mortality, Prostate, Testis, Trends

Abstract Full Text Full Text PDF (1,8 MB)

Abstract

Background

In recent decades, there have been substantial changes in mortality from urologic cancers in Europe.

Objective

To provide updated information, we analyzed trends in mortality from cancer of the prostate, testis, bladder, and kidney in Europe from 1970 to 2008.

Design, setting, and participants

We derived data for 33 European countries from the World Health Organization database.

Measurements

We computed world-standardized mortality rates and used joinpoint regression to identify significant changes in trends.

Results and limitations

Mortality from prostate cancer has leveled off since the 1990s in countries of western and northern Europe, particularly over the last few years while it was still rising in Bulgaria, Romania, and Russia. In the European Union (EU), it reached a peak in 1995 at 15.0 per 100 000 men and declined to 12.5 per 100 000 in 2006. Mortality from testicular cancer has steadily declined in most countries in western and northern Europe since the 1970s. The declines were later and appreciably lower in central/eastern Europe. In EU, rates declined from 0.75 in 1980 to 0.32 per 100 000 men in 2006, with stronger declines up to the late 1990s and an apparent leveling off in rates thereafter. Over the last 15 years, mortality from bladder cancer has declined in most European countries in both sexes. The major exceptions were Bulgaria, Poland, and Romania. In the EU, bladder cancer mortality was stable until 1992 and declined thereafter from 7.3 to 5.5 per 100 000 men and from 1.5 to 1.2 per 100 000 women in 2006. Mortality from kidney cancer increased throughout Europe until the early 1990s and leveled off thereafter in many countries, except in a few central and eastern ones. Between 1994 and 2006, rates declined from 4.9 to 4.3 per 100 000 in EU men and from 2.1 to 1.8 per 100 000 in EU women.

Conclusions

Over the last two decades, trends in urologic cancer mortality were favorable in Europe, with the exception of a few central and eastern countries.

Take Home Message

Recent trends in mortality from bladder, kidney, and prostate cancer were favorable in most European countries, except a few central/eastern ones. There are still substantial delays in the decline of testicular cancer mortality in central/eastern Europe.

Keywords: Bladder cancer, Europe, Kidney, Mortality, Prostate, Testis, Trends.

1. Introduction

In recent years, there have been substantial changes in mortality from urologic cancers in Europe [1] as well as in North America [2]. These have been essentially due to therapeutic improvements for prostatic [3] and [4] and testicular [5] cancer and decreased exposure to tobacco smoking and occupational exposure to carcinogens for bladder [6] and [7] and perhaps kidney [8] and [9] cancer, particularly in men. To provide updated information on the issue, we systematically analyzed trends in mortality from urologic cancers in Europe over the period 1970–2008.

2. Materials and methods

We abstracted official death certification data from urologic cancers (ie, prostate, testis, bladder, and kidney and other urinary sites) for 33 European countries from the World Health Organization (WHO) database available electronically for the period 1970–2008 [10]. Only countries with a mortality coverage of at least 90% were considered. The European Union (EU) was defined as the 27 member states as of 2004, excluding Cyprus, for which data were only available for a limited number of the most recent years. No extrapolation was made for missing years within a country for one or more calendar years, apart from the calculation of EU rates.

Classification of cancer deaths was recoded for all calendar periods and countries according to the International Classification of Diseases, 10th Revision (ICD-10) (prostate=C61, testis=C62, bladder=C67, and kidney and other urinary sites=C64–C66, C68) [11]. Because the change from the 8th to the 10th revision of the ICD in 1995 in Switzerland caused discontinuities in trends, Swiss data between 1980 and 1995 were corrected using age-specific factors [12].

Estimates of the resident populations were derived from the same WHO database [10]. We computed age-standardized rates at all ages and truncated at ages 35–64 year on the basis of the world standard population [13]. To identify significant changes in trends for 23 major countries and for the whole EU, we performed joinpoint regression analysis [14] and [15].

3. Results

Figure 1a–d and Appendix Table 1 give the joinpoint regression analysis for mortality from cancers of the prostate, testis, bladder, and kidney and other urinary sites in men and women for 23 selected European countries and the EU overall over the period 1970–2008. Figure 2a–d show the age-standardized mortality rates for cancers of the prostate, testis, bladder, and kidney and other urinary sites in men and women from 33 European countries, and in the EU overall in the most recent available calendar period.

gr1a gr1b gr1c gr1d

Fig. 1 Joinpoint analysis for mortality from cancers of the (a) prostate, (b) testis, (c) bladder, and (d) kidney and other urinary sites in 23 selected European countries and in the European Union as a whole, 1970–2008. &z.squf;—&z.squf; men, all ages; □—□ men, 35–64 yr of age; ▴—▴ women, all ages; ▵—▵ women, 35–64 yr of age.

gr2ab gr2cd

Fig. 2 Age-standardized (world population) death certification rates per 100 000 for cancers of the (a) prostate, (b) testis, (c) bladder, and (d) kidney and other urinary sites in 33 European countries and in the European Union (EU) as a whole, 2005–2008.

Overall mortality rates from prostate cancer have leveled off since the 1990s in most countries of western and northern Europe. In the EU as a whole, overall prostate cancer mortality reached a peak in 1995 at 15.0 per 100 000 men, and declined to 12.5 per 100 000 in 2006, with a reduction of 3.8% over more recent years (Fig. 1a). Declines in mortality rates were observed only more recently in the Czech Republic, Hungary, and Poland. Mortality was still rising over the most recent years in Bulgaria, Romania, and the Russian Federation. Rates in middle-age adults (35–64 year of age) were more stable than those for the overall population in most European countries.

In 2005–2008, the highest mortality rates from prostate cancer were in the Baltic countries (>20 per 100 000 men), followed by the Nordic countries. The lowest ones were in the Russian Federation and other central and eastern European countries as well as in Italy (<10 per 100 000 men) (Fig. 2a).

Testicular cancer mortality has steadily declined in most countries from western and northern Europe since the 1970s. However, the declines started later (since the 1980s) and were appreciably lower in central/eastern European countries (Fig. 1b). In the EU overall, rates declined from 0.75 in 1980 to 0.32 per 100 000 men in 2006. Overall rates declined by 4% per year between 1980 and 1999, whereas afterward there was a leveling off in rates, particularly in middle-age men. A slowing down in the declining rates over the last decade was observed in the EU as a whole and in several western European countries.

In 2005–2008, the highest overall mortality rates from testicular cancer were in Bulgaria, Hungary, and Latvia (0.8–0.9 per 100 000 men), followed by other countries of central/eastern Europe (0.5–0.7 per 100 000 men); the lowest ones were in the United Kingdom, other countries of northern Europe, and Spain (<0.2 per 100 000 men) (Fig. 2b).

In the EU as a whole, overall bladder cancer mortality was stable until the early 1990s and declined thereafter, particularly in men, from 7.3 in 1992 to 5.5 per 100 000 in 2006 (Fig. 1c); in EU women, rates declined from 1.5 to 1.2 per 100 000. Mortality rates declined in most European countries in both sexes; the major exceptions were Bulgaria, Poland, and Romania. Truncated mortality rates from bladder cancer were generally more favorable (rates declined from 6.5 in 1984 to 4.3 per 100 000 in 2006 in EU men, and from 1.3 in 1980 to 1.1 per 100 000 in 2006 in EU women).

In 2005–2008, the highest bladder cancer mortality rates in men were in Poland, Spain, Latvia, and Lithuania (>7 per 100 000), followed by other eastern European countries and Denmark (6–7 per 100 000); the lowest ones were in Germany, Austria, Switzerland, Ireland, and Finland (<4 per 100 000) (Fig. 2c). In women, the highest rates were in Denmark (2.3 per 100 000), Hungary, and the United Kingdom (1.7 per 100 000); the lowest ones were in Russia, Finland, Ukraine, and Belarus (<0.8 per 100 000).

Mortality from kidney and other urinary sites cancer increased throughout Europe until the early 1990s but leveled off thereafter (Fig. 1d). Between 1994 and 2006, in EU men rates declined from 4.9 to 4.3 per 100 000 at all ages and from 6.7 to 5.4 per 100 000 at age 35–64 year. In EU women, corresponding falls were from 2.1 to 1.8 per 100 000 and from 2.7 to 2.0 per 100 000. Leveling off or declines in rates were observed particularly in northern and western Europe but also in central/eastern European countries characterized by the highest mortality rates. Despite long-term declines, rates remained extremely high in the Czech Republic. Trends were still upward in Bulgaria and Romania, particularly in men.

The highest mortality rates from kidney cancer in 2005–2008 were in the Czech Republic (9 per 100 000 men and 3.7 per 100 000 women) followed by the Baltic countries (7–8 per 100 000 men and 2.5–2.7 per 100 000 women); the lowest ones were in Greece, Portugal, and Luxembourg (<3 per 100 000 men and <1.2 per 100 000 women) (Fig. 2d).

4. Discussion

Mortality from prostate cancer has been declining over the last few decades in many European countries with originally high rates, while it has been increasing up to more recent years in countries with the lowest rates, with a consequent reduction in the geographic gradient across the continent. The recent favorable trends in prostate cancer mortality in several (western) European countries are consistent with those observed over a comparable period in the United States [2] and [16]. They are likely due to the advancements in the management of this neoplasm [3] and [17], including the wider adoption of radical prostatectomy and a more widespread and rational use of combined antiandrogen therapies and radiotherapy for patients with locally advanced disease [18], [19], [20], and [21]. A delay in the adoption of new treatments may explain the later declines in prostate cancer mortality in central/eastern Europe. The introduction of the prostate-specific antigen (PSA) test has increased the proportion of anticipated diagnoses. This produced an increase in prostate cancer incidence in the past two decades [4], [22], [23], and [24], but its impact on national mortality is difficult to evaluate [25], [26], [27], and [28]. It is also difficult to evaluate the role of changes in risk factors exposure on prostate cancer mortality [29].

Changes in diagnosis and certification of the disease, as well as increased awareness of the disease leading to changes in death certification through the attribution to prostatic cancer of deaths from other causes, may partly explain the upward trends in eastern European countries over more recent calendar years, particularly among the elderly [3], [4], and [30]. However, in Poland and the Russian Federation, trends have been similarly upward in middle age too, indicating that improved diagnosis and certification cannot totally account for the observed trends.

With reference to testicular cancer, the favorable trends observed in most European countries over the last decades are consistent with those observed in the United States [5] and [31], although with a substantial delay, particularly in central/eastern Europe. Because testicular cancer is one of the most curable neoplasms, the favorable pattern in mortality is largely attributed to the introduction (since the 1970s) of effective treatments, mainly platinum-derived chemotherapy [5]. As a consequence of improved treatment, survival from this neoplasm has increased throughout European countries over the last decades [22] and [24]. In contrast to mortality, the incidence of testicular cancer has been increasing in most European countries in the last few decades [22]. The delay in the reduction of mortality rates in countries from central/eastern Europe is mainly due to the inadequate availability of treatments in those countries up to recent calendar years [32]. The slowing down of the declines in testicular cancer mortality in countries of western and northern Europe over the most recent years suggests that mortality from this neoplasm is now reaching a plateau in these countries, as it has in the United States [5].

Bladder cancer mortality has declined in most European countries over the last 15 years. Similar declines were observed in the United States too, although in US men they started earlier [2]. Trends in bladder cancer mortality largely reflect the different patterns of tobacco smoking, its major recognized risk factor [6] and [33], in various generations of men and women across Europe, with larger falls in men from western and northern Europe where the declines in tobacco use began earlier. Indeed, in men, the prevalence of smoking has been declining since the mid-1950s in most western and northern European countries but only since the late 1980s in central/eastern Europe [34], [35], and [36]. The relative risk of bladder cancer is appreciably reduced 5 years after stopping smoking [37]. Control of occupational carcinogens (mainly aromatic amines) has also contributed to the favorable patterns in men from various European countries [38] and [39]. In women, bladder cancer mortality rates over the last years were higher in countries where the tobacco epidemic started earlier, such as Denmark, the United Kingdom, and the Netherlands. However, the falls in female bladder cancer mortality rates are not accounted for by tobacco smoking, which has only recently leveled off in European women [40] and [41]. Part of the declines in women may be due to improved control of urinary tract infections, although their role in bladder cancer risk remains unquantified [6] and [33]. The role of diet [42], as well as of other risk factors (ie, hair dyes, alcohol and coffee consumption) [43] on bladder cancer remains undefined but is unlikely to have been appreciable on national mortality rates [7].

It is difficult to evaluate the potential impact of changes in treatment for bladder cancer on survival because clinical and cancer registration series include a variable proportion of noninvasive and invasive cancers [44]. Any such changes, in any case, are unlikely to largely explain the favorable trends observed in Europe. Although bladder cancer incidence rates are highly influenced by changes in classification, coding, and registration practices, these are less likely to affect mortality rates [6] and [22].

Favorable trends in mortality from kidney cancer have been observed since the 1990s in many European countries. Trends were similar in the United States, with declines particularly in men [2]. Tobacco smoking is the best recognized risk factor for kidney cancer [8] and [45]. Consequently, the reduced prevalence of smoking in most (western and northern) European countries can explain, at least in part, the recent favorable trends in men, although they cannot account for female trends. Likewise, tobacco partly, although not totally, explains the long-lasting excess kidney cancer mortality in both sexes in the Czech Republic.

Another important risk factor for kidney cancer is being overweight [46], and the increased prevalence of overweight and obesity over the last decades in several European countries may have had some unfavorable effect on kidney cancer rates [47] and [48]. Hypertension has also been related to kidney cancer [46], although it remains unclear whether pharmacologic control of hypertension has some effect on kidney cancer mortality [9], [49], and [50]. Kidney cancer risk has been inversely related to consumption of fruit and vegetables [51], [52], and [53], but the role of dietary factors on individual risk, and hence on national mortality rates, remains unquantified [8]. Similarly, the effect of reduced occupational exposures on (male) kidney cancer risk remains undetermined but is likely smaller than for bladder cancer [9] and [54].

In a few countries providing national data, trends in kidney cancer incidence were only slightly less favorable than those of mortality. Improved and earlier diagnosis, through ultrasonography and other imaging techniques, as well as advances in medical and surgical treatments for this neoplasm [55], may therefore have had a limited impact on the mortality trends for kidney cancer, but their role remains undefined [9].

In the interpretation of the trends in urologic cancers across Europe, it is important to consider problems related to random variation, which are greater in smaller populations. Differences across countries in the availability and use of diagnostic techniques and the accuracy of death certification can appreciably influence cancer diagnosis and certification [56] and [57].

5. Conclusions

The present updated analysis shows that trends in urologic cancer mortality were favorable over the last two decades in most of Europe, with the exception of a few eastern countries.

Author contributions: Cristina Bosetti had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: La Vecchia, Levi.

Acquisition of data: Bertuccio.

Analysis and interpretation of data: Bertuccio, Bosetti, La Vecchia.

Drafting of the manuscript: Bosetti.

Critical revision of the manuscript for important intellectual content: Chatenoud, La Vecchia, Levi, Negri.

Statistical analysis: Bertuccio.

Obtaining funding: La Vecchia, Levi, Negri.

Administrative, technical, material support: None.

Supervision: Levi.

Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: This work was conducted with the contribution of the Swiss League Against Cancer, the Swiss Foundation for Research Against Cancer, and the Italian Association for Cancer Research. The sponsor had no role in data analysis and interpretation.

See Table A.1.

Table A.1 Joinpoint analysis of mortality from cancers of the prostate, testis, bladder, and kidney and other urinary sites, at all ages and truncated ages 35–64 yr in selected European countries and in the European Union as a whole, 1970–2008

Men
Trend 1 Trend 2 Trend 3 Trend 4
Years APC Years APC Years APC Years APC
PROSTATE
All ages
Austria 1970–1992 1.1b 1992–2000 −0.7 2000–2008 −3.9b
Bulgaria 1970–1974 −2.6 1974–2008 1.7b
Czech Republic 1986–2004 1.1b 2004–2008 −6.9b
Denmark 1970–1992 2.1b 1992–2006 −0.1
Finland 1970–1998 0.9b 1998–2008 −3.1b
France 1970–1980 0.4 1980–1988 1.7b 1988–2003 −1.3b 2003–2007 −4.3b
Germany 1973–1986 0.6b 1986–1994 1.6b 1994–2006 −2.8b
Greece 1970–2004 1.8b 2004–2008 −2.6
Hungary 1970–2000 0.4b 2000–2008 −4.2b
Ireland 1970–1997 1.7b 1997–2008 −2.5b
Italy 1970–1994 0.6b 1994–2007 −1.9b
Latvia 1980–1998 2b 1998–2006 6.3b 2006–2008 −5
Lithuania 1981–2008 3.2b
Netherlands 1970–1995 1.2b 1995–2008 −2.2b
Norway 1970–1996 1.3b 1996–2007 −2b
Poland 1970–1974 −2.6 1974–1992 1.3b 1992–2001 3.2b 2001–2008 −0.3
Portugal 1971–1986 −0.4 1986–1998 2.4b 1998–2006 −3.2b
Romania 1970–1989 −1.2b 1989–1996 3.2b 1996–2008 0.5
Russian Federation 1980–2001 2.4b 2001–2006 3.4b
Spain 1971–1998 0.5b 1998–2005 −3.4b
Sweden 1970–1975 4.4b 1975–1982 −3.2b 1982–1997 1.4b 1997–2007 −1.3b
Switzerland 1970–1996 0.9b 1996–2007 −2.8b
United Kingdom 1970–1982 0.7b 1982–1985 5.7 1985–1992 2.2b 1992–2007 −1.3b
European Union 1980–1988 1.5b 1988–1995 0.7b 1995–2004 −1.4b 2004–2006 −3.8b
35–64 yr
Austria 1970–1993 0.9b 1993–2008 −2.5b
Bulgaria 1970–1974 −7.1 1974–2008 2.2b
Czech Republic 1986–2008 −0.5
Denmark 1970–1997 2b 1997–2006 −3.1b
Finland 1970–1998 1.4b 1998–2008 −4.3b
France 1970–1990 0.8b 1990–2007 −1.6b
Germany 1973–1989 0 1989–1992 3.8 1992–2006 −1.1b
Greece 1970–2008 0.4
Hungary 1970–2002 0.8b 2002–2008 −5.1b
Ireland 1970–2008 0.2
Italy 1970–1988 −0.1 1988–2007 −2.2b
Latvia 1980–2008 2.7b
Lithuania 1981–2008 2.6b
Netherlands 1970–1989 2.4b 1989–2008 −1.1b
Norway 1970–1998 1.4b 1998–2007 −4.9b
Poland 1970–1996 2b 1996–2008 −0.2
Portugal 1971–1977 5.4b 1977–1983 −4.9 1983–1996 2.1b 1996–2006 −4.1b
Romania 1970–1982 −1.7b 1982–2008 1b
Russian Federation 1980–2006 3.2b
Spain 1971–1998 0.3b 1998–2005 −3.4b
Sweden 1970–1983 −0.3 1983–1993 2.5b 1993–2007 −2.7b
Switzerland 1970–2007 −0.9b
United Kingdom 1970–1992 2b 1992–2007 −1.4b
European Union 1980–1992 1.3b 1992–2006 −1b
TESTIS
All ages
Austria 1970–1974 8.4 1974–2001 −6.1b 2001–2008 6.9
Bulgaria 1970–2008 0
Czech Republic 1986–2008 −4b
Denmark 1970–1977 −3.6b 1977–1982 −16.9b 1982–1987 7.2 1987–2006 −5.2b
Finland 1970–2008 −4.2b
France 1970–1981 −1.7b 1981–1993 −5.8b 1993–2007 −1.8b
Germany 1973–1982 1.4 1982–1998 −6.7b 1998–2006 −3
Greece 1970–1999 −2.7b 1999–2002 24.1 2002–2008 −9.3
Hungary 1970–1978 4.8 1978–2008 −1.7b
Ireland 1970–1981 2.8 1981–1985 −16.3 1985–2008 −3.3b
Italy 1970–1977 −0.2 1977–1996 −6.4b 1996–2007 2.1
Latvia 1996–1908 2
Lithuania 1993–1908 −2.7b
Netherlands 1970–1986 −6.7b 1986–2008 −2.4b
Norway 1970–1993 −7.6b 1993–2007 2
Poland 1970–1981 3.9b 1981–2008 −2.1b
Portugal 1980–2003 0.2
Romania 1970–1990 2.9b 1990–2008 −1.2b
Spain 1971–1974 26.2 1974–2005 −2.3b
Sweden 1970–1977 1.1 1977–1991 −10.6b 1991–2007 0
Switzerland 1970–2007 −4.9b
United Kingdom 1970–1977 0.2 1977–1982 −11.1b 1982–2007 −4.7b
European Union 1980–1999 −4b 1999–2006 −0.5
35–64 yr
Austria 1970–2008 −2.1b
Bulgaria 1970–2008 0.6
Czech Republic 1986–1994 3.8 1994–2008 −4.8b
Denmark 1970–1979 −5.7b 1979–1982 −30 1982–1987 21.3 1987–2006 −4.7b
Finland 1970–2008 −3.9b
France 1970–1976 1.2 1976–1993 −5.3b 1993–2007 −0.8
Germany 1973–1982 1.5 1982–2001 −4.3b 2001–2006 0.7
Greece 1970–2008 −1.9b
Hungary 1970–2008 1.4b
Ireland 1970–2008 −3.1b
Italy 1970–1997 −5b 1997–2007 0.7
Latvia 1996–2008 3.7
Lithuania 1993–2008 −0.4
Netherlands 1970–2008 −4.6b
Norway 1970–2007 −4.6b
Poland 1970–2008 −0.7
Portugal 1980–1990 −8.1b 1990–2003 4.1
Romania 1970–2008 1.2b
Spain 1971–2005 −1.9b
Sweden 1970–1976 6.5 1976–1993 −8.5b 1993–2007 1.5
Switzerland 1970–2007 −3.2b
United Kingdom 1970–2007 −3.9b
European Union 1980–2001 −2.9b 2001–2006 1.7
Men Women
Trend 1 Trend 2 Trend 3 Trend 4 Trend 1 Trend 2 Trend 3 Trend 4
Years APC Years APC Years APC Years APC Years APC Years APC Years APC Years APC
BLADDER
All ages
Austria 1970–1985 −0.8a 1985–2008 −2.1a 1970–1982 1.3 1982–2008 −2.1a
Bulgaria 1970–1997 1.1a 1997–2000 −3.7 2000–2008 3a 1970–2008 0.7a
Czech Republic 1986–2008 −1.5a 1986–2008 0
Denmark 1970–1983 1.7a 1983–1998 −0.7 1998–2006 −3.7a 1970–2006 0
Finland 1970–2008 −1.4a 1970–2008 −1.1a
France 1970–1985 1.5a 1985–2007 −0.9a 1970–2007 −0.6a
Germany 1973–1982 3.4a 1982–1993 −0.6 1993–2006 −4.3a 1973–1981 3.4a 1981–1993 0.4 1993–2006 −2.4a
Greece 1970–1986 2.2a 1986–2008 −0.4a 1970–1985 2.2a 1985–2008 −1.3a
Hungary 1970–1994 1.4a 1994–2008 −1.2a 1970–2008 1.3a
Ireland 1970–1990 0.5 1990–2008 −1.7a 1970–2008 −0.6a
Italy 1970–1983 2.6a 1983–1993 −0.1 1993–1996 −7.1 1996–2007 −2.2a 1970–1982 1.4a 1982–1993 −0.9a 1993–1999 −3.9a 1999–2007 −0.9
Latvia 1996–2008 0.2 1996–2008 −1.5
Lithuania 1993–2008 −0.9a 1993–2008 −0.8
Netherlands 1970–1987 0.6a 1987–2008 −1.9a 1970–2008 −0.1
Norway 1970–1984 1.3a 1984–2007 −0.9a 1970–2007 −0.4a
Poland 1970–1994 1.7a 1994–2008 0 1970–2008 1.5a
Portugal 1980–2006 −0.2 1980–2006 −0.4
Romania 1970–1980 0.1 1980–1987 3.7a 1987–2008 0.7a 1970–1990 1.8a 1990–2008 −0.8a
Russian Federation 1999–2002 2.7 2002–2006 −2.3 1999–2006 −0.4
Spain 1971–1977 4.4a 1977–1980 −2.2 1980–1992 1.7a 1992–2005 −0.4a 1971–1978 4.5a 1978–1983 −3.2 1983–1986 6.3 1986–2005 −1.1a
Sweden 1970–2007 −0.5a 1970–1995 −1.1a 1995–2007 0.8
Switzerland 1970–1985 1.7a 1985–2007 −2.1a 1970–2007 −0.8a
United Kingdom 1970–1992 −0.5a 1992–2007 −2.9a 1970–1990 0.1 1990–2007 −1.6a
European Union 1980–1983 1.5 1983–1992 0 1992–2006 −1.9a 1980–1992 0 1992–2006 −1.5a
35–64 yr
Austria 1970–2008 −2.4a 1970–2008 −2a
Bulgaria 1970–2008 0.9a 1970–1974 −11.1 1974–2008 2a
Czech Republic 1986–2008 −3.2a 1986–2008 −0.3
Denmark 1970–1985 0.6 1985–2006 −3.4a 1970–2006 −0.9a
Finland 1970–2008 −2.1a 1970–2008 −2.3a
France 1970–1985 1.4a 1985–2007 −1.5a 1970–1994 −2.1a 1994–2007 1.5
Germany 1973–1984 1.9a 1984–2006 −3.9a 1973–1976 10.1 1976–2006 −1.4a
Greece 1970–1985 0.6 1985–2008 −1.4a 1970–2008 −2.5a
Hungary 1970–2005 1.2a 2005–2008 −8.9 1970–2008 2.6a
Ireland 1970–2008 −2.1a 1970–2008 −2.1a
Italy 1970–1982 1.3a 1982–1991 −1.6a 1991–1997 −7a 1997–2007 −2.5a 1970–2007 −1.9a
Latvia 1996–2008 −0.3 1996–2008 −3
Lithuania 1993–2008 −1.8 1993–2008 −3.5
Netherlands 1970–1988 −0.9a 1988–2008 −2.6a 1970–2008 0.4
Norway 1970–2007 −1.6a 1970–2007 −0.3
Poland 1970–1989 2.5a 1989–2008 −1a 1970–2008 1.3a
Portugal 1980–2006 −0.6a 1980–2006 −1.6a
Romania 1970–1977 −0.9 1977–1993 2.5a 1993–2008 −0.8a 1970–2001 0.3 2001–2008 −6.2a
Russian Federation 1999–2001 3.7 2001–2006 −3.7a 1999–2006 0.5
Spain 1971–1976 3.8 1976–2005 0.1 1971–2005 −0.9a
Sweden 1970–2007 −1.4a 1970–2007 −0.7a
Switzerland 1970–2007 −2a 1970–2007 −1.5a
United Kingdom 1970–1991 −1.4a 1991–2007 −4a 1970–1978 1.5 1978–2007 −2.3a
European Union 1980–1984 0.4 1984–1992 −1a 1992–1997 −3.3a 1997–2006 −1.9a 1980–2006 −1.1a
KIDNEY
All ages
Austria 1970–1989 1.4a 1989–2008 −2.2a 1970–1992 0.3 1992–2008 −3a
Bulgaria 1970–2001 2.3a 2001–2008 5.6a 1970–2008 1.2a
Czech Republic 1986–1992 2.3a 1992–2004 −0.7 2004–2008 −4.8a 1986–1994 4.1a 1994–1997 −7.8 1997–2001 2.2 2001–2008 −4.2a
Denmark 1970–2006 −0.5a 1970–1986 0.3 1986–2006 −2.5a
Finland 1970–1990 1.6a 1990–2008 −2.2a 1970–1989 1.2a 1989–2008 −1.8a
France 1970–1987 2.3a 1987–2007 −0.2 1970–1974 4.4 1974–2002 0 2002–2007 −4.2a
Germany 1973–1981 2.8a 1981–1984 9.2 1984–1993 0.4 1993–2006 −1.8a 1973–1981 0.6 1981–1984 10.6 1984–1993 0.3 1993–2006 −2.2a
Greece 1970–1996 2.1a 1996–2008 0.4 1970–2008 1.1a
Hungary 1970–1991 2.9a 1991–1999 0.6 1999–2008 −2.4a 1970–1999 1.4a 1999–2008 −3.9a
Ireland 1970–2008 1.4a 1970–2008 0.7a
Italy 1970–1989 3.6a 1989–2007 −1.3a 1970–1989 2.2a 1989–2007 −1.4a
Latvia 1996–2008 0.3 1996–2008 −0.5
Lithuania 1993–2008 −0.1 1993–2008 −0.9
Netherlands 1970–1986 1.8a 1986–2008 0 1970–1986 1.2a 1986–2008 −0.5a
Norway 1970–1982 2.1a 1982–2007 −0.7a 1970–2001 −0.1 2001–2007 −6.8a
Poland 1999–2008 −0.4 1999–2001 6.1 2001–2006 −3.3 2006–2008 2.2
Portugal 1984–2003 1.1a 1984–2003 −0.1
Romania 1999–2008 3.3a 1999–2008 −0.3
Spain 1971–1982 1.7a 1982–1997 3.6a 1997–2000 −4.4 2000–2005 0.7 1971–1982 −0.5 1982–1997 1.8a 1997–2005 −1.5
Sweden 1970–1977 1.8 1977–2007 −1.6a 1970–1973 4.6 1973–2007 −1.5a
Switzerland 1970–1988 1.2a 1988–2007 −2.1a 1970–1984 1.4a 1984–2007 −2.5a
United Kingdom 1970–1977 2.4a 1977–1980 −2.8 1980–1984 4.7a 1984–2007 0.4a 1970–1980 0.4 1980–1991 2.4a 1991–1999 −1 1999–2007 1.1a
European Union 1980–1984 4.3a 1984–1994 1.1a 1994–2006 −0.9a 1980–1984 4a 1984–1994 0.5a 1994–2006 −1.4a
35–64 yr
Austria 1970–1989 0.7a 1989–2008 −3.7a 1970–1984 0.7 1984–2008 −3.5a
Bulgaria 1970–2008 2.9a 1970–2008 1.9a
Czech Republic 1986–2005 −1.5a 2005–2008 −8.5 1986–1993 2.1 1993–2008 −4.8a
Denmark 1970–2006 −0.9a 1970–1979 3.7 1979–2006 −3.4a
Finland 1970–1989 1.4a 1989–2008 −3a 1970–1982 1.7 1982–2008 −2.6a
France 1970–1986 2.3a 1986–2007 −0.8a 1970–1980 1.4 1980–2005 −0.8a 2005–2007 −13.2
Germany 1973–1981 1.3 1981–1984 8.7 1984–1993 −1 1993–2006 −3.4a 1973–1990 2a 1990–2006 −4a
Greece 1970–1983 3a 1983–2008 0.2 1970–2008 0.2
Hungary 1970–1990 3.6a 1990–2008 −0.8a 1970–1995 1.5a 1995–2008 −2.3a
Ireland 1970–2008 0.5 1970–2008 −0.3
Italy 1970–1986 3.5a 1986–2007 −2a 1970–1987 2.7a 1987–2007 −2.4a
Latvia 1996–2008 −1 1996–2008 −3.4
Lithuania 1993–2008 −0.9 1993–2008 −2.4a
Netherlands 1970–1987 1a 1987–2008 −1.3a 1970–1983 2.1a 1983–2008 −1.5a
Norway 1970–2007 −0.8a 1970–2002 −0.9a 2002–2007 −13.6
Poland 1999–2008 −1.4a 1999–2008 −1.7a
Portugal 1984–2003 0.6 1984–2003 −0.7
Romania 1999–2008 3.6a 1999–2008 0.7
Spain 1971–1997 2.8a 1997–2005 −0.9 1971–2005 0.5a
Sweden 1970–1978 1.8 1978–2007 −2.7a 1970–1982 0.6 1982–2007 −3.1a
Switzerland 1970–1985 0.4 1985–2007 −2.8a 1970–1979 4.2a 1979–2007 −3.5a
United Kingdom 1970–1990 1.4a 1990–2007 −0.8a 1970–1991 1.8a 1991–2007 −1.7a
European Union 1980–1984 4.7a 1984–1994 0.1 1994–2006 −1.7a 1980–1984 3.6a 1984–1994 −0.3 1994–2006 −2.4a

a First and last year available.

b Significantly different from 0 (p < 0.05).Note: Data for testicular and kidney cancers were not available for Belarus, the Russian Federation, and Ukraine. For Switzerland, data for testicular and kidney cancers between 1995 and 2007 were obtained from the Swiss National Institute for Epidemiology and Registration & Federal Statistic Office [11]. For the Czech Republic, Latvia, Lithuania, and the Russian Federation, data were available since the early/mid 1980s. For Belgium, data were available up to 1999 and for 2004; for Slovakia and Spain, up to 2005; for Denmark, Germany, Luxembourg, Portugal, and the Russian Federation, up to 2006; for Belarus, France, Italy, Norway, the United Kingdom, Switzerland, and Sweden, up to 2007.

APC=annual percentage change.

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Footnotes

a Dipartimento di Epidemiologia, Istituto di Ricerche Farmacologiche “Mario Negri,” Milan, Italy

b Dipartimento di Medicina del Lavoro, Università degli Studi di Milano, Milan, Italy

c Unité d’epidémiologie du cancer et Registres Vaudois et Neuchâtelois des Tumeurs, Institut de médecine sociale et préventive (IUMSP), Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland

lowast Corresponding author. Department of Epidemiology, Istituto di Ricerche Farmacologiche “Mario Negri”, Via Giuseppe La Masa 19, 20156 Milan, Italy. Tel. +39 0239014 526; Fax: +39 0233200 231.

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