More on the Mortality Conjecture: The Components of Demographic Mortality

Trends in All-Cause Mortality Rates in Patients with Follicular Lymphoma in the US before and during the COVID-19 Pandemic: A Retrospective Observational Study

Context: Previous studies documented significant international variation in prostate cancer rates due to differences in detection practices, availability of treatment, and genetic factors. Objective: To provide updated contemporary prostate cancer incidence and mortality patterns across five continents using the most recent cancer incidence data from the International Agency for Research on Cancer and mortality data from the World Health Organization (WHO). Evidence acquisition: We present estimated age-standardized prostate cancer incidence and mortality rates by country and WHO regions for 2012 based on GLOBOCAN. We examined long-term (1980 onwards) trends in prostate cancer incidence and mortality rates for 38 countries with high quality population-based incidence and mortality data. Trends were expressed as annual percent change using Joinpoint model. We also examined short-term (most recent 5 years) trends in prostate cancer among 44 countries with available incidence data and 71 countries with available mortality data. Evidence synthesis: The highest incidence rates during the most recent 5 years are found in Brazil, Lithuania, and Australia, whereas the lowest incidence rates are found in Asia (India, Thailand, and Bahrain). The highest mortality rates are found in the Caribbean (Barbados, Trinidad and Tobago, and Cuba), sub-Saharan Africa (South Africa), parts of former Soviet Union (Lithuania, Estonia, and Latvia), whereas the lowest rates are found in Asia (Thailand and Turkmenistan). Of the 44 countries with high quality incidence data, prostate cancer incidence rates during the most recent five data years increased in 4 countries (with Bulgaria showing the largest increase), decreased in 7 countries (with the biggest decrease in the United States), and stabilized in the remaining 31 countries. During the same time period, in contrast, among the 71 countries considered for the mortality trend, rates decreased in 14 countries, increased in 3 countries, and remained stable in 54 countries. Conclusions: In 2012, prostate cancer was the most commonly diagnosed cancer among men in 96 countries and the leading cause of death in 51 countries. In the most recent 5 years of data examined, prostate cancer incidence and mortality rates are decreasing or stabilizing in most parts of the world. Future studies should monitor trends in mortality rates and late-stage disease to assess the impact of reduction in PSA testing in several countries. Citation Format: MaryBeth Freeman, Ahmedin Jemal. Global variation in prostate cancer incidence and mortality rates, 1980-2013 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-171.

The national breast screening program of the Netherlands was gradually implemented from 1987 to 1997. Dutch women aged 50–69 years were first invited to screening. From 1997 on, women 70–75 years of age were also invited to screening. In their article, Sankatsing et al. have analyzed trends in breast cancer mortality from 1980 to 2010 among women 40–79 years of age after setting the year of screening introduction, i.e., the turning year, as the year for examining incidence trends in years preceding and following screening introduction.1 A further analysis restricted to women aged 55–74 year was done after a categorization of the municipalities in three groups, those with early (1987–1992), intermediate (1993–1994) and late (1995–1997) introduction of screening. From the later analysis, the authors claim that the age-standardized mortality rates before and after the introduction of screening would be similar in the three groups of municipalities. This claim led to the conclusion that breast cancer mortality reductions should be due to screening and not to treatments. We disagree with the method used in this study as well as with the reporting and interpretation of results. First, setting the year of screening introduction as the starting point for assessing trends is artificial because it does not reflect the actual temporal relationships between trends in mortality rates and screening introduction. The real question is to assess how temporal trends in mortality are influenced by screening implementation. To this end, we analyzed the group-specific rates from around 1980 to 2010 reported in the Table 1b of the article Appendix using the joinpoint regression method developed by the US. National Cancer Institute (version 4.4.0.0 of January 2017 with three joinpoints maximum and Poisson regression variance).2 This regression method is the most commonly used for the analysis of temporal trends. It is based on a log-linear model that identifies inflexion points, called joinpoints, separating periods with statistically significant (at p = 0.05) distinct trends in incidence rates. In the early starter group, the analysis found that breast cancer mortality rates started to decline in 1987, after which a steady downward trend of −1.5% per year was observed until 2010. In the intermediate starter group, the analysis found a continuous decrease of mortality rates of −1.3% per year from 1980 to 2010 without inflexion year. In the late starter group, the analysis found that the mortality decline started in 1998, followed by a steady downward trend of −3.0% per year. The absence of a lag-time of at least 3–5 years between screening start and changes in mortality trends in municipalities with early and late screening introduction, as well as the absence of changes in trends in the municipalities with intermediate introduction do not support the hypothesis that screening implementation would be the main cause of changes in breast cancer mortality rates in the Netherlands. Second, we do not understand how municipalities were grouped, as the periods being considered is of 6-year duration in the early starter group of municipalities, two years in the intermediate starter group, and three years in the late starter group. This way of grouping municipalities contrasts with the previous work in which grouping years were 1988–1991, 1992–1993, 1994–1995, 1996–1997.3 Because the turning year in a group was set at the midpoint year of the period considered for the group, the differences in period durations may have introduced substantial imbalance between groups in terms of pre-screening and post-screening mortality data included in the analyses. Third, we do not understand why the article did not report results of the same analysis in women in the 40–54 and 74–79 age groups. If screening was truly the main cause of declining trends, then trends women aged 40–54 and 74–79 years according to the turning year should be substantially different than trends observed in women 55–74 years of age. We re-analyzed with the joinpoint regression method the age-specific breast cancer mortality rates taking mortality data of Dutch women from the WHO mortality database.4 The results are displayed in the Figure 1. In women aged 40–54 years, after the joinpoint year of 1993, rates until 2010 declined by 33%. In women aged 55–74 years, after the joinpoint year of 1993, rates until 2010 declined by 30%. In women aged 75–79 years, after the joinpoint year of 1999, rates until 2010 declined by 38%. In women aged 80 years or more, after the joinpoint year of 1995, rates until 2010 declined by 20%. Hence, declines in women aged 40–54 years reflecting mortality in young age groups not invited to screening started the same year and were of same magnitude than in women aged 55–79 years reflecting mortality in age groups invited to screening. Moreover, the inflexion year of 1993 occurred when screening was implemented in early starter municipalities only, which according to Table 1 of the article, would represent about 44% of the total population. The inflexion in rates in women aged 80 years or more occurred too early for being due to screening. The changes observed in age-specific breast cancer mortality rates over time are essentially the consequence of the introduction of a factor that has affected mortality in all age groups, irrespective of invitation to screening. This factor is most likely the greater provision of adjuvant therapies to Dutch breast cancer patients after 1985 that has been quite equivalent in all age groups.5 The lag-time of at least 8 years between the steep raise in access to adjuvant therapies and the starting years of mortality declines is also consistent with an effect of adjuvant therapies on mortality. Trends in age-specific breast cancer mortality rates in women aged 40 years or more in the Netherlands, 1980–2010 (APC: annual percent change). We certainly agree that the diffusion of mammography screening in populations has much contributed to foster breast awareness and to improve the organization of breast cancer patient management. However, the analysis of mortality data from the Netherlands using standard statistical methods for evaluating temporal trends does not provide clear evidence that mammography screening itself has markedly contributed to the breast cancer mortality reductions observed since 1993.

The aim of this study was to investigate annual and seasonal trends in mortality rates from cardiovascular diseases in Hungary between 1984 and 2013. Annual and monthly mortality and population data were obtained from the Hungarian Central Statistical Office. The annual mortality data by gender and age were available for the following disease classifications of the circulatory system: all cardiovascular diseases, all diseases of the heart, hypertension, coronary heart disease, and cerebrovascular diseases. Six age groups were defined for both sexes. Negative binomial regression was carried out to analyse annual trends in age-standardized mortality rates. The Walter-Elwood method was used to identify seasonal variation using monthly numbers of deaths. Significant decreases in annual mortality rates for all cardiovascular diseases were found, but not for hypertension. Age-standardized death rates were higher for men for all causes, except for hypertension. The greatest sex difference in the average risk of death was observed in the middle-aged groups. The greatest percentage decrease in death rates during the study period was seen for both sexes in the under 35 age group. The lowest percentage change was observed among people aged over 75. Significant seasonality was found in monthly death rates from all causes, with a peak in February. In spite of a decreasing trend in the annual mortality rates for cardiovascular diseases, the Hungarian mortality rate is still high. Moreover, this study demonstrated a significant winter peak in mortality from cardiovascular diseases over a thirty-year period.

The recent trend of death rates from heart diseases, respectively at farm villages, fishing hamlets, and large towns in Japan, was examined in the variety of existing vital statistics.The chief conclusions are as follows.The trend of crude death rate from heart diseases, for the past ten years, has been year by year rather increasing. Now, examining the death rate by age groups, we find that, at the advanced age over eighty, it has by bits increased, but, at the age below that, it has rather decreased. As for the type of diseases, ischemic heart disease has increased a little at the advanced age, but below the middle age, it has rather decreased, and chronic rheumatic and hypertensive heart diseases have also decreased. On the other hand, heart failure and other heart diseases have rather increased.Examining the trend of death rates from heart diseases for the past 25 years, classified, by using the proportion of industrial inhabitants, into the prefecture of farming, that of fishing, and large cities, we find that the death rate from ischemic heart diseases has been high as to the advanced age in large cities, and the death rate from heart failure and other heart diseases has been high as to the advanced and middle ages in the prefecture of farming.From the above, it has become clear that the chief cause of the increases of heart diseases of recent years is the increase of heart failure and other heart diseases, and that it is chiefly discernible at farming villages.Next, we investigated the death rate. from heart diseases separately of villeges which may intimately be related to our lives, in respect of the three villages and towns in the West Izu. The result is that the death rate is high in the towns, and then in the district of farming, and is the lowest in that of fishing. This kind of examination is expected to be done widely in Japan, and the universal conclusion to be got.In addition to the above, we investigated the trend of death rate from heart diseases, from the “ Special Report of Vital Statistics: Occupational and Industrial Aspect”, and we clarified and reported that the death rate of agriculture, forestry and fishing workers, as well as urban occupation, was high in degree, and that, from the investigation separately of the cities, towns and villages of Chiba Prefecture, there was a statistically significant relation between the ratio of agricultural population and the death rate from heart diseases.

Time Trends of Ulcer Mortality in Europe

Aims/hypothesisThe aim of this study was to describe the long-term trends in cancer mortality rates in people with type 2 diabetes based on subgroups defined by sociodemographic characteristics and risk factors.MethodsWe defined a cohort of individuals aged ≥35 years who had newly diagnosed type 2 diabetes in the Clinical Practice Research Datalink between 1 January 1998 and 30 November 2018. We assessed trends in all-cause, all-cancer and cancer-specific mortality rates by age, gender, ethnicity, socioeconomic status, obesity and smoking status. We used Poisson regression to calculate age- and calendar year-specific mortality rates and Joinpoint regression to assess trends for each outcome. We estimated standardised mortality ratios comparing mortality rates in people with type 2 diabetes with those in the general population.ResultsAmong 137,804 individuals, during a median follow-up of 8.4 years, all-cause mortality rates decreased at all ages between 1998 and 2018; cancer mortality rates also decreased for 55- and 65-year-olds but increased for 75- and 85-year-olds, with average annual percentage changes (AAPCs) of –1.4% (95% CI –1.5, –1.3), –0.2% (–0.3, –0.1), 1.2% (0.8, 1.6) and 1.6% (1.5, 1.7), respectively. Higher AAPCs were observed in women than men (1.5% vs 0.5%), in the least deprived than the most deprived (1.5% vs 1.0%) and in people with morbid obesity than those with normal body weight (5.8% vs 0.7%), although all these stratified subgroups showed upward trends in cancer mortality rates. Increasing cancer mortality rates were also observed in people of White ethnicity and former/current smokers, but downward trends were observed in other ethnic groups and non-smokers. These results have led to persistent inequalities by gender and deprivation but widening disparities by smoking status. Constant upward trends in mortality rates were also observed for pancreatic, liver and lung cancer at all ages, colorectal cancer at most ages, breast cancer at younger ages, and prostate and endometrial cancer at older ages. Compared with the general population, people with type 2 diabetes had a more than 1.5-fold increased risk of colorectal, pancreatic, liver and endometrial cancer mortality during the whole study period.Conclusions/interpretationIn contrast to the declines in all-cause mortality rates at all ages, the cancer burden has increased in older people with type 2 diabetes, especially for colorectal, pancreatic, liver and endometrial cancer. Tailored cancer prevention and early detection strategies are needed to address persistent inequalities in the older population, the most deprived and smokers.Graphical abstract

Colorectal cancer has a high worldwide incidence. Japan, a country that is geographically and culturally similar to the Republic of Korea (here after Korea), has recently reported a decreasing trend in the incidence of colorectal cancer. However, Korea had the highest incidence of colorectal cancer among Asian countries in 2012. Our aim was to observe the changing trends in incidence and mortality of colorectal cancer in Korea and to compare them to those in Japan. Incidence data were collected from the Korean Central Cancer Registry and mortality data were collected from Korean Statistical Information Service. Incidence and mortality data on colorectal cancer in Japan were acquired from the National Cancer Center in Japan. Age-standardized incidence and mortality rates were determined based on Segi’s world population. Screening data from both countries were collected from the national cancer center in each country. In Korea, the age-standardized incidence rate of colorectal cancer in both sexes was 20.9 to 38.0 per 100,000 from 1999 to 2012 and the rate in males increased more dramatically than in females. In addition, the increase between 2002 and 2012 was first observed in the age group over 40. In Japan, the incidence of colorectal cancer has been more constant over recent years than in Korea. The age-standardized mortality rate of colorectal cancer in both sexes in Korea was 8.5 to 9.3 per 100,000 from 2000 to 2013, and the trend in mortality was constant during this period. In Japan, the mortality rate decreased slightly during the same period. Crude screening rates were increased overall in both Korea and Japan during the period studied. Since the incidence of colorectal cancer has increased in Korea, the control of this cancer is an important public health issue. As Japan has achieved a reduction in colorectal cancer, adjustment of Korea’s current systems for screening and treatment of colorectal cancer according to those of Japan may contribute to improved colorectal cancer control in Korea.

SummaryBackgroundWith global survival increasing for children younger than 5 years of age, attention is required to reduce the approximately 1 million deaths of children aged 5–14 years occurring every year. Causes of death at these ages remain poorly documented. We aimed to explore trends in mortality by causes of death in India, China, Brazil, and Mexico, which are home to about 40% of the world's children aged 5–14 years and experience more than 200 000 deaths annually at these ages.MethodsWe examined data on 244 401 deaths in children aged 5–14 years from four nationally representative data sources that obtained direct distributions of causes of death: the Indian Million Death Study, the Chinese Disease Surveillance Points, mortality data from the Mexican Instituto Nacional de Estadística y Geografía, and mortality data from the Brazilian Institute of Geography and Statistics. We present data on 12 main disease groups in all countries, with breakdown by communicable and nutritional diseases, non-communicable diseases, injuries, and ill-defined causes. To calculate age-specific and sex-specific death rates for each cause, we applied the national cause of death distribution to the UN mortality envelopes for 2005–16 for each country.FindingsUnlike Brazil, China, and Mexico, communicable diseases still account for nearly half of deaths in India in children aged 5–14 years (73 920 [46·1%] of 160 330 estimated deaths in 2016). In 2016, India had the highest death rates in nearly every category, including from communicable diseases. Fast declines among girls in communicable disease mortality narrowed the gap by 2016 with boys in India (32·6 deaths per 100 000 girls vs 26·2 per 100 000 boys) and China (1·7 vs 1·5). In China, injuries accounted for the greatest proportions of deaths (20 970 [53·2%] of 39 430 estimated deaths, in which drowning was a leading cause). The homicide death rate at ages 10–14 years was higher for boys than for girls in Brazil, increasing annually by an average of 0·7% (0·3–1·1). In India and China, the suicide death rates were higher for girls than for boys at ages 10–14 years. By contrast, in Mexico it was higher for boys than for girls, increasing annually by an average of 2·8% (2·0–3·6). Deaths from transport injuries, drowning, and cancer are common in all four countries, with transport accidents among the top three causes of death for both sexes in all countries, except for Indian girls, and cancer in the top three causes for both sexes in Mexico, Brazil, and China.InterpretationMost of the deaths that occurred between 2005 and 2016 in children aged 5–14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required.FundingWHO and the University of Toronto Connaught Global Challenge.

In accordance with the age parameters specified in Sustainable Development Goal target 3.4, current policy and monitoring of non-communicable disease (NCD) mortality trends focus on people aged 30-69 years. This approach excludes the majority of NCD deaths, which occur at older ages. We aimed to compare cardiovascular mortality for different age groups in the WHO Region of the Americas. We extracted mortality data from the Pan American Health Organization regional mortality database for 36 countries for the period 2000 to 2015. We calculated age-standardised mortality rates (ASMRs) from cardiovascular diseases for different age groups for these countries. Joinpoint regression models were used to estimate mortality trends, providing estimates of the average annual percentage change for the period 2000-15. Individuals aged 70 years or older accounted for the majority of cardiovascular disease deaths in all countries (range 52-82%). Considerable variation in cardiovascular deaths was observed between countries for all age categories. Between 2000 and 2015, in most countries, the largest reductions in ASMR were observed in the older age groups (aged ≥70 years). The total number of regional cardiovascular disease deaths that hypothetically could have been averted in 2015 for people aged 30-79 years was 440 777, of which 211 365 (48%) occurred among people aged 70-79 years. Data for the WHO Region of the Americas are sufficiently robust to permit comparative analysis of cardiovascular disease mortality trends for people aged 70 years and older over time and across countries. Although the reduction of cardiovascular disease mortality in individuals aged 30-69 years is a valid policy goal for the Americas region, this objective should be expanded to include people at older ages. None.

The process of the restructuring of health care system in Lithuania demonstrates the need to continue the monitoring of changes in avoidable mortality. To assess the level of avoidable mortality as well as its changes over time in Lithuania during 2001-2008 and to define the impact of avoidable mortality on life expectancy. The mortality data were taken from the Lithuanian Department of Statistics. Twelve avoidable causes of deaths (treatable and preventable) were analyzed. Mortality trends were assessed by computing the average annual percent change (AAPC). The shortening of average life expectancy was computed from survival tables. During the period 2001-2008, the avoidable mortality was increasing more significantly (AAPC 3.0%, P<0.05) than the overall mortality (AAPC 1.7%, P<0.05) in the population aged 5-64 years. The increasing trend was mainly determined by mortality from preventable diseases (AAPC 4.6%, P<0.05). The avoidable causes of death reduced the life expectancy by 1.77 years (preventable by 1.12 and treatable by 0.63 years). Diversity in trends in mortality of different avoidable causes was disclosed. A declining trend in mortality caused by chronic rheumatic heart disease and lung cancer was observed for males (AAPC -22.6% and -2.1%, respectively; P<0.05). However, the mortality caused by liver cirrhosis was increasing for both genders (AAPC 16.1% for males and 17.6% for females, P<0.01) and that caused by tuberculosis - only for females (AAPC 7.8%, P<0.05). An increasing trend in avoidable mortality was observed. Deaths caused by the diseases that could have been prevented had the greatest impact on the increasing mortality and decreasing life expectancy.

We investigated secular trends in cancer mortality among first-generation Japanese-Brazilians in the state of São Paulo between 1979 and 2001. Results were compared with those for Japanese living in Japan and Brazilians living in the state of São Paulo. We used mortality data for three periods, 1979-1981, 1989-1991, and 1999-2001, and population data from Brazilian censuses in 1980, 1991, and 2000 for Japanese-Brazilians. Available mortality and population data for Japanese living in Japan and Brazilians living in the state of São Paulo corresponding to those for Japanese-Brazilians were obtained. Age-standardized mortality rates for Japanese-Brazilians and standardized mortality ratios based on mortality of Japanese living in Japan in 1980 for the three different periods and populations were calculated. We observed a decreasing trend for stomach cancer and increasing trends for colon, breast and prostate cancer over the 20 years in all three populations. Standardized mortality ratios for stomach cancer in Japanese-Brazilians declined to approximately those of Japanese living in Japan. Although standardized mortality ratios from colon, breast and prostate cancer in Japanese-Brazilians increased over the last 20 years, those for colon cancer were similar to the Japanese living in Japan whereas those for breast and prostate cancer (208 and 423 in 2000, respectively) appeared to be intermediate between those for Japanese living in Japan (152 and 208 in 2000, respectively) and Brazilians living in the state of São Paulo (281 and 536 in 2000, respectively). Standardized mortality ratios for liver and lung cancer increased in Japanese living in Japan over the last 20 years but no increasing trend was observed for Japanese-Brazilians, except for liver cancer in men, and standardized mortality ratios in Japanese-Brazilians seemed to be similar to the Brazilians living in the state of São Paulo. Secular trends in mortality confirm the relative importance of environment in the development of cancer.

Examining trends in mortality following hip fracture and its associated factors is important for population health surveillance and for developing preventive interventions. To examine temporal trends in, and risk factors associated with, mortality following hip fracture over 18 years in Singapore. This retrospective, population-based cohort study included men and women aged 50 years and older admitted to Singapore hospitals for first hip fracture identified and followed up from 2000 to 2017. Demographic information, fracture type, and Charlson Comorbidity Index (CCI) score were retrieved from nationwide claims data, and mortality data were from the National Death Registry. Data were analyzed from August 2018 to December 2019. Adjusted hazard ratios (aHRs) and their 95% confidence intervals were estimated using Cox proportional hazards regression. Kaplan-Meier life table methods were used to calculate survival following the hip fracture on a cohort basis. The crude survival over time since fracture was compared by sex, age group, ethnicity, CCI, and fracture type. Standardized mortality ratios (SMRs) were calculated using all-cause mortality obtained from Singapore population life tables. Among 36 082 first inpatient admissions for hip fractures (mean [SD] patient age, 78.2 [10.1] years; 24 902 [69.0%] female; 30 348 [84.1%] Chinese, 2863 [7.9%] Malay, 1778 [4.9%] Indian, and 1093 [3.0%] other ethnicity), elevated rates of mortality were observed for male sex (aHR, 1.46; 95% CI, 1.41-1.52), Malay ethnicity (aHR, 1.23; 95% CI, 1.15-1.30 vs Chinese ethnicity), older age (aHR, 5.20; 95% CI, 4.27-6.34 for age ≥85 years vs 50-54 years), high CCI score (aHR, 3.62; 95% CI, 3.42-3.84 for CCI ≥6 vs CCI of 0), trochanteric fractures (aHR, 1.11; 95% CI, 1.06-1.16 vs cervical fractures), and earlier cohorts (aHR, 0.59; 95% CI, 0.56-0.62 for 2012-2017 vs 2000-2005). Absolute mortality decreased significantly over time: by 21% in 2006 to 2011 and by 40% in 2012 to 2017, compared with 2000 to 2005. On long-term follow-up, differences in survival associated with sex and ethnicity tended to diminish, whereas differences associated with older age, higher CCI score, and trochanteric fractures increased. In the first year after fracture, reductions in SMR were observed comparing the periods 2013 to 2016 with 2003 to 2007 in women (SMR, 2.05; 95% CI, 1.91-2.20 vs SMR, 2.54; 95% CI, 2.39-2.70, respectively) but not among men (SMR, 3.28; 95% CI, 3.04-3.54 vs SMR, 3.42; 95% CI, 3.18-3.68, respectively). Malay ethnicity, older age, male sex, prefracture comorbidity, and trochanteric fractures were independently associated with increased risk of death, identifying population groups that could be targeted for intervention strategies. The improvement in relative mortality for women but not men suggests the need to develop interventions that improve mortality outcomes for men.

Time trends in cancer risk have often been summarised by the observation that mortality from cancers associated with tobacco is increasing rapidly, while mortality from all other cancers is either stable or falling slightly, this slight decline being dominated by the decrease in mortality from stomach cancer. Until recently, and with some variation between the sexes, this simple summary of cancer mortality trends would have been broadly correct for a number of developed countries, and it remains useful in dismissing claims of an impending and unexplained epidemic of cancer, but it does not apply to all countries, and in some there have recently been striking changes in the trends in mortality from cancers associated with tobacco. Cancer mortality has been widely accepted as the most important measure of progress against cancer, since it reflects the impact of cancer on people, and has been considered less subject to distortion than incidence or survival, although this is open to question. Cancer mortality also reflects trends in incidence and survival to a greater or lesser extent. There has been controversy, however, over how cancer mortality trends should be interpreted, as well as over which measures should be used to assess progress in cancer control. An overall summary of trends in mortality from all cancers combined is of limited value in assessing progress against cancer, in any case. Increases in a common lethal cancer may numerically dominate overall mortality trends, perhaps concealing declines in less common or less lethal cancers, while opposite trends in cancers of the lung and stomach, for example, might lead to an overall impression that little has changed. Further, up to a third of cancer patients will not die of cancer, and cancer mortality statistics do not reflect their experience at all. Cancer mortality trends only indirectly reflect trends in the number of people who are diagnosed with cancer in a given year, and those who do die of cancer in a given year may have been diagnosed more than 3 years previously, even though many die earlier: this blurs the responsiveness of routine cancer mortality statistics as a measure of recent progress, and alternative measures have been proposed. Trends in competing risks of death, especially at higher ages, may also complicate the interpretation of cancer mortality trends. The chance of developing cancer, and in that event, the chances of surviving it, are of direct interest to individuals.(ABSTRACT TRUNCATED AT 400 WORDS)

Research from some industrialised countries indicated a flattening of the declining ischaemic heart disease (IHD) mortality trends in certain population groups. This study aims to investigate age-standardised, as well as sex- and age-specific time trends in IHD mortality in Germany. Using German vital statistics between 1980 and 2007, age-standardised and age-specific IHD mortality rates for men and women were calculated. Joinpoint software was used to estimate average annual percentage changes (AAPC) together with 95% confidence intervals and to identify changing trends in mortality. To account for the reunification in 1990 trends for West Germany alone were investigated in sensitivity analysis. Since 1980, marked decreases in mortality of 50% in men and 39% in women were observed, with AAPC of 2.4 and 1.5%, respectively. While moderate declines in mortality were observed since the early 1980s in men, significant decreases in women were only found after 1995. Trends in mortality varied substantially across age groups, showing decreases in older age (75+ years) only during the last 5-10 years. A flattening of mortality declines was not observed. In West Germany, overall decreases and AAPC were larger and differences between men and women were somewhat smaller. German IHD mortality trends present a complex picture with profound decreases since 1980. However, declines were smaller and delayed compared to other industrialised countries. Also, time trends were not homogeneous in men and women, as well as across age groups. Preventive measures need to be strengthened to account for failures in the past and to counter the increasing burden of modifiable risk factors.