Global Cancer Statistic 2012

CA CANCER J CLIN 2015;00:00–00
Global Cancer Statistics, 2012

Lindsey A. Torre, MSPH1; Freddie Bray, PhD2; Rebecca L. Siegel, MPH3; Jacques Ferlay, ME4;
Joannie Lortet-Tieulent, MSc5; Ahmedin Jemal, DVM, PhD6
Cancer constitutes an enormous burden on society in more and less economically developed countries alike. The occurrence of
cancer is increasing because of the growth and aging of the population, as well as an increasing prevalence of established risk
factors such as smoking, overweight, physical inactivity, and changing reproductive patterns associated with urbanization and
economic development. Based on GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred
in 2012 worldwide. Over the years, the burden has shifted to less developed countries, which currently account for about 57%
of cases and 65% of cancer deaths worldwide. Lung cancer is the leading cause of cancer death among males in both more and
less developed countries, and has surpassed breast cancer as the leading cause of cancer death among females in more devel-
oped countries; breast cancer remains the leading cause of cancer death among females in less developed countries. Other
leading causes of cancer death in more developed countries include colorectal cancer among males and females and prostate
cancer among males. In less developed countries, liver and stomach cancer among males and cervical cancer among females
are also leading causes of cancer death. Although incidence rates for all cancers combined are nearly twice as high in more
developed than in less developed countries in both males and females, mortality rates are only 8% to 15% higher in more devel-
oped countries. This disparity reflects regional differences in the mix of cancers, which is affected by risk factors and detection
practices, and/or the availability of treatment. Risk factors associated with the leading causes of cancer death include tobacco
use (lung, colorectal, stomach, and liver cancer), overweight/obesity and physical inactivity (breast and colorectal cancer), and
infection (liver, stomach, and cervical cancer). A substantial portion of cancer cases and deaths could be prevented by broadly
applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests. CA Cancer J
Clin 2015;000:000-000. V C 2015 American Cancer Society.
Keywords: cancer, epidemiology, health disparities, incidence, survival.
Introduction
Cancer is a leading cause of death in both more and less economically developed countries; the burden is expected to grow
worldwide due to the growth and aging of the population, particularly in less developed countries, in which about 82% of
the world’s population resides. The adoption of lifestyle behaviors that are known to increase cancer risk, such as smoking,
poor diet, physical inactivity, and reproductive changes (including lower parity and later age at first birth), have further
increased the cancer burden in less economically developed countries. In this article, we provide an overview of the global
cancer burden, including the estimated number of new cancer cases and deaths in 2012 and the incidence and mortality rates
by region for selected cancer sites. These statistics are based on GLOBOCAN worldwide estimates of cancer incidence and
mortality produced by the International Agency for Research on Cancer (IARC) for 2012.1 We comment on the scale and
profiles of cancer worldwide and associated risk factors for a number of common cancers, alongside preventive measures
that have the potential to reduce the future cancer burden.
Data Sources and Methods

Data from GLOBOCAN 2012, produced by the IARC, were used.1 GLOBOCAN provides estimates of cancer incidence,
mortality, and prevalence worldwide, and for countries and regions. Incidence data are derived from population-based can-
cer registries (PBCR) that may capture the population of an entire country but more often cover smaller, subnational areas,
1
Epidemiologist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA; 2Head, Section of Cancer Surveillance, International
Agency for Research on Cancer, Lyon, France; 3Director of Surveillance Information, Surveillance and Health Services Research, American Cancer Soci-
ety, Atlanta, GA; 4Informatics Officer, Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France; 5Senior Epidemiolo-
gist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA; 6Vice President, Surveillance and Health Services Research,
American Cancer Society, Atlanta, GA
Corresponding author: Lindsey A. Torre, MSPH, Surveillance and Health Services Research, American Cancer Society, 250 Williams St, NW, Atlanta, GA 30303;
lindsey.torre@cancer.org
DISCLOSURES: The authors report no conflicts of interest.
doi: 10.3322/caac.21262. Available online at cacancerjournal.com
VOLUME 00 _ NUMBER 00 _ MONTH 2015 1

such as urban environments like major cities. Although the ica, Australia/New Zealand, and Japan; less developed coun-
quality of information from less developed countries is often tries include all regions of Africa, Asia (excluding Japan),
considered limited compared with that from more developed Latin America and the Caribbean, Melanesia, Micronesia,
countries, PBCR are a key source of information on the local and Polynesia.7 Rates are age-standardized (per 100,000
scale and profile of cancer and are critical in developing and person-years) using the World Standard Population as pro-
evaluating cancer control programs. The total number of posed by Segi and modified by Doll et al.8,9 The cumulative
cancer deaths by country are collected annually and are made risk of developing or dying of cancer before the age of 75
available by the World Health Organization (WHO).2 The years (in the absence of competing causes of death) is also
advantages of this source of data are its national coverage calculated and is expressed as a percentage. Although wide
and long-term availability, although not all data sets are of variations in the cancer burden occur within regions and
the same quality or completeness. countries, data are generally presented here at the regional
Incidence and mortality rates were estimated using level for the purpose of providing a summary of global data.
GLOBOCAN1 by country, using the most recently avail-
able data collected by the IARC or available in routine
Results and Discussion
reports from the registries themselves. The data sources
and methods are described in further detail elsewhere.3 For
Estimated Number of New Cancer Cases
and Deaths
incidence data, countries are classified based on data quality
and availability as follows: An estimated 14.1 million new cancer cases and 8.2 million
cancer deaths occurred in 2012 worldwide (Fig. 2). Lung and
1. High-quality national data (data included in Cancer breast cancer are the most frequently diagnosed cancers and
Incidence in Five Continents volume IX and/or X4,5) or the leading causes of cancer death in men and women,
high-quality regional data (coverage greater than 50% respectively, both overall and in less developed countries. In
of the population). more developed countries, however, prostate cancer is the
2. High-quality regional data (coverage between 10% most frequently diagnosed cancer among men and lung can-
and 50%). cer is the leading cause of cancer death among women. Other
3. High-quality regional data (coverage less than 10%). frequently diagnosed cancers worldwide include those of the
4. National data (PBCR). liver, stomach, and colorectum among males and those of the
5. Regional data (PBCR). stomach, cervix uteri, and colorectum among females. In
6. Frequency data (hospital-based or pathological-based more developed countries, bladder cancer among males and
series). uterine cancer among females are also frequently diagnosed.
7. No data. In less developed countries, liver and stomach cancer among
men are the second and third most frequently diagnosed can-
For mortality data, countries are classified as follows, cers, respectively, and leading causes of cancer death.
with quality criteria defined by Mathers et al6: Less developed countries account for only 57% of cases
and 65% of cancer deaths worldwide, in spite of their rela-
1. High-quality complete vital registration.
tively larger share of the population. This is largely because
2. Medium-quality complete vital registration.
of the younger age structure, immaturity of the tobacco epi-
3. Low-quality complete vital registration.
demic, and competing causes of death, such as infection, in
4. Incomplete or sample vital registration.
less developed countries. However, the burden of cancer
5. Other sources (cancer registries, verbal autopsy surveys, etc).
will continue to shift to less developed countries due to
6. No data.
growth and aging of the population and increasing preva-
GLOBOCAN presents country-specific incidence and lence of known risk factors.10
mortality rates for 27 types of cancer and for all cancers (except
nonmelanoma skin) combined by sex and for 10 age groups Incidence and Mortality Rates for All Cancers
(birth-14, 15-39, 40-44, 45-49,. . .70-74, and 75 years and Combined and Leading Cancer Sites
older). The full GLOBOCAN 2012 database, as well as Prostate, colorectal, female breast, and lung cancer inci-
detailed descriptions of sources and methods used for individ- dence rates can be several times higher in more developed
ual countries, is available online (globocan.iarc.fr).1 Estimates countries compared with less developed countries (Table 1).
for the 21 world regions (Fig. 1) and for more and less devel- Liver, stomach, and cervical cancers are more common in
oped regions are calculated as the population-weighted aver- less developed countries; these cancers are predominantly
age of the incidence and mortality rates of the component attributable to infection, which accounts for 77%, 75%, and
countries. More developed countries, as defined by the United 100% of cases worldwide, respectively.11 In general, cancer
Nations, include all regions of Europe plus Northern Amer- rates are higher in more developed regions. For example,
2 CA: A Cancer Journal for Clinicians

FIGURE 1. Estimated Number of New Cancer Cases in 21 World Areas, 2012.

*Region estimates do not sum to the worldwide estimate due to calculation method.
Source: GLOBOCAN 2012.
the all-sites cancer incidence rate for both sexes combined More developed countries account for about one-half of all
in Western Europe is more than twice as high as that in breast cancer cases and 38% of deaths. Rates are generally
Eastern Africa (Table 2). high in Northern America, Australia/New Zealand, and
Although incidence rates for all cancers combined are Northern and Western Europe; intermediate in Central and
twice as high in more developed compared with less devel- Eastern Europe, Latin America, and the Caribbean; and low
oped countries, mortality rates are only 8% to 15% higher in most of Africa and Asia (Fig. 4). International variation
in more developed countries. This disparity primarily in breast cancer incidence rates reflects differences in the
reflects differences in cancer profiles and/or the availability availability of early detection as well as risk factors. Risk fac-
of treatment. For example, liver cancer, a highly fatal can- tors for breast cancer include reproductive and hormonal fac-
cer, is much more common in less developed countries, tors such as a long menstrual history, recent use of oral
thus contributing disproportionately to the overall cancer contraceptives, and never having children.12 Giving birth to
mortality rate in these countries. Similarly, cancers are children and breastfeeding decrease the risk of breast can-
more often detected at a later stage in less developed coun- cer.12 Potentially modifiable risk factors include weight gain
tries (Fig. 3), which contributes to the disparity. after age 18 years, being overweight or obese (for postmeno-
pausal breast cancer), use of menopausal hormone therapy
(combined estrogen and progestin), physical inactivity, and
Selected Cancers alcohol consumption.12,13
Female breast cancer Between 1980 and the late 1990s, breast cancer incidence
Breast cancer is the most frequently diagnosed cancer and rates rose approximately 30% in Western countries, likely
the leading cause of cancer death among females worldwide, because of changes in reproductive factors and the use of
with an estimated 1.7 million cases and 521,900 deaths in menopausal hormone therapy and more recently because of
2012 (Fig. 2). Breast cancer alone accounts for 25% of all increased screening.14 Declining incidence rates in the early
cancer cases and 15% of all cancer deaths among females. 2000s have been attributed to the reduced use of menopausal

FIGURE 2. Estimated New Cancer Cases and Deaths Worldwide by Sex and Level of Economic Development.
*Excluding non-melanoma skin cancers.

hormone therapy in countries where it was formerly com- cer death rates have been stable or decreasing since around
mon, such as the United States, the United Kingdom, 1990 in Northern America and higher-resource European
France, and Australia.15-20 Beyond changes in menopausal countries. These reductions have been attributed to early
hormone therapy use, declining or stable incidence rates in detection through mammography and improved treat-
Western countries may also be due to plateaus in participa- ment,14 although the respective contributions of each are
tion in mammographic screening.21 In contrast, breast can- unclear.22-24 Breast cancer incidence rates have been rising
TABLE 1. Incidence and Mortality Rates and Cumulative Probability of Developing Cancer by Age 75 Years by Sex
and Cancer Site for More Developed and Less Developed Areas, 2012
MORE DEVELOPED AREAS LESS DEVELOPED AREAS
INCIDENCE MORTALITY INCIDENCE MORTALITY
CUMULATIVE CUMULATIVE CUMULATIVE CUMULATIVE

RISK, % (AGED RISK, % (AGED RISK, % (AGED RISK, % (AGED
BIRTH TO 74 BIRTH TO 74 BIRTH TO 74 BIRTH TO 74
ASR YEARS) ASR YEARS) ASR YEARS) ASR YEARS)
Males
All cancers* 308.7 30.9 138.0 14.3 163.0 16.6 120.1 12.0
(C00-97, but C44)
Bladder (C67) 16.9 2.0 4.5 0.4 5.3 0.6 2.6 0.3
Brain, nervous 5.9 0.6 4.0 0.4 3.3 0.3 2.6 0.3
system (C70-72)
Colorectum 36.3 4.3 14.7 1.6 13.7 1.6 7.8 0.8
(C18-21)
Esophagus (C15) 6.4 0.8 5.2 0.6 10.1 1.2 9.0 1.0
Gallbladder 2.3 0.3 1.5 0.2 2.0 0.2 1.6 0.2
(C23-24)
Hodgkin lymphoma 2.3 0.2 0.4 0.0 0.8 0.1 0.4 0.0
(C81)
Kaposi sarcoma 0.3 0.0 0.0 0.0 0.9 0.1 0.6 0.1
(C46)
Kidney (C64-66) 12.6 1.5 4.2 0.5 3.4 0.4 1.7 0.2
Larynx (C32) 5.1 0.6 2.2 0.3 3.5 0.4 2.0 0.2
Leukemia (C91-95) 8.8 0.9 4.6 0.5 4.4 0.4 3.7 0.3
Lip, oral cavity 7.0 0.8 2.3 0.3 5.0 0.6 2.8 0.3
(C00-08)
Liver (C22) 8.6 1.0 7.1 0.8 17.8 2.0 17.0 1.8
Lung (C33-34) 44.7 5.4 36.8 4.4 30.0 3.3 27.2 2.9
Melanoma of skin 10.2 1.1 2.0 0.2 0.8 0.1 0.4 0.0
(C43)
Multiple myeloma 3.3 0.4 1.8 0.2 1.0 0.1 0.8 0.1
(C88, C90)
Nasopharynx (C11) 0.6 0.1 0.2 0.0 2.0 0.2 1.3 0.2
Non-Hodgkin lym- 10.3 1.1 3.5 0.4 4.3 0.5 2.8 0.3
phoma (C82-85,
C96)
Other pharynx 4.7 0.6 2.2 0.3 2.8 0.3 2.2 0.3
(C09-10, C12-14)
Pancreas (C25) 8.6 1.0 8.3 1.0 3.3 0.4 3.2 0.4
Prostate (C61) 69.5 8.8 10.0 0.8 14.5 1.7 6.6 0.6
Stomach (C16) 15.6 1.9 9.2 1.0 18.1 2.1 14.4 1.6
Testis (C62) 5.2 0.4 0.3 0.0 0.7 0.1 0.3 0.0
Thyroid (C73) 3.6 0.4 0.3 0.0 1.4 0.1 0.4 0.0

TABLE 1. Continued
MORE DEVELOPED AREAS LESS DEVELOPED AREAS
INCIDENCE MORTALITY INCIDENCE MORTALITY
CUMULATIVE CUMULATIVE CUMULATIVE CUMULATIVE

RISK, % (AGED RISK, % (AGED RISK, % (AGED RISK, % (AGED
BIRTH TO 74 BIRTH TO 74 BIRTH TO 74 BIRTH TO 74
ASR YEARS) ASR YEARS) ASR YEARS) ASR YEARS)
Females
All cancers* 240.6 23.3 86.2 9.0 135.8 13.4 79.8 8.1
(C00-97, but C44)
Bladder (C67) 3.7 0.4 1.1 0.1 1.5 0.2 0.7 0.1
Brain, nervous 4.4 0.4 2.7 0.3 2.7 0.3 1.9 0.2
system (C70-72)
Breast (C50) 74.1 8.0 14.9 1.6 31.3 3.3 11.5 1.2
Cervix uteri (C53) 9.9 0.9 3.3 0.3 15.7 1.6 8.3 0.9
Colorectum 23.6 2.7 9.3 1.0 9.8 1.1 5.6 0.6
(C18-21)
Corpus uteri (C54) 14.7 1.8 2.3 0.3 5.5 0.6 1.5 0.2
Esophagus (C15) 1.2 0.1 0.9 0.1 4.1 0.5 3.6 0.4
Gallbladder 2.0 0.2 1.4 0.1 2.4 0.3 2.0 0.2
(C23-24)
Hodgkin lymphoma 1.9 0.2 0.3 0.0 0.5 0.0 0.3 0.0
(C81)
Kaposi sarcoma 0.1 0.0 0.0 0.0 0.5 0.0 0.3 0.0
(C46)
Kidney (C64-66) 6.2 0.7 1.7 0.2 1.8 0.2 0.9 0.1
Larynx (C32) 0.6 0.1 0.2 0.0 0.4 0.1 0.3 0.0
Leukemia (C91-95) 5.8 0.5 2.8 0.3 3.2 0.3 2.6 0.3
Lip, oral cavity 2.6 0.3 0.6 0.1 2.5 0.3 1.4 0.2
(C00-08)
Liver (C22) 2.7 0.3 2.5 0.3 6.6 0.7 6.4 0.7
Lung (C33-34) 19.6 2.4 14.3 1.7 11.1 1.2 9.8 1.0
Melanoma of skin 9.3 0.9 1.2 0.1 0.7 0.1 0.3 0.0
(C43)
Multiple myeloma 2.2 0.3 1.2 0.1 0.7 0.1 0.6 0.1
(C88, C90)
Nasopharynx (C11) 0.2 0.0 0.1 0.0 0.8 0.1 0.5 0.1
Non-Hodgkin 7.1 0.8 2.0 0.2 2.8 0.3 1.8 0.2
lymphoma
(C82-85, C96)
Other pharynx 0.8 0.1 0.3 0.0 0.7 0.1 0.5 0.1
(C09-10, C12-14)
Ovary (C56) 9.1 1.0 5.0 0.6 5.0 0.5 3.1 0.4
Pancreas (C25) 5.9 0.7 5.5 0.6 2.4 0.3 2.3 0.3
Stomach (C16) 6.7 0.8 4.2 0.4 7.8 0.9 6.5 0.7
Thyroid (C73) 11.1 1.1 0.4 0.0 4.7 0.5 0.7 0.1
ASR indicates age-standardized rate per 100,000. Rates are standardized to the World Standard Population.
*Excludes nonmelanoma skin cancer.

TABLE 2. Estimated Age-Standardized Incidence and Mortality Rates Per 100,000 by World Area, 2012*
INCIDENCE MORTALITY
MALE FEMALE OVERALL MALE FEMALE OVERALL
Eastern Africa 120.7 154.7 137.8 103.8 110.5 106.5

Middle Africa 91.8 110.7 100.8 82.3 82.3 81.2
Northern Africa 133.5 127.7 129.7 99.9 75.7 86.8
Southern Africa 210.3 161.1 177.5 136.5 98.7 112.5
Western Africa 78.7 112.4 95.3 68.5 75.7 71.6
Eastern Asia 225.4 151.9 186.0 159.3 80.2 117.7
South-Central Asia 98.4 103.3 100.1 74.8 64.7 69.3
South-Eastern Asia 147.6 132.6 138.2 114.1 79.5 94.8
Western Asia 192.8 150.2 168.2 129.3 81.3 103.0
Caribbean 207.7 168.0 185.4 119.8 87.7 102.0
Central America 125.8 141.9 133.6 76.6 72.1 73.7
North America 344.2 295.4 315.6 123.2 91.7 105.5
South America 206.7 180.6 190.6 118.0 88.4 101.2
Central and Eastern Europe 260.0 193.5 216.1 173.4 91.6 123.4
Northern Europe 298.4 263.9 277.4 126.2 94.4 108.2
Southern Europe 297.6 220.4 253.6 137.9 78.9 105.2
Western Europe 343.7 263.7 298.7 131.3 83.6 105.0
Australia/New Zealand 365.3 277.9 318.5 115.3 82.6 97.6
Melanesia 152.1 182.1 164.7 117.9 118.5 116.4
Micronesia 202.1 146.3 171.4 106.8 55.8 79.7
Polynesia 226.4 181.6 200.7 125.7 93.3 108.1
*Excludes nonmelanoma skin cancer
in many countries in South America, Africa, and Asia.25 limitations, numerous studies have shown that early detec-
The reasons are not completely understood but likely reflect tion with mammography saves lives and increases treat-
changing reproductive patterns, increasing obesity, decreas- ment options. However, implementation of population-
ing physical activity,26 and some breast cancer screening based, organized mammography screening programs may
activity.14 Mortality rates in these countries are also increas- be cost-prohibitive in many less developed countries and is
ing,27 most likely due to lifestyle changes associated with only recommended for those countries with a good health
westernization compounded by the delayed introduction of infrastructure that can afford long-term screening pro-
effective breast cancer screening programs and, in some grams. Otherwise, the recommended early detection strat-
cases, limited access to treatment.27,28 egies are awareness of early signs and symptoms and
Maintaining a healthy body weight, increasing physical screening by clinical breast examination.30
activity, and minimizing alcohol intake are the best avail-
able strategies to reduce the risk of developing breast can- Colorectal cancer
cer.29 Mammography can often detect breast cancer at an Colorectal cancer is the third most commonly diagnosed
early stage, when treatment is more effective and a cure is cancer in males and the second in females, with an
more likely. However, mammography screening is not per- estimated 1.4 million cases and 693,900 deaths occurring
fect. Not all breast cancers will be detected by a mammo- in 2012 (Fig. 2). The highest incidence rates are in
gram, and some breast cancers that are screen-detected Australia/New Zealand, Europe, and Northern America
still have a poor prognosis. Sometimes mammography (Fig. 5). Rates are low in Africa and South-Central
results in false-positive results, as well as overdiagnosis and Asia. Rates are higher in men than in women in most
overtreatment of some breast cancers. In spite of these parts of the world.

FIGURE 3. Estimated Percentage of Patients Able to Access Radiotherapy, 2013.

*Countries with 100% of patients able to access radiotherapy may also include countries where radiotherapy supply is greater than demand, although dispar-
ities in access may still exist within these countries.
Source: The Cancer Atlas, second edition, as obtained from the International Atomic Energy Agency.
The incidence of colorectal cancer is increasing in certain minimizing consumption of red and processed meat and
countries where risk has been historically low, most notably alcohol, and avoidance of smoking.37-39 Screening can
in Western Asia (Kuwait and Israel) and Eastern Europe detect colorectal polyps that can be removed before they
(Czech Republic and Slovakia).31 Trends in high-risk/ become cancerous, as well as detect cancer at an early stage
high-income countries have varied over the past 20 years; for when treatment is usually less extensive and more success-
example, rates gradually increased in Finland and Norway, ful. There are several accepted screening options (eg, the
stabilized in France and Australia, and declined in the guaiac-based fecal occult blood test [FOBT], the immuno-
United States. The decrease in colorectal cancer incidence in chemical FOBT [or fecal immunochemical test], flexible
the United States is confined to those aged 50 years and sigmoidoscopy, stool DNA test, computed tomography
older, which primarily reflects the increase in screening and [CT] colonography [“virtual colonoscopy”], double-
removal of precancerous adenomas.32 The increase in several contrast barium enema, and colonoscopy), although some
Asian and Eastern European countries may reflect an of these options are less feasible for lower-resource areas.
increased prevalence of risk factors for colorectal cancer, Although colonoscopy is a highly sensitive screening
including unhealthy diet, obesity, and smoking.33 method, it requires a skilled examiner, involves greater cost,
In contrast to incidence trends, decreasing colorectal is less convenient, and has more risk for the patient com-
cancer mortality rates have been observed in a large number pared with other tests.40 FOBT, which is inexpensive and
of countries worldwide and are most likely attributed to easy to perform, is a more practical screening option in
colorectal cancer screening, reduced prevalence of risk fac- many parts of the world.33 Population-based colorectal
tors, and/or improved treatments.32,34 However, increases screening programs may not be recommended in many less
in mortality rates are still occurring in countries that have developed countries where the incidence of the disease is
more limited resources and increasing incidence, including not yet sufficiently high to merit screening programs.43
Brazil and Chile in South America and Romania and Rus- However, future attention should also be focused on the
sia in Eastern Europe.35,36 many areas of the developing world with a growing and
Preventive measures for colorectal cancer include aging population and an increasingly westernized lifestyle.
maintaining a healthy body weight, being physically active, For example, a colorectal cancer screening program using

International variations in lung cancer rates and trends

largely reflect differences in the stage and degree of the
tobacco epidemic.49-51 In several Western countries, such
as the United States, the United Kingdom, and Denmark,
where the tobacco epidemic began earliest and peaked
around the middle of the last century, lung cancer mortality
rates have been decreasing in men and plateauing in
women.52-55 Lung cancer rates are also decreasing in men,
but continuing to increase in women, in countries where
the tobacco epidemic peaked later, such as Spain and
Hungary.55 In contrast, in countries where the epidemic
has been established more recently and smoking has just
peaked or continues to increase, such as China, Indonesia,
and several countries in Africa, lung cancer rates are likely
to continue to increase at least for the next few decades,
barring interventions to accelerate smoking cessation and
avoid initiation.51,56,57
Lung cancer is one of the most preventable cancers. Most
lung cancers could be avoided by eliminating smoking ini-
tiation and increasing smoking cessation among current
smokers. This requires a comprehensive tobacco control
FIGURE 4. Breast Cancer Incidence and Mortality Rates by World Area. program that includes raising the price of tobacco products
through excise taxes, banning smoking in public places and
tobacco sales to minors, restricting tobacco advertising and
the fecal immunochemical test was recently piloted in promotion, counteradvertising, and providing treatment and
Thailand, where colorectal cancer incidence is increasing.44 counseling for tobacco dependence. In the United States,
comprehensive tobacco control programs in many states,
Lung cancer
including California and New York, have markedly
An estimated 1.8 million new lung cancer cases occurred in decreased smoking rates and accelerated the reduction in
2012, accounting for about 13% of total cancer diagnoses.
Lung cancer was the most frequently diagnosed cancer and
the leading cause of cancer death among males in 2012
(Fig. 2). Among females, lung cancer was the leading cause
of cancer death in more developed countries, and the sec-
ond leading cause of cancer death in less developed coun-
tries. In men, the highest lung cancer incidence rates were
in Europe, Eastern Asia, and Northern America, and the
lowest rates were in sub-Saharan Africa (Fig. 6). Among
women, the highest lung cancer rates were in Northern
America, Northern and Western Europe, Australia/New
Zealand, and Eastern Asia (Fig. 6). Lung cancer rates in
Chinese women (20.4 cases per 100,000 women) were
higher than rates among women in some European coun-
tries despite a lower prevalence of smoking. This is thought
to reflect indoor air pollution from unventilated coal-fueled
stoves and cooking fumes.45 Other known risk factors for
lung cancer include exposure to occupational and environ-
mental carcinogens such as asbestos, arsenic, radon, and pol-
ycyclic aromatic hydrocarbons.46 Recently, outdoor pollution
has also been determined to cause lung cancer.47 More than
one-half of the lung cancer deaths attributable to ambient
fine particles were projected to have been in China and
FIGURE 5. Colorectal Cancer Incidence Rates by Sex and World Area.
other East Asian countries.48

estimated to have occurred in 2012 (Fig. 2). It is the most

frequently diagnosed cancer among men in more developed
countries, where about two-thirds of all prostate cancer
cases occur among just 17% of the world’s male population.
Incidence rates vary by more than 25-fold worldwide, and
are highest in Australia/New Zealand, Northern America,
Northern and Western Europe, and some Caribbean
nations, and lowest in Asia (Fig. 7). Much of the variation
reflects differences in the use of prostate-specific antigen
(PSA) testing.64 Prostate cancer is the fifth leading cause of
cancer death worldwide, with the highest mortality rates
found in the Caribbean and Southern and Middle Africa.
The reason for the high prostate cancer risk among some
populations of African descent is still poorly understood,
although it may in part reflect differences in genetic
susceptibility.64,65
Incidence trends in countries with higher uptake of PSA
testing, such as Australia, Canada, and the United States,
follow a consistent pattern, with a rapid rise in the inci-
dence of prostate cancer noted in the early 1990s, soon after
the introduction of PSA testing, followed by a sharp
FIGURE 6. Lung Cancer Incidence Rates by Sex and World Area. decline.64,66 In other high-income countries with more
gradual adoption of PSA testing, such as many countries in
lung cancer occurrence.58,59 In the developing world, many Western Europe, the dramatic peak in incidence is not
of the most populous countries, such as China and India, observed, although rates continue to increase.64 Rates are
are in the earlier stages of the tobacco epidemic.60 If these also increasing in some countries where PSA testing began
and other less developed countries take swift action to pro- later or remains uncommon, such as the United Kingdom,
mote smoking cessation and prevent initiation, they can Japan, and Thailand.64
attenuate future lung cancer rates and avoid the extraordi-
nary burden of smoking-related diseases experienced in
more developed countries.
Results from the National Lung Screening Trial, a clini-
cal trial in the United States designed to determine the
effectiveness of lung cancer screening in high-risk individu-
als, showed 16% to 20% fewer lung cancer deaths among
current or former heavy or long-term smokers (30 pack-
years) who were screened with spiral CT compared with
standard chest x-ray.61 However, it is unknown whether
these results are relevant for individuals who have smoked
less. In addition, there are limitations and risks associated
with screening, including a high rate of false-positive
results, cumulative radiation exposure from multiple CT
scans, and unnecessary lung biopsy and surgery. These
potential harms may be substantially greater in settings that
lack access to high-quality screening.62 The WHO also
recommends that effective treatment capable of reducing
morbidity and mortality should be available if screening is
implemented.63 As a result, screening likely will not benefit
those in low-resource countries in the near future.
Prostate cancer
Prostate cancer is the second most frequently diagnosed FIGURE 7. Prostate Cancer Incidence and Mortality Rates by World Area.
cancer in men worldwide, with 1.1 million new cases

Stomach cancer
An estimated 951,600 new stomach cancer cases and
723,100 deaths occurred in 2012 (Fig. 2). Stomach cancer
rates are generally about twice as high in men as in women
and vary widely across countries. In general, incidence rates
are highest in Eastern Asia (particularly in Korea, Mongolia,
Japan, and China), Central and Eastern Europe, and South
America and lowest in Northern America and most parts of
Africa (Fig. 8). Regional variations in part reflect differences
in dietary patterns, food storage, and the availability of fresh
produce, as well as the prevalence of Helicobacter pylori infec-
tion.71 Chronic infection with H. pylori is the strongest iden-
tified risk factor for stomach cancer, with about 90% of new
cases of noncardia gastric cancer worldwide attributed to this
bacteria.72
A steady decline in stomach cancer incidence and mortal-
ity rates has been observed in the majority of more developed
countries in Northern America and Europe since the middle
of the 20th century.73,74 Similar decreasing trends have been
noted in more recent years in areas with historically high
rates, including several countries in Asia (Japan, China, and
FIGURE 8. Stomach Cancer Incidence Rates by Sex and World Area. Korea), Latin America (Colombia and Ecuador), and
Europe (Ukraine).75 Factors that have contributed to these
declines are thought to include the increased availability of
Death rates for prostate cancer have been decreasing in
fresh fruits and vegetables, decreased reliance on salt-
the majority of more developed countries, including those
preserved foods, and reduction in chronic H. pylori infection
in Northern America, Oceania, and Northern and Western
due to improved sanitation and antibiotics.71 In more devel-
Europe.64 This decrease has been attributed mainly to
oped countries, decreases in smoking prevalence may also
improved treatment and/or early detection, although the
account for some of the decline.27,75 Although stomach can-
specific contribution of PSA testing is debated.64 Studies
cer is declining overall, adenocarcinoma of the gastric cardia
are ongoing to clarify the impact of PSA screening on pros-
is increasing in North America and Europe and is thought
tate cancer death rates.67 In contrast, mortality rates are ris-
to be related to increased obesity and perhaps improvement
ing in some Asian and Central and Eastern European
in classification.27
countries, such as Korea, China (Hong Kong), and Rus-
The primary prevention strategies for stomach cancer
sia.64 The increase is postulated to reflect risk factors asso-
include reducing intake of foods preserved by salting, pick-
ciated with economic development, including an increased
ling, or smoking; increasing consumption of fresh fruits and
consumption of animal fat, obesity, and physical
vegetables; not smoking; and reducing the prevalence of H.
inactivity.64
pylori infection through the improvement of socioeconomic
There are few known modifiable risk factors for prostate
conditions. Screening for and eradication of H. pylori using
cancer. The chemoprevention of prostate cancer is an active
antibiotics has been shown to reduce the risk of stomach
area of research.68 Routine PSA screening is no longer rec-
cancer in recent randomized trials.76 Although this approach
ommended for men at average risk given the large potential
requires further study in additional settings and populations,
for serious side effects associated with prostate cancer treat-
it could represent a promising intervention for the preven-
ment and concerns about frequent overdiagnosis, estimated
tion of stomach cancer.
at 23% to 42% for screen-detected cancers.69 Studies are
underway to evaluate new tests for prostate cancer that Liver cancer
could distinguish more aggressive cancers from those less Liver cancer is much more common in men than in women.
likely to be lethal, to identify men at higher risk of develop- In men, it is the second leading cause of cancer death
ing prostate cancer, and to enable more efficient use of PSA worldwide and in less developed countries (Fig. 2). In more
testing.67 For example, a recent study found that stopping developed countries, it is the sixth leading cause of cancer
screening at age 70 years prevents approximately one-half of death among men. An estimated 782,500 new liver cancer
avoidable deaths from prostate cancer, while greatly reduc- cases and 745,500 deaths occurred worldwide during 2012,
ing the rate of overdiagnosis.70 with China alone accounting for about 50% of the total

Europe, and Northern America. In the United States, age-

adjusted incidence rates of liver cancer more than tripled
between 1975 and 2011, rising from 2.6 per 100,000 to 8.6
per 100,000 (adjusted to the 2000 US standard popula-
tion).83 This increase is thought to be attributable to
increases in chronic HCV infection due to injection drug
abuse, which was common in the 1960s and 1970s, or possi-
bly increases in the prevalence of obesity and diabetes melli-
tus.82,84 In contrast, liver cancer rates are decreasing in some
historically high-risk areas, including China and Japan, most
likely due to reductions in HCV infection in Japan and
HBV infection in China through improved hygiene and
sanitation.85 A more than 80% decline in liver cancer inci-
dence rates among youth and young adults in Taiwan has
been reported as a result of a universal HBV childhood vac-
cination program that began in 1984.86 However, HBV vac-
cination programs cannot be responsible for the decreasing
liver cancer rates noted among adults in most parts of Asia
because of their relatively recent implementation.
The primary causes of liver cancer can be prevented
through public health measures, including vaccination,
FIGURE 9. Liver Cancer Incidence Rates by Sex and World Area. sanitary medical practices, healthy lifestyle choices, and
environmental management strategies. A vaccine that pro-
tects against HBV has been available since 1982. The
number of cases and deaths. Liver cancer rates are the high- WHO recommends that all countries include the HBV
est in East and South-East Asia and Northern and Western vaccine in routine infant immunization programs. By the
Africa and lowest in South-Central Asia and Northern, end of 2012, a total of 183 countries had introduced the
Central, and Eastern Europe (Fig. 9). Most (70% to 90%) HBV vaccine into their national infant immunization
primary liver cancers occurring worldwide are hepatocellu- schedules, with many countries achieving more than 80%
lar carcinoma.77 Cholangiocarcinomas that arise primarily coverage for the full recommended dose (Fig. 10). In con-
from the epithelial lining of the bile duct (intra- and extra- trast, no vaccine is available against HCV, although new
hepatic bile duct) are rare in most parts of the world, but antiviral therapies may prevent chronic infection among
have high incidence rates in Thailand and other parts of those with acute infection. HCV prevention strategies
Asia due to the high prevalence of liver fluke infection.78 include screening of blood, organ, and tissue donors for
The high hepatocellular carcinoma rates in parts of Asia antibodies to HCV; adherence to infection control prac-
and sub-Saharan Africa largely reflect the elevated preva- tices during all medical, surgical, and dental procedures;
lence of chronic hepatitis B virus (HBV) infection, with over and needle exchange programs for injection drug users.
5% of the populations in these regions chronically infected However, these preventive measures have not been imple-
with the virus.79 HBV and hepatitis C virus (HCV) account mented in many less developed countries due to resource
for an estimated 32% of infection-related cancer cases, constraints. Among individuals who are already infected
mostly liver cancer, in less developed countries and 19% in with HBV or HCV, a reduction in the risk of liver cancer
more developed countries.11 Consumption of food contami- has been shown with the use of antiviral treatments.82,87
nated with aflatoxin (a toxin produced by a fungus that However, these treatments may be costly and unfeasible in
infests grains, peanuts, soybeans, and corn that have been many low-resource countries.82 The US Centers for Dis-
stored in warm, moist conditions), is also a risk factor in less ease Control and Prevention recommends a one-time test
developed countries; however, the contribution of aflatoxin for HCV infection for all adults born between 1945 and
exposure to the liver cancer burden in these countries is 1965 because this birth cohort accounts for three-quarters
unknown.80 Other risk factors that are more common in of both HCV-infected individuals and HCV-related
Western countries include obesity, type 2 diabetes, cirrhosis deaths in the United States.88
related to heavy alcohol consumption, nonalcoholic fatty Effective preventive strategies also include limiting alco-
liver disease (associated with obesity), and smoking.81,82 hol consumption and avoiding smoking. Other approaches
Liver cancer incidence is increasing in areas with histori- to reduce liver cancer in less economically developed coun-
cally low rates, including parts of Oceania, Western tries include reducing aflatoxin contamination of foods and

FIGURE 10. Percentage of One-Year-Olds Given the Three-Series Hepatitis B Vaccination*, 2012.
*Countries with no data may represent countries where hepatitis B is not endemic (e.g., Scandinavian countries) and national hepatitis B vaccination programs
have not been introduced.
Source: World Health Organization. Global Health Observatory Data Repository, Hepatitis B (HepB3) Immunization Coverage of 1-year-olds, Data by
Country, 1985-2013 [online database]. Available from: apps.who.int/ghodata/. Accessed November 14, 2014.
preventing and treating parasitic liver fluke infections.

Crop substitution and improved grain storage practices
have been used to reduce contamination with aflatoxin in
areas such as sub-Saharan Africa. Mass drug administration
for liver fluke infection and public health campaigns may
contribute to the prevention of cholangiocarcinoma.89,90
Cervical cancer
There were an estimated 527,600 new cervical cancer cases
and 265,700 deaths worldwide in 2012 (Fig. 2). It is the
second most commonly diagnosed cancer and third leading
cause of cancer death among females in less developed
countries. Incidence rates are highest in sub-Saharan
Africa, Latin America and the Caribbean, and Melanesia
and lowest in Western Asia, Australia/New Zealand, and
Northern America (Fig. 11). Nearly 90% of cervical cancer
deaths occurred in developing parts of the world: 60,100
deaths in Africa, 28,600 in Latin America and the Carib-
bean, and 144,400 in Asia. India, the second most populous
country in the world, accounted for 25% of cervical cancer
deaths (67,500 deaths). In Eastern, Middle, and Southern
Africa, as well as Melanesia, cervical cancer is the leading
cause of cancer death in females. The large geographic vari-
ation in cervical cancer rates reflects differences in the avail- FIGURE 11. Cervical Cancer Incidence and Mortality Rates by World
ability of screening, which allows for the detection and Area.

important that all women, even those who have been vacci-
nated, continue to be screened, because HPV vaccines cannot
protect against established infections, nor do they protect
against all of the types of HPV that cause cervical cancer.
Many low-resource countries do not have the technical
and public health infrastructure to support Papanicolaou
testing, the most common screening tool for cervical cancer
in more developed countries. The most efficient and cost-
effective screening techniques in low-resource countries
include visual inspection using acetic acid and HPV tests.97
A clinical trial in rural India found that a single round of
HPV testing reduced the number of cervical cancer deaths
by about 50%.98
Esophageal cancer
An estimated 455,800 new esophageal cancer cases and
400,200 deaths occurred in 2012 worldwide (Fig. 2).
Esophageal cancer incidence rates vary internationally by
more than 21-fold. The highest rates are found in Eastern
Asia and in Eastern and Southern Africa and the lowest
rates are found in Western Africa (Fig. 12). Esophageal
FIGURE 12. Esophageal Cancer Incidence Rates by Sex and World Area. cancer is usually 3 to 4 times more common among men
than women. The 2 main types of esophageal cancer are
removal of precancerous lesions, and human papillomavirus squamous cell carcinoma and adenocarcinoma. In the
(HPV) infection prevalence.91-93 HPV infection prevalence highest-risk area, often referred to as the “esophageal can-
(all types) varies widely, from as high as 21% in Africa and cer belt,” which stretches from Northern Iran through the
16% in Latin America and the Caribbean to 9% in Asia Central Asian republics to North-Central China, 90% of
and 5% in Northern America.92 cases are squamous cell carcinomas, compared with about
In several Western countries, where screening programs 26% in the United States (among white individu-
have long been established, cervical cancer rates have als).83,99,100 In high-risk areas such as Golestan (Iran) and
decreased by as much as 65% over the past 40 years. For Linxan (China), contributing risk factors are not well
example, in Norway, cervical cancer incidence rates understood, but are thought to include poor nutritional sta-
decreased from 18.7 per 100,000 in 1970 to 9.6 per tus, low intake of fruits and vegetables, and drinking bever-
100,000 in 2011.94 Rates have also decreased in some high- ages at high temperatures.101-104 HPV infection has been
incidence areas, including Colombia, the Philippines, and detected in squamous cell carcinomas, particularly in high-
India, likely due to increased awareness and improved soci- risk areas in Asia. However, more research is needed to
oeconomic conditions.93 In contrast to favorable overall determine whether HPV or other infectious agents increase
trends, cervical cancer rates are reported to be rising in risk.105-108 The primary risk factors for squamous cell carci-
Uganda and in some countries of Eastern Europe (Estonia, noma in Western countries are alcohol and tobacco use,
Lithuania, and Bulgaria).93 Most affected are younger which account for almost 90% of total cases.
women in several countries, including many in Europe, The main known risk factors for esophageal adenocarci-
Central Asia, Japan, and China91,95; this cohort-driven noma are overweight and obesity and chronic gastroesopha-
trend is thought to reflect increases in high-risk HPV prev- geal reflux disease (GERD). GERD can cause metaplastic
alence from changing sexual behaviors.93 changes to the esophagus, referred to as Barrett esophagus,
There are 2 vaccines (Gardasil [Merck and Company, that predispose to dysplasia and adenocarcinoma. However,
Whitehouse Station, NJ] and Cervarix [GlaxoSmithKline, only a small percentage of those with Barrett esophagus go
Brentford, UK]) available for protection against the 2 types on to develop esophageal cancer.109 GERD is most com-
of HPV that cause most (70%) cervical cancers. In economi- mon in overweight men and women. Smoking and low
cally less developed countries, the major barrier to widespread intake of fruits and vegetables are also risk factors for ade-
use is the high cost of the vaccine; however, GAVI, the Vac- nocarcinoma of the esophagus.
cine Alliance, has negotiated lower prices for these countries Temporal trends in esophageal cancer vary greatly. For
and began rolling out HPV vaccination demonstration example, although incidence rates of esophageal squamous
projects in supported countries in 2013.96 It is extremely cell carcinoma have been increasing in some Asian countries,

majority of bladder cancer occurs in men, and there is about

a 10-fold variation in incidence rates internationally. Inci-
dence rates are highest in Europe, Northern America,
Western Asia, and Northern Africa, and lowest in Eastern,
Middle, and Western Africa (Fig. 13). Some of the geo-
graphic variation is due to differences in the reporting of
low-grade tumors (ie, noninvasive lesions detected with
endoscopy).120 The highest mortality among men is in
Turkey, where the estimated death rate in 2012 (12.8 per
100,000) was 50% higher than the highest rates in Europe
(8.3 in Latvia and 8.0 in Poland) and 3 times as high as
that in the United States (4.0). Smoking is the most well-
established risk factor for bladder cancer, with the risk
among smokers reported to be approximately 2-fold to
6-fold that among nonsmokers.121 Smoking is estimated to
cause about 31% of bladder cancer deaths among men and
14% of deaths among women worldwide.122 In the devel-
oping world, particularly Africa and Western Asia, chronic
infection with Schistosoma hematobium (a parasitic worm
that causes urinary schistosomiasis) is associated with an
increased risk of bladder cancer. This parasite, which is
FIGURE 13. Urinary Bladder Cancer Incidence Rates by Sex and World transmitted through contaminated water, is responsible for
Area. an estimated 50% of bladder cancers in some parts of Africa
such as Taiwan,110 they have been steadily declining in and about 3% of cases worldwide.71 Bladder cancers caused
Northern America and Europe due to reductions in alcohol by schistosomiasis usually have a different histology (squa-
and tobacco use.111-113 In contrast, the incidence of adeno- mous cell carcinoma) compared with those associated with
carcinoma of the esophagus has been increasing rapidly in smoking (transitional cell carcinoma).
Western countries such as the United States, Australia, Bladder cancer incidence rates have been declining or stable
France, and England in recent decades, most likely as a result in most Western countries over the past decades after a prior
of increases in the prevalence of overweight/obesity, chronic period of increase. International incidence patterns across coun-
GERD, and Barrett esophagus.114 This trend may also be tries are difficult to interpret due to differences in the reporting
related to the declining prevalence of H. pylori infection, of low-grade tumors. In the United States, mortality rates in
which may protect against esophageal adenocarcinoma.115-117 males decreased from 1975 through 1987 and have subse-
Preventive measures for esophageal cancer include main- quently stabilized, whereas in females rates have been decreas-
taining a healthy body weight, eliminating the use of ing since 1975.123 In most countries of Europe and in urban
tobacco, reducing alcohol consumption, and being physi- China, declines have been observed since the 1990s.35,124 In
cally active. In addition, a healthy diet rich in fruits and Latin America and the Caribbean, mortality has been largely
vegetables may lower a person’s risk. Research is ongoing to stable.120 Decreasing mortality trends in Western countries
determine whether surveillance of those with Barrett largely reflect reductions in smoking prevalence.120
esophagus is a feasible method to reduce esophageal cancer The best measures for bladder cancer prevention are not
mortality.118,119 Treating gastric reflux with proton pump smoking, increasing the intake of fruits and vegetables, and
inhibitor drugs or surgery may prevent Barrett esophagus schistosomiasis control and treatment. In Egypt, schistoso-
and esophageal cancer, although once Barrett esophagus miasis control has substantially reduced the burden of blad-
has developed, preventive measures have not been shown to der cancer, which was once the most common cancer in
prevent esophageal cancer.114 Further risk factor studies are Egyptian men.120 There is currently no screening method
necessary to elucidate primary prevention measures in recommended for individuals at average risk.
high-risk areas (Northern Iran and Central Asia) because Non-Hodgkin lymphoma
the prevalence of established major risk factors for esopha-
An estimated 385,700 new cases of non-Hodgkin lym-
geal cancer is low in those regions.
phoma (NHL) and 199,700 deaths occurred in 2012 (Fig.
Urinary Bladder cancer 2). NHL encompasses a wide variety of disease subtypes for
An estimated 429,800 new cases of bladder cancer and which incidence patterns vary. NHL is more common in
165,100 deaths occurred in 2012 worldwide (Fig. 2). The more developed areas, with the highest incidence rates found

subtypes continued to increase or stabilize during this time

period.128 In less developed countries, the incidence of NHL
is increasing in some populations, also likely due in part to the
AIDS epidemic. Recent decreases among young adults in
these same populations may also reflect the use of ART.129,130
Cancers of the lip and oral cavity
An estimated 300,400 new cases and 145,400 deaths from
oral cavity cancer (including lip cancer) occurred in 2012
worldwide (Fig. 2). The highest rates are found in Melane-
sia, South-Central Asia, and Central and Eastern Europe,
whereas the lowest are in Western Africa and Eastern
Asia (Fig. 15). Smoking, alcohol use, smokeless tobacco
use, and HPV infection are the major risk factors for oral
cavity cancer, with smoking and alcohol having synergistic
effects.131,132 The contribution of each of these risk factors
to the burden varies across regions.45 Smoking is estimated
to account for about 71% of deaths from oral cavity cancer
(including pharynx) in high-income countries and 37% of
deaths in low-income and middle-income countries,
whereas alcohol is estimated to account for about 33% and
14% of deaths, respectively.133 Smokeless tobacco products
FIGURE 14. Non-Hodgkin Lymphoma Incidence Rates by Sex and World
Area.
and betel quid with or without tobacco are the major risk
factors for oral cavity cancer in Taiwan, India, and other
in Australia, Western and Northern Europe, and Northern neighboring countries.45,134,135
America. The lowest rates are found in Asia and Eastern Over the past several decades, oral cavity cancer incidence
Europe (Fig. 14). In general, the incidence of NHL is low in rates have decreased significantly among both males and
Africa, with the exception of some sub-Saharan areas (par- females in Asia, Northern America, and Australia, and
ticularly East Africa) because of the high incidence of among males in Southern and Western Europe. Rates
Burkitt lymphoma (a subtype of NHL) among children. increased among both males and females in several countries
Most of the few known risk factors for lymphoma are associ-
ated with altered immune function. NHL risk is elevated in
individuals who receive immune suppressants to prevent
organ transplant rejection; those with severe autoimmune
conditions; and individuals infected with the human immu-
nodeficiency virus (HIV), human T-cell leukemia virus type
I, and probably HCV. NHL is classified as an acquired
immune deficiency syndrome (AIDS)- defining illness, and
the risk is 60 times greater among patients with AIDS com-
pared with the general population.125 Epstein-Barr virus
(EBV) is linked causally to Burkitt lymphoma and a number
of autoimmune-related NHLs.
The incidence of NHL increased in the majority of more
developed countries up to around 1990 and leveled off there-
after.123,126 Although the increase may be due in part to
improvements in diagnostic procedures and changes in classi-
fication, much of the trend may reflect a true increase in dis-
ease occurrence.127 In the United States, some of the NHL
increase noted throughout the 1980s, particularly among
white males, has been attributed to the onset of the AIDS
epidemic, whereas the decline after 1990 likely reflects the
declining incidence of HIV infection and the success of
antiretroviral therapies (ART). Non-AIDS-associated NHL FIGURE 15. Oral Cavity Cancer Incidence Rates by Sex and World Area.

(Fig. 16); the disease is the sixth most common cancer

among males in this region. Globally, the 3 highest
national incidence rates are estimated to be in Malaysia,
Indonesia, and Singapore, where rates are high among the
Chinese and Malay populations.4 Elsewhere in Asia, high
incidence rates are observed in a number of provinces in
South-Eastern China, including Guangdong and Hong
Kong, and in other parts of Southern Asia (the Philippines,
India, and Thailand).40,41 Rates are also elevated in Micronesia/
Polynesia, Eastern Asia, and Northern Africa (Fig. 16), par-
ticularly in Tunisia and Algeria.141 Other populations where
rates of NPC are relatively high include the Inuit populations
of Alaska, Greenland, and North Canada, as well as Chinese
and Filipinos living in the United States.142 Rates of this
malignancy are considerably lower in most populations living
elsewhere within the Americas and Europe (Fig. 16).
The etiology of NPC appears to have viral, environmen-
tal, and genetic components.143,144 Migrants from high- to
low-risk countries retain incidence rates intermediate to
natives of their host country and their country of origin,145
implicating a role for environmental as well as genetic fac-
FIGURE 16. Nasopharyngeal Cancer Incidence Rates by Sex and World tors, and a possible interaction with EBV. Although the
Area.
virus is considered an important step in NPC progression,
only a fraction of the EBV-infected population develops the
of Eastern and Northern Europe and among females in disease. Moreover, infection with the virus is considered
Southern and Western Europe,136 which largely reflects the both lifelong and ubiquitous in most areas of the world.146
ongoing tobacco epidemic. This contrasts with the decreas- Many studies have reported increased risks associated
ing trends at all ages noted in both males and females in with certain foods eaten within high-risk areas, including
many other more developed countries, where the tobacco salted fish, certain preserved foods, and hot spices, all of
epidemic began and declined earlier. However, incidence which are high in nitroso compounds and volatile nitros-
rates for oral cancer sites related to HPV infections (ie, oro- amines.143 Consumption of these foods in early life may be
pharynx, tonsil, and base of the tongue) are increasing in important because it coincides with the timing of EBV
some of these countries, which is hypothesized to be in part infection.147 Although trends in NPC have been reported
due to changes in oral sexual behavior.137-139 as reasonably stable in high-risk areas of Southern
China,148 declines have been observed in several popula-
Nasopharyngeal cancer tions of Chinese origin over the past 2 decades.149-151 NPC
The term nasopharyngeal carcinoma (NPC) is used here as in higher-resource settings is associated more with smoking
a surrogate for nasopharyngeal cancers (International Classi- and alcohol use; the decreasing smoking prevalence among
fication of Diseases, 10th revision code C11), given that car- US males, for example, has been postulated as a contributor
cinomas represent the vast majority of nasopharyngeal to the overall decline in NPC incidence.152
tumors. There were an estimated 86,700 new cases of NPC
and 50,800 deaths in 2012 (Fig. 2). Although this disease Kaposi sarcoma
may be considered one of the rarer forms of cancer globally, Kaposi sarcoma (KS) is a cancer of cells that line lymph and
it is notable for its high incidence in select geographic and blood vessels. It differs from most other cancers in that it
ethnic populations. is multifocal in origin, growing in several areas of the body
NPC is about 2 to 3 times higher in males than in at once. Before the AIDS epidemic, KS was regarded as
females in both more and less developed countries (Table 1) extremely rare with the exception of certain populations of
(Fig. 16). The geographical disparities in the burden of Mediterranean, Middle Eastern, or Eastern European
NPC in relation to resource are noteworthy, with an esti- descent (predominantly males aged older than 50 years)153
mated 92% of new cases occurring in economically less and, more notably, sub-Saharan African populations.154,155
developed countries. Incidence rates are highest in South- The African form of KS (sometimes termed “endemic”) is
Eastern Asia (at least double those in every other area) diagnosed at younger ages than has been the case in European

TABLE 3. Estimated Number of Cases and Age-Standardized Incidence Rates for Kaposi Sarcoma in Regions of
Sub-Saharan Africa
MALES FEMALES
NUMBER OF CASES INCIDENCE RATE (PER 100,000) NUMBER OF CASES INCIDENCE RATE (PER 100,000)
Eastern Africa* 19,800 15.1 11,100 7.6

†
Southern Africa 2,200 7.6 1,400 4.7
‡
Middle Africa 500 1.2 200 0.4
§
Western Africa 1,100 0.9 900 0.6
Sub-Saharan Africa 23,600 7.2 13,600 3.7
*Burundi, Comoros, Djibouti, Eritrea, Ethiopia, La Reunion (France), Kenya, Madagascar, Malawi, Mozambique, Rwanda, Somalia, South Sudan, Tanzania,
Uganda, Zambia, and Zimbabwe.
†
Botswana, Lesotho, Namibia, South Africa, and Swaziland.
‡
Angola, Cameroon, Central African Republic, Chad, Democratic Republic of Congo, Republic of Congo, Republic of Equatorial Guinea, and Gabon.
§
Benin, Burkina Faso, Cape Verde, Cote d’Ivoire, The Gambia, Ghana, Guinea-Bissau, Guinea, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone,
and Togo.
populations and affects proportionally more females, sub-Saharan Africa, the highest rates of KS were in Israel
although the male-to-female ratio may still be as high as 9 to (1.5 cases per 100,000), French Guyana (1.3), Portugal
1.155,156 KS is also diagnosed in immunosuppressed patient (0.8), Colombia (0.7), and Italy (0.6).1 The KS in these
populations, including transplant recipients and, especially, populations represents a mix of pre-AIDS era and HIV-
individuals infected with HIV. The diagnosis of KS is associated forms.
regarded as AIDS-defining in those who are HIV positive, It is now evident that the KS-associated herpes virus
and for many years KS was the most common cancer observed (human herpes virus type 8 [HHV-8]) is the major cause of
in patients with AIDS and, in part, initially defined the KS but generally requires immunosuppressive conditions in
AIDS epidemic.157 However, since the advent of ART for which to function pathogenically.161 HHV-8 infection is
HIV in the 1990s, this is no longer the case. In populations common in sub-Saharan Africa, in those European popula-
where ART is readily available to those infected with HIV, tions at higher risk of KS, and in all HIV transmission
KS has again become a rare diagnosis.158 Due to the limited high-risk groups.161 Dual HIV and HHV-8 positivity
availability of ART, this is not the case in much of sub- increases the risk of KS by more than 1000-fold.162 Those
Saharan Africa, where KS is one of the most common forms areas of Africa where endemic KS and HHV-8 infection
of cancer and is even diagnosed in young children159; the pro- have been historically common have seen a rapid increase in
vision of ART to those in need is, however, improving.160 the incidence of KS since the onset of the HIV epidemic.
KS is rare in many areas of the world, but it is one of However, recent decreases have been documented in
the most common cancers in sub-Saharan Africa. This Uganda and Zimbabwe, especially among younger men,
region accounted for 84% of KS cases worldwide in 2012, likely due to improvements in the provision of ART, as
with an estimated 23,600 cases in males and 13,600 cases well as HIV prevention activities.163
in females (Table 3). The corresponding estimated age-
standardized incidence rates were 7.2 and 3.7 per 100,000,
respectively. The majority of cases occurred in Eastern Limitations
Africa in both males (19,800 cases) and females (11,100 The global and region-specific estimates presented here are
cases), with age-standardized incidence rates (per aggregated from those for 184 countries or territories,
100,000) of 15.1 in males and 7.6 in females. KS was, together with a set of methods based on the availability of
therefore, the most common cancer in males and the third cancer incidence and mortality data at the country or
most common in females (after cervical and breast cancers) regional level. Therefore, it should be emphasized that the
in Eastern Africa. The countries of Southern Africa had estimates presented in GLOBOCAN 2012 are variable in
the highest rates of KS (7.6 and 4.7 per 100,000, respec- accuracy, depending on the extent and validity of available
tively) after Eastern Africa, followed by Middle Africa data, ranging from real and valid counts of cases and deaths
(1.2 and 0.4 per 100,000, respectively) and Western Africa to estimates based on samples or neighboring rates. Around
(0.9 and 0.6 per 100,000, respectively). Outside of 2005, about 21% of the world’s population was covered by

PBCR164 and one-third was covered by mortality schemes factors known to cause cancer. Economically less developed
based on medically certified deaths.6 A scoring system to countries are experiencing an increased frequency of cancers
indicate the accuracy and quality of the estimate has been with historically low rates, such as female breast, lung, and
developed to help users evaluate the data presented for each colorectal cancers, in addition to a disproportionately high
country in GLOBOCAN; these scores can be accessed on burden of infection-related cancers. A substantial proportion
the GLOBOCAN Web site (globocan.iarc.fr). It should be of the worldwide burden of cancer can be prevented through
noted that the quality and availability of data are improving the widespread application of existing cancer control knowl-
over time, driven in many cases by initiatives to develop can- edge, including tobacco control, vaccination (for liver and
cer incidence and mortality registration. Despite its limita- cervical cancers), early detection, and the promotion of phys-
tions, the GLOBOCAN 2012 estimates are the best cancer ical activity and healthy dietary patterns. Additional suffer-
data available and are a legitimate basis for establishing pri- ing and premature death could be alleviated through the
orities for cancer control actions in different regions and application of appropriate treatments and palliative care.
countries of the world. Much remains to be learned about the causes of several
major malignancies, including prostate, pancreatic, and
Conclusions hematopoietic cancers. A coordinated and intensified
Cancer constitutes an enormous burden worldwide that is response from all sectors of society, including governments,
expected to increase due to the growth and aging of the pop- civil society, the private sector, and individuals, is required to
ulation and because of the adoption of behaviors and lifestyle seize control of the growing burden of cancer. 䊏
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Global Cancer Statistic 2012

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Global Cancer Statistic 2012

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CA CANCER J CLIN 2015;00:00–00

Global Cancer Statistics, 2012

Keywords: cancer, epidemiology, health disparities, incidence, survival.

Data Sources and Methods

DISCLOSURES: The authors report no conflicts of interest.

doi: 10.3322/caac.21262. Available online at cacancerjournal.com

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FIGURE 1. Estimated Number of New Cancer Cases in 21 World Areas, 2012.

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INCIDENCE MORTALITY INCIDENCE MORTALITY

CUMULATIVE CUMULATIVE CUMULATIVE CUMULATIVE

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INCIDENCE MORTALITY INCIDENCE MORTALITY

CUMULATIVE CUMULATIVE CUMULATIVE CUMULATIVE

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MALE FEMALE OVERALL MALE FEMALE OVERALL

Eastern Africa 120.7 154.7 137.8 103.8 110.5 106.5

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FIGURE 3. Estimated Percentage of Patients Able to Access Radiotherapy, 2013.

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International variations in lung cancer rates and trends

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estimated to have occurred in 2012 (Fig. 2). It is the most

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Europe, and Northern America. In the United States, age-

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preventing and treating parasitic liver fluke infections.

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majority of bladder cancer occurs in men, and there is about

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subtypes continued to increase or stabilize during this time

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(Fig. 16); the disease is the sixth most common cancer

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Eastern Africa* 19,800 15.1 11,100 7.6

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