Men & Cancer Scotland

Professor Alan White Centre for Men’s Health Leeds Metropolitan University [email protected]

www.leedsmet.ac.uk/health/menshealth

Comparison of the ratio of total deaths of men and women across the major disease classification groups, age brackets 1 to 24, 25 to 74 and 75+ years 4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

1_24 25_74 75+ White, AK & Cash, K (2003) The state of men’s health across 17 European Countries. Brussels, The European Men’s Health Forum

Median rate ratio between men and women across 44 countries for mortality from all causes, by age 5 4 3 2 1 Highest Low est Median 0 1-4 5-1 4 15 -2 4 25 -3 4 35 -4 4 45 -5 4 55 -6 4 65 -7 4 75+ Age White AK & Holmes M (2006) Patterns of morbidity across 44 Countries among men and women aged 15 44. Journal of Men’s Health & Gender 3(2): 139-151

Death rates for Malignant Neoplasms, for men & women 120 100 80 60 40 20 Male 0 15 to 24 25 to 34 35 to 44 Hungary 02 Thailand (00) Romania 02 Armenia (02) Portugal (02) Latvia 02 Slovakia 00 Estonia 02 Lithuania 02 France 00 Hong Kong 00 Poland 02 Slovenia 02 Spain 01 Czech Rep Denmark 99 Belgium 97 Argentina (01) Greece 01 USA 00 Israel 99 Italy 01 New Zealand (00) Brazil (00) Chile Australia (01) Germany 01 UK 02 Netherlands 03 Austria 02 Canada 00 Norw ay (01) Japan 02 Finland 02 Egypt 00 Sw eden 01 120 100 80 60 40 20 0 Female Hungary 02 Armenia (02) Romania 02 Thailand (00) Lithuania 02 Argentina (01) Latvia 02 Slovakia 00 Denmark 99 New Zealand (00) Poland 02 Portugal 02 Israel 99 Chile (01) Belgium 97 Netherlands 03 Czech Rep 02 France 00 Brazil (00) Estonia 02 UK 02 USA 00 Canada 00 Slovenia 02 Spain 01 Norw ay (01) Italy 01 Australia (01) Germany 01 Hong Kong 00 Austria Greece 01 Japan 02 Finland 02 Sw eden 01 15 to 24 25 to 34 35 to 44 Egypt 00 Adapted from White & Holmes (2006)

Patterns of mortality in men and women, 15-44 years, UK, 2002

Males

45 40 15 10 5 0 35 30 25 20 15 to 24 25 to 34 35 to 44 Accidents and adverse effects Diseases of the circulatory system Malignant neoplasms Suicide and self- inflicted injury Chronic liver disease and cirrhosis Homicide and injury purposely inflicted by other persons 20 15 10 5 0 45 40 35 30 25 15 to 24 25 to 34

Females

35 to 44 Malignant neoplasms Diseases of the circulatory system Accidents and adverse effects Suicide and self inflicted injury Chronic liver disease and cirrhosis Homicide and injury purposely inflicted by other persons Calculated from White, AK, Holmes, M, (2006) Patterns of mortality across 44 Countries among men and women aged 15-44. Journal of Men’s Health & Gender 3(2): 139-151

450 400 350 300 250 200 150 100 50 0

Patterns of mortality in men and women, 45-64years, UK, 2002

Males Females 45 to 54 55 to 64 Malignant neoplasms Diseases of the circulatory system Chronic liver disease and cirrhosis Accidents and adverse effects Suicide and self- inflicted injury Homicide and injury purposely inflicted by other persons 450 400 350 300 250 200 150 100 50 0 45 to 54 55 to 64 Malignant neoplasms Diseases of the circulatory system Chronic liver disease and cirrhosis Accidents and adverse effects Suicide and self- inflicted injury Homicide and injury purposely inflicted by other persons Calculated from WHOSIS Mortality Database

Proportion of cardiovascular disease, cancer and violence (injury and poisoning) within total causes of death; 3 years average (2001 2003), EU 27 for Men 100% 80% Other diseases Injury and poisoning 60% 40% Cancers Other forms of cardiovascular diseases 20% Cerebrovascular diseases Ischaemic heart disease 0% 1 4 5 9 10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 65 -6 9 70 -7 4 75 -7 9 80 -8 4 85 +

Age Group

Vitozzi, L (2009) The status of health in the European Union: towards a healthier Europe.

Arriaga decomposition of changes in life expectancies, EU15 average, 1990-2000 35 30 25 20

%

15 10 5 0 Men Women Vitozzi, L (2009) The status of health in the European Union: towards a healthier Europe.

Contribution of change in mortality by circulatory diseases to changes in life expectancy at birth 1980 2000, selected countries, for men Greece Spain France Italy Hungary Netherlands Austria Poland Portugal Romania Sweden United Kingdom Norway Change in life expectancy 0.5

2.4

1.1

2.6

1 1.9

2.4

1.6

1.6

0.1

2.8

2.5

2.5

As a % of change in life expectancy 19.1

67 34.7

43.2

54.5

63.3

39 133.1

36.1

-9.8

61.2

60.2

68.3

Vitozzi, L (2009) The status of health in the European Union: towards a healthier Europe.

Deaths due to selected cancers, for men and women, age 15 - 64 years, Scotland, 2008 Oesophagus

Malignant neoplasm of liver and intrahepatic bile ducts

80 70 20 10 60 50 40 30 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female 180 160 140 120 100 80 60 40 20 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Colon & Rectrosigmoid junction 70 60 50 40 30 20 10 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Stomach 30 25 20 15 10 5 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 ISD Scotland (2009) http://www.isdscotland.org/isd/1508.html

Male Female

Pancreas 15 10 5 35 30 25 20 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Bronchus & lung 250 200 150 100 50 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Brain 35 30 25 20 15 10 5 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Bladder 25 20 15 10 5 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female ISD Scotland (2009) http://www.isdscotland.org/isd/1508.html

Malignant melanoma 10 9 8 5 4 7 6 3 2 1 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female Non-Hodgkins lymphoma 30 25 20 15 10 5 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female ISD Scotland (2009) Kidney, except renal pelvis 25 20 15 10 5 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Male Female deaths by cause, sex and age, in England and Wales, 2003 Series DH2 no.30

Rate ratio of male to female cancer mortality, UK 2007 White, A, Thomson, C, Forman, D,(2009) The Excess burden of cancer in men, NCIN, London

Rate ratio of male to female cancer incidence, UK 2007 White, A, Thomson, C, Forman, D,(2009) The Excess burden of cancer in men, NCIN, London

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

Scotland had the highest overall mortality rates for both males and females, at 17 per cent

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

In Scotland, the overall cancer mortality rates for both sexes were around 16 per cent higher than those for the UK as a whole, and the overall cancer incidence rates were 8 per cent higher.

ONS (2009) Cancer incidence and mortality in the United Kingdom and constituent countries, 2004 –06

• The incidence of lung cancer was 34 per cent higher for males and 49 per cent higher for females than in the UK as a whole. • The incidence of, and mortality from, other smoking-related cancers – oesophagus, lip, mouth and pharynx, and larynx – were also higher in Scotland than in the other countries of the UK. • The incidence of prostate cancer was 14 per cent lower in Scotland than in the UK as a whole.

• The mortality rate for lung cancer in Scotland was 34 per cent higher for males and 48 per cent higher for females than in the UK as a whole. • In males it was nearly three times the mortality rate for prostate cancer and in females it was 56 per cent higher than the mortality rate for breast cancer. • Male mortality from colorectal cancer was 38 per cent higher in Scotland than in the UK and female • Mortality from cancer of the kidney and stomach was 29 and 35 per cent higher, respectively.

Factors involved in the development of cancer in men

• Lifestyle (Martin-Moreno et al. 2008, White 2009) • Genetics (White 2009) • Knowledge of genetic links within families (Moynihan & Huddart 2009) • Reduced uptake of available screening (Brenner, H et al. 2007).

• Humoral and cellular immunity (Bouman et al. 2004) • Help seeking behaviour (Smith et al 2005, Branney 2008) • Knowledge of cancer (Macdonald et al. 2004) White, A, Thomson, C, Forman, D,(2009) The Excess burden of cancer in men, NCIN, London

Incidence and mortality rates by deprivation in Scotland

Considering all cancers combined, the most deprived areas have incidence rates almost 40% higher than the least deprived areas; mortality rates for all cancers combined are approximately 75% higher in the most deprived than the least deprived areas.

Cancer age standardised incidence by deprivation quintile and sex; Northern & Yorkshire

ASR by Deprivation Quintile - All Cancers, 2002-2004

500 450 400 350 300 250 200 150 100 50 0 Q1 Q2 Q3 Q4 Q5 Male Female

imd2004

Forman, White & Farley (2006) Forman, White & Farley (2006)

Cancer age standardised incidence by deprivation quintile and sex after excluding prostate and breast cancers; Northern & Yorkshire

ASR by Deprivation Quintile - All excl. prostate / breast, 2002-2004

500 450 400 350 300 250 200 150 100 50 0 Q1 Q2 Q3 Q4 Q5 Male Female

imd2004

Cancer age standardised incidence by deprivation quintile and sex after excluding sex-specific, breast and lung cancers; Northern & Yorkshire 500 450 400 350 300 250 200 150 100 50 0

ASR by Deprivation Quintile - All excl. sex specific & lung, 2002-2004

Male Female

imd2004

Q1 Q2 Q3 Q4 Q5 Forman, White & Farley (2006)

The advantage of women in cancer survival: An analysis of EUROCARE-4 data • Significant female advantages for head and neck, oesophagus, stomach, and pancreas, salivary glands, colon and rectum, lung, pleura, bone, melanoma of skin, kidney, brain, thyroid, Hodgkin’s disease and non Hodgkin’s lymphoma.

• A significant female disadvantage for biliary tract, leukaemia and Bladder Michelia et al (2009) The advantage of women in cancer survival: An analysis of EUROCARE-4 data. European Journal of Cancer 45 ( 2009) 1017 –102

“Women had significantly higher survival than men for all cancers combined in each age class; however, this advantage reduced progressively with age: from +12.0% points at 15 –44 years to +1.3% points at 75–99 years.” (p1022) Michelia et al (2009) The advantage of women in cancer survival: An analysis of EUROCARE-4 data. European Journal of Cancer 45 ( 2009) 1017 –102

Difference (%) between men and women in cancer survival across Europe 18 16 14 12 10 8 6 4 2 0 Sl ov en C ia ze M ch T al R he ta ep N ub et lic he Sp rla ai nd n E s Ita UR O ly Po C la AR N nd E or 4 th m er ea n n Ire la G nd er m an y Be lg iu m En gl an d Sc ot Sw la nd itz er la nd W al es Fi nl an N d or w ay Ic el an d Ire la nd Au st ria Sw ed en Verdecchia et al (2007) Eurocare 4

Cancer World

Registrations of newly diagnosed cases of malignant neoplasm of colon & rectosigmoid junction & rectum, Scotland, by age and sex, 2008.

Colon, Rectosigmoid junction, Rectum 200 150 100 50 400 350 300 250 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ ISD Scotland (2009) http://www.isdscotland.org/isd/1508.html

Male Female

Deaths registered as a result of malignant neoplasm of colon & rectosigmoid junction,& rectum by age and sex, 2008 for Scotland Colon, Rectrosigmoid junction, Rectum 100 80 60 40 200 180 160 140 120 20 0 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ ISD Scotland (2009) http://www.isdscotland.org/isd/1508.html

Male Female

The case of Colo-rectal cancer

• 35% genetic factor – Hereditary non-polyposis colorectal cancer (3-5% of cancers, with many of these male) – 1 st degree affected relative increases risk 2-4 fold – May include recessive genes, pathogenic mutations of low penetrance and complex gene gene and gene-environment interactions Mitchell et al 2002 – Aggravated by mutations in APC, p53, k Ras and MSH2 genes (Fearon & Volgestein 1990)

• Colo-rectal cancer risk increased by: – Diet low in fruit and vegetables – High intake of red and processed meat – Low physical activity – Alcohol – Smoking – Diabetes – Obesity

CANCER REFORM STRATEGY 2007

6.37 In 2006, a symposium organised by the Men’s Health Forum and chaired by the National Cancer Director discussed the issues around cancer and gender. The event highlighted that there are still many cancer types for which the reason for higher incidence and mortality in men is not known and that this higher incidence may be the result of unidentified risk factors or general biological predisposition. It is clear that more research is needed if we are to fully understand how gender impacts on cancer.

6.38 The Symposium also highlighted that the range of settings in which men are offered advice, information and routine health checks should be expanded from traditional primary and secondary care settings, for example into the workplace.

The causes of these inequalities are not fully understood. Differences in lifestyle (e.g. smoking) and occupational exposure to risk factors are likely to be major factors.

Report of the All Party Parliamentary Group on Cancer’s Inquiry into Inequalities in Cancer, 2009 (p10)

National Cancer Equalities Initiative

• A response to the Cancer Reform Strategy • Gender visioning event in Leeds this year • Report to be published in January 2010 • Research and policy directives will emerge from this group

Conclusion

• • • • Men are more at risk of developing and dying of those cancers that should affect men and women equally The reasons for men’s increased risk are many and are not just associated with higher smoking levels We need to be more proactive in reaching out to men to inform them of the risk and also what can be done about it.

There is now recognition of this at Government and we will see progress…