Cancer Epidemiology:

Principles and Methods

 International Agency for Research on Cancer

The International Agency for Research on Cancer (IARC) was established in 1965 by the
World Health Assembly, as an independently financed organization within the framework of
the World Health Organization. The headquarters of the Agency are at Lyon, France.
The Agency conducts a programme of research concentrating particularly on the
epidemiology of cancer and the study of potential carcinogens in the human environment.
Its field studies are supplemented by biological and chemical research carried out in the
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research institutions in many countries. The Agency also conducts a programme for the
education and training of personnel for cancer research.
The publications of the Agency are intended to contribute to the dissemination of
authoritative information on different aspects of cancer research. Information about IARC
publications and how to order them is also available via the Internet at: http://www.iarc.fr/
 WORLD HEALTH ORGANIZATION
INTERNATIONAL AGENCY FOR RESEARCH ON CANCER

Cancer
Epidemiology:
Principles and
Methods
By
Isabel dos Santos Silva

International Agency for Research on Cancer

Lyon, France
1999
 Published by the International Agency for Research on Cancer,
150 cours Albert Thomas, 69372 Lyon cdex 08, France

International Agency for Research on Cancer, 1999

Distributed by IARCPress (fax: +33 04 72 73 83 02; E-mail: press@iarc.fr)

and by the World Health Organization Distribution and Sales, CH-1211
Geneva 27 (fax: +41 22 791 4857)

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The authors alone are responsible for the views expressed in this publication.

The International Agency for Research on Cancer welcomes requests for permission to
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addressed to the Editorial & Publications Service, International Agency for Research on Cancer,
which will be glad to provide the latest information on any changes made to the text, plans for new
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IARC Library Cataloguing in Publication Data

dos Santos Silva, I.

Cancer epidemiology: principles and methods / Isabel dos Santos Silva

1. Neoplasms epidemiology I. Title

ISBN 92 832 0405 0 (NLM Classification W1)

Contents
Foreword vii

About this book ix

1 Introduction to cancer epidemiology 1

2 Measurement of exposures and outcomes 11

3 Describing and presenting data 45

4 Measures of occurrence of disease and other 57

health-related events

5 Overview of study designs 83

6 Evaluating the role of chance 103

7 Intervention trials 135

8 Cohort studies 165

9 Case-control studies 189

10 Cross-sectional surveys 213

11 Studies based on routine data 231

12 Introduction to survival analysis 263

13 Interpretation of epidemiological studies 277

14 Dealing with confounding in the analysis 305

15 Size of a study 333

16 Cancer prevention 355

17 The role of cancer registries 385

18 Designing, planning and conducting epidemiological research 405

References 427

Subject index 437

v
 Foreword

Within the IARC programme of training courses, high priority is given

to courses on cancer epidemiology, particularly in countries of the
developing world. Population-based epidemiological studies are the only
reliable source on the occurrence and outcome of cancer and form the
basis of any national or regional cancer control programme. Over the
years, the International Agency for Research on Cancer has been faced
with the problem of selecting an appropriate textbook for its courses. To
resolve this difficulty, we decided to publish a textbook suitable for the
course faculty and the non-initiated reader. Isabel dos Santos Silva, from
the London School of Hygiene and Tropical Medicine, a prominent
epidemiologist with extensive teaching experience, has accomplished this
task admirably, in close consultation with external experts and an IARC
Advisory Board (see below).
We hope that this textbook will guide students and health professionals
wishing to understand the basic principles and methods used in cancer
epidemiology.

P. Kleihues
Director, IARC

IARC Advisory Board

Nubia Muoz
D. Maxwell Parkin
Jacques Estve
Paolo Boffetta

vii
 About this book

This book is addressed primarily to medical and public health students,

clinicians, health professionals and all those seeking to understand the
principles and methods used in cancer epidemiology. Its aim is not to
convert the readers into epidemiological experts but to make them
competent in the use of basic epidemiological tools and capable of
exercising critical judgement when assessing results reported by others.
The book is designed to provide an easy understanding of the basic
concepts and methods through the use of illustrative examples, often
using real research data. It was my intention to ensure that the material
would be accessible to everyone new to the field. Knowledge of statistics
is indispensable to the proper conduct, analysis and interpretation of epi-
demiological studies. Thus, statistical concepts (and formulae) are also
presented but the emphasis is on the interpretation of the data rather than
on the actual calculations.
The book is divided into 18 chapters. The first six introduce the basic
principles of epidemiology and statistics. Chapters 713 deal in more
depth with each of the study designs and interpretation of their findings.
Chapters 14 and 15 cover more complex statistical concepts and can be
omitted at a first reading. Chapter 16 deals with methodological issues in
cancer prevention, including primary prevention, early detection
(screening activities) and tertiary prevention. Chapter 17 reviews the role
of cancer registries in cancer epidemiology and prevention. Finally,
Chapter 18 discusses logistic issues and practical considerations that
should be taken into account in the design, planning and conduct of any
type of epidemiological research.
Few, if any, of the ideas and concepts in this book are original. Many of
them derive from my own teaching experience at the London School of
Hygiene and Tropical Medicine and, in particular, to my role as the
organizer of the Schools intensive course in epidemiology and medical
statistics. I am deeply indebted to many colleagues and students with
whom I have worked over the past years for all I have learnt from them.
It would be impossible for me to name all who, in one way or another,
helped me to write this bookI can only hope that they are aware of my
appreciation. I am, however, particularly grateful for the help of my
colleagues (and good friends) Bianca De Stavola and Esa Lr for the long
hours they spent reading earlier drafts and for their helpful comments,
suggestions and stimulating discussionsI certainly learnt a lot from
ix
 them! I would also like to thank IARC for giving me the opportunity to
write this book and, in particular, the members of the editorial committee
(Drs Jacques Estve, Nubia Muoz, Max Parkin and Paolo Boffetta), Dr.
Rengaswami Sankaranarayanan and Dr. Martyn Plummer, for their
suggestions and comments in the earlier stages of the project. I am also
grateful for all the support and encouragement given by my colleagues at
the London School of Hygiene and Tropical Medicine and, in particular,
to the thoughtful comments on earlier versions of various chapters
provided by Professor Peter Smith, Dr Noreen Maconochie and Dr Punam
Mangtani. I also wish to thank Ms Maria Quigley and Mr. Craig Higgins
for giving permission to include some of their teaching examples in
Chapter 14. Part of the material presented in Chapters 6 and 12 was
initially developed as teaching material for our intensive course in
collaboration with Dr Maconochie and Mr Jerry Wheelerthe stimulating
discussions we had at that time and the feedback received from our
students were very helpful in shaping those chapters. Lastly, I would like
to thank Dr John Cheney and Ms Helis Miido for all their editorial
assistance.

Isabel dos Santos Silva