Beruflich Dokumente
Kultur Dokumente
Eero Pukkala
Matti Rautalahti
ISBN 978-952-5815-16-0
ISBN 978-952-5815-17-7 (pdf)
Cancer Society of Finland Publication No. 86
Cancer in Finland aims to give a balanced overview of cancer incidence, prevalence, and mortality
in Finland. The report also presents current information on the causes of cancer and the pos-
sibilities for cancer prevention. The Finnish Cancer Registry, an institute for epidemiological and
statistical cancer research, was founded in 1952. At first, reporting of cancer cases was voluntary,
but in 1961 the National Board of Health issued a by-law making reporting compulsory for all
physicians, hospitals and other relevant institutions. Primary medical care in Finland is provided
to the entire population at only a nominal fee. Every cancer patient receives adequate and modern
treatment as required. Most of the information presented in this book is based on the comprehen-
sive, high quality registration of cancers over the last 60 years and on the extensive epidemiological
research done in Finland.
Trends in cancer incidence have been studied in Finland for an exceptionally long time period.
With the help of information from the registry files, many studies are done at the Finnish Cancer
Registry on risk factors for cancer, prevention, and early diagnosis. The efficacy of the health care
system has been followed using survival statistics of cancer patients.
There are outstanding possibilities in Finland and in the other Nordic Countries for cancer re-
search due to comprehensive data of high quality and the availability of data for research purposes.
Employing and safeguarding these can be considered an important international obligation.
Nea Malila
Professor, Director of the Finnish Cancer Registry
Contents
Introduction 6
The Finnish Cancer Registry 6
Cancer Registration 7
Acknowledgements 7
Cancer screening 50
Cervical cancer screening 50
Screening for breast cancer 52
Colorectal cancer screening 53
Screening for prostate cancer 54
Screening for other cancers 54
Treatments 55
Survival 56
Factors contributing to survival 57
Years of life lost 59
References 69
Introduction
This publication deals with the occurrence of tion, there are a number of researchers working
cancer in Finland. The goal is to distribute in- on project-based funding.
formation related to cancer to those who have
something to do with cancer in their work or The Finnish Cancer Registry
studies, or to those who are otherwise interested
in the topic. The publication describes the fre- • produces descriptive information on the inci-
quency of cancer among different population dence, prevalence and mortality of cancer as
groups, risk factors for cancer, treatments for well as changes and predicted changes in the
cancer, the detection of cancer in pre-malignant situation;
and early stages through mass screening, the
survival of cancer patients as well as projections • produces countrywide and regional estimates
of cancer occurrence in the future. of cancer patient survival;
The publication is based for the most part on • acts as a specialist organization in questions
the data and results from the research work of related to cancer epidemiology and in the
the Finnish Cancer Registry. planning and evaluation of mass-screening
programmes and other actions against cancer,
The Finnish Cancer Registry and
The Finnish Cancer Registry is an institute for • researches the causes of cancer and the ef-
statistical and epidemiological cancer research fectiveness of treatments using epidemiol-
founded in 1952. In 2013 there were some 30 ogy and statistics, provides data to outside
permanent employees in the Cancer Registry: researchers and helps them in the planning
administrative personnel as well as experts in and execution of their studies.
medicine, epidemiology, and statistics. In addi-
Introduction | 7
1
stats.cancerregistry.fi/Publications/publications.html
2
www.cancer.fi/syoparekisteri/en/general/doctoral-student-education
8 | Cancer in Finland
Factors associated with a person’s lifestyle and cause symptoms. A single cause cannot be iden-
environment are significant in the development tified for the majority of cancer cases.
of many cancers but for some cancers genetic
characteristics may also be an important factor. Cancer is a complex group of diseases whose
In order to prevent cancer, it is crucially impor- causes, development, symptoms and treatment
tant to know those factors which influence the can differ greatly from one to another.
probability of developing cancer.
Internal factors
Risk factors for cancer can be roughly divided
into the following groups: Age. The majority of cancer cases are related to
dioactive materials and asbestos hormones) also influence the risk of cancers
other than those of the reproductive organs.
• lifestyle related factors such as physical activ-
ity and diet Heritability. A cancerous tumour or cell is not
contagious, nor is it passed from parent to child.
The development of cancer is a series of events As cancer is a common disease, approximately
occurring over many years, where the DNA of every third Finn will fall ill from cancer dur-
a normal, healthy cell is damaged. The cells ing his or her lifetime. Thus it is normal that
change, through many stages, into malignant in nearly every family there will be some can-
cells which grow independently of the normal cer patients, but this results from both genetic
regulatory systems of the tissues and finally and environmental influences. Susceptibility to
Risk factors for cancer and their effect | 9
Figure 1
Cancer begins as a result of genetic mutations lasting many years after complicated series of events
that are influenced by numerous different environmental risks.
g g
g g g
cancer (an increased risk of developing cancer) organ presents in several affected family mem-
can be inherited. This means that one or more bers. Young age at onset, and the occurrence
inherited gene defects relevant to the develop- of multiple primary tumours, are also features
ment of cancer are already in place in all of the suggestive of hereditary predisposition. Domi-
person’s cells, and they can be passed on to off- nantly inherited susceptibility is passed on to
spring through the germ line. an average of every second offspring. If a mem-
ber of a family with hereditary susceptibility
While in rare cases a single gene defect may lead has not inherited the faulty gene(s), his or her
to a greatly increased risk of cancer, it is much children do not have an increased risk of cancer.
more common that there are multiple gene de- These types of cancer are rare and account for
fects, each contributing a minor increase in risk. only a small fraction of all cancers.
Depending on the inherited combination of
such genes, inherited susceptibility may be larg- However, most common cancers have some
er or smaller. In addition to such defects, envi- hereditary component, including breast and
ronmental risk factors are also required to cause intestinal cancers, thyroid cancer, uterine and
the additional changes in the cells necessary for ovarian cancers as well as prostate cancer, based
the development of a malignant tumour. on analyses of large twin cohorts (Lichtenstein
et al 2000). In the past five years, genome-wide
For cancers where there are only a single or few studies have discovered tens of genetic loci as-
gene defects it is typical that cancer of the same sociated with increased risk of common cancers
10 | Cancer in Finland
on the latest research, the people who lived in tions are intended to ensure that the exposure
those – now demolished – buildings have not of workers to asbestos remains as small as pos-
had any more cancers than others in Helsinki sible. Despite this, for those who have done
after 1999. asbestos spraying work, the risk of developing
mesothelioma and lung cancer is still greater
In recent years, there have been more measure than for the rest of the population (Oksa et
ments of the environmental situation, and with al 1997). Tobacco has, however, proven to be
their help, we can better evaluate the asso- many times more important as a cause of can-
ciation between environmental pollutants and cer than asbestos. The risk of lung cancer for a
cancer risk. non-smoking asbestos worker is only 1.4 times
that of a non-smoker not exposed to asbestos.
Occupational hazards. The influence of work- However, a smoker not exposed to asbestos has
related hazards, such as chemicals, on the risk a 14-times greater risk, and a smoker exposed
of cancer has been identified in hundreds of to asbestos has a 17-times greater risk, of lung
different studies. The web page of the Finn- cancer. Almost all mesotheliomas are caused by
ish Institute for Occupational Health (www. asbestos (Meurman et al 1994).
occuphealth.fi) has good information about
cancer risks resulting from occupational envi- Exposures considered to be relatively safe in
ronment hazards and about their measurement. the working environment may change into
significant risk factors, if they occur together,
In the Cancer Registry, research has been done for example, with tobacco use. The Finnish Job
over many decades on the risk of cancer, among Exposure Matrix (FINJEM), developed by the
others, for healthcare personnel, workers in Finnish Institute of Occupational Health, helps
the chemical wood processing industry and to estimate exposures to different chemicals and
sawmill industry, employees in the printing other factors for workers in different occupa-
industry, shipyard workers and machinists, oil tions. With its help, we can estimate quantita-
refinery employees, glass and glass fibre work- tive amounts of exposure to carcinogenic factors
ers, shipping personnel, airline personnel, train for every person in the population (Pukkala et
engineers, farmers, bush insecticide sprayers, al 2005). Currently, comparable estimates can
hairdressers as well as employees exposed to be made for the populations of all Nordic coun-
asbestos, styrene, trichloroethylene, formalde- tries (Kauppinen et al 2009).
hyde, PCB, lead, nickel and other metals. Many
of these worker cohorts are still being followed. Large variations in cancer risk in different oc-
cupational categories have been demonstrated
Asbestos is considered to be an important fac- in the large Nordic Occupational Cancer Study,
tor in increasing the risk of cancer in the work- NOCCA (astra.cancer.fi/nocca) which studied
ing environment, and that is why, for example, the risks for cancers associated with different
clear regulations have been given for the repair occupations.
and demolition of older houses. The regula-
12 | Cancer in Finland
Figure 2
Occupations with the lowest and highest incidence of cancers in men in the Nordic countries
1961–2005 (Pukkala et al 2009).
Mesothelioma
Farmers Plumbers
Pharynx cancer
Farmers Waiters
Oral cancer
Farmers Waiters
Liver cancer
Farmers Waiters
Tongue cancer
Farmers Waiters
Lip cancer
Doctors Fishermen
Laryngeal cancer
Farmers Waiters
Oesophageal cancer
Doctors Waiters
Lung cancer
Nurses Waiters
Nasal cancer
Military workers Wood workers
Skin melanoma
Fishermen Dentists
Gastric cancer
Dentists Fishermen
Skin, squamous cell carcinoma
Forestry workers Nurses
Bladder cancer
Farmers Waiters
Gallbladder cancer
Farmers Laundry service
Testicular cancer
Forestry workers Doctors
Pancreatic cancer
Farmers Beverage workers
Non-Hodgkin lymphoma
Chimneysweeps Tobacco industry
Kidney cancer
Nurses Tobacco industry
Colon cancer
Forestry workers Chimneysweeps
Prostate cancer
Domestic assistants Dentists
Rectal cancer
Nurses Waiters
Central nervous system cancer
Chimneysweeps Physicians
Table 1
Occupations with the highest and lowest cancer incidence in Finland 1971–2005: Standardized inci-
dence ratios (SIR) that are statistically significantly increased in relation to the mean in the population
(SIR = 1.00) are highlighted in red and those which are decreased in green (Pukkala et al 2009).
N = number of cancers.
MEN WOMEN
Occupational category N SIR Occupational category N SIR
The NOCCA study confirms known connec- ar bombs in the 1950s. Radiation particularly
tions between occupational factors and cancer, increases the risk of leukaemia, thyroid cancer,
but points in addition to the influence of life- breast cancer, lung cancer and bladder cancer.
style related choices such as use of tobacco and
alcohol. The increase in office work reduces The most important source of radiation among
work-related physical activity, which would the Finnish population is radon in indoor air,
protect against cancer. Shift work is now also with a dose averaging 2 mSv received annu-
seen to be a probable cancer risk factor (Straif ally, which is about half of the total radiation
et al 2009). Ultraviolet rays from sunlight are a received by Finns. Alpha radiation produced by
significant risk for certain occupations: for ex- radon does not penetrate material deeply, and
ample lip cancer is found particularly often in therefore inhaled radon results in radiation ex-
fishermen and farmers, while the risk of skin posure only to the lung. The only clearly estab-
melanoma is greatest for indoor workers whose lished health impact of radon is increased lung
skin is not accustomed to the sun and burns cancer risk. In an extensive European study, also
easily on holiday. involving Finnish researchers, the proportionate
increase in lung cancer risk was 8 percent (Dar-
The greatest cancer risk for Finnish men is in the by et al 2005) at a concentration close to the av-
tobacco industry and in mining work (Table 1). erage in Finnish houses (100 Bq/m3). Radon in
The occurrence of cancer for those working in indoor air is estimated to cause about ten per-
these areas is about thirty percent more than cent of lung cancer among Finns or about two
the average for Finnish men. hundred lung cancer cases every year, which is
far less than that attributable to smoking but
The biggest cancer risk for Finnish women is comparable to the burden from e.g. environ-
in military and security work, which also in- mental tobacco smoke.
cludes women working as police officers or as
security guards. Next on the list are dentists and In diagnostic radiology the benefits of inves-
doctors. There is a significantly less-than-aver- tigations using x-rays need to be considered
age cancer risk, for example, for women forest relative to the small risk caused by radiation
workers and bricklayers. exposure. Occupational groups exposed to ra-
diation include, for example, radiologists, x-ray
Radiation. Ionizing radiation is ubiquitous, be- technicians or nurses and nuclear power plant
cause radiation is produced, for example, by workers. The radiation doses received by these
natural radioactive materials in the Earth’s crust. groups nowadays are generally rather small. No
Ionizing radiation has been estimated to cause increased cancer risk has been shown among
1–3 percent of all cancers. X-rays were found to Finnish nuclear power station workers or phy-
cause cancer in the early 1900s. Strong scien- sicians occupationally exposed to radiation
tific proof that small doses increase the impact (Auvinen et al 2002, Jartti et al 2006). The pro-
of radiation risk was obtained from research on duction of nuclear energy in normal circum-
survivors of the Hiroshima and Nagasaki nucle- stances causes radiation exposure, in practice,
Risk factors for cancer and their effect | 15
intensive UV-radiation to skin unaccustomed ing in Finland, Sweden, Denmark, Great Brit-
to this, causing burning of the skin, particularly ain and the Netherlands.
in children and adolescents. In particular, light
skinned, blue-eyed people and those who burn Lifestyle
easily and tan poorly are at risk. Some melano-
mas occur in moles, and having a large number Tobacco. The use of tobacco products is the
of moles (over 100 pigmented naevi) increases most important single factor that increases can-
melanoma risk. cer risk. The risk from tobacco is based on a
large amount of carcinogenic (cancer-causing)
Power lines and electrical appliances generate compounds, which are already in tobacco prod-
low frequency magnetic fields (50–60 Hz). ucts or are formed during the burning process.
The impact on cancer risk, and particularly on
childhood leukaemia, has been studied exten- It has been estimated that tobacco products
sively, and increased risk estimates for child- cause one third of all cancers. The impact of
hood leukaemia, related to very high exposure smoking on lung cancer is the best known. The
levels, have been shown in several studies. For probability of getting lung cancer is greater the
other cancers, no clear indication of excess risk younger a person starts smoking, the more the
has been demonstrated. According to Finnish person smokes daily and the longer the smok-
research series covering the entire population, ing continues (Hakulinen and Pukkala 1981). If
children and adults do not have an increased a person has smoked 20 cigarettes daily for 50
cancer risk related to proximity to power lines years, his or her risk of getting lung cancer is 50
(Verkasalo et al 1993 and 1996). Occupational times higher than that of non-smokers. After
exposure to electromagnetic fields occurs in stopping smoking, the danger of lung cancer
many workplaces, but there is no indication of quite rapidly approaches the lung cancer risk of
cancer risk as a result of such exposures. a non-smoker of the same age, but never drops
to the same level. Those who have smoked for a
Radar, radio transmitters, mobile phones and long time will still benefit the most from stop-
base stations, among others, generate radiofre- ping smoking.
quency electromagnetic fields (in the megahertz
range). Radiofrequency fields do not cause ge- Smoking is a significant cause of laryngeal can-
netic changes, and have not increased cancers cer, and is also linked to cancers of the mouth,
in animal tests. In epidemiologic research, the throat, kidney, pancreas, oesophagus, uterus
use of mobile phones has been linked to an and bladder. Smoking may also increase the risk
increased cancer risk (Interphone Study Group of breast cancer (Xue et al 2011).
2010), but problems with this research include
a fairly short ten-year follow-up period and the In 2009, 22 percent of Finnish men and 16 per-
unreliability of information on mobile phone cent of Finnish women smoked daily (Helakor-
use based on questionnaires. More reliable evi- pi 2010). In addition, about 8 percent of adults
dence is expected from follow-up studies ongo- smoked occasionally. Smoking among men
Risk factors for cancer and their effect | 17
workers have the highest cancer risk of all oc- cancer risk does not differ significantly with
cupations in the Nordic countries (Pukkala et the type of alcohol drink consumed. The most
al 2009). important risk factor is the amount of ethanol
consumed.
Cancer risk often increases significantly through
the combined impact of smoking and some Alcohol, or ethanol, may cause cancer through
other factor. Smoking and outdoor work to- several possible mechanisms. The most sig-
gether increase increase for instance the risk of nificant is probably that, in the body, alcohol
lip cancer by 15-fold, although outdoor work breaks down into acetaldehydes, which are
alone or smoking increases lip cancer risk only capable of causing DNA damage (Salopuro
by two-fold (Lindqvist 1979). Correspondingly, 2009). In addition, the breakdown of alcohol
smoking increases the impact of asbestos and blocks the body’s removal of toxins and makes
many such materials used in the working en- it possible for the other cancer risk factors to ac-
vironment, which alone are not particularly cumulate in tissues. Alcohol is also an efficient
dangerous. solvent, which may harm mucous membranes
from the mouth to the stomach and, therefore,
Alcohol. There is a clear causal relation between make it possible for other substances to have an
the use of alcohol and several cancers. There is influence.
convincing evidence that the use of alcohol in-
creases cancers of the mouth, throat, larynx, Dietary factors. The effects of diet on cancer
oesophagus and liver (Baan et al 2007, www. have been researched intensively for decades.
dietandcancerreport.org). Thirty years ago it was estimated that diet was
the most important modifiable cause of cancer.
Four daily servings of alcohol (50 g ethanol), for Diet is a complex mix of components in which
example, increase the risk of mouth and phar- combined and contradictory effects are difficult
ynx cancers by two-fold. Other factors may in- to understand.
crease the impact of alcohol. Drinking alcohol
and smoking together very strongly increase the Diet has been considered to have the strongest
risk of cancers of the mouth, throat and larynx. influence on the risk of cancer of the stomach,
colon, rectum, as well as the oesophagus, kidney,
With regard to breast cancer, there is no safe bladder, prostate, lung, breast and corpus uteri.
amount of alcohol intake, but rather the These are common cancers in Finland and other
risk of cancer increases directly in relation to countries with western diets. Dietary factors can
the amount of alcohol consumed. Moderate cause cell transformations in many ways:
amounts of alcohol taken infrequently are not
significant. On the other hand, excessive use of • Some dietary factors can in themselves cause
alcohol increases the cancer risk and causes oth- cancer (for example alcohol).
er clear health problems regardless of whether
drinking alcohol is infrequent or regular. The • Cancer causing substances can be found in
Risk factors for cancer and their effect | 19
food which is spoiled or not clean (for exam- Many of these vitamins are important antioxi-
ple aflatoxin of certain moulds). dants in the body. They prevent oxidation of
fatty acids and protect the body from harmful
• In some methods of preparing food, cancer- substances arising from oxidation. Low levels of
causing substances are formed (for example vitamin D seem to be linked to an increased
polycyclic aromatic hydrocarbons when grill- risk of some cancers, but high levels of vitamin
ing). D are also linked to a higher than usual cancer
risk (Tuohimaa et al 2007).
• Certain dietary factors can become cancer-
causing in the body (nitrites). Several studies have indicated that a diet rich in
vegetables and fruit decreases the risk of many
• The lack of dietary factors which are protec- cancers. Vitamin products have been also re-
tive against cancer (for example a lack of vi- searched in cancer prevention experiments, but
tamins and minerals) increase the risk of get- none have so far been proven to prevent cancer
ting disease. alone or in combination (ATBC 1994). It is
probable that from the point of cancer preven-
A diet that has an excessive energy content, or tion, a balanced totality, not single nutrient fac-
the resulting excess in body weight, increases tors, is the most crucial aspect of diet.
the risk of many cancers. Based on many ani-
mal experiments, it has been found that fat Among the minerals, selenium has been the
in the diet increases the risk of cancers of the most researched. It is estimated that a lack of
breast, colon and pancreas. Information con- selenium increases cancer risk. The selenium
cerning humans is not yet so convincing that content of Finnish food is nowadays sufficient;
dependable conclusions could be drawn on therefore additional selenium products are not
the impact of fat in the diet on the cancer risk. needed.
Cancer tissue also needs energy and minerals,
and therefore, dietary factors can – as well as Some food preparation methods cause chemi-
causing cancer – also influence the growth of cal changes that lead to cancer-causing factors.
cancer. Smoking and grilling fatty food on an open
fire or otherwise at a high temperature creates
Dietary fibre probably protects against colon small amounts of polycyclic aromatic hydrocar-
cancer (Bingham 2003). Hence root vegetables bons (PAH) on the surface of the food, which
and rye bread, which belong to the traditional increase the cancer risk. Acrylamide in potato
Finnish diet, are also healthy in this regard. chips, French-fries and hard bread is classified
as a possible cancer risk compound, but eating
Vitamins are one of the most important areas food containing acrylamide has not been found
of research concerning links between food and to have a connection to cancers (Mucci et al
cancer. The greatest interest has been in carot- 2003). Excessive use of food preserved by salt
enoids, A, E, C and D vitamins and folates. increases the risk of gastric cancer.
20 | Cancer in Finland
Exercise and weight control. A link between ex- Reproduction and hormones. Cancer of wom-
ercise and cancer risk has been observed in sev- en’s reproductive organs and breast cancer are
eral studies. Scientific proof has been collected clearly linked to sexual and reproductive behav-
of the protective effects of exercise, particularly iour. If a woman herself – or her sexual partner
concerning cancers of the breast, colon, uterus – has had several partners, she is more likely
and prostate (www.dietandcancerreport.org). than other women to get cervical cancer. The
explanation for this is that sexually transmitted
Moderate exercise changes the metabolism of viruses are important factors in cervical cancer
certain hormones and strengthens the func- (see Infections).
tioning of the body’s general protective mech-
anisms. Exercise reduces the amount of fat Giving birth at a young age and having many
tissue, and the amounts of different growth children protect from breast cancer. The pro-
factors become more balanced. The diet of an tective impact is increased if a woman has many
actively exercising person often includes more children (Hinkula et al 2001). Not having chil-
components that protect from cancer. dren is also a risk factor for cancers of the ovary
and corpus uteri, and early sexual maturity and
According to the latest research, the benefits of late menopause increase the number of a wom-
exercise are generally achieved by about an hour an’s menstrual cycles and increase the risks of
of daily exercise, such as walking or cycling to the above-mentioned cancers.
work or to the shops, going up the stairs or rak-
ing the yard. For weight control, it is sufficient Modern contraceptive pills protect against can-
to have half an hour of exercise three times a cers of the ovary and corpus uteri. During men-
week. Those doing office work in particular opause, women who have undergone lengthy
should exercise regularly in order to avoid being hormone therapy are, on the other hand, diag-
overweight. Brisk exercise several times a week nosed with more cancers of the breast, endome-
can give an extra benefit in preventing cancer trium and ovary than women who do not use
(Latikka et al 1998). hormone therapy (Jaakkola et al 2009, Lyytinen
et al 2010, Koskela-Niska et al 2013). Linking
Exercise is also beneficial when rehabilitating the progesterone hormone to estrogen replace-
from cancer or in preventing a relapse (Knols ment therapy increases the risk of breast cancer,
et al 2005). Finnish BREX study concerning but protects against cancer of the uterus. The
this issue started in 2005 (Penttinen et al 2009). benefits of hormonal therapy during meno-
While nothing can yet be said of the cancer pause must be considered individually in rela-
prevention potential of exercise, this 12-month tion to the cancer risk.
aerobic jumping and circuit training interven-
tion completely prevented femoral neck bone Infections. Some viral infections increase can-
loss in premenopausal breast cancer patients cer risk. Infections caused by some bacteria
(Saarto et al 2012). may also increase risks of certain cancers. For
example, Helicobacter pylori increases the risk
Risk factors for cancer and their effect | 21
of gastric cancer (Rehnberg-Laiho et al 2001). mune defence linked to the illness. In this situa-
Some tropical parasitic diseases also increase the tion, the HHV8 virus can cause Kaposi sarcoma.
cancer risk, but they are very unusual in Fin-
land. Socio-economic position
Human papilloma viruses (HPV) are the most The overall cancer incidence for working aged
researched virus family of those which cause can- men in the lowest social class is about one third
cer. Some cause chronic infection and, through higher than in the highest class. On the other
this, cervical cancer (Lehtinen et al 1996). Papil- hand, the cancer incidence for women is high-
loma viruses may also cause other cancers, such est in the highest social class. Typical cancers in
as pharyngeal cancer (Mork et al 2001). the lower class are those of the lip, stomach and
nose as well as throat and laryngeal cancer (Fig-
Vaccines aimed at preventing infections caused ure 5). In the lower classes, there are also more
by papilloma viruses have been on the market cervical cancers and vaginal cancers in women
for some years. Vaccine efficacies against low- and lung cancers in men. Cancers linked to a
grade cervical intraepithelial neoplasia (CIN) high standard of living are cancers of colon,
have been defined for both licensed vaccines breast and testis as well as melanoma of skin
(Lehtinen et al 2013). Ongoing studies with on the trunk and limbs. Differences in cancer
long-term follow-up will by 2015 and 2022 incidence between social classes may be as great
find out if HPV-vaccines also prevent higher as five-fold.
grades of CIN3 and invasive cervical cancer,
respectively (Lehtinen et al 2006, Rana et al Differences between social classes have increased
2012). rather than decreased (Pukkala and Weiderpass
1999 and 2002). The socio-economic pattern
An increased risk of liver cancer is also linked to can also change: for example, lung cancer in
chronic liver infection (hepatitis B and C viral women changed very rapidly from an illness re-
infections). The Hepatitis B virus (HBV) vacci- lated to a high standard of living to one related
nation campaign that began in Taiwan in 1984 to a low standard of living at the turn of 1980s.
led first to a reduction in HBV incidence and
then to a significant reduction in liver cancer Socio-economic position impacts on cancer risk
incidence in the age groups vaccinated (Chang through lifestyle and work-related factors. In
2011). most cancers in the lower social classes, smok-
ing is an important cancer risk factor. Smoking
HIV infection and AIDS are linked to an in- among men and young women in Finland is
creased risk of lymphoma and Kaposi sarcoma, most common in the lower social classes. For
which would otherwise be a very rare disease more than three decades, smoking differences
(Kaasinen et al 2013). These cancers are not have been accepted as explaining almost all of
caused directly by cancer-causing features of the the differences in the frequency of lung can-
HIV virus, but by the collapse of general im- cer and many other cancers between the social
22 | Cancer in Finland
Figure 5
Connection of socio-economic position to cancer incidence in Finland 1971–2005. The graph is based
on information from NOCCA study (Pukkala et al 2009) and it shows standardized incidence ratios
(SIR) in relation to the population mean (1.0).
MEN
SIR
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
Lip cancer Oesophageal Gastric Colon cancer Nose cancer Laryngeal Lung cancer Skin melanoma
cancer cancer cancer
WOMEN
SIR
1.6
• Higher level clerical employees
• Lower level clerical employees
1.4 • Unskilled
Skilled workers
• workers
1.2
• Farmers
1.0
• Economically inactive
0.8
0.6
0.4
0.2
0
Laryngeal Lung cancer Breast cancer Cervical Skin melanoma
cancer cancer
Risk factors for cancer and their effect | 23
classes (Pukkala et al 1983). Dietary differences that the medicine being developed could cause
have been suggested to be related to social class cancer. The side effects of medicines that are al-
differences in cancer risk (Pukkala and Teppo ready on the market are monitored closely, and
1986). manufacturers remove products readily from
the market. However, it is unlikely that medi-
Cancer and other illnesses cines already in use nowadays or those which
are newly introduced new medicines have sig-
Generally, cancer risk is independent of that nificant cancer risks. For example the risks of
for other illnesses. For example, cancer risk cancer associated with the use of antibiotics and
does not increase in those with injuries from statins have been researched in Finland (Kilkki-
accidents or in those receiving treatment for nen et al 2008, Haukka et al 2010). At the mo-
heart ailments. Although lung cancer risk is ment, diabetes medicines are being researched
increased for people suffering from asthma for any possible impact on cancer risk. Pre-
(Vesterinen et al 1993), the risk is not caused liminary results suggest that, although diabetics
by asthma but by smoking, which causes both have an increased risk of getting cancer, there
illnesses. is no connection between diabetic medication
and cancer.
Depression, anxiety, grief and work-related
stress have little impact on cancer risk. Finnish Relatively toxic medicines and other treatments
schizophrenics have less cancer than the popu- which are used for treating complex illnesses are
lation average (Lichtermann et al 2001). Hip or a different matter. For example, radiation ther-
knee prostheses (Visuri et al 2010, Mäkelä et al apy for cancer, and some medical treatments,
2012) and silicone breast implants (Pukkala et may increase the risk of getting cancer later
al 2002 a) do not lead to an increased cancer (Kumpulainen et al 1998, Salminen et al 1999,
risk. Metayer et al 2000, Travis et al 1999, 2002,
2003, Dores et al 2002, Pukkala et al 2002 c,
Normal everyday ailments of the working age Gilbert et al 2003, Worrillow et al 2008, Jakobs-
population, such as headache, tiredness, diar- son et al 2011, Morton et al 2011). However, the
rhoea, weak spells or anaemia connected to the benefits of these types of cancer treatment have
menstrual cycle, are not normally associated been estimated to be greater than their adverse
with cancer, although they can sometimes be effects.
symptoms of cancer. Epilepsy does not increase
the risk of cancer, but epilepsy can be a symp- The body’s immune system must be suppressed
tom of a hidden brain tumour (Lamminpää et for organ transplants, so that the transplanted
al 2002). organ will not be rejected. Because the immune
system protects against cancer, the cancer risk
Medicines are tested in clinical research before for people who have received kidney or liver
they are used. Research and development work transplants, for example, is above average (Bir-
is stopped if there are even small indications keland et al 1995, Åberg et al 2008). The virus
24 | Cancer in Finland
causing HIV infection and AIDS suppresses to which tobacco and diet were both responsi-
the immune system and increases the risk of ble for one third of cancer deaths in the United
cancer. The body’s disturbed immune system States (Doll and Peto 1981). According to Nor-
in rheumatic illnesses (Kauppi et al 1997, Hill dic estimates (Olsen et al 1997) tobacco causes
et al 2001), in certain intestinal tract and skin only about 15 percent of new Finnish cancer
ailments (Collin et al 1996) as well as in carti- cases. The difference is explained, among other
lage-hair hypoplasia (Mäkitie et al 1999) also things, by the fact that lung cancer is a disease
increase the cancer risk. with a poor prognosis and its proportionate
share of cancer deaths is therefore bigger than
Many genetic syndromes also include cancers its share of cancer incidence. The significance
as one aspect, sometimes giving rise to several of various factors also differs according to re-
tumours in different organs. For some inherited gional and local circumstances, health behav-
illnesses, the cancer risk is increased, although iour and socio-economic situation.
cancer itself does not belong to the group of
symptoms. For example Down syndrome is Possibilities for cancer
linked to an increased risk of leukaemia (Patja
prevention
et al 2006).
It is in principle possible to attempt to prevent
Getting one cancer does not protect against cancer at different phases of the chain of events
other cancers. Cancer patients can develop new leading to the disease. We may affect the factors
cancers just like healthy people. According to that begin the process, or its progression, by
the data of the Finnish Cancer Registry, among helping the body to correct early changes or by
those who have recovered from the first cancer treating early stages of disease before the actual
about one in ten gets a new cancer (Sankila et al cancer has developed.
1995). The factors causing the first cancer can
also increase the risk of the second cancer: for The possibility of preventing cancer depend on
example patients with laryngeal cancer have an whether it is possible to change cancer risk fac-
increased risk of getting lung cancer (Teppo et tors related to environment and lifestyle. It was
al 1985). estimated in 1980 that the annual number of
lung cancer cases in men would decrease from
Attributable fractions 2000 cases, at that time, to a few hundred if all
Finns stopped smoking immediately (Hakuli
of risk factors
nen and Pukkala 1981). Smoking did not stop
There have been attempts to put the population completely, but has decreased so much that the
attributable fractions of different cancer-related age-adjusted incidence of lung cancer has fallen
factors in order of importance. The most well- to less than half of the highest level in 1970s.
known estimate of the contribution of environ- According to estimates, the incidence of lung
mental and other causes to the risk of cancer is cancer will continue to decrease up to the year
the study of Doll and Peto in 1981, according 2020 (see page 65).
Risk factors for cancer and their effect | 25
Finland was the first country to add tobacco alcohol, salt and mouldy products should be
smoke to the list of carcinogenic substances limited. Artificial dietary supplements should
and, in its legislation, states that tobacco smoke not be used.
causes cancer. The aim of the tobacco law of
2010 is to stop smoking in Finland by the year The development of cancer normally requires
2040. If this happened, it would have a great a long time. Any current changes in exposure
impact on the incidence of lung and other can- will mainly impact on cancer risk after the
cers. 2020s. Although significant changes in cancer
incidence cannot be expected in the coming
The potential of reducing other risk factors decades, deaths from cancer can be reduced
does not look as promising. For example, the through the development of methods for early
cancer-causing and cancer-protective charac- cancer detection and improvement in treat-
teristics of food products are not well enough ments, amongst others. An excellent example
known for cancer risk to be reduced through of cancer prevention is the systematic screening
specific changes in eating habits. The knowl- of cell changes in the cervix by the Pap test and
edge of many other risk factors is equally insuf- the treatment of these cell changes, which has
ficient and inaccurate. dramatically reduced cervical cancer in Finland
(see page 50).
Recently, many have begun to consider increas-
ing exercise as a significant method of cancer There are excellent conditions in Finland for
prevention. For example, the European rec- carrying out epidemiologic research on cancer
ommendations on cancer prevention (Boyle et risk factors. A well-functioning personal identi-
al 2003) list avoiding obesity and taking daily ty code system makes it possible for information
exercise as the second most important practi- collected from different sources to be combined
cal steps in cancer prevention. Only refraining reliably (Pukkala 2011). In addition, Finnish
from smoking is more important. The World legislation allows the combination of informa-
Cancer Research Fund and the American Can- tion from different registries, for scientific stud-
cer Society published in 2007 the recommen- ies that will benefit society and individuals. For
dations of an extensive group of experts on example, research on dietary factors, the risks
reducing the risk of cancer through diet and of living in certain areas, working environ-
exercise. The recommendations and justifica- ments, heritable factors and the inequality of
tions can be found on the Internet (www.di- social groups have all been based on combining
etandcancerreport.org). The messages of most information from registries. It is of the utmost
dietary recommendations are similar: they un- importance that the possibility of doing high
derline the importance of staying as slim as pos- quality epidemiologic research is safeguarded
sible, as long as weight remains within normal when cancer research becomes more and more
limits. Exercise should be taken every day. Diet complex and requires detailed information.
should be mainly of vegetable origin. Intake of Then the co-operation of several information
high-energy foods, red meat, meat products, providers is needed even more than before.
26 | Cancer in Finland
Figure 6
Number of cancer cases for men and women in 1953 and 2011. The surface area of the circle
describes the total number of cancer cases.
MEN
Pancreas 473
2011
Kidney 563
Rectum 623
Lung 1 570
Non-Hodgkin lymphoma 651
Other 1 265
Soft tissues 129
Gallbladder 132
Liver 156
Cervix 168
Multiple myeloma 171
Bladder 215
Stomach 280
Breast 4 865
Leukaemia 285
Thyroid 314
Kidney 417
WOMEN
Ovary 433
2011
Rectum 436
Pancreas 540
Colon 874
Figure 7
Number of deaths caused by cancer in Finland in 2011.
Other 1 602
Lung 2 100
Gallbladder 220
Skin melanoma 223
Oesophagus 231
Multiple myeloma 258
Colon and rectum 1 152
Bladder 283
Leukaemia 328
Ovary 360
Liver 74
Pancreas 1008
Central nervous system 399
Kidney 420
Prostate 886
Non-Hodgkin lymphoma 476
Stomach 499 Breast 844
Frequency of cancer in Finland | 29
3 000
2 000
• Women, incidence
• Women, mortality
1 000
Figure 9
0
Trends of annual numbers in new cancer cases
0 20 40 60 80 100 Age
and cancer deaths in Finland in 1953–2011.
Number of cases
16 000
12 000
10 000
8 000
2 000
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year
30 | Cancer in Finland
the number of those getting cancer annually increased at first and then reduced as smoking
has increased over three-fold in 50 years (Figure declined. The same phenomenon is seen, but
9), this increase does not describe changes in slightly less marked, in the incidence of pancre-
the risk of getting cancer. Population increase, atic cancer (Figure 12). Developing lymphoma
particularly in older age groups, also has an im- is linked, among other things, to the reduced
pact on the growth in case numbers. functioning of the immune system. This hap-
pens, for example, when many serious illnesses
Cancer risks at different time periods, in different are treated successfully. This phenomenon may
regions and populations, can be made compara- explain the increasing risk for lymphoma at the
ble using age-standardization. Figure 10 shows population level. The incidence of lip cancer
trends in the age-standardized cancer incidence has decreased heavily, reflecting the fact that
and mortality rate for all cancers over the years. Finns have moved to indoor work and that their
In the absence of population aging, the annual exposure to sunlight and tobacco has reduced.
number of cancers would have stayed approxi-
mately the same, if breast cancers detected by The risk of breast cancer in women has in-
screening and prostate cancers detected by PSA creased continuously, and breast cancer is now
tests were excluded from the figures. The age- the most common cancer among women (Fig-
standardized cancer mortality is now only one- ure 11). The occurrence of breast cancer in-
half the rate of the peak years. creased by about one-tenth in 1987, when the
national mammographic screening programme
Gastric cancer, which was the most common for breast cancer began (see page 52). More
cancer in men and women up to the 1950s, has than one thousand breast cancers are detected
decreased during the whole period of cancer annually through screening, most of which are
registration (Figure 11). Since the 1950s, lung asymptomatic. Another significant reason for
cancer in men has increased dramatically, as the increase in breast cancers is hormone treat-
men had started smoking during the war in the ment of menopause (Jaakkola et al 2009, Lyyti
early 1940s. Thereafter, smoking among men nen et al 2010). The reduction of lengthy hor-
has decreased, which can be seen as a reduced mone therapy at the beginning of 2000s is seen
lung cancer risk. The risk of prostate cancer has clearly in a decrease in breast cancer incidence
increased steadily since the early 1990s. Since in Norway and Sweden, with a smaller decrease
then, PSA testing, used in the early diagnosis of in Finland (Hemminki et al 2008).
prostate cancer, has become increasingly com-
mon. This has increased the detection rate of The increase in the risk of cancer of corpus
prostate cancer so strongly up to the year 2005 uteri ended in the 2000s (Figure 11). This phe-
(Figure 11)), that it has produced an overall in- nomenon is partly explained by the fact that
crease in the incidence of all cancers (Figure 10). the uterus has been removed from nearly one-
third of all 70-year old women, and that there
Of the more rare cancers among Finnish men, is no longer a risk of cervical cancer (Luoto et
for example, the incidence of bladder cancer al 2004). No clear reasons have been found for
Frequency of cancer in Finland | 31
Figure 10
Age-standardized cancer incidence and mortality in Finland 1953–2011.
Incidence/100 000
350
200
150
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year
32 | Cancer in Finland
Figure 11
Age-standardized incidence of the most common cancers in Finland 1953–2011.
MEN
Incidence/100 000
120
100
• Prostate cancer
80
60
40
• Lung cancer
• Colorectal cancer
20
• Gastric cancer
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year
Frequency of cancer in Finland | 33
WOMEN
Incidence/100 000
100
• Breast cancer
80
60
40
20 • Colorectal cancer
• Endometrial cancer
• Gastric cancer
0
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year
Figure 12
Age-standardized incidence rates for selected cancers in men in Finland 1957–2011
in five-year periods.
Incidence/100 000
16
• Bladder cancer
• Non-Hodgkin lymphoma
12
• Skin melanoma
• Pancreatic cancer
8
• Lip cancer
0
1957– 1962– 1967– 1972– 1977– 1982– 1987– 1992– 1997– 2002– 2007– Year
1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011–
Figure 13
Age-standardized incidence rates for selected cancers in women in Finland 1957–2011
in five-year periods.
Incidence/100 000
16
4 • Cervical cancer
• Oesophageal cancer
0
1957– 1962– 1967– 1972– 1977– 1982– 1987– 1992– 1997– 2002– 2007– Year
1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011–
Frequency of cancer in Finland | 35
the changes in the incidence of ovarian cancer cancer frequency. The age-standardized rate of
(Figure 13). In other Nordic countries ovarian laryngeal cancer for men is ten times that for
cancer risk has decreased even more than in women. For lung and lip cancers, the difference
Finland, which might suggest a role of decreas- is currently about three times, but in the 1950s
ing use of lengthy hormone therapies (Koskela- the risk was 15 times greater. This phenomenon
Niska et al 2013). The incidence of female lung is mainly explained by the fact that smoking
cancer has increased continuously as smoking habits among men and women have developed
among women has become more common. different manners in recent decades.
Tumours of the central nervous system, and Bladder cancer risk is four times greater, and
especially benign tumours of brain membranes gastric cancer risk nearly two times greater for
(meningiomas) in women have become more men than for women, and many other cancers
common. This is linked to more advanced im- are more common in men. On the other hand,
aging techniques, through which symptomless thyroid cancer is over three times more com-
tumours inside the skull are found, for exam- mon in women than in men.
ple, in connection with the examination of the
blood circulation in the brain. Cancer and age
Skin melanoma is one of the increasingly com- Cancer is typically an illness of elderly people.
mon cancer types in both women and men. People aged under 40 get cancer only rarely,
This is linked to travel to the south, the pop- but after that the probability of getting cancer
ularity of sun tanning and repeated sunburn- grows rapidly with increasing age (Figure 8).
ing. Skin melanomas are found mostly among For some cancers, the dependency of incidence
clerical workers in towns and much less in those on age differs from the average (Figure 15).
who work outside and whose skin, being used For instance, at the start of the 1960s cervical
to sun, does not burn (Pukkala et al 1995). On cancer was the most common cancer among
the other hand the most important cause of women aged 50-54 years, and the disease risk
the other main types of skin cancer, basal cell was relatively high even for 40-year old wom-
carcinoma and squamous cell carcinoma, is the en. Nowadays the cancer is most common in
cumulative lifespan dose of UV-radiation. 70-year old women. For the middle-aged and
younger, disease risk has reduced considerably
Cancer and gender because of mass screening.
Of the new female cancers detected in 2011, Lung cancer is most common among people
44 percent were in the breast or the reproduc- in their eighties, but quite rare in even older
tive organs (Figure 14). Prostate cancer made age groups (Figure 15). Smoking increases mor-
up 31 percent of all cancers in men. Apart tality rates for causes other than lung cancer,
from gender-based cancers, there are other which is why there are fewer long-term smokers
clear differences between men and women in among people over 80 years. For men over 50
36 | Cancer in Finland
Figure 14
Age-standardized incidence of cancer by gender in 2011.
MEN WOMEN
Prostate cancer
Breast cancer
Lung cancer
Colon cancer
Skin melanoma
Non-Hodgkin lymphoma
Cancer of central nervous system
Skin cancer, non-melanoma
Rectum cancer
Bladder cancer
Kidney cancer
Pancreatic cancer
Leukaemia
Cervical cancer
Gastric cancer
Thyroid cancer
Ovary cancer
Liver cancer
100 50 0 50 100
Incidence/100 000
Frequency of cancer in Finland | 37
Figure 15
Incidence of some cancers by to age in 2005–2009. The age distribution for 1959–1962
(before starting systematic screening) is shown for cervical cancer, and for prostate cancer
in 1985–1989 (before PSA-testing became common).
2005–2009
1958–1962
40 800
20 400
1985–1989
2005–2009
0 0
0 10 20 30 40 50 60 70 80 90 Age 0 10 20 30 40 50 60 70 80 90 100 Age
300
10
200
Hodgkin
Women lymphoma
5
100
0 0
0 10 20 30 40 50 60 70 80 90 100 Age 0 10 20 30 40 50 60 70 80 90 Age
38 | Cancer in Finland
Table 2
Average annual cancer cases for children under 15 years old in Finland 2005–2009.
Leukaemia 53 36
Brain tumours 34 23
Lymphomas 15 10
Neuroblastoma 9 6
Soft tissue sarcomas 8 5
Kidney tumours 7 5
Germ cell tumours 5 3
Bone sarcomas 4 3
Liver tumours 3 2
Retinoblastoma 2 1
Others 8 5
years of age, prostate cancer, which is very rare childhood cancers has not changed significantly
for men under 45, is clearly the most common over the past decades.
cancer. Before PSA screening, prostate cancer
was mostly detected in even older age groups The incidence of brain and nervous system tu-
than nowadays (Figure 15). mours and leukaemia (Figure 15), on the other
hand, is quite high among children. Testicular
About 150 young Finns, under the age of 15 cancer and Hodgkin lymphoma are typical ma-
years, develop cancer each year. The portion lignancies of young adults (Figure 15).
of childhood cancer is therefore about half a
percent of the total population cancer cases. The likelihood of an individual getting can-
Childhood cancer can differ from adult cancer, cer can be estimated from the age-specific in-
among other ways, in the cell type and in its cidence figures. For example, about one in 15
biological behaviour. The most common child- women will develop breast cancer before reach-
hood cancers are leukaemia and brain tumours, ing retirement age, and more than every tenth
the combined number of which comprises over woman during her entire life span (Figure 16).
half the cancers for those under 15 years (Table Almost every third Finn has been diagnosed
2). The different cancer types are almost equal with cancer by the age of 85 years.
in number for boys and girls. The frequency of
Frequency of cancer in Finland | 39
Figure 16
Probability of getting cancer up to each age. Calculation is based on the incidence of cancer
2005–2009.
MEN
• All cancers
30
20
%
30
WOMEN
• All cancers
20
• Breast cancer
10
Figure 17
Incidence of gastric cancer in men and melanoma of skin in women by birth year and age
in 1955–2009.
Incidence/100 000
1 000
MEN, gastric cancer
Birth year 1880
500
200
1900
100
50
1940
20
1920
10
5 1960
1
35 40 45 50 55 60 65 70 75 80 85+ Age
Incidence/100 000
100
WOMEN, skin melanoma
Birth year 1915
50
1930
1950
20
1970
10
5
1880
1900
2
1
20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Age
42 | Cancer in Finland
Figure 18
Variations in incidence of some cancers in EU countries 2008 (Ferlay et al 2010).
Belgium Ireland
Denmark Norway
Finland Finland
Sweden
Holland
Spain Italy
Estonia Estonia
Denmark Hungary
Great-Britain Poland
Sweden Estonia
Finland Finland
Estonia Portugal
Spain Sweden
0 10 20 30 40 0 20 40 60 80 100
Incidence/100 000 Incidence/100 000
Denmark Norway
Switzerland Denmark
Finland Sweden
Italy Finland
Estonia Estonia
Spain Spain
0 5 10 15 20 25 0 5 10 15
Incidence/100 000 Incidence/100 000
Frequency of cancer in Finland | 43
Figure 19
Age-standardized incidence in Nordic countries 1943–2009 for gastric cancer in men and
colorectal cancer in women.
Incidence/100 000
70
MEN, gastric cancer
60
50
40
30
20
• Finland
10 • Denmark
• Norway
• Sweden
0
1940 1950 1960 1970 1980 1990 2000 2010 Year
Incidence/100 000
40
WOMEN, colorectal cancer
35 • Norway
• Denmark
30
25 • Sweden
20
• Finland
15
10
0
1940 1950 1960 1970 1980 1990 2000 2010 Year
44 | Cancer in Finland
Figure 20
Age-standardized incidence of cervical cancer in 1943–2009.
Incidence/100 000
35
30
25
20
15
10 • Denmark
• Norway
• Sweden
5
• Finland
0
1940 1950 1960 1970 1980 1990 2000 2010 Year
tion from neighbouring municipalities is com- cidence has been the lowest in the country (Fig-
bined, for example as shown in Figures 23 and ure 24). For example, lung and breast cancer
24. are most common for women living in Helsinki
and the surrounding areas. A benign papillary
The cancer risk for women living in towns in form of thyroid cancer has been diagnosed
southern Finland has been consistently about mostly around Oulu, which probably derives
one and a half times greater than that for from different regional diagnostic practices for
women in the north-east of Finland, whose in- thyroid masses.
Frequency of cancer in Finland | 45
Regional variations in overall cancer incidence mations on this subject (see for example astra.
among men are small. In the 1950s the inci- cancer.fi/cancermaps/suomi5308/fi).
dence in coastal towns was slightly above aver-
age, and from there the higher incidence spread Most cancer types are more common in towns
to other towns, until regional variations disap- than in rural areas. For many cancers this dif-
peared entirely in the 1980s (Pukkala and Pata- ference has declined over the decades, but the
ma 2010). Prostate cancer, which became more incidence of lung cancer in women is still about
common in the 1990s, increased the number two times higher in bigger towns than in rural
of cancer cases firstly mainly in the capital city towns. Lip cancer is the only type that is found
area but in more recent years also in the Tam- more frequently in rural areas than in towns.
pere area in southern mid-Finland (Figure 23). Similar differences have been found when mu-
The cancer burden is lowest in the most north- nicipalities are classified according to average
ern part of Finland, due to an exceptionally low income or family size of the population, be-
cancer incidence rate among the Sami popula- cause the income of those living in rural areas
tion: the Sami people have fewer cancers of any is lower and there are more children in families
kind than other people living in the same area than in those living in industrialized communi-
(Soininen et al 2002). This difference is not ex- ties (Teppo et al 1980).
plained by known variations in lifestyle.
The impact on cancer incidence of the envi-
The geographical variation in most cancers ronment in which people live can be studied,
has remained relatively constant, although the for example, through the quality of soil, air or
overall incidence level has changed in the whole drinking water. This can be studied when good
country. Changes in the factors causing cancer background information about the environ-
can however little by little alter the regional ment is available. The excellent Finnish popula-
emphasis in cancer incidence. The different de- tion registry system makes this kind of research
velopment of smoking habits in different parts possible for very small area units – even for a
of Finland has shifted the main focus of lung 250 meter square map grid (Kokki et al 2002).
cancer in men from southern Finland to the
east-central part of Finland, where lung cancer Comparing differences in regional incidence
incidence was least common in the 1950s. On and their trends can indicate possible causes of
the other hand, prostate cancer was diagnosed cancer. More accurate clarification of causal re-
in the 1990s mostly in the Tornio area in the lations, however, requires studies in which large
southwest part of Lapland, then in the capital numbers of people, who are exposed in differ-
area and Tampere, and in the 2000s in South ent ways, are compared using individual-level
Ostrobothnia in western Finland. The webpage information.
of the Cancer Registry has illustrative map ani-
46 | Cancer in Finland
Figure 21
Incidence of skin melanoma in men in the Nordic countries 2004–2010.
21.0
19.1
17.4
15.8
14.3
13.0
11.9
10.8
9.80
8.91
8.10
7.36
6.69
6.08
5.53
5.03
4.57
4.15
Frequency of cancer in Finland | 47
Figure 22
Incidence of lung cancer in women in the Nordic countries 2004–2010.
42.0
38.2
34.7
31.6
28.7
26.1
23.7
21.6
19.6
17.8
16.2
14.7
13.4
12.2
11.1
10.1
9.14
8.31
48 | Cancer in Finland
Figure 23
Variation in incidence of some cancer types among men in Finland 2000–2009.
Average in Finland = 1.00.
2.00
All cancers
1.33 Lung cancer
1.00
0.75
0.50
Figure 24
Variation in incidence of some cancer types among women in Finland 2000–2009.
Average in Finland = 1.00.
2.00
All cancers
1.33 Lung cancer
1.00
0.75
0.50
Cancer screening
The objective of cancer screening is to detect Cervical cancer screening began in Finland at
pre-clinical disease in its early stages, when can- the initiative of the Cancer Society of Finland
cer can still be cured. The main aim is to reduce at the beginning of the 1960s. Based on the
mortality from cancer, and also sometimes its in- decree on screening, about 250 000 women
cidence. The latter is possible if the progression between the ages of 30–60 years are screened
of pre-cancerous lesions to cancer can be pre- annually. All women belonging to the target
vented by treating them in the precursor phase. age group are invited for smear taking every
five years. Certain high risk women are referred
Municipalities in Finland are obliged to organ- for testing more often than the normal five year
ise free cancer screening for their population. interval. This improves early detection of can-
The Health Care Act (1326/2010) and the cer cases (Hakama and Pukkala 1977, Hakama
Government Decree on Screening (339/2011) et al 1979).
regulate this area. According to the Decree on
Screenings, screening for cervical cancer should Cervical cancer screening is carried out using
be offered to women aged 30–60 years every 5 cells from the cervix, the so-called Papanicolau
years and breast cancer screening to those aged test. Since 1999 new screening techniques have
50–69 at 20–26 month intervals. The obliga- also been studied, such as automated PAPNET
tion to organise breast cancer screening for screening (Anttila et al 2006) and HPV-based
women over 60 years concerns women born screening test to indicate the presence of the
in 1947 and later. In addition to these manda- human papilloma virus (Kotaniemi-Talonen et
tory screening programmes, some municipali- al 2005). In addition to these, screening sam-
ties have voluntarily started colorectal cancer ples taken at home have been tried for those
screening for men and women aged 60–69 women who have not participated in regular
years every two years. screening (Virtanen et al 2011).
Figure 25
Number of new cervical cancers annually 1953–2009, by age group.
Number of cases
300
250
35–59 years
200
150
100
60–69 years
50 70–89 years
20–34 years
0
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year
has happened in other Nordic countries when decreased. Annually detected new cases in the
screening for cervical cancer has become part of population and the mortality rate from cancer
the healthcare system (Figure 20). of uterine cervix have reduced to a fifth from
the starting point. It has been estimated that
Since the start of screening, cervical cancer screening averts over 200 deaths from cervical
has become rarer, and the mortality rate has cancer annually.
52 | Cancer in Finland
ion quality specifications. Breast cancer mortal- haemorrhoids, infection of the intestinal tract
ity for 50–69-year-old women was 22 percent or benign polyps.
lower in those invited for screening than the
estimated rate without screening. Breast cancer Screening of men and women aged 60–69 for
mortality was reduced by 28 percent in screen- colorectal cancer has begun in Finland since
ing participants (Hakama et al 1997, Sarkeala et 2004 in municipalities that were willing to start
al 2005, Sarkeala 2008). the screening program. In 2010, 45 percent of
60–69-year-old people were living in munici-
Colorectal cancer screening palities taking part in the screening program.
Screening begins with those aged 60–64 years,
Cancer of the colon and rectum are the third and expands gradually to include the entire
most common cancers of Finns, after prostate 60–69-year-old age group in the screening pro-
cancer and breast cancer. The primary treat- gram within five years. In the implementation
ment of these cancers is surgery. In most cases phase, only half of this age group is screened
the patient will be cured if the cancer is lim- and the other half remains as a control group,
ited to the bowel wall. If the cancer has spread as the benefit-risk ratio is not yet clear.
into regional lymph nodes or further within
the body, chemotherapy and possibly radiation In Finland, the screening program for colorec-
therapy are given as additional treatments. tal cancer works well, and population participa-
tion in screening is extremely high. About 70
In Finland, almost half of all colorectal cancers percent of those invited participate in screening
have already spread beyond the bowel wall in (Malila et al 2008, 2011). Follow-up investi-
patients seeking treatment based on symptoms. gations associated with the screening program
Early detection is difficult, because symptoms have also been effective, and it has been pos-
of cancer in the abdominal area are often un- sible to do colonoscopies with very short wait-
clear or there are no symptoms at all. ing times. Colorectal cancer or neoplastic early
stages have been detected as predicted, i.e.
In randomized screening studies carried out about in every tenth of those sent for a colo-
abroad, it has been observed that screening can noscopy.
reduce the mortality rate for colorectal cancer
by about 16 percent (Hewitson 2007). Colo- Colorectal cancer can also be screened by co-
rectal cancer is screened using a test indicating lonoscopy, but screening carried out this way
faecal blood. The screening sample is taken at is expensive, and serious harm may be caused
home and is returned by mail to the screening by the procedure. The use of colonoscopy as a
centre. Those with faecal blood detected are re- screening method is currently being studied in
ferred for follow-up examination by colonosco- Europe and the United States. In Finland colo-
py. Two to three persons of every hundred have noscopy screening is used only if a person has
occult faecal blood. For most, the occult blood an increased risk of getting bowel cancer, for
is caused by something else than cancer, such as example, in patients suffering from adenomas
54 | Cancer in Finland
or in close relatives of those with an inherited would have ever advanced to harmful cancer.
susceptibility to colorectal cancer. Based on the results, it is not certain if screen-
ing causes more benefit or harm. The most
Screening for prostate cancer important disadvantage of screening for pros-
tate cancer is the detection of indolent cases,
Prostate cancer is the most common cancer i.e. cancers that would not have been found
in men in Finland. Finland has been partici- without screening and would not have caused
pating in the European Randomised Prostate any harm during the man’s lifetime. It is not
Cancer Screening (ERPSC) trial, the results of possible to differentiate the detectable small,
which indicate that PSA testing reduced deaths histologically malignant but clinically benign,
from prostate cancer by one fifth (Schroder prostate cancers from those aggressive cancers
et al 2009). These findings are based on the that would spread and cause death eventually.
screening of 262 000 people during a nine-
year period. Altogether 80 000 men from Fin- Screening for other cancers
land were randomised, of whom 30 000 were
screened with PSA-testing at age 55–71 years Other cancers considered for screening are, for
2–3 times at four-year intervals. The remain- example, oral cancer, especially in developing
ing men formed the control group. Men from countries, ovarian cancer, stomach or gastric
the area surrounding Tampere and from the cancer, and lung cancer. It is not yet known if
Helsinki capital area were invited for screening. screening would reduce mortality for these can-
The actual screening stage was concluded at the cers in the population, but the issue is being
end of 2007. investigated in randomised studies. Of these,
the results of the effects of a screening for lung
Screening can detect cancer at an early stage, cancer directed towards smokers and based on
when it can still be cured. However, many more low dose spiral computer tomography were
prostate cancers were detected in the screened published in 2011 (The National Lung Screen-
group than in the control group in the ERSPC. ing Trial Research Team 2011).
This could mean that not all early stage tumours
Treatments | 55
Treatments
Surgery, radiation therapy, chemotherapy, hor- cer grade in order to determine the most appro-
mone treatment and biologic treatments (for priate treatment combination for each cancer.
example interferon treatment) are used in treat-
ing cancer. Different treatment methods are of- Breast cancer, for example, may be treated ei-
ten combined, in order to get the best possible ther by removal of the whole breast or by local
result. removal of the tumour, sparing the breast. It
is often necessary to also remove lymph nodes
The selection of treatment methods is based from the armpit. The patient is generally given
on cancer type and stage, the general condition radiation therapy and chemotherapy in addi-
and age of the patient, among other things. Ex- tion to surgery in order to secure the destruc-
perts from different areas of medicine take part tion of all tumour cells. Long-term hormonal
in the selection of the treatment method. The treatment can be given as follow-up treatment
newest treatments are targeted drugs, which af- in order to prevent a relapse of the cancer. In
fect only the cancer. They cause fewer side ef- some cases, a surgically removed breast can be
fects for the patient than cytotoxic drugs and replaced with a silicon prosthesis or with the
hormonal treatments. The treatment of each patient’s own tissue. If the cancer has spread,
patient is planned individually, and so patients the patient’s symptoms can often be relieved
with the same cancer may have different treat- with additional surgery or radiation therapy.
ments. Some cancers can progress so slowly that
the situation can be followed up for some time Combinations of medical treatment may be
before selecting a treatment method. changed if one combination begins to lose ef-
fect. If the cancer has spread and death gets
After cancer is suspected and detected, a diag- closer, the focus changes to relieving pain and
nosis is made and the stage is defined. In these symptoms so that the patient’s quality of life
investigations, ultrasound, x-ray and magnetic remains as good as possible. A cancer patient’s
resonance imaging are used in addition to labo- final treatment stage is called hospice care.
ratory tests. Pathologists also identify the can-
56 | Cancer in Finland
Survival
Cancer treatments have progressed consider- 2009. Correspondingly, for those with prostate
ably in the last decades. Nowadays a large num- cancer the five-year survival ratio is predicted to
ber of cancer patients live a normal life after the be 93 percent, but this figure is distorted by the
detection and treatment of cancer and eventu- many good prognosis prostate cancers discov-
ally die from causes other than cancer. ered through PSA testing. Many of the cancers
discovered by PSA testing are such that they do
The relative survival ratio is used as an indirect not have an impact on life span and these men
measure of recovery from cancer. It indicates will die of other diseases. The five-year relative
the proportion of cancer patients that live for survival ratio for testicular cancer has improved
a certain period after diagnosis, compared to considerably due to improved treatment and
the rest of the population of the same age dur- nowadays exceeds 95 percent (Figure 27). The
ing the same period. If the annual relative sur- notorious skin melanoma is discovered nowa-
vival ratio is less than 100 percent, cancer has days mainly in the form of a thin local tumour,
caused additional deaths. Five years is generally for which surgery is almost always curative (Ta-
considered the statistical limit of recovery, al- ble 3).
though for some cancers there are a small num-
ber of extra deaths after that limit, and in some The most common cancer types of recent dec-
cases statistical recovery may be reached earlier ades, gastric cancer and lung cancer, are cancers
(Dickman et al 1999). with a poor prognosis. However, as the propor-
tion of these cancers of the overall cancer bur-
The five-year relative survival ratio is 62 percent den is decreasing, and the prognosis for other
for men and 65 percent for women for Finnish cancers is improving, the overall reputation of
patients who developed cancer in 2007–2009 cancer as a killing disease is slowly changing.
(Table 3). This calculation does not take into
consideration basal cell carcinomas, which Some cancers remain difficult to cure. Among
cause almost no additional deaths. The higher these are cancers of the liver, gallbladder and
survival ratio for women is largely a result of pancreas. Less than three percent of those suf-
the considerably better prognosis for breast fering from pancreatic cancer will survive five
cancer, the most common cancer for women, years from the date of diagnosis. However,
compared to lung cancer, the most common for with modern treatments, even cancer that has
men. already spread can be controlled for some time
and survival ratios improve, although the pa-
The five-year survival ratio is 89 percent for tient finally dies of cancer.
those Finns who got breast cancer in 2007–
Survival | 57
Figure 27
Trends in relative five-year survival ratio for cancer patients in 1955–2009.
%
100
• Testicular cancer
• Prostate cancer
• Breast cancer, women
• Childhood leukaemia
80
• All cancers
60
40
20
• Lung cancer
• Pancreatic cancer
0
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year
Survival | 59
1990s more than four patients out of five are countries are often due to differences in pa-
still alive five years after the disease was detected tients. In international comparisons, the sur-
(Figure 27). The average five-year survival ratio vival ratios of Finnish patients are at the top
for all cancer patients has increased by nearly 10 level both in Europe and worldwide (Sant et al
percent units in ten years. 2009).
Figure 28
Average cancer detection age for men and number of life years lost due to cancer.
Cancers detected in 1998–2007.
30 40 50 60 70 80 90 Age
Skin, non-melanoma
Lip
Bladder
500 cases/year
Prostate
Lung
Myeloma
Liver
Stomach
Colon
Pancreas
Rectum
Oesophagus
Kidney
Larynx
Non-Hodgkin lymphoma
Skin melanoma
Leukaemia
Soft tissue
Thyroid
Hodgkin
lymphoma Central nervous system
Testicle
30 40 50 60 70 80 90 Age
Survival | 61
Figure 29
Average cancer detection age for women and number of life years lost due to cancer.
Cancers detected in 1998–2007.
30 40 50 60 70 80 90 Age
Skin, non-melanoma
Oesophagus
Gall bladder
Pancreas 500 cases/year
Bladder
Liver
Average age of Lost years of life
Myeloma
getting disease caused by cancer
Stomach
Colon
Rectum
Lung
Kidney
Non-Hodgkin lymphoma
Corpus uteri
Ovary
Soft tissue
Leukaemia
Breast
Skin melanoma
Central nervous system
Cervix uteri
Thyroid
Hodgkin
lymphoma
30 40 50 60 70 80 90 Age
62 | Cancer in Finland
In the Finnish Cancer Registry, predictions of Future trends for most cancer types will follow
cancer incidence have been developed on sev- the previously observed directions (Figures 30–
eral occasions, and there is a lot of experience 31). Intestinal cancer will probably become still
concerning the accuracy of different methods. more common, and will probably be the sec-
According to a prediction made in 2009 (Finn- ond most common cancer of men and women
ish Cancer Registry 2009) age-standardized can- from 2015 onwards. Lung cancer among men
cer incidence in men will reduce noticeably in will become rarer, but the age-standardized in-
the coming years, and the cancer incidence for cidence for lung cancer in women is projected
women will also reduce slightly (Table 4). Al- to continue to increase. In 2020 there will be
though the age-standardized incidence will fall over 900 cases of lung cancer detected among
as predicted, in 2020 about 3 000 more can- women, which would be only about 40% less
cers will be detected than in 2011. According than for men.
to the prediction, about 17 700 cancer cases
will be detected among Finnish men in 2020 The increase in case numbers means that can-
and about 16 100 cases among women. This cer will require more health care resources than
increase in case numbers is due to the fact that today. Cancer types with a poor prognosis, for
the average life span for Finns is longer and the example lung cancer, gastric cancer and cancer
more populous age groups born after World of oesophagus will reduce in numbers. A larger
War II will move into the ages in which cancer portion of cancers will be cured. Treatments
incidence is the highest. will develop, although in most cases in small
increments. From the perspective of treatment
The prediction of cancer incidence for men is results, it will be important that, in the future,
affected largely by what will happen with regard cancer is detected in an early enough stage and
to prostate cancer. A prediction model for this that the cancer patient can get the best possible
book assumes that prostate cancer incidence treatment without delay.
Cancer in the future | 63
Table 4
Age-standardized incidence of most common cancers per 100 000 people in 2009 and
prognosis for 2020 (Finnish Cancer Registry 2009).
MEN
Number of cases Age- Number of cases Age-
standardized standardized
incidence incidence
2009
2020
All cancers 14 863 304.9 All cancers 17 659 282.3
1 Prostate cancer 4 595 89.5 1 Prostate cancer 5 872 85.8
2 Lung cancer 1 676 32.0 2 Colorectal cancer 1 980 30.7
3 Colorectal cancer 1 391 27.5 3 Skin cancer 1 844 27.2
4 Skin cancer 1 344 26.8 4 Lung cancer 1 550 22.3
5 Non-Hodgkin lymphoma 650 14.6 5 Non-Hodgkin lymphoma 774 13.5
6 Cancer of bladder 708 13.6 6 Cancer of bladder 715 9.9
7 Cancer of 7 Pancreatic cancer 698 10.7
central nervous system 409 11.3 8 Cancer of
8 Kidney cancer 500 10.4 central nervous system 493 13.3
9 Pancreatic cancer 506 9.9 9 Leukaemia 432 10.2
10 Leukaemia 360 9.2 10 Kidney cancer 385 6.4
WOMEN
Number of cases Age- Number of cases Age-
standardized standardized
incidence incidence
2009
2020
All cancers 13 946 254.3 All cancers 16 052 252.1
1 Breast cancer 4 469 92.1 1 Breast cancer 5 119 90.2
2 Skin cancer 1 200 18.8 2 Colorectal cancer 1 528 22.3
3 Colorectal cancer 1 255 18.4 3 Skin cancer 1 421 18.5
4 Cancer of corpus uteri 808 14.0 4 Cancer of
5 Cancer of central nervous system 749 16.2
central nervous system 591 13.9 5 Cancer of corpus uteri 1 015 13.6
6 Lung cancer 691 11.0 6 Lung cancer 908 12.7
7 Non-Hodgkin lymphoma 559 9.7 7 Non-Hodgkin lymphoma 655 10.1
8 Ovary cancer 435 8.2 8 Ovary cancer 495 8.6
9 Thyroid cancer 298 8.2 9 Pancreatic cancer 770 8.3
10 Kidney cancer 399 6.9 10 Thyroid cancer 266 7.0
64 | Cancer in Finland
Figure 30
Number of new cases detected annually for men in 1982–2009 and projected number of cases
until 2027. Projection of prostate cancer has been made separately; others are carried out with
the NORDCAN spreadsheet tool (Engholm et al 2011).
Number of cases
7 000
Projected period
• Prostate cancer
6 000
5 000
4 000
3 000
2 000
• Colorectal cancer
• Lung cancer
1 000 • Skin melanoma
• Non-Hodgkin lymphoma
• Cancer of bladder
• Gastric cancer
0
1980 1990 2000 2010 2020 2030 Year
Cancer in the future | 65
Figure 31
Number of new cases detected annually for women in 1982–2009 and projected number of
cases until 2027. Projection of breast cancer is made separately; others are carried out with the
NORDCAN spreadsheet tool (Engholm et al 2011).
Number of cases
7 000
Projected period
6 000
• Breast cancer
5 000
4 000
3 000
2 000
• Colorectal cancer
• Lung cancer
1 000
• Cancer of corpus uteri
• Skin melanoma
• Non-Hodgkin lymphoma
• Gastric cancer
0
1980 1990 2000 2010 2020 2030 Year
66 | Cancer in Finland
Figure 32
Age-standardized cancer mortality rate for men in 1982–2009 and projected rate until 2027.
Projections are made with the NORDCAN spreadsheet tool (Engholm et al 2011).
25
• Lung cancer
20
15
10 • Prostate cancer
• Colorectal cancer
5 • Gastric cancer
• Cancer of bladder
• Non-Hodgkin lymphoma
• Kidney cancer
• Skin melanoma
0
1980 1990 2000 2010 2020 2030 Year
Cancer in the future | 67
Figure 33
Age-standardized cancer mortality rate for women in 1982–2009 and projected rate until 2027.
Projection is made with the NORDCAN spreadsheet tool (Engholm et al 2011).
16
14
12
10 • Breast cancer
• Lung cancer
8
6
• Colorectal cancer
• Gastric cancer
• Cancer of corpus uteri
2
• Leukaemia
Non-Hodgkin lymphoma
• Cervical cancer
•
0
1980 1990 2000 2010 2020 2030 Year
68 | Cancer in Finland
Results presented in this book indicate that the living environment can be made safer and
cancer is closely linked to the individual’s life- which can support the population to change
style, behavioural habits and environmental as- their lifestyle habits to encourage better health.
pects. Some cancers can be prevented, and it
is possible to change the future trends in the Cancer is a very common group of diseases,
cancer incidence. and is familiar to every family. However, cancer
deaths are becoming fewer (Figures 32–33). In
The main challenges for cancer research for the a Gallup poll held in May 2006, every fourth
coming decades have not changed: it is still im- Finn considered cancer a very scary disease, but
portant to find the causes of cancer and to de- in the future this fear is likely to lessen. Already
velop appropriate methods for detecting cancer the well-educated population fears cancer the
in an early stage. It is left as a challenge to deci- least: correct knowledge reduces pain.
sion-makers in society to find means by which
References | 69
References
Aaltonen LA, Peltomäki P, Leach F et al. Clues to the Bojesen SE, Pooley KA, Johnatty SE et al. Multiple
pathogenesis of familial colorectal cancer. Science 1993; independent variants at the TERT locus are associated
260: 812–6. with telomere length and risks of breast and ovarian
cancer. Nat Genet 2013; 45(4): 371–84.
Aaltonen LA, Salovaara R, Kristo P et al. A. Incidence
of hereditary nonpolyposis colorectal cancer and the Boyle P, Autier P, Bartelink H et al. European code against
feasibility of molecular screening for the disease. N Engl J cancer and scientific justification: third version (2003).
Med 1998; 338: 1481–7. Ann Oncol 2003; 14: 973–1005.
Aarnio M, Sankila R, Pukkala E et al. Cancer risk in But A, Kurttio P, Heinävaara S, Auvinen A. No increase
mutation carriers of DNA mismatch repair genes. Int J in thyroid cancer among children and adolescents in
Cancer 1999; 81: 214–8. Finland due to Chernobyl accident. Eur J Cancer 2006; 42:
1167–71.
Alhopuro P, Phichith, Tuupanen S et al. Unregulated
smooth-muscle myosin in human intestinal neoplasia. Chang MH. Hepatitis B virus and cancer prevention.
PNAS 2008; 105: 5513–8. Recent Results Cancer Res 2011; 188: 75–84.
Amin Al Olama A, Kote-Jarai Z, Schumacher FR et al. Collin P, Pukkala E, Reunala T. Malignancy and survival in
A meta-analysis of genome-wide association studies to dermatitis herpetiformis: a comparison to coeliac disease.
identify prostate cancer susceptibility loci associated with Gut 1996; 38: 528–30.
aggressive and non-aggressive disease. Hum Mol Genet
2013; 22(2): 408–15. Dickman, PW, Hakulinen T, Luostarinen T et al. Survival of
cancer patients in Finland 1955-1994. Acta Oncol 1999;
Anttila A, Hakama M, Kotaniemi-Talonen L, Nieminen P. 38(Suppl 12).
Alternative technologies in cervical cancer screening: a
randomised evaluation trial. BMC Public Health 2006; 6: Doll P, Peto R. The causes of cancer. Quantitative
252. estimates of avoidable risks of cancer in the United States
today. Oxford Medical Publications. Oxford: Oxford
ATBC (The Alpha-Tocopherol, Beta-Carotene Cancer University Press, 1981.
Prevention Study Group). The effect on vitamin E and
beta carotene on the incidence of lung cancer and other Dores GM, Metayer C, Curtis RE et al. Second malignant
cancers on male smokers. N Engl J Med 1994; 330: neoplasms among long-term survivors of Hodgkin’s
1029–35. disease: a population-based evaluation of 32,591 patients
over 25 years. J Clin Oncol 2002; 20: 3484–94.
Auvinen A, Karjalainen S, Pukkala E. Social class and cancer
patient survival in Finland. Am J Epidemiol 1995; 142: Dyba T, Hakulinen T. Comparison of different approaches
1089–102. to incidence prediction based on simple interpolation
techniques. Stat Med 2000; 19: 1741–52.
Auvinen A, Pukkala E, Hyvönen H, Hakama M, Rytömaa T.
Cancer incidence among Finnish nuclear reactor workers. Eeles RA, Olama AA, Benlloch S et al. Identification of 23
J Occup Environ Med 2002; 44: 634–8. new prostate cancer susceptibility loci using the iCOGS
custom genotyping array. Nat Genet 2013; 45(4): 385–91.
Baan R, Straif K, Grosse Y et al. Carcinogenicity of
alcoholic beverages. Lancet Oncol 2007; 8: 292–3. Eerola H, Pukkala E, Pyrhönen S, Blomqvist C, Sankila
R, Nevanlinna H. Risk of cancer in BRCA1 and BRCA2
Bingham SA, Day NE, Luben R et al. Dietary fibre in food mutation-positive and negative breast cancer families
and protection against colorectal cancer in the European (Finland). Cancer Causes Control 2001; 12: 739–46.
Prospective Investigation into Cancer and Nutrition (EPI
C): an observational study. Lancet 2003; 361: 1496–501. Elovainio L, Kajantie R, Louhivuori K, Hakama M.
Syöpäjärjestöjen rintasyöpäseulonnat 1987. Duodecim
Birkeland SA, Storm HH, Lamm LU et al. Cancer risk after 1989; 105: 1184–90.
renal transplantation in the Nordic countries, 1964–1986.
Int J Cancer 1995: 60: 183–9.
70 | Cancer in Finland
Engholm G, Ferlay J, Christensen N et al. NORDCAN Hakama M, Pukkala E, Saastamoinen P. Selective screening:
– a Nordic tool for cancer information, planning, quality theory and practice based on high-risk groups of cervical
control and research. Acta Oncol 2010; 49(5): 725–36. cancer. J Epidemiol Comm Health 1979; 33: 257–61.
Engholm G, Ferlay J, Christensen N et al. NORDCAN: Hakama M, Pukkala E. Selective screening for cervical
Cancer Incidence, mortality, prevalence and survival in the cancer. Experience of Finnish mass screening system. Br J
Nordic countries, Version 4.0. Association of the Nordic Prev Soc Med 1977; 31: 238–44.
Cancer Registries. Danish Cancer Society, 2011. [www.
ancr.nu]. Hakulinen T, Magnus K, Tenkanen L. Is smoking sufficient
to explain the large difference in lung cancer incidence
Engholm G, Ferlay J, Christensen N et al. NORDCAN: between Finland and Norway? Scand J Soc Med 1987;
Cancer incidence, mortality, prevalence and survival in the 15: 3–10.
Nordic Countries, Version 5.1 (March 2012). Association
of the Nordic Cancer Registries. Danish Cancer Society. Hakulinen T, Pukkala E, Hakama M, Lehtonen M, Saxén
[www.ancr.nu, accessed on day/month/year.] E, Teppo L. Survival of cancer patients in Finland in
1953–1974. Ann Clin Res 1981; Suppl 31.
Erkko H, Xia B, Nikkilä J et al. A recurrent mutation in
PALB2 in Finnish cancer families. Nature 2007; 446: 316–9. Hakulinen T, Pukkala E. Future incidence of lung cancer:
Forecasts based on hypothetical changes in the smoking
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin habits of males. Int J Epidemiol 1981; 10: 233–40.
DM. GLOBOCAN 2008, Cancer Incidence and Mortality
Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, Haukka J, Sankila R, Klaukka T et al. Incidence of cancer
France: International Agency for Research on Cancer, and statin usage: record linkage study. Int J Cancer 2010;
2010. [globocan.iarc.fr] 126: 279–84.
Finnish Cancer Registry. Cancer in Finland 2006 and 2007. Heinävaara S, Toikkanen S, Pasanen K, Verkasalo PK ,
Cancer Statistics on the National Institute for Health and Kurttio P, Auvinen A. Cancer incidence in the vicinity of
Welfare. Cancer Society of Finland Publication No. 76, Finnish nuclear power plants: an emphasis on childhood
Helsinki 2009. leukemia. Cancer Causes Control 2010; 21(4): 587–95.
French JD, Ghoussaini M, Edwards SL et al. Functional Helakorpi S, Holstila A-L, Virtanen S, Uutela A. Health
Variants at the 11q13 Risk Locus for Breast Cancer behaviour and health among the Finnish adult population.
Regulate Cyclin D1 Expression through Long-Range Spring 2011. National Institute for Health and Welfare
Enhancers. Am J Hum Genet 2013. [Epub ahead of print] (THL), Report 45/2012. Helsinki 2012.
Garcia-Closas M, Couch FJ, Lindstrom S et al. Genome- Hemminki A, Markie D, Tomlinson I et al. A serine/
wide association studies identify four ER negative-specific threonine kinase gene defective in Peutz-Jeghers
breast cancer risk loci. Nat Genet 2013; 45(4): 392–8. syndrome. Nature 1998; 391: 184–7.
Georgitsi M, Raitila A, Karhu A et al. Molecular diagnosis Hemminki E, Kyyrönen P, Pukkala E. Postmenopausal
of pituitary adenoma predisposition, caused by aryl hormone drugs and breast and colon cancer: Nordic
hydrocarbon receptor interacting protein gene mutations. countries 1995–2005. Maturitas 2008; 61: 299–304.
Proc Natl Acad Sci 2007; 104: 4101–5.
Hewitson P, Glasziou P, Irwig L, Towler B, Watson E.
Gilbert ES, Stovall M, Gospodarowics M et al. Lung cancer Screening for colorectal cancer using the faecal occult
after treatment for Hodgkin’s disease: focus on radiation blood test, Hemoccult. Cochrane Database Syst Rev
effects. Radiat Res 2003; 159: 161–73. 2007(1): CD001216.
Hakama M, Pukkala E, Heikkila M, Kallio M. Effectiveness Hill CL, Zhang Y, Sigurgeirsson B et al. Frequency of
of the public health policy for breast cancer screening in specific cancer types in dermatomyositis and polymyositis:
Finland: population based cohort study. BMJ 1997; 314: a population-based study. Lancet 2001; 357: 96–100.
864–7.
References | 71
Hill DA, Gilbert E, Dores GM et al. Breast cancer Koivusalo M, Pukkala E, Vartiainen T, Jaakkola JJK, Hakulinen
risk following radiotherapy for Hodgkin lymphoma: T. Drinking water chlorination and cancer – a historical
modification by other risk factors. Blood 2005; 106: cohort study in Finland. Cancer Causes Control 1997; 8:
3358–65. 192–200.
Hinkula M, Pukkala E, Kyyrönen P, Kauppila A. Grand Kokki E, Pukkala E, Verkasalo P, Pekkanen J. Small area
multiparity and the risk of breast cancer: populationbased statistics on health (SMASH): a system for rapid
study in Finland. Cancer Causes Control 2001; 12: investigations of cancer in Finland. In: Briggs DJ, Forer P,
491–500. Järup L, Stern R (eds.). GIS for emergency preparedness
and health risk reduction. Dordrecht: Kluwer Academic
Howe JR, Roth S, Ringold JC, Summers RW et al. Publishers, 2002: s. 255–66.
Mutations in the SMAD4/DPC4 gene in juvenile
polyposis. Science 1998; 280: 1086–8. Koskela-Niska V, Pukkala E, Lyytinen H, Ylikorkala O, Dyba
T. Effect of various forms of postmenopausal hormone
Jaakkola S, Lyytinen H, Pukkala E, Ylikorkala O. therapy on the risk of ovarian cancer – a population
Endometrial cancer in postmenopausal women using based case control study from Finland. Int J Cancer 2013
estradiolprogestin therapy. Obstet Gynecol 2009; 114: (in press).
1197–204.
Kotaniemi-Talonen L, Nieminen P, Anttila A, Hakama M.
Jakobsson M, Pukkala E, Paavonen J, Tapper AM, Gissler Routine cervical screening with primary HPV testing and
M. Cancer incidence among Finnish women with surgical cytology triage protocol in a randomised setting. Br J
treatment for cervical intraepithelial neoplasia, 1987– Cancer 2005; 93: 862–7.
2006. Int J Cancer 2011; 128: 1187–91.
Kumpulainen EJ, Hirvikoski PP, Pukkala E, Johansson RT.
Jartti P, Pukkala E, Uitti J, Auvinen A. Cancer incidence Cancer risk after adjuvant chemo- or chemohormonal
among physicians occupationally exposed to ionizing therapy of breast cancer. Anti-Cancer Drugs 1998; 8:
radiation in Finland. Scand J Work Environ Health 2006; 131–4.
32: 368–73.
Kurttio P, Pukkala E, Ilus T, Rahola T, Auvinen A. Radiation
Kaasinen E, Aavikko M, Vahteristo P et al. Nationwide doses from global fallout and cancer incidence among
registry-based analysis of cancer clustering detects strong reindeer herders and Sami in Northern Finland. Occup
familial occurrence of Kaposi sarcoma. PLOS ONE 2013 Environ Med 2010; 67: 737–43.
(in press).
Kurttio P, Pukkala E, Kahelin H, Auvinen A, Pekkanen J.
Kauppi M, Pukkala E, Isomäki H. Elevated incidence of Arsenic concentrations in well waters and risk of bladder
hematological malignancies in patients with Sjögren’s and kidney cancer in Finland. Environ Health Perspect
syndroma compared with patients with rheumatoid 1999; 107: 705–10.
arthritis (Finland). Cancer Causes Control 1997; 8: 201–4.
Lamminpää A, Pukkala E, Teppo L, Neuvonen PJ. Cancer
Kauppinen T, Heikkilä P, Plato N et al. Construction of incidence among patients using antiepileptic drugs:
jobexposure matrices for the Nordic Occupational a longterm follow-up of 28,000 patients. Eur J Clin
Cancer Study (NOCCA). Acta Oncol 2009; 48: 791–800. Pharmacol 2002; 58: 137–41.
Kilkkinen A, Rissanen H, Klaukka T et al. Antibiotic use Lampi P, Hakulinen T, Luostarinen T, Pukkala E, Teppo L.
predicts an increased risk of cancer. Int J Cancer 2008; Cancer incidence following chlorophenol exposure in
123: 2152–5. a community in Southern Finland. Arch Environ Health
1992; 47: 167–75.
Knols R, Aaronson NK, Uebelhart D et al. Physical
exercise in cancer patients during and after medical Lampi P, Tuomisto J, Hakulinen T, Pukkala E. Follow-up
treatment: A systematic review of randomized and study of cancer incidence after chlorophenol exposure in
controlled clinical trials. JCO 2005; 23: 3830–42. a community in southern Finland. Scand J Work Environ
Health 2008; 34: 230–3.
72 | Cancer in Finland
Latikka P, Pukkala E, Vihko V. Relationship between the risk Malila N, Palva T, Malminiemi O et al. Coverage and
of breast cancer and physical activity. Sports Med 1998; performance of colorectal cancer screening with the
26: 133–43. faecal occult blood test in Finland. J Med Screen 2011; 18:
18–23.
Lehtinen M, Dillner J. Clinical trials of human
papillomavirus vaccines and beyond. Nature 2013 (in Matikainen MP , Sankila R, Schleutker J, Kallioniemi O,
press). Pukkala E. Nationwide cancer family ascertainment using
Finnish Cancer Registry on family names and places of
Lehtinen M, Dillner J, Knekt P et al. Serological diagnosis birth for 35,761 prostate cancer patients. Int J Cancer
of human papillomavirus type 16 infection and the risk of 2000; 88: 307–12.
cervical carcinoma. BMJ 1996; 312: 537–9.
Metayer C, Lynch CF, Clarke EA et al. Second cancers
Lehtinen M, Herrero R, Mayaud P et al. Studies to assess among long-term survivors of Hodgkin’s disease
long-term efficacy and effectiveness of HPV vaccination diagnosed in childhood and adolescence. J Clin Oncol
in developed and developing countries. Vaccine 2006; 24: 2000; 18: 2435–43.
233–41.
Meurman LO, Pukkala E, Hakama M. Incidence of cancer
Lichtenstein P, Holm N, Verkasalo PK et al. Environmental among anthophyllite asbestos miners in Finland. Occup
and heritable factors in the causation of cancer –analyses Environ Med 1994; 51: 421–5.
of cohorts of twins from Sweden, Denmark and Finland.
New Engl J Med 2000; 343: 78–85. Michailidou K, Hall P, Gonzalez-Neira A et al. Large-scale
genotyping identifies 41 new loci associated with breast
Lichtermann D, Ekelund J, Pukkala E, Tanskanen A, cancer risk. Nat Genet 2013; 45(4): 353–61.
Teppo L, Lönnqvist J. Cancer incidence is decreased in
schizophrenia patients, but decreased in their relatives. Mork J, Lie AK, Glattre E et al. Human papillomavirus
Arch Gen Psychiatry 2001; 58: 573–8. infection as a risk factor for squamous-cell carcinoma of
the head and neck. N Engl J Med 2001; 344: 1125–31.
Lindqvist C. Risk factors in lip cancer - an epidemiological
study. Proc Finn Dent Soc 1979; 75(Suppl 1). Morton LM, Gilbert ES, Hall P et al. Risk of treatment-
related esophageal cancer among breast cancer survivors.
Luo J, Ye W, Zendehdel K et al. Oral use of Swedish moist Ann Oncol 2012 (advance access June 27, 2012).
snuff (snus) and risk for cancer of the mouth, lung, and
pancreas in male construction workers: a retrospective Mucci LA, Dickman PW, Steineck G, Adami H-O,
cohort study. Lancet 2007; 369: 2015–20. Augustsson K. Dietary acrylamide and cancer of large
bowel, kidney and bladder: absense of an association in
Luoto R, Raitanen J, Pukkala E, Anttila A. Effect of a population-based study in Sweden. Br J Cancer 2003;
hysterectomy on incidence trends of endometrial and 88: 84–9.
cervical cancer in Finland 1953–2010. Brit J Cancer 2004;
90: 1756–59. Mäkitie O, Pukkala E, Teppo L, Kaitila I. Increased incidence
of cancer in patients with cartilage-hair hypoplasia. J
Lyytinen HK, Dyba T, Ylikorkala O, Pukkala EI . A Pediatr 1999; 134: 315–8.
casecontrol study on hormone therapy as a risk factor for
breast cancer in Finland: intrauterine system carries a risk The National Lung Screening Trial Research Team.
as well. Int J Cancer 2010; 126: 483–89. Reduced lung-cancermortality with low-dose computed
tomographic screening. New Engl J Med 2011;365:
Malila N, Oivanen T, Hakama M. Implementation of 395–409.
colorectal cancer screening in Finland: experiences from
the first three years of a public health programme. Oksa P, Pukkala E, Karjalainen A, Ojajärvi A, Huuskonen
Gastroenterol 2008; 46(Suppl 1): 25–8. MS. Cancer incidence and mortality among Finnish
asbestos sprayers and in asbestosis and silicosis patients.
Am J Industr Med 1997; 31(6): 693–8.
References | 73
Oliver SE, May MT, Gunnell D. International trends in breast implants, 1970–1999. J Long-Term Effects Med
prostate-cancer mortality in the “PSA era”. Int J Cancer Impl 2002; 12: 271–9. (b)
2001; 92: 893–8.
Pukkala E, Guo J, Kyyrönen P, Lindbohm M-L, Sallmén M,
Olsen J, Andersen A, Dreyer L et al. (eds.). Avoidable Kauppinen T. National job-exposure matrix in analyses of
cancers in the Nordic countries. APMI S 1997; 105(Suppl census-based estimates of occupational cancer risk. Scand
76): 1–146. J Work Environ Health 2005; 31: 97–107.
Olsen JH, Hahnemann J, Børresen-Dale A-L et al. Cancer Pukkala E, Helminen M, Haldorsen T et al. Cancer
in patients with ataxia-telangiectasia and in their relatives incidence among Nordic airline cabin crew. Int J Cancer
in the Nordic countries. J Natl Cancer Inst 2001; 93: 2012; 131: 2886–97.
121–7.
Pukkala E, Kyyrönen P, Sankila R, Holli K. Tamoxifen
Patja K, Pukkala E, Sund R, Iivanainen M, Kaski M. Cancer and toremifene treatment of breast cancer and risk of
incidence of persons with Down syndrome in Finland: a subsequent endometrial cancer: a population-based
population-based study. Int J Cancer 2006; 118: 1769–72. casecontrol study. Int J Cancer 2002; 100: 337–41. (c)
Peltomäki P, Aaltonen LA, Sistonen P et al. Genetic Pukkala E, Martinsen JI, Lynge E et al. Occupation and
mapping of a locus predisposing to human colorectal cancer - follow-up of 15 million people in five Nordic
cancer. Science 1993; 260: 810–2. countries. Acta Oncol 2009; 48: 646–790.
Penttinen H, Nikander R, Blomqvist C, Saarto Pukkala E, Patama T. Small-area based map animations of
T. Recruitment of breast cancer survivors into a cancer incidence in Finland, 1953-2008. Finnish Cancer
12-month supervised exercise intervention is feasible. Registry 2010. [astra.cancer.fi/cancermaps/suomi5308/]
Contemporary Clinical Trials 2009; 30: 457–63.
Pukkala E, Pönkä A. Increased incidence of cancer and
Pokhrel A, Martikainen P, Pukkala E, Rautalahti M, Seppä asthma in houses built on a former dump area. Environ
K, Hakulinen T. Education, survival and avoidable deaths Health Perspect 2001; 109: 1121–5.
in cancer patients in Finland. Brit J Cancer 2010; 103:
1109–14. Pukkala E, Teppo L, Hakulinen T, Rimpelä M. Occupation
and smoking as risk determinants on lung cancer. Int J
Pukkala E. Biobanks and registers in epidemiological Epid 1983; 12: 290–6.
research on cancer. . In: Dillner J (eds.). Methods in
Biobanking. Methods in Molecular Biology, 2011, Volume Pukkala E, Teppo L. Socioeconomic status and educational
675. Totowa: Humana Press, 2011, 127–64. risk determinants of gastrointestinal cancer. Prev Med
1986; 15: 127–38.
Pukkala E. Cancer risk by social class and occupation. A
survey of 109,000 cancer cases among Finns of working Pukkala E, Weiderpass E. Time trends in socio-economic
age. Contributions to Epidemiology and Biostatistics. Basel: differences in incidence rates of cancers of the breast and
Karger, 1995. female genital organs (Finland, 1971–1995). Int J Cancer
1999; 81: 56–61.
Pukkala E, Aspholm R, Auvinen A et al. Incidence of
cancer among Nordic airline pilots over five decades: Pukkala E, Weiderpass E. Socio-economic differences in
occupational cohort study. BMJ 2002; 235: 567–9. (a) incidence rates of cancers of the male genital organs in
Finland, 1971–1995. Int J Cancer 2002; 102: 643–8.
Pukkala E, Auvinen A, Wahlberg G. Cancer incidence
among Finnish airline cabin crew 1967–92. BMJ 1995; 311: Pylkäs K, Vuorela M, Otsukka M, Kallioniemi A, Jukkola-
649–52. Vuorinen A, Winqvist R. Rare copy number variants
observed in hereditary breast cancer cases disrupt
Pukkala E, Boice JD Jr, Hovi S-L et al. Incidence of breast genes in estrogen signaling and TP53 tumor suppression
and other cancers among Finnish women with cosmetic network. PLoS Genet 2012; 8(6): e1002734.
74 | Cancer in Finland
Pönkä A, Pukkala E, Hakulinen T. Lung cancer and ambient Finnish breast cancer screening programme from 1991 to
air pollution in Helsinki. Environ Int 1993; 19: 221–31. 2000. Eur J Cancer 2004; 40: 2116–25.
Rana MM, Huhtala H, Apter D et al. Understanding long- Sarkeala T, Anttila A, Saarenmaa I, Hakama M. Validity
term protection of human papillomavirus vaccination of process indicators of screening for breast cancer to
against cervical carcinoma: cancer registry-based follow- predict mortality reduction. J Med Screen 2005; 12: 33–7.
up. Int J Cancer 2013; 15 (132): 2833–8.
Schroder FH, Hugosson J, Roobol MJ et al. Screening and
Rehnberg-Laiho L, Rautelin H, Koskela P et al. Decreasing prostate-cancer mortality in a randomized European
prevalence of helicobacter antibodies in Finland, with study. N Engl J Med 2009; 360: 1320–8.
reference to the decreasing incidence of gastric cancer.
Epidemiol Infect 2001; 126: 37–42. Soininen L, Järvinen S, Pukkala E. Cancer incidence among
Sami in Northern Finland, 1979-1998. Int J Cancer 2002;
Roosaar A, Johansson ALV, Sandborgh-Englund G, Axéll 100: 342–6.
T, Nyrén O. Cancer and mortality among users and
nonusers of snus. Int J Cancer 2008; 123; 168–73. Solyom S, Aressy B, Pylkäs K et al. Breast cancer-
associated Abraxas mutation disrupts nuclear localization
Saarto T, Sievänen H, Kellokumpu-Lehtinen P et al. and DNA damage response functions. Sci Transl Med
Effect of supervised and home exercise training on 2012; 4(122): 122ra23.
bone mineral density among breast cancer patients. A
12-month randomised controlled trial. Osteoporosis Straif K, Baan R, Secretan B et al. on behalf of the WHO
Internat May 2012; 23(5): 1601–12. International Agency for Research on Cancer Monograph
Working Group. Carcinogenicity of shift-work, painting,
Salaspuro M. Acetaldehyde as a common denominator and fire-fighting. Lancet Oncol 2007; 8: 1065–6.
and cumulative carcinogen in digestive tract cancers.
Scand J Gastroenterol 2009; 44: 912–25. Sur IK, Hallikas O, Vähärautio A et al. Mice Lacking a Myc
enhancer element that includes human SNP rs6983267
Salminen E, Pukkala E, Teppo L. Second cancers in patients are resistant to intestinal tumors. Science 2012; 338:
with brain tumours – impact of treatment. Eur J Cancer 1360–3.
1999; 35: 102–5.
Teppo L, Pukkala E, Hakama M, Hakulinen T, Herva A,
Salminen EK , Pukkala E, Kiel KD, Hakulinen T. Impact Saxèn E. Way of life and cancer incidence in Finland. A
of radiotherapy in the risk of esophageal cancer as municipality-based ecological analysis. Scand J Soc Med
subsequent primary cancer after breast cancer. Int J 1980: (Suppl 19).
Radiat Oncol Biol Phys 2006; 65: 699–704.
Teppo L, Pukkala E, Lehtonen M. Data quality and quality
Sankila R, Pukkala E, Teppo L. Risk of subsequent malignant control of a population-based cancer registry. Experience
neoplasms among 470,000 cancer patients in Finland, in Finland. Acta Oncol 1994; 33: 365–9.
1953–1991. Int J Cancer 1995; 60: 464–7.
Teppo L, Pukkala E, Saxén E. Multiple cancer – an
Sant M, Allemani C, Santaquilani M, Knijn A, Marchesi epidemiologic exercise in Finland. J Natl Cancer Inst 1985;
F, Capocaccia R & the EUROCARE Working Group. 75: 207–17.
EUROCARE-4. Survival of cancer patients diagnosed in
1995–1999. Results and commentary. Eur J Cancer 2009; The National Lung Screening Trial Research Team.
45: 931–91. Reduced lung-cancer mortality with low-dose computed
tomographic screening. New Engl J Med 2011; 365:
Sarkeala T. Performance and effectiveness of organized 395–409.
breast cancer screening in Finland. Acta Oncol 2008; 47:
1618. Tomlinson IPM, Alam NA, Rowan AJ et al. Germline
mutations in the fumarate hydratase gene predispose to
Sarkeala T, Anttila A, Forsman H, Luostarinen T, Saarenmaa dominantly inherited uterine fibroids, skin leiomyomata
I, Hakama M. Process indicators from ten centres in the and renal cell cancer. Nature Genetics 2002; 30: 406–10.
References | 75
Travis LB, Andersson M, Gospodarowics M et al. Vierimaa O, Georgitsi M, Lehtonen R et al. Pituitary
Treatment-associated leukemia following testicular cancer. adenoma predisposition caused by germline mutations in
J Natl Cancer Inst 2000; 92: 1165–71. the AIP gene. Science 2006; 312: 1228–30.
Travis LB, Gospodarowics M, Curtis RE et al. Lung cancer Virtanen A, Anttila A, Luostarinen T, Nieminen P.
following chemotherapy and radiotherapy for Hodgkin’s Selfsampling versus reminder letter: Effects on cervical
disease. J Natl Cancer Inst 2002; 94: 182–92. cancer screening attendance and coverage in Finland. Int J
Cancer 2011; 128: 2681–7.
Travis LB, Hill DA, Dores GM et al. Breast cancer
following radiotherapy and chemotherapy among young Virtanen A, Pukkala E, Auvinen A. Angiosarcoma after
women with Hodgkin’s disease. JAMA 2003; 290: 465–75. radiotherapy: a cohort study of 332,163 Finnish cancer
patients. Brit J Cancer 2007; 97: 115–7.
Travis LB, Holowaty EJ, Bergfeldt K et al. Risk of leukemia
after platinum-based chemotherapy for ovarian cancer. Virtanen A, Pukkala E, Auvinen A. Incidence of bone and
New Engl J Med 1999; 340: 351–7. soft tissue sarcoma after radiotherapy: a cohort study of
295,712 cancer patients. Int J Cancer 2006; 118: 1017–21.
Tuohimaa P, Pukkala E, Scélo G et al. Does solar exposure,
as indicated by the non-melanoma skin cancers, protect Visuri T, Pulkkinen P, Paavolainen P, Pukkala E. Cancer risk
from solid cancers: Vitamin D as a possible explanation. is not increased after conventional hip arthroplasty. Acta
Eur J Cancer 2007; 43: 1701–12. Orthop 2010; 81: 77–81.
Tuupanen S, Turunen M, Lehtonen R et al. The common Worrillow LJ, Smith AG, Scott K et al. Polymorphic ML
colorectal cancer predisposition SNP rs6983267 at H1 and risk of cancer after methylating chemotherapy for
chromosome 8q24 confers potential to enhanced Wnt Hodgkin lymphoma. J Med Genet 2008; 45: 142–6.
signaling. Nature Genetics 2009; 41: 885–90.
Worrillow LJ, Travis LB, Smith AG et al. An intron splice
Verkasalo P, Pukkala E, Hongisto M et al. Cancer risk of acceptor polymorphism in hMSH2 and risk of leukemia
Finnish children living close to power lines: a nationwide after treatment with chemotherapeutic alkylating agents.
follow-up study. BMJ 1993; 307: 895–9. Clin Cancer Res 2003; 9: 3012–20.
Verkasalo PK , Kokki E, Pukkala E et al. Cancer risk near a Xue F, Willett WC, Rosner BA, Hankinson SE, Michels KB.
polluted river in Finland. Environ Health Perspect 2004; Cigarette smoking and the incidence of breast cancer.
112: 1026–31. Arch Intern Med 2011; 171: 125–33.
Verkasalo PK , Pukkala E, Kaprio J, Heikkilä KV, Koskenvuo Zendehdel K, Nyrén O, Luo J et al. Risk of
M. Magnetic fields of high voltage power lines and cancer gastroesophageal cancer among smokers and users of
risk in Finnish adults: nationwide cohort study. BMJ 1996; Scandinavian moist snuff. Int J Cancer 2008; 122: 1095–9.
313: 1047–51.
Åberg F, Pukkala E, Sankila R, Höckerstedt K, Isoniemi H.
Vesterinen E, Pukkala E, Timonen T, Aromaa A. Cancer Risk of malignant neoplasms after liver transplantation: a
incidence among 78 000 asthmatic patients. Int J population-based study. Liver Transpl 2008; 14: 1428–36.
Epidemiol 1993; 22: 976–82.
How to find information about cancer
on the internet
Cancer frequency (incidence, mortality clicking on the flag. If the basic information package is
and prevalence) in the whole of Finland enough for you, choose the desired cancer and coun-
or by municipality try from the selection “Cancer Fact Sheets” and click
Go the Cancer Registry’s web page (www.cancer.fi) on “Go” (generate fact sheet). If you need other kinds
and click on the word ”Statistics”. Choose the link of tables, they can easily be done through the link “On-
”Cancer Statistics”. Choose an area of your interest line Analysis”. Graphics that can be easily copied and
and then a table. The selection of tables includes pasted into a PowerPoint presentation, for example,
figures on the incidence, mortality and prevalence as appear within a few seconds. With the easy-to-use
numbers of cases and as rates. The table’s essential tool of NORDCAN, the user can make predictions
figures can be highlighted and copied, for example about cancer frequency in the future.
into Excel, from which presentation graphics can be
made. Ready-made graphic presentations exist in the Cancer Frequency in other countries
Statistics section link ”Graphics about Cancer Frequen- Estimation data about cancer incidence and mortality
cies” (www.cancer.fi/syoparekisteri/en/statistics/ in the whole world can be found from the WHO’s
graphics-about-cancer-frequencie/), but these graphic international cancer research center’s (International
images are not regularly updated. Agency for Research on Cancer) GLOBOCAN data
bank, which can be accessed through the website
Cancer frequency www-dep-iarc.fi. It can be navigated in the same way
in an out of the ordinary way as the above-mentioned NORDCAN information da-
The Cancer registry can chart cancers in ways tabase. Cancer data from the United States is related
exceptional to the traditional categories, among oth- on the page seer.cancer.gov/.
ers, according to topographical sub-categories (i.e.,
cardia), morphology (i.e. adenocarsinoma), staging Cancer Frequency according to
(local, spread to regional lymph nodes, or spread occupation in Finland and
further) and the method of detection (for example, other Nordic Countries
microscopically confirmed), if the tables are for a Thanks to broad Nordic countries’ cooperative
justified need. Requests for tables should be sent to NOCCA study (Nordic Occupational Cancer Study),
kirjaamo@cancer.fi. plenty of informational tables about the number of
cancer cases and the risk for cancer according to
Cancer frequency by municipality occupation categories (Pukkala, et al. 2009) are avail-
The frequency of cancer can also be charted accord- able. They are found on the website through the link
ing to justified need by municipality, but there may be astra.cancer.fi/NOCCA. For English language tables,
questions of privacy protection connected to limited click on the link “Table downloads”. After that, you can
population based tables. Requests for these tables choose tables according to the cancer type (more
should also be sent to kirjaamo@cancer.fi. than 80 alternatives) or the occupation (54 occupa-
If you want to compare the cancer situation be- tion categories). Word tables can be edited and
tween residential areas, it can easily be done by using sorted in the normal way or transferred, for example,
the presentation materials in map format. That can be to Excel.
found through the link in Cancer Registry’s Statistics
section “Graphics about Cancer Frequencies” (including Cancer patient survival
the links “Spatial and Temporal change in relation, Fin- The Cancer Registry calculates at least every other
land animations” and “Nordic countries’ map animations” year patients’ survival ratios, which are always a part
(http://astra.cancer.fi/cancermaps/Nord124/pub/). of the published English language yearly statistics.
Electronic versions of the statistics can be accessed
Cancer frequency in Finland and other by clicking on the book cover icons on the web page
Nordic countries in tables and graphs www.cancerregistry.fi => ”Statistics”. Tables concern-
Go to the Nordic Countries’ Cancer Registry ing the survival ratios for cancer patients from all of
(ANCR) website (www.ancr.nu) and choose the link the Nordic countries can be found in NORDCAN.
NORDCAN - on the Web. Choose the language by
Finnish Cancer Registry
Institute for Statistical and Epidemiological Cancer Research
Pieni Roobertinkatu 9
FI-00130 Helsinki
Tel. +358 9 135 331 (switchboard)
registry@cancer.fi
www.cancerregistry.fi