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Gastrointestinal (GI) tract cancers, commonly including esophageal, stomach, and colorectal cancer, have been a leading causes of death causing 2.2 million deaths and 46.5 million years of life lost (YLLs) as estimated in the Global Burden of Diseases Study (GBD) 2017 (1). Stomach, esophageal, and colorectal cancers were ranked as the seventh, eleventh, and fifteenth leading causes of YLLs in both men and women in China (2). Previous reports have noted that the cancer mortality in the Huai River Basin was higher than the national level during 2004–2006 (3). In this study, mortality data was used for the first time to demonstrate temporal trends, population distributions, and geographical distributions of GI tract cancer in the Huai River Basin from 2008 to 2018 (3). Trends of GI tract cancer mortality were examined by sex, age group, and region of the Huai River Basin. Study results indicated that, from 2008 to 2018, age-standardized mortality rate (ASMR) of esophageal and stomach cancer decreased annually by 6.7% and 5.9%, respectively, for both sexes, and the decrease in ASMR also occurred in some specific demographic and geographic subgroups. However, the ASMR of colorectal cancer did not decrease significantly and actually significantly increased among men aged 45 to 54 years (average annual percent change [AAPC]: 3.3%, 95% CI①: 0.5%–7.2%) and among women aged below 55 years (AAPC aged 0–44 years group: 2.7%, 95% CI: 1.1%–5.3%; AAPC aged 45–54 years group: 7.5%, 95% CI: 3.4%–11.8%). This study also displayed geographic disparities for GI tract cancers, and the mortality of GI tract cancers in the Huai River Basin in 2018 was similar with national levels through related targeted prevention and control measures over the past 11 years (4). Continuous early diagnosis and treatment of GI tract cancers in the Huai River Basin, improved water quality, and improved healthcare conditions may play roles in decreasing mortality. As the lifestyles and dietary habits of Chinese residents have changed, prevention strategies should be further strengthened to target GI tract cancers, and colorectal cancer should be prioritized.
Mortality data of GI tract cancers were obtained from China CDC’s Cause of Death Reporting System (CDRS) from 2008 and 2018. According to the International Classification of Diseases, 10th revision (ICD-10), esophageal cancer, stomach cancer, and colorectal cancer were coded as C15, C16, and C18–C21, respectively, for this study.
Based on the geographical distribution of the Huai River, its tributaries, and the “Encyclopedia of Rivers and Lakes in China”, 14 districts and counties from 4 provinces (Anhui, Henan, Shandong, and Jiangsu) in the Huai River Basin were divided into 5 categories: the upstream basin (upper stream) including 2 counties; the midstream north basin (midstream-north) including 6 counties or districts; the midstream south basin (midstream-south) including 1 county; the downstream basin (downstream) including 3 counties; and the Yishui River Basin including 2 counties. This report used the Sixth Chinese National Census (2010) as the standard population to calculate the age-standardized mortality rate (ASMR). Joinpoint regression was used to examine the significance of trends and to calculate the AAPC by different sub-regions of the basin, diseases, sex, and age groups during 2008–2018. When AAPC>0, the ASMR showed an upward trend, otherwise it showed a downward trend (5).
A total of 70,691 deaths were reported due to GI tract cancer from 2008 to 2018, with 47,131 males and 23,560 females. The ASMRs per year were higher among men than women by diseases. From 2008 to 2018, the ASMR of esophageal cancer decreased steadily from 28.5 per 100,000 population to 13.2 and for stomach cancer from 32.1 per 100,000 population to 16.5. For esophageal cancer and stomach cancer, the AAPC decreased –6.7% (95% CI: −7.7% to –5.8%, p<0.001) and −5.9% (95% CI: −7.0% to −4.9%, p<0.001) per year, respectively. Downward trends were significant across both sexes, and the AAPC of ASMR for esophageal and stomach cancers were higher among men compared to women (esophageal cancer: AAPC=−6.7% in men, AAPC=−7.7% in women; stomach cancer: AAPC=−6.0% in men, AAPC=−6.5% in women). However, the ASMR of colorectal cancer showed stability from 2008 to 2018 for both men and women, and there was no statistical difference (Table 1).
Year Esophageal cancer Stomach cancer Colorectal cancer Both Male Female Both Male Female Both Male Female CMR ASMR CMR ASMR CMR ASMR CMR ASMR CMR ASMR CMR ASMR CMR ASMR CMR ASMR CMR ASMR 2008 24.3 28.5 31.0 40.5 17.3 18.4 27.4 32.1 36.0 46.6 18.3 19.6 5.9 6.8 6.5 8.4 5.2 5.6 2009 21.0 24.3 27.1 35.2 14.5 15.2 25.6 29.6 33.3 42.6 17.5 18.5 5.8 6.8 6.5 8.6 5.0 5.3 2010 21.5 24.8 29.1 37.1 13.6 14.4 26.1 29.9 34.9 43.9 16.8 17.8 6.2 7.2 7.2 9.3 5.2 5.6 2011 23.8 23.4 31.7 34.3 15.8 14.1 28.6 28.3 39.1 42.3 18.1 16.5 7.5 7.5 8.5 9.4 6.4 5.9 2012 21.8 19.4 29.6 27.8 14.0 11.5 25.6 23.0 35.5 33.5 15.5 13.2 7.1 6.5 7.8 7.5 6.5 5.5 2013 20.9 18.9 27.3 25.9 14.5 12.3 25.2 22.8 34.2 32.4 16.2 13.6 7.4 6.7 8.1 7.8 6.7 5.7 2014 20.8 18.1 29.1 26.6 12.5 10.1 25.4 22.4 34.7 32.1 16.1 13.3 7.9 7.1 9.0 8.5 6.8 5.8 2015 20.8 17.8 27.9 25.2 13.9 11.2 25.2 21.8 34.9 31.7 15.6 12.7 9.0 7.9 10.4 9.6 7.6 6.3 2016 20.7 16.2 28.0 23.4 13.4 9.6 24.7 20.0 33.8 28.5 15.6 12.0 8.3 6.8 9.9 8.4 6.8 5.3 2017 19.4 15.1 27.4 22.7 11.4 8.0 24.2 19.5 33.8 28.6 14.5 11.1 9.4 7.7 10.8 9.3 7.9 6.1 2018 18.1 13.2 24.5 19.2 11.5 7.6 21.8 16.5 29.8 23.9 13.6 9.4 8.9 6.8 10.4 8.5 7.4 5.3 AAPC – −6.7* – −6.7* – −7.7* – −5.9* – −6.0* – −6.5* – 0.5 – 0.2 − 0.4 (95% CI) (−7.7 to −5.8) (−7.8 to −5.5) (−9.1 to −6.3) (−7.0 to −4.9) (−7.2 to −4.8) (−7.6 to −5.5) (−0.9 to 1.9) (−1.5 to 1.9) (−0.8 to 1.7) Abbreviations: CI=confidence interval, CMR=Crude Mortality Rate, ASMR=age-standardized mortality rate, AAPC=average annual percent change.
* p<0.05.Table 1. Age-standardized mortality rate (per 100,000) and average annual percent change (%) of gastrointestinal tract cancers in the Huai River Basin by sex, 2008–2018.
The mortality rate of GI tract cancers increased with age in both men and women, and the rate was much higher among those aged 65 years and above. There was an obviously statistical difference for mortality of esophageal and stomach cancer in all age-groups for men and women. For both sexes, the mortality rate of stomach cancer decreased significantly among those aged 55 years and above and decreased to a lesser degree among those aged below 55 years old. The mortality rates of colorectal cancer in different age groups presented different characteristics. The mortality rate increased significantly among men aged 45 to 54 years (AAPC: 3.3%, 95% CI: 0.5%–7.2%) and women aged below 55 years old (AAPC aged 0–44 years group: 2.7%, 95% CI: 1.1%–5.3%; AAPC aged 45–54 years gourp: 7.5%, 95% CI: 3.4%–11.8%). There were no significant differences in mortality rate between men and women aged 55 years old and above (Table 2).
Sites/Age group (years) 2008 2018 AAPC (95% CI) Both Male Female Both Male Female Both Male Female Esophageal cancer <45 0.3 0.4 0.2 0.1 0.1 0.1 –9.7*(–16.4 to –2.5) –8.2(–17.5 to 2.3) –11.8*(–18.7 to –4.4) 45–54 12.1 18.4 5.5 4.3 7.2 1.6 –8.5*(–11.1 to –5.8) –7.1*(–9.8 to –4.2) –12.1*(–16.8 to –7.1) 55–64 50.6 71.0 29.6 24.1 37.7 10.1 –7.6*(–9.7 to –5.4) –6.5*(–8.8 to –4.2) –10.5*(–13.0 to –8.0) 65–74 157.4 214.8 100.0 79.2 113.3 43.7 –5.4*(–6.8 to –4.0) –5.1*(–6.5 to –3.7) –6.4*(–9.0 to –3.7) ≥75 352.7 495.2 250.0 164.7 229.2 113.6 –6.6*(–8.5 to –4.7) –7.0*(–8.5 to –5.5) –6.7*(–8.2 to –5.2) Stomach cancer <45 1.1 1.2 1.0 0.6 0.7 0.5 –3.7(–9.0 to 2.0) –3.3(–7.3 to 0.8) –6.2(–12.3 to 0.3) 45–54 16.9 25.3 8.3 11.5 16.3 7.0 –3.8*(–6.5 to –1.0) –3.5*(–5.9 to –1.1) –3.7(–8.2 to 0.9) 55–64 56.5 82.5 29.8 31.1 46.5 15.4 –6.5*(–8.9 to –4.1) –6.0*(–7.8 to –4.1) –6.7*(–9.2 to –4.2) 65–74 171.2 246.1 96.3 94.2 137.0 49.8 –4.8*(–6.0 to –3.6) –4.7*(–6.0 to –3.3) –5.7*(–7.2 to –4.1) ≥75 375.7 537.4 259.2 173.2 248.8 113.3 –7.0*(–8.5 to –5.6) –7.0*(–8.7 to –5.4) –7.6*(–9.1 to –6.1) Colorectal cancer <45 0.9 0.7 1.0 0.5 0.8 0.3 0.0(–3.9 to 4.0) 2.6(–4.1 to 6.5) 2.7*(1.1 to 5.3) 45–54 4.3 6.0 2.5 6.6 7.2 6.1 4.9*(1.7 to 8.3) 3.3*(0.5 to 7.2) 7.5*(3.4 to 11.8) 55–64 13.3 15.7 10.8 13.6 17.2 10.0 0.2(–2.3 to 2.7) 0.5(–2.1 to 3.3) –0.4(–3.3 to 2.7) 65–74 30.7 36.2 25.2 31.1 35.7 26.4 1.5(–0.9 to 3.9) 2.1(–1.0 to 5.4) 0.5(–2.3 to 3.3) ≥75 70.4 89.8 56.5 70.6 92.4 53.2 –0.6(–2.3 to 1.1) –1.2(–3.3 to 0.9) –0.1(–2.3 to 2.1) Abbreviations: CI=confidence interval, AAPC=average annual percent change.
*p<0.05.Table 2. Mortality rate (per 100,000) and average annual percent change (%) of gastrointestinal tract cancers in the Huai River Basin, by sex and age group, 2008 and 2018.
Overall, the ASMRs by spatial distribution of the Huai River Basin were presented in Table 3. The downstream basin had the highest ASMR of GI tract cancers for men and women from 2008 to 2018, among which, the mortalities of 2 cancers decreased significantly (esophageal cancer: from 47.2 to 21.3 per 100,000; AAPC=−6.3%, 95% CI: −7.7% to −5.0%; stomach cancer: from 40.7 to 21.7 AAPC=−5.9%, 95% CI: −6.6% to −5.2%), and mortality of colorectal cancer did not decrease significantly (from 8.6 to 9.3 AAPC=1.2%, 95% CI: −0.5% to 3.1%), followed by the Yishui River Basin and midstream-south basin. The AMSR of colorectal cancer increased significantly among women in the Yishui River Basin (AAPC=4.2%, 95% CI: 0.1% to 8.3%).
Basin/Sites 2008 2018 AAPC
(95% CI) for ASMRBoth Male Female Both Male Female CDR ASMR CDR ASMR CDR ASMR CDR ASMR CDR ASMR CDR ASMR Both Male Female Upper stream Esophageal cancer 20.1 21.3 26.9 32.1 12.9 12.3 15.9 11.3 21.4 17.1 10.1 6.1 –6.4*
(–7.8 to –5.0)–6.1*
(–7.6 to –4.6)–7.1*
(–8.9 to –5.3)Stomach cancer 32.7 34.0 46.2 52.6 18.4 18.0 26.0 19.3 37.7 30.2 14.0 9.3 –5.3*
(–6.7 to –4.0)–5.3*
(–7.4 to –3.1)–6.0*
(–8.1 to –3.9)Colorectal cancer 8.2 8.5 9.4 10.4 6.9 6.6 10.8 8.1 12.2 9.7 9.4 6.5 1.0
(–1.6 to 3.8)1.0
(–2.3 to 4.3)0.8
(–2.6 to 4.3)Midstream–north Esophageal cancer 15.9 19.7 19.2 26.9 12.4 13.7 11.9 9.4 16.0 13.5 7.7 5.5 –7.3*
(–8.4 to –6.1)–7.1*
(–9 to –5.3)–8.4*
(–10.2 to –6.6)Stomach cancer 20.4 25.4 25.2 35.4 15.2 17.0 16.6 13.8 21.6 19.2 11.6 8.6 –5.7*
(–7.2 to –4.1)–5.8*
(–7.5 to –4.1)–6.1*
(–7.6 to –4.5)Colorectal cancer 4.8 5.9 5.4 7.5 4.1 4.6 6.8 5.6 8.3 7.4 5.2 4.0 –0.1
(–2.1 to 1.8)–0.6
(–2.7 to 1.6)0.1
(–2.5 to 2.7)Midstream–south Esophageal cancer 26.5 29.3 39.5 44.2 12.6 13.9 15.5 11.0 24.1 16.7 6.1 4.5 –9.5*
(–10.9 to –8.1)–9.7*
(–11.3 to –8.1)–10.5*
(–13.5 to –7.3)Stomach cancer 31.7 35.8 46.4 54.6 15.8 17.5 27.0 19.2 38.0 26.7 14.9 10.8 –6.4*
(–8.0 to –4.7)–7.0*
(–8.9 to –5.0)–6.0*
(–7.6 to –4.4)Colorectal cancer 5.3 5.7 5.9 6.4 4.7 4.9 9.1 7.0 11.2 8.7 6.7 5.2 –0.8
(–4.3 to 2.8)0.8
(–3.1 to 4.8)–2.9
(–6.1 to 0.3)Downstream Esophageal cancer 42.9 47.2 54.5 67.6 30.9 30.9 33.9 21.3 43.3 29.9 24.5 13.8 –6.3*
(–7.7 to –5.0)–6.4*
(–7.9 to –4.8)–7.0*
(–8.9 to –5.0)Stomach cancer 38.5 40.7 52.6 62.1 24.0 23.4 33.3 21.7 47.2 32.7 19.6 11.9 –5.9*
(–6.6 to –5.2)–6.1*
(–6.9 to –5.3)–6.2*
(–8.1 to –4.3)Colorectal cancer 8.1 8.6 8.2 10.5 7.9 7.6 13.9 9.3 16.3 11.7 11.5 7.4 1.2
(–0.5 to 3.1)1.4
(–0.5 to 3.4)0.2
(–2.4 – 2.8)Yishui River Basin Esophageal cancer 35.3 42.4 44.9 60.3 25.5 27.4 26.3 18.9 37.4 29.1 14.9 9.5 –5.7*
(–7.4 to –3.9)–5.4*
(–7.2 to –3.6)–7.1*
(–9.9 to –4.3)Stomach cancer 33.0 40.1 41.2 55.2 24.6 27.0 20.9 15.8 29.0 23.6 12.6 8.4 –7.4*
(–11.9 to –2.6)–5.9*
(–10.3 to –1.4)–8.6*
(–11.5 to –5.6)Colorectal cancer 6.1 7.3 6.9 8.8 5.3 5.8 9.6 7.1 9.6 7.7 9.6 6.6 1.7
(–0.3 to 3.8)–0.4
(–2.5 to 1.8)4.2*
(0.1 to 8.3)Abbreviations: CI=confidence interval, CDR=crude death rate, ASMR=age–standardized mortality rate.
*p<0.05.Table 3. Mortality rate (per 100,000), age-standardized mortality rate (per 100,000), and average annual percent change (%) of gastrointestinal tract cancers in the Huai River Basin, by sex and basins, 2008 and 2018.
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FootNote
① | CI=confidence interval. |
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