Keun-Young Yoo

Professor Seoul National University College of Medicine (SNUCM)

H. President National Cancer Center, Korea (NCC-K)

Secretary-General Asian Pacific Organization for Cancer Prevention (APOCP)

The Supercourse Dec., 2010

Cancer Epidemiology in Korea

http://www.korea.net

Republic of Korea (KOR)

A Land of Morning CalmRabindranath Tagore (1861ㅡ1941)

land area

222,154 km2 (=Britain)

99,000 km2 (south)

147,000 km2 (Nepal)

5000 years of Korean History

World Cultural Heritage

by

UNESCO

What Do You Know About Korea?

Korean war (1950-1951)

poverty and starvation

What Do You Know About Korea?

Export-Driven Economic Development since 1960s

urbanization

industrialization

westernization

What Do You Know About Korea?

Semiconductors, automobiles

What Do You Know About Korea?

Semiconductors, automobiles, ships, mobile telecoms,

What Do You Know About Korea?

Semiconductors, automobiles, ships, mobile telecoms, chemicals, steels, consumer electronics

What Do You Know About Korea?

World Cup (2002)

Seoul Olympiad (1988)

population: 49 M (south)(ranked 18th in the world) 23 M (north) as of 2007

life expectancy: 75.7 yrs (M) / 82.4 yrs (F)

aging (65+): 9.0% (2005)20.0% (2026)

population IR: 0.33% (2007)

health insurance: universal coverage

per capita GNI: USD 20,045 (2007)

major industries: semiconductors, automobiles, ships, mobile telecoms, chemicals, steels, consumer electronics

.

Health and Welfare StatisticsRepublic of Korea

20091911

Cause of death = infections Cause of death = cancer

Life expectancy < 45 yrs

Per capita GNI < US$20

Life expectancy = 78 yrs

Per capita GNI = US$20,000

Traditional medicine Universal health insurance

Korea

Incredible Changes in Korean Society fromAgricultural to Highly Advanced Industrial Country

(%)

Source: Korea National Statistical Office, 2008

Causes of Deaths in Korea

11.3%

28.0%Cancer

CVA

Heart Disease

Liver Disease

DM

Trend in Age-standardized Incidence Rates of Cancer

Korea Central Cancer Registry, 1999-2007

Sex

Annual

Percent

Change

(%)

Total 2.9 *

Male 1.3 *

Female 4.9 *

* P < .05

Relative Frequency of Incident Cancer Cases in Korea 2003~2005

Unit : %

Source: Korea Central Cancer Registry, 2008

Ten Major Sites of Cancer in Korea1999-2002

0 10 20 30 40 50 600102030405060

Stomach (59.8)

Liver (42.5)

Lung (43.0)

Colorectal (26.2)

Bladder (7.7)

Esophagus (7.2)

Gallbladder, etc (6.8)

Pancreas (6.8)

Prostate (6.6)

Lip, oral cavity, pharynx (5.9)

Stomach (31.4)

Colorectal (20.7)

Breast (27.8)

Cervix uteri (18.5)

Lung (15.5)

Thyroid (14.5)

Liver (14.0)

Gallbladder, etc (6.9)

Ovary (5.6)

Pancreas (5.0)

crude incidence rate /100,000

Male Female

The Korea Central Cancer Registry, 2007

Trend in Major Cancer Mortality Rates

Male Female

Age-standardized rate per 100,000

Year of Death

Source: Annual Report of Causes of Death, Korea National Statistical Office(age-standardized rates on the 2000 Korea registration population )

lung

liver

stomach

colorectum

stomach

liver

breastcolorectum

* P < .05

Site

Year Annual

percent

change

(%)1999 2007

Stomach 68.4 62.8 -0.7 *

Lung 51.9 48.1 -0.6 *

Colon and

rectum27.0 44.5 7.0 *

Liver 48.5 39.6 -2.2 *

Prostate 8.5 20.1 13.2 *

Thyroid 2.3 11.6 24.5 *

Trend in Age-standardized Incidence Rates of Cancer

Male, Korea Central Cancer Registry, 1999-2007

* P < .05

Site

Year Annual

percent

change

(%)1999 2007

Thyroid 11.9 64.8 26.0 *

Breast 24.5 39.9 6.6 *

Stomach 28.3 25.7 -0.7 *

Colon and

Rectum17.1 24.3 5.3 *

Lung 12.9 13.7 1.2 *

Cervix uteri 18.6 12.2 -4.9 *

Liver 12.6 10.9 -1.6 *

Trend in Age-standardized Incidence Rates of Cancer

Female, Korea Central Cancer Registry, 1999-2007

Cumulative Risk of Cancer in Korea

28.9%34.4% Cumulative risk

83 years76 yearsLife expectancy(2007)

FemaleMale

1 out of 3 1 out of 4

Source: Korea National Statistical Office, 2009

Lung Cancer

increase in tax on cigarettes

ban on smoking in public places, health education, etc.

limit cigarette advertising

prohibit promoting the sale of tobacco

warning on cigarette packets

expand public anti-smoking campaign & education

limit sales to minors

Anti-Smoking Program of Korea

0

10

20

30

40

50

60

%

Males 25 31 29.8 19.4 30 16.7 28 48.3 25.7 49.3

Females 25 25 19.1 15.7 25 18.3 24 13.6 19.3 4.8

Newziland Denmark Germany USA Belgium Sweden UK Japan Finland Korea

Source: OECD health data,2005

Smoking Rate in OECD Countries

Initiatives to Reduce the Tobacco Use

• Major TVs, Newspapers Banish Tobacco 2002-2004

KBSSBSMBC

• Increase in Tax on Cigarettes

• Ban on smoking in public places, health education, etc.

• Ban by legislation on the manufacture and sale of tobacco products

(Tobacco Free World Alliance: ToFWA)

Quitline Service for Smoking Cessationat NCC

since April 2006 by telephone & website

providing smoking cessation coaching

releasing knowledge on hazards of smoking

collaboration with 248 Health Centers

for pharmacotherapy : NRT and bupropion

by all the health centers charge free

Smoking Prevalence : Adults

79.3

43.4

45.950.3

57.8

56.7

60.5

69.9

67.6

64.969.8

72.9

75.1

75.3

71.2

3.72.83.143.56

3.134.45.33.55.1

7.7812.6

0

10

20

30

40

50

60

70

80

90

1980 1985 1990 1992 1994 1996 1999 2000 2001 2002 2003 2004 2005 2006 2007

Male

Female

Source: Ministry of Health & Welfare, Korean Association of Smoking & Health

MNNG

Post MNNG 37wks

nitrite (salts, foods, additives, etc.)

enzymatic blockage (비타민C, 냉장고)

nitrate nitrosamine(carcinogenic)

+

amine(foods, drugs)

Stomach Cancer

Helicobactor pylori2-7mm X 5,300

癌! 바로 알기

Gwack et al. Brit J Cancer 2006

CagA-producing Helicobacter pylori Increased Risk of Stomach Cancer in Korea

Codes of Conduct for Cancer Prevention

Cancer is Preventable

& Avoidable!!

國民癌豫防守則

Intake of Vegetables/Fruits, Use of Refrigerator and Stomach Cancer Mortality in Korea, 1973-2005

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

0

50

100

150

200

250

300

350

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

vegetables intake(g/day) fruits intake(g/day) mortality rates of gastric cancer(per a hundred thousand persons) refrigerator(per house)

(Mortality) Korea National Statistical Office. Annual Report of Causes of Death.(Nutrition) Ministry for Health, Welfare and Family Affairs. The Third Korea National Health and Nutrition Examination Survey(Refrigerator) Korea Power Exchange. The number of refrigerators in use in Korea.

refrigeratorsfruits

vegetables

stomach cancer mortality rates

Chronic carrier

Chronic cirrhosis

Liver cancer

HBV HCV

80-90%1-10%adults

Acute hepatitis

90%Vertical

transmission

30-40%

1.5-4%/yr

20-30%

3-6.5%/yr

Liver Cancer癌! 바로 알기

Korea Center for Disease Control & Prevention

Se

rop

ositiv

ity o

f H

BsA

g(%

)HBsAg seropositivity

year

<HBsAg seropositivity among blood donors>

HBV vaccination

introduced in Korea

National vaccination program for

infants and children

Vaccination against

vertical transmission

Liver Cancer Mortality Ratesin Young Koreans

0

0.1

0.2

0.3

0.4

0.5

0.6

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

year

mo

rta

lity

ra

te p

er

10

0,0

00

0-9yr

10-19yr

National

vaccination

program for infants

and children

Vaccination

against vertical

transmission

Korea National Statistical Office 2008

Change in Breast Cancer Mortality Ages 25-49, % Change during 1985-87 to 1995-97

Bray et al. Breast Cancer Res 2004

Source: WHO Mortality database

http://www-depdb.iarc.fr/

Republic of KoreaChina: rural areas

Japan

Age-Incidence Curves of Breast Cancer in selected Asian Countries

Source: Globocan 2002

Countries All ages ASR (World)

Pakistan 35.6 50.1

Singapore 58.9 48.7

Philippines 33.5 46.6

Japan 49.6 32.7

Malaysia 26.2 30.8

Indonesia 23.3 26.1

Turkey 19.9 22.0

Nepal 15.6 21.8

Korea 23.5 20.4

India 16.5 19.1

China 20.1 18.7

Iran 13.4 17.1

Thailand 16.3 16.6

Viet Nam 13.1 16.2

Mongolia 4.9 6.6

Trend of Age-standardized Incidence Rate by Site Female, 1999-2005, Korea

28.3

24.5

18.6

17.1

Lung : 12.9

Liver : 12.6

Thyroid : 11.9

40.8

35.5

28.1

23.0

Lung : 13.6

Cervix uteri : 13.1

Liver : 11.4

breast

* ASR (standardized by Korean population in 2000)

Selected Food Intake in Korea(1969-2005)

grain

animal foods

fishery

vegetables

meats

gra

m p

er

da

y p

er

ca

pita

Source: National Health and Nutrition Survey Report, 2007

Lifestyle Changes in Korea

mean age at first marriage 24.9 (1990) 27.3 (2003) 28.1 (2007)

total fertility rate 2.0 (1980) 1.19 (2003) 1.26 (2007)

age at menarche*

13.5 (1988) 12.7 (1998)

total calorie supply (per capita per day) 2,622 (1983) 2,927 Kcal (2006)

Source: National Statistical Office. 2007

* Cho et al. 1999

Breastfeeding Trend AmongKorean Women

0%

20%

40%

60%

80%

1985 1988 1994 1997 2000

breast feeding combined milk

Source: Korea Institute for Health & Social Affairs. 2000National Health and Nutrition Survey, 2003

Projection of Breast Cancer Mortality Korea, all ages, 2005-2020

Mort

alit

y ra

tes,

per

a h

undre

d t

housa

nd

FEMALE BREAST CANCER

4.18

2.83

3.81

2.34National Cancer Screening Program

5.12

9.19

7.61

0

2

4

6

8

10

12

14

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2005

2010

2015

2020

based on Poisson regression model

6.30

3.9

times

2.8 times

Source : National Statistical Office 2002Choi et al. Asian Pacific J Cancer Prev 2005

자궁 질 세포검사 (Pap smear)

• 1928, George N. Papanicolaou

• 자궁경부에서 세포를 채취, 도말 후 현미경으로 관찰

• 민감도 50 – 70%, 특이도 60 – 90%

National Action against Cancer in Korea

1996 1st Term 10-year Plan for Cancer Control 第1期 癌征服推進事業

1999 National Cancer Screening Program 國家癌檢診事業

2000 Cancer Control Division, Health Promotion Bureau,

Ministry of Health & Welfare 保健福祉部 健康增進局 癌管理課

2001 National Cancer Center 國立癌센터(中心)

2003 National Cancer Act 癌管理法

2004 Regional Cancer Centers 地域癌센터(中心)

2006 2nd Term 10-year Plan for Cancer Control 第2期 癌征服推進事業

National Cancer Information Center at NCC

NCIC provides a comprehensive cancer information services through website, telephone, and on-site education.

NCIC provides some booklets and leaflets on various aspect of cancer.

NCIC have supported health professionals with information on cancer research relates and have developed educational booklets and leaflets on most aspects of cancer.

http://www.cancer.go.kr/

Cancer Eligible Frequency Test /Procedure

Stomach40 & over

adultsevery 2 yrs endoscopy or UGI

Breast40 & overwomen

every 2 yrs mammography & CBE

Cervix30 & overwomen

every 2 yrs Pap smear

Liver40 & over

high risk group* every 6 mo sonography & AFP

Colorectal 50 & over

adultsevery 1 yr

FOBT colonoscopy or barium enema

* 40 & over with HBsAg positive or anti-HCV positive or liver cirrhosis

Screening Guideline of NCSP

Performance of NCSP by Cancer Type

No. of participants(1,000)

No. of cancer detected(detection rate, %)

2005 2006 2007 2005 2006 2007

Stomach 1,150 1,525 1,724 1,383 (0.12) 1,717 (0.11) 1,784 (0.10)

Breast 729 946 1,064 112 (0.02) 124 (0.01) 104 (0.01)

Cervix 73 70 80 28 (0.04) 27 (0.04) 28 (0.03)

Liver 100 117 111 145 (0.15) 152 (0.13) 122 (0.11)

Colorectum 537 692 783 207 (0.04) 289 (0.04) 350 (0.04)

Total 2,589 3,350 3,750 1,875 (0.07) 2,309 (0.07) 2,388 (0.06)

Cancers 2004 2005 2006 2007 2008

Stomach 39.2 39.4 43.3 45.6 53.5

Liver 20.0 16.3 16.5 22.7 19.7

Colon 19.9 25.4 29.4 34.1 39.7

Breast 33.2 38.4 40.6 45.8 49.3

U. cervix 58.3 38.4 54.9 57.0 59.9

unit: %

Source: National Cancer Center. Nationwide Survey for Health Screening Performance Rate, 2004~2007

Note: Cancer screening performance rate by any programs in a given year under the screening guideline recommended by the National Cancer Center and the Ministry of Health & Welfare

Screening rates, All Combined, Korea

Stage Frequency of Breast Cancer

Source: Korea Central Cancer Registry,Korean Breast Cancer Society

36.9%

26.9%

22.7%

49.6%

57.0%

58.7%

11.7%

13.1%

14.8%

1.9%

3.0%

3.8%

Five Year Survival of Cancer Sites of National Screening Program

MEN

WOMEN

1) Ries LAG, et al (eds). SEER Cancer Statistics Review, 1975-2005, National Cancer Institute, 2008

2) National Cancer Center in Japan. Cancer Statistics in Japan, 2008

(Unit: %)

International Comparison of Five Year Relative survival

Korea (‘01-’05)

USA 1)

(’96-’04)Japan 2)

(‘97-’99)Eurocare 2)

(‘95-’99)

Stomach 56.4 24.7 62.1 24.1

Lung 15.5 15.2 25.6 12.6

Colorectum 64.8 64.4 65.2 53.5

Liver 18.9 11.7 23.1 8.6

Thyroid 98.1 96.9 92.4 86.5

Breast 87.3 88.7 85.5 81.1

Cervix uteri 81.1 71.2 71.5 66.5

Prostate 76.9 98.9 75.5 77.0

All Cancers 52.2 65.3 54.3 51.9

National R&D Program for Cancer Control (since 1996~)

Causes and Mechanisms of Common Cancers

Cancer etiology

Cancer metastasis and progression

Tumor immunology

Functions of tumor suppressors

Cancer Therapeutic Technologies

Surgical, radiological chemo-therapeutics

Anticancer drug candidates

Bone marrow transplantation

Molecular/cellular therapeutics for cancer

Alternative medicine for cancer

Multi-institutional clinical trials for cancers

Cancer Diagnostic Technologies

Diagnosis of precancerous lesions

Discovery of new tumor markers

Development of new diagnostic technologies

using novel targets or tools

Studies on the movement, storage and reproduction of diagnostic media

Cancer Prevention and Control

Intervention studies on risk factors for

cancer prevention

Cancer education, awareness, and information

Enhancing the quality of cancer screening

Improving of life for cancer patients and

palliative care

Cancer control policies

Cancer Facts in Korea, Today

United StatesWar against Cancer, 1971Decline in cancer mortality, 1991

KoreaNCC, 20011st NCCP, 1996NCSP, 1999(stomach)-04(colon)

0

30

60

90

120

150

180

210

'95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 07

Male

Female

Annual % change male : -1.13%female : -0.80%

Overall Cancer Mortality Rates

JapanNCC, 1962NCCP, 1965NCSP, 1966(stomach)-92(colon)

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Year

Death

rate

per

100,0

00 p

op.

Crude(M)

Crude(F)

AgeAdj(M)

AgeAdj(F)

Data: Vital Statistics of Japan (1950-2000)

Death rate from all sites of cancer in Japan

Cancer Incidence, 2003~2005

Numbers of Cancer cases Crude Rates

Age-standardized Rates

(Unit : Rate per 100,000)

(Unit : Rate per 100,000)

Five Year Survival of Ten Major Cancer Sites(2001-2005)

Economic Burden of CancerKorea, 2005

Million Won

Total : 14 billion USD (1.7% of GDP)

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

Liver Stomach Lung Colorectum Breast Leukemia Pancreas

Productivity loss cost of early death

Productivity loss cost of disability

Non-Medical Cost

Medical Cost

Source: Kim et al. Eu J Cancer Care 2007

Total(10,000 persons)

15~64 years(10,000 persons)

65+ years(10,000 persons)

Old Dependency

Ratio

4,2343,812 4,814 4,934 4,863

2,372

146

6.2

3,598

707

19.6

3,123

1,181

37.8

2,242

1,616

72.1

3,453

437

12.7

20302018 20501980 2005

Age 15

Age 65

Age Tsunami: Baby Boomer born 1953-1958

Estimated Cancer Incidences andCancer Deaths by 2015

45.8% increase in cancer incidences

127,716

154,851

186,244

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Cancer Cases

69,154

80,281

89,934

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Cancer Death

30.0% increase in cancer deaths

2nd 10-Year Plan for Cancer ControlKorea, 2006-2015

40000

45000

50000

55000

60000

65000

70000

75000

80000

85000

90000

1995 2000 2005 2010 2015

Expected Objective

69,154(2005)

89,934(2015)

30.0% ↑

116.7/100,000 94.1

/100,000

19.4% ↓

Cancer mortality reduction

Improvement in 5-years survival rate

2nd 10-Year Plan for Cancer ControlKorea, 2006-2015

17.6% ↑

National Budget for 1st Term NCSP (1996-2005)

Total budget : 579.7 million USD

0

20

40

60

80

100

120

140

160

1995 1997 1999 2001 2003 2005

Prevention

Supportive & Palliative care

Research

Regional Cancer Center

National Cancer Center

20.8 22.9 21.9

33.4

53

40.5

58

45.5

64.269.3

150

USD, million

USD, million

Year

2nd Term Ten-year Plan for National Cancer Control (2006-15)

Total budget : 5.81 billion USD

National budget : 3.48 billion USDHealth promotion fund : 2.33 billion USD

Cancer Prevention for All in Asia

감사합니다!

Thank You for

Your Attention!