TRENDS IN ORAL CANCER MORTALITY IN THE
UNITED STATES, SWEDEN, FRANCE AND HONG KONG, 1950-1980
by
Joseph M. Janis
Lisa Kammerman
Kathleen Edwards
Lawrence L. Kupper
Department of Biostatistics
University of North Carolina at Chapel Hill
Institute of Statistics Mimeo Series No. 1481
February 1985
TRENDS IN ORAL CANCER MORTALITY IN THE
UNITED STATES, SWEDEN, FRANCE AND HONG KONG, 1950-1980
by
Joseph M. Janis, DrPH
Lisa Kammerman, PhD
Kathleen Edwards, MPH
Lawrence L. Kupper, PhD
February 12, 1985
Department of Biostatistics
University of North Carolina
Chapel Hill, North Carolina 27514
TABLE OF CONTENTS
.£AGE
I.
II.
III.
IV.
V.
VI.
Summary
......
1
List of Figures .
List of Tables
3
................
5
Introduction
7
Definition of Oral Cancer •
8
Oral Cancer Mortality in the United States
13
A.
Major Source of Data:
Institute
13
B.
Categories of Mortality Data: Age-..
specific vs. Age-adjusted Rates
National Cancer
13
1) Age-specific Mortality Rates
2) Age-adjusted (Standardized)
Mortality Rates
C.
Oral Cancer Mortality Rates in the. . • • • 15
United States, 1950 to 1980
1) Age-specific Mortality Rate Trends
2) Age-adjusted Mortality Rate Trends
VII.
Comparison of U.S. Oral Cancer Mortality.
Rates with Sweden, Hong Kong, and France
A.
• 22
World Health Organization Mortality Data . • 22
1) Reliability of Oral Cancer Mortality
Data
2) Coding of Neoplasms in WHO Data
B.
Age-specific Mortality Rates.
1)
2)
3)
4)
C.
. . . . . . . 23
Sweden
Hong Kong
France
United States
Age-adjusted Oral Cancer Mortality Rates. • 23
for Sweden, Hong Kong, France and the
United States
VIII.
IX.
X.
XI.
Site-Specific Oral Cancer Mortality Data.
Discussion and Conclusion .
Bibliography • . .
Appendix.
Rates
.....
. • • 33
• • • 34
•
•
• 36
Tables of Age-Specific Mortality • • 38
e-
I.
SUMMARY
The main objective of this study is to examine the
trends of oral cancer mortality rates from 1950 to 1980 for
the United States, France, Sweden and, Hong Kong. For the
purposes of this report, oral cancer is defined as those
neoplasms included in the International Classification of
Diseases (lCD) numbers 140-149. This includes the lip,
tongue, major salivary glands, gum, floor of mouth,
oropharynx, nasopharynx, hypopharynx, and other unspecified
parts of the mouth. A diagram is enclosed (Figure 1) which
shows the location of these sites. Although the lCD
classifications are revised each decade, the trends of oral
cancer shown in this report are not affected since the ICD
general category of oral cancer (ICD numbers 140-149) has
not changed over the period 1950 to 1980. This report
includes both age-specific and age-standardized trends of
oral cancer mortality for males and females of all four
countries1 race-specific mortality trends are also shown for
the United States. Mortality rate data were obtained from
the National Cancer Institute and the World Health
Organization. Although oral cancer morbidity data (numbers
of new cases/ population at risk) were obtained from the
Connecticut Registry, those trends will be shown in the
second report of this series. The major conclusions of the
study thus far are:
1.
Trends of the age-standardized mortality curves for oral
cancer should be supplemented with trends of the agespecific curves, since the former curves alone can be
misleading.
2.
Analogously, trends of the general category of oral
cancer mortality rates (ICD numbers 140-149) should be
supplemented with trends of the site-specific curves
(i.e., essentially the individual ICD numbers), since
collapsing the sites into a general category can mask
important site-specific trends.
3.
In the United States, the age-standardized oral cancer
mortality rate for white males is decreasing slightly
from 1950 to 1980 (see Figure 6). This decrease in the
age-standardized rate is due primarily to a decrease in
the trends of the rates for the older age groups, ages
70 to 84 [see Figure 2(b)]. The trends of the rates of
the middle age groups, ages 45 to 69, are relatively
constant over this time period.
4.
Trends of oral cancer mortality rates of non-white males
in the United States are increasing rapidly relative to
the rates for white males (see Figure 6) .
2
5.
The age-adjusted and age-specific oral cancer mortality
rates from 1950 through 1979 for Hong Kong are
considerably higher than the mortality rate trends of
the United states, Sweden and France, for both males and
females (see Figures 13 and 14).
6.
The oral cancer mortality rate trends are considerably
greater for males as compared to females in Hong Kong,
France and the United states. In Sweden, the male
trends are slightly higher than the female trends (see
Figure 13).
7.
The most significant increase in oral cancer mortality
rates is for French males over the period 1950 to 1980
[see Figure l4(b)].
In 1950, the mortality rates for
both French and United states males were about 100
deaths per million. From 1950 to 1980, while the rates
for United states males stayed at the same level, the
French rate increased with a constant slope to about 400
deaths per million [see Figure l4(b)].
are:
The major recommendations based on this study thus far
1.
Trends of site-specific mortality rates of oral cancer
for each of the four countries should be obtained and
studied for possible etiological clues.
2.
The epidemiological literature on oral cancer indicates
that certain regions in the United states have higher
mortality rates. Data on trends of the rates in various
geographical regions should be obtained and graphed for
comparison purposes.
3.
The French epidemiological literature on oral cancer
should be searched for possible reasons for the dramatic
increase in oral cancer mortality rates for males during
the period 1950-1980.
4.
The Connecticut morbidity rate trends for oral cancer
already obtained should be graphed and studied.
e-
II.
LIST OF FIGURES
FIGURE 1.
LOCATION OF SOME COMMON ORAL CANCER . •
SITES.
FIGURE 2.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) • • . 16
MORTALITY RATES FOR U.S. WHITE MALES,
NUMBER OF DEATHS PER MILLION, AGES 45-84,
1950-1980.
FIGURE 3.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) . • . 17
MORTALITY RATES FOR U.S. WHITE FEMALES,
NUMBER OF DEATHS PER MILLION, AGES 45-84,
1950-1980.
FIGURE 4.
AGE-SPECIFIC ORAL CANCER (ICD 140-149). • • 18
MORTALITY RATES FOR U.S. NON-WHITE MALES,
NUMBER OF DEATHS PER MILLION, AGES 45-84,
1950-1980.
FIGURE 5.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) . • . 19
MORTALITY RATES FOR U.S. NON-WHITE FEMALES,
NUMBER OF DEATHS PER MILLION, AGES 45-84,
1950-1980.
FIGURE 6.
AGE-ADJUSTED ORAL CANCER (ICD 140-149) • • . 21
MORTALITY RATES FOR U.S. WHITE AND NON-WHITE
MALES AND FEMALES, NUMBER OF DEATHS PER
MILLION, 1970 U.S. STANDARD POPULATION,
AGES 35-84, 1950-1980.
FIGURE 7.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) •
24
MORTALITY RATES FOR SWEDEN MALES, NUMBER OF
DEATHS PER MILLION, AGES 45-84, 1950-1979.
FIGURE 8.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) • • • 25
MORTALITY RATES FOR SWEDEN FEMALES, NUMBER
OF DEATHS PER MILLION, AGES 45-84,
1950-1979.
FIGURE 9.
AGE-SPECIFIC ORAL CANCER (ICD 140-149).
26
MORTALITY RATES FOR HONG KONG MALES, NUMBER
OF DEATHS PER MILLION, AGES 45-75+,
1950-1978.
FIGURE 10.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) .
MORTALITY RATES FOR HONG KONG FEMALES,
NUMBER OF DEATHS PER MILLION, AGES 45-75+,
1950-1978.
27
4
FIGURE 11.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) . • . 28
MORTALITY RATES FOR FRANCE MALES, NUMBER
OF DEATHS PER MILLION, AGES 45-84,
1950-1977.
FIGURE 12.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) .
MORTALITY RATES FOR FRANCE FEMALES, NUMBER
OF DEATHS PER MILLION, AGES 45-84,
1950-1977.
FIGURE 13.
AGE-ADJUSTED ORAL CANCER (ICD 140-149) . • • 31
MORTALITY RATES FOR U.S.A., SWEDEN,
HONG KONG, AND FRANCE, MALES AND FEMALES,
1960 STANDARD WORLD POPULATION, NUMBER OF
DEATHS PER MILLION, AGES 35-74, 1950-1979.
(THE FOUR COUNTRIES SHOWN INDIVIDUALLY).
FIGURE 14.
AGE-ADJUSTED ORAL CANCER (ICD 140-149) • • • 32
MORTALITY RATES FOR U.S.A., SWEDEN,
HONG KONG, AND FRANCE, MALES AND FEMALES,
1960 STANDARD WORLD POPULATION, NUMBER OF
DEATHS PER MILLION, AGES 35-74, 1950-1979.
(MALES AND FEMALES SHOWN INDIVIDUALLY).
29
e-
s
III.
LIST
~TABLES
~
TABLE 1.
ORAL CANCER NOMENCLATURE.. • • • • • •
10
TABLE 2.
ICD CODES FOR ORAL CANCER SITES BASED .
ON THE 6TH, 7TH, 8TH AND 9TH REVISIONS
. • 11
TABLE A.l.
ORAL CANCER (ICD 140-149) MORTALITY..
RATES FOR U.S. WHITE MALES, NUMBER OF
DEATHS PER MILLION, AGES 0-85+,
1950-1980.
39
TABLE A.2.
ORAL CANCER (ICD 140-149) MORTALlY . • . . 40
RATES FOR U.S. WHITE FEMALES, NUMBER
OF DEATHS PER MILlON, AGES 0-85+,
1950-1980.
TABLE A.3.
ORAL CANCER (ICD 140-149) MORTALITY . • . • 41
RATES FOR U.S. NON-WHITE MALES,
NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1980.
TABLE A.4.
ORAL CANCER (ICD 140-149) MORTALITY • . • . 42
RATES FOR U.S. NON-WHITE FEMALES,
NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1980.
TABLE A.5.
ORAL CANCER (ICD 140-149) MORTALITY • • • • 43
RATES, SWEDEN MALES, NUMBER OF DEATHS
PER MILLION, AGES 0-85+, 1951-1979.
TABLE A.6.
ORAL CANCER (ICD 140-149) MORTALITY . • . • 44
RATES, SWEDEN FEMALES, NUMBER OF DEATHS
PER MILLION, AGES 0-85+, 1951-1979.
TABLE A.7.
ORAL CANCER (ICD 140-149) MORTALITY • • • • 45
RATES FOR HONG KONG MALES, NUMBER OF
DEATHS PER MILLION, AGES 0-85+,
1961-1978.
TABLE A.8
ORAL CANCER (ICD 140-149) MORTALITY
RATES FOR HONG KONG FEMALES, NUMBER OF
DEATHS PER MILLION, AGES 0-85+,
1961-1978.
TABLE A.9
ORAL CANCER (ICD 140-149) MORTALITY • . • . 47
RATES, FRANCE MALES, NUMBER OF DEATHS
PER MILLION, AGES 0-85+, 1950-1977.
. • 46
6
TABLE A.10. ORAL CANCER (ICD 140-149) MORTALITY • • • • 48
RATES, FRANCE FEMALES, NUMBER OF
DEATHS PER MILLION, AGES 0-85+,
1950-1977.
TABLE A.11. ORAL CANCER (ICD 140-149) MORTALITY • • • • 49
RATES, U.S.A. MALES, NUMBER OF DEATHS
PER MILLION, AGES 0-85+, 1950-1979
(WHITE AND NON-WHITE COMBINED).
TABLE A.12. ORAL CANCER (ICD 140-149) MORTALITY . • • • 50
RATES, U.S.A. FEMALES, NUMBER OF
DEATHS PER MILLION, AGES 0-85+,
1950-1978 (WHITE AND NON-WHITE
COMBINED) .
e-
7
IV.
INTRODUCTION
This study has two objectives:
1) to examine the trends of oral cancer mortality rates
in the United States~ and,
2) to compare the United states oral cancer mortality
trends with those of France, Sweden and Hong Kong.
The present study is the first stage of a continuing
project which will review the literature of oral cancer,
investigate trends in oral cancer mortality and morbidity
data, and address the possible etiological factors of this
disease. As of the time of this report, there are a number
of general reviews of oral cancer published in the
epidemiological literature [Smith (1979), Pindborg (1980),
Winn (1980) and Mahboudi and Sayed (1982)]. However, none
of these reviews identifies research that analyzes the
trends of oral cancer mortality or morbidity rates either in
the U.S. or in other countries. In the present report, only
mortality rate trends will be presented, although a
preliminary report of work done on Connecticut morbidity
rates will be made.
Oral cancer mortality trends in the United States are
of obvious national interest in this country. With regard
to comparing United states rates to those of other
countries, France and Hong Kong were chosen for their
reported high mortality rates, and Sweden for its low rates
[Mahboudi and Sayed (1982), Winn (1980)]. Data were
obtained from three major sources: the National Cancer
Institute, the Connecticut Cancer Registry, and the World
Health Organization. The data frOm these sources will be
discussed later in this report.
v.
DEFINITION
or
OBAL CANCER
The term "oral cancer" is defined in this report to
include those malignant neoplasms which are categorized by
the International Classification of Disease (lCD) codes as
rCD numbers 140 through 149, inclusive. Since the time
trends in this report encompass the years 1950 to 1980, four
revisions of the lCD code are included [World Health
Organization, 6th revision (1947), 7th revision (1957), 8th
revision (1967), and 9th revision (1977)].
Locations of the major sites of oral cancer and their
proximity to the sites of cancers of the larynx and
esophagus are shown in Figure 1. Table 1 gives the lCD Code
(9th Revision) of the oral cancer sites, and some of the
important phrases used in the oral cancer literature. The
pharynx is broken down into 1) the nasopharynx (ICD 147) ,
which is close to the nasal passages; 2) the oropharynx (lCD
146), which is close to the mouth; and 3) the hypopharynx
(ICD 148), which is close to the throat. The oral (buccal)
cavity pertains to the entire mouth. Literally, "buccal"
refers to the cheek, but is commonly used when referring to
the entire oral cavity. In the 6th, 7th, 8th and 9th
revisions of the ICD Code, ICD Numbers 140-149 include the
entire oral cavity site; however, many researchers prefer to
consider cancers of the lip (ICD 140), and the nasopharynx
(ICD 147) separately because of their connections with
existing etiological factors. Cancer of the lip has been
associated with exposure to the sun [Mahboudi, (1977)], and
cancer of the nasopharynx has a possible genetic causal
component since it is primarily found in Chinese populations
(Simons, et a1. 1976). The term "pharyngeal" is used as
pertaining to the pharynx; since the pharynx is an integral
part of the oral cancer site, some researchers prefer the
more inclusive term "oral and pharyngeal cancers" when
relating to oral cancer. Other important terms are "mucosa"
and "gingiva", pertaining to the lining of the mouth, and to
the gums, respectively.
For the period covered by this study, 1950 to 1980,
there were numerous changes in the classification of
specific oral cancer sites over the four revisions which
took place during this period (6th, 7th, 8th and 9th
revisions). These changes can be seen by reference to Table
2. ICD CODES FOR ORAL CANCER SITES BASED ON THE 6TH, 7TH,
8TH, AND 9TH REVISIONS. This table was adapted from the lCD
revisions of the World Health Organization (1948, 1957,
1967, 1977), and the NCI monograph #59 by McKay, Hanson and
Miller (1982). The specific oral cancer sites in column (1)
and the descriptive comments in column (2) were taken from
the NCI reference. Note that the major changes took place
between the 7th and 8th revision; there was very little
e-
9
ORAL (BUCCAL)
CAVITY
OROPHARYNX
ESOPHAGUS
BACK WALL OF PHARYNX
(OROPHARYNX)
FTmlRE I.
REFERENCE:
LOCATION OF SOME COMMON ORAL CANCER SITES
Figure adapted from drawings by F. Netter, M.D., Copyright
CIBA Corporation.
10
TABLE 1.
ORAL CANCER NOMENCLATURE
MALIGNANT NEOPLASM OF LIP,
ORAL CAVITY AND PHARYNX.
1) LIP.
2)
3)
4)
5)
6)
7)
8)
9)
10)
. .
.
.
.
.
.
.
. ..
lCD CODE
(NINTH REVISION)
ICD 140-149
. . . . . . 140
TONGUE • . • . • • • • • • • . • • • . • • 141
MAJOR SALIVARY GLANDS • • • • • . • . • • . 142
GUM • . • • • • • • . •
• .143
FLOOR OF MOUTH • • • • • • . • • ••
.144
OTHER AND UNSPECIFIED PARTS OF MOUTH. • • .145
OROPHARYNX • • • . • • • • • • • ••
.146
NASOPHARYNX . • • • . • • • • • • • • • . .147
HYPOPHARYNX • • . • • • • • . • • . • • • • 148
OTHER AND ILL-DEFINED SITES WITHIN THE LIP,
ORAL CAVITY AND PHARYNX . • • . • . • • • 149
SOME COMMON ORAL CANCER TERMS
PHARYNGEAL:
LARYNGEAL:
Pertaining to the pharynx
Pertaining to the larynx
ESOPHAGEAL:
Pertaining to the esophagus
BUCCAL:
Literally refers to the cheek, but commonly
used when referring to the entire oral
cavity.
MUCOSA:
Lining of the mouth
GINGIVA:
Pertaining to the gums
PHRASES:
Oral and Pharyngeal Cancer
Cancer of the Buccal Cavity
Cancer of the Buccal Mucosa
•REFERENCE:
World Health Organization (1977).
•
TABLE 2.
ORAL CANCER
SITES
leD CODES FOR ORAL CANCER SITES BASED ON '!BE 6TH, 7TH, 8TH, AND 9TH REVISIONS
DESCRIPTIVE COMMENTS
6TH REVISION
(1948)
RANGE OF ICD CODES
7TH REVISION
8TH REVISION
(1957)
(1967)
9TH REVISION
(1977)
1.
LIP
Includes lip and mucous
membrane of the lip
(except skin of the lip).
140
140-140.9
140-140 .9
140-140.9
2.
TONGUE
Includes tongue only.
141
141-141.9
141-141.9
141-141.9
3.
SALIVARY GLANDS
Includes parotid, sublingual, submaxillary,
and salivary glands.
142-142.1
142-142.9
142-142.9
142-142.9
4•
FLOOR OF MOUTH
Includes floor of mouth
and lower gum.
143
143
143.1, 144
143.1, 144
5•
ORAL MESOPHARYNX
Includes tonsils,
epiglottis, and oropharynx.
145
145-145.9
146-146.9
146-146.9
6.
NASOPHARYNX
Includes adenoid tissue,
lymph-adenoid tissue, and
pharyngeal bursa.
146
146
147
147
7.
HYPOPHARYNX
Includes postcricoid region
and the p-vriform fossa.
147
147
148-148.9
148-148.9
8.
PHARYNX UNSPECIFIED
Includes throat and pharynx.
148
148
149
149
9.
OTHER AND UNSPECIFIED
PflRTS OF TIl E mUTH
144
144
145-145.9
145-145.9
140-148
140-148
140-149
140-149
10.
BUCCAL CAVITY PLUS
ORAL PHARYNX
REFERENCE:
Includes all of the above.
World Health Organization (1948,1957,1967,1977), McKay, Hanson and Miller (1982).
......
12
change between the 6th and 7th revisions, and no discernible
changes between the 8th and 9th revisions. The importance
of Table 2 for this study is that the combined oral cancer
sites, BUCCAL CAVITY PLUS ORAL PHARYNX, did not change over
the four revisions. Thus, a general oral cancer category
encompassing ICD numbers 140-149 includes all of the oral
cancer sites for each of the four revisions. In this
report, we will only be investigating trends of this more
general oral cancer category over time, and thus our present
study is unaffected by the lCD revisions. However, in our
second report, which will look at the trends for specific
oral cancer sites, the ICD revisions will need to be
considered.
e-
13
VI.
A.
ORAL CANCER MORTALITY
Major Source of Data:
IN-~UNITED
STATES
National Cancer Institute
Mortality data for oral cancer in the u.S. were
obtained from the National Cancer Institute (NCI).
Mortality rates for the years 1950 to 1980 were obtained
from a data tape supplied by F. W. McKay of the NCI [McKay,
Hanson, and Miller (1982)], this tape gives the latest data
published. These data include the mortality rates for the
years 1950-1977, which are also found in NCI Monograph No.
59. The original data were obtained from death certificates
by the National Center for Health Statistics, and were then
arranged in publishable form by NCI.
B.
Categories of Mortality Data:
Adjusted Rates
Age-Specific vs. Age-
The oral cancer mortality data given by NCI are
categorized by sex (male and female), by race (white and
non-white), by age (0 to 85+), by year (1950 to 1980), and
by ICD codes (140 to 149). The graphs presented here will
display each of these important variables. As mentioned
previously, the lCD codes 140 to 149 are combined and
treated as a single category of oral cancer.
1.
Age-Specific Mortality Rates
To show the trends of oral cancer mortality rates in
the United States ove~ time, age-specific rates are plotted
by sex and race from 1950 to 1980. The term "age-specific"
is used to indicate "specific" bands of five-year age
groups. Although the data are originally obtained from
death certificates for each individual year of age, they are
collapsed over five-year age ranges for brevity. Also,
although the oral cancer data are obtained from birth to age
85+, the data of interest are in the middle age and older
age groups. Therefore, the graphs for the U.S. and Sweden
will present the oral cancer mortality data in five-year age
bands from 45-49 to 80-84. Because of the higher rates in
Hong Kong and France, five-year age bands from a wider age
interval, 25-29 to 84 are presented. The final category,
age 85+, is deleted, primarily because the data which make
up this oldest age category are relatively unreliable.
2.
Age-Adjusted Mortality Rates
Although age-specific graphs over time can show
important trends, a large number of plots are needed. For
example, it takes eight curves to show the trends from ages
45-49 to 80-84 over the time period 1950 to 1980.
Comparisons of trends ,between males and females, between
14
whites and non-whites, and among countries become quite
cumbersome under these conditions. Thus, it is necessary to
summarize these curves through a process of age-adjustment
(also called age-standardization). Besides summarizing a
large number of curves into a single curve for clarity
purposes, an age-adjustment process is used to standardize
for differences in age distribution when comparing two
groups. (For details, please refer to Kleinbaum, Kupper and
Morgenstern (1981». By using a standard population such as
the 1970 u.s. population, the oral cancer mortality trends
of u.s. males and females can be adjusted for their
differences in age composition, and thus can be more
equitably compared. In this report, when comparing the
mortality trends of any of the groups, two important
criteria will be met:
1) the same standard population will be used to obtain
the age-standardized curves; and,
2) the same age range will be used to obtain these
curves.
This latter criterion, which concerns the same age
range of the comparison groups, needs clarification. For
many diseases, mortality data are obtained over the age
range 0 to 85+. However, the entire age range may not be
applicable to the study or some data may be missing. As
mentioned previously, oral cancer generally occurs in middle
age or older popUlations. Thus, a choice can be made to
standardize over the range age 35 and above, or over any
other age range. As long as both groups are standardized
over the same age range, a comparison can be made,
providing, of course, that the same standard popUlation is
used.
TO summarize, the mortality trends in this report are
presented in two forms: 1) an age-specific form, and 2) an
age-standardized form. The age-specific form contains many
curves and thus it becomes cumbersome to use when comparing
groups. The age-standardized form compresses the agespecific graphs into one summary curve which makes
comparisons easier. As with any summary measure, however,
some information is lost and this must be taken into
consideration when interpreting the results. For example,
important variations in age-specific plots will be
suppressed. Finally, when two or more groups are compared
in this report, the same standard popUlation and the same
age range are used to obtain the comparison curves.
The next section in this report investigates the agespecific oral cancer mortality rate trends of u.s. white and
non-white males and females, followed by a section in which
the age-standardized trends are compared for the same
categories.
e-
15
C.
Oral Cancer Mortality Rates in the U.S., 1950 to 1980
1.
Age-Specific Mortality Rate Trends
Figures 2(a) and 2(b) show the age-specific mortality
rate trends of oral cancer for U.S. white males from 1950 to
1980. The mortality rate data used in these graphs are
listed in Table A.l in the Appendix (which contains listings
of the data for all of the graphs shown in this report).
Figure 2(a) shows the curves of the four age groups from 4549 to 60-64, and Figure 2(b) shows the curves of the older
age-groups from 65-69 to 80-84. The mortality rate scale is
the same in both graphs (namely, number of deaths per
million); however, the scale for Figure 2(a) extends from 0
to 500, while that for Figure 2(b) extends from 200 to 700
to encompass the larger rates at the older ages. The trends
in Figure 2(a) are relatively smooth and constant, while
those in Figure 2(b) are more erratic. The trends
representing the two oldest age groups in Figure 2(b), 75-79
and 80-84, are clearly decreasing over time, in contrast to
the relatively constant trends for the other age groups.
Some of the differences in the trends among the age groups
may be caused by less than reliable data. Mortality rate
data for older populations are generally considered to be
less reliable than for younger populations. This is true
both for the number of deaths reported as well as for the
estimates of the population sizes of these age groups.
Figures 3(a) and 3(b) and Table A.2 show oral cancer
mortality rate trends for U.S. white females. The curves in
Figures 3(a) and 3(b) cover the same age ranges as those for
white males in Figures 2(a) and 2(b), but the mortality rate
scale for u.s. white females extends over a smaller range (0
to 200) than the males (0 to 500 and 200 to 700) •
Comparing Figures 3(a) and 3(b), the trends for the older
female age groups are more erratic than for their younger
counterparts. This is analogous to the erratic trends in
the rates of the older male age groups. Also, in contrast
to the constant slopes for the male mortality trends among
younger age groups, some of the female mortality curves
roughly suggest an increasing trend over time.
The next four graphs, Figures 4(a) and 4(b), and 5(a)
and 5(b), and two tables, Table A.3 and Table A.4, show the
age-specific mortality rate trends for U.s. non-white males
and females, respectively. In Figures 4(a) and 4(b), the
trends for the non-white males show a definite increase from
1950 to 1980 in all age groups. This increase did not occur
in the white male trends. In fact, as pointed out
previously, some of the trends in the older age groups for
white males, Figure 2(b), reflect a decrease over time. The
mortality rate trends for the younger non-white females in
Figure 5(a) show an increase, but this does not seem to be
16
AGE-SPECIFIC ORAL CANCER (lCD 140-149) HORTALITY RATES FOR U. S.
WHITE MALES, NO. OF DEATHS PER MILLION, AGES 45-84, 1950-1980.
FIGURE 2.
FIGURE 2 (a).
MIDDLE AGE GROUPS, 45-64
....,---------------------------"1
500
400
o
o
o
oo
JOO
o
~
.......
Vl
J:
~
w
200
a
""
100
..........-,..._r_~,......,._.....__._...._'T""'""".._._....,...-.....~..--._,_-.--
0+-~
1950
o
1955
~5-4c)
+
1960
1965
50-54
YEAR
o
FIGURE 2(b).
........_r--~....__1
1970
55-59
OLDER AGE GROUPS,
1975
d
1980
60-64
65-84
700....,-------------------------,
600
o
o
q
g
500 -
q
-.......
Vl
J:
~
w
400
a
""
JOO
200 -h~~~,_,..........--.-....-.,.__,......,.-.....-.-_r_..........-.-~_._~ ........--.-........-...--.--.-...,
1975
1980
1950
1955
1960
1965
1970
o
REFERENCE:
65-69
+
70-74
MCKAY, HANSON AND MILLER
YEAR
o
(1982).
75-79
d
eO-84
e-
17
FIGURE 3.
AGE-SPEClrIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR U.S.
WHITE FEMALES, NUMBER or DEATHS PER MILLION, AGES 45-84, 1950-1980.
PIGURE 3(a).
MIDDLE AGE GROUPS, 45-64
-r--------------------------,
o
8
o
&
..
"
VI
1:
200
190
1 8CJ 17CJ
160
150
140
lJO
120
110
100
90
S
o
.... ~~
~~=
40 ..
, )
·~0
i.
..... , .... ~~
... 1 · .......,_~._A
zel ..•.•
10
~'~. tL--+--
J/-Q..'V'
o ..
~
.~lr-t.--A.. .~*:.q........
_"(l.•• ""-tr~~/v~
-"'-_/, .. 11<
-~.. • ~ ':" ~
-+--,/ '-t-~'
-A
_~.·~.b.~
-i3-e-·u-~-
I-,._...--.-_.._-.,.--.-~..__...._r__.__...,...~...._......_
1950
1955
1960
+
FIGURE 3(b).
50-54
1965
YEAR
o
-
,+--.. _.+-t-~
.....
'uA.~"'.......-a...._ (
- - --v-I-B-er~1
........__T_..__.._...._...._...___.___.._..._............__l
1970
1975
1980
1975
1980
55-59
OLDER AGE GROUPS, 65-84
o
o
o
o
o
.-q.....
VI
.....1:
{
W
[\
-,
~(J -
20 ..
In 1950
1960
1955
+
REFERENCE :
1965
YEAR
70-74
o
MCKAY, IIANSON AND MILLER (1982).
1970
75-79
.1
80-84
18
FIGURE 4.
AGE-SPECIFIC ORAL CANCER (lCD 140-149) MORTALITY RATES FOR U. S.
NON-WHITE MALES, NUMBER OF DEATHS PER MILLION, AGES 45-84, 1950-1980.
FIGURE 4 (a) .
MIDDLE AGE GROUPS, 45-64
500 . . . - - - - - - - - - - - - - - - - - - - - - - - - - ,
400
a
a
o.
a
a
q
300
........
U1
I
r-
~
200
0
'It:
100
O+-.,..--,.........-.--,-.....-.--.--r-.-....-...-..,.........-.....-.....-........--,--..-....-...-.-,--...--.-.,...........;
o
1960
1955
1950
45-49
+
FIGURE 4(b).
50-54
1965
YEAR
o
1975
1970
55-59
A
1980
60-64
OLDER AGE GROUPS, 65-84
500 . , - - - - - - - - - - - - - - - - - - - - - - - - - ,
400
a
a
0
a
0
300
q
........
U1
:I:
3
200
0
'It:
100
O+-..--.,.........--.--,-...,................-.--.-....-..--.---r-r--.-.,.....,........--ro..,........-....-.--r-.--.-...-........-1
1950
c
REFERENCE:
65-69
1955
1960
+
70-74
1965
YEAR
o
MCKAY, HANSON AND MILLER (1982).
11il75
1970
75-79
A
80-84
11il80
e-
19
FIGURE 5.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR U.S.
NON-WHITE FEMALES. NUMBER OF DEATHS PER MILLION. AGES 45-84, 1950-1980.
FIGURE 5(a).
MIDDLE AGE GROUPS, 45-64
200 190
181) .
,.,0
160
l~n
IJ
14·0··
1 .~I) -
0
171) ."
"'VI
1UI) .
90
0
0
f)
,~
:r:
l-
L.'i
1 I Ij
-
eo
0
70
'Ito
(Jr)
\
flr) .
""0
./
30 ..:
LO
10
0
1950
,
'-'
1955
-1.!:" . 4"
II
•
I
•
1960
t
FIGURE 5(b).
50-54
•
•
I
•
1965
YEAR
o
,
I
•
1970
1975
1980
55-59
OLDER AGE GROUPS. 65-84
200 . . , . . - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
190
180
170
160
1~0
o
o
o
oo
-
140
130
120
q
110
~
100
90
80
70
60
8
o
'II::
~o
40
30
20
10
O-f-..--.........-.-...,-.....................,-,.-......-.--r............-."""""'-r...--........--...---r-.-...-..--.-\
1950
C
REFERENCE:
6~-69
1955
+
1960
1965
70-74
YEAR
o
MCKAY, IIANSON AND MILLER (1982).
1970
7~-79
1975
A
80-84
1980
20
the case for the older non-white females in Figure 5(b).
The curves in Figures 5(a) and 5(b) are so erratic that it
is difficult to make any definitive statements regarding
trends.
2.
Age-Adjusted Mortality Rate Trends
The above eight gr'aphs show the age-specific mortality
rate trends in oral cancer for U.S. males and females of
both races. For clarity, all of these curves can be
summarized into one graph by use of the age-standardized
techniques discussed earlier. Figure 6 shows the ageadjusted curves which compare the oral cancer mortality rate
trends for U.s. white and non-white males and females. The
1970 U.s. population was used to standardize over the age
range of 35 to 84 years. The curves in Figure 6 reflect a
definite increase in the oral cancer mortality rate trend
for non-white males from 1950 to 1980, and a possible small
decrease for white males over the same time period. The
trends for both white and non-white females appear to be
increasing very slightly. Trends in the age-adjusted curves
are generally consistent with trends in the age-specific
curves; however there are some differences, especially in
the trends for white males, which will be discussed later in
this report.
21
FIGURE 6.
AGE-ADJUSTED ORAL CANCER CICD 140-149) MORTALITY RATES FOR U.S.
WHITE AND NON-WHITE MALES AND FEMALES, NUMBER OF DEATHS PER MILLION,
1970 U.S. STANDARD POPULATION, AGES 35-84, 1950-1980.
300
280
260
240
220
0
0
0
0
0
0
........
V)
200
180
160
140
J:
I-
120
0
100
~
=II:':
80
60
40
20
0
1950
1955
W-FEMALE
+
1960
1970
1965
1975
1980
YEAR
Cl
REFERENCE:
NW-FEMALE
MCKAY, HANSON AND MILLER (1982).
0
W-MALE
Ii.
NW-MALE
22
VII.
A.
COMPARISON OF UNITED STATES ORAL CANCER MQRTALITX
RATES WITH SWEDEN, HONG KONG, AND FRANCE
World Health Organization Mortality Data
In the first part of this study, mortality data for the
U.s. population were obtained from the National Cancer
Institute since they were available in a detailed format
(i.e., age, race and sex specific) and covered the time
frame 1950 to 1980. For comparison of the U.s. mortality
rates with those of other countries, data from the World
Health Organization (WHO) were used [World Health
Organization (1983)]. The WHO has assembled oral cancer
mortality data for most of the countries of the world; only
data for the less developed countries, and for some of the
Eastern Communist Bloc nations, are not tabulated by WHO.
1.
Reliability of Oral Cancer Mortality Data
The reliability of the WHO data varies considerably
with the country of origin, although an attempt has been
made to maintain as high a standard for reporting as is
possible under the circumstances. As of now, mortality data
are generally available from 1950 to 1980. Some data are
missing, however. For example, oral cancer mortality data
for the years 1950 to 1959 are missing for Hong Kong, one of
the countries we will be investigating. Most of the oral
cancer data are available, however, for the remaining three
countries under consideration, namely, the United States,
Sweden, and France.
2.
Coding of Neoplasms in WHO Data
Neoplasms in the WHO data are coded into A and B lists.
The A list contains ICD Revision numbers of the Sixth
(1948), Seventh (1957), and Eighth (1967) Revisions, while
the B list contains only the Ninth Revision (1977). The A
list combines the ICD codes 140-149 into a single category
for oral cancer called Buccal Cavity and Oral Pharynx. In
the present study, we will use only the A list because it
covers a broader time span and uses the single oral cancer
category.
To compare the oral cancer mortality rate trends of the
four countries, both age-specific and age-adjusted rates
will be used for each country, in a manner similar to that
used for the United States in a previous section of this
report. The age-specific rates for males and females for
each country will be shown first, followed by a comparison
of the age-adjusted rates. A brief commentary will then be
made describing the trends for each country; a more detailed
discussion will be given later.
B.
Age-Specific Mortality Rates
1.
Sweden
The age-specific mortality rate trends for oral cancer
in Sweden for males are shown in Figures 7(a) and 7(b) and
Table A.5, and for females in Figures 8(a) and 8(b) and
Table A.6. The age range is from 45 to 84 in five-year
groups1 the time range is from 1951 to 1979 in single years.
The trends for the younger ages (45 to 64) are roughly
constant. The trends for the older ages (65 to 84) in both
sexes are quite unstable, and it is impossible to detect any
patterns.
2.
Hong Kong
Figures 9(a), (b) and (c) and Table A.7 show the agespecific mortality rate trends for Hong Kong males. The
three graphs cover ages 25 to 84 from 1961 to 1978. The
same format is used to show the trends for females in
Figures 10(a), (b) and (c) and Table A.8. Again, data for
the older ages show considerable variability, but the trends
seem to be roughly constant over time.
3.
France
The age-specific curves for French males are shown in
Figures ll(a), (b) and (c) and Table A.9. In contrast to
the comparable curves for Sweden and Hong Kong, these show a
distinctly increasing trend for all 5-year age groups from
35-39 to 80-84. This unexpected and important finding will
be discussed further in a later section. Although the agespecific curves for French females in Figures l2(a), (b) and
(c) and Table A.lO also show an increasing rate, it is small
compared to the rate of increase shown for the French males.
4.
United states
The age-specific and race-specific curves for males and
females in the U.S. have already been shown in Figures 2(a)
and (b), 3 (a) and (b), 4 (a) and (b), and 5 (a) and (b). The
age-specific data obtained from the World Health
Organization for U.s. males and females (comparable to the
data for Sweden, Hong Kong and France) are shown in Table
A.ll. The United States data obtained from the WHO are the
same data published by the National Cancer Institute, but
the WHO data is not race-specific.
C.
Age-Adjusted Oral Cancer Mortality Rates for Sweden,
Hong Kong, France and the United States
A comparison of the mortality rate trends for males and
females among the four countries are shown in Figures 13 and
24
FIGURE 7.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR SWEDEN
MALES, NUMBER OF DEATHS PER MILLION, AGES 45-84, 1950-1979.
FIGURE 7(a).
MIDDLE AGE GROUPS, 45-64
500,------------------------.,
•
400 0
0
0
0
0
300
~
.........
If)
:r:
~
-t.:
W
0
200 -
...
100
0
45-49
11,)63
1959
1955
50-54
+
'967
YEAR
11,)7'
~5-59
0
'975
4
'971,)
60-64
OLDER AGE GROUPS, 65-84
FIGURE 7(b).
500 - - . - - - - - - - - - - - - - - - - - - - - - - - - - ,
o
o
0:>
o
o
o
."
If)
r
t-
<t:
W
o
"'"
0-
1951
o
REFERENCE:
•
•
I
i i i
I
1955
65-69
I
1959
+
70-7~
1963
'967
YEAR
o
WORLD HEALTI1 ORGANIZATION (1983).
7~-79
U7,
1975
4
80-8~
1979
25
FIGURE 8.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR SWEDEN
FEMALES, NUMBER OF DEATHS PER MILLION, AGES 45-84, 1950-1979.
FIGURE Sea).
MIDDLE AGE GROUPS, 45-64
500 - , - - - - - - - - - - - - - - - - - - - - - - - - ,
400 -
o
o
,:;,
g
JOO -
q
vi
~
'.
I.lJ
...
o
200 -
100
1959
o
4-5-4-9
+
1963
50-54-
FIGURE 8(b).
1967
YEAR
0
1971
55-59
1975
4
1979
60-64-
OLDER AGE GROUPS, 65-84
500 - , - - - - - - - - - - - - - - - - - - - - - - - - - ,
400
0
0
0
0
0
q
-
JOO
......
II)
:r
~
i0JJ
...
100
..........,._......-...-._,_.........-.-......-_r_""'.........--.-.,_....-~~
O+-~...--.._,_-.--...-r_"-....
1951
o
REFERENCE:
1955
65-69
1959
+
70-7 ...
1963
1967
YEAR
o
WORLD IIEALTH ORGANIZATION (1983).
75-79
1975
1971
4
80-84-
1979
26
FIGURE 9.
AGE-SPECIFIC ORAL CANCER (lCD 140-149) MORTALITY RATES FOR 1I0NG KONG
MALES, NUMBER OF DEATHS PER MILLION, AGES 45-75+, 1950-1978.
FIGURE 9(a). YOUNGER AGE GROUPS, 25-44
"00
UOO
1100
,....
-
0
8
'00
0
-
~
'00
"on
:r
3
..
500
0
100
'GO
100
100
•
'90&
leel
+
2~-29
D
FIGURE 9(b).
1909
JO-J.
197~
197J
"tEAR
•
A
J&-~9
.0-••
MIDDLE AGE GROUPS, 45-64
"00
..O'!
UOO
1100
0
8
0
~
Z
III
,-
-
'oo
-.
,eo
3 ...
.
0
.....
~
...
,..
0
•
~-.9
+
FIGURE 9 (c) .
,
...
1909
190&
leel
~O-ll.
"tEAR
•
eO-09
A
eo-e.
OLDER AGE GROUPS, 65-75+
o
~
"-
vi
3
..
o
•
REFERENCE:
."77
19U
WORLD HEALTH ORGANIZATION (1983).
71+
27
FIGURE 10.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR HONG KONG
FEMALES, NUMBER OF DEATHS PER MILLION, AGES 45-75+, 1950-1978.
FIGURE 10(a).
YOUNGER AGE GROUPS, 25-44
!i00 . , . - - - - - - - - - - - - - - . ; - - - - - -
400
0
8
,&
5
..
0
.100
VI
:r
200
0
100
ls.e~
ls.e!i
a
Z!i-Zs.
+
FIGURE 10(b).
30-34
1S.13
YEAR
0
35-39
',.11
A
40-44
MIDDLE AGE GROUPS, 45-64
!i00 . . . - - - - - - - - - - - - - - - - - - - _ - .
400
o
8
~
.100
3
o
zoo
~
x
.
100
, 0 +-~-.-__.-.__-~-.-___r--..-__r__._--_~_._-l
uel
ue9
A eo-e4
PIGURE 10(e).
OLDER AGE GROUPS, 65-75+
!i00
400
0
8
0
&
VI'
....r
....0...
..
200
100
O+-.....-_........--,-...-...-_-.-_........--._.--...--.-.....---.--l
Il1el
REFERENCE:
WORLD HEALTH ORGANIZATION (1983).
U1J
11111
28
FIGURE 11.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR FRANCE
MALES, NUMBER OF DEATHS PER MILLION, AGES 45-84, 1950-1977.
FIGURE
11(a).
700...,-----
YOUNGER AGE GROUPS, 25-44
1100
0
~oo
8
<:>
0
q
400
.
....
JOO
,
vi
I
..
«
0
200
100
0
11150
19~+
1ll~1!I
2~-29
0
+
FIGURE 11 (b) .
30-34
19112
191111
YEAR
•
1970
..
3&-39
197+
40- ....
MIDDLE AGE GROUPS, 45-64
700
1100
0
0
0
<:>
~OO
~
.:::..
400
:I:
300
II)
3
..
0
200
100
0
19~0
0
18&4
+~-+9
111511
+
FIGURE !l(e).
&0-5+
191111
leU
YEAR
•
5&-59
1970
.
187..
eo-e..
OLDER AGE GROUPS, 65-84
900
1100
0
0
0
<:>
700
~
1100
"':<
500
II)
:I:
.
w
0
+00
300
200
19~0
0
REFERENCE:
19&4
ti~-t.9
le~lI
+
70-7"
1ge1l
1902
YEAR
•
7&-7e
WORLD HEALTH ORGANIZATION (1983) .
1970
..
1117+
eO-II+
-,
29
FIGURE 12.
AGE-SPECIFIC ORAL CANCER (ICD 140-149) MORTALITY RATES FOR FRANCE
FEMALES, NUMBER OF DEATHS PER MILLION, AGES 45-84, 1950-1977.
FIGURE 12(a).
YOUNGER AGE GROUPS, 25-44
140
I~:)
140
'30
120
::>
~
"0
~
'-:x:
II'
§
--
1IoJ
'00
\)0
eo
70
eo
!>c
40
30
20
10
0 ~-IU+
,"0
Q
IIl&lI
30-34
Z&-ZP
FIGURE 12(b).
IIlU
Illeo
YEAR
•
11170
,)6-,)11
A
1117+
.0-4.
MIDDLE AGE GROUPS, 45-64
leo
0
8
<:>
~
"~
II'
'"
Q
--
160
140
130
IZO
110
100
110
1I0
70
00
60
40
30
20
10
0
Ill~O
0
11111+
4&-411
FH~lJRE
150
140
IU8
+
12(c).
50-&+
IIlU
neo
YEAR
•
1170
5&-&11
A
1117+
eo-04
OLDER AGE GROUPS, 65-84
130
120
1\0
0
8
100
"II'
1I0
70
~
~
'"'"
Q
--
110
eo
&0
40
30
20
10
0
11150
Des-ell
REFERENCE:
+
70-74
YEAR
•
75-711
WORLD HEALTH ORGANIZATION (1983).
A
80-84
30
14. In Figure 13, four graphs are shown, each comparing the
male and female mortality rate trends for the respective
countries. The same mortality rate scale is used for each
of the four graphs. In Figure 14, these same data are shown
in two additional graphs: Figure l4(a), which compares the
female rate trends in the four countries; and Figure l4(b),
which compares the male trends. The scales in the latter
two graphs are different (0 to 200 versus 0 to 600) because
the male rates are considerably greater than the female
rates. The 1960 Standard World Population [Doll, Payne, and
Waterhouse (1966) based upon Segi (1960)], and the age range
of 35 to 74, were used to standardize the rates for each
country. The age range was truncated at age 74 because of
incomplete data in some of the countries.
The standardized mortality rate for Hong Kong males is
the highest of the group (roughly 450 deaths per million);
it is considerably higher than the rate both for United
States males (about 100 deaths per million) and for Swedish
males (about 50 deaths per million). The trend for the
French males, however, is increasing at a relatively rapid
rate, so that the later years (1976, 1977) show a rate
(around 400 deaths per million) nearly as large as that for
Hong Kong males (450 deaths per million). The mortality
rate for Hong Kong females (150 deaths per million) is also
considerably higher than the female rates for the other
countries (U.S.: 20-30 deaths per million; Sweden: 20-40
deaths per million (decreasing); France: 10-20 deaths per
million). In each country, the male rate is considerably
higher than the corresponding female rate, except in Sweden.
There, the male-female rates in the early 1950's were about
the same. Since then, the Swedish female rate has declined
slightly, while the male rate has stayed relatively
constant. The contrast between male and female rates is
most noticeable in France, where the male rate is increasing
at a much more rapid pace than the female rate.
FIGURE 13.
0
0
0
AGE-ADJUSTED ORAL Ck~CER (ICD 140-149) MORTALITY RATES FOR U.S.A., SWEDEN, HONG KONG, AND F~~CE,
MALES AND FE~~LES, 1960 STANDARD WORLD POPULATION, NUMBER OF DEATHS PER MILLIO~, AGES 35-74, 1950-1979.
800
800
500
500
0
0
400
g
400
300
~
300
g
ct
"-:r
VI
ct
....
..
..~
~
a
a
200
looL
o
200
~
100
~
: : : : : : : : : : : : : : : : : : : : : : : : : : : :
1II so
11155
IlIlIO
11165
11170
11175
D
MALES
~
J::~::
I
ll1SO
Ill"
I"EIoW.LS
D
--
-
......... ---
- ---
'.110
MALES
11170
11185
~
11175
f'EMALES
JJ
~
FIGURE 13Ca).
0
0
0
U.S.A.
FIGURE 13 Cb) •
800
800
500
500
0
0
0
400
00
400
00
ct
q
5.
300
..
200
"-
300
a
200
VI
~
~
a
SWEDE~
..~
100
0
1950
100
11155
1960
D
IlALES
FIGURE 13(c).
1965
YEAR
+
1970
F'ENALES
HONG KONG
11175
0
11150
11160
11155
D
MALES
FIGURE 13 Cd) •
1965
~
1970
FDlALES
FRANCE
1975
32
FIGURE
14.
AGE-STANDARDIZED ORAL CANCER (Tcn 140-149) MORTALTTY RATES FOR U.S.A.,
SWEDEN, HONG KONG, AND FRANC):, MALES AND PEMAI.ES, 1960 STANDARD
WORLD POPULATION, NUMBER OF DEATHS PER MT I.L TON, ACJ:S 35-74, 1950-] 979.
f;IGURE
200
190
180
170
160
150
°
g
g
°
"
~
14(a).
COMPARISON OF FEMALE RATES
--------_._-----
-----------
140
130
120
110
100
90
~
80
70
60
50
o
~
40
30
20
~
10 ..dr-~e___l't"-"'--e--a---e--
o
, ,
1950
I
I
1955
1'----.--...---'....-,.,---.-,-r-,~~'--'-'-,-,-r,-'--'-"""'-r-->""""'--'-"""
1960
1965
1970
1975
YEAR
o
+
FRANCE
FIGURE
14(b).
HONG KONG
<>
SWEDEN
/1
USA
COMPARISON OF MALE RATES
600
500
°°
°
400
r~
0
0
o.
~
'"
/
300
VJ
I
~0
~
200
O-+-....._..--..--.--r--,--.--_._-.-~,.---,,......,.--.-_r-.--r-...--...._,r_r--r-.,...-.-..,_.....-..--...-I
1950
o
REFERENCE:
1955
1960
1965
1970
1975
YEAR
FRANCE
+
HONG KONG
WORLD HEALTH ORGANIZATION (1983).
<>
SWEDEN
Ii
USA
e-
33
VIII.
SITE-SP~CIFIC
ORAL CANCER MORTALITY DATA
As discussed earlier, all of the mortality rate trends
shown in this report are those of the general category of
oral cancer, ICD numbers 140-149. However, site-specific
mortality rate data for oral cancer are available in NCI
Monograph #59 (McKay, Hanson, and Miller (1982» for the
years 1950 to 1977. Although there will be difficulties in
interpreting trends for specific sites over this period of
time because of revisions to the ICD code, it is important
to do so. Whereas the trend of a curve representing the
general category of oral cancer may be smooth and relatively
constant, the trends of the curves for specific sites of
oral cancer may provide important information.· Thus, for
etiologic purposes, it is important to study the trends for
these specific oral cancer sites. A follow-up report to the
present one will show site-specific trends for both
mortality and morbidity rates for oral cancer .
•Although
not pUblished in this report, site-specific oral
cancer morbidity data have been obtained from the
Connecticut Cancer Registry [Heston, Kelly, Meigs and
Flannery (in press)], and these have been graph~d. The
individual site-specific curves varied considerably, while
the combined oral cancer curve (ICD 140-149) remained
relatively constant over the period 1935 to 1980.
34
IX.
DISCUSSION AND CQijCLUSIONS
From the graphs shown for the United states, Sweden,
France, and Hong Kong, certain conclusions can be drawn
concerning oral cancer mortality trends.
1. In the graphs showing age-specific rates, those for
the older ages are generally more erratic than those for the
younger ages. When standardized, the data are smoothed
considerably. ThUS, each standardized curve should be
studied along with the corresponding age-specific curves to
determine if any important trends are being suppressed. For
example, compare the age-specific mortality rate trends for
U.S. white males in Figures 2(a) and 2(b) with the
corresponding age-adjusted trend in Figure 6. The ageadjusted curve in Figure 6 shows a slight decrease in the
rate for U.S. white males over the period 1950 to 1980. But
the age-specific curves in Figures 2(a) and 2(b) show that
the decrease in age-adjusted oral cancer mortality is
largely due to the decrease in the rates for the older age
groups (70 to 84). The younger age groups (45 to 69) show a
relatively constant trend over this 30 year time period. In
the mortality data for the other countries shown in this
report, there were no major discrepancies between trends of
the standardized curves and age-specific curves.
2.
The age-adjusted oral cancer mortality trends for
U.s. non-whites, both male and female, are increasing at a
faster rate than for U.s. whites (Figure 6). This increase
is very slight for females; the increase in rates for nonwhite males as compared to white males is considerable.
Reference to Figures 4(a) and 4(b) shows that this increase
in non-white male rates for oral cancer mortality is found
in every age-specific group. Further, in comparing Figures
2(b) and 4(b), the rates for the older age groups for white
males are decreasing, while the rates for the older nonwhite males are increasing. The actual value of these rates
in the older age groups (as shown in Figures 2(b) and 4(b))
in 1980 is about the same (300 deaths per million) for both
white and non-white males. The important contrast to be
noted is that the 1980 white male rate was reached via a
decreasing trend for white males, whereas the 1980 non-white
male rate was reached via an increasing trend for non-white
males.
3. The age-adjusted oral cancer mortality rates for
u.s. white and non-white females are increasing slowly
(Figure 6). Since these data encompass the entire country,
different geographical regions, possibly states or counties,
should be studied to see if these summary curves are masking
trends within different regions. Trends in the southern
states, especially, should be investigated since a
e-
3S
number of studies have shown the potential for high rates in
this region. [Winn (1980), Blot and Fraumeni (1977), Mason
et a1. (1975)].
4. Among the oral cancer mortality trends of the four
countries shown here, Hong Kong has by far the highest rates
for both males and females (Figure 13). However, the rates
for French males seem to be catching up and, if current
trends continue, will surpass the rates for Hong Kong males.
The rates for French males show a steady, rapid increase
from 1950 to the present, far surpassing any increase for
the other three comparison countries. Further work should
examine trends in mortality rates for the individual oral
cancer sites to elucidate possible etiologic clues.
Whatever the etiology, it is not reflected in the rates for
French females, since their (age-adjusted) oral cancer
mortality trend is rising very slowly (if at all).
5. The trends in rates for Hong Kong males have also
increased over the time period of the available data, 1960
to 1978 (Figure 13). In contrast, the high rate for Hong
Kong females has remained relatively constant over this time
period. Perhaps the type of exposure is the same for both
males and females in Hong Kong, but at a higher dose and
with more frequent usage for males.
36
x.
BIBLIQGRAPHY
1.
Blot WJ, Fraumeni JF Jr. (1977). -Geographic patterns
of oral cancer in the United states: etiologic
implications," ~ronic Dieeaaea, 30: 747-57.
2.
Doll R, Payne P, Waterhouse J, eds. (1966).
"Comparison between registries" in Cancer Incidence in
Five Continents, International Union Against Cancer,
Switzerland.
3.
Heston JF, Kelly JB, Meigs JW, Flannery JT (in press).
Forty-five years of cancer incidence in Connecticut:
1935-79; National Cancer Institute Monograph,
Government Printing Office, Washington, DC.
4.
Kleinbaum DG, Kupper LL, Morgenstern H (1982).
Epidemiologic Research: Principles and Quantitative
Methods, Wadsworth, Inc., Belmont, California.
5.
Mahboudi E (1977). "The epidemiology of oral cavity,
pharyngeal and esophageal cancer outside of North
America and Western Europe,· Cancef, 40: 1879-1886.
6.
Mahboudi E and Sayed GM (1982). "Oral cavity and
pharynx," Chapter 33 in Cancer Epidemiology ang
Prevention, Schottenfeld 0 and Fraumeni JR, Jr. eds.,
we Saunders Co., Philadelphia, Pennsylvania.
7.
Mason TJ, McKay FW, Hoover R, Blot WJ, and Fraumeni JF
(1975). Atlas of Cancer Mortality for u.s. Countries:
1950-1969; Government Printing Office, Washington, DC.
8.
McKay FW, Hanson Ma, and Miller RW (1982). NCI
Monograph #59, Cancer Mortality in the Uniteg States:
1950-1977; Government Printing Office, Washington, DC
(this describes the data tape furnished by McKay for
the years 1950-1980).
9.
Pindborg JJ (1977). "Epidemiological studies of oral
cancer," Intefnational Denta~Journal, 27: 172-178.
10.
Pindborg JJ (1980). Qral Cancer ang Precancer, John
Wright and Sons, Ltd., Bristol, England.
11.
Segi M. (1960). "Cancer mortality for selected sites
in 24 countries (1950-57), Department of Public Health,
Tokoku University School of Medicine, Sendai, Japan.
e-
37
12.
Simons MJ, Wee GB, Goh EH, et ale (1976).
"Immunonogenetic aspects of nasopharyngeal carcinoma.
IV. Increased risk in Chinese of nasopharyngeal
carcinoma associated with a Chinese-related HLA profile
(Aw, Singapore 2)," Journal of the National Cancer
Institute, 57: 977-980.
13.
Smith EM (1979). "Epidemiology of oral and pharyngeal
cancers in the united States: review of recent
literature," Journal of the National Cancer Institute,
63: 1189-1198.
14.
Winn DW (1980). Oral and pharyngeal cancer in relation
to tob~cco use. alcohol, and occupation, unpublished
Ph.D. dissertation, Department of Epidemiology,
University of North Carolina, Chapel Hill (literature
review is part of her dissertation).
15.
World Health Organization (1977). International
Classification of Disease, 9th revision, (8th revision,
19671 7th revision, 19571 6th revision, 1947), Geneva,
Switzerland.
16.
World Health Organization (1983). "Users' guide to
standardized computer tape transcripts," Annex I in
World Health statistics Annual, Geneva, Switzerland
(the data were furnished on a tape that is described
here).
38
XI.
APPENDIX.
TABLES OF
AGE-~CIFIC
MORTALITY RATES
e-
TABLE A.l.
rei,
1'51
1f51
ItSI
1m
1",
ttS5
1m
19S1
1m
1m
1960
1961
1962
1961
1961
H&5
""
IW
"61
1H9
mo
1m
1972
1m
1971
1975
1m
1977
/97,
m'
19ID
REFERENCE:
ORAL C~~CER (ICD 140-149) MORTALITY RATES FOR U.S. WHITE MALES, NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1980.
..•.•. _-.--..........................__... ;~ .•__..• til ...............__......_._................ _.~..._...
ILL
5&.1
51.'
52.5
51.5
51.1
~5.1
5'.1
5~.S
51
~5.1
51.'
~'.5
51.T
51
$2. ,
~I.I
51
~1.1
5S
56.1
55.1
51.5
52.1
51.1
54,5
5i.1
~? .f
,/.1
5~ 5
51.'
5D.S
01-0'
0.1
0.'
o.f
0.6
0.'
0.7
0.7
t.6
0.1
o.t
0.1
0.1
'"
0.1
0.1
C.l
0.1
0.1
0.5
C.5
0
0.1
0
0.1
0
0.1
0
0.5
0.1
0.1
0.1
IH9
1
'.5
0.1
U
0.1
0.5
0.5
I
0.6
0.5
0.'
0.6
0.5
0./
0••
0.3
0.1
O. I
I
0.6
0.1
O. ,
o.t
0.1
D.I
0.5
0
D.l
0.1
0.1
0.1
10-11
0.6
I ••
0
0.2
O.T
0.7
t.6
0.7
0.6
O. ,
0.'
0.5
0.6
0••
0.1
0.7
O.T
0.5
0.6
0.1
0.1
0.1
o. ,
0.1
0.6
M
o.t
0.6
0.:
D.I
0.1
IH'
1.1
1.1
H-U
o.t
o.t
I.'
1.6
1.5
1.1
1.1
1.6
1.5
1.7
1.1
1.2
1.'
0.'
1.1
1.1
0.6
1.1
I
1
2.1
1
1.1
I
1.1
0.'
0.6
1.1
0.7
0.7
0.1
0.7
O. ,
1.5
0.7
0.9
0.5
0.5
D.I
0
I.'
1.1
",
0.5
1.1
1.1
0.7
I
1.1
1.1
1
I.'
1.5
O.f
/ .1
0••
1
1.1
/
0.'
2719
2
1.1
:.'
0.7
I.T
1.1
2.5
2. ,
1.1
1.'
1
1.1
2.1
1.'
1••
I
1.2
1.9
M
1.1
1
1.5
1.5
0.7
1.1
1.2
1.5
1.6
1. ,
1.9
1.1
MCKAY, HANSON AND MILLER (1982).
It-1'
2.1
1.'
t.i
i
1.7
1.5
2.1
2.1
1.1
f.9
,..
1.1
2.f
t.2
2.'
2.1
1.5
:.1
1.7
15- It
7.6
1.1
u
7.1
6.'7.7
1.1
1.9
1.6
2
:.1
1.9
1.7
1.7
t.'
1.'
17.6
1M
1t.I
10.5
,5-1,
Uo5'
'f.!
71.t
fl.T
70.1
77.1
77.1
,5,6
fl.:
15.T
11.1
IU
6
tl
It.I
'.1
6.1
1.1
5.6
19
1M
17.'
1'.1
1M
19.1
1M
11.1
17.'
11
19.2
1'.9
1'.9
1r.:
16.1
n.2
51.5
n.I
5o.r
19.5
52.6
51.1
5/.2
14.1
ft.6
12.f
fO.f
51.f
10.7
s.r
'"
6.1
U
6.1
7.1
/., '"
I.'
,.."
U.l
6
6.7
7.1
6.1
f.1
5.7
£.l
1.'
6./
5.1
2.'
6.1
6.1
17.'
18.1
14./
16.6
If.J
15.1
11.J
1..,
f2
fl.1
f6
16.5
50.6
~M
15.1
fl.2
16
11.1
17.'
"
".1
.'"
tI
91.1
101.5
~u
m.'
lfU
11M
117••
m.l
71-7'
17I.T
121.2
122.6
1:6.6
12M
m.T
16/••
I'M
55-5'
11I.T
m.1
IIU
115
m.1
HI
111.6
IOU
11M
".7· U9.9
101.5
117
11M 161.1
m.1
H.I
16U
106.2 165••
107.5
m
151.6
101.1
m.6
102.1
m.7
HI.5
97.1
167.1
'5. ,
l5f.5
152.1
'D.7
lSI. 1
'7.1
He.5
".9
lIt.J
12.7
m.1
96./
m.l
"
91.'
to.' 110.1
m.'
17.1
191.7
m.7
111.7
1'5.2
111.'
197••
65-"
1'5.1
:51.'
21M
:,'"
m.s
W.,
111.1
:5'"
:0.
19",
200.1
to/.1
111.'
255.6
206
It 9.6
101.1
US.5
206.9
221.1
m.I
m.2
211.1
221.1
111.'
201.9
221.'
216.'
12M
:11.1
m
m.l
m.l
217.9
"'.5
2".'
1Jf
m.7
199.1
m.1
290.1
100.'
ITt.S
III.' m.'
HI.I
m.'
211.' %9D.9
m.1
m.'
m.1
:10.1
m.1
75-7'
m.1
m.1
'15.f
ff1.6
III
(,J7
Sf",
m.I
m.1
m.6
I.",
m.7
lIf.T
1#0.5
161.6
m.6
111
m.•
101.5
19M
15'.5
m
271.'
m
187
117.9
W.6
121.5
m.5
10D.l
m.9
m.1
211.1
26/.6
m.l
m.'
111.9
lSI. 5
m.1
5TU
flM
116.1
1'9.9
271.6. 116.1
m.f
m.7
151.9
:'5.5
"'.5
551
55'.1
6.,
I1U
m.7
m.9
lIf.9
iff. 6
111
m.1
100
m.7
,,.,, 'S-"
,,1.1
SOM
m.2
16/.'
169.5
TH••
616,t
"M·
Tf6
711.'
111
707.'
721.1
W.2
U5.5
616.9
657.'
m.T
m m.l
110.1
611
171.1
116.1
171.5
SSt.!
199.7
119.6
1DI.7
195.9
119.2
m.1
116.9
m
510.1
5t9
519.1
511.1
111.1
50/.1
m.1
ISM
m.' 119.2
1ft.'
m.'
m.7
m.l
1:1.5
m.1
m.~
'Oo.T
J9M
101.1
(;l
~
.
I
TABLE A.2.
1m
1950
HSI
1951
1m
1m
1m
1'"
1m
,,~
1'5'
1960
It"
1961
lf61
''''
tn5
""
"'7
I~U
""
m.
1971
1m
ml
1m
11.1
H.7
H.'
11.1
1",
15.6
15.'
16.'
14.7
17
16.1
15.6
lU
/7.1
17
".2
-It.7
fO.7
11.1
20
U.,
1m
1976
1m
fl.J
fl
1'1m7'
1t.6
21.1
fM
REFERENCE:
~~ITE
FEMALES, NUMBER OF DEATHS PER MILLION,
..................................................... HE .....................................................
50·51 $S·n ",.61
10·11
15· l'
05-0'
to-" tH' 10-11 lS·n 10-41
6.5
27.1
0.7
1.1
IJ.P
U.S
0.1
0.6
I
I
11
0.1
0.1
1'.'
II. ,
O. ,
7.6
t.5
1M
14.1
15
0.7
D.f
D.6
1
13.6
D.2
1.'
7.1
fl.7
11.6
/.5
1.6
0.6
0.7
0.2
I
0
0.5
H.2
ILL
fl.'
12.1
Itt'
e
ORAL CANCER (ICD 140-149) MORTALITY RATES FOR U.S.
AGES 0-85+, 1950-1980 .
'5-#'
0'-0'
0.'
'"
'"
D.'
0.5
0.1
0.1
0.1
0.1
0.5
0.2
0.1
0.1
0.1
'.1
0.1
~.5
t.6
0.5
'.2
..,
'./
'.1
'.1
'.1
0
0
0
0.1
0./
0.1
0
0.2
0
0.5
0.1
U
'.5
D.6
'.1
0.1
.., ..,
0.1
f.6
'.1
'.1
'.1
U
'.1
0.1
f.l
'.5
t.1
..,
0.1
O.J
0.1
0.1
'.1
'.7
'.1
'.5
'.1
U
'.J
f.l
0.7
0.5
0
'.1
0.#
'"
.., ..,
.., • •
D.6
D.6
f.6
0.7
1
0
0.'
O.J
'.7
...
0.1
•••
0.1
0.1
f.6
M
0.1
0.'
'.1
0.1
f.6
I
1.1
I.J
'.1
..1
1
0.1
'.1
1
1.1
• .....,
0.5
U
'.1
0.5
'.7
••1
•
•
•• '"• '.1 ..,
0
0.1
0.6
0.1
0.'
t.I
'.1
..,
M
..,
M
'.1
••7
U
'.1
U
0.7
0.'
t.I
l.t
1.1
1.7
0.'
1.5
1.1
1
I
'"
U
U
'.T
/
1
1.,
1.'
1.1
I
1.1
1.1
1.1
1.7
1.1
1
I
t.t
•••
1.'
1.t
1.1
1.'
I.'1
• •
0.'
'.1
U
U
1.1
1.' -
o.s
••1
l.6
1.t
1,J,
f.7
1.7
1.7
l.6
1
1.5
l.I
'.5
1.1
t.5
1.1
1.5
.1
lot
1.6
5.'
J.I
M
1.1
I.J
I
1.2
I
1.5
M
-,
2.'
f.J
1.5
I.'
U
1.7
f.I
7.2
7.'
I.'
6.1
7.t
'.1
U
1M
T.'
••• If.'
11.7
/7.1
15
/1.2
11.1
11.1
11.6
16.5
21.J
fl.l
10
lU
'.1
6.5
6.1
U
6.1
11.6
/7.1
16
1M
15.1
1f.7
17
17.1
T.'
U
1.1
7
7.1
7
7.2
7.1
to
17.7
17
1M
21.1
1'.1
fM
f6.f
15.1
1f.1
f6.5
fl.f
IO.J
11.1
IU
1M
11.1
11.1
n.'
11.1
J7
10
II.'
11
11.1
16.1
16.1
Jl
II
1:.5
IU
II.'
11.5
11.1
11.1
1&.6
17.'
,1.1
6.1
11.2
5.1
6.1
7.'
15.1
15.J
11.1
11.1
f'
n.6
11.6
11.1
5.1
26.1
1M
17.1
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116
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MCKAY, HANSON AND MILLER (1982).
e
e
TABLE A.3.
mt
"SO
1f51
1'$1
1m
1951
1m
1956
1m
195.
"5'
mo
1961
1961
IW
ml
1965
''''
1967
19;'1
m9
1970
1971
1m
1971
P71
1975
1m
19i7
1m
1979
1910
REFERENCE:
ORAL C~~CER (ICD 140-149) MORTALITY RATES FOR U.S. NON-WHITE MALES, NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1980 .
•••••••••••-. ................._ ...................... liE ......................................;...._ ........ ,.."
05-0.
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60-61
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0
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0
1.6
21
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1.6
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11.7
110.6
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1.6
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MCKAY, HANSON AND MILLER (1982).
12.'
J.'
m.'
m.'
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166.'
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TABLE A.4.
rEAl
- - - - - - - - - - - - - - - - - - - - - - - - - AU - - - - - - - - - . 3s-n
fO-44
3~-Jf
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1m
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1958
195'
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1m
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m.
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1971
1972
1973
mf
1975
197'
1977
1918
197'
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REFERENCE:
e
ORAL CANCER (ICD 140-149) MORTALITY RATES FOR U.S. NON-WHITE FEMALES, NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1980.
II.'
11.'
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11.4
11.1
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AND MILLER (1982).
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e
•
TABLE A.5.
ORAL C~~CER (ICD 140-149) MORTALITY RATES,
1951-1979.
S\~DEN
MALES,
~IBER
OF DEATHS PER MILLION, AGES 0-85+,
ME ...",
ru,
USI
lfS1
lfSl
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1971
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17
15
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1978
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INDICATES THAT THE RATES FOR AGES 2, 3
THESE VALUES ARE OUT OF RANGE OF \iHAT WOULD BE
COMPUTER TAPE.
REFERENCE:
zs-zt
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4 ARE INCORPORATED IN THE RATE AT AGE 1 .
THUS SHOULD BE TREATED AS AN ERROR ON THE
~
:,l
TABLE A.6.
ORAL CANCER (ICD 140-149) MORTALITY RATES, SWEDEN FEMALES, NUMBER OF DEATHS PER MILLION, AGES 0-85+,
1951-1979.
AU fA",
YEA,
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* THESE VALUES ARE OUT OF RANGE OF \~T WOULD BE EXPECTED·~~D THUS SHOULD BE TREATED AS ~\ ERROR ON THE
COMPUTER TAPE.
REFERENCE: WORLD HEALTH ORG~~IZATION (1983).
CA:
e
e
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•
ORAL C~~CER (ICD 140-149) MORTALITY RATES FOR HONG KONG MALES, NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1961-1978.
TABLE A.7.
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IN THE RATE AT AGE 1. THIS S~~E SYMBOL UNDER AGES 80-84 AND 85+ INDICATES THAT THE RATES FOR
THESE AGES ARE INCORPORATED IN THE RATE AT AGES 75-79. AS DISCUSSED IN THE TEXT, HOWEVER, THE
LAST THREE COLUMNS OF DATA: 75-79, 80-84, A~D 85+ ARE SUSPECTED OF BEING IN ERROR AND HAVE NOT
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* THIS VALUE IS OUT OF RANGE OF
COMPUTER TAPE
REFERENCE:
i\~T
WOULD BE EXPECTED AND THUS SHOULD BE TREATED AS AN ERROR ON THE
WORLD HEALTH ORGANIZATION (1983).
..,.
U1
TABLE A.8.
ORAL CANCER (ICD 140-149) MORTALITY RATES FOR HONG KONG
AGES 0-85+, 1961-1978.
NUMBER OF DEATHS PER MILLION,
FE~~LES,
AU it",
YEA'
lUI
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WORLD HEALTH ORGANIZATION (1983).
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m.
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ORAL Cfu~CER (ICD 140-149) MORTALITY RATES, FRANCE
1950-1977.
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Itt
l1t
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1tI
211
211
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141
151
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311
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171
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117
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171
m
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1'7
151
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m
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m
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11
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101
104
174
m
m
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115
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221
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1'1
522
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126
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211
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280
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III
m
m
m
J70
J62
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m
m
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572
m
m
m
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m
m
701
m
m
m
m
m
572
660
m
m
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585
651
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140
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511
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m
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604
m
m
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15
7..14 75-71 . , .
w
m
m m
m
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5"
580
U7
600
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114
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5"
571
m
HI
600
110
SID
us
THIS SYMBOL INDICATES THAT THE RATES FOR AGES 2, 3 AND 4 ARE INCORPORATED IN THE RATE AT AGE 1.
REFERENCE:
WORLD HEALTH
ORG~~IZATION
(1983) .
..,.
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IX
TABLE A.ll.
ORAL CANCER (ICD 140-149) MORTALITY RATES, U.S.A.
1950-1979 (WHITE AND NON-WHITE COMBINED).
,
n. IClIEJlSIII -----ALL
US.
6
6
,
,
,,
I~S/
1tS2
1tS3
HSf
6
ms
6
US6
1m
US,
115'
1
1
7
7
7
1
1
7
1
7
Jf6.
""
""
ms
/961
mf
""
1967
1968
196'
/970
1971
1972
/97J
197f
1975
197'
1977
1978
,
,,
,
8
8
8
,
8
8
8
.. - -----....--_ ..
fIA :
Sf
51
5/
S/
S3
Sf
53
SS
S2
Sf
SJ
Sf
Sf
SJ
SJ
51
5J
52
55
51
55
55
5J
Sf
S5
55
55
56
55
I
I
•
I
I
°•
•
°1
°°
0
I
,*
/*
.*
1*
0*
/*
1*
/*
0*
1*
.*
.*
1*
.*
0*
•*
1
J
4
fl.
ft.
ft.
ft.
fl.
fl.
ftA
fIA
fl.
fl.
.fA
,fA
fl.
fl.
fl.
,fA
.fA
,fA
,IA
fl.
fl.
flA
,fA
fl.
fIA
If.
fl.
fl.
fl•
...
'AA
,fA
fl.
fl.
0
0
@fA
m
fIlA
fIlA
UA
twA
0
0
0
flA
0
I
0
/
0
0
1
/
a
0
0
0
0
/
0
0
/*
.*
0*
0*
0*
0*
0
0
0
0
0
/
0
INA
flA
ft.
.fA
,fA
'IA
,fA
io.
NUMBER OF DEATHS PER MILLION, AGES 0-85+,
ME rJtfl
•
°• •
•
0
~~LES,
fl.
fIA
flA
1
0
UA
UA
m
,fA
fIA
.IA
fIA
fIA
fl.
0
0
fIlA
'NA
m
,fA
fIA
twA
0
0
0
I
0
-
--------------15#
s-t 11-14 !s-jf 21-14 15-1' Jl-U JS-Jf 4Hf .Hf Sl-54 55-5, """" 'H' 71-7. 75-7'......
I
I
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,
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I
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1
1
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I
I
I
0
0
0
0
0
0
0
0
0
0
0
/
I
2
1
/
2
/
7
I
I
2
2
2
1
1
2
I
2,
2
3
I
1
2
2
/
I
3
2
3
2
I
2
I
•
0
0
/
2
2
I
2
1
I
2
2
2
I
I
/
/
/
/
/
0
/
I
/
I
I
0
0
0
0
0
•
•
• •
•
/
I
2
I
I
I
I
/
I
2
I
/
/
I
I
I
/
/
1
2
7
2
2
2
2
I
I
I
7
2
/
I
I
2
2
/
2
2
1
J
3
f
3
3
f
S
f
S
2
J
J
2
l
3
3
J
J
f
J
J
2
2
1
J
2
,,
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,
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,
7
7
,
7
,
7
,
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10
7
6
7
,
,,
7
6
14
11 .
17
10
12
24
21
If
If
46
44
"
US
m
m
76
It
7t
11.
" "
"
126
13;
IJ7
4S
51
S5
2J
S.
11
S3
11
11
SJ
11
S7
7f
58
5S
72
1f
Sf
2f ~ Sf
22
11
51
25
5'
26
S2
25
52
2f
5J
11
56
58
2J
25
58
2/
62
58
21
2/
58
2f
57
"
""
'2
IIJ
In
III
,.8
'"
101
104
I/O
1/8
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/07
/06
'6
/01
"
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/00
lOS
ID9
m
m
114
IU
m
1'2
m
117
4S4
211
117
117
3/7
J2t
305
2U
161
m
'"'"m ""
264
2ff
167
J25
271
1"
300
1'7
65t
S25
7S2
US
f24
40t
402
5Z7
61.
577
545
S'3
7"
4JO
3'S
171
J71
J65
JJ7
S02
m
m
Ifl
lIS
Iff
206
131
137
2S6
2Jf
153
200
1S'
'"
7'S
270
210
275
100
30f
JIB
2.2
JJI
m
m
lot
185
277
J07
JfI
JIl
Ifl
IJ7
16'
/64
201
202
2/7
232
188
m
251
2SJ
7f6
250
2f0
221
253
21S
/7f
2J6
2f7
IS7
170
IS7
/76
m
m
/68
I6J
/65
15'
155
I6f
ISO
203
211
22f
2/7
216
2JI
m
m
165
2t6
;u
m
m
J05
2Jf
27J
25,;
m
m
221
m
260
125
Jf8
JOI
JOI
J6/
m
m
m
2B1
277
JH
HZ
5SJ
70t
"'
61J
6"
m
m
fIf
U7
'07
m
.40
'2'
m
m
Jf5
JI6
m
Jf8
J86
Jf6
S77
51J
50t
fit
160
JB1
J1J
J'f
J'2
178
S27
m
m
fI7
fII
lff
JS7
151
Iff
17/
m
ffO
f51
f62
f51,
us
_-------
THIS SYMBOL INDICATES THAT THE RATES FOR AGES 2, 3
REFERENCE:
WORLD HEALTH ORGANIZATION (1983) .
Al~D
4 ARE INCORPORATED IN THE RATE AT AGE 1.
.j:::o
\D
TABLE A.12.
ORAL CANCER (ICD 140-149) MORTALITY RATES, U.S.A. FEMALES, NUMBER OF DEATHS PER MILLION,
AGES 0-85+, 1950-1978 (WHITE AND NON-WHITE COMBINED).
MEum
YEAI
mo
ml
1952
/m
1m
m5
1m
1757
/m
"5'
I'"
1961
1m
1163
1964
"'5
""
m,
/167
n6f
1170
1m
1972
1m
1174
/975
m,
1977
m,
H':
----_
.... -------------------------------------------------------------------------------------------_.. _--------------------Ie, .mSlO.
ALL
0
/
2
3
4 H /~If 15-1f 2H4 2$-1' 3~34 35-J' 41'-44 4H' 5~54 5H' ,o-U '$-6' 7H4 75-7' 'N. '5'
o
14
14
If
6
6
6
6
6
1
o
o
14
,
,
/
If
If
If
If
IS
IS
6
7
7
7
7
7
7
/
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UA
fl.
'IA
'IA
rIA
rIA
H'
HA
lfA
flA
fl.
H'
UA
fl.
fl.
fU
fl.
fl.
ffA
fl'
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ffA
ffA
W
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0*
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fl.
fl.
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fl.
fl.
fl.
17
n
2
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16
16
11
,
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m
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16
7
lAA
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7
7
7
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fl.
fl.
1
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19
20
21
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2.
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2/
21
22
22
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23
22
I
UA
IrA
UA
fl.
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UA
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UA
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1
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5
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7
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14
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16
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17
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20
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n
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m
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110
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120
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n
n
n
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n
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n
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"
n
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n
u
54
n
nn
n
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u
n
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n
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m
n
"
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202
191
m
m m
211
lU
202
m
n
m
"u
u
m
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us
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7JJ
102
242
Iff
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lJJ
fl
m
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m
m
m
219
111
~
122
209
5'
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16/
112
U2
121
H
In
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lU
16'
ISO
15J
~
~
~
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54
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n
u
"
n
n
n
~
n
u
»
u
m
o
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22/
111
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112
711
m
"
n
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n
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n "
u
n
"n " n mv
u n n u n
U
H7
HI
1U
THIS SYMBOL INDICATES THAT THE RATES FOR AGE 2, 3 AND 4 ARE INCORPORATED IN THE RATE AT AGE 1.
REFERENCE:
WORLD HEALTH ORGANIZATION (1983).
e
e
•
•
•
,
e