[CANCER RESEARCH 48. 7285-7293. December 15, 1988]
Comparative Epidemiology of Cancer between the United States and Italy1
Carlo La Vecchia,2 Randall E. Harris, and E. L. Wynder3
"Mario Negri" Institute for Pharmacological Research, Via Eritrea, 62, 20157 Milan, Italy [C. L. VJ; Institute of Social and Preventive Medicine, University of
Lausanne, 1005 Lausanne, Switzerland [C. L. V]; and the American Health Foundation, Division of Epidemiology, New York, New York 10017
¡R.E. H., E. L. W.]
ABSTRACT
Available statistics on smoking, alcohol, food supply, reproductive
history, and other lifestyle habits from the U. S. and Italy were compared
and related to mortality rates of common neoplasms over the period 1955
to 1980. Per capita cigarette consumption has declined in the U. S. since
the early 1960s but continues to rise in Italy, chiefly due to the recent
increase in cigarette smoking among Italian women. Alcohol consumption
has increased in both countries, being persistently about 40% higher in
Italy. Changes were relatively limited in the American diet, but substan
tial for the Italian one which had particularly marked increases in meat,
milk, and fat consumption. Fertility rates have declined in both countries
but more sharply in the U. S. These lifestyle changes were reflected by
distinctly divergent trends in cancer mortality rates between the two
countries. In Italian males, mortality rates of urinary bladder cancer and
alcohol-related neoplasms of the aerodigestive tract (oral cavity, larynx,
and esophagus) increased in a similar manner and were persistently
elevated relative to American males. Similarly, Italian lung cancer rates,
while starting from lower values, rose steadily to overtake American
rates in the younger and middle age groups of both sexes, and neoplasms
of the intestines, breast, and ovary, starting from considerably lower
values, tended to approach the American rates over the 25-year period
considered. Within Italy, mortality rates of most common neoplasms
were substantially elevated in the North of the country relative to the
South, thereby paralleling the distinct North to South gradient in socioeconomics, diet, and affluent lifestyle which exists in the country. In our
opinion, most of these trends are real, and their explanation should be
sought, partly or largely, in the changes in tobacco and alcohol use, and
the reproductive and dietary patterns described. The evidence presented
underlies the importance of this kind of exercise to formulate and test
etiological hypotheses of human diseases, which may be overlooked in
studies based on populations with more homogeneous lifestyle habits or
environmental exposures.
INTRODUCTION
Studies of the geographical variation in cancer mortality
provide a basic framework for formulating and testing etiolog
ical hypotheses. Indeed, the concept that most human cancers
are due to environmental factors and, hence, are in principle
preventable is based on the marked international variation in
site-specific cancer incidence and mortality (1). Therefore, com
parative analyses of countries with divergence of cancer rates
and lifestyle habits but reliability of vital statistics are clearly
of major interest.
Recent studies of Japan and the U. S. reveal that as the
Japanese diet and lifestyle have become more "westernized,"
there has been a gradual convergence in the rates of breast,
ovarian, corpus uterine, prostate, pancreatic, and colon cancers
for the two countries (2, 3).
Received 2/17/88; revised 6/30/88, 9/14/88; accepted 9/20/88.
The costs of publication of this article were defrayed in part by the payment
of page charges. This article must therefore be hereby marked advertisement in
accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
1This work was supported by the CNR (Italian National Research Council)
Applied Project Oncology (contract 85.00549.58), the Italian League Against
Tumors, Milan, Italy, and by Public Health Service Grant CA32617 from the
National Cancer Institute and Grant SIG-8 from the American Cancer Society.
2 Supported in part by a travel fellowship from the Italian Association for
Cancer Research, Milan, Italy.
3 To whom requests for reprints should be addressed, at American Health
Foundation, 320 East 43rd Street, New York, NY 10017.
Among other developed countries, Italy provides one of the
best opportunities for comparative studies, since its vital statis
tics are satisfactorily reliable and show substantial differences
from those of several other western countries over recent cal
endar periods (4, 5). Thus, in this paper, we present and discuss
patterns and trends in lifestyle and site-specific cancer mortality
in Italy and the U. S. over the last three decades.
MATERIALS
AND METHODS
Smoking habits in Italy and the U. S. were examined based on sales
data (6, 7) and interview-based national surveys (8, 9). Alcohol and
food consumption data were derived from disappearance statistics
included in the Food Balance Sheets compiled by the United Nations
Food and Agricultural Organization (FAO) (10, 11). Cancer mortality
rates, age-standardized to the 1960 world population were obtained for
the period 1955 to 1980 from various sources (4, 6, 12-14). Trends in
mortality were computed over separate calendar quinquennia and in
two different age groups (35-49 and 50-64 years), since changes in
lifestyle and their implications for cancer risk probably differ at younger
and older ages. Since there were large differences in cancer mortality
between various geographical areas in Italy (5), Italian mortality rates
for the period 1975 to 1977 were also compared in four different areas
defined on the basis of latitude (North, North Center, South Center,
South).
Site-specific cancer mortality rates for Italy were considered satisfac
torily reliable and comparable with those of the U. S. since similar
registration techniques have been utilized in both countries throughout
the period considered, i.e., the same revisions of the International
Classification of Disease (ICD) were employed, death certificates were
signed by physicians and reviewed centrally, and the proportion of
unclassified neoplasms or ill defined causes of death under age 65 was
small (i.e., about 5% of all cancer deaths and less than 1% of all deaths,
respectively, in Italy) (4, 5). Furthermore, internal and external checks
have shown satisfactory comparability in cancer mortality data for
similar Italian populations, and in particular for younger age groups
wherein death certification is known to be more reliable (15). Moreover,
death certification and cancer registration data show high concordance
(over 75% for the third digit of the ICD in Italian Cancer Registries)
(16).
RESULTS
AND COMMENTS
Tobacco
Trends in average numbers of cigarettes sold per adult in the
two countries between 1920 and 1980 are summarized in Fig.
1. In the U. S., the major increases occurred in the first half of
the century, and sales have declined since the mid 1960s (6). In
Italy, steady rises have been observed up to 1980, although with
a delay of two to three decades compared to American levels.
Recent Italian data show a plateau in cigarette sales in the
1980s (9), thus confirming the approximately 2-decade delay
between Italian and American trends. Upward trends in Italian
cigarette sales were particularly pronounced in three decades:
the 1920s and the 1950s (due to increases in cigarette smoking
among men after World War I and II, respectively), and the
1970s (due to increased smoking among women) (7).
Table 1 gives the proportion of cigarette smoking in the two
countries on the basis of representative sample-based surveys
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COMPARATIVE CANCER EPIDEMIOLOGY IN THE U. S. AND ITALY
g
«ooH
4000 U.S.A.
"g
-o
01
3
M
3500
-
3000 2500
C
o
<•»
2000
ti
o
1500
o
o
01
U
1000
^o
fl>
500
_0
E
1920
1930 1940 1950 1960
1970
1980
Year
Fig. 1. Number of cigarettes consumed per adult per year in the U. S. and
Italy. 1920-1979 (Kristein (6) and La Vecchia (7)J.
Table 1 Estimateli proportion of current cigarette smokers, adults, U. S. and
Italy. 1955-1985
Sources: Surgeon General, (17, 18); La Vecchia (21).
Calendar
year1955
1965
1975
1980
1985U.S.52.6
Italy24.5
S.
51.1
33.3
60.353.2
41.9
32.0
40.9
54.3
16.727.9
33.2
45.0°FemalesU.
33.2MalesItaly65.0
6.2
7.7
16.3
17.7°
°1983.
(7, 9, 17-21). Between 1955 and the mid 1980s, the proportion
of current smokers among males has been persistently about
10% higher in Italy, although in both countries an approximate
20% decrease was observed over this time period. The propor
tion of smokers among American women rose from 25 to 33%
between 1955 and 1965, and remained relatively constant until
1980, then falling to 28%. In Italy, smoking was extremely
uncommon among women in 1955 (6.2% were current smokers)
but steady increases have followed (reaching 17% in the 1980s).
Data from recent National Health Surveys in the two coun
tries were used to estimate the prevalence of cigarette smoking
in successive cohorts after appropriate correction for excess
mortality (8, 9) and the findings are plotted in Fig. 2. The
results reflect distinct cohort effects in that successive genera
tions show different patterns of starting and stopping smoking.
In both countries, the highest smoking prevalence for males
occurred in the generations born in the 1920s, but subsequent
declines have occurred later and at lower rates in Italy than in
the U. S. Among females, the rise in smoking prevalence
occurred earlier in the U.S., with a peak rate of about 45% for
the 1931-1940 generation. In contrast, cigarette smoking was
extremely uncommon among Italian females born prior to
1920; however, later female cohorts show rapid acceleration of
the smoking habit, and the 1950 cohorts of both Italy and the
U. S. have strikingly similar patterns in smoking prevalence
with about one third of females being current smokers in 1980.
Fig. 3 compares the average number of cigarettes smoked per
day in the two countries in 1965 and 1980. Values were higher
in the U. S. in both calendar years, particularly for females.
These data, however, may be conservative since information on
smoking obtained from interview-based surveys are known to
include substantial underestimates (up to 30% in comparison
with sales data). The sales weighted average tar yield of Amer
ican cigarettes dropped from 37 mg in 1955 to 14 mg in 1980
(22). In Italy, filter-tipped cigarettes were introduced later and
became popular in the 1960s. Thus, the reduction in tar yield
occurred later in Italy with the average value still being 18 mg
of tar per cigarette in 1980 (7).
Alcohol. On the basis of sales data (10, 11, 23-26), alcohol
consumption has been increasing in both countries over the last
three decades, remaining about 40% higher in Italy than in the
U. S. (Fig. 4). The profile of alcoholic beverages was also
substantially different in the two countries, beer and spirits
being the major sources of alcohol in the U. S., whereas wine
was by far the most common type of alcoholic beverage in Italy.
The estimated intake of alcohol in Italy (over 15 liters of ethanol
per adult per year in 1980) was among the highest in the world.
Diet. A summary of national trends in food supply per capita
is given in Table 2. Based on these data, temporal changes in
American supplies between the late 1940s and the late 1970s
were relatively limited, the major modifications being restricted
to decreases in potatoes and starchy foods (—37%), fruits
(-32%), and vegetables (-18%) and increases in meats exclud
ing fish (+40%), sugar and sweets (+29%). The changes were
much more marked in Italy where supplies decreased for cereals
but rose substantially for sugar and sweets (+188%), vegetables
(+51%), fruits (+96%), meat (319%), eggs (+94%), milk
(+53%), and fats or oils (+119%). Although these trends are
probably partly artefactual and reflect the decreased proportion
of home-produced foods by small farmers in Italy, the overall
pattern of trends from the two countries is clearly different.
Nevertheless, in more recent calendar periods, Italian supply
values were still considerably higher than the U. S. for cereals
(348 versus 198 g per day), but substantially lower for meat
(176 versus 314 g per day), eggs (31 versus 44 g per day), and
milk (395 versus 476 g per day).
Table 3 gives total fat supply estimates and major fat sources
in the two countries. In the U. S., changes wee comparatively
small, and restricted to increases in lipids from meat and fats
or oils and decreases in those from milk resulting a 10% increase
in total fat. In Italy, upward trends were much more marked
for all the common sources resulting in an 88% increase in
total fat.
A summary of trends in major fat consumption in Italy
between 1951 and 1977 is given in Table 4 (25), and major
differences in consumption of selected foods between broad
Italian geographical areas based on National Household surveys
(26) are summarized in Table 5. Historical differences still
influence the type of fats used in different Italian Regions,
butter and other animal fats being used in Northern Italy, while
olive oil is by far the most common seasoning in Southern Italy.
Estimated consumption levels of meat, milk, cheese, eggs,
sugar, and coffee were greater in Northern regions but those of
bread, pasta, fish, and oil were lower than in Southern regions
(26). Over the last decade, differences between the North and
the South of Italy have tended to become smaller.
Table 6 presents the trends in estimated total calorie intake
and percentage of calories attributable to fat, based on disap
pearance statistics. The latter proportionate measure is of par
ticular interest since it is probably less influenced than absolute
values by changes in food distribution and marketing. Between
1955 and 1980, calorie intake increased in both countries (from
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COMPARATIVE CANCER EPIDEMIOLOGY
IN THE U. S. AND ITALY
70-,
60-
50-
¿0
C
4l
30
0>
Q.
20
10
1900
1910
1920
1930
1940
1950
1960
1970
1980
1900
1910
1920
1930
70
;
50.
1950
1960
1970
1980
1920-29
1910-19
60o,
1940
Years
Years
1900-09
1890-99
O>
•¿o
e
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u
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20-
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1960-69
1900-09
1—¿
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1910
o
1910
1920
1930
1940 1950
1960 1970
1980
H
1920
19201910-19
1930 1940
Years
.1960-69
1950
1960 1970
1980
Years
Fig. 2. Changes in the prevalence of cigarette smoking among successive birth cohorts of white U. S. men (A) and women (A), and Italian men (C). and women
(O) [Harris (8). LaVecchia el al. (9)].
ITALY
FEMALES
10-
Fig. 3. Average number of cigarettes smoked per day by current smokers in
the U. S. and Italy [U. S. Office on Smoking and Health (17, 18). Anonymous
(19), Todd (20), La Vecchia (21)]. D, U. S.; •¿.
Italy.
3150
to 3630
in the U. S. and from
2440
to 3230
in Italy).
1960
1970
1980
1960
1970
1980
Fig. 4. Annual per capita absolute alcohol consumption in the U. S. and Italy
for persons 18 years and over. [U. S. Bureau of Census (23), 1STAT 1981 (24,
The
percent of total calories attributable to fats rose by about 10%
26)'-D-wine;•¿â€¢beer;
•¿â€¢spirits;
"'total alcohoL
in the U. S. between the mid 1950s and 1965 levelling off
thereafter, whereas in Italy, more marked increases occurred
totaling 48% for the entire period. Although most of the
changes in the composition of the Italian food supply were in
the direction of bringing the Italian diet closer to that of the
U. S. (and other western countries), appreciable differences
were still present in the last calendar periods considered (i.e.,
total calorie supply and fat proportion were 11 and 21 % lower,
respectively, in Italy, chiefly on account of lower supplies of
meat, milk, and eggs).
Long-term changes in consumption
of selected foods
7287
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COMPARATIVE CANCER EPIDEMIOLOGY
IN THE U. S. AND ITALY
Table 2 Net food supply per capila: Ì948-1979
Values expressed in grams per day; °for U. S. 1968 only; * potatoes and other starchy foods;c for Italy 1977 only [FAO (IO, 11), ISTAT (26)].
9639651783601271271316922263024032412722769850261715672369585219
1
CerealsPotatoes,
etc.*Sugars
sweetsPulses,
and
seedsVegetablesFruitsMeatEggsFishMilkFats
nuts, and
and oils (fat content)U.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.Italy1948-1950210410143105128322427319223293152224425916
Table 3 Nel fai supply per capita: 1948-1969
Values expressed as grams per day [FAO (10. 11)].
CerealsPotatoes,
etc."Pulses,
seedsVegetablesFruitsMeatEggsFishMilkFats
nuts and
oilsTotal
and
fatU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.ItalyU.S.Italy1948-19502.55.40.10.15.82.30.60.50.90.545.55.06.21.71.10.924.48.054.327.2
' Potatoes and other starchy foods.
Table 4 Trends in major fat supply in Italy, ¡951-1977
Table 5 Estimated consumption (in kg or liters per year) of selected food items in
different Italian geographical areas, 1973-1985
Data from National Household Surveys |ISTAT (26)).
Calendar year
Type of fat"
1951
Butter
4.1
13.7
Olive oil
Other oils and margarine
15.2
" Values expressed as kilograms per capita per year
1970
1977
areaFood
5.5
6.0
29.0
27.4
22.5
25.6
[ISTAT (25)].
item
(per capita
kg or
liters/year)Bread center69.7
throughout the current century in Italy are plotted in Fig. 5 in
comparison to the amount consumed in 1906 to 1910 (27).
Changes were relatively small in the first half of the century,
but marked increases occurred after the second world war.
Trends in Cancer Mortality Rates. A summary comparison of
death certification rates from major cancer sites in the two
countries in 1978 is shown in Fig. 6 for males and Fig. 7 for
females (28). The overall age-standardized cancer mortality was
higher in Italy than in the U. S. for males (175.3 versus 159.5/
100,000), but lower for females (98.1 versus 106.6). Major
differences were registered in the rates of gastric cancer (23.2
Year and geographical
center66.7
center62.9
24.0
24.7
24.9
Oil
21.8
22.6
22.8
32.0
48.3
30.7
46.9
26.3
43.1
Pasta
49.9
43.4
Meat
56.2
35.6
58.4
45.6
12.7
6.1
13.0
9.5
16.3
Fish
5.8
Milk
84.6
63.0
82.5
66.4
81.6
69.6
Cheese
13.8
10.8
13.4
11.7
12.2
11.0
Sugar
17.8
13.7
21.4
19.7
14.0
17.1
Wine1973North/120.2South99.7
75.61980North/
109.2South88.3
73.21985North/
80.4South83.8
60.0
in Italy versus 5.9 in the U. S. for males, 11.3 versus 2.9 for
females). Rates of alcohol-related neoplasms (mouth, pharynx,
esophagus, liver and larynx) were higher in Italian males, as
were those of bladder cancer in males and uterine cancer (in-
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COMPARATIVE CANCER EPIDEMIOLOGY
IN THE U. S. AND ITALY
Table 6 Estimated calorie intake and percentage of total calories attributable to
fat, by year, in the V. S. and Italy, 1955-1980
Sources: U. S. Bureau of Census (23); Mariani-Costantini (27).
Calendar year
1955
1960
1965 1970
1975
1980
FEMALES
ALL
Percent
change
1980/1955
»
NEOPLASMS
»O
—¿O MOUTH OR PHARYNX
•¿O
ESOPHAGUS
Estimated calorie
intake
U.S.
Italy
3150
2440
3160 3230 3220 3540 3630
2600 2850 2950 3160 3230
+15.2
+32.4
Percentage of calories
attributable to fat
U.S.
Italy
39%
23%
41%
25%
+10.3
+47.8
O
43%
28%
43%
30%
43%
32%
43%
34%
•¿
STOMACH
•¿-0INTESTINES
—¿â€¢
UTERUS
I CERVIX
8. CORPUS
i
OVARY
•¿O
BLADDER
O« LEUKEMIAS
1
10
100
Fig. 7. Age-standardized death certification rates per 100,000 females for
selected cancer sites, U. S. white and Italian, 1978 [Kurihara et al. (28)[. O, U. S.
white; ».Italian.
100
cereols
1910
1920
1930
1940
1950
1960
1970
1980
Year
Fig. 5. Trends in consumption of selected foodstuffs in Italy compared with
the 1906 to 1910 values posed as 100% [Mariani-Costantini (27)].
MALES
ALL
NEOPLASMS
MOUTH OR PHARYNX
ESOPHAGUS
•¿-OINTESTINES
PANCREAS
PROSTATE
•¿OLEUrEMIAS
1
10
100
Fig. 6. Age-standardized death certification rates per 100,000 males for se
lected cancer sites, U. S. white and Italian, 1978 [Kurihara et al. (28)). O, U. S.
white; •¿,
Italian.
eluding cervix and corpus) in females. Overall standardized
lung cancer death certification rates were slightly higher in
American males (53.1 versus 48.7), and markedly higher in
American females (15.4 versus 5.5). Other neoplastic sites with
rates higher in the U. S. included intestines and pancreas in
both sexes, prostate, breast, and ovary.
More detailed information is presented in Fig. 8, which shows
trends in age-standardized death certification rates for major
cancer sites in the two countries between 1955 and 1980 for
two separate age groups, (35-49 and 50-64 years).
Lung Cancer and Other Aerodigestive Neoplasms. For males,
the Italian rates of lung cancer and other aerodigestive neo
plasms (mouth or pharynx, larynx, and esophagus) have risen
faster than U. S. rates in both age groups. The rise in male
Italian lung cancer mortality was particularly pronounced in
the late 1970s, having overtaken American rates for the 1980s.
Over the 25-year period considered, lung cancer mortality rates
in American males increased only in late middle age whereas
trends were stable or slightly downward for other tobaccorelated cancers and age groups. For females, lung cancer rates
have increased in both countries and age groups, but the in
creases were greater in the U. S.
These trends in lung and aerodigestive cancer rates are con
sistent with the previously described changes in tobacco and
alcohol use in the two countries, i.e., the higher prevalence of
cigarette smoking and alcohol consumption among Italian men,
and the delayed increase in smoking among Italian women.
Stomach Cancer. Stomach cancer rates decreased in males
and females of both age groups in both countries, although the
Italian rates were consistently higher than U. S. rates. It has
been suggested that improved food processing and preservation
play an important role in the declining stomach cancer trends
(29).
Pancreatic Cancer. In the 1950s and 1960s, Italian mortality
rates of pancreatic cancer were among the lowest in the world
(even lower than Japanese rates) (30), but steady and substantial
upward trends followed in males and females of both age
groups. Since cancer of the pancreas is particularly difficult to
diagnose, the rising Italian rates may be heavily influenced by
improved diagnosis and certification. Nevertheless, we believe
that the rising Italian trends in pancreatic cancer were partly or
largely real, particularly since they were observed in both age
groups of each sex.
Intestinal Cancer. Intestinal cancer mortality rates for 19551980 are higher in the U. S. than in Italy; however, the Italian
rates are continuing to rise at a rapid pace, presumptively in
response to increasing consumption of dietary fat and decreas
ing consumption of dietary fiber in Italy. These trends support
7289
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COMPARATIVE CANCER EPIDEMIOLOGY
IN THE U. S. AND ITALY
BUCCAL CAVITY &
PHARYNX-MALES
STOMACH.MALES
STOMACH-FEMALES
£
S loo
S
so
ms
1965
197S 19»
LARYNX-MALES
1955
_.
1965
I97S
1980
ESOPHAGUS-MALES
1965
1975
1980
1955
1965
CALENDAR YEAR
1975
191
CALENDAR YEAR
ESOPHAGUS-FEMALES
§
'9SS
'965
1975 1980
1955
CALENDAR YEAR
I96S
1975 I98D
CALENDAR YEAR
BREAST-FEMALES
UTERUS I All porn I
""
1965
1975
1980
1955
CALENDAR YEAR
1965
1975
I9J(
CALENDAR YEAR
INTESTINES-MALES
INTESTINES-FEMALES
Fig. 8. Age-standardized mortality trends
for selected cancer sites for U. S. whites and
Italian, 1955-1980. O, U. S. white 35-49; D,
U. S. white 50-64; •¿.
Italian 35-49; •¿
Italian 0
50-64.
8
10
1955
1965
I9SS
1975
1965
PANCREAS-MALES
1955
I96S
SS
1975 19S
1965
LYwPHOMAS-MALES
LEUKEMIAS-MALES
1965
CALENDAR
I97S
1*10
LYMPHOMAS-FEMALES
PANCREAS-FEMALES
1975 1980
1955
IMS
1980
CALENDAR YEAR
CALENDAR YEAR
19SS
I97S
CALENDAR YEAR
CALENDAR YEAR
I9SS
IMS
;c
197S 1910
19SS
197S 11
1965
1970
198C
CALENDAR YEAR
YEAR
URINARY BLADDER
n MALES
;0
1
URINARY BLADDER
FEMALES
LEUKEMIAS-FEMALES
S
s <>
I '
195Ì
1965
1975 1980
CALENDAR YEAR
1955
196S
1975 1980
CALENDAR YEAR
955
1965
1975
CALENDAR YEAR
1980
1955
1965
1975
1980
CALENDAR YEAR
7290
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COMPARATIVE
CANCER EPIDEMIOLOGY
the thesis that colorectal cancer risk is increased by high intake
of dietary fat and, conversely, decreased by high intake of
dietary fiber.
Urinary Bladder Cancer. In the U. S., the mortality rates for
cancer of the urinary bladder have declined among older and
younger age groups of both sexes. In contrast, the rates for
Italian males are higher and rising, and the rates for females
also appear to be increasing in recent years. This strikingly
divergent pattern of bladder cancer mortality between the U. S.
and Italy is very similar to the patterns for tobacco and alcoholrelated neoplasms (lung, oral cavity, esophagus, and larynx) for
the two countries. Since wine is the predominant alcoholic
beverage in Italy, the implication is that wine, in addition to
tobacco, should be considered as a possible risk factor in cancer
of the urinary bladder.
Uterine Cancer. A downward trend was observed for rates of
uterine (corpus and cervix) cancer rates in both countries,
although Italian rates have remained higher. Uterine cancer
trends may be related to changes in sexual habits and genital
hygiene, and relatively late adoption of effective screening by
the Papanicolaou test for cervical cancer in Italy (31).
Breast Cancer. Mortality rates of female breast cancer were
substantially higher in the U. S. than Italy in 1955, but the
U. S. rates have remained relatively stable or declined, whereas
Italian rates have increased markedly to approach American
values in the 1970s. Interestingly, the elevation in American
Mortality occurred predominantly in the postmenopausal years,
which is clearly shown by the 1980 age-specific ratios plotted
on a logarithmic scale in Fig. 9.
Classical breast cancer risk factors include late reproductive
history, early menarche, late menopause, and genetic or familial
factors (32, 33), but there is also supportive evidence that diet
may play a significant role in breast cancer etiology (34, 35).
On an international (36) and intranational scale (37), incidence
and mortality rates of breast cancer are positively correlated
with measures of total calories, fat, meat, and dairy products,
and experimental data on rodents suggests that diets rich in
calories and fat (with the possible exception of monounsaturated fats, which are a major component of olive oil) raise the
incidence of mammary tumors (38, 39).
Table 7 contrasts American and Italian fertility rates during
the period 1951-1980. These data show that the average fertil100Û
O—OU.S. While Women
•¿â€”•
ITALIAN
Women
o
cz>
o
80
Fig. 9. Age-specific mortality rate for breast cancer in the U. S. and Italy in
1980 [Pickle et al. (47), Decarli and La Vecchia (14)].
IN THE U. S. AND ITALY
Table 7 Comparison ofU. S. and Italian fertility rates, 1951-1980
Fertility rate/1000 women
aged 15-44
Calendar
year1951
1961
1971
1980U.S.
(whites)107.7
112.0
77.3
64.7Italy77.9
83.3
79.3
54.8
ity rates in the U. S. were about 35% higher than Italy in the
1950s and early 1960s, possibly as a consequence of the post
war "baby boom," but this difference has largely diminished
due to rapidly declining U. S. birthrates after 1970 (40, 41).
The marked reduction in U. S. fertility (40% between 1951 and
1980) and trends toward delayed childbearing (40, 41), in the
face of relatively low Italian rates which have remained stable
over time, contrasts sharply with the evolving inverse pattern
of breast cancer mortality in the two countries, i.e., breast cancer
rates which are stable in the U. S. but increasing steadily in
Italy. Furthermore, in the late 1970s and 1980s, menarche
occurred earlier (12.7 versus 13.1 years) and menopause later
(51.8 versus 48.9 years) in American women relative to Italians
(42-45). However, the more recent fertility rates and menstrual
differences would not be expected to impact on age-adjusted
mortality rates of breast cancer for many years and comparisons
with future rates will be necessary to better evaluate their effects.
Ovarian Cancer. Ovarian cancer mortality patterns for the
U. S. and Italy resemble the breast cancer patterns, suggesting
that the risk factors for neoplasms of both sites may be similar.
In the U. S., rates have declined slightly since the mid-1970s, a
trend which may be, in part, due to better diagnosis and treat
ment (3). A protective effect of oral contraceptives has also
been suggested, which is consistent with the observation that
they were accepted earlier and more widely by American women
than by Italians (it is estimated that about one in four American
women aged 20-49 years used oral contraceptives in 1976
compared to one in 25 Italians) (45, 46).
Other Neoplasms. Differences in the rates of other neoplasms
were modest. American rates of prostate cancer and lymphoma
were slightly higher than Italian rates in the older but not the
younger age group, and no important secular trends were ap
parent for either type of malignancy. Rates of leukemia were
similar and also showed stability over time.
Cancer Mortality Trends within Italy. Table 8 gives geo
graphic-specific standardized cancer mortality ratios (SMR)
relative to total Italy (SMR = 100) for selected cancer sites and
all sites combined. Notably, the rates for most common sites
are considerably elevated in the North of the country and show
a distinct North to South gradient (5, 15). Furthermore, mi
grants from Southern to Northern Italy tend to maintain lower
mortality rates for most cancer sites (48). This peculiar distri
bution is not readily accounted for by systematic biases in death
certification in various areas of Italy, and although Northern
Italy is more industrialized, it is unlikely that specific conse
quences of industrialization per se are responsible for the pat
tern, since cancer mortality is similarly elevated in rural as well
as highly industrialized Northern areas (15). It is therefore
noteworthy that estimated food consumption patterns within
Italy reflect diets which are higher in fat, sugar, and wine, and
lower in fiber in the North Central area of Italy compared to
the South (Table 5). Also, cigarette sales in the early 1950s
were about 40% lower in the South than in the North-Central
area and Southern women had a higher average number of
births (105 versus 68 per 1000 women of fertile age in the
7291
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COMPARATIVE CANCER EPIDEMIOLOGY IN THE U. S. AND ITALY
Table 8 Standardized mortality ratios for selected cancers or groups of cancers in broad Italian geographical areas defined according to latitude only
From Cislaghi et al. (5).
MalesOral
cavityDigestiveRespiratoryBoneSkinGenital
organsUrinaryNervousEndocrineLymphaticLipTonguePharynxEsophagusStomachColon
<North)~J?è£Î7rJ~tN
1451201471121169713113012711013211998133114124106131115107118109114FemalesCN1031181061069810510911
919610313312290113941041341091049712010511710989109114114101110CS909187101110939197839417
{82
160169178123124111137149132112124118121127107127102126112106123109125CN8911810311111111210610711010887
9587981291259111489104150107103112121101120107107102115109107111CS69878089939490997198101
696557869097807381639891938392849671971028710085S5661708379688689857911053523955549555707069628068609559938483767381
719269909199808087879187928295879278849286too91S737068977689728490829267
¿56
(Centre»_^ii>. CN
T576111359
rectumLiverPancreasLarynxLungPleuraMel.
SÃ RS"
North)—
(Centre__^Vgj>^outh)Öl
Vy?rWCS
_806761547810648806089858483708572Legend-AS^feSì;
"iÃ-/^Sf/J
skinBreastUterusOvaryProstateTest
^VA¿Õ
SouthCf^-^yC/^$rXV
S
isBladderKidneyBrainThyroidHodgkin'sNon-HodgkinM.
myelomaLeukemiasAll
neoplasmsN16312613311211212111210312311199
1980s) and lower average age at first birth (25.6 versus 26.4
years) (49). These differences in tobacco and alcohol use, diet,
and fertility appear to parallel the intracountry cancer rates of
Italy, and have tended to diminish in recent calendar periods
with a corresponding gradual convergence in site-specific cancer
rates (50-54).
DISCUSSION
This report documents changes and trends in Italian and
American patterns of lifestyle which appear to be associated
with divergent trends in site-specific cancer mortality. It is our
expectation that Italian rates of lung and aerodigestive cancer
will continue to accelerate in the 1990s, due primarily to
increased smoking, particularly among recent female cohorts,
and high alcohol consumption for which Italy ranks among the
highest of any developed nation. Declining rates of these neo
plasms in the U. S. are expected to parallel the decreases in
these same risk factors. It will be of special interest to monitor
the diverging rates of urinary bladder cancer for sustained
increases in Italy and decreases in the U. S. A continuation of
this pattern would suggest that tobacco and wine should be
considered as possible risk factors. Diminishing differences in
diet and other lifestyle habits are expected to produce conver
gent patterns in rates of other malignancies, particularly neo
plasms of the intestines, pancreas, breast, ovary, and possibly
the prostate. Upward trends in the occurrence of these neo
plasms are expected to continue in Italy as the (Southern)
Italian diet becomes more "westernized" with higher fat and
Although data limitations may be important, they can hardly
eclipse, in our view, the major findings emerging from this
comparative study. Italians and Americans manifest markedly
divergent lifestyles that appear to antedate and be associated
with their substantial differences in mortality from many com
mon neoplasms. Moreover, as lifestyle factors with etiological
portent become either more similar or more dissimilar in the
two populations, neoplastic rates will respond accordingly.
Empirical comparisons of this kind are useful in formulating
and scrutinizing hypotheses of the causes of human diseases
which may be overlooked in studies of populations with rela
tively homogeneous lifestyle habits and environmental expo
sures. Through appropriate international studies in metabolic
epidemiology, we are currently pursuing some of the interesting
leads provided by this comparison of Italian and American
populations.
ACKNOWLEDGMENTS
The authors thank Judy Baggott, Antonella Palmiero, and the G. A.
Pfeiffer Memorial Library staff for editorial assistance.
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Comparative Epidemiology of Cancer between the United States
and Italy
Carlo La Vecchia, Randall E. Harris and E. L. Wynder
Cancer Res 1988;48:7285-7293.
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