1. Recent advances in the management of colorectal cancer Vilnius, May 6-7 Epidemiology of colorectal cancer: what we can learn from Lithuania Juozas Kurtinaitis phD, Public health

2. Colorectal cancer Is the fourth most common cancer in the world accounting for 8,5 % of all new cancers The developed world accounts for over 63 % of all cases Colon cancer is more common in developed countries exhibiting Westernized lifestyle practices Lithuania is moving to market economy and is facing the westernized life style practices

3. Colorectal cancer around the world IncidenceMortality Region MaleFemaleMaleFemale World20,114,68,97,6 More developed regions 40,026,627,512,3 Less developed regions 10,27,74,64,7 Based on world experience, what we expect in future? Lithuania 26,516,8 18,0 11,3 Based on the figures, we are targeting the more developed regions and need to pay attention on the western countries experience. Colorectal cancer is not only geography.

4. Colorectal cancer – Northern Europe 1997-1999 - MALE AreaIncidenceMortalityIncidence/mortality ratio Northern Europe37,517,6 2,1 Denmark41,023,3 1,8 Estonia31,717,9 1,8 Finland25,511,5 2,2 Iceland34,012,8 2,7 Ireland43,123,6 1,8 Latvia24,218,0 1,3 Lithuania26,518,0 1,5 Norway43,420,1 2,2 Sweden33,414,9 2,2 UK39,217,5 2,2

5. Colorectal cancer – Northern Europe 1997-1999 - FEMALE AreaIncidenceMortalityIncidence/mortality ratio Northern Europe26,412,7 2,1 Denmark33,019,2 1,7 Estonia23,212,6 1,8 Finland21,19,8 2,2 Iceland27,013,2 2,0 Ireland27,013,7 2,0 Latvia17,912,3 1,5 Lithuania16,811,3 1,5 Norway37,116,8 2,2 Sweden26,211,1 2,4 United Kingdom26,512,4 2,1

6. Incidence / mortality ratio - what the figures stand for? Male26,518,0 1,5 Female16,811,3 1,5 Lithuanian figures tell us unexpected high mortality compared to incidence Questions: - do we have more advanced stages, compared to other countries in the region? - is the cases management according to best clinical practice? - what is the rank of colorectal cancer in the country? The figure we expect should be around 2

7. Colorectal cancer in Lithuania - 2004 - male 706 new cases (8,6% male malignancies) Site% of cancer death Prostate9,6 Lung28,6 Colorectal10,4 Stomach10,2 Based on mortality distribution figures, colorectal cancer for males is the second ranking place of importance

8. Colorectal cancer in Lithuania 2004 - female 736 new cases (9,5% female malignancies) Site% of cancer death Breast17,4 Colorectal12,6 Ginecological19,0 Stomach9,5 Based on mortality distribution figures, colorectal cancer for females is the third ranking place of importance

9. Colorectal cancer in Lithuania 1978-2002 number of the new cases Population size was stable but total number of cases has doubled Ageing of population is the most important contributor of increasing of colorectal cancer. Woman at elderly make higher proportion of cases

10. Colon – age adjusted incidence and mortality trends Sex Rate, incidence/mortality, cases per 100000, world 19782002 Male6,0 / 4,815,6 / 8,3 Female5,6 / 4,810,5 / 5,6

11. Rectum – age adjusted incidence and mortality trends Sex Rate, incidence/mortality, cases per 100000, world 19782002 Male7,9 / 5,518,0 / 9,9 Female6,4 / 4,88,6 / 5,1

12. Lithuania – can we see a progress in control and management? Based on these figures – suggestion can been made that diagnostic and clinical management has improved over last decades. Is the progress strong enough? RectumRate, incidence/mortality, cases per 100000, world 19782002 Male7,9 / 5,518,0 / 9,9 Female6,4 / 4,88,6 / 5,1 ColonRate, incidence/mortality, cases per 100000, world 19782002 Male6,0 / 4,815,6 / 8,3 Female5,6 / 4,810,5 / 5,6

13. Lithuania colon & rectum by age – lacking power for incidence cases at elderly

14. Colon – stage distribution 1998-2002 Prediction – based on Finland experience 50% patients should survive Stage distribution is comparable to Finland in the period of 1985-1994

15. Stage IV - percentage of new cases by subsite Large number of cases still remains diagnosed late – new clinical implications are needed to change to the positive trend

16. Colorectal cancer stage I-II by age and place of residence Diagnostic services should be improved for rural population

17. Colorectal cancer Do we have enough power on diagnostics?

18. Sporadic and hereditary cancer service Diagnosis Consulting Treatment (reaserch only) Oncology Institute Cancer Registry Regional Oncology Hospitals Human Genetic Center DNA Isolation DNA analysis Public health Follow-up University hospitals

19. Colorectal cancer in Lithuania by subsite Subsite: right side Lithuania 1998- 2002, % Other sources, % MaleFemale Apendix0,20,10,5 Caecum6,28,88 Ascending2,52,43 Hepatic flexsure5,37,58 Transverse colon4,86,16 Splenic flexsure2,11,92 Total 21,126,827,5 Number of new cases at right side almost tripled

20. Colorectal cancer in Lithuania by subsite Lithuania 1998- 2002, % Other sources, % SubsiteMaleFemale Descending colon 8,68,68,78,710 Sigmoid colon19,622,220 Total28,430,930 Number of new cases at left side almost doubled

21. Colorectal cancer in Lithuania by subsite Lithuania 1998- 2002, % Other sources, % SubsiteMaleFemale Rectum46,637,138 Anus1,11,43 Total47,738,541 Number of new cases has slowdown for females

22. Male Survival of cancer patients – Lithuania (1990- 1992) and Europe (Eurocare2) Colon and rectum: Lithuania is below the European average

23. Female Survival of cancer patients – Lithuania (1990- 1992) and Europe (Eurocare2) Colon and rectum: Lithuania is below the European average

24. Survival of colorectal cancer in Lithuania: 1990-921993-951996-981999-01 Male 25,5627,7432,3237,85 Female 29,3530,6037,6540,56 20 30 40 50 60 70 1990-19921993-19951996-19981999-20012002-2004 1 year2 year 3 year4 year 5 year 20 30 40 50 60 70 1990-19921993-19951996-19981999-20012002-2004 1 year2 year 3 year4 year 5 year Survival started to improve

25. Survival of colorectal cancer stage III 1990- 1992 1993- 1995 1996- 1998 1999- 2001 Male26,9130,5932,5538,78 Female32,3132,9739,5243,61 Raising figures: Important improvements in clinical applications

26. Colorectal cancer – what we can learn Based on mortality ranking, the importance of improvement clinical management of colorectal cancer in Lithuania is undervalued Increasing number of cases at right colon indicate on the needs of more extensive colonoscopy examination Incidence not high, there are reasonable resources, bur the survival is to low – clear indication on improvement of clinical management of cases

27. Positive changes in nutritional pattern during last 10 years Lithuania population - nutrition

28. Lithuania – population – selected features Total population 3,4 million Urban - 67%, rural 33% Income level (GNP) – 5200 USD Average size of family – 3,18 Meat consumption - 50 kg per capita per year (137 g/day) Alcohol consumption – 9,2 ltr per capita year Life expectancy –Male - 67 yr Female – 72 yr Cars – 1 million (one car per family) Mobile phones – 3,4 million (one per capita) What the message provide these figures for us?

29. Lithuania – population – selected features Total population 3,4 million Urban - 67%, rural 33% Income level (GNP) – 5200 USD Average size of family – 3,18 Meat consumption - 50 kg per capita per year (137 g/day) Alcohol consumption – 9,2 ltr per capita a year Life expectancy –Male - 67 yr female – 72 yr Cars – 1 million (one car per family) Mobile phones – 3,4 million There is a money but not for health or healthy life style

30. Lithuania: – we looking forward optimistically expecting on advanced clinical management of colorectal cancer

31. meantime being engaged in basketball...

32. … and song festivals

33. Thank You