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World Journal of Gastroenterology logoLink to World Journal of Gastroenterology
. 2003 Feb 15;9(2):209–213. doi: 10.3748/wjg.v9.i2.209

An analysis of esophageal cancer incidence in Cixian county from 1974 to 1996

Yu-Tong He 1,2, Jun Hou 1,2, Cui-Yun Qiao 1,2, Zhi-Feng Chen 1,2, Guo-Hui Song 1,2, Shao-Sen Li 1,2, Fan-Shu Meng 1,2, Hong-Xin Jin 1,2, Chao Chen 1,2
PMCID: PMC4611313  PMID: 12532433

Abstract

AIM: To describe the incidence of esophageal cancer (EC) in Cixian, a county of Hebei province during 1974-1996. We analyzed the sex and age characteristics as well as the geographic distribution of EC, in order to determine the impact so that methods of preventing and controlling EC in Cixian can be put in place.

METHODS: Since the early 1970s, the cancer registry system has been established, which collects the cancer incidence in Cixian county. The malignant tumors were coded according to International Classification of Disease IX (ICD-9). All the data were checked and analyzed using EPIINFO.

RESULTS: The trend of the incidence rate of EC from 1974 to 1996 had declined, (229.9/100000 vs 178.5/100000, Odds ratio = 1.47, 95% CI:1.32~1.63, χ2 = 52.89. trend χ2 = 26.54, P < 0.001). The incidence rate of males declined significantly (281.81/100000 vs 157.96/100000, Odds ratio = 1.61, 95% CI: 1.41~1.84, χ2 = 47.85. Trend χ2 = 44.86, P < 0.001), whereas, the females remained steady (157.96/100000 vs 133.41/100000, odds ratio = 1.28, 95% CI:1.17~1.49, χ2 = 9.26. trend χ2 = 2.69, P > 0.05). Male average annual incidence rate was 142.80/100000 and the female's was 95.18/100000. The sex ratio (males to females) was 1.50:1. The incidence rate was increasing along with the age. As to the geographic distribution, the incidence rate in mountainous areas and hilly areas showed a significantly declining trend (mountainous areas, trend χ2 = 149.93, P < 0.001; hilly areas, trend χ2 = 42.70, P < 0.001). The incidence rate of EC in plain areas had increased (trend χ2 = 22.39, P < 0.001).

CONCLUSION: The incidence rate of EC in Cixian county shows a trend and has declined after two decades, especially in mountainous area. But compared to other regions in the world, Cixian county still had a high incidence rate of EC.

INTRODUCTION

Cixian county is one of the highest incidence rates of esophageal cancer (EC) in China, as well as in the world[1-7]. At the start of the 1970s, a field study of EC prevention and treatment was set up[8]. At the same time the population-based cancer registry system, so called the three-level prevention web, was established. Each clinic doctor in every township was required to report each new case of cancer occurring in the township using a standard card, then the cards were sent to the clinic of the rural administration unit. The unit sorted the cards and sent them to the Cixian Cancer Registry. To this day the Cixian Cancer Registry continues to collect incidence data. This present report came from “A study of incidence, mortality and surveillant method of risk factors of common carcinoma” carried out in the Cixian county of Hebei province, which is adjacent to the Linxian county of Henan province. This study was one of The National Ninth-Five-Year Scientific Championship Project.

MATERIALS AND METHODS

Materials

Cixian is located at latitude 36°C 30' North and longitude 114°C 40' East. It is situated on the east side of the Taihang Mountain, along the Zhanghe River and it lies in the south of the Handan City. Across the Zhanghe River to the south is the Anyang City of Henan Province. Cixian county occupies an area about 951 square kilometers, composed of 35 districts, and its population is 574828, consisting of 289391 males and 285437 females. There is a remarkable variation in the earth stratum of the county, with mountainous, hilly, and level land each constituting about one-third of its total area. The climate is influenced mainly by the warm mainland seasonal winds. The temperature range is bewteen 18-25 °C and the rainfall range is bewteen 600-700 mm. The major soil there is brown and light colored weed earth. Farm products include wheat, corn, millet, rice, red potato and beans. Iron and coal are the main minerals, and coal is the main local fuel of the county.

Cixian Cancer Registry is a population-based registry that was established in 1974. Its aim is to collect and analyze data on every new case of cancer occurring in Cixian county. Initially, it was mainly concerned with collecting data on the incidence and mortality rates of EC in Cixian. However, from 1988, it began to also collect information on the histopathology of the cancers reported.

Methods

The register was conducted by the three-level prevention web. Each clinic doctor in every township (prevention web I) was required to report each new case of cancer occurring in the township by a standard card, then the cards were send to the clinic of the rural administration unit (prevention web II). They were sorted and sent to the Cixian Cancer Registry (prevention web III) once a month, these cards were checked, analyzed, coded and stored there. At the end of each year, a sample survey was conducted, to check the quality of the registration.

The carcinoma were coded according to International Classification of Disease IX (ICD-9)[9]. All the data was checked and analyzed by EPIINFO software. Age-standardized rates (ASR) were standardized to the world population using the direct method and the statistical analysis was carried out by using χ2 and U-test, a probability value of less than 0.05 was considered statistically significant.

RESULTS

Incidence of esophageal cancer

Bewteen the years 1974 and 1996 there were 14207 cases of EC in the county. The annual average incidence rate was 119.43/100000, the ASR was 167.22/100000. In 1974, the incidence rate of EC was 165.81/100000. It declined to 113.49/100000 in 1996, representing a decline of 31.5%. From Table 1 and Figure 1, we can see that the incidence rate of EC in Cixian had a trend of gradual decline. The trend test revealed that χ2 = 26.54, P < 0.001. The incidence rate among males declined significantly (χ2 = 44.86, P < 0.001), whereas, the females remained steady (χ2 = 2.69, P > 0.05). In total, the incidence rate between 1970s and 1990s showed significant differences (U test: P < 0.01). While the difference between 1980s and 1990s was not significant.

Table 1.

Cixian EC incidence rate state from 1974 to 1996

Year Male
 Female
Population Case Incidence rate ASR Population Case Incidence rate ASR
74 221842 450 202.85 281.81 217799 279 128.10 157.96
75 224063 392 174.95 244.74 220937 279 126.28 162.8
76 226098 407 180.01 247.68 222526 236 106.06 131.44
77 227998 335 146.93 195.17 224094 193 86.12 103.31
78 227677 320 140.55 186.94 228524 191 83.58 104.51
79 231485 302 130.46 197.31 229242 190 82.88 108.11
80 235881 323 136.93 199.38 232902 221 94.89 124.86
81 242181 301 124.29 193.06 239136 191 79.87 101.76
82 242211 334 137.90 210.05 244007 194 79.51 106.98
83 251237 348 138.51 220.67 249751 229 91.69 122.07
84 253097 367 145.00 240.89 251332 192 76.39 103.22
85 256616 324 126.26 217.06 254526 214 84.08 113.06
86 260149 374 143.76 250.52 257671 205 79.56 100.92
87 265498 331 124.67 202.98 261498 231 88.34 114.62
88 262726 404 153.80 250.76 264539 287 108.49 153.86
89 272643 401 147.10 237.16 285840 258 90.26 131.13
90 289391 443 153.10 248.1 285437 322 112.81 151.55
91 294993 446 151.20 260.53 287546 305 106.07 139.36
92 299306 430 143.70 240.72 291905 302 103.46 139.6
93 299498 408 136.20 216.73 296060 283 95.59 126.12
94 303761 379 124.80 197.96 295104 260 88.10 114.01
95 302782 359 118.60 192.95 294867 289 98.01 125.92
96 302538 381 125.90 203.65 298596 297 99.47 133.41
Total of 70's 1595044 2529 158.55 - 1576024 1589 100.82 -
Total of 80's 2595749 3627 139.73 - 2593737 2323 89.56 -
Total of 90's 1802878 2403 133.29 - 1764078 1736 98.41 -
Total 5993671 8559 142.80 - 5933839 5648 95.18 -
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Figure 1.

Figure 1

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Cixian EC Incidence Rate State from 1974 to 1996.

The sex and age distribution

During the period there were 8559 males and 5648 females with EC. The incidence rate among males was 142.80/100000, while females was 95.18/100000. The sex ratio was 1.50:1. The sex ratios (males to females) in 1970s, 1980s and 1990s respectively was 1.57:1, 1.56:1 and 1.35:1.

The minimum age group of incidence was 1-year group over 23 years. The incidence rate of EC increased with age after 30 years old. It reached the highest at 80 years old group. In 1970s, the minimum age group was 25 years old group. The incidence rate had significantly increased after 35 years of age, and reached the highest level at 70 years old, then declined in 75-year old group. In 1980s, the minimum incidence group was one-year group. The incidence rate increased with age after that 25-year old group. The male incidence rate reached the highest at 80-year-old group. In females at the 60-year-old group it declined a little and reached the highest at 80-year-old group. In 1990s the minimum incidence group was 10-year-old group. The incidence rate increased with age after 25-year-old group and reached the highest at 80-year-old group. The male incidence rate reached the highest at 80 years old group, while the female declined little at 60-year-old group and reached the highest at 80-year-old group.

Geographic Distribution

In the mountainous area there were 2106 EC cases from 1974 to 1996. The annual average incidence rate was 112.14/100000. The incidence rate of EC in 1974 was 213.60/100000, which declined to 82.55/100000 in 1996. Decreased by 131.05/100000, and the decline rate was 61.35%. From Table 2 and Figure 3 we could find that the incidence rate of EC in mountainous area had significantly decreased. The result of trend test was χ2 = 149.93, P < 0.001. The incidence rates of EC in 1970s, 1980s, and 1990s were 150.44/100000, 109.85/100000 and 75.55/100000, respectively. The U test result between 1970s and 1990s, between 1980s and 1990s was P < 0.01. Both of them had significant difference.

Table 2.

The geographic distribution of esophageal cancer in Cixian from 1974 to 1996 (1/100000)

Year Mountainous area
 Hilly area
 Level land area
Population Cases Incidence rate Population Cases Incidence rate Population Cases Incidence rate
74 77240 165 213.60 145428 241 165.71 216973 323 148.81
75 77581 151 194.63 147830 232 156.93 219589 288 131.15
76 77981 132 169.27 148692 221 148.62 221951 290 130.65
77 78231 116 148.27 149995 192 128.00 223866 220 98.27
78 78257 85 108.60 151456 220 145.25 226488 226 99.78
79 78112 80 102.41 152682 173 113.11 229933 239 103.94
80 78331 92 117.45 155341 210 135.18 235111 242 102.93
81 78555 79 100.56 160010 157 98.12 242752 256 105.45
82 79271 92 116.05 162756 161 98.92 244191 275 112.62
83 80023 100 124.96 166662 186 111.60 254303 290 114.04
84 80294 95 118.32 168296 144 85.56 259276 320 123.42
85 80877 80 98.92 170916 173 101.22 262624 285 108.52
86 82214 101 122.85 172888 179 103.54 266119 296 111.23
87 82291 78 94.79 175132 173 98.78 269573 310 115.00
88 81953 114 139.10 177724 215 120.97 263222 340 129.17
89 82289 91 110.58 179502 206 114.76 275391 355 128.91
90 84228 62 73.61 190411 239 125.52 298185 449 150.58
91 85459 48 56.17 192370 262 136.20 302601 425 140.45
92 85498 59 69.01 194281 250 126.68 307073 405 131.90
93 86484 68 78.63 195963 225 114.88 308956 386 124.94
94 87881 68 77.38 198956 188 94.49 312984 374 119.50
95 87661 78 88.98 198715 195 98.13 311510 413 132.58
96 87221 72 82.55 198276 191 96.33 311009 409 131.51
Total of 70's 545733 821 150.44 1051424 1489 141.62 1573911 1828 116.14
Total of 80's 811995 892 109.85 1724297 1833 106.30 2635636 3176 120.50
Total of 90's 520204 393 75.55 1178561 1311 111.24 1854133 2412 130.09
Total 1877932 2106 112.14 3954282 4633 117.16 6063680 7416 122.30
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Figure 3.

Figure 3

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The Geography Distribution of Cixian EC Incidence from 1974 to 1996.

In the hilly area there were 4633 EC cases. The annual average rate was 117.16/100000. From 1974 to 1996, the incidence rate changed from 165.71/100000 to 96.33/100000. Decreasing in number was 69.38/100000. And declining rate was 41.86%. The result of trend test was χ2 = 42.70, P < 0.001. From Table 2 and Figure 3, we could see that from 1970s to 1980s the incidence rate of EC declined significantly, from 141.62/100000 to 106.30/100000 (U test: P < 0.01). While comparing the incidence rate of EC of 1980s with that of the 1990s' it increased from 106.30/100000 to 111.24/100000 (U test: P < 0.01).

On level land there were 7416 EC cases over 23 years. The annual average incidence rate was 122.30/100000. According to Table 2 and Figure 3 we can see that during the past 23 years incidence rate of EC increased steadily. The result of trend test was χ2 = 22.39, P < 0.001. Comparing 1970s’ incidence rate with 1990s’, it increased from 116.14/100000 to 130.09/100000. The increasing in number was 13.95/100000 and the increasing rate was 12.01% (U test: P < 0.01). Comparing the incidence rate of 1980s with the 1990s’, which increased from 120.50/100000 to 130.09/100000. The increasing in number was 9.59/100000 and the increasing rate was 7.95% (U test: P < 0.01). We could see that the incidence rate of EC in level land was increasing steatidly.

There are 35 townships in Cixian County. In the 1970s, Linfeng township had the highest incidence rate of EC, which was 211.90/100000. While Dudang township had the lowest, which was 66.57/100000. The highest male incidence rate existed in Linfeng and the mumber was 298.02/100000. While the highest female incidence rate existed in Guanglu township and the number was 164.49/100000. The lowest incidence rate of EC of both male and female existed in Dudang, which was 79.71/100000 and 51.51/100000, respectively. The highest rate was 3.18 times as much as the lowest. Cixian County had two high risk areas, one was the mountainous area which was centered around Baitu district (132.23/100000), the other was hilly area which was centered around Lintan district (128.64/100000). Level land had the lowest incidence rate (116.01/100000). After 1980s, the highest incidence rate existed in Guanglu township (232.04/100000) and the lowest existed in Dudang (55.08/100000). Linfeng had the highest male incidence rate of EC (285.37/100000). While Cizhou town had the lowest (64.77/100000). Guanglu had the highest female incidence rate of EC (214.28/100000), while Dudang had the lowest (38.65/100000). The highest EC incidence rate was 4.21 times as much as the lowest. There were 20 towmships whose incidence rate were higher than the average of county wide, forming a high-risk hilly area, which was centered around Lintan district. After 1990s, Ducun township had the highest EC incidence rate of 275.80/100000. While Dudang township had the lowest whose number was 45.92/100000. The highest male incidence rate existed in Ducun township which was 341.08/100000. The highest female incidence rate existed in Guanglu which was 213.26/100000. While the lowest male incidence rate lay in Wuhe township which number was 36.20/100000. The lowest female incidence rate lay in Huangsha township which was 26.98/100000. The highest EC incidence rate was 6.01 times as much as the lowest. There were 19 townships whose incidence rate were higher than the average of county wide, forming a high-risk level land area which was centered around Ducun township.

In the 1970s, the high incidence area existed in mountainious areas which are centered around Baitu district and in hilly area which was centered around Lintan district. After 1990s, the incidence rate of EC in Cixian declined significantly. But the hilly area still had high incidence rate, decilining slowly. While the level land area had increasing trend, forming a high risk area which was centered around Ducun township.

DISCUSSION

Cixian county is one of the highest EC incidence rate areas in China, as well as in the world. Since the early 1970s, cancer registry system has been established where began to collected the cancer incidence in Cixian county[10-21]. Until now Cixian Cancer Registry have piled up the incidence data of more than twenty years. In this study we found the trend of the incidence rate of EC from 1974 to 1996 had declined after two decades. As for the possible causes of EC[22-27], we advocate the inhabitant to take follow prevention: (1) To improve the quality of the drinking water condition; (2) To administer the farm products storage, not to eat the food with mold; (3) Eating more vegetables and fruits, changing the bad life style; (4) Conducting screening survey to find the carcinoma in situ or intramucosal carcinoma especially esophageal epithelium dysplasia (EED). EED is a precancerous lesion which can either develop further into a more severe stage or cancer, stay unchanged, or reverse back to normal again for a period of several years or even a decade[28-34]. It is therefore very promising to detect patients with EED and treat the precancerous lesions before they transform into the irreversible malignant stage. There are several techniques and chemicals or nutrients that have been reported to be effective in blocking precancerous lesions from transforming into cancer[35-38].

The incidence rate among males declined significantly however, females remained steady. As to the geographic distribution, the incidence rate in mountainous area and hilly area showed a declining trend. The incidence rate of EC in level land area had increased. The reasons why these happened needs to be further studied and analysed.

In conclusion, the trend of the EC incidence rate in Cixian county had declined after two decades, especially in mountainous areas. But compared to the other regions in the world Cixian county still had a high incidence rate of EC. By using a register the information can provide the scientific data for cancer prevention and control.

Footnotes

Supported by The National Ninth-Five-Year Scientific Championship Project No.96-906-01-01

Edited by Xia HHX

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