M. Boniol, M.

Heanue
Objective
The key determinant of cancer incidence is age, as the risk of cancer increases exponentially with increasing age. The
crude rate of incidence is therefore influenced by the population structure, and cannot be used alone to evaluate whether
the burden of cancer differs between populations.
To compare the incidence of cancer, the summary rates should be independent of age. A common way to take into
account the age structure of a population is to standardise incidence rates for age using an external (standard) population.

Crude incidence rate

The crude incidence is the rate at which new cases occur in a population during a specific period. This rate is classically
expressed as the average number of cases occurring per 100 000 persons each year or 100 000 person-years. In Cancer

Chapter 7: Age-standardisation and denominators

Incidence in Five Continents (CI-5), Volume IX, numbers of cancer cases are reported for the period 1998–2002. Hence the
crude incidence rate is computed with the following formula:

M. Boniol and M. Heanue Number of new cancer cases observed in the period 1998 - 2002
Crude incidence rate =
Total population in the period 1998 - 2002

Objective Age-standardised
The total population in the period 1998–2002 incidence
corresponds rate
to the sum of population size for each year between 1998 and
The key determinant of cancer incidence is age, as the2002. riskThis
of rateThe age-standardised
is called ratetoiseach
crude because it relates a summary
population of
as athe individual
whole age-specific
and is influenced by the age structure of
cancer increases exponentially with increasing age. Theeachcrude population.rates using
It cannot an for
be used external
comparisonpopulation
purposes. called a standard population. This

rate of incidence is therefore influenced by the population is the incidence that would be observed if the population had the age
structure, and cannot be used alone to evaluate whether the structure
Age-standardised incidenceof the standard population, and corresponds to the crude
rate
burden of cancer differs between populations. incidence rate
thatin thebestandard
would population.
observed if the population hadThe age-standardised
The age-standardised rate is a summary of the individual age-specific rates using an external population called a standard
population. This is the incidence the age structure of the standard population,
To compare the incidence
Chapter 7 Age-standardisation and Denominators of cancer, the summary rates should
and correspondsincidence rate
to the crude incidenceis expressed,
rate as
in the standard is the crude
population. incidence
The age-standardised rate, asrate
incidence theis expressed, as
M. Boniol, M.beHeanue
independent of age. A common way to take into account the number of new cases per 100 000 person-years.
is the crude incidence rate, as the number of new cases per 100 000 person-years.

age structure of a population is to standardise incidence rates for The

The calculation calculation
is a weighted average ofisage-specific
a weighted rates. average of age-specific rates.
Objective age using an external (standard) population.
The key determinant of cancer incidence is age, as the risk of cancer increases exponentially with increasing age. The
dw
crude rate of incidence is therefore influenced by the population structure, and cannot be used alone to evaluate whether
Crude
the burden of cancer incidence
differs rate
between populations.
Age - standardised rate = ¦ i
i i

yi
account the ageThe crude incidence is the rate at rates
which newusingcases occur Such that i represents each age group,
in population.
To compare the incidence of cancer, the summary rates should be independent of age. A common way to take into
structure of a population is to standardise incidence for age an external (standard)
a population during a specific period. This rate is classically di theinnumber
Such that i represents each age group,
di the number of cases
of cases in the ith age group,
the ith age group,
expressed
Crude incidence rate
as the average number of cases occurring per 100
yi the 000
populationyisize thein population
the ith age groupsize in the ith age group,
persons
The crude incidence is theeach
rate atyear
which ornew100
cases000
occurperson-years. In Cancer
in a population during This rate isand
Incidence
and wi the weight
a specific period. wi the
applied
classically weight
for the applied
ith age group, with for the ith age group, with
numbers each of
yearcancer cases aresum ofdInwi/y being the age-specific rates for eachrate ithpercategory
di/yi being the age-specific rates for each ith category
inaverage
expressed as the Five Continents
number of cases(CI5), Volume
occurring per 100 IX,
000 persons or 100 000 person-years.
With the
Cancer
being
i i equal to 100 000 to express the age-standardised 100 000 person-years.
crude incidencereported for with
the the
period 1998–2002. Hence the crude incidence and the sum of wi being equal to 100 000 to express the age-
Incidence in Five Continents (CI-5), Volume IX, numbers of cancer cases are reported for the period 1998–2002. Hence the
rate is computed following formula:
rate is computed with the following formula: standardised rate per 100 000 person-years.
It should be stressed that the objective of age standardisation is essentially to establish rates for comparison purposes. Any
population standard would enable comparison, even considering equal weights for each age group.
The most commonly used standard worldwide is the Segi standard population (Segi 1960). Modified by Doll et al.
Number of new cancer cases observed in the period 1998 - 2002
it was It
Crude incidence rate = (1966), based should
on the be stressed
age structure thatpooling
of the the objective
of populationsof fromage standardisation
46 countries. The use of this standard
Total population in the period 1998 - 2002 population allows international comparison and evaluation of changes in incidence by comparing them to rates published
is essentially
in previous volumes of CI-5. to establish rates for comparison purposes. Any
The total population in the period 1998–2002 corresponds to the population standard would enable comparison, even considering
sum of population size for each year between 1998 andAnyear
The total population in the period 1998–2002 corresponds to the sum of population size for each
2002.
example
between
equal
of this
weights for each age group.
ageand
1998 standardisation appears in table 1.
2002. This rate is called crude because it relates to each population as a whole and is influenced by the age structure of
This
each population. ratebeisused
It cannot called crude because
for comparison purposes. it relates to each population as a The most commonly used standard worldwide is the Segi
whole and is influenced by the age structure of each population. standard population (Segi, 1960). Modified by Doll et al. (1966),
It cannot
Age-standardised incidencebe used for comparison purposes.
rate it was based on the age structure of the pooling of populations
The age-standardised rate is a summary of the individual age-specific rates using an external population called a standard
population. This is the incidence that would be observed if the population had the age structure of the standard population,
and corresponds to the crude incidence rate in the standard population. The age-standardised incidence rate is expressed, as
is the crude incidence rate, as the number of new cases per 100 000 person-years. 111
Table 7.1 Computation of age-standardised incidence rates (Melanoma cancer, Denmark, males, 1998–2002)
The calculation is a weighted average of age-specific rates.
Age-specific
d i wi Standard world Expected cases in
Age group Age - standardis
No. of
edcases
rate = ¦ Person-years at risk incidence
population standard population
i yi (per 105 years)
Such that i represents each agei group, di yi 105(di /yi) wi di wi /yi
di the number of cases in the ith age group,
yi the population size in the 0–4
ith age group 0 869 668 0.00 12 000 0.00
and wi the weight applied for the ith age group, with
5–9for each ith category
di/yi being the age-specific rates 0 878 535 0.00 10 000 0.00
With the sum of wi being equal to 100 000 to express the age-standardised rate per 100 000 person-years.
10–14 0 779 915 0.00 9 000 0.00
It should be stressed that the objective of age standardisation is essentially to establish rates for comparison purposes. Any
population standard would15–19
enable comparison, even considering7 equal weights for each age 723 313
group. 0.97 9 000 0.09
(1966), it was based on the age structure of the pooling of populations from 46 countries. The use of this standard2.74
20–24 23 840 592 8 000 0.22
The most commonly used standard worldwide is the Segi standard population (Segi 1960). Modified by Doll et al.

25–29 59 961 907

population allows international comparison and evaluation of changes in incidence by comparing them to rates published
in previous volumes of CI-5.
6.13 8 000 0.49
30–34
An example of this age standardisation appears in table 1.
83 1 042 749 7.96 6 000 0.48
35–39 117 1 041 800 11.23 6 000 0.67
40–44 153 953 731 16.04 6 000 0.96
45–49 188 930 210 20.21 6 000 1.21
50–54 262 990 187 26.46 5 000 1.32
55–59 303 871 969 34.75
111 4 000 1.39
60–64 272 649 423 41.88 4 000 1.68
65–69 223 523 486 42.60 3 000 1.28
70–74 217 439 676 49.35 2 000 0.99
75–79 162 342 435 47.31 1 000 0.47
80–84 119 210 084 56.64 500 0.28
85+ 115 140 073 82.10 500 0.41
Total 2 303 13 189 753 17.46 100 000 11.94

99
 Age-standardisation and denominators

from 46 countries. The use of this standard population allows The sum of the age specific rates between ages 0–74 is: (0.97
international comparison and evaluation of changes in incidence +2.74+6.13+7.96+11.23+16.04+20.21+26.46+34.75+41.88+4
by comparing them to rates published in previous volumes of CI5. 2.60+49.35)/100 000 = 260.33/100 000. Hence the cumulative
Table 1. Computation of age-standardised incidence rates (Melanoma cancer, Denmark, males, 1998–2002)
An example of this age standardisation appears in Table 7.1. rate is (260.33/100 000) × 5, or 1.3%.
Age group No. ofIn thisPerson-years
example, the at crudeAge-specific
rate is 2303 / 13Standard 189 753world = 17.46Expected cases in
casescases per 100 risk000 person-years, and the age-standardised
incidence population rate is The standard age-specific incidence rates calculated in a registry are
11.94 per 100 000 person-years. (per 105The years) cumulative incidence rate ranges derived
population between
from different 0 and 75,birth and cohorts;
by its construction
i.e. populations overestimates
born at the probability of
I di The age-standardised
yi rate
105(dis i)lower
ai /ycancer than
during thelife
w crude
when
The cumulativei incidence rate ranges rate
incidence different
d wrates
/y periods
are high. who experienced
However when different
incidence
i i i between 0 and 75, and by its construction overestimates the probability of devellevels
rates of areexposure
sufficiently small, apart fro
0–4 because
0 the
869standard
668 population 0.00is on average
cancer sites younger
combined,
12 000 thanthe the
cumulative to carcinogens.
0.00 rate is not The cohort
significantly effect
a cancer during life when incidence rates are high. However when incidence rates are sufficiently small, apart from all is
affected an important
by this bias. determinant
5–9 Danish
0 population.
878 535 However, the 0.00rateInofthe 11.94
cancer can
previous
sites
10be 000 compared
example
combined, the of the
forcumulative 0.00 observed
melanoma rate inismen incidence
not in Denmark,
significantly for most the cancer
affected cumulative
by this sites. bias. For can
rate example,
be estimated from the age
10–14 with other rates standardised on the
0 779 915 0.00
rates: world population.
In the
9 000
previous example mesothelioma
for
0.00
melanoma inincidence
men in is driventhe
Denmark, by asbestos
cumulative exposure
rate can that
be took
estimated from the age-spec
15–19 7 723 313 0.97 9 000 0.09
20–24 23 840 592 The
2.74 sum of
rates: the age
8 000 specific rates place
between
0.22
in the agespast (until
0–74 the
is: 1990s in most developed countries),
25–29 59Reference 961population
907 6.13 The sum of 8the 000age specific rates and0.49
(0.97+2.74+6.13+7.96+11.23+16.04+20.21+26.46+34.75+41.88+42.60+49.35)/100 the
betweencumulative ages 0–74 ratesis:calculated in CI5 Volume IX would 000 =not260.33/100 000. Henc
30–34 83A new standard
1 042 749 population was
7.96 proposed
cumulative by WHO in 2000 reflect the
(0.97+2.74+6.13+7.96+11.23+16.04+20.21+26.46+34.75+41.88+42.60+49.35)/100
rate 6 000
is 260.33/100 000*5, 0.48or 1.3%. lifetime risk of mesothelioma of a population 000 = born 260.33/100 000. Hence the
35–39 117(Ahmad1 et 8002000). This new
041al., 11.23standard allows
The
cumulative the
cumulative
6rate
000 estimation
is 260.33/100in000*5,
incidence rate2000.
ranges between 0 and 75, and by its construction overestimates the probability of developing
0.67 or 1.3%.
40–44 153of incidence 953 731 for the theoretical 16.04world population. a cancer 6 000This new
during life when Nevertheless, the cumulative rate reflects the burden of cancersmall, apart from all
incidence
0.96 rates are high. However when incidence rates are sufficiently
population is, however, not of great utility The age-specific
cancer incidence
sites combined, rates
the calculated
cumulative rateinhas
is anotregistry
addedare
significantly derived
affectedover byfrom different
this bias. birth cohorts; i.e. populatio
45–49 188 930 210 20.21
The for cancer incidence
age-specific
In the
6 000
incidence
previous example
in a place,
ratesfor
1.21
calculated
melanoma
and
ininmenatheregistry
in Denmark,
advantage
are derived
the cumulativefromthe age-standardised
different
rate can be birth cohorts;
estimated i.e.the
from populations
age-specific bo
50–54 262standardisation
990 187for two main reasons: different periods
26.46 5 000who experienced rate of
1.32 different
not imposing levels an of exposure
external population to carcinogens.
structure. The cohort effect is an
55–59 303 871 969 34.75 different
rates: periods
4 000 who experienced different levels of exposure to
1.39 for most cancer sites. For example, mesothelioma incidence is driven b carcinogens. The cohort effect is an imp
This new standard population is supposed
determinant
Thetosum
determinant ofbetter
the represent
observed incidence
60–64 272 649 423 41.88 4 of
of the
000 the observed
age specificincidencerates
1.68between for mostages 0–74 cancer is: sites. For example, mesothelioma incidence is driven by asb
65–69 223the theoretical
523 486world population42.60 compared
exposure to Segi’s
that
exposure population,
took
that placeplace
took inbutthe in the Statistical
past past(until
(until tests
(0.97+2.74+6.13+7.96+11.23+16.04+20.21+26.46+34.75+41.88+42.60+49.35)/100
3 000 1.28
thethe1990s1990sin in most developedcountries),
most developed countries), 000 and=and thethe cumulative
cumulative
260.33/100 ratesrates
000. Hence the ca
calcula
70–74 217still does 439so insufficiently,
676 as population
volume
49.35 data
volume is lacking
IXcumulative
would
IX not
would
2 000 for
rate notismany
reflect reflect theStatistical
260.33/100 lifetime
the lifetime
000*5,
0.99 ortests,
riskrisk
1.3%. the results of which
ofofmesothelioma
mesothelioma of are not born
of aa population
population published
born in in here,
2000.
2000.
75–79 162regions in342 the435 world. Secondly, thereNevertheless,
47.31 is noNevertheless,
additional thestatistical
1 000 cumulative
the cumulative were
rate
0.47 used
ratereflects to flag
reflects the certain
theburden
burden of registries
of cancer
cancer in as
inaa‘unusual’
place,and
place, and orhashas
possibly
thethe added
added advantage
advantage over ov the
80–84 119property from 210 084 this standard to the 56.64Segi population
standardised Therate
standardised forof comparison
500
age-specific
rate not incidence
of imposing
not imposing inconsistent
0.28
rates
an calculated
external
an external with inprevious published
are deriveddata.
a registrystructure.
population
population structure. from different birth cohorts; i.e. populations born a
85+ 115purposes 140 (Bray,
073 2002). For data 82.10in the present different volume,
500
periods forwho all experienced 0.41 different levels of exposure to carcinogens. The cohort effect is an importan
cancer13incidences excluding 17.46non-melanoma skin cancer, we life
The cumulative incidence rate ranges between 0 and 75, and by its construction overestimates the probability of developing
Total 2 303 189 753
Statistical
100 000
determinant tests of the during
observed Calculation
11.94
incidence of variance
for most cancer of sites.
ASRswhen For example, mesothelioma incidence is driven by asbesto
Statisticalexposure tests that took place in the past (untilrates
a cancer when incidence are high. However incidence rates are sufficiently small, apart from all
estimated the Spearman correlation (r)Statistical between the tests,ratesthe
cancer using
results
sites combined,ofVariances
which are ofnot
the cumulative age-standardised
the 1990s
published
rate mostrates
in here,
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developed
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by this are
to usedcertain
countries),
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bias. to
andassess the as rates
theregistries
cumulative calculated
‘unusual’ or poin
In this example, the crude rate is 2303 / 13 189 753 = 17.46 cases
Segi’s standard compared to the new Statistical
per 100 000
standard. tests,
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The results
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notprevious which
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example are not published
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inthe
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2000.Volume
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is 11.94 per 100 000 person-years. inconsistent with previous published data.
inconsistent with previous published data.
The age-standardised variation notthan
explained
the crudeby thebecause
new standard compared to isthe old VIII andrates Volume IX 0–74andis:to compute confidence intervals of
Nevertheless, rates: the cumulative rate reflects the burden of cancer in a place, and has the added advantage over the age
rate is lower rate the standard population
standardised The
ratesum on average
of ofnottheimposing
age younger
specific than the population
between ages
Danish population. However, standard
the rate(1-r 2
) wascan
of 11.94 0.14% for menwith
be compared andother
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Calculation women.
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standardised When
on the ofworld
ASRs rates inanVolume
external IX. We based
(0.97+2.74+6.13+7.96+11.23+16.04+20.21+26.46+34.75+41.88+42.60+49.35)/100
population.
structure. the estimation of 000 variance
= 260.33/100of 000. Hence the
looking at ranking of registries by level Calculation of incidence,
Variances of variance
of the new ASR
cumulative of
age-standardized ASRsrate is on(ASR)
260.33/100
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000*5, or
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Statistical tests
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useFor aexample,
binomial mesothelioma
assumption incidence(Keyfitz
is driven by1966)
asbestosfor the v
standardisation for two mainThereasons:
lack of clear difference between incidence rates computed
exposure that took place in the past (until the 1990s in most developed countries), and the cumulative rates calculated in
This new standard population is supposed to better represent
with Segi’s population compared to the new world
the crude Calculation
age-specific
the theoretical world
of population
variance
rates.
volume
standard
IX would
does
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ASRs
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Segi’s risk of mesothelioma 18 §
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ypopulation
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i �
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population, but still does so insufficiently, as population data is lacking for Variances
not justify the use of the new population.
many regions
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VIII
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in
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in w
i ¸
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age- rates in
no additional statistical property from this standard to the Segi population for comparison purposes (Bray, 2002). For data
in the present volume, for all Forcancer
these incidences
reasons, and to allow
excluding international
non-melanoma skin comparisons
variance of ASRwe
cancer, on Breslow and
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the crude age-specific rates. 2
i
correlation (r) between the rates using Segi’s standard standard. Statistical percentage of variation
tests, the results of whichnot
Var ( ASR )
= 1
§ used toi· flag certain
18
registries
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explained by the new standard world standard. 2
to the old standard (1-r ) was 0.14% for men and 0.11%
inconsistent for women.
with previous publishedWhen data. = 18 §
¦
d *¨( y18 � wdi ¸) *2 w · 2
looking at ranking of registries by level of incidence, the new standard produces an average change of 2.9 rank levels for ¨ i ©§ i =1i 3 ¹i · i ¸ ¦
men and 1.9 for women in Cumulative
data includingrate
change for women. The lack of clear difference between incidence rates computed with Segi’s
Calculation of variance
population
of ASRs
all registries; this corresponds to an average of 0.7% change for men and 0.5%
compared Var
Variances of age-standardized rates
to (
the ASR
(ASR) are)used
=
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The cumulative rate is an approximation We of the 95%
estimated probability
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Volume intervals
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IX and to of rates
compute based
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intervals 2 in of
of rates the
Volume normal distribution
IX. We based of the
the estimation of rates.
new world standard does not justify the use of the new population. § a binomial
18
· assumption (Keyfitz
to develop a cancer during a certain period—for example,
variance of aASR We
For these reasons, and to allow international comparisons with continuity from the previous
the crudevolumes,
estimated
on Breslow
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age-specific
95%
and Day’s
use here only confidence
method modified tointervals
use
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i ¸ of rates based on an
1966)
¦
for the variance of

Segi’s world standard. lifetime. We present the cumulative rates for the
We estimated 95% lifeconfidence
spans of intervals
assumption (CI)ofoftherates
normal distribution
CI = based
±1.96 18on an =1 of ¹the rates.
© i assumption
§* Var ( ASR )2 ·
of the normal distribution of the rat
0–64 and 0–74 years. This has the advantage of summarising d i * ( yi � d i ) * wi
¦ ¨¨ ¸
¸
the age-specific rates independently of the We ageestimated
structure95% of the
3
Cumulative rate confidence intervals (CI) of rates basedi =1on yi
an assumption of ¹the normal distribution of the rates.
The cumulative rate is anpopulation,
Var ( ASR) = © CI = ±1.96 * Var ( ASR )
approximation andofgives the probability
the probability of ana individual
to develop cancer duringdeveloping
a certain period—for example, a
§ 18
·
2

a cancer. rates
lifetime. We present the cumulative Thisforcalculation
the life spansisoftheoretical
0–64 and 0–74and assumes
years. This hasthat no
the advantage of summarising ¨ ¦ wi ¸
CI = ±1.96 * Var © ( ASR )
death occurs in the period, and that the
the age-specific rates independently of the age structure of the age-specific
population,
Comparisonand givesincidence
the
of ASRs probability
from Volume of an
Comparison individual
of ASRs
IX with the values from Volume VIII
from Volume i =1
IX¹ with the values from
developing a cancer. This calculation is theoretical and assumes that no death occurs in the period, and that the age-specific
rates will be stable for an individual. To identify significant
incidence rates will be stable for an individual. We estimated 95%Volume
changes in VIII
incidence
confidence between
intervals (CI) Volume
of rates based VIII and
on an assumption Volume
of the IX we ofestimated
normal distribution the rates. the Compa
Tocorresponds
Incidence Figure (CIF), which identify significant changes
to the ratio of theinage
incidence between
standardised Volumerate
incidence VIIIin Volume IX divided b
Comparison of ASRs15fromd i inVolume IX with the values from Volume VIII
Cumulative rate between 0 -To age-standardised
74 identify
years = 5 × ofrate
oldsignificant
Comparison ASRs from and
Volume Volume
VIII.
Volume IXthe
IX with wevalues
estimated
¦
CI =from
±1.96 the
* Comparative
VolumeVar ( ASR ) Incidence Figure
VIII
changes in incidence
(CIF), in
which between
corresponds
between to
Volume
the ratioVIII the
VIIIofand
and Volume
age IX we estimated the C
standardised
=1 yi
To identify i significant changes incidence Volume ASR
Volume IX we estimated the Comparativ
Such that i = 5-year age groups,
Incidence Figure (CIF), which incidence
corresponds
Incidence Figure (CIF), Comparativ rate
to in
the Volume
ratio
which correspondsetoIncidence of IX
the divided
age
the ratio of theFigure by the
standardisedage-standardised
incidence
Volume rate
= incidence rate inIXVolume
age standardised
from in Volume IXbydivi
IX divided the
di=number of cases in theSuch
ith agethat i = and
group, 5-year age groups, age-standardised rateComparison
in Volume
age-standardised rate in
VIII.
rate inofVolume Volume
VIII. VIII.
ASRs from Volume IX with the values from Volume VIII ASR from Volume VIII
di=number ofgroup.
cases in the ith age group, and
yi=number of person-years in the ith age
yi=number of person-years in the ith age group. Comparative Incidence Figure
Figure ==
ASR
ASR
To identify significant changes in incidence between Volume VIII and Volume IX we estimated the Comparative
fromfrom
Volume IX
The upper Comparativ
(CIu)age-standardised
and lower (CI l) 95%
rate e Incidence
Incidence Figure (CIF), which corresponds to the ratio of the age standardised incidence
confidence
in Volume VIII.
rate inVolume
Volume IXdivided by the
IX
interval limits of CIF were computed using the following formula:
ASR
The cumulative incidence rate ranges between ages 0 and ASR
ASRfrom VolumefromIXVolume VIII
from Volume VIII
Comparative Incidence Figure =
75, and by its construction overestimates the probability of The upper (CI
The upper (CIu) and lower (CIl) 95% confidence ) and lower
Var (CI
( ASR
interval limits )
l of
95% confidence
ASR
CIF were IX )
computedinterval
Var (VIII
ASR limits )
)±u 1.96
(CIF computed fromVolume
+ using the followingVIII
fromVolume formula:
=e
developing a cancer during life when incidence
(CIurates
) andare high.(CIl) of Ln
CIF were * using the following
from Volume
formula:
The upper lower
However when incidence rates are sufficiently small, apart u / (CI
The upper
95% confidence
CI interval
l u) and lower (CIl) 95% confidence interval
limits
ASR of CIF
fromVolume
limits of CIF were
were2 computed using the following
IXcomputed using ASR the fromVolume VIII
following formula:
2 formu
from all cancer sites combined, the cumulative rate is not Var ( ASRfromVolume IX ) Var ( ASRfromVolume VIII )
Ln (CIF )±1.96*
=e
+
significantly affected by this bias.
( ) CI Var (
Var
ASR ASR
( ASR fromVolume
fromVolume IX ) IX ) ASR
2 Var ( ASR
Var ( ASR ) 2
VIII2fromVolume
fromVolume VIII VIII VIII ) if the

=e
( )
e
u / l Ln
We considered the difference betweenCIF Ln
rates1 CIF
. *±1
in96Volume. 96 * XI compared to2rates in +Volume
fromVolume IX + fromVolume to be significant
In the previous example for melanoma in men in Denmark CI u / l = ±
CI
1.0 was not included in the 95% confidence interval of the
(Table 7.1), the cumulative rate can be estimated from uthe/ lage- ASR
ASRfromVolume IX
CIF.
fromVolume IX
2 ASR
ASRfromVolume VIII 2
fromVolume VIII

specific rates: We considered the difference between rates in Volume XI compared to rates in Volume VIII to be significant if the value
We considered the difference between rates in Volume XI compared to rates in Volume VIII to be significant if the value
1.0 was not 1.0
included in the 95% confidence interval of the CIF.
was not included in the 95% confidence interval of the CIF.
We considered the difference between rates in Volume XI compared to rates in Volume VIII to be significant i
1.0 was not included in the 95% confidence interval of the CIF.

100
113
 Age-standardisation and denominators

We considered the difference between rates in Volume XI compared population estimate. Moreover, population estimates are often
to rates in Volume VIII to be significant if the value 1.0 was not revised once a new census is available but not all cancer registries
included within the 95% confidence interval of the CIF. collect these updated figures. Hence the drift and even a significant
change in incidence rate between the year of the census and the
Comparison of percentage of microscopically verified cases preceding year could occur simply because of the imprecision of
(MV%) from volumeof IX
Comparison with theofvalues
percentage from volume
microscopical VIII(MV%) from the
verification volume population
IX with the estimate.
values from This is especially
volume VIII true when population
We estimated the Z statistic
We estimated as: as:
the Z statistic sizes are small and susceptible to more variability, for example,
when there is migration within a country.
§V · §V · Despite these considerations, for most countries contributing
Ln¨¨ VIII ¸¸ �- Ln¨¨ IX ¸¸ to CI5 a census occurred during the period 1998–2002. Hence,
© nVVIII ¹ © nVIX ¹ we can expect that the biases described earlier could be largely
Z= alleviated. However, in some registries the population figures
1 1 1 1 were estimated from a census performed more than 10 years
+ + + before the period used in Cancer Incidence in Five Continents,
VVIII nVVIII VIX nVIX Volume IX.
With VVIII and VIX being the number of cases microscopically Another limitation in the population figure is the choice of
verified With
in Volumes
VVIII and VIII andthe
VIX being IX, respectively,
number and nVVIII and
of cases microscopically verifiedthe date in VIII
in volumes the and
yearIX,for population
respectively, andestimate.
nVVIII and The best estimate
nV being the number of cases not microscopically verified in Volumes VIII and IX, respectively.
nVIX being IXthe number of cases not microscopically verified in of the population at risk
We considered the difference in the proportion of cases microscopically verified to be significant if Z was greater
for a specific year in which cancer
Volumesthan VIII1.96.
and IX, respectively. incidence was observed is considered to be at mid-year, and
We considered the difference in the proportion of some registries provided yearly population estimates for the 1st
microscopically
Population verified
at risk cases to be significant if Z was greater of July. However, this is not a systematic practice and many
than 1.96.Population at risk figures are used as denominators in the formulas forregistries the calculationprovided populations
of incidence rates, crude statistics
or adjusted. estimated at the
These denominators are often disregarded, and readers tend to onlybeginning focus on the of final
the year, using
incidence theand
rates 1st discuss
of January.
the In a population
Population at riskin incidence data gathering (completeness, classification).
variability thatThis increases,
notion isthe use by
driven of 1the of January for population size could
st age standardisation
process, which tends to eliminate the effect of population age structure and gives the reassuring but false impression that
Population at riskstructure
population figures arelonger
is no usedinfluencing
as denominators
the incidencein theIt must
rates. induce a systematic
be stressed overestimation
that denominators are an essentialof incidence
part rates. It is
formulasofforthethecalculation
calculation of incidence
of incidence rates,rates, crudetheir
and have or adjusted.
own biases and expected to have
limitations only be
that must a minor
kept ininfluence
mind. Theinage Cancer Incidence in
These denominators
standardisationare often
process disregarded,
is not and imprecise
intended to solve readers tend to size
population Continents, which uses a period of 5 years combined.
Fiveestimation.
only focus on the final
Numbers of incidence
population at rates
riskand
are discuss
routinelythe variability
collected by registries from official statistical offices for example and
in incidence dataprovided
registries gatheringthese(completeness,
figures to Cancer classification).
Incidence in Five This
Continents Migration
along with their incidence figures.
notion is driven by the age standardisation process, which tends Population size could also be overestimated or underestimated
Comparability
to eliminate the effect of population age structure and gives the if migration flux patterns are not considered. Some registries
Population size estimates are frequently calculated by the official statistical office using the results from a census and a
reassuring but
projectionfalse impression
for the that population
years following the most recentstructure is no
census. The closer collected population
the year a population estimatedata
is tocorrected
a census date,for the immigration and
longer influencing
more accuratethe theincidence
estimate willrates. It mustwhen
be. Therefore be stressed
countries that emigration.
do not have Between-country
the same census year, there willmigration
be differencesis often
in better handled
denominators are anofessential
the precision part of estimate.
their population the calculation
Moreover, ofpopulation
incidenceestimatesthan are within countryonce
often revised migration,
a new census which is of major concern to
is available
rates, andbuthave
not alltheir
cancerown biasescollect
registries and these
limitations
updated that must
figures. Hencebe theregional
drift and evenregistries taskedchange
a significant with maintaining
in incidence rate optimal coverage of
kept in mind.
between Thetheageyearstandardisation
of the census andprocess is notyear
the preceding intended to their
could occur simplypopulation.
because of the Indeed, populations
imprecision of a highly nomadic nature
of the population
solve imprecise
estimate. population size estimation.
This is especially true when population sizes are small and make the production
susceptible of inter for
to more variability, censal population
example, when estimates a real
there is migration within a country.
Numbers of population at risk are routinely collected challenge. Hence incidence figures for these populations must be
Despite these considerations, for most countries contributing to CI5 a census occurred during the period 1998-2002.
by registries
Hence,fromwe can official
expectstatistical
that the biasesoffices for example
described and be evaluated
earlier could with care,
largely alleviated. and their
However, in somecomparability
registries theis to be questioned.
registriespopulation
providedfiguresthesewerefigures to Cancer
estimated Incidence
from a census performedin more
Five than 10 years before the period used in Cancer Incidence
Continents along
in Five with their
Continents, incidence
Volume IX. figures. A few words of caution
Another limitation in the population figure is the choice of theCancer date in isthe a disease
year for that mainlyestimate.
population occurs The at older
best ages, and standard
Comparability
estimate of the population at risk for a specific year in which cancerpopulations incidence wassuch
st
as Segi
observed have the to
is considered tendency
be at mid- to give more weight
Population size
year, andestimates are frequently
some registries provided yearlycalculated by the
population official
estimates for theto1 incidence in young
of July. However, this age
is notgroups
st and hide
a systematic differences observed
practice
and many registries provided populations statistics estimated at the beginning of the year, using the 1 of January. In a
statisticalpopulation
office using the results from a census and a projection in older populations. Therefore it cannot be stressed enough
that increases, the use of 1st of January for population size could induce a systematic overestimation of
for the years following
incidence the
rates. It is most recent
expected census.
to have only Theinfluence
a minor closer the
in CancerthatIncidence
neitherintheFiveage-standardised
Continents, which uses ratea nor
periodthe cumulative rate
year a population estimate is to a census date, the more accurate are alternatives to the age-specific incidence rates, which should
of 5 years combined.
the estimate will be. Therefore when countries do not have the always be the starting point and foundation of any thorough
same census year, there will be differences in the precision of their analysis of the incidence data.
Migration
Population size could also be overestimated or underestimated if migration flux patterns are not considered. Some
registries collected population data corrected for immigration and emigration. Between-country migration is often better
handled than within country migration, which is of major concern to regional registries tasked with maintaining optimal
References
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population estimates a real challenge. Hence incidence figures for these populations have to be evaluated with care, and
Ahmad their
O., comparability
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questioned. Incidence
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WHOA few
standard.
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GPE Discussion Paper Series: no31. Verlag (for UICC).
Geneva:World Healththat
Cancer is a disease Organization.
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weight to incidence in young age groups and hide differences observed in older populations. Therefore it cannot be
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101