Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study

Rafael Cardoso, Feng Guo, Thomas Heisser, Monika Hackl, Petra Ihle, Harlinde De Schutter, Nancy Van Damme, Zdravka Valerianova, Trajan Atanasov, Ondřej Májek, Jan Mužík, Mef Christina Nilbert, Anne Julie Tybjerg, Kaire Innos, Margit Mägi, Nea Malila, Anne Marie Bouvier, Véronique Bouvier, Guy Launoy, Anne Sophie WoronoffMélanie Cariou, Michel Robaszkiewicz, Patricia Delafosse, Florence Poncet, Alexander Katalinic, Paul M. Walsh, Carlo Senore, Stefano Rosso, Ieva Vincerževskienė, Valery E.P.P. Lemmens, Marloes A.G. Elferink, Tom Børge Johannesen, Hartwig Kørner, Frank Pfeffer, Maria José Bento, Jessica Rodrigues, Filipa Alves da Costa, Ana Miranda, Vesna Zadnik, Tina Žagar, Arantza Lopez de Munain Marques, Rafael Marcos-Gragera, Montse Puigdemont, Jaume Galceran, Marià Carulla, María Dolores Chirlaque, Monica Ballesta, Kristina Sundquist, Jan Sundquist, Marco Weber, Andrea Jordan, Christian Herrmann, Mohsen Mousavi, Anton Ryzhov, Michael Hoffmeister, Hermann Brenner*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

206 Citations (Scopus)


Background: Colorectal cancer screening programmes and uptake vary substantially across Europe. We aimed to compare changes over time in colorectal cancer incidence, mortality, and stage distribution in relation to colorectal cancer screening implementation in European countries. Methods: Data from nearly 3·1 million patients with colorectal cancer diagnosed from 2000 onwards (up to 2016 for most countries) were obtained from 21 European countries, and were used to analyse changes over time in age-standardised colorectal cancer incidence and stage distribution. The WHO mortality database was used to analyse changes over time in age-standardised colorectal cancer mortality over the same period for the 16 countries with nationwide data. Incidence rates were calculated for all sites of the colon and rectum combined, as well as the subsites proximal colon, distal colon, and rectum. Average annual percentage changes (AAPCs) in incidence and mortality were estimated and relevant patterns were descriptively analysed. Findings: In countries with long-standing programmes of screening colonoscopy and faecal tests (ie, Austria, the Czech Republic, and Germany), colorectal cancer incidence decreased substantially over time, with AAPCs ranging from −2·5% (95% CI −2·8 to −2·2) to −1·6% (−2·0 to −1·2) in men and from −2·4% (−2·7 to −2·1) to −1·3% (−1·7 to −0·9) in women. In countries where screening programmes were implemented during the study period, age-standardised colorectal cancer incidence either remained stable or increased up to the year screening was implemented. AAPCs for these countries ranged from −0·2% (95% CI −1·4 to 1·0) to 1·5% (1·1 to 1·8) in men and from −0·5% (−1·7 to 0·6) to 1·2% (0·8 to 1·5) in women. Where high screening coverage and uptake were rapidly achieved (ie, Denmark, the Netherlands, and Slovenia), age-standardised incidence rates initially increased but then subsequently decreased. Conversely, colorectal cancer incidence increased in most countries where no large-scale screening programmes were available (eg, Bulgaria, Estonia, Norway, and Ukraine), with AAPCs ranging from 0·3% (95% CI 0·1 to 0·5) to 1·9% (1·2 to 2·6) in men and from 0·6% (0·4 to 0·8) to 1·1% (0·8 to 1·4) in women. The largest decreases in colorectal cancer mortality were seen in countries with long-standing screening programmes. Interpretation: We observed divergent trends in colorectal cancer incidence, mortality, and stage distribution across European countries, which appear to be largely explained by different levels of colorectal cancer screening implementation. Funding: German Cancer Aid (Deutsche Krebshilfe) and the German Federal Ministry of Education and Research.

Original languageEnglish
Pages (from-to)1002-1013
Number of pages12
JournalThe Lancet Oncology
Issue number7
Publication statusPublished - 1 Jul 2021

Bibliographical note

Funding Information:
HDS and NVD are employed by the Belgian Cancer Registry, which is financed by regional and federal authorities for collecting data regarding new cancer diagnoses and cancer screening in Belgium, and for disseminating associated epidemiological parameters. FPf reports having received a research grant from Intuitive Surgery, and payment or honoraria from Amgen (for a lecture) and Intuitive Surgery (for a video presentation), outside the submitted work. All other authors declare no competing interests.

Funding Information:
This study was supported in part by grants from the German Cancer Aid (Deutsche Krebshilfe) (70112095) and the German Federal Ministry of Education and Research (01GL1712). The work of KI was supported by Estonian Research Council (grant number PRG722). The work of AR was supported by the Ministry of Health of Ukraine (0118U003733). We are thankful to all cancer registries and their staff for the efforts in collecting and preparing the data for this study?specifically, the Austrian Cancer Registry, Belgian Cancer Registry, Bulgarian National Cancer Registry, Czech National Cancer Registry, Danish Colorectal Cancer Group Database, Danish Cancer Registry, National Cancer Registration and Analysis Service?Public Health England (data provided under the Open Government Licence:, Estonian Cancer Registry, Finnish Cancer Registry (permission from the Finnish Institute for Health and Welfare: THL/555/5.05.00/2019; permission from Statistics Finland: TK-53-1276-19), Digestive Cancer Registry of Burgundy, Digestive Tumors Registry of Calvados, Cancer Registry of Doubs, Digestive Tumors Registry of Finistere, Cancer Registry of Isere, German Center for Cancer Registry Data, National Cancer Registry Ireland, Piedmont Cancer Registry, Lithuanian Cancer Registry, Netherlands Cancer Registry, Cancer Registry of Norway, North Region Cancer Registry of Portugal, South Region Cancer Registry of Portugal, Slovenian Cancer Registry, Basque Cancer Registry, Girona Cancer Registry, Murcia Cancer Registry, Tarragona Cancer Registry, Swedish Cancer Registry, Bern Cancer Registry, Cancer Registry East Switzerland, Graub?nden and Glarus Cancer Registry, and National Cancer Registry of Ukraine. We are also grateful to the US National Cancer Institute for providing the Joinpoint regression software for our analyses.

Publisher Copyright:
© 2021 Elsevier Ltd


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