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Brain, other CNS and intracranial tumours incidence statistics

Incidence statistics for brain, other parts of the central nervous system (CNS) and intracranial tumours by country in the UK, age, tumour aggressiveness and trends over time are presented here. There are also data on the distribution of cases, morphology, lifetime risk, geography and metastatic brain tumours.

Data here covers:

The ICD-10 codes for brain, other CNS and intracranial tumours are C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, and D44.3-D44.5 (which are brain, meninges, spinal cord and other parts of CNS, pineal gland, pituitary gland, and craniopharyngeal duct). Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9 (which are some tumours of other and unspecified parts of CNS), because of known variation in coding practice. Primary CNS lymphomas (PCNSLs) are not included here but included in the statistics for Hodgkin and Non-Hodgkin lymphoma, because the site in which the lymphoma arises is not typically captured by cancer registries (although neuro-oncology services usually make the PCNSL diagnosis). Cancers of the skull are included with bone cancers, not here.

The latest incidence statistics available for brain, other CNS and intracranial tumours in the UK are 2010. Find out why these are the latest statistics available.

By country in the UK

In 2010, 9,156 new brain, other CNS and intracranial tumour cases were registered in the UK (Table 1.1): 4,541 (50%) in men and 4,615 (50%) in women.1-4 The crude incidence rate shows that there are 14.8 new brain, other CNS and intracranial tumour cases for every 100,000 males in the UK and 14.6 for every 100,000 females (Table 1.1).1-4

The European age-standardised incidence rates (AS rates) are significantly lower in England compared with Northern Ireland, Wales, and (for females only) Scotland (Table 1.1).1-4 It is unknown whether this geographical variation is real or reflects differences in registration practices between the countries.

Table 1.1: Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5), Number of New Cases, Crude and European Age-Standardised (AS) Incidence Rates per 100,000 Population, UK, 2010

England Wales Scotland Northern Ireland United Kingdom
Male Cases 3,653 321 398 169 4,541
Crude Rate 14.2 21.8 15.7 19.1 14.8
AS Rate 12.5 18.1 13.6 18.3 13.1
AS Rate - 95% LCL* 12.1 16.1 12.3 15.6 12.7
AS Rate - 95% UCL* 12.9 20.1 14.9 21.1 13.4
Female Cases 3,651 342 466 156 4,615
Crude Rate 13.8 22.3 17.3 17.0 14.6
AS Rate 11.2 16.8 13.7 14.7 11.8
AS Rate - 95% LCL* 10.9 15.1 12.4 12.4 11.5
AS Rate - 95% UCL* 11.6 18.6 14.9 17.0 12.2
Persons Cases 7,304 663 864 325 9,156
Crude Rate 14.0 22.1 16.5 18.1 14.7
AS Rate 11.8 17.4 13.6 16.3 12.4
AS Rate - 95% LCL* 11.6 16.1 12.7 14.5 12.1
AS Rate - 95% UCL* 12.1 18.7 14.5 18.1 12.7

Download this table XLS (34KB) PPT (168KB) PDF (262KB)

Please note that Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9, whilst these codes are included for the other UK countries.

Under-recording of brain, other CNS and intracranial tumours by cancer registries is possible, though there are presently no reliable data on the extent of this. Two small studies in the 1990s estimated that around 50% of brain, other CNS and intracranial tumours went unrecorded in UK cancer registries;5,6 however, the situation is now thought to have improved.7,8 Fatal and/or heavily-treated cases are more likely to be captured by cancer registries (because data on these cases appear in multiple systems to which the registries have access, including death records). Thus, it is likely that non-fatal or conservatively-treated cases represent the majority of any unrecorded tumours.5 The National Brain Tumour Registry for England has been set up to provide more detailed and consistent information in the future.8,9

section reviewed 28/03/13
section updated 28/03/13

By age

Incidence of brain, other CNS and intracranial tumours is related to age, with the highest incidence rates overall being in older men and women. In contrast to most sites, however, brain, other CNS and intracranial tumours occur relatively frequently across all age groups, with a small peak in incidence during childhood (Figure 1.1).1-4 In this age group, brain, other CNS and intracranial tumours are the second most common group of cancers (after leukaemia), accounting for more than a quarter (27%) of all tumours diagnosed in children. In teenagers and young adults (aged 15-24), brain, other CNS and intracranial tumours are the fourth most common group of cancers, accounting for 14% of all tumours diagnosed in this age group. Further information on brain, other CNS and intracranial tumours as well as other childhood and teenage and young adult cancers is available in the Childhood cancer and Teenage and Young Adult cancer sections of our website.

In the UK between 2008 and 2010, less than half (an average of 43%) of brain, other CNS and intracranial tumour cases were diagnosed in men and women aged 65 and over, with 10% diagnosed in people under the age of 30 (Figure 1.1).1-4 Age-specific incidence rates remain relatively stable from infancy to around age 20-24, then rise steadily to around age 45-49, before increasing more sharply (particularly in males) with the highest rates in the older age groups. Males and females have very similar age-specific incidence rates until around age 55-59. From then on, males have higher rates than females (Figure 1.1).1-4

Figure 1.1: Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5), Average Number of New Cases per Year and Age-Specific Incidence Rates, UK, 2008-2010

cases_crude_allbrain.swf

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Please note that Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9, whilst these codes are included for the other UK countries.

section reviewed 28/03/13
section updated 28/03/12

By tumour aggressiveness

Brain, other CNS and intracranial tumours are classified according to different systems by different organisations, between which systems very broad parallels may be drawn (Table 1.2). There is substantial heterogeneity within and between these broad groups, and data categorising brain, other CNS and intracranial tumours along these lines should be interpreted with caution.

Table 1.2: Systems for Classification of Brain & CNS Tumours

Used by cancer registries generally Used by cancer clinicians generally
ICD-10 codes ICD-10 groups WHO Grade Aggressiveness
C70-C72 and C75.1-C75.3 Malignant (sometimes also known as invasive, or cancer) Few Grade I, most Grade II, almost all Grade III-IV More aggressive
D32-D33, D35.2-D35.4, D42-D43, and D44.3-D44.5 Benign, uncertain or unknown behaviour (sometimes also known as non-invasive) Almost all Grade I, few grade II, very few Grade III-IV Less aggressive

UK national data are mainly collected and reported by cancer registries using the WHO International Classification of Diseases, version 10 (ICD-10). ICD-10 codes can be grouped into either (i) malignant (or invasive, or C-codes) or (ii) benign and uncertain or unknown behaviour types (or non-invasive, or D-codes). While this division underestimates the complexity and diversity of these tumours – even ‘benign’ tumours can invade surrounding tissue to some degree, and can be fatal depending on their location and size – these groupings are the best available for UK national data, and so are typically used by organisations which present national-level statistics. ICD-10 codes can also be mapped, very broadly, onto the WHO Classification of Tumours of the Central Nervous System, which is used by clinicians when diagnosing tumours and planning treatment; under this system tumours are assigned WHO Grades ranging from I-IV, with I being the least malignant and IV the most.10 Clinicians may also describe tumours according to their aggressiveness, or how quickly they are growing. In coming years, all UK cancer registries will code tumours according to the WHO International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3), meaning it may be possible to present UK national data by grade in the future.7

In 2010 in the UK, 54% of brain, other CNS and intracranial tumours were malignant and 46% were of benign and uncertain or unknown behaviour types. However, there was a noticeable difference in the occurrence of these types of tumour between the sexes; malignant brain, other CNS and intracranial tumours were more common in males (male:female ratio of around 14:10), whilst benign and uncertain or unknown types were diagnosed more often in females (male:female ratio of around 7:10).1-4

For males and females combined, malignant tumours are more common than benign and uncertain or unknown ones in most age groups; the exceptions are age 30-49 and age 85+. For males only, malignant tumours are more common than benign and uncertain or unknown ones in all age groups except 85+; whilst for females only, benign and uncertain or unknown tumours are more common than malignant ones in all age groups except the under-15s and women aged 65-80 (Figure 1.2).1-4

Incidence of benign and uncertain or unknown tumours increases steadily from young adulthood then rises more rapidly in the elderly, while incidence of the malignant types increases rapidly from around age 45-49 and drops slightly in the over-75s.1-4

Figure 1.2: Brain, Other CNS and Intracranial Tumours, Malignant (C70-C72, C75.1-C75.3) and Benign and Uncertain or Unknown (D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5), Age-Specific Incidence Rates, UK, 2008-2010

cases_rates_byage_brain.swf

Download this chart XLS (62KB) PPT (151KB) PDF (284KB)

Please note that Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9, whilst these codes are included for the other UK countries

section reviewed 28/03/13
section updated 28/03/13

Trends over time

Trends over time for brain, other CNS and intracranial tumours are heavily influenced by improvements in data collection and diagnostic capabilities, and the extent of this influence varies by tumour behaviour.1-3

For many of the benign and uncertain or unknown tumours, collection of all relevant ICD-10 codes across all UK registries was not instituted until the late 1990s, and for some codes not until the early 2000s,8,11 and so collection was not consistent across the UK. The apparent trend for these types of tumours reflects the inclusion of a growing number of codes by a growing number of registries. As well as improved recording of data on low-grade tumours, the detection of non-clinically significant benign tumours (such as small meningiomas) using modern radiology, is likely to explain the difference between the increases between the tumour groups.12-14

For all types of brain, other CNS and intracranial tumours, the introduction of new and more accurate diagnostic techniques including computed tomography (CT) scanning and magnetic resonance imaging (MRI) will have increased the incidence rates considerably.12,13 The National Brain Tumour Registry for England will improve future data collection, allowing accurate trends to be observed.7

Brain, other CNS and intracranial tumour recorded incidence trends since 1993 for the UK are shown in Figure 1.3.1-4 Over the last decade (between 1999-2001 and 2008-2010), the European AS rates have remained stable for males, and increased by 10% in females. However, the increase in the female rates is confined to the benign and uncertain or unknown tumours (these are the types of tumour more likely to be diagnosed in females), indicating that increased collection of these tumours by cancer registries explains the trend.1-4

Figure 1.3:  Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5), European Age-Standardised Incidence Rates, UK, 1993-2010

inc_asr_uk_allbrain.swf

Download this chart XLS (51KB) PPT (140KB) PDF (249KB)

Please note that Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9, whilst these codes are included for the other UK countries.

Malignant tumours have been collected by cancer registries for many decades, making long-term trends more reliable. Recorded malignant brain, other CNS and intracranial tumour incidence rates have overall increased in Great Britain since the mid-1970s (Figure 1.4).1-3 For males, European AS incidence rates increased by 42% between 1975-1977 and 2008-2010, though rates peaked in 1999-2001 (47% increase between 1975-1977 and 1999-2001) and have since remained stable. The rise is similar for females, with rates increasing by 39% between 1975-1977 and 2008-2010, but the increase being fairly consistent over this period. Increases over this period have been slow but steady, at a rate of 1-3 percentage points per year in most years. Diagnostic and data collection improvements account for much of this trend,12,13 as shown by the much smaller increases in mortality rates over the same period.  However, increases in the registration of some specific subtypes (including high-grade astrocytomas and other gliomas) require further investigation.12

Figure 1.4: Malignant Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3), European Age-Standardised Incidence Rates, Great Britain, 1975-2010

inc_asr_gb_brain.swf

Download this chart XLS (55KB) PPT (141KB) PDF (141KB)

Recorded malignant brain, other CNS and intracranial tumour recorded incidence rates have overall increased for most of the broad age groups in Great Britain since the mid-1970s (Figure 1.5).1-3 Rates have increased the least for people aged 0-49, with a 15% increase between 1975-1977 and 2008-2010. In people aged 50-59, rates increased by 18% between 1975-1977 and 1990-1992, and have since decreased by 11%. By far the largest increases have been in people aged 80+, with European AS incidence rates increasing by almost eightfold between 1975-1977 and 2008-2010.1-3 This increase is thought mainly to be due to an increased use of diagnostic techniques, such as better access to CT machines, in older patients.14

Figure 1.5: Malignant Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3), European Age-Standardised Incidence Rates, by Age, Great Britain, 1975-2010

inc_asr_age_p_allbrain.swf

Download this chart XLS (58KB) PPT (144KB) PDF (355KB)

section reviewed 28/03/13
section updated 28/03/13

Distribution of cases

The majority of brain, other CNS and intracranial tumours in the UK between 2008 and 2010 were recorded as occurring in the brain itself (58%), with a further 23% in the meninges, 8% in other parts of the CNS, and 11% in the intracranial endocrine glands (Table 1.3).1-3

Marked differences are seen between the registry-recorded locations of more and less aggressive tumours. Almost all (94%) of more aggressive tumours occurred in the brain itself, with very small proportions in the meninges (2%), spinal cord and other parts of the CNS (3%), and intracranial endocrine glands (1%).1-4 In contrast, only 16% of less aggressive tumours were in the brain, with almost half (47%) occurring in the meninges, 14% in other parts of the CNS, and the remaining 23% in the intracranial endocrine glands.1-4

Table 1.3: Brain, Other CNS and Intracranial Tumours (C70-C72, C75.1-C75.3, D32-D33, D35.2-D35.4, D42-D43, D44.3-D44.5), by Location and Behaviour, Proportion of Cases, UK, 2008-2010

  All brain, other CNS and intracranial tumours More aggressive (ICD-10 C codes) Less aggressive (ICD-10 D codes)
Brain (C71, D33.0-D33.2, D43.0-D43.2) 58% 94% 16%
Meninges (C70, D32, D42) 23% 2% 47%
Other CNS (C72, D33, D43) 8% 3% 14%
Endocrine glands (C75.1-C75.3, D35.2-D35.4, D44.3-D44.5) 11% 1% 23%
Total 100% 100% 100%

Please note that Northern Ireland data excludes ICD-10 D33.7, D33.9, D43.7 and D43.9, whilst these codes are included for the other UK countries.

section reviewed 28/03/13
section updated 28/03/13

By morphology

The most common morphological types of brain, other CNS and intracranial tumours recorded in England in 2006-2010 were astrocytomas (34%) and meningiomas (21%) (Table 1.4).7 Around 80% of astrocytomas were the very aggressive subtype glioblastoma (WHO Grade IV). Almost all of the meningiomas were less aggressive (WHO Grade I). Most of the pituitary tumours were adenomas. There were 14% of brain, other CNS and intracranial tumours recorded by registries as unknown or unspecified type; in many cases this may be because pathological samples (required to ascertain cell type) could not be obtained due to the location of the tumour.

Table 1.4: Brain, Other CNS and Intracranial Tumours, by Morphology, Proportion of Cases, England, 2006-2010

Morphological Group % of all Brain, other CNS and intracranial tumour cases % of these more aggressive % of these less aggressive
Astrocytomas 34% 95% 5%
Meningiomas 21% 8% 92%
Pituitary 8% 1-2% 98-99%
Gliomas unspecified 6% * *
Cranial and paraspinal nerve tumours 6% 5% 95%
Oligodendrogliomas 3% * *
Ependymomas 2% 75% 25%
Embryonal tumours 2% 100% 0%
Other tumour types 5% * *
Unknown or unspecified type 14% * *

Download this table XLS (34KB) PPT (195KB) PDF (234KB)

*Heterogeneous groups cannot be broken down by levels of aggressiveness. 
Data supplied by Eastern Cancer Registry and Information Centre (ECRIC) from the National Brain Tumour Registry.
7

section reviewed 28/03/13
section updated 28/03/13

Lifetime risk

Lifetime risk is an estimation of the risk that a newborn child has of being diagnosed with cancer at some point during their life.  It is a summary of risk in the population but genetic and lifestyle factors affect the risk of cancer and so the risk for every individual is different. In 2010, the lifetime risk of developing a brain and other CNS tumour in the UK was 1 in 77 for both men and women.15

The lifetime risk for brain and other CNS tumour has been calculated by the Statistical Information Team using the ‘Adjusted for Multiple Primaries’ (AMP) method; this accounts for the possibility that someone can have more than one diagnosis of brain and other CNS tumour over the course of their lifetime.16

section reviewed 28/03/13
section updated 28/03/13

Worldwide

Although cancer registration has a long history in many countries of the world, particularly in the more affluent regions such as the UK, nearly 80% of the world’s populations live in regions that are not covered by such systems.17 Even in regions with good cancer registration, figures on brain, other CNS and intracranial tumours may be affected by under-recording and inconsistent registration.18 Nonetheless, with a view to characterising the global burden of the disease, the International Agency for Research on Cancer (IARC) routinely uses the available data to estimate worldwide cancer incidence.19

With these limitations in mind, it is estimated that Worldwide, every year around 445,000 people are diagnosed with tumours that start in the brain or elsewhere in the CNS. There were an estimated 238,000 new cases of malignant brain and other CNS tumours (C70-C72 only) worldwide in 2008, according to the IARC figures.19 We estimate that there were around 187,000 benign, uncertain or unknown behaviour brain or other CNS tumour cases worldwide in 2002. This estimate was reached by multiplying the number of malignant brain or other CNS tumour cases around the world in 2002, by the ratio of malignant to benign, uncertain and unknown behaviour brain and other CNS tumours in published papers from various world regions; it is therefore subject to a number of potential biases including possible under-recording of malignant brain tumours.18,20

section reviewed 28/03/13
section updated 28/03/13

Secondary brain cancers

There are presently no reliable data on the incidence of secondary brain, other CNS and intracranial cancers – tumours which have metastasised (spread) to these sites from elsewhere in the body. In some patients, brain, other CNS and intracranial metastases may not manifest clinically in the patient’s lifetime, or a formal diagnosis may not be obtained if the patient is extremely unwell with their primary cancer. Therefore current estimates of the number of secondary tumours are thought to be conservative.21 However, data collection is improving, and in coming years it should be possible to report national data for the number of cancers in the brain, other CNS and intracranial region which started elsewhere in the body.7

The best current estimate is that secondary brain cancers occur in at least 6% of all cancer patients, with marked variation by primary cancer site.21 The proportion ranges from less than 1% of patients with thyroid, liver, stomach, prostate, uterine or ovarian cancers, to 20% of those with lung cancer.21,22 Based on this estimate, metastatic brain tumours are thought to outnumber primary malignant brain tumours by at least three to one.21

section reviewed 31/05/13
section updated 31/05/13

Prevalence

Prevalence refers to the number of people who have previously received a diagnosis of cancer and who are still alive at a given time point. Some patients will have been cured of their disease and others will not.

In the UK more than 9,700 people were still alive at the end of 2006, up to ten years after being diagnosed with a malignant brain and other CNS tumour (Table 1.5).23

Table 1.5: Brain and other CNS tumours (C70-C72), One, Five and Ten Year Cancer Prevalence, UK, 31st December 2006

1 Year Prevalence 5 Year Prevalence 10 Year Prevalence
Male 1,448 3,633 5,456
Female 986 2,650 4,252
Persons 2,434 6,283 9,708

Download this table XLS (30KB) PPT (120KB) PDF (17KB)

Worldwide, it is estimated that there were around 317,000 patients with these tumours were still alive in 2008, up to five years after their malignant brain and other CNS tumour diagnosis.19

section reviewed 17/05/13
section updated 17/05/13

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References for brain, other CNS and intracranial tumours incidence

  1. Data were provided by the Office for National Statistics on request, June 2012. Similar data can be found here: http://www.ons.gov.uk/ons/search/index.html?newquery=cancer+registrations
  2. Data were provided by ISD Scotland on request, April 2012. Similar data can be found here: http://www.isdscotland.org/Health-Topics/Cancer/Publications/index.asp
  3. Data were provided by the Welsh Cancer Intelligence and Surveillance Unit on request, April 2012. Similar data can be found here: http://www.wales.nhs.uk/sites3/page.cfm?orgid=242pid=59080
  4. Data were provided by the Northern Ireland Cancer Registry on request, October 2012. Similar data can be found here: http://www.qub.ac.uk/research-centres/nicr/CancerData/OnlineStatistics/
  5. Pobereskin L. The Completeness Of Brain Tumour Registration In Devon And Cornwall. Eur J Epidemiol 2001;17(5):413-416.
  6. Counsell C, Collie D, Grant R. Limitations of using a cancer registry to identify incident primary intracranial tumours. J Neurol Neurosurg Psychiatry 1997;63:94-97.
  7. Eastern Cancer Registry and Information Centre (ECRIC), National Brain Tumour Registry.  Personal communication, February 2013.
  8. UK Cancer Registry representatives. Personal communication, 2008.
  9. National Cancer Intelligence Unit (NCIN). Central Nervous System (CNS) Tumours – developing a national tumour registry. London: NCIN; 2011.
  10. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (eds). WHO Classification of tumours of the central nervous system. 4th ed. Lyon, France: IARC, 2007.
  11. European Network of Cancer Registries (ENCR). ENCR recommendations of the Working Group on Data Definitions Brain and Central Nervous System Tumours. 2009.
  12. Arora RS, Alston RD, Eden TOB, et al. Are reported increases in incidence of primary CNS tumours real? An analysis of longitudinal trends in England, 1979–2003. Eur J Cancer 2010; 46(9):1607–1616.
  13. Caldarella A, Crocetti E, Paci E. Is the incidence of brain tumors really increasing? A population-based analysis from a cancer registry. J Neuro-Oncol 2011;104(2):589-594.
  14. Central Nervous System Cancers Site-Specific Clinical Reference Group. Personal communication, February 2013.
  15. Lifetime risk was calculated by the Statistical Information Team at Cancer Research UK, 2012
  16. Sasieni PD, Shelton J, Ormiston-Smith N, Thomson CS, Silcocks PB. What is the lifetime risk of developing cancer?: The effect of adjusting for multiple primaries. Br J Cancer 2011;105(3):460-5.
  17. Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917.
  18. McCarthy BJ, Schellinger KA, Propp JM, et al. A case for the worldwide collection of primary benign brain tumors. Neuroepidemiology 2009; 33(3): 268-75.
  19. Ferlay J, Shin HR, Bray F, et al. DM GLOBOCAN 2008 v1.2, Cancer incidence and mortality worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from http://globocan.iarc.fr. Accessed May 2011.
  20. Cancer Research UK Statistical Information Team. Estimate of worldwide incidence of brain and other CNS tumours in 2008. Calculated using (i) 2008 Worldwide malignant brain and other CNS tumours incidence from GLOBOCAN 2008 v1.2., IARC, version 1.2; (ii) ratio of malignant to benign, uncertain and unknown behaviour brain and other CNS tumours in the UK, 2010; and (iii) ratio of malignant to benign, uncertain and unknown behaviour brain and other CNS tumours in published papers from various world regions, given in McCarthy BJ, Schellinger KA, Propp JM, et al. A case for the worldwide collection of primary benign brain tumors. Neuroepidemiology 2009;33(3):268-75.
  21. Davis FG, Dolecek TA, McCarthy BJ, et al. Toward determining the lifetime occurrence of metastatic brain tumors estimated from 2007 United States cancer incidence data. Neuro-Oncology 2012;14(9):1171-77.
  22. Barnholtz-Sloan JS, Sloan AE, et al. Incidence proportions of brain metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit Cancer Surveillance System. J Clin Oncol 2004;22(14):2865-72.
  23. National Cancer Intelligence Network (NCIN). One, Five and Ten Year Cancer Prevalence by Cancer Network, UK, 2006. London: NCIN; 2010.

 

Updated: 28 March 2013