CERVICAL CARCINOMA IN THE MALTESE POPULATION

INTRODUCTION

There are few cancers that have been so intensively studied from the epidemiological and basic science aspect as that of carcinoma of the cervix. The aetiology seems to be related to sexual behavious and many factors referable to the male and female have been incriminated. The rarity of cervical cancer in certain orders of nuns was first described as early as 1842 by Rigoni-Stern of Verona [1]. Rigoni-Stern’s comment apprears to have been the starting point for many epidemiological studies on the relationship between cancer of the uterine cervix and the sexual behavious of women and/or their partners. Since cervical cancer may be considered to be a ‘sexually transmitted disease’, the incidence patterns in a community over a time scale should reflect the changing social norms of that population. The Maltese population shows definite changing attitudes regards sexual practice as reflected by the increasing illegitimacy rates in the last decade and the changing attitudes towards contraceptive practices [2,3]. This short study attempts to identify similar trends regarding cervical cancer.

MATERIAL AND METHODS
The epidemiological data was obtained from a number of published [4,5,6,7,8] and unpublished sources as listed in Table 1. These sources allowed for the identification of cases of cervical carcinoma, together with the ages of the patients. The age-structure of the population for each year during the period under study 1967-93 was obtained from the annual demographic publication of the Central Office of Statistics [4].

EPIDEMIOLOGY
Death registration by cause of death became a legal requirement before burials in 1870. Publication of mortality statistics by cause of death was initiated in 1872, first as forthnightly reports and after 1896 as departmental annual reports. Legislation regarding cancer notification dates to 1957, while the data collected was published annually after 1960. The accuracy of these reports are dependant on the reliability of practitioners who undertake certification.

The incidence of cervical cancer shows very wide annual fluctuations (Figure 1). These fluctuations are the result of the rather small number of cases which are reported and the relatively small total female population. Figure 1 does however suggest a steady rise in incidence trends in the last fifteen years. This rise is better observed after assessing the mean annual incidence rates over five year perods (Figure 2; Table 2). Thus the average annual incidence rose from 6.30 per 100000 population in 1977-81 to 6.95 in 1987-91 [7.59 per 100000 population in 1992-93]. The five-year average incidence rates thus suggest that there may have been a rise in the incidence of cervical carcinoma since the late 1970s. The low average figure for the period 1972-76 appears not to conform to expected rates, and the low figure probably reflects discrepancies in registration of cases. A similar discrepancy has also been noted for endometrial and breast malignancy [9].

Figure 1: Annual Incidence and Mortality Trends: Maltese Islands 1960-1993

The annual specific mortality rates appear to have maintained a steady trend, though with varied fluctuations (Figure 1). The five year averages (Figure 2; Table 3) suggest that there may have been a very slight decrease in the specific mortality rates during the last fifteen years from 3.04 per 100000 population in 1982-86 to 2.91 in 1987-91 [2.44 per 100000 population in 1992-93].

The age-specific rates suggests that there may have been a rise in the incidence of cervical carcinoma in the younger age groups with a concomitant fall in the elderly women (Table 2). The noted increased incidence of cervical carcinoma in the younger age groups may reflect earlier diagnosis, though the increasing overall rates may reflect increasing promiscuity and earlier sexual exposure than in past years.

The five-year average specific mortality rates suggest that there may have been a drop in the overall mortality rates in the last decade (Table 3). The drop in mortality rates appears evident in all the age groups, except the very elderly >65 years (Table 3). The decrease in mortality rates, in the presence of increasing incidence pattern, suggests that patients are probably being identified at an early stage of the disease allowing for more effective therapy to be instituted.

CONCLUSION
While the incidence of cervical cancer in Malta appears to be gradually on the increase, the rates still remain low in comparison to other European countries (European average 10.1 per 100000 population). Because of the active free-service sceening facilities offered in Government Clinics since 1977, there appears to have been a definate shift in the age at which diagnosis is being made. Cervical cancer is being more and more diagnosed in the younger age group, possibly reflecting early diagnosis resulting from screening and/or earlier onset of disease resulting from earlier sexual activity. In spite of the screening, the specific mortality rates from cervical cancer in Malta have shown little if any change over the years, though they remain significantly lower than those reported in other European countries (European average 4.3 per 100000 population). The possible slight decrease in mortality rates in the last decade in the presence of an increase in incidence rates may reflect the positive advantages of routine cervical screening. This advantage would become more evident if pre-malignant lesions of the cervix (at present non-notifiable) are also considered.

COMPARISON TO EUROPEAN DATA The specific mortality rate from cervical cancer in Malta shows wide fluctuations, but appears to be similar to rates reported from France. The mortality rate appears lower than the European Average but higher than the rates reported from our neighbours - Italy (Table 4). Malta appears to have lower incidence rates for cervical cancer than other European countries.

TABLE 4: Cervical Cancer incidence & mortality in Europe

REFERENCES
1. Rigoni-Stern D.: Fatti Statistici alle malattie Cancerose. Gio. Servire Progr. Path. Terap., 1842, 2:507
2. Savona-Ventura C.: The influence of the Roman Catholic Church on Midwifery Practice in Malta. Medical History, 1995, 39:18-34
3. Savona-Ventura C.: Illegitimacy in the Roman Catholic community of Malta. Planned Parenthood in Europe. 1993, 22(2):30-32
4. C.O.S.: Demographic Review for the Maltese Islands for the years 1960-1993. Central Office of Statistics; Malta, 1961-1994 (annual publications)
5. D.O.H.: Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the years 1960-1971. Dept of Health; Malta, 1962-1972 (annual publications)
6. D.O.H.: Vital Statistics and Statistical Information on the Incidence and Mortality of Disease in the Maltese Islands for the years 1972-1980. Dept of Health; Malta, 1973-1981 (annual publications)
7. H.I.S.U.: Cancer Incidence in Malta :1992. Health Information Systems Unit; Malta, 1993.
8. H.I.S.U.: Cancer Incidence and Mortality in Malta: 1993. H.I.S.U.; Malta, 1994
9. Savona-Ventura C. and Grech E.S.: Endometrial carcinoma in the Maltese islands: An epidemiological review. Eur. J. Gynaecol. Onccol., 1986, 7(3):209-217

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Citation: C. Savona-Ventura: The Health of the Maltese Population. Internet Home Page [http://www.oocities.org/savona.geo/index.html], 1996