Cancer is now responsible for more deaths than cardiovascular disease (CVD) in 12 European countries, with dramatic falls in CVD mortality rates over the last 10 years seen across the entire continent, an analysis of World Health Organization (WHO) data indicates.

Nick Townsend, PhD, senior researcher at the BHF Centre on Population Approaches for Non-Communicable Disease Prevention at the University of Oxford, United Kingdom (UK) and colleagues found 4 million CVD deaths in Europe in 2013, accounting for 45% of all deaths.

There were differences between European regions, however, with the proportion of deaths due to CVD at 33% among countries that joined the European Union (EU) before 2004, vs 38% of deaths in countries that joined the EU after 2004, and 54% of all deaths in non-EU countries.

Dr Townsend told Medscape Medical News that approximately half of the reduction in CVD mortality is due to reduced incidence, while the other half is due to reduced case fatality.

He explained that there are "less people suffering, having cardiovascular events, and when they do have them, less people are dying of them," adding: "So, it's a combination of public health, population-based interventions to decrease things like smoking rates but then also treatments [such as] drug therapy alongside things like more use of stents."

The research, which was published online by the European Heart Journal on August 15, showed, however, huge variations in CVD mortality rates between European countries, with age-adjusted rates lowest in France but up to 6 times higher in countries such as Ukraine and Kyrgyzstan.

Nevertheless, CVD mortality rates decreased dramatically between 2003 and 2013, with rates falling by between a quarter and a half in most European countries. The result is that now CVD mortality rates are lower than those for cancer in men and women in a dozen European countries.

Dr Townsend believes that there are several potential explanations for this phenomenon. One is that purely decreasing CVD deaths rates increases longevity, therebyincreasing an individual's chances of getting cancer.

Another is that previous studies have suggested that around 85% of CVD can be attributed to behavioral risk factors, such as smoking, physical activity, diet, and alcohol intake, whereas only half of cancer cases can be linked to such causes.

"So, actually, on a population level, when we reduce smoking rates and we really focus on these behaviors, then we can have a bigger impact on CVD than cancer," Dr Townsend said.

Furthermore, he noted that CVD has strong predictors, such as hypertension and cholesterol levels. Using those, "we can identify people and we can bring those things down, firstly with behavioral changes and then drug therapy and things like that," he said.

Describing cancer as "a more complex set of diseases," he added that there are many different cancers, with many different causes. An "obvious" example, he said, is that "if you bring down smoking, and you decrease lung cancer rates, but you're not going to have such a big impact on bowel cancer or pancreatic cancer, or prostate cancer or breast cancer."

Details of the Study

To examine the current burden of CVD in Europe, the researchers gathered data on the 53 member states that are included in the WHO definition of the European region.

Within that, the team also focused on the 15 countries that were part of the European Union (EU) before May 1 2004 (EU-15), comprising Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain and the UK. They then focused on EU-28, which includes the 13 additional countries that joined the EU after that date: Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, and Slovenia. The remaining 25 countries were non-EU countries, primarily in eastern Europe.

They used the most recent update of the WHO Mortality Database, from November 2015. This presents age- and cause-specific mortality data, along with age-specific population data, for each country. This database is, in turn, based on data provided by national authorities from their civil registration systems. The data were then standardized by using the 2013 European Standard Population, which was developed by the European Commission to reflect the structure of the current European population.

Finally, the team obtained morbidity data from the WHO and the European Social Survey to compare disability-adjusted life-years, which is the equivalent to the loss of 1 healthy life-year, both between countries and between conditions.

The results show that there were over 4 million deaths from CVD, of which 1.8 million were attributable to coronary heart disease and 1.0 million to cerebrovascular disease. Overall, CVD mortality accounted for 45% of all deaths across Europe. CVD mortality was higher in women than in men, at 2.2 million deaths vs 1.8 million deaths, or 49% and 40% of all deaths, respectively.

The team found 1.4 million CVD deaths in people younger than age 75 years, while just under 700,000 deaths occurred in people younger than age 65 years. Although there were more premature CVD deaths in men than in women, at 0.9 million vs 0.5 million, the greater total number of premature deaths in men than in women meant that the proportion of CVD deaths was similar in the two sexes.

The CVD burden differed substantially between European countries. CVD accounted for 33% of all deaths in the EU-15 countries, compared with 38% of deaths in EU-28 countries and 54% of all deaths in the remaining non-EU countries.

Moreover, 21.4% of premature deaths were due to CVD in EU-15 countries, rising to 26.0% among EU-28 countries and 35.8% in non-EU countries.

Age-standardized death rates (ASDRs) also varied widely. France had the lowest rate in the EU-15 countries, at 275.2/100,000 in men and 174.1/100,000 women. The highest rate overall in men was seen in Ukraine, at 1544.9/100,000, while that in women was 1087.4/100,000, in Kyrgyzstan.

Between 2003 and 2013, ASDRs decreased dramatically in most countries. In the EU-15, decreases in ASDRs ranged from 25.2% in Austria to 49.7% in Luxembourg in men and from 25.3% in Italy to 49.7% in Portugal in women.

In EU-28 countries outside the EU-15 group, the decreases in ASDRs were more modest, ranging from 13.1% in Slovakia to 34.4% in Croatia in men and from 15.5% in Slovakia to 43.0% in the Czech Republic in women. Outside the EU, the decreases were smaller still, although Kazakhstan had decreases of 56.5% in men and 65.6% in women.

The consequence of the decreases in CVD mortality was that more men died of cancer than of CVD in 12 countries, while more women died of cancer than of CVD in 2 countries. All of these countries were in western Europe and 9 were in the EU-15. The countries were Belgium, Denmark, France, Italy, Israel, Luxembourg, the Netherlands, Norway, Portugal, Slovenia, Spain, and the UK.

The first country in which this transition happened was France, in 1988, followed by Spain, in 1999. In countries where the change happened the earliest, the ratio of cancer to CVD deaths is now also higher, suggesting that the relative increase in the burden of cancer mortality is continuing.

While the results for CVD mortality are encouraging, Dr Townsend said that there is a "little caveat." He explained that recent years have seen "vast increases in diabetes and also increases in the prevalence of overweight and obesity."

He said, "So although we've had these massive decreases in deaths from CVD recently, we are aware that these unprecedented increases in levels of these other intermediary risk factors, particularly obesity and diabetes, could influence future trends, and actually plateau out the numbers or even reverse them."

Dr Townsend received funding from the British Heart Foundation. Coauthor Melanie Nicholls is supported by an Alfred Deakin Postdoctoral Fellowship. The authors have disclosed no relevant financial relationships.

Eur Heart J. Published online August 15, 2016. Abstract

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