Letters

Inequalities in health in Europe

EDITORMarmot and Bobak analysed the increased inequalities in health in eastern Europe.¹ Cervical cancer is an avoidable cause of death and a relevant indicator of women's health. National death certification data do not allow analysis of mortality from cervical cancer in Europe since 20-65% of deaths from uterine cancers are certified reliably as uterus, unspecified.² Most deaths from uterine cancer in women aged under 45 arise from the cervix.

We analysed age standardised death certification rates from uterine cancer in women aged 20-44 in the 15 countries of the European Union and in six eastern European countries providing reliable data to the World Health Organization's database for 1960-97.² In the European Union death rates declined from 5.6/100 000 in 1960-4 to 2.0/100 000 in 1995-7. In contrast, after a fall from 8.9 to 5.5/100 000 between 1960-4 and 1975-9, death rates from all uterine cancers in eastern Europe rose to 6.8 in 1995-7 (figure). Thus in recent years the difference in mortality from cervical cancer between the European Union and selected east European countries was over threefold. In Russia mortality from cervical cancer in young women rose from 3.1/100 000 in 1980-4 to 4.2/100 000 in 1995-7. 

View larger version (23K): [in this window] [in a new window]   Trends in age standardised (world population) death certification rates of uterine cancer per 100 000 women aged 20-44 in European Union and eastern Europe (Bulgaria, Czech Republic, Hungary, Poland, Romania, and Slovakia) from 1960-4 to 1995-7

These trends are essentially owing to the use of cervical screening. Organised screening programmes were first adopted in the 1970s in selected Nordic countries and the Netherlands, which showed earlier declines in mortality from cervical cancer.³ However, opportunistic screening as operated in France, Germany, and Italy also had a relevant impact on cervical cancer rates, at least in young women, although in the 1980s inadequate screening contributed to over 80% of cervical cancers in Italy.⁴ The gross excess of mortality from cervical cancer still observed in eastern Europe is therefore largely attributable to inadequate screening implementation and underlines the importance of implementing rational and organised screening programmes.

Other factors may, however, also have a role. The increases observed in eastern Europe since the early 1980s are likely to be due to changed sexual habits in younger generations, with increased exposure to herpesvirus, but a minor role of other risk factors for cervical cancer, including tobacco and oral contraceptives, is also feasible.⁵ Cervical cancer represents a relevant indicator of the worsening women's health conditions in eastern Europe and an important avoidable cause of death.

Fabio Levi, director. 
Registre vaudois des tumeurs, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland fabio.levi{at}inst.hospvd.ch

Franca Lucchini, staff scientist. 
Institut universitaire de médecine sociale et préventive, CH-1005 Lausanne

Silvia Franceschi, head. 
Unit of Field and Intervention Studies, International Agency for Research on Cancer, F-69372 Lyons, France

Eva Negri, head. 
Unit of Epidemiological Methods, Istituto di Ricerche Farmacologiche Mario Negri, I-20157 Milan, Italy

Carlo La Vecchia, associate professor of epidemiology. 
Università degli Studi di Milano, 20133 Milan