China's high mortality rate is the result of a lack of awareness that results in late detection of the disease, as Yang Wanli reports.

Zhang Chongpin from Northwest China's Gansu province had never considered having a medical checkup until he discovered fresh blood in his feces one Sunday morning in early March. Ten days later, the 43-year-old was diagnosed with colon cancer at a provincial-level hospital in Gansu.

"It's a huge blow to our family - our children are both still in high school," said Li Guiqin, Zhang's wife, who closed her small corner store in their home village so she would be able to travel to Beijing with her husband and help him obtain treatment at one of China's best cancer hospitals.

Earlier this month, the couple left their small home village in Gansu and took their first trip outside the province. Li lined up at the registration counter at the Cancer Hospital of the Chinese Academy of Medical Sciences at 4 am, four hours before it opened, to secure an appointment with one of China's most respected colon cancer specialists. Zhang is now undergoing a series of tests to determine the stage of the disease and if it can be treated effectively.

Zhang is just one of millions of Chinese with some form of cancer. On Monday at 10:30 am, two and a half hours after the registration counter opened at the CAMS cancer hospital, patients and relatives still formed a zigzag line about 200 meters long that filled the hall of the hospital.

Last year, the hospital received more than 2,000 outpatients every day, and the number has been rising by 10 to 20 percent every year for the past decade, according to data provided by the hospital administration.

In the past 40 or so years, the rates of incidence of, and deaths from, cancer have been rising in China while falling in many other countries, including Germany, the United States, Australia and Singapore.

Rising death toll

Meanwhile, national surveys of the causes of death conducted in the 1970s, the 1990s and the 2000s show the number of deaths from cancer rose from 0.7 million to 1.7 million, leading to the country's mortality rate soaring by 83 percent over the 45-year period.

The figures stand in stark contrast to those in the US, where the 2015 Cancer Report, published by the American Cancer Society, shows that the overall cancer mortality rate fell by nearly 22 percent from 1991 to 2011.

The cancer patterns, which show the different causes of deaths from cancer country by country, are one of the major causes of the contrasting mortality rates in China and the US, according to Chen Wanqing, director of the National Central Cancer Registry, established in 2002 by the National Health and Family Planning Commission to improve the systematic management of cancer surveillance.

According to the ACS, at 26 percent prostate cancer accounts for the highest proportion of all new cancer cases among US males, and the survival rate five years after diagnosis is close to 100 percent.

In China, however, lung cancer accounted for about 25 percent of all new cancer cases in 2011, and although the five-year survival rate was close to the global average, about 60 percent of patients died one year after diagnosis and 70 percent died after two years, according to Chen.

Early detection plays an important role in explaining the disparity in the overall cancer mortality rates in the US and China. For example, breast cancer has the highest rate of incidence among women in both countries, but the survival rates are vastly different.

Last year, the NCCR published research that focused on 140,000 cases in 17 cancer registration centers across China. It showed that the five-year survival rate for breast cancer was just 40 percent, while in the US it was 80 to 90 percent.

Promoting awareness

"The problem in China is that many cases - about 70 percent of breast cancer cases, for example - are detected too late. That means a large number of patients miss the 'golden period' for treatment that could save their lives," said Sun Qiang, director of the Breast Cancer Clinic at Peking Union Medical College Hospital.

Sun said successful surgical techniques and advanced clinical treatments mean the survival rate for patients whose breast cancer is detected at an early stage is much higher - as high as 90 percent within five years after treatment - than for people who are diagnosed at later stages.

Because early detection is a crucial factor in the overall mortality rate for cancer, the US has promoted greater awareness through national educational campaigns, which has resulted in earlier detection and diagnosis, he said.

In China's rural areas, though, few people undergo annual health checks because the procedure isn't covered by ordinary medical insurance. Urban dwellers are luckier because their employers usually bear the cost.

Despite that, cancer cases are still being missed because many of the checkups being offered are rudimentary. "Even people who live in cities and have annual checkups are at risk, because little attention is paid to early detection of the most common cancers, such as lung and breast," Sun said, adding that the problem is compounded by the fact that specialized tests are only available in a small number of larger, better-equipped hospitals, and because many large companies only started providing annual health checks for employees relatively recently.

In the past few years, wealthier patients have been happy to pay for tests to determine if they are genetically predisposed to certain forms of cancer, but the cost - thousands of yuan to detect just one form of the disease - means the procedures are far beyond the financial scope of most people, according to Chen of the NCCR.

"Actually, we really know very little about the genes that can cause cancer. For example, we know that the discovery of mutations in two genes - called BRCA1 and BRCA2 - is helpful in determining a person's likelihood of developing breast and ovarian cancers, but the test is still being assessed in relation to other forms of cancer. So in China, we will focus on early detection, prevention and treatment of those cancers where the patient's life can be prolonged with the treatments available at present," he said.

A huge burden

In recent decades, cancer has imposed a huge burden on China's health authorities. The NCCR's 2014 Annual Cancer Report showed that more than 3.3 million new cases were diagnosed in 2011, meaning that one in five cancer patients worldwide that year was Chinese. About 2.1 million Chinese died from cancer in 2011, accounting for a quarter of global deaths from the disease.

The IARC estimates that the number of deaths from cancer will hit 2.76 million in China by 2020.

"With a population of almost 1.4 billion, China plays a significant role in the global cancer burden and cancer control effort," said Liu Lihua, director of data utilization at the Los Angeles Cancer Surveillance Program at the University of Southern California.

"These numbers underline the urgent need for the development of effective cancer-control programs in China, and also underline the significance of such programs on the global effort to curb the rapidly increasing incidence of cancer and mortality, especially in developing countries. In other words, China is an obvious major battlefield in the global fight against the disease," he added.

He urged the authorities to implement a national program of data collection and related research to help with the formulation of the best plans to control cancer and educate the public about the disease.

The role played by the NCCR means it is possible to achieve the aims of further standardizing the registry workflow and improving the quality of relevant data by the end of the year. By 2020, the registry is expected to have high-quality, representative national and regional data.

"Cancer is still one of the leading causes of morbidity and mortality among the Chinese, and they have higher rates of incidence and death for certain cancers, such as liver, stomach, breast, lung and colorectal," said Marion M. Lee, professor emeritus of epidemiology at the University of California's School of Medicine.

Lee said the best way of reducing the risk of contracting many common forms of cancer is to maintain a healthy lifestyle by avoiding tobacco and alcohol, engaging in regular physical activity and keeping an eye on one's weight. He added that studies have clearly shown that prolonged psychological stress and aging also contribute to the development of cancer.

"The most urgent problem affecting cancer deaths and general mortality in China is smoking, which can cause death not only from lung cancer, but also by cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, liver, kidney, bladder and cervix," he said.

Tang Lili, director of the Rehabilitation Department at the Beijing Cancer Hospital, said she has seen many patients whose limited awareness of cancer prevention meant they ignored the danger signs and missed the optimum time for treatment. She said that there is an urgent need for better education and greater public awareness of the causes of cancer.

"Also, a lack of knowledge may lead some people to become unduly pessimistic after diagnosis," Tang said. "A diagnosis of cancer doesn't always equate to a death sentence. The aim of educating the public about cancer isn't to scare people, but to help them be aware of the disease and to react positively."

Zhao Xu contributed to this story.

Contact the writer at yangwanli@chinadaily.com.cn

(China Daily 04/17/2015 page6)