Secular trends in breast cancer mortality in five East Asian populations: Hong Kong,Japan, Korea,Singapore and Taiwan

Breast cancer risk is increasing in most Asian female populations, but little is known about the long‐term mortality trend of the disease among these populations. We extracted data for Hong Kong (1979–2005), Japan (1963–2006), Korea (1985–2006), and Singapore (1963–2006) from the World Health Organization (WHO) mortality database and for Taiwan (1964–2007) from the Taiwan cancer registry. The annual age‐standardized, truncated (to ≥20 years) breast cancer death rates for 11 age groups were estimated and joinpoint regression was applied to detect significant changes in breast cancer mortality. We also compared age‐specific mortality rates for three calendar periods (1975–1984, 1985–1994, and 1995–2006). After 1990, breast cancer mortality tended to decrease slightly in Hong Kong and Singapore except for women aged 70+. In Taiwan and Japan, in contrast, breast cancer death rates increased throughout the entire study period. Before the 1990s, breast cancer death rates were almost the same in Taiwan and Japan; thereafter, up to 1996, they rose more steeply in Taiwan and then they began rising more rapidly in Japan than in Taiwan after 1996. The most rapid increases in breast cancer mortality, and for all age groups, were in Korea. Breast cancer mortality trends are expected to maintain the secular trend for the next decade mainly as the prevalence of risk factors changes and population ages in Japan, Korea, and Taiwan. Early detection and treatment improvement will continue to reduce the mortality rates in Hong Kong and Singapore as observed in Western countries. (Cancer Sci 2010; 101: 1141–1246)     

Some epidemiologic observations on cancer in Hong Kong

The average incidence by age-group per 100,000 for both sexes and the age-standardized incidence rates for the 10 most common cancers in Hong Kong for 1974 were determined. A comparison between the incidence and death rates for these 10 cancers indicated that a good coverage of the actual incidence has been achieved by the Cancer Registry for cancers of the nasopharynx, bronchus, esophagus, colon, rectum, breast, cervix, and bladder, but it was incomplete for cancers of the liver and stomach. A study of their age-specific incidence curves showed a sharp rise in the curve after age 20-24 in cancers of the nasopharynx and liver (males), after age 25-29 in cancers of the cervix and breast (females), and after age 35-39 for the remaining tumors studied; thus a difference in the period of life at which carcinogenesis was initiated was indicated. Epidemiologic observations on nasopharyngeal, esophageal, hepatocellular, and uterine cervical carcinoma were compared, and it is believed that epidemiology is the key to the solution of the cancer problem in Hong Kong.     

Cancer incidence patterns in Koreans in the US and in Kangwha,South Korea

Objective: In the US, Koreans are a rapidly growing group and comprised 10.5% of the total Asian population as of 2000. However, little has been published regarding cancer patterns in this subpopulation. Methods: Using data from the Surveillance, Epidemiology, and End Results program, the California Cancer Registry, and the International Association for Research on Cancer, we compared age-adjusted and age-specific incidence rates for cancers of the prostate, breast, cervix, lung, colon, rectum, stomach, liver, and esophagus in US Koreans with rates of these cancers in residents of Kangwha, South Korea, and in US whites as a reference. Results: While the most frequently diagnosed cancer was lung among US Korean males and breast among US Korean females, it was stomach cancer for both sexes in Kangwha. Rates of prostate, breast, and colon cancer were considerably higher for Koreans in the US than in Kangwha, but were not as high as in whites. Cervical and stomach cancers showed the opposite racial/ethnic pattern, with rates highest in Kangwha, intermediate among US Koreans, and lowest among whites. Rates of rectal cancer in females and esophageal cancer in males were two-times higher in Kangwha than in US Koreans but esophageal cancer rates were similar between US Koreans and whites. Liver cancer rates were similar between Kangwha residents and US Koreans, but nearly 10-times lower among whites. Conclusions: Although these comparisons may have methodologic limitations, including data quality and racial/ethnic misclassification, the differences seen in migrant and native Koreans for some cancers warrant further investigation in this growing subpopulation.     

Cancer mortality among Chinese, Japanese, and Indians in British Columbia, 1964-73

We compared age-adjusted mortality rates for cancer of selected sites for Chinese, Japanese, and native Indian residents of British Columbia during the years 1964-73 to the corresponding rates for the white population. Mortality from all cancers of the Chinese did not differ significantly from that of whites. Elevated rates are seen for cancer of the nasopharynx in both sexes, of the liver and esophagus in males, and of the lung in females. Chinese males had a lower mortality than whites from stomach, prostate, and bladder cancer and brain tumors, whereas females had a lower mortality from tumors of the colon, breast, and ovary; both sexes had a lower mortality from leukemia. For Japanese males and females, the mortality rates for all cancers combined were similar to those of the white population. The rates for cancer of the stomach and gallbladder were higher in both sexes; males also showed a higher rate of liver cancer. Prostate and breast cancer mortality rates were lower. Native Indian males had a lower mortality rate from all cancers combined; the difference was significant for stomach, colon, lung, and prostate cancers, and for leukemia. Native Indian females showed a lower rate for ovarian cancer and a higher rate of tumors of the gallbladder and uterine cervix, but their overall cancer mortality was similar to that of whites.     

Trends in the Incidence of 15 Common Cancers in Hong Kong, 1983-2008

Background: The objective of this study WAS to describe cancer incidence rates and trends among THE HongKong population for the period 1983-2008. Methods: Incident cases and population data from 1983 to 2008 wereobtained from the Hong Kong Cancer Registry and the Census and Statistics Department, respectively. Agestandardizedincidence rates (ASIR) were estimated and joinpoint regression was applied to detect significantchanges in cancer morbidity. Results: For all cancers combined, the ASIR showed declining trends (1.37%in men, 0.94% in women), this also being the case for cancers of lung, liver, nasopharynx, stomach, bladder,oesophagus for both genders and cervix cancer for women. With cancer of thyroid, prostate, male colorectal,corpus uteri, ovary and female breast cancer an increase was evident throughout the period. The incidence forleukemia showed a stable trend since early 1990s, following an earlier decrease. Conclusions: Although overallcancer incidence rates and certain cancers showed declining trends, incidence trends for colorectal, thyroid andsex-related cancers continue to rise. These trends in cancer morbidity can be used as an important resource toplan and develop effective programs aimed at the control and prevention of the spread of cancer amongst theHong Kong population. It is particularly useful in allowing projection of future burdens on the society with theincrease in certain cancer incidences.     

上海市浦东新区1993-2007年恶性肿瘤死亡趋势分析

目的:分析浦东新区1993-2007年恶性肿瘤死亡的变化趋势.方法:利用1993-2007年浦东新区居民的死因监测资料,分性别计算死亡率,用世界标准人口计算标化率,用对数直线回归法估算死亡率年度变化百分比(annual percent change,APC).结果:1993-2007年浦东新区恶性肿瘤死亡率上升,标化死亡率下降.主要恶性肿瘤中,肺癌、结直肠癌和女性乳腺癌的死亡率上升,结直肠癌和女性乳腺癌标化死亡率上升;女性胃癌、肝癌和食管癌死亡率下降,男性肺癌、胃癌、肝癌和食管癌的标化死亡率下降.结论:肺癌、结直肠癌和乳腺癌是浦东新区肿瘤防治工作的重点.     

Mortality from all cancers and lung, colorectal, breast and prostate cancer by country of birth in England and Wales, 2001-2003

Mortality from all cancers combined and major cancers among men and women aged 20 years and over was compared by country of birth with that of the whole of England and Wales as the reference group. Population data from the 2001 Census and mortality data for 2001-2003 were used to estimate standardised mortality ratios. Data on approximately 399 000 cancer deaths were available, with at least 400 cancer deaths in each of the smaller populations. Statistically significant differences from the reference group included: higher mortality from all cancers combined, lung and colorectal cancer among people born in Scotland and Ireland, lower mortality for all cancers combined, lung, breast and prostate cancer among people born in Bangladesh (except for lung cancer in men), India, Pakistan or China/Hong Kong, lower lung cancer mortality among people born in West Africa or the West Indies, higher breast cancer mortality among women born in West Africa and higher prostate cancer mortality among men born in West Africa or the West Indies. These data may be relevant to causal hypotheses and in relation to health care and cancer prevention.     

江苏省昆山市2006～2010年恶性肿瘤发病与死亡分析

[目的]分析昆山市2006～2010年恶性肿瘤的发病和死亡水平。[方法]收集昆山市肿瘤登记处2006～2010年恶性肿瘤的发病资料和死亡资料,统计和分析恶性肿瘤的发病(死亡)率、标化发病(死亡)率、年龄别发病(死亡)率等指标。[结果]昆山市2006～2010年共报告恶性肿瘤新发病例10 466例,死亡病例6 562例,恶性肿瘤粗发病率为306.03/10万(其中男性357.72/10万,女性254.35/10万),粗死亡率为191.99/10万(其中男性243.78/10万,女性139.98/10万)。男性发病率前5位的恶性肿瘤依次为胃癌、肺癌、肝癌、食管癌和结肠癌,女性依次为乳腺癌、胃癌、肺癌、肝癌和结肠癌。[结论]昆山市恶性肿瘤发病和死亡水平较高,应该加强对主要恶性肿瘤的防控。     

Cancer incidence among Korean-American immigrants in the United States and native Koreans in South Korea.

BACKGROUND: While previous studies demonstrated contrasting patterns of cancer risk among migrant populations from different ethnic groups in the United States, few studies have focused on the Korean-American population. This study compares cancer incidence rates between Korean-Americans, whites, and blacks in the United States and native Koreans. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) program and International Association for Research on Cancer were used to calculate age-standardized incidence rates among whites, blacks, and Korean Americans in the United States and native Koreans. RESULTS: The risk of stomach, liver, gallbladder, larynx, and esophageal cancer has sharply declined in Korean-American men compared with their native counterparts while prostate, colon, and rectum cancer risk has increased. In women, stomach, liver, gallbladder, and cervical cancers have declined, and breast, lung, colon, rectum, and endometrial cancers have increased. Cancer rates for stomach, liver, gallbladder, and esophagus are higher in native Koreans compared to US whites. Recently, cancer rates for Korean-American immigrants have increased for prostate, breast, colon, and rectal cancers. CONCLUSIONS: The study provides evidence that the risk of cancers common in Western countries is higher for Korean Americans than for their native counterparts. Recent trends among Korean Americans also revealed a stronger Western profile.     

Toward a comparison of survival in American and European cancer patients

BACKGROUND: Only recently have extensive population-based cancer survival data become available in Europe, providing an opportunity to compare survival in Europe and the United States. METHODS: The authors considered 12 cancers: lung, breast, stomach, colon, rectum, melanoma, cervix uteri, corpus uteri, ovary, prostate, Hodgkin disease, and non-Hodgkin lymphoma. The authors analyzed 738,076 European and 282,398 U.S. patients, whose disease was diagnosed in 1985-1989, obtained from 41 EUROCARE cancer registries in 17 countries and 9 U.S. SEER registries. Relative survival was estimated to correct for competing causes of mortality. RESULTS: Europeans had significantly lower survival rates than U.S. patients for most cancers. Differences in 5-year relative survival rates were higher for prostate (56% vs. 81%), skin melanoma (76% vs. 86%), colon (47% vs. 60%), rectum (43% vs. 57%), breast (73% vs. 82%), and corpus uteri (73% vs. 83%). Survival declined with increasing age at diagnosis for most cancers in both the U.S. and Europe but was more marked in Europe. CONCLUSIONS: Survival for most major cancers was worse in Europe than the U.S. especially for older patients. Differences in data collection, analysis, and quality apparently had only marginal influences on survival rate differences. Further research is required to clarify the reasons for the survival rate differences.     

Cancer mortality risk among Japanese in the United States

Earlier findings on cancer mortality experiences of Nisei and Issei were updated to around 1970. Compared with U.S. whites, Japanese in Japan had a high standardized mortality ratio (SMR) for cancers of the esophagus, stomach, biliary passages, and cervix, whereas they had low ratios for cancers of most other sites. Among U.S. Japanese, the direction and magnitude of the SMR transition varied by site, but generally the SMR moderated toward that of U.S. whites. Specifically, mortality from stomach cancer was elevated through the ratio has been reduced. In addition, mortality from cancers of the liver and biliary passages remained high. In contrast to a sharp decline in the SMR for esophageal cancer, the SMR for cancer of the colon and lymphomas rose closer to the levels for whites. The SMR for cancers of the ovary and prostate gland represented a rise above that of Japan. A higher Issei than Nisei SMR was observed for most cancer sites, regardless of the risk level in Japan. The reverse was true for cancers of the liver and nasopharynx among males, cancers of the breast and ovary among females, and lymphosarcoma and leukemia among both sexes.     

Trends in the incidence of cancer in the Sousse region,Tunisia, 1993–2006

In this article, we analyzed trends in incidence rates of the major cancer sites for a 14‐year period, 1993–2006, in the Sousse region localized in the centre of Tunisia. Five‐year age‐specific rates, crude incidence rates (CR), world age‐standardized rates (ASR), percent change (PC) and annual percent change (APC) were calculated using annual data on population size and its estimated age structure. A total of 6,975 incident cases of cancer were registered, with a male to‐female sex ratio of 1.4:1. ASRs showed stable trends (?0.1% in males, and +1.0% in females). The leading cancer sites in rank were lung, breast, lymphoma, colon‐rectum, bladder, prostate, leukemia, stomach and cervix uteri. For males, the incidence rates of lung, bladder and prostate cancers remained stable over time. While, cancers of colon‐rectum showed a marked increase in incidence (APC: +4.8%; 95% CI: 1.2%, 8.4%) and non‐Hodgkin's lymphoma (NHL) showed a notable decline (APC: ?4.4%; 95% CI: ?8.2, ?0.6). For females, cancers of the breast (APC: +2.2%; 95% CI: 0.4%, 4.0%) and corpus uteri (APC: +7.4%; 95% CI: 2.8%, 12.0%) showed a marked increase in incidence during the study period, while the cervix uteri cancer decreased significantly (APC: ?6.1%; 95% CI: ?9.2%, ?3.0%). The results underline the increasing importance of cancer as a cause of mortality and morbidity in Tunisia. Our findings justify the need to develop effective program aiming at the control and prevention of the spread of cancer amongst Tunisian population.     

Trends in incidence of and mortality from cancer in The Netherlands in the period 1989-1998

This paper summarises the population-based major trends in cancer incidence and mortality in the period 1989-1998 in The Netherlands. Trends of the European age-adjusted incidence and mortality rates were estimated by the Estimated Annual Percentage Change (EAPC) method. Increases in incidence were found for cancer of the breast and lung for females. For males, an increase was observed for cancer of the prostate, colon, rectum and testis. In both groups, oesophageal and pharyngeal cancer increased, but that of stomach and gallbladder cancer decreased. The main increases in mortality were found for pharyngeal cancer in males, lung in females and oesophageal cancer in both sexes. Decreases were shown for stomach cancer for both sexes and lung cancer for males. Trends in incidence may be a result of changes in behaviour, smoking habits in preceding decades are related to the increase in lung cancer for females, and early detection, screening programmes increased the incidence for breast and prostate cancers. Decreases in mortality may be related to more successful treatment of leukaemia, Hodgkin's lymphoma, colorectal and testicular cancers. Primary prevention of cancer remains important.     

安徽省肿瘤登记地区2013年恶性肿瘤发病与死亡分析

[目的]分析安徽省肿瘤登记地区2013年恶性肿瘤的发病和死亡情况.[方法]对23个肿瘤登记处数据进行审核,结果18个肿瘤登记处数据被纳入分析,按照地区(城乡)、性别分层计算恶性肿瘤发病率、死亡率、前10位恶性肿瘤顺位、构成比、累积率.采用2000年中国标准人口构成和Segi's世界人口构成分别计算中国和世界人口年龄标化发病/死亡率.[结果]安徽省18个肿瘤登记处共覆盖登记人口17 387 263人,报告恶性肿瘤新病例47 420例,死亡病例28 893例,病理学诊断比例为57.94％,只有死亡证明书比例为3.30％,死亡发病比为0.61.恶性肿瘤发病率为272.73/10万(男性326.60/10万,女性215.82/10万),中国人口标化率为215.64/10万,世界人口标化率为213.24/10万,累积率(0～74岁)为25.34％.恶性肿瘤死亡率为166.17/10万(男性215.70/10万,女性113.85/10万),中国人口标化率为127.49/10万,世界人口标化率为126.56/10万,累积率(0～74岁)为14.41％.肺癌、胃癌、食管癌、肝癌、女性乳腺癌、结直肠癌、宫颈癌、前列腺癌、脑瘤和子宫体癌是安徽省主要的恶性肿瘤,约占全部新发病例的79％.肺癌、胃癌、肝癌、食管癌、结直肠癌、女性乳腺癌、胰腺癌、脑瘤、宫颈癌和白血病是主要的肿瘤死因,约占全部肿瘤死亡病例的87％.[结论]肺癌、胃癌、食管癌、肝癌以及女性乳腺癌是安徽省主要的发病和死亡癌种,对居民健康危害严重.在肿瘤防控工作中,要重点加强这几类恶性肿瘤的早期预防和控制.     

Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities

Many studies demonstrate that cancer incidence and mortality patterns among Asian Americans are heterogeneous, but national statistics on cancer for Asian ethnic groups are not routinely available. This article summarizes data on cancer incidence, mortality, risk factors, and screening for 5 of the largest Asian American ethnic groups in California. California has the largest Asian American population of any state and makes special efforts to collect health information for ethnic minority populations. We restricted our analysis to the 4 most common cancers (prostate, breast, lung, colon/rectum) and for the 3 sites known to be more common in Asian Americans (stomach, liver, cervix). Cancer incidence and mortality were summarized for 5 Asian American ethnic groups in California in order of population size (Chinese, Filipino, Vietnamese, Korean, and Japanese). Chinese Americans had among the lowest incidence and death rate from all cancer combined; however, Chinese women had the highest lung cancer death rate. Filipinos had the highest incidence and death rate from prostate cancer and the highest death rate from female breast cancer. Vietnamese had among the highest incidence and death rates from liver, lung, and cervical cancer. Korean men and women had by far the highest incidence and mortality rates from stomach cancer. Japanese experienced the highest incidence and death rates from colorectal cancer and among the highest death rates from breast and prostate cancer. Variations in cancer risk factors were also observed and were for the most part consistent with variations in cancer incidence and mortality. Differences in cancer burden among Asian American ethnic groups should be considered in the clinical setting and in cancer control planning.     

Cancer patterns among Koreans in Japan, Koreans in Korea and Japanese in Japan in relation to life style factors

Cancer incidences for major sites were compared among Koreans in Osaka, Japan, Koreans in Korea and Japanese in Osaka by calculating standardized proportional incidence ratios (SPIR's), in addition to updating the findings on cancer mortality experiences of Koreans and Japanese in Osaka reported before. Compared with Japanese, Koreans in Osaka had significantly higher mortality rates from cancers of the esophagus, liver and lung in males, and liver in females. Mortality rates among Koreans in Osaka were significantly lower for stomach cancer in both sexes and for breast cancer in females. Compared with Korean counterparts in the homeland, Koreans in Osaka had a reduced risk for cancers of the stomach in males and the uterus in females. On the other hand, an elevated risk was observed for cancers of the esophagus, colon, liver and lung among Korean males in Osaka and for cancers of the colon and liver among Korean females in Osaka. The risk for cancer of the breast in females was similar among Koreans in the host and home countries. These different cancer patterns among Koreans in the host and home countries and Japanese are discussed in relation to their life styles, such as smoking, drinking and dietary habits, which have been investigated by means of questionnaire surveys.     

Cancer survival in Hong Kong SAR, China, 1996-2001

The Hong Kong cancer registry was established in 1963, and cancer registration is done by passive and active methods. The registry contributed data on 45 cancer sites or types registered during 1996-2001 for this survival study. Follow-up has been carried out by passive methods with median follow-up ranging from 4-60 months. The proportion of cases with histologically verified cancer diagnosis ranged from 38-100%; death certificates only (DCOs) ranged from 0-11%; 83-99% of total registered cases were included for survival analysis. The 5-year age-standardized relative survival exceeded 100% for lip and non-melanoma skin followed by thyroid (94%) and testicular (92%) cancers. The corresponding survival for common cancers were breast (90%), colon (61%), liver and Lung (22%), nasopharynx (70%), rectum (59%) and stomach (39%). The 5-year relative survival by age group showed a decreasing trend with increasing agegroups for most cancers. A decreasing survival with increasing clinical extent of disease was noted.     

Differences in breast cancer mortality worldwide: unsolved problems.

Breast cancer mortality remains a major cause of female mortality. Between 1970 and 2000 both important increases and decreases in breast cancer mortality rates occurred. Large differences in breast cancer mortality exist among countries worldwide. Contradictory findings concerning the role of lifestyle, especially nutrition, remain to be explained. Possible explanations for the observed mortality differences will be explored. Breast cancer mortality rates have been correlated with other causes of mortality; both cancer and noncancer, using data obtained from 47 countries worldwide (World Health Organization). They have also been correlated with dietary data, especially concerning fat (animal and vegetal) intake (Food and Agricultural Organization). Highly significant correlations existed between breast cancer mortality and mortality from other cancers (e.g. colon, stomach) obtained from both sexes. These correlations have been confirmed over a period of more than 40 years. Highly significant positive correlations also existed with the intake of animal (saturated) fat, covering a period of 30 years. In multivariate regression, only the relationship with the colon, prostate cancer and total energy intake remained significant. Ecological data point to nutritional factors, especially animal fat, as major promoters of breast cancer mortality worldwide. This contrasts with the results of most cohort studies. These contradictory results and the relationship between breast cancer mortality and other causes of mortality remain to be explained. More refined and standardized dietary data are necessary.     

International comparisons of mortality rates for cancer of the breast, ovary, prostate, and colon, and per capita food consumption

The 1978-1979 mortality rates for cancers of the breast, prostate, ovary, and colon in 26 to 30 countries were related to the average 1979-1981 food availability data published by the United Nations. The previously described relationship between breast cancer mortality rates and animal fat consumption continues to be evident, and applies also to the other three tumor types. The correlation with breast cancer was particularly strong in postmenopausal women. Since 1964, particularly notable increases in both breast cancer mortality rate and dietary fat intake have occurred in those countries with a relatively low breast cancer risk. The international comparisons support evidence from animal experiments that diets in which olive oil is a major source of fat are associated with reduced breast cancer risk. The excess in mortality rates for breast and ovarian cancer in Israel relative to the national animal fat consumption may be due to the mixed ethnic origin of the Israeli population. Positive correlations between foods and cancer mortality rates were particularly strong in the case of meats and milk for breast cancer, milk for prostate and ovarian cancer, and meats for colon cancer. All four tumor types showed a negative correlation with cereal intake, which was particularly strong in the case of prostate and ovarian cancer. Although, in general, there was a good positive correlation between prostate and breast cancer mortality rates and between prostate cancer and animal fat, discrepancies in national ranking indicate the operation of other etiologic factors that modify risk. The observed positive correlations between the four cancer mortality rates and caloric intake from animal sources, but negative correlations for vegetable-derived calories, suggest that, of the two, animal fat and not energy is the major dietary influence on cancer risk.     

Estimates of the worldwide mortality from eighteen major cancers in 1985. Implications for prevention and projections of future burden

This report presents worldwide estimates of annual mortality from all cancers and for 18 specific cancer sites around 1985. Crude and age-standardized mortality rates and numbers of deaths were computed for 24 geographical areas. Of the estimated 5 million deaths from cancer (excluding non-melanoma skin cancer), 56% occurred in developing countries. The most frequent neoplasm is lung cancer, accounting for 22% of cancer deaths in men. Among women breast cancer is the leading malignancy, accounting for 16% and 11% of all cancer deaths in developed and developing countries, respectively. In developing countries, cancer of the cervix uteri ranks first, breast cancer second. The second most frequent cause of death from cancer in both sexes is cancer of the stomach, followed by liver cancer in men and by colon/rectum cancer in women. Cancers of the colon/rectum and prostate maintain a high rank in men living in developed countries, while cancers of the lung, ovary and pancreas occupy similar ranks among women. In developing countries, cancers of the oesophagus and mouth/pharynx follow those previously mentioned in both sexes. If the estimated rates continue to prevail, increases in the numbers of deaths of 20.4% in developed and 18.1 % in developing countries are expected by the year 2000, simply as a consequence of demographic trends towards ageing and population growth. Our results provide an indication of the potential impact of preventive practices. It is estimated that 20% of all cancer deaths (1 million) could be prevented by eliminating tobacco smoking. Mortality from cancers of the liver and uterine cervix, both major problems in developing countries, could be substantially reduced by immunization against hepatitis B virus infection and early detection through Pap smears, respectively.