The European cancer burden in 2020: Incidence and mortality estimates for 40 countries and 25 major cancers

Cancer accounts for a greater number of deaths among persons aged under 65 years than any other disease in the member states of the European Union (EU) []. Cancer is a major public concern on the continent: almost one-quarter of all global cancer cases occur in Europe, which is home to only one-tenth of the world's population [,]. In economic terms, cancer cost the EU almost €97 billion in 2018 []. Estimates of cancer burden at the national level are based on population-based cancer registry data and provide an important motivator for cancer-control policies. In Europe, the individual members of the European Network of Cancer Registries (ENCR, http://www.encr.eu/) are the institutions hosting the national or regional cancer-registry information systems providing this baseline information.

European estimates of the cancer burden have been made available for over 30 years [, , , , , , , ]. The latest figures for 2020 are presented herein, and they are based on the collaboration between the European Commission's Joint Research Centre (JRC, which also serves as the ENCR secretariat), the Cancer Surveillance Branch of the International Agency for Research on Cancer (IARC, which also serves as the Secretariat of the International Association of Cancer Registries – IACR) with the support of the ENCR and IACR.

Estimated incidence and mortality figures are based on several data sources, namely: the historical time series available in the European Cancer information System (ECIS) of the European Commission [] and the data submitted to the project ‘Cancer Incidence in Five Continents Vol. XI (CI5-XI)’ [] – for the incidence predictions; the World Health Organisation (WHO) database [] – for the mortality predictions; ECIS, Eurostat [] and the United Nation (UN) Population Division sources [] – for the population data.

The 2020 cancer-burden estimates are described for the 25 most common cancer sites for each of the 39 UN-defined European countries [] and Cyprus. In addition, aggregated results are provided for the EU-27 Member States; the four UN-defined European areas (Central and Eastern, Northern, Southern and Western Europe) []; and the whole of Europe.

The complete set of estimates for the 25 cancers, with additional cancer entities, is available from the ECIS web application (https://ecis.jrc.ec.europa.eu/) and from IARC's Global Cancer Observatory (GCO, https://gco.iarc.fr/).

The numbers of new cancer diagnoses and cancer deaths estimated to occur in Europe for 2020 (in thousands) by cancer type and sex are reported in Fig. 1 and Table 2. The estimated cancer burden in Europe for 2020 is 4.0 million new cancer cases (all cancer types, excluding non-melanoma skin cancer) and 1.9 million cancer deaths. The corresponding cumulative risk (below 75 years) of receiving a cancer diagnosis is 31% for males (1 in 3 men) and 24% for females (1 in 4 women), while the corresponding risk of dying due to cancer is 15% for males (1 in 7 men) and 9% for females (1 in 11 women). Cancer overall affect men slightly more than women, with 53% (2.1 million) of new cases and 55% (1.1 million) of cancer deaths occurring in males. Cancer disproportionately affects older adults, with 60% of the estimated new diagnoses and 73% of estimated deaths occurring in persons aged 65 years or older, 34% and 25% occurring in people 45–64 years old, and 7% and 3% in people younger than 45 years.

Four cancer types are responsible for approximately 50% of all cancer diagnoses. Breast cancer is the most commonly diagnosed cancer accounting for 13.1% of all cancer diagnoses (530,000 cases; females only), followed by colorectal (520,000, 12.9%), lung (480,000, 11.8%) and prostate (470,000, 11.7%) cancers. When distinguishing by sex (Fig. 2), the most common cancers among males are prostate (22.2% of the male total), lung (320,000, 14.8%), colorectum (280,000, 13.2%) and bladder (160,000, 7.3%). In women, breast cancer is by far the most frequently diagnosed malignant neoplasm (27.8% of the female total), followed by colorectal (240,000, 12.4%), lung (160,000, 8.5%) and corpus uteri (130,000, 6.8%) cancers.

For mortality, the most common causes of cancer death are due to lung (380,000 deaths, corresponding to one-fifth of the overall share), colorectal (250,000 deaths, 12.6%), breast (140,000, 7.3%; females only) and pancreatic (130,000, 6.8%) cancers. All together, these cancers account for 47% of all-cancers mortality. When considering the male population only (Fig. 2), lung cancer is the most common cause of cancer-related death (260,000 estimated deaths, corresponding to 24.2% of the male total) followed by colorectal (130,000, 12.3%) and prostate (110,000, 10.0%) cancers. For females, breast cancer is the leading cause of cancer death (140,000, 16.4% of female total), followed by lung (120,000, 14.3%) and colorectal (110,000, 13.0%) cancers. In Table 3, the leading three types of cancer for incidence and mortality are reported by European country, for males and females separately .

Focussing on the EU-27 (Table 4), the cancer burden in 2020 corresponds to 2.7 million new cases and 1.3 million deaths, representing 66% of all new cases and 65% of cancer deaths of the whole of Europe. The overall cumulative risk of cancer diagnosis and deaths are very similar to European figures. Breast cancer is the most commonly diagnosed cancer with over 360,000 new female cases (13.3% of all cancer diagnoses), followed by colorectal (340,000, 12.7%), prostate (340,000, 12.5%) and lung (320,000, 11.9%) cancers. The most common causes of cancer death are lung (260,000 deaths, 20.4% of all deaths), colorectal (160,000, 12.4%), breast (90,000, 7.3%; females only) and pancreatic (90,000, 7.1%) cancers.

Age-stratified analyses, relating to three different age groups (0–44, 45–64 and 65 years and over, Fig. 3), revealed that the five most common cancers for incidence and mortality predominantly affect middle-aged and older adults. In the 0–44 years group, more than 50% of incident cases are due to breast, thyroid, and cervical cancer among females, and to testicular cancer, melanoma of the skin, brain and other CNS, leukaemia and non-Hodgkin lymphoma among males. In older age groups, the most commonly diagnosed cancer among females is breast (34.5% in 45–64 and 22.5% in 65+), followed by colorectal (9.5% and 15.8%), corpus uteri (8.6% and 6.4%), lung (8.1% and 9.9%), thyroid (4.4% in the 45–64 age groups) and pancreatic (5.1% in the 65+ age group) cancers. Among males, prostate cancer is the most commonly diagnosed (19.4% in 45–64 and 25.3% in 65+), followed by lung (15.7% and 15.2%), colorectal (12.3% and 14.3%), and bladder (5.8% and 8.6%) cancers. The fifth most common cancer in males is kidney cancer in the 45–64 years group (5.1%) and stomach cancer (4.1%) in the 65+ years group.

Similar to incidence, younger age groups have different mortality distributions as compared to middle and older ages (Fig. 3). Among males, lung cancer accounts for the highest number of cancer-related deaths (29.2% in 45–64 and 22.8% in 65+), followed by colorectal (9.8% and 13.3%) and pancreatic (7.1% and 5.9%) cancers. Liver (5.4%) and stomach (6.1%) cancers are the main causes of cancer deaths in the age class 45–64 years, while prostate (12.8%) and bladder (5.7%) cancers rank highest in the older age classes. Among females, breast cancer has the highest proportion of cancer deaths (19.3% in 45–64 and 15.1% in 65+ years), followed by lung (17.9% and 13.7%), colorectal (9.4% and 14.5%), ovary (6.9% and 4.5%), and pancreatic (6.2% and 8.2%) cancers.

For the 40 European countries analysed, Appendix Table A1a, Appendix Table A1b present the estimated number of new cases and the incidence rates by sex and site, while Appendix Table A2a, Appendix Table A2b present the estimated number of deaths and mortality rates by sex and site. Appendix Table A3, Appendix Table A4 report the estimated number of new cases and deaths with the incidence and mortality rates by age group and site.

Sections 3.1, 3.2, 3.3, 3.4, 3.5, 3.6 provide a brief description of the overall cancer patterns and highlight the five cancers that are the most common cancer diagnoses or main causes of cancer-related deaths in Europe.

We estimate over 4 million new cancer cases (excluding non-melanoma skin cancers) and close to 2 million deaths from cancer in Europe in 2020, indicating that on average 11,000 new cancer cases and 5000 cancer deaths occurred every day in Europe over the year. Half of the overall cancer burden in Europe is attributed to breast, colorectal, prostate and lung cancers. The same diseases were also the major causes of cancer deaths in Europe for 2020, but additionally, pancreatic cancer ranks as the fourth leading cause of cancer mortality.

The 2020 estimates still show considerable geographic variability in the incidence and mortality rates among European countries [] and reflect a number of possible determinants. These include geographic differences in the prevalence of key risk factors for specific cancers, in the effective delivery of national cancer control plans, and in the effective implementation of cancer screening programmes for breast, cervical and colorectal cancers, as well variations in diagnostic practice (e.g. with respect to prostate and thyroid cancer detection) [,]. National strategies need to be applied or further implemented to reduce the extent of the cancer burden in Europe.

The cancer-data collection process incurs inevitable delays of several years in order to ensure the harmonisation, completeness, and quality of data necessary for the effective monitoring and control of cancer. Estimates are therefore an efficient interim means of providing a timely snapshot of the cancer situation prior to the availability of up-to-date data. The methodology used in this article is consistent with that previously applied [, , , ] and utilises the most recently collected data, such as national mortality rates for the years 2004–2018, and national and regional incidence rates for the period 2003–2018. Such a short horizon of prediction increases the accuracy and reliability of prediction provided that the baseline data is sufficient in terms of availability and accuracy.

Owing mainly to the difficulties in ascertaining and certifying the cause of death and incompleteness of death registrations, cancer mortality data are generally associated with a lower accuracy (and thus validity) than cancer-registry statistics. This may have led to under- or overestimation of the true mortality of cancer for specific sites and to the subsequent bias in incidence estimates when applying mortality to incidence ratios to obtain 2020 incidence. Sensitivity analyses were applied in such cases: incidence estimates obtained based on local incidence data were compared with incidence estimated using mortality to incidence ratios. Results obtained using the former approach were then chosen for selected cancer sites if necessary.

As performed previously for the 2018 European estimates [], we also implemented the redistribution of ill-defined causes of deaths and of ill-defined cancers (other than the usual category "uterus unspecified") across specific cancer sites, which may have led to overestimated mortality. While compatibility with previous 2018 estimates [] is granted, direct comparison with other estimates is not straightforward, although another set of 2020 estimates for cancer mortality in the EU-27 plus United Kingdom was published in 2020 [] reporting an estimated total number of cancer deaths of 1.43 million (in line with 1.44 million cancer deaths reported in the present study). These figures are very similar despite the different approaches and the redistribution of the ill-defined causes of death and of ill-defined cancers across specific categories (especially on uterine cancer estimates) applied in our analysis. When considering site-specific results, the inclusion of metastatic cancers along with primary neoplasms may have overestimated mortality rates for some sites, including liver, lung and brain.

Screening programmes and specific diagnostic practices in place in Europe may have inflated regional and national differences in incidence rates observed especially in some cancers: the interpretation of breast, prostate and thyroid cancer variations should be treated with particular care. Similarly for bladder cancer, which may include some carcinomas in situ or tumours of uncertain or unknown in incidence (but not in mortality) depending on the definition of malignancy in each cancer registry []. In addition, several sources of data were used in generating the incidence statistics. Incidence rates at national level were provided by 25 European countries, representing 50% of the total European population.

If the size of the population covered by local registries was sufficiently large (≥60% of the national population), the estimated incidence was predicted using local incidence data (method 1, as for example the case for Germany). This was considered preferable to the calculation making use of mortality-to-incidence ratios (methods 3A and 3B, as in the case of other 15 countries) since the latter requires the additional constraint of stability in the mortality to incidence ratios on the most recent historical data. Moreover, estimation method 3A, in which all incidence and mortality data come from the same country, should be considered more reliable than method 3B, where the mortality to incidence ratio comes from neighbouring countries.

Despite the possible limitations of the data and methodology described above, the estimates provide a generally balanced overview of the European cancer burden and the associated geographical variations, and they are a valuable and appropriate means of identifying and monitoring cancer-control actions in Europe.

It has been estimated that almost 40% of cancer cases are preventable [] and thus cancer prevention knowledge and action is crucial (https://ec.europa.eu/jrc/en/health-knowledge-gateway). The European Code Against Cancer [] is a flagship initiative promoting preventive measures in fighting cancer. The Code describes twelve preventive actions that could avoid almost half of all European cancer deaths if respected. The first recommendation concerns smoking habits and tobacco control and is arguably the most important recommendation considering that lung cancer is the leading cause of cancer death in Europe, and furthermore that geographic variations in rates are largely determined by past exposure to tobacco smoking. Among males, incidence and mortality rates of lung cancer show decreasing trends in many European countries, especially in Northern and Western Europe, while in Central and Eastern Europe rates are still high but tending to stabilise or decline []. In contrast, female lung cancer incidence rates are still rising in Europe (e.g. France, Spain), although starting to stabilise, notably in the high-risk Nordic countries []. The more recent history of tobacco exposure among women can explain the different geographical patterns and time trends compared with males.

Incidence and mortality of tobacco-related cancers (mainly lung cancer, but also cancers of the head and neck, oesophagus, pancreas and urinary tract) could largely be avoided by primary prevention interventions on smoking habits and tobacco use [,]. At the European level, policies on tobacco control are led by the WHO Framework Convention on Tobacco Control (WHO FCTC) [] and the European Tobacco Products Directive (TPD) [], which facilitates EU Member States to transpose the directives into national law. Among the 50 countries in the WHO European Region having ratified the WHO FCTC, only half of them have raised excise taxes on tobacco products. Moreover, only 14 countries have introduced laws on smoke-free public places, and only eight countries offer cessation programmes [].

The 2020 estimates place colorectal cancer as the second leading cause of cancer death in males, and the third in females. Risk for colorectal cancer has been associated with diets high in red meat and processed meat, overweight, smoking, and alcohol consumption []. Persons with a family history of colorectal cancer are also at higher risk []. Protective factors are a diet rich in whole grains, fruits and vegetables, as well as maintenance of a healthy life style, abstinence from smoking, limited alcohol intake and regular physical activity []. An IARC Handbook Working Group reported there was sufficient evidence that screening for colorectal cancer with currently established stool-based tests (guaiac testing and faecal immunochemical test [FIT]) and lower endoscopy (sigmoidoscopy and colonoscopy) reduce the risk of death from colorectal cancer and that the benefits outweigh the harms associated with each type of screening [].

Breast cancer is the most diagnosed cancer in the female population across all European countries, and is the first cause of cancer death in women in Europe for 2020. However, a number of factors contribute to the observed geographical variations of breast cancer incidence, including implementation of organised and opportunistic screening activities, different prevalence and distribution of the major risk factors (e.g. parity, maternal age at first birth []), and possible methodological artefacts applied to countries with little or no data. Breast-cancer mortality rates are nevertheless decreasing in most European countries, especially in Northern and Western Europe []. The favourable mortality trends reflect the advances in earlier detection (due both to screening and increasing breast cancer awareness), improvements in treatment [,], and the possible declining use of hormone replacement therapy [HRT] after 2003 [].

Prostate cancer is the fourth most common cancer diagnosed in Europe for 2020. Prostate cancer diagnoses followed the rapid increase in the detection of early-stage prostate cancers during the early to mid-1990s with the introduction of PSA testing, which is largely responsible for the increase of prostate cancer incidence levels [,]. After increasing for many years, prostate cancer incidence trends are stabilising or decreasing in the last observed 5 years (approximately after 2005), likely due in part to clinical caution in use of PSA testing given intrusive investigation and the possibility of unnecessary diagnosis of clinically irrelevant disease []. Decreasing mortality trends of prostate cancer in several European countries can be attributed to improvements in prostate cancer treatment [,], while geographical differences of mortality levels are still difficult to explain and can only partially be explained by delayed and limited access to modern effective treatments [].

Pancreatic cancer is the fourth cause of cancer death in Europe and in the EU-27 for both sexes. Considering a low and unchanging pancreatic cancer survival [] and the stable or increasing mortality trends [], a growing number of deaths is expected due to the ageing of the European population. The most important recognised risk factors are tobacco smoking, obesity, dietary habits, alcohol consumption and diabetes mellitus [,]; the different smoking prevalence patterns by generation could partly explain the increasing mortality rates among females [].

The incidence and mortality historical data used as baseline in our prediction process refer to the period prior to the coronavirus disease 2019 (COVID-19) pandemic and therefore the applied methodology does not account for any impact of COVID-19. A future comparison of the 2020 estimates with the recorded cancer incidence and mortality data for the same year, once available, will allow quantification of possible discrepancies for which there is already some evidence. A study published in mid 2020 from the Netherlands showed a notable decrease in cancer diagnoses in 2020 compared with the preceding period []; this effect was observed across all age groups and almost all cancer sites, while it was most pronounced for skin cancers. At the end of the year, the Netherlands Cancer Registry estimated that the decrease of cancer incidence in 2020 was only 3.5% (https://iknl.nl/persberichten/aantal-nieuwe-kankerpatienten-in-2020-gedaald-door). A Slovenian study [] reported a significant decrease in numbers of first referrals, which may account for the drop of 30% in cancer notifications in April 2020 during the first surge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case (indicating delayed cancer diagnosis for some patients). A Danish study found a substantial reduction amounting to one-third of the number of incident cancer diagnoses during the first three months of the pandemic compared with the previous years []. In Northern Ireland, the number of new patients presenting a first pathological sample indicating cancer in the period March 2020–March 2021 was 14% lower than the average reported in previous years (https://www.qub.ac.uk/research-centres/nicr); in this same country the pathologic diagnoses of Barrett's oesophagus fell by 59% compared to historical rates during the first six months of the COVID-19 pandemic []. A JRC survey among 40 cancer registries from 22 European countries reported that cancer-screening programmes were mostly stopped or slowed down in the majority of cancer registries' areas, and that cancer diagnostic and treatment activities were severely disrupted []. The impact of COVID-19 on cancer mortality data is not always reported for the year 2020 and will be more difficult to ascertain due to the trade-off of possible opposing effects. On the one hand, any delay in cancer diagnosis and/or treatment will generally increase the observed number of cancer deaths, whilst on the other, a harvesting effect on late-stage cancer patients will tend to decrease cancer mortality [].

Population-based cancer registries are the baseline source for cancer monitoring and planning of cancer control activities at population level []. The results presented in this study would have not been possible without the longstanding existence of more than 150 subnational and national cancer registries and their close and continued collaboration in maintaining and providing data under the coordination of the ENCR at the European level. The need for accurate, timely cancer data will only increase, yet the contemporary financial support and advocacy to registries in some countries in Europe does not mirror the increasing demand. The recent requirement to comply with the EU General Data Protection Regulation (GDPR) places additional strain on the registry's activities. This unfavourable condition requires swift and appropriate action from political decision-makers.

No funding declared.

Tadeusz Dyba: Conceptualisation, Methodology, Software, Formal analysis, Writing – Original draft preparation and Review; Giorgia Randi: Conceptualisation, Methodology, Software, Formal analysis, Writing – Original draft preparation and Review, Visualization; Freddie Bray: Conceptualization, Methodology, Writing – Review; Carmen Martos: Data Curation, Writing – Review; Francesco Giusti: Data Curation, Writing – Review; Nicholas Nicholson: Writing – Original draft preparation and Review; Anna Gavin: Writing – Review; Manuela Flego: Writing – Review; Luciana Neamtiu: Writing – Review; Nadya Dimitrova: Writing – Review; Raquel Negrão Carvalho: Conceptualisation, Writing – Review; Jacques Ferlay: Conceptualisation, Methodology, Software, Writing – Review, Supervision; Manola Bettio: Conceptualization, Methodology, Writing – Original draft preparation and Review, Supervision.

The authors gratefully acknowledged the following cancer registries who contributed their data to enable the estimates produced in this study via submission to Cancer Incidence in Five Continents Volume XI and to European Cancer Information System (ECIS): Austria: Austrian Cancer Registry; Belarus: Belarussian National Cancer Registry; Belgium: Belgian Cancer Registry; Bosnia and Herzegovina: Republika of Srpska Cancer Registry; Bulgaria: Bulgarian National Cancer Registry; Croatia: Croatian National Cancer Registry; Cyprus: Cyprus Cancer Registry; North Cyprus Cancer Registry; Czechia: Czech National Cancer Registry; Denmark: Danish Cancer Registry; Estonia: Estonian Cancer Registry; France: Bas-Rhin Cancer Registry, Calvados Cancer Registry, Doubs Cancer Registry, Gironde Cancer Registry, Haut-Rhin Cancer Registry, Herault Cancer Registry, Isere Tumour Registry, Lille-Metropole Cancer Registry, Limousin Cancer Registry, Loire-Atlantique Cancer Registry, Manche Cancer Registry, Somme Cancer Registry, Tarn Cancer Registry, Territoire de Belfort Cancer Registry, Cancer Registry of Poitou-Charentes, Calvados Registry of Digestive Tumours, Bourguignon Digestive Cancer Registry, Cote d Or Hemopathy Registry, Finistere Registry of Digestive Tumours, Gironde Registry of Malignant Hemopathy, Cancer registry of tumours on the nervous system in Gironde, Lower Normandy Hemopathy Registry, Poitou-Charentes Cancer Registry; Germany: Cancer Registry Bavaria, Common Cancer Registry of the federal states Berlin, Brandenburg, Mecklenburg-Western Pomerania, Saxony-Anhalt and of the Free States of Saxony and Thuringia (CCR), Bremen Cancer Registry, Hamburg Cancer Registry, Hessen Cancer Registry, Lower Saxony Cancer Registry, Epidemiological Cancer Registry North Rhine-Westphalia, Cancer Registry of Rhineland-Palatinate, Saarland Cancer Registry, Schleswig–Holstein Cancer Registry; Iceland: Icelandic Cancer Registry; Ireland: National Cancer Registry Ireland; Italy: Aosta Valley Cancer Registry, Barletta Cancer Registry, Basilicata Cancer Registry, Bergamo Cancer Registry, Province of Biella Cancer Registry, Cancer Registry of the Brescia Local Health Unit, Brindisi Cancer Registry, Cancer Registry of Caserta, Integrated Cancer Registry of Catania-Messina-Siracusa-Enna, Catanzaro Tumour Registry, Cancer Registry of Como province, Cremona Cancer Registry, Ferrara Province Cancer Registry, Friuli-Venezia Giulia Cancer Registry, Latina Province Cancer Registry, Cancer Registry of Puglia - Province of Lecce, Lecco Cancer Registry, Liguria Region Tumour Registry, Cancer Registry of Lodi, Cancer Registry of Pavia (South Lombardy in Cancer Incidence and Five Continents, Volume XI),Macerata Province Tumour Registry, Mantova Cancer Registry, Milano Tumour Registry, Tumour Registry of Modena, Monza and Brianza Cancer Registry, Naples Cancer Registry, Nuoro Cancer Registry, Palermo Province Cancer Registry, Parma Cancer Registry, Piacenza Cancer Registry, Ragusa Cancer Registry, Reggio Emilia Province Tumour Registry, Romagna Tumour Registry, Salerno Province Tumour Registry, Sassari Province Tumour Registry, Sondrio Province Tumour Registry, South Tyrol Cancer Registry, Cancer Registry of the Province of Syracuse, Taranto Cancer Registry, Trapani Cancer Registry, Trento Cancer Registry, Piedmont Tumour Registry, Tuscany Region Tumour Registry, Umbrian Tumour Registry, Varese Tumour Registry, Veneto Tumour Registry, Viterbo Province cancer Registry; Latvia: Latvian Cancer Registry; Lithuania: Lithuanian Cancer Registry; Malta: Malta National Cancer Registry; Montenegro: Registry of Malignant Neoplasms of Montenegro; Netherlands: Netherlands Cancer Registry; Norway: Cancer Registry of Norway; Poland: National Registry of Poland, Cracow City and District Cancer Registry, Greater Poland Cancer Registry, Kielce Regional Cancer Registry, Lower Silesian Cancer Registry, Lublin Cancer Registry, Podkarpackie Cancer Registry; Portugal: Azores Cancer Registry, Central Region Cancer Registry, North Region Cancer Registry, South Region Cancer Registry; Romania: Cluj Regional Cancer Registry, Timisoara Regional Cancer Registry; Russian Federation: Arkhangelsk Cancer Registry, Chelyabinsk Cancer Registry, Karelia Cancer Registry, Saint Petersburg Cancer Registry, Samara Cancer Registry; Serbia: Central Serbia Cancer Registry; Slovakia: Slovakia National Cancer Registry; Slovenia: Cancer Registry of the Republic of Slovenia; Spain: Albacete Cancer Registry, Asturias Cancer Registry, Basque Country Cancer Registry, Canary Islands Cancer Registry, Castellón Cancer Registry, Ciudad Real Cancer Registry, Cuenca Cancer Registry, Girona Cancer Registry, Granada Cancer Registry, La Rioja Cancer Registry, Mallorca Cancer Registry, Murcia Cancer Registry, Navarra Cancer Registry, Tarragona Cancer Registry; Switzerland: Aargau Cancer Registry, Basel Cancer Registry, Bern Cancer Registry, Central Switzerland Cancer Registry, Fribourg Tumour Registry, Geneva Cancer Registry, Graubünden and Glarus Cancer Registry, Neuchatel Cancer Registry, St. Gallen-Appenzell Cancer Registry, Thurgau Cancer Registry, Ticino Cancer Registry, Valais Cancer Registry, Vaud Cancer Registry, Zürich and Zug Cancer Registry; United Kingdom: National Cancer Registration Service (NCRS), Northern Ireland Cancer Registry, Scottish Cancer Registry, Welsh Cancer Intelligence and Surveillance Unit; Ukraine: National Cancer Registry of Ukraine.

The authors are grateful to Mr Fabrizio Zaro for his help in the visualisation and data presentation.