Analysis of cancer incidence and mortality in Bosnia and Herzegovina and comparison with Slovenia , Croatia and Serbia

Bosnia and Herzegovina (BiH) is a country in Southbordered by Croatia, Serbia and Montenegro. Bosnia and Herzegovina is divided into Federation of Bosnia and Herzegovina (FBiH), Republic of Srpska (RS) and Brčko District (BD). We carried analysis of data available from Public Health Institute of the Federation of Bosnia and Herzegovina, Public Health Institute of Republic of Srpska and from Agency for statistics of Bosnia and Herzegovina. From this analysis we assessed cancer incidence and mortality in Federation of Bosnia and Herzegovina, Republic of Srpska and Brčko District. After that we compared our data with other countries Croatia, Slovenia and Serbia. We developed multiple linear regression model for prediction of male and female crude death rate from gross value added for health and social work and incidence in FBiH. We have found that there is extremely high number of newly diagnosed patients in HercegovinaNeretva comparing to different cantons of FBiH. This result should be further examined. Eight leading causes of cancer death in FBiH (bronchus and lung, colon and rectum, stomach, liver and intrahepatic bile ducts, breast, pancreas, brain, prostate) were analyzed for different periods and for difference between genders. ko District Estimated number of citizens in FBiH for date 30.06.2012.is 2.338.277 total, 1.160.651 males and 1.177.626 females (Federal office of statistics, Bosnia and Herzegovina, Federation of Bosnia and Herzegovina). In a year 2011. 20,9% deaths were because of cancer, 24,3% males and 17,4% females (Institute for public health of FBiH, Health statistics annual Federation of Bosnia and Herzegovina 2011). Estimated number of citizens in RS in year 2011 is 1.429.668 total, 695.884 males and 733.784 females. In a year 2011. 20,5% deaths were because of cancer, 24,1% males and 16,8% females (Republic of Srpska, Institute of statistics. Demographic statistics.Statistical bulletin No 15). Estimated number of citizens in BD in y 75,674 total, 37,816 males and 37,858 females. In a Eastern Europe,


INTRODUCTION
Cancer is one of the major causes of deaths in the world.According to the World Health Organization (WHO) cancer is a leading cause of death in the world.In year 2008 7.6 million people died because of cancer and this number is around 13% of all deaths in the world (WHO, Cancer, Globocan 2008).Bosnia and Herzegovina (BiH) is a country in the South-East Europe.It is bordered by Croatia, Serbia and Montenegro.This country is divided to three main parts: Federation of Bosnia and Herzegovina (FBiH), Republic of Srpska (RS) and Brč (BD).
Cancer is one of the major causes of deaths in the world.According to the World Health Organization (WHO) cancer is a leading cause of death in the world.In year 2008 7.6 million people died because of cancer and this number is around 13% of all n the world (WHO, Cancer, Globocan and Herzegovina.From this analysis we assessed cancer incidence and mortality in Federation of Bosnia and ko District.After that we compared our data with other countries Croatia, Slovenia and Serbia. ultiple linear regression model for prediction of male and female crude death rate from gross value added for health and social work and incidence in FBiH.We have found that there is extremely high number of newly diagnosed patients in HercegovinaNeretva canton comparing to different cantons of FBiH.This result should be further examined.Eight leading causes of cancer death in FBiH (bronchus and lung, colon and rectum, stomach, liver and intrahepatic bile ducts, alyzed for different periods and Herzegovina.For analysis of the most frequent cancer forms we selected seven most frequent forms for men and women in year 2011 in FBiH.Age adjusted rates were not calculated since there are no relevant data about current population in Bosnia and Herzegovina.Multiple linear regression was used to create model of influence of incidence and gross value added for health and social work on death rates.After we created model for male and female population the Chow test was used to compare the regression coefficients.With this test we were able to determine whether the same theoretical model could be applied to both males and females.The null hypothesis is that corresponding regression coefficients in the equations for males and females are equal.Statistically significant difference in Chow test means that one or more of the coefficients are not equal.Type 1 ANOVA was used to compare death rates between different parts of Bosnia and Herzegovina (FBiH, RS, BD) and other countries (Croatia, Serbia and Slovenia).Data for Croatia were collected from Cancer register of Croatian national institute of public health.Data for Serbia were collected from Institute of public health of Serbia "Dr.Milan JovanovićBatut".Data for Slovenia were collected from Institute of oncology Ljubljana, Epidemiology and cancer registry.To precise the analysis of temporal trends for the leading sites of neoplasms time period have been divided into two parts.For calculation of trend rate we used the least square method.Mean (m) with 95% confidence intervals (CI) was calculated and periods were compared by their means and confidence intervals.Only if confidence intervals of the means of the differences between time periods did not overlap they were considered as statistically significant.For analyses we used SPSS for Windows v. 16 (SPSS Inc., Chicago, IL, USA), and Excel program with the level of significance P<0.05.

Estimation of influence of incidence, gender and gross value added for health and social work on crude death rates in Federation of Bosnia and Herzegovina
We used multiple linear regression to develop models of influence of incidence and gross value added for health and social work on crude death rates for male and female population in FBiH.We used data for period between 2005 and 2011.Backward stepwise procedure with elimination of those variables that were not significant at the α=0.1 level was used.For male population incidence had to be removed from the model (Sig.0.695).After removal of incidence we obtained the model which is weak (adjusted R square value is 0.699) with the equation: Male crude death rate=148.294+ 0.053 gross value added for health and social work For the female population we had different situation.Value of adjusted R square for female model was 0.875 meaning that 87.5% of variability of crude death rate for female population is explained by the variability of incidence and gross value.This model has very small coefficient of variation 0.037% so we can conclude that it is useful for prediction purposes.(standardized predicted values were significant predictors contrary to their square values which are not significant predictors).

Analysis of seven leading neoplasms for males and females in FBiH
In figures (1,2 and 3) we can see seven leading neoplasms as cause of death in FBiH in year 2011 for men, women and eight leading neoplasms in total population.

Malignant neoplasms of colon and rectum
In the world, in year 2008 about 608,700 deaths and estimated 1.2 million cases of colorectal cancer occurred.Colorectal cancer is the third most common cancer in men and the second in women worldwide (American Cancer Society.Global Cancer Facts & Figures 2nd Edition).In FBiH it is second cancer as cause of death in men, and third in women.In FBiH we have increase in crude death rate due to cancer of colon and rectum and this difference is statistically significant when we compare 2008-2011 (m=15,95, 95% CI 13,78-18,11) (m=15,95, 95% CI 13,78-18,11) with period 2003-2007 (m=12,88, 95% CI 12,18-13,57 (m=12,88, 95% CI 12,18-13,57) (figure 6).In FBiH pancreas cancer is the sixth leading cause of cancer death in men and seventh in women.

CONCLUSIONS
Bosnia and Herzegovina has lower cancer mortality when compared to Croatia, Slovenia and Serbia.On the other side there are increasing trends of some of the leading cancer deaths (bronchus and lung, colorectal cancer, brain, pancreas, prostate).There should be more programs for cancer prevention with the aim to reduce number of cancer deaths.Also, it is important to further investigate and try to find explanation about very high cancer incidence in HercegovinaNeretva canton, especially in the last few years (2008)(2009)(2010)(2011).

Fig. 1 .
Fig. 1.Seven leading malignant neoplasms as cause of death for men in year 2011

Fig. 5 .
Fig. 5. Male and female crude death rate per 100.000 for malignant neoplasms of bronchus and lung in FBiH for period 2005-2011

Fig. 14 .
Fig. 14.Male and female crude death rate per 100.000 for malignant neoplasms of pancreas in FBiH for period 2005-2011

Fig. 15 .
Fig. 15.Crude death rate per 100.000 for malignant neoplasms of the brain in FBiH for period1999- 2011Alajbegović et al., 2012 found that at the Neurology Clinic Sarajevo during period 1999 to 2005 there were significantly more man patients with brain tumors and in the period 2005 to 2009 this was reversed to more women patients.In this work we have found that there is no significant difference between men (m=8,70, 95% CI 7,43-9,97) and women (m=6,88, 95% CI 6,08-7,68) in crude death rate for malignant neoplasms of brain (figure16).

Fig
Fig. 16.Male and female crude death rate per 100.000 for malignant neoplasms of the brain in FBiH for period 2005-2011

Fig. 21 .
Fig. 21.Comparison of number of patients (rate per 100.00) between cantons in FBiH for years 2005 to 2011 Serbia and Montenegro.Bosnia and Herzegovina (FBiH), Republic ko District (BD).We carried analysis of data available from Public Health Institute of the Federation of Bosnia and Herzegovina, Public Health Institute of Republic of Srpska and from females.In a year 2011.20,5% deaths were because of cancer, 24,1% males and 16,8% females (Republic of Srpska, Institute of statistics.Demographic statistics.Statistical bulletin No 15).Estimated number of citizens in BD in y 75,674 total, 37,816 males and 37,858 females.In a Analysis of cancer incidence and mortality in Bosnia and Herzegovina

Equation is: Female crude death rate=55.91 + 0.167*incidence + 0.049 gross value added for health and social work
Worldwide, pancreas cancer is the eight leading cause of cancer death in men and the ninth leading cause in women.It is estimated that 138,100 men and 127,900 women died because of pancreas cancer in year 2008 (American Cancer Society.Global Cancer Facts & Figures 2nd Edition).

Table 1 .
(Zwierzchowski and Tabeau, 2010)adjusted death rates since we don't have exact data about population in Bosnia and Herzegovina.The last census was conducted in year 1991., before the war, which had huge influence on population of our country with the estimated number of 104,732 deaths(Zwierzchowski and Tabeau, 2010).Comparison of mean difference in crude death rates per 100.000 for different cantons of FBiH in year 2011.*means that difference is statistically significant.Shadowed are places where canton in column has statistically significantly higher crude death rate per 100.000 when compared with canton in row.Crude death rate per 100.000Female,crude death rate per 100.000Fromfigures 21 and 22 we can see that cantons with the biggest number of patients are HercegovinaNeretva and Sarajevo.This is mainly due to better diagnostics of cancer and it is not the real situation.However, it is important to point out that in Sarajevo canton we have the best diagnostics resources and despite this fact HercegovinaNeretva canton (m=1650, CI 95% 1432,21-1867,79) has significantly higher number of patients when compared with Sarajevo canton