Introduction

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Some fundamental changes have occurred since the Atlas of Cancer Mortality in the Federal Republic of Germany was published in 1984. First and foremost, political developments have expanded the territory that the atlas must cover. Our original plan was to take up where the previous atlas left off and quickly publish a new edition covering the decade from 1981 to 1990. But German reunification in 1990 offered an unprecedented opportunity to present a complete and comprehensive overview of the "cancer landscape" of the reunited Germany. Much extra time had to be spent gathering data from the former German Democratic Republic (GDR) and putting it in a form that could be meaningfully analyzed and compared with data from the west.

Another significant development is that the mortality rates for certain types of cancer in Germany have appeared to reverse their upward trend. As a result, the long-term decline in age-adjusted cancer mortality rates for females has been accompanied by a decline in cancer death rates for males during the past few years. This raises the question of whether declining cancer mortality is actually a result of decreasing morbidity, or whether the incidence of cancer is continuing to rise and there has simply been a downturn in mortality. These questions are addressed in the "Overview of Cancer Mortality" chapter. The problems involved in making reliable estimates of cancer incidence are discussed at the start of the chapter on "Data Material, Methods, and Organization of Sections."

Another change is that our awareness of the causes of various cancers is more advanced today than it was in 1984. Admittedly there has been little progress in the treatment of cancer : each year more than 340 000 persons in Germany develop cancer and more than 210 000 die from their disease. But at the same time, our improved knowledge of cancer etiology affords many clues as to how the occurrence of cancer can be prevented. Thus, a basic goal of this new edition of the Cancer Atlas, more so than in 1984, is to present and interpret cancer epidemiology in ways that will advance the science of cancer prevention. A "Conclusions" chapter has been added to provide details on prevention strategies.

The cancer maps were rendered using a direct, color coded scale that provides an overview of cancer mortality and its regional variations while also portraying the marked differences in the frequencies of different types of cancer. In this way the maps can be read directly, like the maps in a geographic atlas. The first edition of the Cancer Atlas used a "relative scale" that portrayed regional variations but not the differences in the absolute frequency of different cancers. Small relative-scale maps are included in this new edition to supplement the old maps, but it should be noted that relative-scale mapping can distort the "cancer landscape" by overemphasizing the importance of regional differences and drawing attention away from an unfavorable overall situation. This can easily give false signals about where necessary preventive efforts should be directed.

Given the systematic differences in cancer mortality data between eastern and western Germany, cancer mapping on a relative scale can lead to a distorted east-west comparison. The present edition avoids this problem by mapping the two parts of the country separately whenever a relative scale is used. Details of mapping methods are discussed in the chapter on "Data Material, Methods, and Organization of Sections".

Acknowledgements

The regional mortality data and population data used in this atlas were processed by the Statistical Bureaus of the German states and made available to the German Cancer Research Center. We gratefully acknowledge the efforts and cooperativeness of the Statistical Bureaus in this regard. We particularly acknowledge the efforts of the Statistical Bureaus in the five new German states, which had to convert the data of the former GDR to conform to the new territorial status of the unified Germany.

The data on long-term mortality trends since 1952 were furnished partly (1952-1990) by the World Health Organization (WHO) and partly (1991-1995) by the Federal Statistical Bureau of Germany. The Robert Koch Institute (RKI) supplied a portion of the data for the former GDR (1961-1972). We are grateful to all these institutions and their workers for furnishing the data and helping to solve the occasional problems that arose.

We also thank the cancer registry of the Saarland and the joint cancer registry of the five new German states for supplying essential data and for their kind responsiveness to inquiries.

Many colleagues deserve thanks for heir help in completing this book. We thank our departmental colleagues, Dr. Heiko Becher, Dr. Maria Blettner, and Dr. Jenny Chang-Claude, and Dr. Rainer Frentzel-Beyme from the Bremer Institute of Preventive Research and Social Medicine (BIPS) for critically reviewing and text and making valuable additions. We express thanks to Dr. Bernd Dörken (Berlin) and Dr. H. Maier (Ulm) for revising selected sections of "Cancer Mortality by Site." Mrs. Beate Edinger and Mrs. Dorothea Niehoff helped with the documentation work, and their assistance is gratefully acknowledged.

Problems invariably arise when large amounts of data are processed. We are grateful tothe Central Data Processing Department, particularly Mr. Günther Krysmanski, and to Dr. Werner Rittgen of the Biostatistics Department for their help in solving these problems.

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