br Methods br Results br Discussion
Discussion Using the nationally representative NHIRD we found that the crude incidence of newly diagnosed MM in Taiwan increased significantly by 30% between 2007 and 2012, or by 13% in the age-adjusted analysis. Consistent with the epidemiology of MM elsewhere, MM was more frequent in men and increased markedly with age . MM incidence rates among men and women were similar until around 50 years of age, after which they diverged with higher incidences usually observed in men. A study by Huang et al , observed an increasing incidence of MM between 1979–1988 and 1994–2003 (from 0.36 to 1.21 per 100 000 population) and our study confirms that this trend has continued in Taiwan though 2012. The reasons for the increasing trend are not known; we did not observe any change in demographic or clinical features of MM patients over time that might indicate a change in disease characteristics or earlier diagnosis. The significant increase in the age-adjusted incidences over time indicates that the ageing population does not account for all of the increased incidence in MM observed over the study Salvinorin A in Taiwan. By contrast, Tzeng et al , noted that after adjustment for age, MM incidence in Taiwan (1997–2009) only increased in the 60+ year age group and not in younger adults. Taiwan has an ageing population and more than 20% of the population is expected to be 65+ years of age by 2025 . Higher levels of environmental pollutants among older Taiwanese than in younger individuals has been proposed as potentially contributing to the increase in MM in Taiwan [12,14]. Over the study period we observed dramatic changes in the patterns of treatment use among patients with MM, coinciding with the introduction of novel agents in Taiwan (thalidomide was approved for use in 2000, bortezomib in 2007). Co-incident with this change was a 24% decrease in case fatality over the study period, possibly reflecting the positive impact of novel agents on early survival when used as initial therapy, particularly in younger patients as reported by observational studies of survival trends before and after the availability of novel agents [5,15]. The results of our study are consistent with trends observed previously in Taiwan. Chen et al , used the NHIRD to describe characteristics of survivors with MM versus those who died from MM from 1997 to 2013. The average (unadjusted) incidence of MM across the study period was 1.83 per 100 000 population over the study period, with 24% fatality, which is in the range observed annually in our study.
Funding The work was supported by Janssen Research and Development (Titusville, New Jersey, United States).
Conflict of interest
Introduction In 2012 the International Agency of Research for Cancer (IARC), confirming the first evaluation , endorsed that there is sufficient evidence in humans for the carcinogenicity of all forms of asbestos (chrysotile, crocidolite, amosite, tremolite, actinolite, and anthophyllite): asbestos causes extrapleural, as well as pleural, mesothelioma and cancer of the lung, larynx, and ovary. Limited evidence of the associations between all forms of asbestos and pharynx, stomach, and colorectum cancers was defined . More recently, IARC has established the carcinogenicity of fluoro-edenitic fibres, because of sufficient evidence in humans with respect to MM . The burden of MM at global level is unclear. The estimates of MM mortality, for 1994–2008 period, were reported from approximately 6,150cases/year  to 14,200 cases/year . More recently, Odgerel et al. estimated the global mesothelioma burden in the range of 36,300 to 38,400 annual deaths, in 1994–2014 period for 230 countries . The global burden of disease attributable to occupational asbestos exposure in 2004 was reported to be 107,000 deaths, of which 59,000 for MM . Quantifying the proportion of cases attributable to environmental exposure is more difficult. The risk of pleural mesothelioma associated with exposure for living near an industrial asbestos source (mines, mills, asbestos processing plants) has been clearly confirmed; non-occupational exposure to asbestos may explain approximately 20% of mesothelioma in industrialized countries .