The Public Health Agency of Canada (PHAC), in collaboration with other governmental and non-governmental organizations, conducts national surveillance of cancer to support the planning and evaluation of cancer-related policies, programs, and services. For this fact sheet, data from the Canadian Cancer Registry, the Canadian Vital Statistics – Death Database, and the Canadian Community Health Survey were used to provide current statistics on the burden of cancer in Canada.

The Public Health Agency of Canada (PHAC), in collaboration with other governmental and non-governmental organizations, conducts national surveillance of cancer to support the planning and evaluation of cancer-related policies, programs, and services. For this fact sheet, data from the Canadian Cancer Registry, the Canadian Vital Statistics – Death Database, and the Canadian Community Health Survey were used to provide current statistics on the burden of cancer in Canada.

Number and rate of new cancer cases diagnosed annually from 1992 to the most recent diagnosis year available. Included are all invasive cancers and in situ bladder cancer with cases defined using the Surveillance, Epidemiology and End Results (SEER) Groups for Primary Site based on the World Health Organization International Classification of Diseases for Oncology, Third Edition (ICD-O-3). Random rounding of case counts to the nearest multiple of 5 is used to prevent inappropriate disclosure of health-related information.

The files included here are SAS code provided as documentation for reproducibility of results in the study titled: "Independent effects of individual- and area-level income on site-specific cancer incidence in Canada from 2006–2015: a data linkage study" by Parker Tope, Talía Malagón, Samantha Morais, Mariam El-Zein, and Eduardo L. Franco. Data Source: Statistics Canada, Canadian Census Health and Environment Cohorts 2006 & 2011, 2006 long-form census, 2011 National Household Survey, Canadian Vital Statistics Death Database 2006-2015, and Canadian Cancer Registry 2006-2015. The Postal CodeOM Conversion File Plus (7D) is based on data licensed by Canada Post Corporation. Reproduced and distributed on an "as is" basis with the permission of Statistics Canada. This does not constitute an endorsement by Statistics Canada of this product. Statistics Canada is the owner and steward of the data used in this report, and access to the data is regulated by the 1985 Statistics Act. To access the data, researchers must become deemed employees of Statistics Canada and sign a research contract. Members of post-secondary institutions such as faculty, students, or staff may apply for data access to Statistics Canada microdata through the Research Data Centre program using the Microdata Access Portal (https://www.statcan.gc.ca/en/microdata/data-centres/access).

This product presents comparable time-series data for a range of health indicators from a number of sources including the Canadian Community Health Survey, Vital Statistics, and Canadian Cancer Registry.

This product presents comparable time-series data for a range of health indicators from a number of sources including the Canadian Community Health Survey, Vital Statistics, and Canadian Cancer Registry.

This Regulation regulates the cancer registry operated by the RHA, including information and disclosure requirements.

Data sources include Statistics Canada's Canadian Cancer Registry Database and Demography Division Population estimates as of July 1st 2017, released September 30th, 2019 . Statistics Canada maintains the CCR which is comprised of data supplied by the provinces and territories whose cooperation is gratefully acknowledged. / Les sources de données comprennent la base de données du Registre canadien du cancer de Statistique Canada et les estimations démographiques de la Division de la démographie au 1er juillet 2017, publiées le 30 septembre 2019. Statistique Canada tient à jour le CCR, qui comprend des données fournies par les provinces et les territoires dont la coopération est grandement appréciée.

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Cancer Registry Software Market Size 2025-2029

The cancer registry software market size is valued to increase USD 121.9 million, at a CAGR of 14% from 2024 to 2029. The growing prevalence of cancer cases will drive the cancer registry software market.

Major Market Trends & Insights

North America dominated the market and accounted for a 51% growth during the forecast period.
By End-user - Government and third party segment was valued at USD 24.20 million in 2023
By Type - Stand-alone software segment accounted for the largest market revenue share in 2023

Market Size & Forecast

Market Opportunities: 181.04 million
Market Future Opportunities: USD 121.90 million
CAGR : 14%
North America: Largest market in 2023

Market Summary

The market encompasses a continually evolving landscape shaped by advancements in core technologies and applications, service types, and regulatory frameworks. With the growing prevalence of cancer cases worldwide, the demand for robust and efficient cancer registry software solutions has surged. The growth is fueled by the increasing clinical research for oncology and the need for accurate, standardized data collection and analysis.
However, data privacy and security concerns pose significant challenges, necessitating stringent compliance with regulations such as HIPAA and GDPR. As regional healthcare systems adopt digital transformation, the market is witnessing a proliferation of solutions tailored to specific needs in North America, Europe, and Asia Pacific.

What will be the Size of the Cancer Registry Software Market during the forecast period?

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How is the Cancer Registry Software Market Segmented and what are the key trends of market segmentation?

The cancer registry software industry research report provides comprehensive data (region-wise segment analysis), with forecasts and estimates in 'USD million' for the period 2025-2029, as well as historical data from 2019-2023 for the following segments.

End-user

  Government and third party
  Pharma biotech and medical device companies
  Hospitals and medical practice
  Private payers
  Research institutes


Type

  Stand-alone software
  Integrated software


Deployment

  On-premises
  Cloud-based


Geography

  North America

    US
    Canada
    Mexico


  Europe

    France
    Germany
    Italy
    Spain
    UK


  APAC

    China
    Japan


  Rest of World (ROW)

By End-user Insights

The government and third party segment is estimated to witness significant growth during the forecast period.

Cancer registry software plays a pivotal role in assisting government and third-party agencies in managing and analyzing data related to cancer cases. These solutions facilitate the collection, storage, and statistical modeling of oncology data, enabling agencies to monitor cancer incidence, prevalence, and mortality rates. This information is essential for public health planning, resource allocation, and policy development. Governments utilize cancer registry software to ensure data quality through data validation rules, de-identification, and HIPAA compliance. They also employ data visualization tools, reporting dashboards, and data integration methods to analyze trends and patterns. This data analysis helps identify high-risk populations, geographic disparities, and emerging cancer types.

Moreover, cancer registry software supports population health management and patient data management, ensuring secure data storage, user access control, and audit trails. API integrations enable seamless data exchange with other healthcare systems, facilitating clinical data exchange and follow-up procedures. The future of cancer registry software is promising, with adoption expected to grow significantly. According to recent studies, the number of cancer registries worldwide is projected to increase by 20%, while the use of electronic registries is anticipated to surge by 30%. These trends reflect the ongoing digitization of healthcare and the growing recognition of the value of data-driven insights in improving cancer care and outcomes.

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The Government and third party segment was valued at USD 24.20 million in 2019 and showed a gradual increase during the forecast period.

Furthermore, cancer registry software supports cancer surveillance, disease registries, and cancer staging, providing valuable data for mortality reporting and treatment protocols. It also facilitates incidence reporting, case ascertainment, and survival analysis, ensuring that governments and third-party agencies have access to the most accurate and up-to-date information for informed decision-making. In conclusion, cancer registry software is a crucial tool for governments and third-party agencies seeking to monitor and improve cancer care. Its features, including

IntroductionChronic infection with hepatitis C virus (HCV) is an established risk factor for liver cancer. Although several epidemiologic studies have evaluated the risk of extrahepatic malignancies among people living with HCV, due to various study limitations, results have been heterogeneous.MethodsWe used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for HCV in the Province since 1990. We assessed hepatic and extrahepatic cancer incidence using data from BC Cancer Registry. Standardized incidence ratios (SIR) comparing to the general population of BC were calculated for each cancer site from 1990 to 2016.ResultsIn total, 56,823 and 1,207,357 individuals tested positive and negative for HCV, respectively. Median age at cancer diagnosis among people with and without HCV infection was 59 (interquartile range (IQR): 53-65) and 63 years (IQR: 54-74), respectively. As compared to people living without HCV, a greater proportion of people living with HCV-infection were men (66.7% vs. 44.7%, P-value

There is an increasing demand for real-world data pertaining to the usage of cancer treatments, especially in settings where no standard treatment is specifically recommended. This study presents the first real-world analysis of third-line treatment patterns in HER2-positive metastatic breast cancer (mBC) patients in Canada. The purpose was to assess evolution of clinical practice and identify unmet needs in post-second-line therapy. Retrospective data from medical records of 66 patients who received third-line treatment before 31st October 2018, and data from 56 patients who received third-line treatment after this date, extracted from the Personalize My Treatment (PMT) cancer patient registry, were analyzed. In the first cohort, the study revealed heterogeneity in the third-line setting, with trastuzumab, lapatinib, and T-DM1 being the main treatment options. Even though data were collected before the wide availability of tucatinib, neratinib and trastuzumab deruxtecan in Canada, the PMT cohort revealed the emergence of new therapeutic combinations and a shift from lapatinib usage to T-DM1 choice was observed. These findings underscore the evolving nature of third-line treatment strategies in Canada, a facet that is intrinsically tied to the availability of new drugs. The absence of a consensus on post-second-line treatment highlights the pressing need for more efficient therapeutic alternatives beyond the currently available options. This study not only offers valuable insights into the present landscape of third-line treatment in Canada but validates the significance and effectiveness of the PMT registry as a tool for generating pan-Canadian real-world evidence in oncology and its capacity to provide information on evolution of therapeutic practices.

BackgroundThe National Lung Screening Trial (NLST) results indicate that computed tomography (CT) lung cancer screening for current and former smokers with three annual screens can be cost-effective in a trial setting. However, the cost-effectiveness in a population-based setting with >3 screening rounds is uncertain. Therefore, the objective of this study was to estimate the cost-effectiveness of lung cancer screening in a population-based setting in Ontario, Canada, and evaluate the effects of screening eligibility criteria.Methods and FindingsThis study used microsimulation modeling informed by various data sources, including the Ontario Health Insurance Plan (OHIP), Ontario Cancer Registry, smoking behavior surveys, and the NLST. Persons, born between 1940 and 1969, were examined from a third-party health care payer perspective across a lifetime horizon. Starting in 2015, 576 CT screening scenarios were examined, varying by age to start and end screening, smoking eligibility criteria, and screening interval. Among the examined outcome measures were lung cancer deaths averted, life-years gained, percentage ever screened, costs (in 2015 Canadian dollars), and overdiagnosis. The results of the base-case analysis indicated that annual screening was more cost-effective than biennial screening. Scenarios with eligibility criteria that required as few as 20 pack-years were dominated by scenarios that required higher numbers of accumulated pack-years. In general, scenarios that applied stringent smoking eligibility criteria (i.e., requiring higher levels of accumulated smoking exposure) were more cost-effective than scenarios with less stringent smoking eligibility criteria, with modest differences in life-years gained. Annual screening between ages 55–75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago yielded an incremental cost-effectiveness ratio of $41,136 Canadian dollars ($33,825 in May 1, 2015, United States dollars) per life-year gained (compared to annual screening between ages 60–75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago), which was considered optimal at a cost-effectiveness threshold of $50,000 Canadian dollars ($41,114 May 1, 2015, US dollars). If 50% lower or higher attributable costs were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $38,240 ($31,444 May 1, 2015, US dollars) or $48,525 ($39,901 May 1, 2015, US dollars), respectively. If 50% lower or higher costs for CT examinations were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $28,630 ($23,542 May 1, 2015, US dollars) or $73,507 ($60,443 May 1, 2015, US dollars), respectively.This scenario would screen 9.56% (499,261 individuals) of the total population (ever- and never-smokers) at least once, which would require 4,788,523 CT examinations, and reduce lung cancer mortality in the total population by 9.05% (preventing 13,108 lung cancer deaths), while 12.53% of screen-detected cancers would be overdiagnosed (4,282 overdiagnosed cases). Sensitivity analyses indicated that the overall results were most sensitive to variations in CT examination costs. Quality of life was not incorporated in the analyses, and assumptions for follow-up procedures were based on data from the NLST, which may not be generalizable to a population-based setting.ConclusionsLung cancer screening with stringent smoking eligibility criteria can be cost-effective in a population-based setting.

BackgroundExtensive-stage small-cell lung cancer (ES-SCLC) is an incurable cancer with poor prognosis in which characteristics predictive of long-term survival are debated. The utility of agents such as immune checkpoint inhibitors highlights the importance of identifying key characteristics and treatment strategies that contribute to long-term survival and could help guide therapeutic decisions.ObjectiveThis real-world analysis examines the characteristics, treatment patterns, and clinical outcomes of patients receiving chemotherapy without immunotherapy for ES-SCLC in Manitoba, Canada.MethodsA retrospective cohort study assessed patient characteristics, treatment, and survival duration (short: <6 months; medium: 6–24 months; long: >24 months) using the Manitoba Cancer Registry and CancerCare Manitoba records. Eligible patients were aged >18 years with cytologically confirmed ES-SCLC diagnosed between January 1, 2004, and December 31, 2018, and received cytotoxic chemotherapy (CT). The one-, two-, and five-year probabilities of overall survival (OS) were assessed relative to patient, disease, and treatment characteristics using Kaplan-Meier methods and Cox proportional hazards models.ResultsThis analysis included 537 patients. Cisplatin was used in 56.1% of patients, 45.6% received thoracic radiotherapy (RT), and few received prophylactic cranial irradiation (PCI). In the overall cohort, one-, two- and five-year OS rates were 26%, 8%, and 3%, respectively. For patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0, OS rates at one, two, and five years were 43%, 17%, and 10%, respectively, vs. 27%, 8%, and 2% for those with ECOG PS 1–2, and 16%, 3%, and 3% for those with ECOG PS 3–4. In long-term survivors, ECOG PS scores were lower and abnormal laboratory test results were less frequent. Overall, 74.4% of long-term survivors received thoracic RT and 53.5% received PCI. Known poor prognostic factors – including brain/liver metastases, high lactate dehydrogenase (LDH), abnormal sodium, and low hemoglobin levels – were less common but still seen in long-term survivors.ConclusionAlthough rare, patients with ES-SCLC may experience long-term survival with CT ± thoracic RT ± PCI. Factors predicting long-term survival include traditional prognostic factors such as ECOG PS, LDH level, and receipt of thoracic RT or PCI. These findings support current treatment algorithms for ES-SCLC and provide baseline survival estimates to assess the real-world impact of adding immune checkpoint inhibitors in the future.

Time trends in 5-year relative survival of lymphoid leukemia and lymphoma in children and adolescents in Manitoba, Canada.

This dataset contains the metadata records about research products (research literature, data, software, other types of research products) with funding information available in the OpenAIRE Graph produced on July 2024.Records are grouped by funder in a dedicated archive file (.tar). fundRef contains the following funders 100007490 Bausch and Lomb Ireland 100007630 College of Engineering and Informatics, National University of Ireland, Galway 100007731 Endo International 100007819 Allergan 100008099 Food Safety Authority of Ireland 100008124 Department of Jobs, Enterprise and Innovation 100008303 Department for Economics, Northern Ireland 100009098 Department of Foreign Affairs and Trade, Ireland 100009099 Irish Aid 100009770 National University of Ireland 100010399 European Society of Cataract and Refractive Surgeons 100010546 Deparment of Children and Youth Affairs, Ireland 100010547 Irish Youth Justice Service 100010993 Irish Nephrology Society 100011096 Jazz Pharmaceuticals 100011396 Irish College of General Practitioners 100012733 National Parks and Wildlife Service 100012734 Department for Culture, Heritage and the Gaeltacht, Ireland 100012754 Horizon Pharma 100012891 Medical Research Charities Group 100012919 Epilepsy Ireland 100012920 GLEN 100012921 Royal College of Surgeons in Ireland 100013029 Iris O'Brien Foundation 100013206 Food Institutional Research Measure 100013381 Irish Phytochemical Food Network 100013433 Transport Infrastructure Ireland 100013917 Society for Musicology in Ireland 100014251 Humanities in the European Research Area 100014364 National Children's Research Centre 100014384 Amarin Corporation 100014902 Irish Association for Cancer Research 100015023 Ireland Funds 100015278 Pfizer Healthcare Ireland 100015319 Sport Ireland Institute 100015442 Global Brain Health Institute 100015992 St. Luke's Institute of Cancer Research 100017144 Shell E and P Ireland 100017897 Friedreich’s Ataxia Research Alliance Ireland 100018064 Department of Tourism, Culture, Arts, Gaeltacht, Sport and Media 100018172 Department of the Environment, Climate and Communications 100018175 Dairy Processing Technology Centre 100018270 Health Service Executive 100018529 Alkermes 100018542 Irish Endocrine Society 100018754 An Roinn Sláinte 100019428 Nabriva Therapeutics 100019637 Horizon Therapeutics 100020174 Health Research Charities Ireland 100020202 UCD Foundation 100020233 Ireland Canada University Foundation 100022895 Health Research Institute, University of Limerick 100022943 National Cancer Registry Ireland 501100001581 Arts Council of Ireland 501100001582 Centre for Ageing Research and Development in Ireland 501100001583 Cystinosis Foundation Ireland 501100001584 Department of Agriculture, Food and the Marine, Ireland 501100001586 Department of Education and Skills, Ireland 501100001587 Economic and Social Research Institute 501100001588 Enterprise Ireland 501100001591 Heritage Council 501100001592 Higher Education Authority 501100001593 Irish Cancer Society 501100001594 Irish Heart Foundation 501100001595 Irish Hospice Foundation 501100001596 Irish Research Council for Science, Engineering and Technology 501100001598 Mental Health Commission 501100001599 National Council for Forest Research and Development 501100001600 Research and Education Foundation, Sligo General Hospital 501100001601 Royal Irish Academy 501100001603 Sustainable Energy Authority of Ireland 501100001604 Teagasc 501100001627 Marine Institute 501100001628 Central Remedial Clinic 501100001629 Royal Dublin Society 501100001630 Dublin Institute for Advanced Studies 501100001631 University College Dublin 501100001633 National University of Ireland, Maynooth 501100001634 University of Galway 501100001635 University of Limerick 501100001636 University College Cork 501100001637 Trinity College Dublin 501100001638 Dublin City University 501100002736 Covidien 501100002755 Brennan and Company 501100002919 Cork Institute of Technology 501100002959 Dublin City Council 501100003036 Perrigo Company Charitable Foundation 501100003037 Elan 501100003496 HeyStaks Technologies 501100003553 Gaelic Athletic Association 501100003840 Irish Institute of Clinical Neuroscience 501100003956 Aspect Medical Systems 501100004162 Meath Foundation 501100004210 Our Lady's Children's Hospital, Crumlin 501100004321 Shire 501100004981 Athlone Institute of Technology 501100006518 Department of Communications, Energy and Natural Resources, Ireland 501100006553 Collaborative Centre for Applied Nanotechnology 501100006554 IDA Ireland 501100006759 CLARITY Centre for Sensor Web Technologies 501100009246 Technological University Dublin 501100009269 Programme of Competitive Forestry Research for Development 501100009315 Cystinosis Ireland 501100010808 Geological Survey of Ireland 501100011030 Alimentary Glycoscience Research Cluster 501100011031 Alimentary Health 501100011103 Rannís 501100011626 Energy Policy Research Centre, Economic and Social Research Institute 501100012354 Inland Fisheries Ireland 501100014384 X-Bolt Orthopaedics 501100014531 Physical Education and Sport Sciences Department, University of Limerick 501100014710 PrecisionBiotics Group 501100014745 APC Microbiome Institute 501100014826 ADAPT - Centre for Digital Content Technology 501100014827 Dormant Accounts Fund 501100017501 FotoNation 501100018641 Dairy Research Ireland 501100018839 Irish Centre for High-End Computing 501100019905 Galway University Foundation 501100020270 Advanced Materials and Bioengineering Research 501100020403 Irish Composites Centre 501100020425 Irish Thoracic Society 501100020570 College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway 501100020871 Bernal Institute, University of Limerick 501100021102 Waterford Institute of Technology 501100021110 Irish MPS Society 501100021525 Insight SFI Research Centre for Data Analytics 501100021694 Elan Pharma International 501100021838 Royal College of Physicians of Ireland 501100022542 Breakthrough Cancer Research 501100022610 Breast Cancer Ireland 501100022728 Munster Technological University 501100023273 HRB Clinical Research Facility Galway 501100023551 Cystic Fibrosis Ireland 501100023970 Tyndall National Institute 501100024242 Synthesis and Solid State Pharmaceutical Centre 501100024313 Irish Rugby Football Union 501100024834 Tusla - Child and Family Agency AKA Academy of Finland ANR French National Research Agency (ANR) ARC Australian Research Council (ARC) ASAP Aligning Science Across Parkinson's CHISTERA CHIST-ERA CIHR Canadian Institutes of Health Research EC_ERASMUS+ European Commission - Erasmus+ funding stream EC_FP7 European Commission - FP7 funding stream EC_H2020 European Commission - H2020 funding stream EC_HE European Commission - HE funding stream EEA European Environment Agency EPA Environmental Protection Agency FCT Fundação para a Ciência e a Tecnologia, I.P. FWF Austrian Science Fund HRB Health Research Board HRZZ Croatian Science Foundation INCA Institut National du Cancer IRC Irish Research Council IReL Irish Research eLibrary MESTD Ministry of Education, Science and Technological Development of Republic of Serbia MZOS TOADDNAME NHMRC National Health and Medical Research Council (NHMRC) NIH National Institutes of Health NSERC Natural Sciences and Engineering Research Council of Canada NSF National Science Foundation NWO Netherlands Organisation for Scientific Research (NWO) SFI Science Foundation Ireland SNSF Swiss National Science Foundation SSHRC Social Sciences and Humanities Research Council TARA Tara Expeditions Foundation TIBITAK Türkiye Bilimsel ve Teknolojik Araştırma Kurumu UKRI UK Research and Innovation WT Wellcome Trust Each tar archive contains gzip files with one json record per line. Json records are compliant with the schema available at https://doi.org/10.5281/zenodo.13121069. You can also search and browse this dataset (and more) in the OpenAIRE EXPLORE portal and via the OpenAIRE API.

Background/rationalePET/CT plays a crucial role in esophageal (EC) and gastroesophageal junction cancer (GEJ) diagnosis and management. Despite endorsement in clinical guidelines, variation in acceptance of PET/CT exists. The aim of this study was to assess the early use of PET/CT among EC and GEJ patients in a regionalized setting and identify factors contributing to disparity in access.Materials and methodsRetrospective cohort study of adults with EC or GEJ between 2012 and 2014 from the Population Registry of Esophageal and Stomach Tumours of Ontario and Ontario Health (Cancer Care Ontario). Receipt of PET/CT and relevant demographics were collected, and statistical analysis performed. Continuous data were analysed with t-tests and Wilcoxon rank sum test. Categorical data were analysed with chi-square test. Kaplan–Meier methods were used to estimate median survival.ResultsFifty-five percent of patients diagnosed with EC or GEJ between 2012 and 2014 received PET/CT (1321/2390). Eighty-four percent of patients underwent surgical resection (729/870), and 80% receiving radical treatment (496/622) underwent PET/CT. The use of PET/CT increased from 2012 to 2014. Male patients received more PET/CT than females (85% vs.78% p 

ObjectivesTo test for time and spatial trends in lymphoid malignancies, including lymphoid leukemia (LL), Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL), in children and adolescents in the province of Manitoba, Canada.MethodsIncident cases diagnosed between 1984 and 2013 were identified from the Manitoba Cancer Registry. We assessed time trends in age-standardized incidence rates using joinpoint regression and in 5-year relative survival using Poisson regression model. Kulldorff's scan method was used to assess spatial variation and clustering.ResultsAge-standardized incidence rates (per million person-years) in males and females were 34.0 (95% confidence interval [CI] 28.9–39.1) and 26.2 (95% CI 21.5–30.7) for LL, 10.5 (95% CI 7.7–13.3) and 12.5 (95% CI 9.4–15.7) for HL, 12.5 (95% CI 9.3–15.4) and 7.7 (95% CI 5.2–10.2) for NHL (except for Burkitt lymphomas), and 3.2 (95% CI 1.6–4.7) and 1.5 (95% CI 0.4–2.5) for Burkitt lymphomas. Age- and sex- standardized LL incidence rate increased 1.4% (95% CI 0.3%-2.5%) per year, while the changes for HL and NHL incidence rates were not statistically significant. There were geographic differences in age-standardized incidence rates for LL, HL, and NHL and spatial clusters were detected in southern part of the province. Five-year relative survival has improved over time and there was no difference between rural and urban areas.ConclusionsLymphoid leukemia incidence rate increased over time and varied by geographic area. Further research should examine the factors contributing to these trends.