Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Incidence and death rates are age-standardized to the 2000 US standard million population. A total of 1,437,180 new cancer cases and 565,650 deaths from cancer are projected to occur in the United States in 2008. Notable trends in cancer incidence and mortality include stabilization of incidence rates for all cancer sites combined in men from 1995 through 2004 and in women from 1999 through 2004 and a continued decrease in the cancer death rate since 1990 in men and since 1991 in women. Overall cancer death rates in 2004 compared with 1990 in men and 1991 in women decreased by 18.4% and 10.5%, respectively, resulting in the avoidance of over a half million deaths from cancer during this time interval. This report also examines cancer incidence, mortality, and survival by site, sex, race/ethnicity, education, geographic area, and calendar year, as well as the proportionate contribution of selected sites to the overall trends. Although much progress has been made in reducing mortality rates, stabilizing incidence rates, and improving survival, cancer still accounts for more deaths than heart disease in persons under age 85 years. Further progress can be accelerated by supporting new discoveries and by applying existing cancer control knowledge across all segments of the population.
Cancer is a major public health problem in the United States and many other parts of the world. Currently, one in 4 deaths in the United States is due to cancer. In this article, we provide an overview of cancer statistics, including updated incidence, mortality, and survival rates, and expected numbers of new cancer cases and deaths in 2008.
MATERIALS AND METHODS
Mortality data from 1930 to 2005 in the United States were obtained from the National Center for Health Statistics (NCHS).1 Incidence data for long-term trends (1975 to 2004), 5-year relative survival rates, and data on lifetime probability of developing cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute, currently covering about 26% of the US population.2, , –5 Incidence data (1995 to 2004) for projecting new cancer cases were obtained from cancer registries that participate in the SEER program or the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries (NPCR) through the North American Association of Central Cancer Registries (NAACCR). State-specific incidence rates were abstracted from Cancer in North America (2000–2004) Volume One,6 based on data collected by cancer registries participating in the SEER program and NPCR. Population data were obtained from the US Census Bureau.7 Causes of death were coded and classified according to the International Classification of Diseases (ICD-8, ICD-9, and ICD-10).8, –10 Cancer cases were classified according to the International Classification of Diseases for Oncology.11
Estimated New Cancer Cases
The precise number of cancer cases diagnosed each year in the nation and in every state is unknown because complete cancer registration has not yet been achieved in some states. Furthermore, the most recent year for which incidence and mortality data are available lags 3 to 4 years behind the current year due to the time required for data collection and compilation. Estimated new cancer cases in the current year (2008) were projected using a spatio-temporal model12 based on incidence data from 1995 through 2004 from 41 states and the District of Columbia that met NAACCR's high-quality data standard for incidence, covering about 85% of the US population. The method also considers geographic variations in socio-demographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence, and accounts for expected delays in case reporting.
Estimated Cancer Deaths
We used the state-space prediction method13 to estimate the number of cancer deaths expected to occur in the United States and in each state in the year 2008. Projections are based on underlying cause of death from death certificates as reported to the NCHS.1 This model projects the number of cancer deaths expected to occur in 2008 based on the number that occurred each year from 1969 to 2005 in the United States and in each state separately.
We provide mortality statistics for the leading causes of death as well as deaths from cancer in the year 2005. Causes of death for 2005 were coded and classified according to ICD-10.8 This report also provides updated statistics on trends in cancer incidence and mortality rates, the probability of developing cancer, and 5-year relative survival rates for selected cancer sites based on data from 1975 through 2004.3 All age-adjusted incidence and death rates are standardized to the 2000 US standard population and expressed per 100,000 population.
The long-term incidence rates and trends (1975 to 2004) are adjusted for delays in reporting where possible. Delayed reporting primarily affects the most recent 1 to 3 years of incidence data (in this case, 2002 to 2004), especially for cancers such as melanoma, leukemia, and prostate that are frequently diagnosed in outpatient settings. The National Cancer Institute has developed a method to account for expected reporting delays in SEER registries for all cancer sites combined and many specific cancer sites.14 Delay-adjusted rates provide a more accurate assessment of trends in the most recent years for which data are available.
We also provide estimates of the total number of cancer deaths avoided due to the reduction in age-standardized cancer death rates since 1991 in men and 1992 in women. We applied the age-specific cancer death rates in the peak year for the age-standardized cancer death rates (1990 for males and 1991 for females) to the corresponding age-specific populations in the subsequent years through 2004 to obtain the number of expected deaths in each calendar year if the death rates had not decreased. We then summed the difference between the number of expected and observed deaths in each age group and calendar year for men and women separately to obtain the total number of cancer deaths avoided over the 13- or 14-year interval.
Expected Numbers of New Cancer Cases
Table 1 presents estimates of the numbers of new cases of invasive cancer expected among men and women in the United States in 2008. The overall estimate of about 1.44 million new cases does not include carcinoma in situ of any site except urinary bladder, nor does it include basal cell and squamous cell cancers of the skin. More than 1 million cases of basal cell and squamous cell skin cancer, about 67,770 cases of breast carcinoma in situ, and 54,020 cases of in situ melanoma are expected to be newly diagnosed in 2008. The estimated numbers of new cancer cases for each state and selected cancer sites are shown in Table 2.
Table TABLE 1. Estimated New Cancer Cases and Deaths by Sex, United States, 2008*
Table TABLE 2. Age-standardized Incidence Rates for All Cancers Combined, 2000 to 2004, and Estimated New Cases* for Selected Cancers by State, United States, 2008
Figure 1 indicates the most common cancers expected to occur in men and women in 2008. Among men, cancers of the prostate, lung and bronchus, and colon and rectum account for about 50% of all newly diagnosed cancers. Prostate cancer alone accounts for about 25% (186,320) of incident cases in men. Based on cases diagnosed between 1996 and 2003, an estimated 91% of these new cases of prostate cancer are expected to be diagnosed at local or regional stages, for which 5-year relative survival approaches 100%.
The 3 most commonly diagnosed types of cancer among women in 2008 will be cancers of the breast, lung and bronchus, and colon and rectum, accounting for about 50% of estimated cancer cases in women. Breast cancer alone is expected to account for 26% (182,460) of all new cancer cases among women.
Expected Number of New Cancer Deaths
Table 1 also shows the expected number of deaths from cancer projected for 2008 for men, women, and both sexes combined. It is estimated that about 565,650 Americans will die from cancer, corresponding to over 1,500 deaths per day. Cancers of the lung and bronchus, prostate, and colon and rectum in men, and cancers of the lung and bronchus, breast, and colon and rectum in women continue to be the most common fatal cancers. These 4 cancers account for half of the total cancer deaths among men and women (Figure 1). Lung cancer surpassed breast cancer as the leading cause of cancer death in women in 1987. Lung cancer is expected to account for 26% of all female cancer deaths in 2008. Table 3 provides the estimated number of cancer deaths in 2008 by state for selected cancer sites.
Table TABLE 3. Age-standardized Death Rates for All Cancers Combined, 2000 to 2004, and Estimated Deaths* from All Cancers Combined and Selected Sites by State, United States, 2008
Regional Variations in Cancer Rates
Table 4 depicts cancer incidence for select cancer sites by state. For some sites, rates vary widely across states. For example, among the cancers listed in Table 4, the largest variations in the incidence rates, in proportionate terms, occurred in lung cancer in which rates (cases per 100,000 population) ranged from 40.3 in men and 20.9 in women in Utah to 137.9 in men and 74.9 in women in Kentucky. In contrast, the variation in female breast cancer incidence rates was small, ranging from 105.4 cases per 100,000 population in Mississippi to 142.2 cases in Washington. Factors that contribute to state variations in incidence rates include differences in the prevalence of risk factors, access to and utilization of early detection services, and completeness of reporting. For example, the state variation in lung cancer incidence rates primarily reflects differences in smoking prevalence. Utah ranks lowest in adult smoking prevalence and Kentucky highest.
Table TABLE 4. Cancer Incidence Rates* by Site and State, United States, 2000 to 2004
Trends in Cancer Incidence and Mortality
Figures 2, FIGURE 2, FIGURE 3, FIGURE 4 to 5 depict long-term trends in cancer incidence and death rates for all cancers combined and for selected cancer sites by sex. Table 5 shows incidence and mortality patterns for all cancer sites and for the 4 most common cancer sites based on joinpoint analysis. Trends in incidence were adjusted for delayed reporting. Delay-adjusted cancer incidence rates were stable in males from 1995 to 2004 and in females from 1999 to 2004. Death rates for all cancer sites combined decreased by 2.6% per year in males and by 1.8% in females from 2002 to 2004 compared with declines of 1.5% per year in males from 1992 to 2002 and 0.8% per year in females from 1994 to 2002.
Table TABLE 5. Trends in Cancer Incidence and Death Rates for Selected Cancers by Sex, United States, 1975 to 2004
Mortality rates have continued to decrease across all 4 major cancer sites in both men and women, except for female lung cancer, in which rates continued to increase by 0.2% per year from 1995 to 2004 (Table 5). The incidence trends are mixed, however. Lung cancer incidence rates are declining in men and plateauing in women after increasing for many decades. The lag in the temporal trend of lung cancer incidence rates in women compared with men reflects historical differences in cigarette smoking between men and women; cigarette smoking in women peaked about 20 years later than in men. Colorectal cancer incidence rates have decreased from 1998 through 2004 in both males and females. Female breast cancer incidence rates decreased by 3.5% per year from 2001 to 2004 after increasing since 1980, likely reflecting both delays in diagnosis due to a decrease in mammography utilization and declines in hormone replacement therapy use among postmenopausal women.15–16 Prostate cancer incidence rates have stabilized from 1995 through 2004 following a short-term rapid increase and subsequent decrease between 1988 and 1995; these trends are thought to reflect changes in utilization of prostate-specific antigen testing.17–18
Table 6 shows the contribution of individual cancer sites to the total decrease in overall cancer death rates. Death rates from all cancers combined peaked in 1990 for men and in 1991 for women. Between 1990/1991 and 2004, death rates from cancer decreased by 18.4% among men and by 10.5% among women. Among men, reductions in death rates from lung, prostate, and colorectal cancers account for nearly 80% of the total decrease in cancer death rates, while reductions in death rates from breast and colorectal cancers account for 60% of the decrease among women. Lung cancer in men and breast cancer in women alone account for nearly 40% of the sex-specific decreases in cancer death rates. The decrease in lung cancer death rates among men is due to reduction in tobacco use over the past 40 years, while the decrease in death rates for colorectal, female breast, and prostate cancer largely reflects improvements in early detection and treatment.18 Between 1990/1991 and 2004, death rates increased substantially for lung cancer in women and for liver and intrahepatic bile duct cancer in men.
Table TABLE 6. The Contribution of Indvidual Cancer Sites to the Decrease in Cancer Death Rates, 1990 to 2004
Recorded Number of Deaths from Cancer in 2005
A total of 559,312 cancer deaths were recorded in the United States in 2005, the most recent year for which actual data are available, accounting for about 23% of all deaths (Table 7). Despite a decrease in age-standardized death rates, there were 5,424 more cancer deaths reported in 2005 than in 2004 (3,592 in men and 1,832 in women) (Table 8). This contrasts with the decrease in the total number of cancer deaths that occurred from 2002 to 2003 and 2003 to 2004, in part due to a larger decrease in the age-standardized death rates from 2002 to 2004 (about 2% per year) compared with 2004 to 2005 (about 1% per year). With respect to the 4 major cancer sites, colorectal cancer death rates decreased by about 6% from 2003 to 2004 compared with only about 3% from 2004 to 2005. The declines in death rates for cancers of the lung and bronchus and prostate in men and breast in women were similarly attenuated from 2004 to 2005.
Table TABLE 7. Fifteen Leading Causes of Death, United States, 2005
Table TABLE 8. Trends in the Recorded Number of Deaths for Selected Cancers by Sex, United States, 1990 to 2005.
Cancer is one of the 5 leading causes of death in all age groups among both males and females (Table 9). Cancer is the leading cause of death among women aged 40 to 79 years and among men aged 60 to 79 years. Cancer is the leading cause of death among men and women under age 85 years (Figure 6). A total of 475,848 people under age 85 years died from cancer in the United States in 2005 compared with 408,550 deaths from heart disease.
Table TABLE 9. Ten Leading Causes of Death by Age and Sex, United States, 2005
Table 10 presents the number of deaths from the 5 most common cancer sites for males and females at various ages. Among males under age 40 years, leukemia is the most common fatal cancer, while cancer of the lung and bronchus predominates in men aged 40 years and older. Among females, leukemia is the leading cause of cancer death before age 20 years, breast cancer ranks first at age 20 to 59 years, and lung cancer ranks first at age 60 years and older.
Table TABLE 10. Reported Deaths for the Five Leading Cancer Sites by Age and Sex, United States, 2005
Figure 7 shows the total number of cancer deaths avoided since death rates began to decrease in 1991 in men and in 1992 in women. As a result, over a half million cancer deaths (408,400 in men and 136,100 in women) were averted during the time interval of 1991/1992 through 2004.
CANCER OCCURRENCE BY RACE/ETHNICITY
Cancer incidence and death rates vary considerably among racial and ethnic groups (Table 11). For all cancer sites combined, African American men have a 19% higher incidence rate and a 37% higher death rate than White men, whereas African American women have a 6% lower incidence rate but a 17% higher death rate than White women. For the specific cancer sites listed in Table 11, incidence and death rates are consistently higher in African Americans than in Whites, except for cancers of the breast (incidence) and lung (incidence and mortality) among women and kidney (mortality) among both men and women. Factors known to contribute to racial disparities in mortality vary by cancer site and include differences in exposure to underlying risk factors (eg, historical smoking prevalence for lung cancer among men), access to high-quality regular screening (breast, cervical, and colorectal cancers), and timely diagnosis and treatment (for many cancers). The higher breast cancer incidence rates among Whites are thought to reflect a combination of factors that affect both diagnosis (such as more frequent mammography in White women) and the underlying factors that affect disease occurrence (such as later age at first birth and greater use of hormone replacement therapy among White compared with African American women).19
Table TABLE 11. Cancer Incidence and Death Rates* by Site, Race, and Ethnicity, United States, 2000 to 2004
Among other racial and ethnic groups, cancer incidence and death rates are lower than those in Whites and African Americans for all cancer sites combined and for the 4 most common cancer sites. However, incidence and death rates are generally higher in minority populations than in Whites for cancers of the uterine cervix, stomach, and liver. Stomach and liver cancer incidence and death rates are more than twice as high in Asian American/Pacific Islanders as in Whites, reflecting increased exposure to infectious agents such as Helicobacter pylori and hepatitis B and C.20 Kidney cancer mortality rates are the highest among American Indians/Alaska Natives, although obesity is the only factor known to contribute to this disparity.
Trends in cancer incidence can be adjusted for delayed reporting only in Whites and African Americans because long-term incidence data required for delay adjustment are not available for other racial and ethnic subgroups. From 1995 to 2004, incidence rates in males for all cancer sites combined (unadjusted for delayed reporting) decreased among all racial and ethnic groups except American Indian/Alaska Native men; among women, rates stabilized in all racial and ethnic groups during the same time period. In contrast, death rates from cancer significantly decreased in each racial and ethnic group, with larger decreases in men than in women.3
Death Rates by Educational Attainment, Race, and Sex
Table 12 shows death rates for all cancers combined and the 4 major cancers by educational attainment among White and African American men and women aged 25 to 64 years in 2001.21 The death rate for all cancers combined among less-educated (≤12 years of education) compared with more-educated (>12 years of education) people was more than twice as high in men and about 40% higher in women. For specific cancer sites, the ratio of death rates in the less-educated compared with the more-educated group ranged from 1.16 for breast cancer among African American women to 3.36 for lung cancer among White men. For lung cancer in men and women and for colorectal cancer in men, the absolute difference in death rates between the less educated and more educated was larger than the difference between Whites and African Americans by sex at each level of educational attainment. Factors that contribute to higher death rates from cancer in less-educated men and women include higher prevalence of risk factors such as smoking and obesity and limited access to medical services.
Table TABLE 12. Cancer Death Rates* by Educational Attainment, Race, and Sex, United States, 2001
Lifetime Probability of Developing Cancer
The lifetime probability of being diagnosed with an invasive cancer is higher for men (45%) than women (38%) (Table 13). However, because of the relatively early age of breast cancer onset, women have a slightly higher probability of developing cancer before age 60 years. It is noteworthy that these estimates are based on the average experience of the general population and may over- or underestimate individual risk because of differences in exposure and/or genetic susceptibility.
Table TABLE 13. Probability of Developing Invasive Cancers Within Selected Age Intervals by Sex, United States*
Cancer Survival by Race
Compared with Whites, African American men and women have poorer survival once cancer is diagnosed. Five-year relative survival is lower in African Americans than in Whites within each stratum of stage of diagnosis for nearly every cancer site (Figure 8). These disparities may result from inequalities in access to and receipt of quality health care and/or from differences in comorbidities.18 As shown in Figure 9, African Americans are less likely than Whites to be diagnosed with cancer at a localized stage, when the disease may be more easily and successfully treated, and are more likely to be diagnosed with cancer at a regional or distant stage of disease. The extent to which factors other than stage at diagnosis contribute to the overall differential survival is unclear.22 However, some studies suggest that African Americans who receive cancer treatment and medical care similar to that of Whites experience similar outcomes.23
There have been notable improvements since 1975 in relative 5-year survival rates for many cancer sites and for all cancers combined (Table 14). This is true for both Whites and African Americans. Cancers for which survival has not improved substantially over the past 25 years include uterine corpus, cervix, larynx, lung, and pancreas. The improvement in survival reflects a combination of earlier diagnosis and improved treatments.
Table TABLE 14. Trends in 5-Year Relative Survival Rates* (%) by Race and Year of Diagnosis, United States, 1975 to 2003
Relative survival rates cannot be calculated for racial and ethnic populations other than Whites and African Americans because accurate life expectancies (the average number of years of life remaining for persons who have attained a given age) are not available. However, based on cause-specific survival rates of cancer patients diagnosed from 1992 to 2000 in SEER areas of the United States, all minority populations except Asian American/Pacific Islander women have a greater probability of dying from cancer within 5 years of diagnosis than non-Hispanic Whites, after accounting for differences in stage at diagnosis.18,24 For the 4 major cancer sites (prostate, female breast, lung and bronchus, and colon and rectum), minority populations are more likely to be diagnosed at distant stage compared with non-Hispanic Whites.24
CANCER IN CHILDREN
Cancer is the second most common cause of death among children between the age of 1 and 14 years in the United States, surpassed only by accidents (Table 15). Leukemia (particularly acute lymphocytic leukemia) is the most common cancer in children (aged 0 to 14 years), followed by cancer of the brain and other nervous system, neuroblastoma, renal (Wilms) tumors, and non-Hodgkin lymphoma.3 Over the past 25 years, there have been significant improvements in the 5-year relative survival rate for all of the major childhood cancers (Table 16). The 5-year relative survival rate among children for all cancer sites combined improved from 58% for patients diagnosed in 1975 to 1977 to 80% for those diagnosed in 1996 to 2003.3
Table TABLE 15. Fifteen leading Causes of Death Among Children Aged 1 to 14, United states, 2005
Table TABLE 16. Trends in Five-year Relative Survival Rates* (%) for Children Under Age 15, United States, 1975 to 2003
Estimates of the expected numbers of new cancer cases and cancer deaths should be interpreted cautiously. These estimates may vary considerably from year to year, particularly for less common cancers and in states with smaller populations. Estimates are also affected by changes in method. The introduction of a new method for projecting incident cancer cases beginning with the 2007 estimates substantially affected the estimates for a number of cancers, particularly leukemia and female breast (see Pickle et al12 for more detailed discussion). Not all changes in cancer trends are captured by modeling techniques. For these reasons, we discourage the use of these estimates to track year-to-year changes in cancer occurrence and death. The preferred data sources for tracking cancer trends are the age-standardized or age-specific cancer death rates from the NCHS and cancer incidence rates from SEER or NPCR, even though these data are 3 and 4 years old, respectively, by the time that they become available. Nevertheless, the American Cancer Society estimates of the number of new cancer cases and deaths in the current year provide reasonably accurate estimates of the burden of new cancer cases and deaths in the United States.