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Keywords:

  • cancer cases;
  • cancer statistics;
  • death rates;
  • incidence;
  • mortality;
  • survival;
  • trends

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the National Cancer Institute (Surveillance, Epidemiology, and End Results [SEER] Program), the Centers for Disease Control and Prevention (National Program of Cancer Registries), and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2016, 1,685,210 new cancer cases and 595,690 cancer deaths are projected to occur in the United States. Overall cancer incidence trends (13 oldest SEER registries) are stable in women, but declining by 3.1% per year in men (from 2009-2012), much of which is because of recent rapid declines in prostate cancer diagnoses. The cancer death rate has dropped by 23% since 1991, translating to more than 1.7 million deaths averted through 2012. Despite this progress, death rates are increasing for cancers of the liver, pancreas, and uterine corpus, and cancer is now the leading cause of death in 21 states, primarily due to exceptionally large reductions in death from heart disease. Among children and adolescents (aged birth-19 years), brain cancer has surpassed leukemia as the leading cause of cancer death because of the dramatic therapeutic advances against leukemia. Accelerating progress against cancer requires both increased national investment in cancer research and the application of existing cancer control knowledge across all segments of the population. CA Cancer J Clin 2016;7–30. © 2015 American Cancer Society.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Cancer is a major public health problem worldwide and is the second leading cause of death in the United States. In this article, we provide the expected numbers of new cancer cases and deaths in 2016 in the United States nationally and for each state, as well as a comprehensive overview of cancer incidence, mortality, and survival rates and trends using the most current population-based data. In addition, we estimate the total number of deaths averted during the past 2 decades as a result of the continual decline in cancer death rates. We also present the actual number of deaths reported in 2012 by age for the 10 leading causes of death and for the 5 leading causes of cancer death.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Incidence and Mortality Data

Mortality data from 1930 to 2012 were provided by the National Center for Health Statistics (NCHS).[1, 2] Forty-seven states and the District of Columbia met data quality requirements for reporting to the national vital statistics system in 1930. Texas, Alaska, and Hawaii began reporting mortality data in 1933, 1959, and 1960, respectively. The methods for abstraction and age adjustment of mortality data are described elsewhere.[2, 3]

Population-based cancer incidence data in the United States have been collected by the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) Program since 1973 and by the Centers for Disease Control and Prevention's National Program of Cancer Registries (NPCR) since 1995. The SEER program is the only source for long-term population-based incidence data. Long-term incidence and survival trends (1975-2012) were based on data from the 9 oldest SEER areas (Connecticut, Hawaii, Iowa, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco-Oakland, and Seattle-Puget Sound), representing approximately 9% of the US population.[4] As of 1992, SEER data have been available for 4 additional SEER registries (Alaska Natives, Los Angeles county, San Jose-Monterey, and rural Georgia) that increase coverage of minority groups, allowing for stratification by race and ethnicity. Delay-adjusted data from these (SEER 13) registries, which represent 14% of the US population, were the source for the annual percent change in incidence from 1992 to 2012.[5] The SEER program added 5 additional catchment areas beginning with cases diagnosed in 2000 (greater California, greater Georgia, Kentucky, Louisiana, and New Jersey), achieving 28% population coverage. Data from all 18 SEER areas were the source for cancer stage distribution, stage-specific survival, and the lifetime probability of developing cancer.[6] The probability of developing cancer was calculated using NCI's DevCan software (version 6.7.3).[7] Much of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975-2012.[8]

The North American Association of Central Cancer Registries (NAACCR) compiles and reports incidence data from 1995 onward for cancer registries that participate in the SEER program and/or the NPCR. These data approach 100% coverage of the US population in the most recent time period and were the source for the projected new cancer cases in 2016 and incidence rates by state and race/ethnicity.[9, 10] Some of the data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2008-2012.[11, 12]

All cancer cases were classified according to the International Classification of Diseases for Oncology except childhood and adolescent cancers, which were classified according to the International Classification of Childhood Cancer (ICCC).[13] Causes of death were classified according to the International Classification of Diseases.[14] All incidence and death rates were age-standardized to the 2000 US standard population and expressed per 100,000 population, as calculated by NCI's SEER*Stat software (version 8.2.1).[15] The annual percent change in rates was quantified using NCI's Joinpoint Regression Program (version 4.2.0.2).[16]

Whenever possible, cancer incidence rates presented in this report were adjusted for delays in reporting, which occur because of a lag in case capture or data corrections. Delay adjustment has the largest effect on the most recent years of data for cancers that are frequently diagnosed in outpatient settings (eg, melanoma, leukemia, and prostate cancer) and provides a more accurate portrayal of the cancer burden in the most recent time period.[17] For example, the leukemia incidence rate for 2012 is 16% higher after adjusting for reporting delays.[6, 18]

Projected Cancer Cases and Deaths in 2016

The most recent year for which incidence and mortality data are available lags 2 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we projected the numbers of new cancer cases and deaths in the United States in 2016 to provide an estimate of the contemporary cancer burden. The number of invasive cancer cases was estimated using a 3-step spatio-temporal model based on high-quality incidence data from 49 states and the District of Columbia representing approximately 94% population coverage (data were lacking for all years for Minnesota and for some years for other states). First, complete incidence counts were estimated for each county from 1998 through 2012 using geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence.[19] Then these counts were adjusted for delays in cancer reporting and aggregated to obtain national- and state-level estimates. Finally, a temporal projection method (the vector autoregressive model) was applied to the last 15 years of data to estimate counts for 2016. This method cannot estimate numbers of basal cell or squamous cell skin cancers because data on the occurrence of these cancers are not required to be reported to cancer registries. For complete details of the case projection methodology, please refer to Zhu et al.[20]

New cases of female breast carcinoma in situ and melanoma in situ diagnosed in 2016 were calculated by first approximating the number of cases occurring annually from 2003 through 2012 based on age-specific NAACCR incidence rates (data from 44 states and the District of Columbia with high-quality data every year) and US population estimates provided in SEER*Stat. The average annual percent change in case counts from 2003 through 2012 generated by the joinpoint regression model was then used to project cases to 2016. In contrast to previous years, the estimate for breast carcinoma in situ was not adjusted for reporting delays because delay-adjustment factors were not available.

The number of cancer deaths expected to occur in 2016 was estimated based on the annual percent change in reported numbers of cancer deaths from 1998 through 2012 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al.[21]

Other Statistics

The number of cancer deaths averted in men and women due to the reduction in overall cancer death rates was estimated by subtracting the number of recorded deaths from the number that would have been expected if cancer death rates had remained at their peak. The expected number of deaths was estimated by applying the 5-year age-specific cancer death rates in the peak year for age-standardized cancer death rates (1990 in men and 1991 in women) to the corresponding age-specific populations in subsequent years through 2012. The difference between the number of expected and recorded cancer deaths in each age group and calendar year was then summed.

Selected Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Expected Numbers of New Cancer Cases

Table 1 presents the estimated numbers of new cases of invasive cancer expected in the United States in 2016 by sex. The overall estimate of 1,685,210 cases is the equivalent of more than 4,600 new cancer diagnoses each day. In addition, about 61,000 cases of female breast carcinoma in situ and 68,480 cases of melanoma in situ are expected to be diagnosed in 2016. The estimated numbers of new cases by state for selected cancer sites are shown in Table 2.

Table 1. Estimated New Cancer Cases and Deaths by Sex, United States, 2016a
 ESTIMATED NEW CASESESTIMATED DEATHS
 BOTH SEXESMALEFEMALEBOTH SEXESMALEFEMALE
  1. a

    Rounded to the nearest 10; cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.

  2. About 61,000 cases of carcinoma in situ of the female breast and 68,480 cases of melanoma in situ will be diagnosed in 2016.

  3. b

    Deaths for colon and rectum cancers are combined because a large number of deaths from rectal cancer are misclassified as colon.

  4. c

    More deaths than cases may reflect lack of specificity in recording underlying cause of death on death certificates and/or an undercount in the case estimate.

All sites1,685,210841,390843,820595,690314,290281,400
Oral cavity & pharynx48,33034,78013,5509,5706,9102,660
Tongue16,10011,7004,4002,2901,570720
Mouth12,9107,6005,3102,5201,630890
Pharynx16,42013,3503,0703,0802,400680
Other oral cavity2,9002,1307701,6801,310370
Digestive system304,930172,530132,400153,03088,70064,330
Esophagus16,91013,4603,45015,69012,7202,970
Stomach26,37016,4809,89010,7306,5404,190
Small intestine10,0905,3904,7001,330710620
Colonb95,27047,71047,56049,19026,02023,170
Rectum39,22023,11016,110   
Anus, anal canal, & anorectum8,0802,9205,1601,080440640
Liver & intrahepatic bile duct39,23028,41010,82027,17018,2808,890
Gallbladder & other biliary11,4205,2706,1503,7101,6302,080
Pancreas53,07027,67025,40041,78021,45020,330
Other digestive organs5,2702,1103,1602,3509101,440
Respiratory system243,820132,620111,200162,51089,32073,190
Larynx13,43010,5502,8803,6202,890730
Lung & bronchus224,390117,920106,470158,08085,92072,160
Other respiratory organs6,0004,1501,850810510300
Bones & joints3,3001,8501,4501,490860630
Soft tissue (including heart)12,3106,9805,3304,9902,6802,310
Skin (excluding basal & squamous)83,51051,65031,86013,6509,3304,320
Melanoma of the skin76,38046,87029,51010,1306,7503,380
Other nonepithelial skin7,1304,7802,3503,5202,580940
Breast249,2602,600246,66040,89044040,450
Genital system297,530191,640105,89057,73026,84030,890
Uterine cervix12,990 12,9904,120 4,120
Uterine corpus60,050 60,05010,470 10,470
Ovary22,280 22,28014,240 14,240
Vulva5,950 5,9501,110 1,110
Vagina & other genital, female4,620 4,620950 950
Prostate180,890180,890 26,12026,120 
Testis8,7208,720 380380 
Penis & other genital, male2,0302,030 340340 
Urinary system143,190100,92042,27031,54021,6009,940
Urinary bladder76,96058,95018,01016,39011,8204,570
Kidney & renal pelvis62,70039,65023,05014,2409,2405,000
Ureter & other urinary organs3,5302,3201,210910540370
Eye & orbit2,8101,5101,300280150130
Brain & other nervous system23,77013,35010,42016,0509,4406,610
Endocrine system66,73016,20050,5302,9401,4001,540
Thyroid64,30014,95049,3501,9809101,070
Other endocrine2,4301,2501,180960490470
Lymphoma81,08044,96036,12021,27012,1609,110
Hodgkin lymphoma8,5004,7903,7101,120640480
Non-Hodgkin lymphoma72,58040,17032,41020,15011,5208,630
Myeloma30,33017,90012,43012,6506,4306,220
Leukemia60,14034,09026,05024,40014,13010,270
Acute lymphocytic leukemia6,5903,5903,0001,430800630
Chronic lymphocytic leukemia18,96010,8308,1304,6602,8801,780
Acute myeloid leukemia19,95011,1308,82010,4305,9504,480
Chronic myeloid leukemia8,2204,6103,6101,070570500
Other leukemiac6,4203,9302,4906,8103,9302,880
Other & unspecified primary sitesc34,17017,81016,36042,70023,90018,800
Table 2. Estimated New Cases for Selected Cancers by State, 2016a
STATEALL CASESFEMALE BREASTUTERINE CERVIXCOLON & RECTUMUTERINE CORPUSLEUKEMIALUNG & BRONCHUSMELANOMA OF THE SKINNON-HODGKIN LYMPHOMAPROSTATEURINARY BLADDER
  1. a

    Rounded to the nearest 10; excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder.

  2. b

    Estimate is fewer than 50 cases.

  3. Note: These are model-based estimates that should be interpreted with caution. State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 cases.

Alabama27,0203,9602202,1907109004,2201,3901,0302,9501,110
Alaska3,330500b270110120440100140330150
Arizona32,5104,9002302,5501,0601,1603,9801,5101,3003,1501,630
Arkansas16,4602,0901501,4104705102,6103406701,670700
California173,20026,7301,46013,7706,1206,37018,1408,5607,76017,2407,580
Colorado24,7304,1101801,7908601,0202,5201,4601,1103,0601,080
Connecticut21,7003,2901201,6108807902,7706809202,4601,130
Delaware5,630800b430190180850320220690260
Dist. of Columbia2,910470b2001008030011011046090
Florida121,24016,7701,0509,7103,9403,93017,3606,2005,37013,3105,940
Georgia48,6707,1604303,9801,4501,4906,6702,5401,8305,5701,830
Hawaii6,8501,13060650280220740410300610250
Idaho8,1201,110506102803609904903701,010430
Illinois65,09010,1605505,5802,6902,3708,8202,5002,8607,2503,040
Indiana35,1804,9802902,9801,3101,1905,5201,4601,5003,5101,620
Iowa17,1002,3101101,5007007302,4201,0007901,670840
Kansas14,5302,2101101,1505605401,9708206401,510650
Kentucky25,7203,4702002,2008109804,9601,4501,0802,4601,120
Louisiana25,0703,4002202,1706207103,7306201,0902,950940
Maine9,2701,310507203803801,410340400960570
Maryland30,9904,8802302,3901,1701,0004,1001,5901,2303,8401,330
Massachusetts37,6206,0102102,7501,5601,3404,9101,3801,7204,3502,030
Michigan56,5308,1503804,5702,2901,8908,4402,5602,5206,0003,000
Minnesota29,1304,3001402,1801,0701,2803,6601,2201,3702,9301,300
Mississippi16,6802,3301501,5304305202,5504905701,770600
Missouri34,2705,0302502,8501,2501,2205,4501,6101,4403,2601,550
Montana6,070890b460210270750350270770330
Nebraska9,7401,480608503803901,220470440960460
Nevada14,3902,0101101,1403905201,7004405501,320670
New Hampshire8,6801,280b6203502901,140290350910490
New Jersey49,7507,4203704,0202,0501,8705,5802,4702,4305,9702,460
New Mexico9,7501,480807603303801,0204504101,020390
New York110,28016,3607908,7304,3604,49013,2004,2504,86012,0105,220
North Carolina54,4507,8304004,2801,7801,8707,8702,8502,2105,9902,280
North Dakota3,930530b310130150480190160400180
Ohio66,0209,3904705,3402,6402,14010,5502,8802,8206,7603,180
Oklahoma19,6502,7601801,6305907203,1505708602,080840
Oregon22,5103,4301501,6108507502,9701,5309802,4901,130
Pennsylvania83,56011,3105406,3903,2903,02010,5003,7503,5408,3504,260
Rhode Island6,190940b490250210890210260640350
South Carolina27,9804,0102102,2208609204,2801,5401,0803,1901,210
South Dakota4,690680b390170180590210210470230
Tennessee37,6505,4203003,1301,1001,3506,0101,8501,5103,3701,590
Texas116,69016,8001,3309,6803,7004,21014,6202,9205,12013,2104,150
Utah11,0301,420707204004708908405101,310430
Vermont4,050580b280160140510180170450220
Virginia43,1906,6203003,2401,4901,3105,6902,3401,6604,8201,910
Washington37,7705,8202302,7001,3901,4904,6702,4401,7504,4301,830
West Virginia11,7701,490901,0104504102,0206404901,030600
Wisconsin32,9704,7302002,5201,3101,2604,2301,3501,4903,5701,630
Wyoming2,920420b220100110310180120380160
United States1,685,210246,66012,990134,49060,05060,140224,39076,38072,580180,89076,960

Figure 1 indicates the most common cancers expected to occur in men and women in 2016. Prostate, lung and bronchus, and colorectal cancers account for 44% of all cases in men, with prostate cancer alone accounting for 1 in 5 new diagnoses. For women, the 3 most commonly diagnosed cancers are breast, lung and bronchus, and colorectum, representing one-half of all cases; breast cancer alone is expected to account for 29% all new cancer diagnoses in women.

image

Figure 1. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2016.

Estimates are rounded to the nearest 10 and cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.

Download figure to PowerPoint

Expected Numbers of Cancer Deaths

Table 1 also shows the expected numbers of cancer deaths in 2016. It is estimated that 595,690 Americans will die from cancer this year, corresponding to about 1,600 deaths per day. The most common causes of cancer death are cancers of the lung and bronchus, prostate, and colorectum in men and lung and bronchus, breast, and colorectum in women. These 4 cancers account for 46% of all cancer deaths (Fig. 1), with more than one-quarter (27%) due to lung cancer. Table 3 provides the estimated numbers of cancer deaths in 2016 by state for selected cancer sites.

Table 3. Estimated Deaths for Selected Cancers by State, 2016a
STATEALL SITESBRAIN & OTHER NERVOUS SYSTEMFEMALE BREASTCOLON & RECTUMLEUKEMIALIVER & INTRAHEPATIC BILE DUCTLUNG & BRONCHUSNON-HODGKIN LYMPHOMAOVARYPANCREASPROSTATE
  1. a

    Rounded to the nearest 10.

  2. b

    Estimate is fewer than 50 deaths.

  3. Note: These are model-based estimates that should be interpreted with caution. State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 deaths.

Alabama10,6503006709204304203,260340260690470
Alaska1,070b7090b50290bb70b
Arizona11,8003607809805105902,830410310900590
Arkansas6,8301704306002602602,190210150420270
California59,0601,7604,4005,1802,5603,60012,2302,1401,5304,3903,050
Colorado7,7602705606503303701,690260240560430
Connecticut6,7801904504503103001,690220170540320
Delaware2,0505013015080100600605014090
Dist. of Columbia980b9090b80210bb9070
Florida43,6001,0802,8803,5001,7701,87011,9601,4809403,0801,970
Georgia16,8404601,2601,5006207304,7004904201,090730
Hawaii2,480b1302309015057010050230100
Idaho2,8109018022012011067010070210160
Illinois24,0806001,6602,0301,0109306,5408005701,6401,020
Indiana13,5103508601,0705704604,020440300860520
Iowa6,4701903805702602301,770250160430280
Kansas5,5401803604602602101,540200130390220
Kentucky10,3502506008303903603,570330200610340
Louisiana9,1102206307903304702,620280180650360
Maine3,3209017023014012097012060230130
Maryland10,5602708208503905102,670310260800480
Massachusetts12,6303307708905206303,380390330930530
Michigan21,1006101,4101,6408508006,0307804801,520790
Minnesota9,8502806107504804102,430500240660470
Mississippi6,4801504206302402801,930170110440280
Missouri12,9703208801,0505205503,950370250860470
Montana2,0206013017080705207060130120
Nebraska3,50011021033015013089013070240180
Nevada4,9701503804801802101,390160110360240
New Hampshire2,77080170190110907708060210130
New Jersey16,1504001,2801,4506406703,8305104401,260680
New Mexico3,690100260350150210790130110240200
New York34,9108802,4102,8301,4601,6508,7701,2009202,6601,550
North Carolina19,6206001,3601,4807508305,8206104501,240820
North Dakota1,270b8012050b330bb9060
Ohio25,5106301,7002,0601,0001,0207,4208505701,8001,060
Oklahoma8,2602205306903403302,470280190500340
Oregon8,1502405006603404302,100280220570410
Pennsylvania28,7006801,9402,3401,2401,1407,5301,0307002,0901,190
Rhode Island2,090501201609010058060b12090
South Carolina10,3302506908303604203,010310240730450
South Dakota1,64050110130706046050b11080
Tennessee14,5603609001,2305506304,610450300870540
Texas39,4501,0502,7803,5201,6602,4709,6201,3209502,6501,520
Utah2,97012027024014013046012090250200
Vermont1,39050701005060390bb10070
Virginia14,9103901,0801,1605806404,0804903901,050630
Washington12,7704108209705106603,170440350920630
West Virginia4,7501202704001801401,46017090270160
Wisconsin11,6303507108405404203,060460300840550
Wyoming1,000b709050b230bb70b
United States595,69016,05040,45049,19024,40027,170158,08020,15014,24041,78026,120

Lifetime Probability of Developing Cancer

The lifetime probability of being diagnosed with an invasive cancer is higher for men (42%) than for women (38%) (Table 4). Reasons for increased susceptibility in men are not well understood, but to some extent reflect differences in environmental exposures, endogenous hormones, and probably complex interactions between these influences. Adult height, which is determined by genetics and childhood nutrition, is positively associated with cancer incidence and death in both men and women,[22] and has been estimated to account for one-third of the sex differences in cancer risk.[23] For adults aged younger than 50 years, however, cancer risk is higher for women (5.4%) than for men (3.4%) because of the relatively high burden of breast, genital, and thyroid cancers in young women. The estimated probability of developing cancer is based on the average experience of the general population and may over- or underestimate individual risk because of differences in exposure (eg, smoking history), medical history, and/or genetic susceptibility.

Table 4. Probability (%) of Developing Invasive Cancer Within Selected Age Intervals by Sex, United States, 2010 to 2012a
  BIRTH TO 4950 TO 5960 TO 69≥70BIRTH TO DEATH
  1. a

    For people free of cancer at beginning of age interval.

  2. b

    All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder.

  3. c

    Probabilities are for whites.

All sitesbMale3.4 (1 in 29)6.5 (1 in 15)14.5 (1 in 7)34.6 (1 in 3)42.1 (1 in 2)
 Female5.4 (1 in 19)6.0 (1 in 17)10.0 (1 in 10)26.1 (1 in 4)37.6 (1 in 3)
BreastFemale1.9 (1 in 53)2.3 (1 in 44)3.5 (1 in 29)6.7 (1 in 15)12.3 (1 in 8)
ColorectumMale0.3 (1 in 300)0.7 (1 in 149)1.2 (1 in 82)3.7 (1 in 27)4.7 (1 in 21)
 Female0.3 (1 in 318)0.5 (1 in 195)0.9 (1 in 117)3.4 (1 in 30)4.4 (1 in 23)
Kidney & renal pelvisMale0.2 (1 in 467)0.3 (1 in 295)0.6 (1 in 158)1.3 (1 in 76)2.0 (1 in 49)
 Female0.1 (1 in 748)0.2 (1 in 576)0.3 (1 in 317)0.7 (1 in 136)1.2 (1 in 83)
LeukemiaMale0.2 (1 in 415)0.2 (1 in 591)0.4 (1 in 261)1.4 (1 in 72)1.8 (1 in 57)
 Female0.2 (1 in 508)0.1 (1 in 939)0.2 (1 in 458)0.9 (1 in 115)1.2 (1 in 82)
Lung & bronchusMale0.2 (1 in 608)0.7 (1 in 145)2.0 (1 in 51)6.4 (1 in 16)7.2 (1 in 14)
 Female0.2 (1 in 572)0.6 (1 in 177)1.5 (1 in 67)4.8 (1 in 21)6.0 (1 in 17)
Melanoma of the skincMale0.3 (1 in 297)0.4 (1 in 238)0.8 (1 in 127)2.2 (1 in 45)3.0 (1 in 33)
 Female0.5 (1 in 206)0.3 (1 in 321)0.4 (1 in 242)0.9 (1 in 107)1.9 (1 in 52)
Non-Hodgkin lymphomaMale0.3 (1 in 376)0.3 (1 in 347)0.6 (1 in 174)1.8 (1 in 55)2.4 (1 in 42)
 Female0.2 (1 in 546)0.2 (1 in 477)0.4 (1 in 237)1.4 (1 in 73)1.9 (1 in 53)
ProstateMale0.3 (1 in 325)2.1 (1 in 48)5.8 (1 in 17)10.0 (1 in 10)14.0 (1 in 7)
ThyroidMale0.2 (1 in 560)0.1 (1 in 821)0.2 (1 in 635)0.2 (1 in 451)0.6 (1 in 169)
 Female0.8 (1 in 131)0.4 (1 in 281)0.3 (1 in 306)0.4 (1 in 258)1.7 (1 in 58)
Uterine cervixFemale0.3 (1 in 364)0.1 (1 in 850)0.1 (1 in 871)0.2 (1 in 576)0.6 (1 in 157)
Uterine corpusFemale0.3 (1 in 355)0.6 (1 in 170)0.9 (1 in 107)1.3 (1 in 76)2.8 (1 in 36)

Trends in Cancer Incidence

Figures 2 and 3 illustrate long-term trends in cancer incidence rates for all cancers combined and for selected cancer sites by sex. Cancer incidence patterns in the United States reflect trends in behaviors associated with cancer risk, improvements in cancer prevention and control, and changes in medical practice. Trends in overall incidence are driven by the 4 major cancers (lung, breast, prostate, and colorectal). For example, the spike in incidence rates in men in the late 1980s and early 1990s (Fig. 2) is due to the surge in detection of asymptomatic prostate cancer (Fig. 3) as a result of widespread prostate-specific antigen (PSA) testing.[24] The increase in incidence in women during the 1980s reflects increases in both lung cancer, as a result of the tobacco epidemic, and breast cancer, because of changes in female reproductive patterns and the increased detection of asymptomatic disease during the rapid uptake of mammography screening.[25]

image

Figure 2. Trends in Cancer Incidence and Death Rates by Sex, United States, 1975 to 2012.

Rates are age adjusted to the 2000 US standard population. Incidence rates are adjusted for delays in reporting.

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image

Figure 3. Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2012.

Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting.

*Includes intrahepatic bile duct.

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Table 5 presents the annual percent change in delay-adjusted incidence rates in the SEER 13 registries from 1992 through 2012 along with the average annual percent change over the past 5 and 10 years of data based on joinpoint regression analysis. Joinpoint is a tool used to describe and quantify trends by fitting observed rates to lines connected at “joinpoints” where trends change in direction or magnitude.[8, 26] The overall incidence rate in women has remained stable since 1998, but has declined in men by 3.1% per year since 2009. The recent rapid decline in prostate cancer diagnoses accounts for about one-half of the total decline in men. Routine screening with the PSA test is no longer recommended because of growing concerns about high rates of overdiagnosis, estimated at 23% to 42% for screen-detected cancers.[27, 28] Despite declines in the prevalence of PSA screening from 2010 to 2013, one-third of men aged 65 years and older with limited life expectancy were screened in 2013.[29]

Table 5. Trends in Cancer Incidence (Delay-Adjusted) and Death Rates for Selected Cancers by Sex, United States, 1992 to 2012
 TREND 1TREND 2TREND 3TREND 42003-2012 AAPC2008-2012 AAPC
 YEARSAPCYEARSAPCYEARSAPCYEARSAPC
  1. APC indicates annual percent change based on incidence (delay adjusted) and mortality rates age adjusted to the 2000 US standard population; AAPC, average annual percent change.

  2. a

    The APC or AAPC is significantly different from zero (P < .05).

  3. Note: Trends analyzed by the Joinpoint Regression Program, version 4.2.0, allowing up to 3 joinpoints. Incidence trends based on Surveillance, Epidemiology, and End Results (SEER) 13 areas.

All sites          
Incidence          
Overall1992-1994−3.1a1994-19980.41998-2009−0.3a2009-2012−1.5a−0.7a−1.2a
Male1992-1994−5.8a1994-2009−0.5a2009-2012−3.1a  −1.4a−2.5a
Female1992-19980.8a1998-2003−0.62003-20120.0  0.00.0
Death          
Overall1992-2001−1.0a2001-2012−1.5a    −1.5a−1.5a
Male1992-2001−1.4a2001-2012−1.8a    −1.8a−1.8a
Female1992-1995−0.21995-1998−1.2a1998-2001−0.42001-2012−1.4a−1.4a−1.4a
Female breast          
Incidence1992-19991.3a1999-2004−2.2a2004-20120.3  0.00.3
Death1992-1995−1.3a1995-1998−3.5a1998-2012−1.9a  −1.9a−1.9a
Colorectum          
Incidence          
Male1992-1995−2.6a1995-19981.41998-2008−2.5a2008-2012−3.6a−3.0a−3.6a
Female1992-1995−1.8a1995-19981.81998-2008−2.0a2008-2012−3.8a−2.8a−3.8a
Death          
Male1992-2002−2.0a2002-2005−3.9a2005-2012−2.6a  −2.9a−2.6a
Female1992-2001−1.7a2001-2012−2.9a    −2.9a−2.9a
Liver & intrahepatic bile duct          
Incidence          
Male1992-20123.7a      3.7a3.7a
Female1992-20123.0a      3.0a3.0a
Death          
Male1992-20072.2a2007-20123.3a    2.8a3.3a
Female1992-20081.3a2008-20123.2a    2.1a3.2a
Lung & bronchus          
Incidence          
Male1992-2009−1.9a2009-2012−3.3a    −2.4a−3.0a
Female1992-20070.02007-2012−1.9a    −1.1a−1.9a
Death          
Male1992-2005−1.9a2005-2012−3.0a    −2.7a−3.0a
Female1992-19951.4a1995-20030.3a2003-2007−0.82007-2012−1.9a−1.4a−1.9a
Melanoma of skin          
Incidence          
Male1992-19965.0a1996-20122.0a    2.0a2.0a
Female1992-20052.4a2005-20120.5    0.9a0.5
Death          
Male1992-20120.3a      0.3a0.3a
Female1992-2012−0.5a      −0.5a−0.5a
Pancreas          
Incidence          
Male1992-20010.02001-20121.2a    1.2a1.2a
Female1992-1999−0.11999-20121.1a    1.1a1.1a
Death          
Male1992-1996−1.0a1996-20120.3a    0.3a0.3a
Female1992-1997−0.41997-20120.4a    0.4a0.4a
Prostate          
Incidence1992-1995−11.1a1995-20002.12000-2010−1.8a2010-2012−11.2a−4.0a−6.6a
Death1992-1994−1.51994-2012−3.6a    −3.6a−3.6a
Thyroid          
Incidence          
Male1992-1995−3.21995-20125.3a    5.3a5.3a
Female1992-19994.1a1999-20096.9a2009-20121.8  5.2a3.0a
Death          
Male1992-20121.5a      1.5a1.5a
Female1992-1994−6.41994-20100.9a2010-2012−5.1  −0.5−2.2
Uterine corpus          
Incidence1992-2006−0.12006-20122.3a    1.5a2.3a
Death1992-1997−0.7a1997-20090.3a2009-20122.5a  1.1a2.0a

Lung cancer incidence rates began declining in the mid-1980s in men and in the mid-2000s in women (Fig. 3) as a result of reductions in smoking prevalence that began decades earlier.[30] Contemporary differences in lung cancer incidence patterns between men and women reflect historical differences in tobacco use. Women took up smoking in large numbers later than men, first initiated smoking at older ages, and were slower to quit, including recent upturns in smoking prevalence in some birth cohorts.[31, 32] Declines in lung cancer incidence and death rates continue to be larger in men than in women (Table 5).

The long-term declines in colorectal cancer incidence rates since the mid-1980s have been attributed to both changes in risk factors and the introduction of screening.[33] However, the recent rapid declines are likely driven by the increased uptake of screening with colonoscopy, which can prevent cancer by allowing for the removal of precancerous lesions.[34, 35] Among adults aged 50 to 75 years, colonoscopy use increased from 19% in 2000 to 55% in 2013.[36] Colorectal cancer incidence and death rates declined by about 3% per year in both men and women from 2003 through 2012, with momentum gaining in the most recent years (Table 5). However, rates increased by 1.8% per year from 1992 through 2012 in men and women aged younger than 50 years, among whom screening is not recommended for those at average risk.[5]

In contrast to stable or declining trends for most cancers, incidence rates increased from 2003 to 2012 (SEER registries combined) among both men and women for some leukemia subtypes and for cancers of the tongue, tonsil, small intestine, liver, pancreas, kidney, renal pelvis, and thyroid.[8] In addition, incidence rates increased in men for melanoma; myeloma; and cancers of the breast, testis, and oropharynx. Recent declines in incidence for melanoma and liver cancer among young adults may portend a reduction in the burden of these cancers in future generations (Fig. 4). Among women, incidence rates increased for cancers of the anus, vulva, and uterine corpus. Uterine corpus cancer incidence rates have been increasing since the early 1990s in black women, but only since the mid-2000s in white women, perhaps due to steeper temporal increases in obesity among black women.[37] Excess weight increases endometrial cancer risk by 50% for every 5 body mass index (BMI) units; although the highest risk occurs among the most obese women, some elevation in risk is apparent even within the normal BMI range.[38] It is important to note that rates of uterine corpus cancer typically do not account for hysterectomy prevalence, thus substantially underestimating true disease risk. A recent study found that incidence rates corrected for hysterectomy prevalence were 73% higher among white women and 90% higher among black women compared with uncorrected rates.[39]

image

Figure 4. Incidence Trends for Melanoma and Liver Cancer by Age, United States, 1992 to 2012.

Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting.

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Thyroid cancer continues to be the most rapidly increasing cancer (>5% per year in both men and women), partially due to overdiagnosis because of increased use of advanced imaging techniques. A recent study estimated that over the past 2 decades, about one-half of all papillary thyroid cancers diagnosed in women, and 40% of those in men aged ≥50 years, were clinically irrelevant.[40] However, increases across tumor size and stage, as well as for follicular carcinoma (a more aggressive subtype), suggest that some of the rise may be due to changes in environmental risk factors, such as obesity.[41-43]

Trends in Cancer Survival

Over the past 3 decades, the 5-year relative survival rate for all cancers combined has increased 20 percentage points among whites and 23 percentage points among blacks (Table 6). Progress has been most rapid for hematopoietic and lymphoid malignancies due to improvements in treatment protocols, including the discovery of targeted therapies. For example, the 5-year survival for acute lymphocytic leukemia increased from 41% during the mid-1970s to 70% during 2005 to 2011. The use of BCR-ABL tyrosine kinase inhibitors (eg, imatinib) doubled survival for patients with chronic myeloid leukemia in less than 2 decades,[44] from 31% in the early 1990s to 63% during 2005 to 2011. A recent study found that improvements in survival since 1990 for the most common cancers have been much more pronounced among patients aged 50 to 64 years than among those aged older than 65 years.[45] This disparity may reflect differential care and/or lower efficacy or use of new therapies in the elderly population.

Table 6. Trends in 5-Year Relative Survival Ratesa (%) by Race and Year of Diagnosis, United States, 1975 to 2011
 ALL RACESWHITEBLACK
 1975 TO 19771987 TO 19892005 TO 20111975 TO 19771987 TO 19892005 TO 20111975 TO 19771987 TO 19892005 TO 2011
  1. a

    Survival rates are adjusted for normal life expectancy and are based on cases diagnosed in the Surveillance, Epidemiology, and End Results (SEER) 9 areas from 1975 to 1977, 1987 to 1989, and 2005 to 2011, all followed through 2012.

  2. b

    The difference in rates between 1975 to 1977 and 2005 to 2011 is statistically significant (P < .05).

  3. c

    The standard error of the survival rate is between 5 and 10 percentage points.

  4. d

    Survival rate is for 1978 to 1980.

All sites495569b505770b394362b
Brain & other nervous system222935b222833b253240b
Breast (female)758491b768592b627181b
Colorectum506066b506067b455259b
Esophagus51020b61121b4714b
Hodgkin lymphoma727988b728089b707286b
Kidney & renal pelvis505774b505774b495574b
Larynx666663b676765585651
Leukemia344362b354463b333555b
Liver & intrahepatic bile duct3518b3618b2313b
Lung & bronchus121318b121319b111116b
Melanoma of the skin828893b828893b57c79c70
Myeloma252749b242748b303050b
Non-Hodgkin lymphoma475172b475173b494664b
Oral cavity & pharynx535466b545668b363445b
Ovary363846b353846b423438
Pancreas348b338b267b
Prostate688399b6984>99b617198b
Stomach152030b141829b161928b
Testis839597b839597b73cd88c91
Thyroid929498b929499b909297b
Urinary bladder727979b738079b506367b
Uterine cervix697069707371655760b
Uterine corpus878283b888485b605766b

In contrast to the steady increase in survival for most cancers, advances have been slow for lung and pancreatic cancers, for which the 5-year relative survival is currently 18% and 8%, respectively (Table 6). These low rates are partly because more than one-half of cases are diagnosed at a distant stage (Fig. 5), for which 5-year survival is 4% and 2%, respectively (Fig. 6). There is promise for improving lung cancer survival rates because of earlier detection through screening with spiral computed tomography.[46] However, it is important to realize that screening, as well as other changes in detection practices, introduces lead time bias in survival rates, thereby reducing their usefulness in measuring progress against cancer.[47] For example, the jump in 5-year relative survival rates for prostate cancer from 83% in the late 1980s to 93% in the early 1990s to 99% since 2000 predominantly reflects lead time and overdetection. Thus, advances against cancer are best measured using age-standardized death rates.[48]

image

Figure 5. Stage Distribution of Selected Cancers by Race, United States, 2005 to 2011.

Stage categories do not sum to 100% because sufficient information is not available to stage all cases.

*The proportion of cases of carcinoma in situ of the urinary bladder is 51% in all races combined, 52% in whites, and 40% in blacks.

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image

Figure 6. Five-Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis, United States, 2005 to 2011.

*The standard error of the survival rate is between 5 and 10 percentage points.

The survival rate for carcinoma in situ of the urinary bladder is 96% in all races combined, 96% in whites, and 90% in blacks.

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Trends in Cancer Mortality

The overall cancer death rate rose during most of the 20th century, largely driven by rapid increases in lung cancer deaths among men as a consequence of the tobacco epidemic. Steady reductions in smoking, as well as advances in cancer prevention, early detection, and treatment, have resulted in a 23% drop in the cancer death rate, from a peak of 215.1 (per 100,000 population) in 1991 to 166.4 in 2012. The decline, which is larger in men (28% since 1990) than in women (19% since 1991), translates into the avoidance of approximately 1,711,300 cancer deaths (1,199,200 in men and 512,100 in women) that would have occurred if peak rates had persisted (Fig. 7).

image

Figure 7. Total Number of Cancer Deaths Averted From 1991 to 2012 in Men and From 1992 to 2012 in Women.

The blue line represents the actual number of cancer deaths recorded in each year, and the red line represents the number of cancer deaths that would have been expected if cancer death rates had remained at their peak.

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Figure 8 depicts trends in cancer death rates since 1930 among men and women overall and for selected cancer sites by sex. In contrast to male cancer death rates, which rose continuously prior to 1990, female cancer death rates fell from the late 1940s to the mid-1970s (Fig. 8A). It is interesting to note that prior to 1941, death rates were higher in women than in men due to the high death rate for uterine cancer (uterine corpus and uterine cervix combined), which was the leading cause of cancer death among women in the early 20th century. Uterine cancer death rates declined by more than 80% between 1930 and 2012 (Fig. 8C), largely due to the widespread uptake of the Papanicolaou test for the prevention and early detection of cervical cancer. However, in contrast to continuing declines for cancers of the uterine cervix, death rates for uterine corpus cancer began to increase around 2000 in the wake of rising incidence rates (Fig. 8C, inset) (Table 5).[8]

image

Figure 8. Trends in Death Rates Overall and for Selected Sites by Sex, United States, 1930 to 2012.

Rates are age adjusted to the 2000 US standard population. Due to changes in International Classification of Diseases (ICD) coding, numerator information has changed over time. Rates for cancers of the lung and bronchus, colorectum, liver, and uterus are affected by these changes.

*Mortality rates for liver, pancreatic, and uterine corpus cancers are increasing.

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A similarly dramatic decline occurred for stomach cancer, which accounted for 30% and 20% of male and female cancer deaths, respectively, in the 1930s, but only about 2% for each in 2012. Although reasons for the decrease in stomach cancer occurrence in the United States and most other parts of the world are complex and not completely understood, contributors are thought to include a lower prevalence of Helicobacter pylori infection because of improved hygiene and lower salt intake and a higher consumption of fresh fruits and vegetables because of advances in food preservation techniques (eg, refrigeration).[49] However, studies indicate that incidence rates for certain subtypes of stomach cancer are increasing for some subsets of the US population for reasons that remain unknown.[50, 51]

The decline in cancer death rates over the past 2 decades is driven by continued decreases in death rates for the 4 major cancer sites (lung, breast, prostate, and colorectum). Death rates for female breast cancer are down 36% from peak rates, and those for prostate and colorectal cancers are each down about 50% as a result of improvements in early detection and treatment.[8, 33, 52, 53] Lung cancer death rates declined 38% between 1990 and 2012 among males and 13% between 2002 and 2012 among females[8] due to reduced tobacco use as a result of increased awareness of the health hazards of smoking and the implementation of comprehensive tobacco control.[54] Researchers recently estimated that tobacco control efforts adopted in the wake of the first Surgeon General's report on smoking and health in 1964 have resulted in 8 million fewer premature smoking-related deaths, one-third of which are due to cancer.[55, 56] Despite this progress, 80% of deaths from lung cancer and one-half of all deaths from cancers of the oral cavity, esophagus, and urinary bladder are caused by smoking.[57]

In contrast to declining trends for the major cancers, joinpoint analysis indicates that from 2003 to 2012, death rates rose in both sexes for cancers of the anus, liver, and pancreas.[8] Death rates also increased in men for melanoma (slightly) and for cancers of the tonsil, oropharynx, and soft tissue (including the heart) and in women for uterine and vulvar cancers. Thyroid cancer death rates also increased slightly in men, from 0.43 (per 100,000 population) in 2003 to 0.51 in 2012.

Recorded Number of Deaths in 2012

A total of 2,543,279 deaths were recorded in the United States in 2012, of which 582,623 (23%) were from cancer. Overall, cancer is the second leading cause of death following heart disease, which accounted for 24% of total deaths. However, cancer is the leading cause of death among adults aged 40 to 79 years (Table 7). It is also the leading cause of death in 21 states (Alaska, Arizona, Colorado, Delaware, Florida, Georgia, Idaho, Kansas, Maine, Massachusetts, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, Oregon, South Carolina, Vermont, Virginia, and Washington), primarily due to exceptional gains made in the progress against heart disease. In Minnesota, for example, the death rate for heart disease is 30% below the national average (118 vs 170 per 100,000 population) compared with a 6% lower death rate for cancer. In addition, cancer is the leading cause of death among both Hispanics and Asian/Pacific Islanders (APIs), who combined comprise one-quarter of the US population.[58]

Table 7. Ten Leading Causes of Death by Age and Sex, United States, 2012
 ALL AGESAGES 1 TO 19AGES 20 TO 39AGES 40 TO 59AGES 60 TO 79AGES ≥80
 MALEAll Causes 1,273,722FEMALE All Causes 1,269,557MALE All Causes 12,655FEMALE All Causes 6,837MALE All Causes 62,383FEMALE All Causes 28,688MALE All Causes 226,518FEMALE All Causes 143,713MALE All Causes 496,567FEMALE All Causes 388,343MALE All Causes 462,360FEMALE All Causes 691,439
  1. HIV indicates human immunodeficiency virus.

  2. a

    Includes primary and secondary hypertension.

  3. Note: Deaths within each age group do not sum to all ages combined due to the inclusion of unknown ages. In accordance with the National Center for Health Statistics' cause-of-death ranking, “Symptoms, signs, and abnormal clinical or laboratory findings” and categories that begin with “Other” and “All other” were not ranked.

  4. Source: US Final Mortality Data, 2012, National Center for Health Statistics, Centers for Disease Control and Prevention, 2015.

1Heart diseases 312,491Heart diseases 287,220Accidents (unintentional injuries) 4,602Accidents (unintentional injuries) 2,296Accidents (unintentional injuries) 22,740Accidents (unintentional injuries) 8,105Cancer 54,140Cancer 50,462Cancer 161,254Cancer 132,104Heart diseases 133,654Heart diseases 189,726
2Cancer 305,670Cancer 276,953Assault (homicide) 1,781Cancer 822Intentional self-harm (suicide) 9,935Cancer 4,407Heart diseases 51,906Heart diseases 21,666Heart diseases 121,201Heart diseases 73,030Cancer 85,193Cancer 89,122
3Accidents (unintentional injuries) 80,010Cerebro- vascular diseases 75,908Intentional self-harm (suicide) 1,598Intentional self-harm (suicide) 495Assault (homicide) 7,408Intentional self-harm (suicide) 2,481Accidents (unintentional injuries) 25,157Accidents (unintentional injuries) 12,226Chronic lower respiratory diseases 32,909Chronic lower respiratory diseases 32,460Chronic lower respiratory diseases 28,926Cerebro- vascular disease 51,133
4Chronic lower respiratory diseases 67,673Chronic lower respiratory diseases 75,816Cancer 1,110Assault (homicide) 483Heart diseases 5,127Heart diseases 2,397Intentional self-harm (suicide) 12,475Chronic lower respiratory diseases 5,591Cerebro- vascular disease 19,987Cerebro- vascular disease 19,040Cerebro- vascular disease 25,241Alzheimer disease 50,416
5Cerebro- vascular diseases 52,638Alzheimer disease 57,984Congenital anomalies 562Congenital anomalies 467Cancer 3,930Assault (homicide) 1,376Chronic liver disease & cirrhosis 11,390Chronic liver disease & cirrhosis 5,240Diabetes mellitus 18,530Diabetes mellitus 14,433Alzheimer disease 20,408Chronic lower respiratory diseases 37,399
6Diabetes mellitus 38,584Accidents (unintentional injuries) 47,782Heart diseases 380Heart diseases 251Chronic liver disease & cirrhosis 890Pregnancy, childbirth & puerperium 692Diabetes mellitus 7,673Cerebro-vascular diseases 5,056Accidents (unintentional injuries) 14,689Accidents (unintentional injuries) 8,611Influenza & pneumonia 13,682Influenza & pneumonia 18,360
7Intentional self-harm (suicide) 31,780Diabetes mellitus 35,348Chronic lower respiratory diseases 132Influenza & pneumonia 104Diabetes mellitus 843Diabetes mellitus 616Cerebro- vascular disease 6,539Diabetes mellitus 4,657Chronic liver disease & cirrhosis 8,964Nephritis, nephrotic syndrome & nephrosis 7,591Accidents (unintentional injuries) 12,136Accidents (unintentional injuries) 16,048
8Alzheimer disease 25,653Influenza & pneumonia 26,623Influenza & pneumonia 121Cerebro- vascular disease 92HIV disease 833Cerebro- vascular disease 536Chronic lower respiratory diseases 5,357Intentional self-harm (suicide) 4,120Nephritis, nephrotic syndrome & nephrosis 8,803Alzheimer disease 7,375Diabetes mellitus 11,495Diabetes mellitus 15,599
9Influenza & pneumonia 24,013Nephritis, nephrotic syndrome & nephrosis 22,891Cerebro- vascular disease 112Chronic lower respiratory diseases 92Cerebro- vascular disease 704Chronic liver disease & cirrhosis 491HIV disease 3,283Septicemia 2,300Influenza & pneumonia 7,459Septicemia 7,070Nephritis, nephrotic syndrome & nephrosis 10,992Nephritis, nephrotic syndrome & nephrosis 13,140
10Nephritis, nephrotic syndrome & nephrosis 22,731Septicemia 19,053In situ, benign, and unknown neoplasms 84In situ, benign, and unknown neoplasms 88Congenital anomalies 477HIV disease 444Viral hepatitis 3,181Nephritis, nephrotic syndrome & nephrosis 1,860Septicemia 7,262Influenza & pneumonia 6,042Parkinson disease 9,242Hypertension & hypertensive renal diseasea 12,121

Table 8 presents the number of deaths from all cancers combined and from the 5 most common sites for each 20-year age group by sex. More cancer deaths occur in men than in women except for those aged 20 to 39 years and 80 years or older. Breast cancer is the leading cause of cancer death in women aged 20 to 59 years, but is replaced by lung cancer in women aged 60 years or older. Among men, lung cancer is the leading cause of cancer death for those aged 40 years or older.

Table 8. Five Leading Types of Cancer Death by Age and Sex, United States, 2012
ALL AGES<2020 TO 3940 TO 5960 TO 79≥80
  MALE 
  1. NHL indicates non-Hodgkin lymphoma; ONS, other nervous system.

  2. a

    Liver includes intrahepatic bile duct.

  3. Note: Ranking order excludes category titles that begin with the word “Other.”

ALL SITES 305,670ALL SITES 1,144ALL SITES 3,930ALL SITES 54,140ALL SITES161,254ALL SITES 85,193
Lung & bronchusBrain & ONSBrain & ONSLung & bronchusLung & bronchusLung & bronchus
86,69032354314,08751,81620,526
ProstateLeukemiaLeukemiaColorectumColorectumProstate
27,2453105045,71413,34414,216
ColorectumBones & jointsColorectumLiver*ProstateColorectum
26,8701054584,75511,6667,340
PancreasSoft tissue (including heart)Lung & bronchusPancreasPancreasUrinary bladder
19,7181032543,82511,1254,955
Liver*NHLNHLEsophagusLiver*Pancreas
15,563332532,8098,2544,679
  FEMALE  
ALL SITES 276,953ALL SITES 851ALL SITES 4,407ALL SITES 50,462ALL SITES 132,104ALL SITES 89,122
Lung & bronchusBrain & ONSBreastBreastLung & bronchusLung & bronchus
70,73625298411,35639,91819,481
BreastLeukemiaUterine cervixLung & bronchusBreastBreast
41,15222444611,13417,76011,050
ColorectumSoft tissue (including heart)ColorectumColorectumColorectumColorectum
24,651743674,2069,90510,170
PancreasBones & jointsLeukemiaOvaryPancreasPancreas
19,079733453,0189,4077,031
OvaryNHLBrain & ONSPancreasOvaryNHL
14,404273362,5717,3844,170

Among children and adolescents (aged birth to 19 years), brain cancer has surpassed leukemia as the leading cause of cancer death (Table 8). Although treatment options have improved for both cancers based on collaborative efforts and outcomes from randomized clinical trials,[59] therapeutic advances for leukemia have been particularly dramatic. From 1970 to 2012, the death rate in this age group declined by 76% for leukemia compared with 31% for tumors of the brain and other nervous system (Fig. 9A). This progress has occurred despite a slow increase in the incidence of both cancer types over this time period (in the 9 oldest SEER areas) (Fig. 9C). Since the mid-1970s, the 5-year relative survival rate has increased from 50% to 87% for leukemia and from 57% to 74% for brain and other nervous system tumors.[8]

image

Figure 9. Trends in Leukemia and Brain Tumor Occurrence Among Children and Adolescents (Aged Birth to 19 Years), 1970 to 2012.

Rates are age adjusted to the 2000 US standard population. Incidence rates are adjusted for delays in reporting. Underlying mortality data provided by the National Center for Health Statistics (cdc.gov/nchs).

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Cancer Occurrence by Race/Ethnicity

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Cancer incidence and death rates vary considerably between and within racial and ethnic groups. For example, among men in the 5 broadly defined population groups in Table 9, black men have the highest overall cancer incidence and death rates-about double those of API men, who have the lowest rates. Rates are higher among black than non-Hispanic white men for every site included in Table 9 with the exception of kidney cancer mortality, for which rates are similar. The largest disparities are for stomach and prostate cancers, for which death rates in black men are about 2.5 times those in white men.

Table 9. Incidence and Death Rates by Site, Race, and Ethnicity, United States, 2008 to 2012
 NON-HISPANIC WHITENON-HISPANIC BLACKASIAN/PACIFIC ISLANDERAMERICAN INDIAN/ ALASKA NATIVEaHISPANIC
  1. Rates are per 100,000 population and age adjusted to the 2000 US standard population. Nonwhite and nonblack race categories are not mutually exclusive of Hispanic origin.

  2. a

    Data based on Indian Health Service Contract Health Service Delivery Areas (CHSDA) counties. Incidence rates exclude data from Kansas.

Incidence
All sites     
Male528.9592.3316.8423.3408.5
Female436.2408.1287.5372.9330.4
Breast (female)128.1124.388.391.991.9
Colorectum     
Male47.460.339.050.444.6
Female36.244.129.240.130.6
Kidney & renal pelvis     
Male21.824.210.829.720.6
Female11.313.04.918.311.8
Liver & intrahepatic bile duct     
Male9.316.520.618.719.3
Female3.24.87.98.97.2
Lung & bronchus     
Male79.393.447.466.243.3
Female58.751.428.352.726.0
Prostate123.0208.767.890.5112.1
Stomach     
Male7.815.114.512.013.5
Female3.58.08.56.67.8
Uterine cervix7.110.06.39.410.2
      
Mortality
All sites     
Male210.6267.7128.4186.7148.0
Female149.2170.491.2133.999.4
Breast (female)21.931.011.415.014.5
Colorectum     
Male18.227.613.018.815.6
Female12.918.29.415.69.6
Kidney & renal pelvis     
Male5.95.72.98.75.0
Female2.62.61.24.72.4
Liver & intrahepatic bile duct     
Male7.612.814.513.912.9
Female3.14.46.16.35.6
Lung & bronchus     
Male62.274.934.049.129.5
Female41.436.718.232.113.7
Prostate19.947.29.420.217.8
Stomach     
Male3.69.47.97.47.2
Female1.84.54.73.64.2
Uterine cervix2.04.11.83.52.7

Factors known to contribute to racial disparities vary by cancer site and include differences in risk factor prevalence and access to high-quality health care, including cancer prevention and early detection, timely diagnosis, and optimal treatment.[60, 61] Even among Medicare-insured patients, blacks are less likely than whites to receive standard-cancer therapies for lung, breast, colorectal, and prostate cancers.[62] A major source of these inequalities is the disproportionately high burden of poverty in the black community. According to the US Census Bureau, 26% of blacks lived in poverty and 12% were without health insurance in 2014, compared with 10% and 8%, respectively, of non-Hispanic whites.

Higher mortality rates among blacks compared with whites partly reflect a later stage of disease at diagnosis. This disparity is particularly striking for cancers of the uterine corpus, oral cavity, female breast, and cervix (Fig. 5). Moreover, black patients have lower stage-specific survival for most cancer types (Fig. 6). As a result, although black women have a lower breast cancer incidence rate than white women, they have a higher breast cancer death rate (Table 9). The historically higher incidence rate among white women is thought to reflect a combination of factors that affect both diagnosis (more prevalent mammography) and underlying disease occurrence (such as later age at first birth and greater use of menopausal hormone therapy).[63] However, a recent study reported that breast cancer incidence rates in white and black women are converging because of a stable trend in whites but an increasing trend in blacks.[64] The higher risk of death from breast cancer among black women is thought to reflect a higher prevalence of comorbidities, a longer time to follow-up after an abnormal mammogram, less receipt of high-quality treatment, higher body mass index, and a higher prevalence of aggressive tumor characteristics.[65-68] However, an analysis of clinical trial data showed that black women were less likely than white women to survive their breast cancer despite uniform treatment, even after controlling for stage of disease, tumor characteristics, follow-up, and socioeconomic status.[69]

Cancer incidence and death rates are lower among APIs, American Indians/Alaska Natives (AI/ANs), and Hispanics than non-Hispanic whites for all cancer sites combined and for the 4 most common cancer sites. However, cancers associated with infectious agents (eg, those of the uterine cervix, stomach, and liver) are generally more common in nonwhite populations. For example, stomach and liver cancer incidence and death rates are twice as high in the API population as in whites, reflecting a higher prevalence of chronic infection with Helicobacter pylori and hepatitis B virus, respectively, in immigrant countries of origin.[70] Kidney cancer incidence and death rates are highest among AI/ANs, which may be due in part to high rates of obesity, smoking, and hypertension in this population. Regional variation in the prevalence of these risk factors likely contributes to the striking geographic differences in kidney cancer death rates among AI/AN men, which are highest in the Southern and Northern Plains and lowest in the East and Pacific Coast.[71]

Regional Variations in Cancer Rates

Tables 10 and 11 depict current cancer incidence and death rates for selected cancers by state. Geographic patterns in cancer occurrence reflect differences in risk factors, such as smoking and obesity, as well as disparities in the national distribution of poverty and access to health care, which have increased over time.[72, 73] The largest geographic variation in cancer occurrence by far is for lung cancer, reflecting the large historical and continuing differences in smoking prevalence among states.[54] For example, lung cancer incidence rates in Kentucky, which has historically had the highest smoking prevalence, are 3.5 times higher than those in Utah, which has the lowest smoking prevalence. There is a 2-fold difference for prostate cancer incidence rates, which range from 89.8 (per 100,000 population) in Arizona to 184.1 in the District of Columbia, likely reflecting both state differences in PSA testing prevalence and population demographics.[24] In contrast, state variations for other cancer types are smaller in both absolute and relative terms. For example, breast cancer incidence rates range from 107.7 (per 100,000 population) in Arkansas to 141.7 in the District of Columbia, a relative difference of just 24%. Some of this variation is attributable to differences in mammography prevalence.[74]

Table 10. Incidence Rates for Selected Cancers by State, United States, 2008 to 2012
 ALL CANCERSBREASTCOLORECTUMLUNG & BRONCHUSNON-HODGKIN LYMPHOMAPROSTATEURINARY BLADDER
STATEMALEFEMALEFEMALEMALEFEMALEMALEFEMALEMALEFEMALEMALEMALEFEMALE
  1. Rates are per 100,000 and age adjusted to the 2000 US standard population.

  2. a

    This state's data are not included in the US combined rates because it did not meet high-quality standards for one or more years during 2008 to 2012 according to the North American Association of Central Cancer Registries (NAACCR).

  3. b

    Rates are based on incidence data for 2008 to 2009.

  4. c

    This state's registry did not submit cancer incidence data to the NAACCR.

  5. d

    Rates are based on incidence data for 2008 to 2010.

Alabama560.8398.0119.554.238.299.254.219.613.7146.133.67.5
Alaska479.3419.2125.550.540.674.459.920.514.7111.836.510.8
Arizona420.4373.9111.040.530.959.247.018.313.389.831.98.3
Arkansasab550.2383.7107.754.339.4103.659.921.515.5148.132.97.7
California485.6394.8122.146.035.155.842.122.815.5126.932.67.8
Colorado473.7396.5125.240.031.652.843.322.115.5133.232.58.3
Connecticut554.4456.9137.148.236.572.657.625.417.7139.947.312.6
Delaware578.7446.3126.545.634.983.763.323.417.0156.342.311.2
Dist. of Columbia564.1436.0141.748.640.974.548.721.512.8184.125.68.9
Florida502.1400.2115.245.034.275.855.521.714.9118.934.98.4
Georgia554.5409.0123.549.636.789.054.122.314.6150.134.08.0
Hawaii466.5403.9130.255.137.259.538.421.814.7105.024.16.1
Idaho510.4410.9118.942.833.859.147.422.116.7142.739.28.9
Illinois546.2439.8127.755.240.382.859.923.516.5138.938.69.7
Indiana513.0425.1119.051.040.293.261.923.516.5108.936.48.9
Iowa545.6439.4123.054.241.181.753.627.418.6126.240.48.8
Kansas541.9427.3123.250.537.875.553.423.416.7143.139.19.1
Kentucky598.2466.6121.360.544.1120.480.725.417.3122.640.89.8
Louisiana595.5417.9121.959.642.795.256.024.616.7161.133.78.1
Maine546.3452.8124.446.536.785.866.924.617.7120.247.812.5
Maryland512.0419.5129.944.334.670.053.921.014.9141.134.59.1
Massachusetts539.2458.6136.545.736.075.462.924.016.4135.642.211.8
Michigan544.8428.6121.446.835.981.459.924.517.1147.340.310.4
Minnesotac------------
Mississippi577.5406.0116.859.443.4106.456.921.414.6149.730.97.5
Missouri511.4427.0124.751.738.792.164.422.215.6113.633.58.6
Montana508.4424.5124.246.636.366.052.822.315.9133.537.810.4
Nebraska501.8417.2122.752.041.170.750.023.417.7125.734.88.2
Nevadaad502.2401.8114.050.536.371.460.320.314.8136.038.810.7
New Hampshire558.1458.4135.143.136.375.763.825.817.8140.750.212.9
New Jersey564.7450.5130.251.039.469.353.725.417.9157.342.111.3
New Mexico431.2367.2112.141.231.349.737.418.013.8110.426.16.0
New York568.6451.2128.649.638.173.955.326.418.1153.741.810.6
North Carolina546.6417.9127.146.334.392.356.122.215.2138.736.78.9
North Dakota517.1411.5122.254.740.568.345.422.818.5141.437.38.5
Ohio522.1421.7120.550.337.387.559.822.815.6127.138.59.4
Oklahoma520.1411.8119.250.338.890.160.221.915.4128.833.68.1
Oregon489.5427.9128.443.334.066.956.622.515.6122.837.49.5
Pennsylvania559.2458.3128.152.639.781.356.826.117.9133.644.210.9
Rhode Island544.3456.4129.944.836.279.964.024.117.7130.646.813.7
South Carolina538.7408.6125.346.835.990.654.020.013.5138.133.18.6
South Dakota495.0416.7125.953.240.068.649.223.716.7129.334.49.3
Tennessee552.7420.1120.650.337.798.961.722.215.8135.535.58.1
Texas488.5384.4113.148.433.573.046.721.815.4115.728.26.6
Utah480.6368.0113.836.729.434.723.723.915.4156.830.75.8
Vermont514.7439.8128.043.434.775.462.524.717.2121.639.911.0
Virginia485.4397.6124.643.034.377.953.020.914.3126.332.08.3
Washington524.1444.3135.043.035.069.255.925.617.3133.937.99.5
West Virginia541.2436.7111.255.341.3102.867.422.316.2114.139.510.9
Wisconsin524.4430.7125.646.135.771.854.424.917.5129.640.19.8
Wyoming472.4387.6111.244.833.355.745.818.813.8127.137.111.8
United States522.6419.0123.148.336.676.754.123.116.0131.536.49.0
Table 11. Death Rates for Selected Cancers by State, United States, 2008 to 2012
 ALL SITESBREASTCOLORECTUMLUNG & BRONCHUSNON-HODGKIN LYMPHOMAPANCREASPROSTATE
STATEMALEFEMALEFEMALEMALEFEMALEMALEFEMALEMALEFEMALEMALEFEMALEMALE
  1. Rates are per 100,000 and age adjusted to the 2000 US standard population.

Alabama246.8152.422.621.214.182.640.17.95.113.39.926.4
Alaska211.4151.521.018.013.761.244.87.85.013.79.221.9
Arizona180.0128.119.715.911.346.631.97.24.611.58.919.4
Arkansas246.5156.622.322.715.388.044.28.25.513.29.422.7
California183.4135.321.216.812.243.730.57.44.611.89.321.1
Colorado173.8129.419.715.311.840.829.77.04.310.89.022.6
Connecticut192.2138.420.314.811.049.735.87.14.513.210.220.2
Delaware218.1156.322.117.512.266.445.26.94.813.69.522.6
Dist. of Columbia227.1161.629.018.716.654.633.97.13.715.712.234.9
Florida197.1136.921.017.212.158.137.37.54.512.19.018.7
Georgia218.2143.522.919.513.168.037.27.34.212.29.024.6
Hawaii171.7114.815.116.810.744.425.07.44.512.910.214.8
Idaho189.3134.920.716.011.845.933.68.04.912.38.924.7
Illinois215.9154.423.020.314.062.440.78.25.013.010.022.4
Indiana232.4157.822.720.314.075.344.78.65.312.89.522.0
Iowa209.1145.320.719.814.361.437.58.85.212.49.220.7
Kansas206.1144.721.318.712.861.739.18.74.812.79.719.2
Kentucky253.6170.022.621.815.292.255.28.85.712.89.421.5
Louisiana247.4161.025.022.715.177.442.88.65.014.911.424.2
Maine223.8154.619.418.412.866.544.18.85.312.010.621.1
Maryland207.4148.023.718.912.857.138.67.34.313.410.222.5
Massachusetts205.5147.120.317.112.256.240.37.44.512.610.220.5
Michigan215.9155.023.118.613.264.742.89.25.413.410.120.3
Minnesota197.0141.120.016.511.849.735.69.45.412.09.022.5
Mississippi260.4158.524.523.916.588.541.47.84.414.410.628.4
Missouri222.7156.823.420.513.972.845.27.85.012.79.819.9
Montana188.5138.620.316.112.549.737.28.04.311.28.223.4
Nebraska200.9140.819.819.814.655.535.57.95.012.09.422.0
Nevada201.9149.023.321.013.855.944.16.84.312.59.221.5
New Hampshire208.3147.620.416.213.057.742.17.24.313.69.420.8
New Jersey199.0147.423.919.613.852.035.37.44.713.310.320.3
New Mexico181.0128.120.418.012.240.927.26.04.311.18.021.9
New York193.8141.721.517.913.051.935.17.64.713.010.020.6
North Carolina222.2145.022.218.012.372.039.17.54.711.99.223.5
North Dakota198.1130.219.819.613.153.331.86.34.613.37.822.6
Ohio228.2158.523.820.914.170.943.89.05.313.410.122.0
Oklahoma233.6159.623.221.714.475.745.38.95.312.49.622.4
Oregon203.6149.820.917.312.855.241.28.35.012.39.723.2
Pennsylvania218.5153.323.220.214.162.438.78.75.213.310.121.1
Rhode Island216.1143.319.817.613.162.541.67.74.212.78.420.8
South Carolina232.7148.823.219.613.472.738.97.64.513.010.125.5
South Dakota196.9142.820.718.513.258.235.07.55.010.89.620.8
Tennessee245.9156.722.621.314.883.645.18.75.012.99.622.6
Texas201.8137.721.018.912.556.433.77.74.611.88.919.6
Utah153.0108.620.813.210.226.415.67.24.610.98.123.3
Vermont206.2149.918.716.213.357.243.88.24.613.410.222.4
Virginia211.5145.822.817.912.962.538.27.94.612.59.522.7
Washington201.8146.420.316.412.253.939.78.35.112.710.222.2
West Virginia242.5165.222.522.915.080.549.38.45.812.08.620.1
Wisconsin208.9146.821.017.412.356.338.18.65.213.110.123.1
Wyoming187.0140.319.518.312.246.533.76.34.810.98.320.3
United States207.9145.421.918.613.159.837.87.94.812.69.621.4

Cancer in Children

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Cancer is the second most common cause of death among children aged 1 to 14 years in the United States, surpassed only by accidents. In 2016, an estimated 10,380 children (birth to 14 years) will be diagnosed with cancer (excluding benign/borderline brain tumors) and 1,250 will die from the disease. Benign and borderline brain tumors are not included in the 2016 case estimates because the calculation method requires historical data and these tumors were not required to be reported until 2004.

Leukemia (76% of which are lymphoid leukemias) accounts for 30% of all childhood cancers (including benign brain tumors). Cancers of the brain and other nervous system are the second most common cancer type (26%), followed by soft tissue sarcomas (7%, almost one-half of which are rhabdomyosarcoma), neuroblastoma (6%), non-Hodgkin lymphomas, including Burkitt lymphoma (6%), renal (Wilms) tumors (5%), and Hodgkin lymphomas (3%).[8]

Cancers in adolescents (aged 15 to 19 years) differ somewhat from those in children in terms of type and distribution. For example, a smaller proportion of the cancers diagnosed in adolescents are leukemias and a larger proportion are lymphomas. Cancers of the brain and other nervous system are most common (20%), followed by leukemia (14%), Hodgkin lymphoma (13%), gonadal germ cell tumors (12%), and thyroid carcinoma (11%). Melanoma accounts for 4% of the cancers diagnosed in this age group.

Cancer incidence rates increased in children and adolescents by 0.6% per year from 1975 through 2012. In contrast, death rates have declined continuously, from 6.5 (per 100,000 population) in 1970 to 2.4 in 2012, an overall reduction of 63% (65% in children and 60% in adolescents). Table 12 provides trends in survival rates for the most common childhood cancers. The 5-year relative survival rate for all cancer sites combined improved from 58% for children diagnosed during 1975 to 1977 to 83% for those diagnosed during 2005 to 2011. The substantial progress for all of the major childhood cancers reflects both improvements in treatment and high levels of participation in clinical trials.[59]

Table 12. Trends in 5-Year Relative Survival Ratesa (%) for Children (Birth to 14 Years) by Year of Diagnosis, United States, 1975 to 2011
 1975 TO 19771978 TO 19801981 TO 19831984 TO 19861987 TO 19891990 TO 19921993 TO 19951996 TO 19981999 TO 20012002 TO 20042005 TO 2011
  1. a

    Survival rates are adjusted for normal life expectancy and are based on follow-up of patients through 2012.

  2. b

    The difference in rates between 1975 to 1977 and 2005 to 2011 is statistically significant (P < .05).

  3. c

    The standard error of the survival rate is between 5 and 10 percentage points.

All sites5862676872767779818383b
Acute lymphocytic leukemia5766717278838487899291b
Acute myeloid leukemia192627c31c37c4241c49586167b
Bones & joints50c4857c57c67c677470707877b
Brain & other nervous system5758576264647175747574b
Hodgkin lymphoma8187889087979596949898b
Neuroblastoma5357555263766766727374b
Non-Hodgkin lymphoma4353677071778183908588b
Soft tissue6174697366807771778579b
Wilms tumor7379879192929292948994b

Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

Although the numbers of cancer cases and deaths expected in 2016 provide a reasonably accurate portrayal of the contemporary cancer burden, they are model-based, 4-year-ahead projections that should be interpreted with caution and not be used to track trends over time. First, the estimates may be affected by changes in methodology, which are implemented regularly as modeling techniques improve and surveillance coverage becomes more complete. Second, although the model is robust, it can only account for trends through the most recent year of data (currently 2012) and cannot anticipate abrupt fluctuations for cancers affected by changes in detection practice, such as prostate cancer. Third, the model can be oversensitive to sudden or large changes in observed data. The most informative indicators of cancer trends are age-standardized or age-specific cancer death rates from the NCHS and cancer incidence rates from SEER, NPCR, and/or NAACCR.

Errors in reporting race/ethnicity in medical records and on death certificates may result in underestimates of cancer incidence and mortality rates in nonwhite and nonblack populations. This is particularly relevant for AI/AN populations. It is also important to note that cancer data in the United States are primarily reported for broad, heterogeneous racial and ethnic groups, masking important differences in the cancer burden within these subpopulations.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References

The continuous decline in cancer death rates over 2 decades has resulted in an overall drop of 23%, resulting in more than 1.7 million cancer deaths averted. Despite this progress, cancer is now the leading cause of death for much of the US population. Moreover, incidence and death rates are increasing for several cancer types, including liver and pancreas—2 of the most fatal cancers. Advancing the fight against cancer will require continued clinical and basic research, which is dependent on funding, as well as the application of existing cancer control knowledge across all segments of the population, with an emphasis on disadvantaged groups.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Selected Findings
  6. Cancer Occurrence by Race/Ethnicity
  7. Cancer in Children
  8. Limitations
  9. Conclusions
  10. References
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