Cancer Statistics, 2017

Authors


  • DISCLOSURES: The authors report no conflicts of interest.

Abstract

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 Surveillance, Epidemiology, and End Results Program; the 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 2017, 1,688,780 new cancer cases and 600,920 cancer deaths are projected to occur in the United States. For all sites combined, the cancer incidence rate is 20% higher in men than in women, while the cancer death rate is 40% higher. However, sex disparities vary by cancer type. For example, thyroid cancer incidence rates are 3-fold higher in women than in men (21 vs 7 per 100,000 population), despite equivalent death rates (0.5 per 100,000 population), largely reflecting sex differences in the “epidemic of diagnosis.” Over the past decade of available data, the overall cancer incidence rate (2004-2013) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2005-2014) declined by about 1.5% annually in both men and women. From 1991 to 2014, the overall cancer death rate dropped 25%, translating to approximately 2,143,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the cancer death rate was 15% higher in blacks than in whites in 2014, increasing access to care as a result of the Patient Protection and Affordable Care Act may expedite the narrowing racial gap; from 2010 to 2015, the proportion of blacks who were uninsured halved, from 21% to 11%, as it did for Hispanics (31% to 16%). Gains in coverage for traditionally underserved Americans will facilitate the broader application of existing cancer control knowledge across every segment of the population. CA Cancer J Clin 2017;67:7–30. © 2017 American Cancer Society.

Introduction

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 2017 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 population-based data. The most current cancer data are available through 2013 for incidence and through 2014 for mortality. We also estimate the total number of deaths averted as a result of the continual decline in cancer death rates since the early 1990s. In addition, we present the actual number of deaths reported in 2014 by age for the 10 leading causes of death and for the 5 leading causes of cancer death.

Materials and Methods

Incidence and Mortality Data

Mortality data from 1930 to 2014 were provided by the National Center for Health Statistics (NCHS).[1-3] 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.[3, 4]

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 (CDC'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 (1975-2013) 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.[5, 6] The lifetime probability of developing cancer, stage distribution, and survival by stage and for children and adolescents were based on data from all 18 SEER registries (the SEER 9 registries plus Alaska Natives, California, Georgia, Kentucky, Louisiana, and New Jersey), covering 28% of the US population.[7] The probability of developing cancer was calculated using NCI's DevCan software (version 6.7.4).[8] Some of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975-2013.[9]

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 2017 and incidence rates by state and race/ethnicity.[10, 11] Some of the incidence data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2009-2013.[12, 13]

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).[14, 15] Causes of death were classified according to the International Classification of Diseases.[16] 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 8.3.2).[17] The annual percent change in rates was quantified using NCI's Joinpoint Regression Program (version 4.3.1.0).[18]

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.[19] For example, the leukemia incidence rate for 2013 is 14% higher after adjusting for reporting delays.[20]

Projected Cancer Cases and Deaths in 2017

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 2017 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 95% 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 (or health service area for rare cancers) from 1999 through 2013 using geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence.[21] Then these counts were adjusted for delays in cancer reporting using registry-specific or combined NAACCR delay ratios and aggregated to obtain national- and state-level counts for each year. Finally, a temporal projection method (the vector autoregressive model) was applied to all 15 years of data to estimate counts for 2017. 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.[22]

New cases of female breast carcinoma in situ and melanoma in situ diagnosed in 2017 were estimated by first approximating the number of cases occurring annually from 2004 through 2013 based on age-specific NAACCR incidence rates (data from 46 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 2004 through 2013 generated by the joinpoint regression model was then used to project cases to 2017. The estimates for in situ cases were not adjusted for reporting delays.

The number of cancer deaths expected to occur in 2017 was estimated based on the most recent joinpoint-generated annual percent change in reported numbers of cancer deaths from 2000 through 2014 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al.[23]

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 2014. The difference between the number of expected and recorded cancer deaths in each age group and calendar year was then summed.

Selected Findings

Expected Numbers of New Cancer Cases

Table 1 presents the estimated numbers of new cases of invasive cancer expected in the United States in 2017 by sex. The overall estimate of 1,688,780 cases is the equivalent of more than 4,600 new cancer diagnoses each day. In addition, about 63,410 cases of female breast carcinoma in situ and 74,680 cases of melanoma in situ are expected to be diagnosed in 2017. 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, 2017a
 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 63,410 cases of carcinoma in situ of the female breast and 74,680 cases of melanoma in situ will be newly diagnosed in 2017.

  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 Sites1,688,780836,150852,630600,920318,420282,500
Oral cavity & pharynx49,67035,72013,9509,7007,0002,700
Tongue16,40011,8804,5202,4001,670730
Mouth13,2107,8005,4102,5801,680900
Pharynx17,00013,7803,2203,0502,340710
Other oral cavity3,0602,2608001,6701,310360
Digestive system310,440175,650134,790157,70092,35065,350
Esophagus16,94013,3603,58015,69012,7202,970
Stomach28,00017,75010,25010,9606,7204,240
Small intestine10,1905,3804,8101,390770620
Colonb95,52047,70047,82050,26027,15023,110
Rectum39,91023,72016,190   
Anus, anal canal, & anorectum8,2002,9505,2501,100450650
Liver & intrahepatic bile duct40,71029,20011,51028,92019,6109,310
Gallbladder & other biliary11,7405,3206,4203,8301,6302,200
Pancreas53,67027,97025,70043,09022,30020,790
Other digestive organs5,5602,3003,2602,4601,0001,460
Respiratory system243,170133,050110,120160,42088,10072,320
Larynx13,36010,5702,7903,6602,940720
Lung & bronchus222,500116,990105,510155,87084,59071,280
Other respiratory organs7,3105,4901,820890570320
Bones & joints3,2601,8201,4401,550890660
Soft tissue (including heart)12,3906,8905,5004,9902,6702,320
Skin (excluding basal & squamous)95,36057,14038,22013,5909,2504,340
Melanoma of the skin87,11052,17034,9409,7306,3803,350
Other nonepithelial skin8,2504,9703,2803,8602,870990
Breast255,1802,470252,71041,07046040,610
Genital system279,800172,330107,47059,10027,50031,600
Uterine cervix12,820 12,8204,210 4,210
Uterine corpus61,380 61,38010,920 10,920
Ovary22,440 22,44014,080 14,080
Vulva6,020 6,0201,150 1,150
Vagina & other genital, female4,810 4,8101,240 1,240
Prostate161,360161,360 26,73026,730 
Testis8,8508,850 410410 
Penis & other genital, male2,1202,120 360360 
Urinary system146,650103,48043,17032,19022,2609,930
Urinary bladder79,03060,49018,54016,87012,2404,630
Kidney & renal pelvis63,99040,61023,38014,4009,4704,930
Ureter & other urinary organs3,6302,3801,250920550370
Eye & orbit3,1301,8001,330330180150
Brain & other nervous system23,80013,45010,35016,7009,6207,080
Endocrine system59,25015,61043,6403,0101,4401,570
Thyroid56,87014,40042,4702,0109201,090
Other endocrine2,3801,2101,1701,000520480
Lymphoma80,50044,73035,77021,21012,0809,130
Hodgkin lymphoma8,2604,6503,6101,070630440
Non-Hodgkin lymphoma72,24040,08032,16020,14011,4508,690
Myeloma30,28017,49012,79012,5906,6605,930
Leukemia62,13036,29025,84024,50014,30010,200
Acute lymphocytic leukemia5,9703,3502,6201,440800640
Chronic lymphocytic leukemia20,11012,3107,8004,6602,8801,780
Acute myeloid leukemia21,38011,9609,42010,5906,1104,480
Chronic myeloid leukemia8,9505,2303,7201,080610470
Other leukemiac5,7203,4402,2806,7303,9002,830
Other & unspecified primary sitesc33,77018,23015,54042,27023,66018,610
Table 2. Estimated New Cases for Selected Cancers by State, 2017a
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.

Alabama26,1603,9602102,2107207703,8801,3209602,4101,090
Alaska3,600500b280120100450130140320150
Arizona35,8104,8702402,6301,1101,1703,9402,0501,4102,9901,670
Arkansas16,0402,1001501,3904805802,6206106601,440710
California176,14027,9801,49013,8906,2806,74018,2709,1807,88014,5207,500
Colorado24,3303,8401701,7708909602,4201,5901,0902,8801,120
Connecticut21,9003,4201201,6008908002,5409709502,1401,220
Delaware5,660840b440200180850340250590270
Dist. of Columbia3,070520b2101109031012011038090
Florida124,74018,1701,0409,9304,2305,07019,0007,6105,41012,8306,430
Georgia48,8507,8204104,0401,5101,5506,6102,9301,8905,4101,880
Hawaii6,5401,12050660290210700460260500240
Idaho7,3101,08050610290310980550370870480
Illinois64,72010,2105205,5802,7402,3508,6002,8102,7506,4103,070
Indiana36,4405,1402903,0801,3701,2805,5401,7301,5603,4101,710
Iowa17,2302,4001001,5107007602,4101,0208001,430870
Kansas14,4002,1801101,1705405601,8808306301,320640
Kentucky26,2203,5902102,2508301,0504,8301,4101,0702,0501,190
Louisiana24,2203,3202302,1506307703,5109609902,620980
Maine8,7501,350b7103803101,380450380720570
Maryland31,8205,2502202,4301,2001,0004,0201,7001,2603,4001,390
Massachusetts37,1305,9402002,7601,6001,2204,8901,8901,6303,9302,050
Michigan57,6008,1603704,6602,3202,0108,1902,7802,4805,3503,050
Minnesota30,0004,2301402,1701,0801,2903,6201,3301,3702,7501,320
Mississippi17,2902,3401401,5204105302,5705605601,380620
Missouri34,4004,9302402,8601,2501,2105,6201,6901,4202,9901,610
Montana6,140900b500220260750400280750350
Nebraska9,5201,450608403803801,220490440840450
Nevada13,8402,0101101,1604004601,6805605601,190700
New Hampshire8,6701,260b6203502901,150470340770520
New Jersey51,6807,8903604,0002,1001,9905,5402,7902,3805,1802,560
New Mexico10,0401,410808003503701,010490400960390
New York107,53016,3108108,4904,4204,32012,7004,9004,76010,0605,410
North Carolina56,9008,5804004,2901,8101,9707,9403,0602,1805,5602,500
North Dakota4,180550b330140150480210170360200
Ohio68,1809,4304605,5102,6702,27010,6603,1402,8605,8403,360
Oklahoma18,7102,6901701,6105907603,0507908401,700860
Oregon21,7803,4501401,6208707302,9001,5809702,0601,070
Pennsylvania77,71011,3005206,3003,2702,8009,9304,1403,3107,3204,190
Rhode Island5,870930b480250190860270260780350
South Carolina28,6804,2502102,2708909904,3201,7401,1203,2501,260
South Dakota4,920690b410180200590240210430240
Tennessee37,0805,5102903,0801,0901,3005,8301,8401,4902,8301,620
Texas116,20017,0601,3009,6903,8904,55014,5604,2405,25012,5504,270
Utah10,9901,460707404004608509504901,240430
Vermont4,000580b280160110510220170380240
Virginia42,7707,0202803,2601,4901,3805,4002,5001,7203,9501,870
Washington35,5605,9502502,7201,3801,3904,3902,5901,7403,5801,830
West Virginia11,6901,520801,0504504101,980700480840610
Wisconsin32,9904,8501802,6501,3601,4604,2801,5901,3803,5701,670
Wyoming2,780410b220100100320190120320150
United States1,688,780252,71012,820135,43061,38062,130222,50087,11072,240161,36079,030

Figure 1 depicts the most common cancers expected to occur in men and women in 2017. Prostate, lung and bronchus, and colorectal cancers account for 42% of all cases in men, with prostate cancer alone accounting for almost 1 in 5 new diagnoses. For women, the 3 most commonly diagnosed cancers are breast, lung and bronchus, and colorectum, which collectively represent one-half of all cases; breast cancer alone is expected to account for 30% of all new cancer diagnoses in women.

Figure 1.

Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2017.

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

Expected Numbers of Cancer Deaths

An estimated 600,920 Americans will die from cancer in 2017, corresponding to about 1,650 deaths per day (Table 1). The most common causes of cancer death are cancers of the lung and bronchus, colorectum, and prostate in men and lung and bronchus, breast, and colorectum in women (Fig. 1). These 4 cancers account for 46% of all cancer deaths, with more than one-quarter (26%) due to lung cancer. Table 3 provides the estimated numbers of cancer deaths in 2017 by state for selected cancer sites.

Table 3. Estimated Deaths for Selected Cancers by State, 2017a
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.

Alabama10,5303206509404204703,200320250710450
Alaska1,070b70100b60280bb8050
Arizona12,0503808101,0205506602,820430310930600
Arkansas6,8001804206002502802,160210150430260
California59,4001,8304,4405,2402,6103,75012,0002,1401,5304,5103,130
Colorado7,8402705706603403801,640260240580450
Connecticut6,6101904304503003001,630230170490310
Delaware2,0505013015070110590705015090
Dist. of Columbia1,060b10090b90220bb10070
Florida43,8701,2502,9103,6201,8002,02011,7901,5109703,1702,050
Georgia17,2804901,3201,5406208504,7205104201,160780
Hawaii2,520501402409017059010050220100
Idaho2,90010019025011012068011070230170
Illinois24,0406101,6802,0309901,0406,4707905701,6501,040
Indiana13,5903508601,1105505204,030450300900550
Iowa6,4601903805702602401,740240150440280
Kansas5,4401703304702602301,500180120400230
Kentucky10,4002505908303904003,560330200640340
Louisiana9,2402206208303205202,610300170700370
Maine3,26010017022013012096011060220140
Maryland10,6502808208604105602,630340260840470
Massachusetts12,6203507609105406703,270410320950550
Michigan21,0505701,4101,6808308605,6507605001,560830
Minnesota9,8602806107604803902,450390230710470
Mississippi6,5602204206502303001,940170110460280
Missouri14,3803308601,0705505804,030390250910500
Montana2,0306013017080805107050140120
Nebraska3,52011023033015013090012070250180
Nevada5,2001503805002002301,400160120360270
New Hampshire2,71080170200110907608060200120
New Jersey15,8804201,2501,4206407003,7605104101,270700
New Mexico3,63090250340150220760110100250200
New York35,9609102,4102,8701,4601,6808,6601,2109102,7501,560
North Carolina20,0206001,3601,5307609405,8306204401,350840
North Dakota1,290b7012060b340bb9070
Ohio25,4306401,6902,1309909907,3008605701,8101,020
Oklahoma8,2002005307103403602,450270200520350
Oregon8,1402605206603204402,030290230580410
Pennsylvania28,5107001,9002,3901,2101,2207,4201,0106902,1101,200
Rhode Island2,1605012017090110610605014090
South Carolina10,3202607008303804402,920300230710460
South Dakota1,66060110160906045050b11070
Tennessee14,8303809201,2205706704,590470310950550
Texas40,2601,1002,8303,7001,6902,6209,5401,3809202,7801,650
Utah3,180130270260170150460120100270210
Vermont1,40050701005050400bb11070
Virginia14,8703901,0601,1905506703,8104903701,080650
Washington12,7204108509705206803,100460330920620
West Virginia4,7801102804301901701,45016090280160
Wisconsin11,7103607408805404403,070420220870570
Wyoming960b608060b220bb70b
United States600,92016,70040,61050,26024,50028,920155,87020,14014,08043,09026,730

Trends in Cancer Incidence

Figure 2 illustrates long-term trends in cancer incidence rates for all cancers combined by sex. Cancer incidence patterns reflect trends in behaviors associated with cancer risk and changes in medical practice, such as the introduction of screening. The volatility in incidence for males compared with females reflects rapid changes in prostate cancer incidence, which spiked in the late 1980s and early 1990s (Fig. 3) due to a surge in the detection of asymptomatic disease as a result of widespread prostate-specific antigen (PSA) testing.[24] Over the past decade of data, the overall cancer incidence rate in men declined by about 2% per year, with the pace accelerating in more recent years (Table 4). This trend reflects large continuing declines for cancers of the lung and colorectum, in addition to a sharp reduction in prostate cancer incidence of more than 10% annually from 2010 to 2013. This drop is attributed to decreased PSA testing in the wake of US Preventive Services Task Force recommendations against routine use of the test to screen for prostate cancer because of growing concerns about overdiagnosis and overtreatment.[25, 26] The effect of reduced screening on the occurrence of advanced disease is being watched closely. Incidence rates for distant stage disease, which accounted for 4% of diagnoses during 2006 to 2012 (Fig. 4), have been stable since the mid-2000s following at least a decade of decline.[6]

Table 4. Trends in Delay-Adjusted Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2013
 TREND 1TREND 2TREND 3TREND 4TREND 5TREND 62004-2013 AAPC2009-2013 AAPC
 YEARSAPCYEARSAPCYEARSAPCYEARSAPCYEARSAPCYEARSAPC
  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 4.3.0.0, allowing up to 5 joinpoints. Trends are based on Surveillance, Epidemiology, and End Results (SEER) 9 areas.

All sites              
Overall1975-19891.2a1989-19922.81992-1995−2.41995-19981.01998-2009−0.3a2009-2013−1.5a−0.8a−1.5a
Male1975-19891.3a1989-19925.2a1992-1995−4.9a1995-19990.61999-2009−0.6a2009-2013−2.9a−1.6a−2.9a
Female1975-1979−0.31979-19871.6a1987-19950.11995-19981.51998-2003−0.62003-20130.10.10.1
Female breast1975-1980−0.51980-19874.0a1987-1994−0.21994-19991.8a1999-2004−2.3a2004-20130.4a0.4a0.4a
Colorectum              
Male1975-19851.1a1985-1991−1.2a1991-1995−3.2a1995-19982.31998-2013−3.0a  −3.0a−3.0a
Female1975-19850.31985-1995−1.9a1995-19981.81998-2008−2.0a2008-2013−3.8a  −3.0a−3.8a
Liver & intrahepatic bile duct
Male1975-19800.71980-20133.8a        3.8a3.8a
Female1975-19830.61983-19964.1a1996-20132.8a      2.8a2.8a
Lung & bronchus              
Male1975-19821.5a1982-1991−0.5a1991-2008−1.7a2008-2013−2.9a    −2.4a−2.9a
Female1975-19825.6a1982-19913.4a1991-20060.5a2006-2013−1.4a    −1.0a−1.4a
Melanoma of skin              
Male1975-19855.6a1985-20053.2a2005-20131.7a      1.8a1.7a
Female1975-19805.5a1980-20082.4a2008-20130.4      1.3a0.4
Pancreas              
Male1975-1993−0.8a1993-20030.22003-20063.02006-20130.4    0.90.4
Female1975-19841.3a1984-1999−0.31999-20131.3a      1.3a1.3a
Prostate1975-19882.6a1988-199216.5a1992-1995−11.5a1995-20002.32000-2010−1.7a2010-2013−10.7a−4.8a−8.6a
Thyroid              
Male1975-1980−4.71980-19971.9a1997-20135.4a      5.4a5.4a
Female1975-19776.51977-1980−5.21980-19932.3a1993-19994.5a1999-20097.1a2009-20131.54.6a1.5
Uterine corpus1975-1979−6.0a1979-1988−1.7a1988-19970.7a1997-2006−0.4a2006-20093.7a2009-20130.01.10.0
Figure 2.

Trends in Cancer Incidence (1975 to 2013) and Death Rates (1975 to 2014) by Sex, United States.

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

Figure 3.

Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2013.

Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting. *Includes intrahepatic bile duct.

Figure 4.

Stage Distribution by Race, United States, 2006 to 2012.

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

The overall incidence rate in women has remained generally stable since 1987 because declines in lung and colorectal cancers are being offset by increasing or stable rates for breast, uterine corpus, and thyroid cancers and for melanoma (Table 4). The slight increase in breast cancer incidence from 2004 to 2013 is driven wholly by nonwhite women; rates increased by about 2% per year among women other than white or black and by 0.5% per year among black women, while remaining stable among white women.[6]

Lung cancer incidence rates continue to decline about twice as fast in men as in women (Table 4). Sex differences in lung cancer trends reflect historical differences in tobacco use. Women took up smoking in large numbers later and at older ages than men, but were also slower to quit, including recent upturns in smoking prevalence in some birth cohorts.[27, 28] In contrast, incidence patterns for colorectal cancer are very similar in men and women, with rates declining by 3% per year from 2004 through 2013 (Table 4). While declines in colorectal cancer incidence rates prior to 2000 are attributed equally to changes in risk factors and the introduction of screening,[29] recent rapid declines are thought to primarily reflect the increased uptake of colonoscopy and the removal of precancerous adenomatous polyps.[30, 31] Colonoscopy use among adults aged 50 years and older has tripled, from 21% in 2000 to 60% in 2015.[32] In contrast to the rapid declines in colorectal cancer incidence among screening aged adults, rates increased by about 2% per year from 1993 to 2013 in individuals aged younger than 50 years.[6]

Incidence rates continue to increase rapidly for liver cancer, by about 3% per year in women and 4% per year in men, although rates have begun to decline in adults aged younger than 50 years.[25] Similarly, the long-term, rapid rise in melanoma incidence appears to be slowing, particularly among younger age groups. Incidence rates for thyroid cancer also appear to have begun stabilizing in recent years after changes in clinical practice guidelines were initiated in 2009, including more conservative indications for biopsy, following increased awareness of the “epidemic in diagnosis.”[33] In an effort to further reduce overdiagnosis and overtreatment, an international panel of experts convened by the NCI recently proposed downgrading the terminology for a common subtype of thyroid cancer from encapsulated follicular variant of papillary thyroid carcinoma to noninvasive follicular thyroid neoplasm with papillary-like nuclear features.[34] These indolent tumors, which represent approximately 20% of thyroid cancer diagnoses in the United States, have a recurrence rate of <1% at 15 years when removed with limited surgery (ie, thyroid lobectomy).

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 24 percentage points among blacks. Improvements in survival for the most common cancers have been similar by sex, but are much more pronounced among patients aged 50 to 64 years than among those aged older than 65 years,[35] likely reflecting lower efficacy or use of new therapies in the elderly population. Progress has been most rapid for hematopoietic and lymphoid malignancies due to improvements in treatment protocols, including the discovery of targeted therapies. For example, comparing patients diagnosed in the mid-1970s with those diagnosed during 2006 to 2012, the 5-year relative survival rate has increased from 41% to 71% for acute lymphocytic leukemia and from 22% to 66% for chronic myeloid leukemia.[9] Most patients with chronic myeloid leukemia who are treated with tyrosine kinase inhibitors experience near normal life expectancy, particularly those diagnosed before age 65 years, based on a recent review of clinical trial data.[36] Although historical groupings of lymphoid malignancies are still used to track progress, they do not reflect the substantial biologic variation by subtype that is captured by the more contemporary World Health Organization classification system.[37]

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 (Fig. 5). These low rates are partly because more than one-half of cases are diagnosed at a distant stage (Fig. 4), for which the 5-year survival is 4% and 3%, respectively. There is potential for lung cancer to be diagnosed at an earlier stage through the use of screening with low-dose computed tomography, which has been shown to reduce lung cancer mortality by up to 20% among current and former smokers with a smoking history of 30 or more pack-years.[38, 39] However, only 2% to 4% of the 8.7 million Americans eligible for screening reported undergoing a computed tomography scan of the chest to check for lung cancer in 2010.[40]

Figure 5.

Five-Year Relative Survival Rates by Stage at Diagnosis and Race, United States, 2006 to 2012.

*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, 96% in whites, and 90% in blacks.

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, but has declined by about 1.5% per year since the early 1990s. From its peak of 215.1 (per 100,000 population) in 1991, the cancer death rate dropped 25% to 161.2 in 2014. This decline, which is larger in men (31% since 1990) than in women (21% since 1991), translates into approximately 2,143,200 fewer cancer deaths (1,484,000 in men and 659,200 in women) than what would have occurred if peak rates had persisted (Fig. 6).

Figure 6.

Total Number Of Cancer Deaths Averted From 1991 to 2014 in Men and From 1992 to 2014 in Women, United States.

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.

The decline in cancer mortality over the past 2 decades is the result of steady reductions in smoking and advances in early detection and treatment, reflected in considerable decreases for the 4 major cancers (lung, breast, prostate, and colorectum) (Fig. 7). Specifically, the death rate dropped 38% from 1989 to 2014 for female breast cancer, 51% from 1993 to 2014 for prostate cancer, and 51% from 1976 to 2014 for colorectal cancer. Lung cancer death rates declined 43% from 1990 to 2014 among males and 17% from 2002 to 2014 among females due to reduced tobacco use because of increased awareness of the health hazards of smoking and the implementation of comprehensive tobacco control.[41] Tobacco control efforts adopted in the wake of the first Surgeon General's report on smoking and health in 1964 have resulted in an estimated 8 million fewer premature smoking-related deaths, one-third of which are due to cancer.[42, 43] Despite this progress, in much of the Southern United States, 40% of cancer deaths in men in 2014 were caused by smoking.[44]

Figure 7.

Trends in Death Rates by Sex Overall and for Select Cancers, United States, 1930 to 2014.

Rates are age adjusted to the 2000 US standard population. Due to improvements in International Classification of Diseases (ICD) coding over time, numerator data for cancers of the lung and bronchus, colon and rectum, liver, and uterus differ from the contemporary time period. For example, rates for lung and bronchus include pleura, trachea, mediastinum, and other respiratory organs.

In contrast to declining trends for the 4 major cancers, death rates rose from 2010 to 2014 by almost 3% per year for liver cancer and by about 2% per year for uterine cancer (Table 5). Pancreatic cancer death rates continued to increase slightly (by 0.3% per year) in men but have leveled off in women.

Table 5. Trends in Death Rates for Selected Cancers by Sex, United States, 1975 to 2014
 TREND 1TREND 2TREND 3TREND 4TREND 5TREND 62005-2014 AAPC2010-2014 AAPC
 YEARSAPCYEARSAPCYEARSAPCYEARSAPCYEARSAPCYEARSAPC
  1. APC indicates annual percent change based 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 4.3.1.0, allowing up to 5 joinpoints.

All sites              
Overall1975-19840.5a1984-19910.3a1991-1994−0.51994-1998−1.3a1998-2001−0.82001-2014−1.5a−1.5a−1.5a
Male1975-19791.0a1979-19900.3a1990-1993−0.51993-2001−1.5a2001-2014−1.8a  −1.8a−1.8a
Female1975-19900.6a1990-1994−0.21994-2002−0.8a2002-2014−1.4a    −1.4a−1.4a
Female breast1975-19900.4a1990-1995−1.8a1995-1998−3.3a1998-2014−1.8a    −1.8a−1.8a
Colorectum              
Male1975-19780.81978-1984−0.31984-1990−1.3a1990-2002−2.0a2002-2005−3.9a2005-2014−2.5a−2.5a−2.5a
Female1975-1984−1.0a1984-2001−1.8a2001-2014−2.8a      −2.8a−2.8a
Liver & intrahepatic bile duct
Male1975-19851.5a1985-19963.8a1996-19990.51999-20142.6a    2.6a2.6a
Female1975-1978−1.51978-19881.4a1988-19953.9a1995-20000.42000-20081.5a2008-20142.8a2.4a2.8a
Lung & bronchus              
Male1975-19782.4a1978-19841.2a1984-19910.3a1991-2005−1.9a2005-2012−3.0a2012-2014−4.0a−3.2a−3.5a
Female1975-19826.0a1982-19904.2a1990-19951.7a1995-20030.3a2003-2007−0.82007-2014−2.0a−1.7a−2.0a
Melanoma of skin              
Male1975-19902.2a1990-20020.02002-20090.9a2009-2014−1.3a    −0.3−1.3a
Female1975-19880.8a1988-2014−0.6a        −0.6a−0.6a
Pancreas              
Male1975-1986−0.8a1986-2000−0.3a2000-20140.3a      0.3a0.3a
Female1975-19840.8a1984-20020.12002-20080.6a2008-2014−0.2    0.1−0.2
Prostate1975-19870.9a1987-19913.0a1991-1994−0.51994-1999−4.1a1999-2014−3.4a  −3.4a−3.4a
Uterine corpus1975-1993−1.5a1993-20080.22008-20142.1a      1.4a2.1a

Recorded Number of Deaths in 2014

A total of 2,626,418 deaths were recorded in the United States in 2014, 23% of which were from cancer (Table 6). Cancer is the second leading cause of death following heart disease. However, it is the leading cause of death in 22 states,[45] and in Hispanic and Asian Americans.[46, 47] Cancer is also the leading cause of death among women aged 40 to 79 years and among men aged 45 to 79 years when data are analyzed by 5-year age group.[1]

Table 6. Ten Leading Causes of Death by Age and Sex, United States, 2014
 ALL AGESAGES 1 to 19AGES 20 to 39AGES 40 to 59AGES 60 to 79AGES ≥80
 MALE All Causes 1,328,241FEMALE All Causes 1,298,177MALE All Causes 12,128FEMALE All Causes 6,538MALE All Causes 65,486FEMALE All Causes 30,221MALE All Causes 227,562FEMALE All Causes 147,196MALE All Causes 534,113FEMALE All Causes 411,138MALE All Causes 475,956FEMALE All Causes 692,702
  1. HIV indicates human immunodeficiency virus.

  2. *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, 2014, National Center for Health Statistics, Centers for Disease Control and Prevention, 2016.

1Heart diseases 325,077Heart diseases 289,271Accidents (unintentional injuries) 4,409Accidents (unintentional injuries) 2,023Accidents (unintentional injuries) 24,467Accidents (unintentional injuries) 8,850Cancer 52,478Cancer 49,683Cancer 167,075Cancer 136,649Heart diseases 137,360Heart diseases 187,680
2Cancer 311,296Cancer 280,403Intentional self-harm (suicide) 1,681Cancer 757Intentional self-harm (suicide) 10,353Cancer 4,440Heart diseases 52,140Heart diseases 22,465Heart diseases 129,926Heart diseases 76,242Cancer 86,662Cancer 88,842
3Accidents (unintentional injuries) 85,448Chronic lower respiratory diseases 77,645Assault (homicide) 1,563Intentional self-harm (suicide) 581Assault (homicide) 7,040Intentional self-harm (suicide) 2,649Accidents (unintentional injuries) 26,259Accidents (unintentional injuries) 12,789Chronic lower respiratory diseases 34,508Chronic lower respiratory diseases 33,872Chronic lower respiratory diseases 28,801Alzheimer disease 56,533
4Chronic lower respiratory diseases 69,456Cerebro- vascular disease 77,632Cancer 1,028Assault (homicide) 477Heart diseases 5,077Heart diseases 2,459Intentional self-harm (suicide) 12,196Chronic lower respiratory diseases 5,960Cerebro- vascular disease 21,645Cerebro- vascular disease 19,932Cerebro- vascular disease 26,324Cerebro- vascular disease 52,068
5Cerebro- vascular disease 55,471Alzheimer disease 65,179Congenital anomalies 498Congenital anomalies 428Cancer 4,020Assault (homicide) 1,287Chronic liver disease & cirrhosis 11,443Chronic liver disease & cirrhosis 5,646Diabetes mellitus 20,335Diabetes mellitus 14,965Alzheimer disease 22,353Chronic lower respiratory diseases 37,397
6Diabetes mellitus 41,111Accidents (unintentional injuries) 50,605Heart diseases 373Heart diseases 266Chronic liver disease & cirrhosis 971Pregnancy, childbirth & puerperium 748Diabetes mellitus 8,118Cerebro- vascular disease 4,959Accidents (unintentional injuries) 16,588Accidents (unintentional injuries) 9,714Influenza & pneumonia 13,482Influenza & pneumonia 17,954
7Intentional self-harm (suicide) 33,113Diabetes mellitus 35,377Chronic lower respiratory diseases 158Influenza & pneumonia 126Diabetes mellitus 970Chronic liver disease & cirrhosis 628Cerebro- vascular disease 6,585Diabetes mellitus 4,947Chronic liver disease & cirrhosis 10,620Alzheimer disease 8,462Accidents (unintentional injuries) 13,047Accidents (unintentional injuries) 16,726
8Alzheimer disease 28,362Influenza & pneumonia 28,641Influenza & pneumonia 145Chronic lower respiratory diseases 89HIV disease 784Diabetes mellitus 624Chronic lower respiratory diseases 5,550Intentional self-harm (suicide) 4,389Nephritis, nephrotic syndrome & nephrosis 9,698Nephritis, nephrotic syndrome & nephrosis 8,352Nephritis, nephrotic syndrome & nephrosis 11,665Diabetes mellitus 14,817
9Influenza & pneumonia 26,586Nephritis, nephrotic syndrome & nephrosis 23,710Cerebro- vascular disease 96Cerebro- vascular disease 83Cerebro- vascular disease 766Cerebro- vascular disease 548Influenza & pneumonia 3,236Septicemia 2,664Influenza & pneumonia 9,030Septicemia 7,854Diabetes mellitus 11,644Nephritis, nephrotic syndrome & nephrosis 13,234
10Chronic liver disease & cirrhosis 24,584Septicemia 20,607Septicemia 77Septicemia 78Influenza & pneumonia 602Influenza & pneumonia 511HIV disease 2,943Influenza & pneumonia 2,592Septicemia 8,227Influenza & pneumonia 7,359Parkinson disease 10,059Hypertension & hypertensive renal disease* 11,724

Table 7 presents the number of deaths in 2014 for the 5 leading cancer types by age and sex. The leading causes of cancer death are brain cancer, leukemia, and female breast cancer before age 40 years and lung cancer in those aged 40 years or older. In 2013, lung cancer surpassed breast cancer as the leading cause of cancer death among women aged 40 to 59 years. Cervical cancer is the second leading cause of cancer death in women aged 20 to 39 years, underscoring the need to improve screening rates in this age group, as well as increase acceptance of and access to human papillomavirus vaccination. In 2014, only 40% of females aged 13 to 17 years had completed the 3-dose series, up slightly from 37% in 2013.[48]

Table 7. Five Leading Types of Cancer Death by Age and Sex, United States, 2014
ALL AGES<2020 TO 3940 TO 5960 TO 79≥ 80
MALE
  1. ONS indicates other nervous system.

  2. *Includes intrahepatic bile duct.

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

ALL SITES 311,296ALL SITES 1,050ALL SITES 4,020ALL SITES 52,478ALL SITES167,075ALL SITES 86,662
Lung & bronchusBrain & ONSBrain & ONSLung & bronchusLung & bronchusLung & bronchus
84,86131452913,07851,71419,821
ProstateLeukemiaLeukemiaColorectumColorectumProstate
28,3442725075,94713,31714,529
ColorectumBones & jointsColorectumLiver*ProstateColorectum
27,1341004464,46112,4897,422
PancreasSoft tissueNon-HodgkinPancreasPancreasUrinary bladder
 (including heart)lymphoma   
20,755782463,83011,9975,269
Liver*Non-HodgkinLung & bronchusEsophagusLiver*Pancreas
 lymphoma    
16,623462362,5819,5034,815
FEMALE
ALL SITES 280,403ALL SITES 787ALL SITES 4,440ALL SITES 49,683ALL SITES 136,649ALL SITES 88,842
Lung & bronchusBrain & ONSBreastLung & bronchusLung & bronchusLung & bronchus
70,6672451,05110,81240,25619,415
BreastLeukemiaUterine cervixBreastBreastBreast
41,21318444610,70818,46110,991
ColorectumBone & jointsColorectumColorectumColorectumColorectum
24,517813764,21410,0609,864
PancreasSoft tissueLeukemiaOvaryPancreasPancreas
 (including heart)    
19,664653632,86910,0196,914
OvaryNon-HodgkinBrain & ONSPancreasOvaryLeukemia
 lymphoma    
14,195233072,6607,4194,190

Cancer Disparities by Sex

The lifetime probability of being diagnosed with invasive cancer is slightly higher for men (40.8%) than for women (37.5%) (Table 8). Reasons for the 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,[49] and has been estimated to account for one-third of the gender disparity in cancer risk.[50]

Table 8. Probability (%) of Developing Invasive Cancer Within Selected Age Intervals by Sex, United States, 2011 to 2013a
  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 for non-Hispanic whites only.

All sitesbMale3.4 (1 in 30)6.3 (1 in 16)14.0 (1 in 7)33.3 (1 in 3)40.8 (1 in 2)
 Female5.4 (1 in 18)6.0 (1 in 17)10.0 (1 in 10)25.9 (1 in 4)37.5 (1 in 3)
BreastFemale1.9 (1 in 52)2.3 (1 in 44)3.5 (1 in 29)6.8 (1 in 15)12.4 (1 in 8)
ColorectumMale0.3 (1 in 294)0.7 (1 in 149)1.2 (1 in 84)3.5 (1 in 28)4.6 (1 in 22)
 Female0.3 (1 in 318)0.5 (1 in 198)0.8 (1 in 120)3.2 (1 in 31)4.2 (1 in 24)
Kidney & renal pelvisMale0.2 (1 in 457)0.3 (1 in 289)0.6 (1 in 157)1.3 (1 in 75)2.1 (1 in 48)
 Female0.1 (1 in 729)0.2 (1 in 582)0.3 (1 in 315)0.7 (1 in 135)1.2 (1 in 83)
LeukemiaMale0.2 (1 in 410)0.2 (1 in 574)0.6 (1 in 259)1.4 (1 in 72)1.8 (1 in 57)
 Female0.2 (1 in 509)0.1 (1 in 901)0.4 (1 in 447)0.9 (1 in 113)1.2 (1 in 81)
Lung & bronchusMale0.2 (1 in 643)0.7 (1 in 149)1.9 (1 in 53)6.2 (1 in 16)7.0 (1 in 14)
 Female0.2 (1 in 598)0.6 (1 in 178)1.5 (1 in 68)4.8 (1 in 21)6.0 (1 in 17)
Melanoma of the skincMale0.5 (1 in 220)0.5 (1 in 198)0.9 (1 in 111)2.5 (1 in 40)3.5 (1 in 28)
 Female0.6 (1 in 155)0.4 (1 in 273)0.5 (1 in 212)1.0 (1 in 97)2.3 (1 in 44)
Non-Hodgkin lymphomaMale0.3 (1 in 385)0.3 (1 in 353)0.4 (1 in 175)1.8 (1 in 55)2.4 (1 in 42)
 Female0.2 (1 in 547)0.2 (1 in 483)0.2 (1 in 245)1.3 (1 in 74)1.9 (1 in 54)
ProstateMale0.3 (1 in 354)1.9 (1 in 52)5.4 (1 in 19)9.1 (1 in 11)12.9 (1 in 8)
ThyroidMale0.2 (1 in 533)0.1 (1 in 799)0.2 (1 in 620)0.2 (1 in 429)0.6 (1 in 163)
 Female0.8 (1 in 127)0.4 (1 in 275)0.3 (1 in 292)0.4 (1 in 258)1.8 (1 in 57)
Uterine cervixFemale0.3 (1 in 371)0.1 (1 in 868)0.1 (1 in 899)0.2 (1 in 594)0.6 (1 in 161)
Uterine corpusFemale0.3 (1 in 352)0.6 (1 in 169)1.0 (1 in 105)1.3 (1 in 76)2.8 (1 in 36)

Table 9 shows sex differences in cancer-specific incidence and mortality. Overall, incidence rates are about 20% higher in men while mortality rates are about 40% higher. The larger disparity for mortality reflects differences in the composition and distribution of cancers. For example, rates of liver cancer, which is highly fatal, are 3 times higher in men than in women. The largest sex disparities are for cancers of the esophagus, larynx, and bladder, for which incidence and death rates are about 4-fold higher in men. However, incidence rates are higher in women for cancers of the anus, gallbladder, and thyroid. Notably, thyroid cancer incidence rates are 3 times higher in women than in men (21 vs 7 per 100,000 population), despite equivalent death rates (0.5 per 100,000 population). This pattern is indicative of a preponderance of nonfatal thyroid tumors in women, which is consistent with more prominent and prolonged overdiagnosis in women than in men.[51] However, consistency in the gender disparity for thyroid cancer globally and across racial/ethnic groups in the United States suggests a higher underlying disease burden in women,[52] despite unknown etiologic mechanisms.[53]

Table 9. Sex Differences in Cancer Incidence and Mortality Rates, 2009 to 2013
  INCIDENCEMORTALITY
  RATERATE RATIO (M/F)(95% CI)RATERATE RATIO (M/F)(95% CI)
  1. 95% CI indicates 95% confidence interval; F, female, M, male, ONS, other nervous system.

All sitesFemale418.5  143.4  
 Male512.11.2(1.22-1.23)204.01.4(1.42-1.43)
Oral cavity and pharynxFemale6.3  1.3  
 Male17.22.7(2.69-2.75)3.82.8(2.77-2.89)
EsophagusFemale1.8  1.5  
 Male8.14.5(4.44-4.60)7.44.8(4.75-4.93)
StomachFemale4.6  2.4  
 Male9.22.0(1.97-2.02)4.51.9(1.85-1.91)
Colon and rectumFemale35.6  12.7  
 Male46.91.3(1.31-1.32)18.11.4(1.42-1.44)
Colon excluding rectumFemale26.6     
 Male32.41.2(1.21-1.22)   
Rectum and rectosigmoid junctionFemale8.9     
 Male14.51.6(1.61-1.64)   
Anus, anal canal, and anorectumFemale2.1  0.3  
 Male1.50.7(0.68-0.72)0.20.8(0.77-0.87)
Liver and intrahepatic bile ductFemale4.0  3.6  
 Male11.82.9(2.89-2.96)9.12.5(2.45-2.52)
GallbladderFemale1.4  0.7  
 Male0.80.6(0.59-0.62)0.50.7(0.62-0.68)
PancreasFemale10.9  9.5  
 Male14.11.3(1.28-1.30)12.51.3(1.30-1.33)
LarynxFemale1.4  0.4  
 Male6.24.5(4.39-4.57)1.94.8(4.62-4.97)
Lung and bronchusFemale53.5  37.0  
 Male75.01.4(1.40-1.41)57.81.6(1.55-1.57)
Melanoma of the skinFemale16.1  1.7  
 Male25.91.6(1.60-1.62)4.12.4(2.35-2.45)
Urinary bladderFemale8.9  2.2  
 Male36.24.1(4.02-4.08)7.73.5(3.47-3.59)
Kidney and renal pelvisFemale11.3  2.5  
 Male21.71.9(1.90-1.93)5.72.3(2.25-2.32)
Brain and ONSFemale5.6  3.5  
 Male7.81.4(1.37-1.40)5.31.5(1.48-1.52)
ThyroidFemale20.8  0.5  
 Male7.00.3(0.34-0.34)0.51.0(0.99-1.08)
Hodgkin lymphomaFemale2.4  0.3  
 Male3.11.3(1.27-1.32)0.51.6(1.53-1.70)
Non-Hodgkin lymphomaFemale15.9  4.7  
 Male23.01.4(1.44-1.46)7.71.7(1.63-1.67)
MyelomaFemale5.2  2.7  
 Male8.01.5(1.51-1.54)4.21.6(1.54-1.59)
LeukemiaFemale10.6  5.2  
 Male17.31.6(1.62-1.65)9.31.8(1.78-1.82)
Acute lymphocytic leukemiaFemale1.4  0.4  
 Male1.81.3(1.27-1.33)0.51.4(1.36-1.50)
Chronic lymphocytic leukemiaFemale3.1  0.9  
 Male6.11.9(1.90-1.95)2.02.2(2.15-2.27)
Acute myeloid leukemiaFemale3.4  2.2  
 Male5.01.5(1.44-1.49)3.71.7(1.65-1.72)
Chronic myeloid leukemiaFemale1.4  0.2  
 Male2.21.6(1.57-1.65)0.41.7(1.64-1.83)

Melanoma incidence rates are about 60% higher in men than in women, while death rates are more than double. The larger disparity for mortality reflects an earlier stage at diagnosis and better stage-specific survival in women than in men. Sex disparities in melanoma survival, which have also been observed in Europe and Australia,[54, 55] partly reflect more unfavorable prognostic indicators (eg, thick tumors, ulceration, and trunk loci) and an older age at diagnosis in men compared with women. However, sex is a predictor of survival independent of clinicopathologic factors for reasons that remain unclear.[56] While hormonal influences are thought to play a role, survival is higher and disease progression less likely in women, regardless of menopausal status, even for patients with advanced disease.[57] A recent study found a survival advantage for women when melanoma arose de novo (70%–80% of tumors), but no difference in survival for nevi-associated tumors, which are associated with better outcomes.[58]

Cancer Disparities by Race/Ethnicity and Socioeconomic Status

Cancer incidence and death rates vary considerably between racial and ethnic groups, with rates generally highest among blacks and lowest among Asian/Pacific Islanders (APIs) (Tables 10 and 11). Importantly, there are considerable differences within all of the broadly defined population groups described here, despite scant data. For example, while overall cancer incidence rates are 40% lower for API men than non-Hispanic white men based on aggregated data, rates in Hawaiians and Samoans are similar to those in non-Hispanic whites.[47] The same is true for Puerto Ricans within the lower risk Hispanic population.

Table 10. Incidence Rates by Site, Race, and Ethnicity, United States, 2009 to 2013
 ALL RACES COMBINEDNON-HISPANICWHITENON-HISPANICBLACKASIAN/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 and exclude data from Kansas.

All sites      
Male512.1519.3577.3310.2426.7398.1
Female418.5436.0408.5287.1387.3329.6
Breast (female)123.3128.3125.189.398.191.7
Colorectum      
Male46.946.158.337.851.442.8
Female35.635.242.727.841.229.8
Kidney & renal pelvis      
Male21.721.924.410.829.920.7
Female11.311.313.04.817.611.9
Liver & intrahepatic bile duct      
Male11.89.716.920.418.519.4
Female4.03.35.07.68.97.5
Lung & bronchus      
Male75.077.790.846.671.342.2
Female53.558.251.028.356.225.6
Prostate123.2114.8198.463.585.1104.9
Stomach      
Male9.27.814.714.411.213.1
Female4.63.57.98.46.57.8
Uterine cervix7.67.09.86.19.79.9
Table 11. Death Rates by Site, Race, and Ethnicity, United States, 2010 to 2014
 ALL RACES COMBINEDNON-HISPANICWHITENON-HISPANICBLACKASIAN/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.

All sites      
Male200.4204.0253.4122.7183.6142.5
Female141.5145.5165.988.8129.197.7
Breast (female)21.221.130.011.314.114.4
Colorectum      
Male17.717.325.912.419.515.0
Female12.412.316.98.814.09.2
Kidney & renal pelvis      
Male5.65.85.72.78.94.9
Female2.42.52.51.14.22.3
Liver & intrahepatic bile duct      
Male9.28.013.314.314.913.1
Female3.73.34.66.16.85.8
Lung & bronchus      
Male55.958.369.831.746.227.3
Female36.339.835.518.030.813.4
Prostate20.018.742.88.819.416.5
Stomach      
Male4.43.48.77.17.56.9
Female2.31.74.24.33.84.1
Uterine cervix2.32.13.91.72.82.6

In 2014, the cancer death rate was 15% higher in blacks than in whites. The racial disparity has been most striking for men, with the excess risk growing from 20% in 1970 to 47% in 1990. However, that gap had narrowed to 21% in 2014, due in part to more rapid declines in smoking-related cancers in blacks driven by sharper reductions in smoking initiation in the 1970s and early 1980s.[59, 60] The racial disparity has declined similarly in women, from a peak of 20% in 1998 to 13% in 2014. Other than behavioral differences, racial disparities are caused by unequal access to and use of high-quality health care, including cancer prevention and early detection, timely diagnosis, and optimal treatment.[61, 62] Blacks are more likely than whites to be diagnosed with cancer at an advanced stage (Fig. 4), but also have lower stage-specific survival for most cancer types (Fig. 5). Both stage at diagnosis and survival are closely aligned with health insurance coverage,[63] which is lower among minorities than non-Hispanic whites. However, this gap is also narrowing rapidly. As a result of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, together referred to as the Affordable Care Act or ACA, 11% of blacks and 7% of non-Hispanic whites were uninsured in 2015, down from 21% and 12%, respectively, in 2010.[64, 65] Progress for Hispanics is similar, with the uninsured rate dropping from 31% in 2010 to 16% in 2015. If maintained, these shifts should help to expedite progress in reducing socioeconomic disparities in cancer, as well as other health conditions.

Cancer incidence and death rates among APIs, American Indians/Alaska Natives (AI/ANs), and Hispanics are lower than among non-Hispanic whites for the 4 most common cancers, but higher for cancers associated with infectious agents (eg, those of the stomach and liver). For example, liver cancer incidence rates in these populations are double those in non-Hispanic whites, reflecting a higher prevalence of risk factors such as chronic infection with hepatitis B and/or hepatitis C viruses, obesity, diabetes, and binge drinking.[66] AI/ANs have the highest rates of kidney cancer, although there is striking geographic variation, most likely reflecting differences in the prevalence of renal cancer risk factors such as obesity, smoking, and hypertension.[67]

Regional Variations in Cancer Rates

Tables 12 and 13 depict average annual cancer incidence and death rates for selected cancers by state. State variation in cancer occurrence reflects differences in medical practice and the prevalence of risk factors, such as smoking and obesity. Geographic disparities often reflect the national distribution of poverty and access to health care, which have increased over time and may continue to exacerbate because of differential state expansion of Medicaid facilitated by the ACA.[68-70] The largest geographic variation by far is for lung cancer, reflecting the large historical and continuing differences in smoking prevalence among states.[41] For example, lung cancer incidence rates in Kentucky (118 per 100,000 population in men and 80 per 100,000 population in women), which has historically had the highest smoking prevalence, are about 3.5 times higher than those in Utah (34 per 100,000 population in men and 24 per 100,000 population in women), which continues to have the lowest smoking prevalence. Smoking history similarly predicts state disparities in smoking-attributable mortality; the proportion of total cancer deaths caused by smoking is 38% in men and 29% in women in Kentucky, compared with 22% and 11%, respectively, in Utah.[44] The 2-fold difference for prostate cancer incidence rates, which range from 84 (per 100,000 population) in Arizona to 169 in the District of Columbia, reflect state differences in PSA testing prevalence and racial composition.[24] State variations are smaller for cancers without particularly strong risk factors or early detection tests (eg, pancreas).

Table 12. Incidence Rates for Selected Cancers by State, United States, 2009 to 2013
 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 they did not meet high-quality standards for one or more years during 2009 to 2013 according to the North American Association of Central Cancer Registries (NAACCR).

  3. b

    Rates are based on incidence data for 2009 to 2010.

  4. c

    Rates are based on incidence data for 2009 to 2012.

Alabama548.1395.6119.352.837.395.353.419.813.9139.134.07.7
Alaska459.7411.9123.549.240.471.655.621.414.3100.334.710.8
Arizona418.1375.1111.039.630.558.046.418.613.584.132.18.0
Arkansas531.2390.7111.550.137.099.659.420.814.8128.435.77.2
California473.0390.9121.443.833.753.641.222.815.3118.732.07.6
Colorado458.0393.8124.838.731.049.842.421.514.9122.132.78.3
Connecticut541.8459.1137.846.535.170.957.725.317.7130.347.412.5
Delaware581.7451.2130.044.333.383.462.325.017.3151.141.811.1
Dist. of Columbia543.1444.8143.047.941.172.049.722.113.9169.124.49.3
Florida490.1398.5115.343.433.173.654.421.314.8111.234.18.3
Georgia542.5409.6123.448.836.286.753.221.714.6139.833.67.7
Hawaii454.0408.7134.453.136.458.038.721.814.996.523.36.1
Idaho496.0408.7119.442.232.256.446.920.716.1131.839.08.7
Illinois531.6437.6128.553.438.981.058.523.516.2128.838.29.5
Indiana503.2425.9120.049.539.491.161.723.316.4102.036.48.9
Iowa536.5438.8122.652.239.780.252.726.718.5119.239.78.8
Kansas529.0426.8122.048.836.073.653.523.616.6133.538.89.2
Kentucky593.8470.2122.059.643.7118.380.225.417.1118.140.09.7
Louisiana585.0420.0123.457.341.892.155.524.016.6154.434.28.0
Maine529.7450.8124.544.835.686.066.124.017.6106.546.612.5
Maryland506.0421.0130.242.533.867.952.921.215.1135.036.09.2
Massachusetts522.5454.4136.043.835.072.761.923.816.7124.941.511.4
Michigan530.2428.3123.045.234.978.959.124.517.2137.039.510.2
Minnesotaa518.7431.8130.144.635.362.950.127.218.5130.338.39.5
Mississippi567.0405.4116.158.942.6103.156.520.814.4142.730.97.3
Missouri504.9427.6124.850.537.390.864.722.315.3106.333.68.5
Montana500.4425.5122.745.734.562.654.923.315.8127.337.010.5
Nebraska493.8414.0120.749.538.970.449.924.017.8119.234.88.4
Nevadaa, b496.9397.1113.950.735.167.958.620.514.2135.438.011.1
New Hampshire544.2460.9138.141.434.773.564.426.217.9133.550.112.8
New Jersey555.2452.9131.449.538.867.753.125.417.8148.741.611.0
New Mexicoa, c424.2365.8112.941.130.649.636.817.813.8106.125.56.0
New York557.3450.6128.447.936.672.054.726.318.0145.241.410.6
North Carolina534.8419.5128.444.833.490.555.921.715.0130.236.18.8
North Dakota515.5415.5124.654.540.269.847.522.718.3130.938.58.7
Ohio513.8423.8122.048.936.285.659.722.915.7119.738.89.3
Oklahoma511.4409.8117.749.938.187.758.521.714.9120.633.88.1
Oregon478.5424.0128.142.232.565.354.922.515.4110.637.59.2
Pennsylvania550.8460.4129.051.338.680.056.526.117.8125.444.111.0
Rhode Island528.3459.2130.442.735.378.364.025.017.8117.446.313.3
South Carolina530.6409.6125.645.534.487.854.320.413.4129.034.28.7
South Dakota487.0428.6130.650.939.867.450.923.616.3119.633.89.4
Tennessee540.5420.6121.747.636.697.661.222.015.1126.335.18.1
Texas474.1381.1112.347.032.870.145.521.515.2106.427.96.5
Utah468.6369.8112.736.128.234.424.223.415.1144.430.25.8
Vermont505.6439.3128.341.233.474.261.225.418.2109.840.09.8
Virginia473.3399.3125.542.233.575.252.221.114.4116.531.78.3
Washington513.3442.2135.641.734.067.154.725.617.0125.737.89.5
West Virginia533.4440.0114.454.340.8101.065.922.116.1106.639.910.9
Wisconsin517.9433.5127.244.634.370.354.525.017.3122.040.010.0
Wyoming458.1380.7109.644.031.652.643.118.414.4116.036.710.5
United States512.1418.5123.346.935.675.053.523.015.9123.236.28.9
Table 13. Death Rates for Selected Cancers by State, United States, 2010 to 2014
 ALL SITESBREASTCOLORECTUMLUNG & BRONCHUSNON-HODGKIN LYMPHOMAPANCREASPROSTATE
STATEMALEFEMALEFEMALEMALEFEMALEMALEFEMALEMALEFEMALEMALEFEMALEMALE
  1. Rates are per 100,000 and age adjusted to the 2000 US standard population.

Alabama235.7148.222.020.613.377.139.57.54.813.29.723.8
Alaska203.5146.720.418.513.554.741.77.13.711.99.920.5
Arizona174.2126.219.515.611.242.930.46.84.311.59.018.2
Arkansas237.0153.822.121.814.681.043.97.65.212.79.420.8
California176.7130.420.415.911.539.828.57.14.411.89.220.0
Colorado166.4125.119.214.511.136.428.16.64.010.98.621.7
Connecticut182.5133.519.113.810.446.334.47.14.312.59.818.6
Delaware208.3150.521.917.110.862.342.67.84.614.19.619.2
Dist. of Columbia210.0160.029.318.615.549.633.56.13.315.512.133.6
Florida189.4132.720.216.311.354.135.57.24.212.08.917.6
Georgia212.3140.522.519.412.664.135.67.14.112.39.123.4
Hawaii167.3114.915.017.510.740.825.16.74.012.49.813.7
Idaho185.4132.620.415.911.143.731.47.95.112.89.723.3
Illinois208.3150.322.519.113.259.039.47.84.612.89.820.9
Indiana224.8153.721.819.313.471.242.98.65.113.19.621.0
Iowa206.5142.219.419.213.959.136.08.75.112.79.319.8
Kansas200.9143.020.118.412.657.338.47.74.913.09.919.1
Kentucky249.4167.121.920.914.289.654.79.05.113.39.619.8
Louisiana237.7157.124.221.714.972.941.58.65.015.111.322.4
Maine215.7150.418.016.511.864.443.37.65.311.810.619.8
Maryland198.1143.322.817.612.152.236.67.14.213.99.920.3
Massachusetts196.6140.218.815.911.351.838.07.14.412.69.919.4
Michigan209.2151.622.417.712.760.841.58.85.213.310.119.5
Minnesota188.7135.818.815.211.547.633.98.65.212.48.820.6
Mississippi252.2158.523.923.716.182.741.07.24.214.311.026.2
Missouri216.6154.522.519.113.269.344.77.54.713.09.918.2
Montana182.5138.220.216.211.146.237.27.54.110.59.021.4
Nebraska197.1138.320.118.514.254.334.67.25.112.58.920.8
Nevada194.1145.422.720.213.852.841.46.94.012.29.021.1
New Hampshire197.7143.420.314.013.353.940.76.84.112.99.519.9
New Jersey191.3141.622.918.212.848.433.77.34.413.210.219.4
New Mexico176.2123.819.317.311.338.126.46.04.110.98.120.7
New York187.1138.020.616.912.149.033.87.34.413.09.919.5
North Carolina215.1142.121.617.311.667.937.97.44.512.69.221.6
North Dakota189.6128.017.817.913.152.031.46.94.512.17.919.8
Ohio219.6155.023.119.813.666.542.78.55.113.310.019.9
Oklahoma227.2157.423.420.613.871.544.98.35.012.49.920.8
Oregon196.2145.920.816.612.250.539.18.24.912.59.521.2
Pennsylvania210.5149.422.218.913.559.037.18.34.913.610.019.7
Rhode Island209.2143.518.816.412.959.141.86.84.712.69.119.8
South Carolina223.0145.722.718.712.967.037.87.24.413.19.723.4
South Dakota196.9138.520.219.812.855.535.27.54.311.69.119.5
Tennessee236.2153.922.120.114.078.443.78.34.812.610.020.7
Texas195.1133.220.418.311.952.231.77.44.411.79.018.7
Utah151.0111.220.813.09.724.616.26.84.711.48.622.1
Vermont202.5147.018.615.812.754.341.58.04.412.710.021.1
Virginia201.9141.321.917.012.057.436.57.54.412.99.421.0
Washington191.4140.120.115.211.249.936.37.94.812.39.820.4
West Virginia236.7163.322.122.115.077.247.28.15.312.28.718.2
Wisconsin202.0144.020.516.412.153.437.58.14.913.210.021.8
Wyoming177.9134.918.917.110.641.932.56.64.610.88.418.5
United States200.4141.521.217.712.455.936.37.64.612.69.520.0

Cancer in Children and Adolescents

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 2017, an estimated 10,270 children (birth to 14 years) will be diagnosed with cancer (excluding benign/borderline malignant brain tumors) and 1,190 will die from the disease. Benign and borderline malignant brain tumors are not included in the 2017 case estimates because the calculation method requires historical data and these tumors were not required to be reported to cancer registries until 2004.

Leukemias (76% of which are lymphoid leukemias) account for 29% of all childhood cancers (including benign and borderline malignant brain tumors). Cancers of the brain and other nervous system are the second most common cancer type (26%). The third most common category is lymphomas and reticuloendothelial neoplasms (11%), almost one-half of which are non-Hodgkin lymphoma (including Burkitt lymphoma) and more than one-quarter of which are Hodgkin lymphoma. Soft tissue sarcomas (almost one-half of which are rhabdomyosarcoma) and neuroblastoma each account for 6% of childhood cancers, followed by renal (Wilms) tumors (5%).[10]

Cancers in adolescents (aged 15 to 19 years) differ somewhat from those in children in terms of type and distribution. For example, the most common cancer type in adolescents is lymphoma (21%), almost two-thirds of which is Hodgkin lymphoma. Cancers of the brain and other nervous system account for 17% of cases, followed by leukemia (14%), germ cell and gonadal tumors (12%), and thyroid carcinoma (11%). Melanoma accounts for 5% of the cancers diagnosed in this age group.

Although overall cancer incidence in children and adolescents has been increasing slightly (by 0.6% per year) since 1975, rates appear to have stabilized during the most recent data years. In contrast, death rates among those aged birth to 19 years have declined continuously, from 6.5 (per 100,000 population) in 1970 to 2.2 in 2014, an overall reduction of 66% (68% in children and 60% in adolescents). The 5-year relative survival rate for all cancers combined improved from 58% during the mid-1970s to 83% during 2006-2012 for children and from 68% to 84% for adolescents. However, survival varies substantially by cancer type and age at diagnosis (Table 14).

Table 14. Five-Year Relative Survival Rate (%) by Age and ICCC Type, Ages Birth to 19 Years, United States, 2006 to 2012
 BIRTH TO 1415 TO 19
  1. ICCC indicates International Classification of Childhood Cancer.

  2. Survival rates are adjusted for normal life expectancy and are based on follow-up of patients through 2013.

  3. a

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

  4. b

    Statistic could not be calculated due to fewer than 25 cases during 2006 to 2012.

All ICCC groups combined83.083.9
Lymphoid leukemia90.274.7
Acute myeloid leukemia64.259.7
Hodgkin lymphoma97.796.4
Non-Hodgkin lymphoma90.786.0
Central nervous system neoplasms72.679.1
Neuroblastoma & other peripheral nervous cell tumors79.774.2a
Retinoblasoma95.3b
Renal tumors90.668.1a
Hepatic tumors77.147.4a
Osteosarcoma69.563.4
Ewing tumor & related bone sarcomas78.759.2
Soft tissue and other extraosseous sarcomas74.069.1
Rhabdomyosarcoma69.648.9
Germ cell and gonadal tumors93.391.9
Thyroid carcinoma99.799.7
Malignant melanoma93.794.0

Limitations

Although the estimated numbers of new cancer cases and deaths expected to occur in 2017 provide a reasonably accurate portrayal of the contemporary cancer burden, they are model-based, 3-year- or 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 as we take advantage of improvements in modeling techniques and cancer surveillance coverage. Second, although the model is robust, it can only account for trends through the most recent year of data (currently 2013 for incidence and 2014 for mortality) 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 metrics for tracking 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 substantial and important differences in the cancer burden within these subpopulations. For example, among API men, lung cancer incidence rates in Hawaiian men are just as high as those in non-Hispanic white men and 3-fold higher than those in Asian Indian/Pakistani men based on limited data available by population subgroups. Thus, the high burden of lung and other cancers among Hawaiians is completely concealed with the presentation of aggregated API data.

Conclusions

The continuous decline in cancer death rates over 2 decades has resulted in an overall drop of 25%, resulting in 2.1 million fewer cancer deaths during this time period. Moreover, racial disparities in cancer death rates are continuing to decline and the proportion of blacks who are uninsured has halved since 2010, potentially expediting further progress. Despite these successes, death rates are increasing rapidly for cancers of the liver (one of the most fatal cancers) and uterine corpus, both of which are strongly associated with obesity. Advancing the fight against cancer requires continued clinical and basic research to improve detection practices, as well as treatment. In addition, creative new strategies are also needed to increase healthy behaviors nationwide and to more broadly apply existing cancer control knowledge across all segments of the population, with an emphasis on disadvantaged groups.

Author Contributions

Rebecca L. Siegel: Conceptualization, formal analysis, investigation, writing–original draft, writing–review and editing, and visualization. Kimberly D. Miller: Software, formal analysis, investigation, writing–review and editing, and visualization. Ahmedin Jemal: Conceptualization, methodology, writing–review and editing, visualization, and supervision.

Ancillary