Cancer statistics, 2014

Cancer statistics, 2014 Introduction Cancer is a major public health problem in the United States and many other parts of the world. One in 4 deaths in the United States is due to cancer. In this article, we provide the expected numbers of new cancer cases and deaths in 2014 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 available. In addition, we estimate the total number of deaths averted since the early 1990s as a result of 2 decades of declining cancer death rates and present the actual number of deaths reported in 2010 by age for the 10 leading causes of death and the 5 leading causes of cancer death. Materials and Methods Incidence and Mortality Data Mortality data from 1930 to 2010 were obtained from the National Center for Health Statistics (NCHS). Population‐based cancer incidence data in the United States are collected both by the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) Program and the Centers for Disease Control and Prevention's (CDC's) National Program of Cancer Registries (NPCR). The SEER program reports long‐term (beginning in 1973), high‐quality incidence, prevalence, and survival data. Long‐term incidence and survival trends (1975‐2010) were based on data from the 9 oldest SEER areas (Connecticut, Iowa, Hawaii, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco‐Oakland, and Seattle‐Puget Sound), representing approximately 10% of the US population. As of 1992, SEER data have been available for 4 additional populations (Alaska Natives, Los Angeles County, San Jose‐Monterey, and rural Georgia) that increase the coverage of minority groups and allow for stratification by race and ethnicity. Data from these SEER 13 registries were the source for the annual percent change in incidence from 1992 to 2010. 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. Much of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review, 1975‐2010 . 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 or the NPCR. These data approach 100% coverage of the US population and were the source for incidence rates by state and race/ethnicity, as well as the projection of new cancer cases in 2014. Some of the data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2006‐2010 . All cancer cases were classified according to the International Classification of Diseases for Oncology . The lifetime probability of cancer was calculated using the NCI's DevCan software (version 6.7.0). 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 8.1.2). Cancer incidence rates in this report were adjusted for delays in reporting whenever possible. This adjustment, which is available only for SEER data, is based on historic patterns of case ascertainment and accounts for anticipated future corrections to registry data primarily due to a lag in case reporting. 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. For example, melanoma incidence rates adjusted for reporting delays are 14% higher than unadjusted rates in the most recent data year. Delay‐adjusted rates were obtained from the SEER Canques database ( surveillance.cancer.gov/delay/canques.html [accessed August 6, 2013]). Projected Cancer Cases and Deaths in 2014 The most recent year for which incidence and mortality data are available lags 3 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we project the numbers of new cancer cases and deaths in the United States in the current year in order to provide an estimate of the contemporary cancer burden. These estimates are not useful for tracking cancer occurrence over time because they are model‐based and because the calculation methodology changes every few years in order to take advantage of improvements in modeling techniques, increased cancer registration coverage, and updated risk factor surveillance. A 3‐step spatio‐temporal model was used to project the number of new invasive cancer cases that will be diagnosed in 2014 based on 1995 through 2010 high‐quality incidence data from 49 states and the District of Columbia, representing 89% population coverage. (All states did not meet high quality data standards for all years and Minnesota did not submit incidence data to NAACCR during the 2012 call for data.) This method accounts for expected delays in case reporting and considers geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence. First, complete incidence counts were estimated for each county from 1995 through 2010. Then these counts were adjusted to account for delays in cancer reporting. Finally, a temporal projection method (the vector autoregressive model) was applied to the last 15 years of data (1996‐2010) to estimate counts for 2014, which were then aggregated to obtain state‐level estimates. This method cannot estimate numbers of basal cell or squamous cell skin cancers because data on the occurrence of these cancers are not reported to cancer registries. For the complete details of the case projection methodology, please refer to Zhu et al. To estimate the number of in situ female breast and melanoma cases diagnosed in 2014, we first estimated the number of cases occurring annually from 2001 through 2010 by applying age‐specific SEER 13 incidence rates to the corresponding US population estimates provided in SEER*Stat. (Delay‐adjusted rates were available for in situ breast cancer but not for in situ melanoma.) We then projected the total number of cases in 2014 based on the average annual percent change in case counts from 2001 through 2010 generated by the joinpoint regression model. We estimated the number of cancer deaths expected to occur in 2014 in the United States overall and in each state using the joinpoint regression model based on the actual numbers of cancer deaths from 1995 through 2010 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al. Other Statistics The estimated number of cancer deaths averted in men and women due to the reduction in overall cancer death rates was calculated by first estimating the number of cancer deaths that would have occurred if 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 the subsequent years through 2010. Then the difference between the number of expected and recorded cancer deaths in each age group and calendar year was summed for men and women separately. Selected Findings Expected Numbers of New Cancer Cases Table presents the estimated numbers of new cases of invasive cancer expected among men and women in the United States in 2014. The overall estimate of 1,665,540 new cases is the equivalent of more than 4,500 new cancer diagnoses each day. About 62,570 cases of breast carcinoma in situ and 63,770 cases of melanoma in situ are expected to be newly diagnosed in 2014. The estimated numbers of new cancer cases by state for selected cancer sites are shown in Table . Estimated New Cancer Cases and Deaths by Sex, United States, 2014 ESTIMATED NEW CASES ESTIMATED DEATHS BOTH SEXES MALE FEMALE BOTH SEXES MALE FEMALE All sites 1,665,540 855,220 810,320 585,720 310,010 275,710 Oral cavity & pharynx 42,440 30,220 12,220 8,390 5,730 2,660 Tongue 13,590 9,720 3,870 2,150 1,450 700 Mouth 11,920 7,150 4,770 2,070 1,130 940 Pharynx 14,410 11,550 2,860 2,540 1,900 640 Other oral cavity 2,520 1,800 720 1,630 1,250 380 Digestive system 289,610 162,730 126,880 147,260 84,970 62,290 Esophagus 18,170 14,660 3,510 15,450 12,450 3,000 Stomach 22,220 13,730 8,490 10,990 6,720 4,270 Small intestine 9,160 4,880 4,280 1,210 640 570 Colon 96,830 48,450 48,380 50,310 26,270 24,040 Rectum 40,000 23,380 16,620 Anus, anal canal, & anorectum 7,210 2,660 4,550 950 370 580 Liver & intrahepatic bile duct 33,190 24,600 8,590 23,000 15,870 7,130 Gallbladder & other biliary 10,650 4,960 5,690 3,630 1,610 2,020 Pancreas 46,420 23,530 22,890 39,590 20,170 19,420 Other digestive organs 5,760 1,880 3,880 2,130 870 1,260 Respiratory system 242,550 130,000 112,550 163,660 90,280 73,380 Larynx 12,630 10,000 2,630 3,610 2,870 740 Lung & bronchus 224,210 116,000 108,210 159,260 86,930 72,330 Other respiratory organs 5,710 4,000 1,710 790 480 310 Bones & joints 3,020 1,680 1,340 1,460 830 630 Soft tissue (including heart) 12,020 6,550 5,470 4,740 2,550 2,190 Skin (excluding basal & squamous) 81,220 46,630 34,590 12,980 8,840 4,140 Melanoma‐skin 76,100 43,890 32,210 9,710 6,470 3,240 Other nonepithelial skin 5,120 2,740 2,380 3,270 2,370 900 Breast 235,030 2,360 232,670 40,430 430 40,000 Genital system 338,450 243,460 94,990 58,970 30,180 28,790 Uterine cervix 12,360 12,360 4,020 4,020 Uterine corpus 52,630 52,630 8,590 8,590 Ovary 21,980 21,980 14,270 14,270 Vulva 4,850 4,850 1,030 1,030 Vagina & other genital, female 3,170 3,170 880 880 Prostate 233,000 233,000 29,480 29,480 Testis 8,820 8,820 380 380 Penis & other genital, male 1,640 1,640 320 320 Urinary system 141,610 97,420 44,190 30,350 20,610 9,740 Urinary bladder 74,690 56,390 18,300 15,580 11,170 4,410 Kidney & renal pelvis 63,920 39,140 24,780 13,860 8,900 4,960 Ureter & other urinary organs 3,000 1,890 1,110 910 540 370 Eye & orbit 2,730 1,440 1,290 310 130 180 Brain & other nervous system 23,380 12,820 10,560 14,320 8,090 6,230 Endocrine system 65,630 16,600 49,030 2,820 1,300 1,520 Thyroid 62,980 15,190 47,790 1,890 830 1,060 Other endocrine 2,650 1,410 1,240 930 470 460 Lymphoma 79,990 43,340 36,650 20,170 11,140 9,030 Hodgkin lymphoma 9,190 5,070 4,120 1,180 670 510 Non‐Hodgkin lymphoma 70,800 38,270 32,530 18,990 10,470 8,520 Myeloma 24,050 13,500 10,550 11,090 6,110 4,980 Leukemia 52,380 30,100 22,280 24,090 14,040 10,050 Acute lymphocytic leukemia 6,020 3,140 2,880 1,440 810 630 Chronic lymphocytic leukemia 15,720 9,100 6,620 4,600 2,800 1,800 Acute myeloid leukemia 18,860 11,530 7,330 10,460 6,010 4,450 Chronic myeloid leukemia 5,980 3,130 2,850 810 550 260 Other leukemia 5,800 3,200 2,600 6,780 3,870 2,910 Other & unspecified primary sites 31,430 16,370 15,060 44,680 24,780 19,900 Rounded to the nearest 10; estimated new cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. About 62,570 carcinoma in situ of the female breast and 63,770 melanoma in situ will be newly diagnosed in 2014. Estimated deaths for colon and rectum cancers are combined. 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. Incidence Rates for All Cancers Combined (2006‐2010) and Estimated New Cases for Selected Cancers (2014) by State STATE INCIDENCE RATE ALL CASES FEMALE BREAST UTERINE CERVIX COLON & RECTUM UTERINE CORPUS LEUKEMIA LUNG & BRONCHUS MELANOMA OF THE SKIN NON‐HODGKIN LYMPHOMA PROSTATE URINARY BLADDER Alabama 469.6 26,770 3,660 210 2,350 650 690 4,160 1,320 990 3,760 990 Alaska 469.3 3,750 450 280 100 100 430 90 140 530 150 Arizona 401.1 32,830 4,520 210 2,560 910 950 4,280 1,430 1,320 4,390 1,490 Arkansas 460.6 16,520 2,050 140 1,500 400 480 2,660 490 660 2,240 640 California 442.2 171,730 26,130 1,550 13,930 5,650 5,650 18,780 8,440 7,770 23,010 7,210 Colorado 432.5 23,810 3,780 160 1,720 750 870 2,540 1,400 1,060 3,680 1,040 Connecticut 505.7 22,070 3,160 120 1,650 790 610 2,730 1,090 920 3,120 1,170 Delaware 511.7 5,320 760 420 180 150 790 290 220 800 260 Dist. of Columbia 486.9 2,840 430 250 100 60 320 80 100 510 80 Florida 452.0 114,560 15,480 960 10,230 3,410 3,810 17,960 5,320 5,050 16,590 5,800 Georgia 471.3 47,390 7,010 420 3,940 1,310 1,370 6,540 2,180 1,820 7,600 1,710 Hawaii 430.1 6,640 1,090 60 700 270 220 890 410 300 810 250 Idaho 455.6 7,990 1,100 50 610 230 290 960 450 360 1,320 390 Illinois 491.2 66,840 9,230 470 5,530 2,290 2,180 9,100 2,440 2,890 8,820 3,090 Indiana 464.0 35,560 4,590 260 3,020 1,070 1,060 5,540 1,550 1,480 4,390 1,600 Iowa 485.6 17,630 2,320 100 1,580 610 640 2,330 980 800 2,340 830 Kansas 476.8 14,630 2,090 100 1,120 470 490 1,900 780 650 1,980 620 Kentucky 523.2 25,770 3,370 200 2,170 720 790 4,690 1,540 1,070 3,280 1,100 Louisiana 494.1 24,300 3,160 200 2,270 540 720 3,470 750 960 3,720 940 Maine 511.1 9,270 1,220 50 700 340 310 1,400 440 380 1,160 540 Maryland 462.0 30,680 4,570 230 2,500 1,020 800 3,990 1,400 1,210 5,000 1,280 Massachusetts 503.3 37,940 5,560 200 2,800 1,320 1,140 4,930 1,800 1,600 5,600 2,030 Michigan 492.3 58,610 7,660 340 4,570 2,010 1,830 8,090 2,830 2,500 8,740 2,930 Minnesota ‐ 29,340 3,820 130 2,240 950 1,050 3,070 1,030 1,240 3,870 1,220 Mississippi 480.9 15,740 2,130 140 1,510 360 410 2,420 560 560 2,210 540 Missouri 467.7 33,890 4,610 240 2,970 1,090 1,040 5,370 1,510 1,430 4,010 1,530 Montana 466.3 5,850 860 500 180 200 760 290 260 1,010 300 Nebraska 464.5 9,550 1,360 60 880 320 330 1,220 460 440 1,250 430 Nevada 448.7 14,450 1,880 120 1,290 350 440 2,040 470 550 1,890 680 New Hampshire 507.2 8,450 1,150 600 300 250 1,110 400 350 1,160 460 New Jersey 503.7 51,130 7,290 380 4,280 1,820 1,560 6,130 2,590 2,250 7,320 2,510 New Mexico 405.9 10,210 1,450 80 830 300 370 1,060 470 400 1,400 400 New York 504.1 107,200 15,230 850 8,590 4,040 3,460 13,720 4,240 4,720 15,440 5,330 North Carolina 477.2 52,550 7,580 380 4,230 1,570 1,550 7,850 2,540 2,110 7,580 2,170 North Dakota 460.0 3,730 510 350 110 130 400 160 160 460 180 Ohio 474.7 67,000 8,710 400 5,450 2,280 1,890 9,760 3,170 2,860 8,690 3,110 Oklahoma 475.8 19,830 2,700 160 1,760 530 660 3,320 650 850 2,570 830 Oregon 462.2 22,530 3,320 130 1,540 720 640 2,950 1,440 960 3,200 1,080 Pennsylvania 502.6 79,920 10,660 500 6,790 2,840 2,420 10,290 3,820 3,420 10,930 4,070 Rhode Island 506.5 6,370 870 500 230 180 870 260 250 840 340 South Carolina 463.8 26,390 3,750 210 2,200 750 790 4,130 1,350 1,030 4,000 1,100 South Dakota 439.7 4,490 600 410 150 160 540 200 200 590 210 Tennessee 475.8 36,570 4,840 290 3,030 930 1,040 5,980 1,910 1,470 4,670 1,510 Texas 441.5 115,730 16,080 1,140 9,760 3,130 4,190 14,890 3,420 5,030 15,900 4,190 Utah 418.6 10,780 1,440 60 650 350 390 650 770 490 1,780 420 Vermont 489.8 4,130 560 290 140 110 550 220 160 580 210 Virginia 449.0 40,970 6,170 290 3,280 1,300 1,080 5,580 2,130 1,640 6,330 1,700 Washington 483.0 38,230 5,620 230 2,670 1,160 1,250 4,630 2,410 1,710 5,380 1,730 West Virginia 484.6 11,700 1,350 90 1,060 380 330 2,090 540 480 1,450 570 Wisconsin 466.0 32,480 4,330 190 2,520 1,140 1,150 4,020 1,440 1,410 4,630 1,580 Wyoming 435.0 2,890 420 240 90 90 330 150 120 490 140 United States 469.6 1,665,540 232,670 12,360 136,830 52,630 52,380 224,210 76,100 70,800 233,000 74,690 Rounded to the nearest 10; excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder. Rates are per 100,000 and age adjusted to the 2000 US standard population. US rate excludes cases from Arkansas, Minnesota, Nevada, Ohio, and Virginia. Estimate is fewer than 50 cases. High‐quality incidence data were not available for all 5 years. Arkansas rate is based on cases diagnosed during 2006 to 2008; Nevada and Ohio rates are based on 2006 to 2009. Incidence data were not available. Note: These model‐based estimates are offered as a rough guide and should be interpreted with caution. State estimates may not add to US total due to rounding. Figure indicates the most common cancers expected to occur in men and women in 2014. Among men, cancers of the prostate, lung and bronchus, and colorectum will account for about 50% of all newly diagnosed cancers. Prostate cancer alone will account for 27% (233,000) of incident cases in men. The 3 most commonly diagnosed types of cancer among women in 2014 will be breast, lung and bronchus, and colorectum, accounting for one‐half of all cases in women. Breast cancer alone is expected to account for 29% (232,670) of all new cancers among women. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2014. *Estimates are rounded to the nearest 10 and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. Expected Numbers of Cancer Deaths Table also shows the expected numbers of deaths from cancer projected for 2014. It is estimated that about 585,720 Americans will die from cancer this year, corresponding to about 1,600 deaths per day. Cancers of the lung and bronchus, prostate, and colorectum in men and cancers of the lung and bronchus, breast, and colorectum in women continue to be the most common causes of cancer death. These 4 cancers account for almost half of the total cancer deaths among men and women (Fig. ), with more than one‐quarter of all cancer deaths due to lung cancer. Table provides the estimated numbers of cancer deaths in 2014 by state for selected cancer sites. Death Rates for All Cancers Combined (2006‐2010) and Estimated Deaths for Selected Cancers (2014) by State STATE DEATH RATE ALL SITES BRAIN & OTHER NERVOUS SYSTEM FEMALE BREAST COLON & RECTUM LEUKEMIA LIVER & INTRAHEPATIC BILE DUCT LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA OVARY PANCREAS PROSTATE Alabama 196.4 10,510 270 690 950 410 350 3,310 310 280 630 540 Alaska 182.5 990 70 90 270 60 60 Arizona 155.2 11,400 310 780 990 500 470 2,840 390 310 790 640 Arkansas 198.0 6,730 150 420 620 270 210 2,200 200 140 400 310 California 160.3 57,950 1,590 4,270 5,150 2,510 3,140 12,590 2,000 1,560 4,150 3,380 Colorado 152.8 7,480 240 530 670 330 300 1,720 240 240 510 450 Connecticut 166.4 6,880 180 470 460 290 250 1,760 220 180 520 390 Delaware 187.7 1,980 120 160 70 90 600 60 50 130 90 Dist. of Columbia 199.0 1,010 80 100 60 230 80 80 Florida 168.4 42,740 920 2,770 3,560 1,760 1,620 12,050 1,430 940 2,890 2,170 Georgia 179.2 16,320 380 1,220 1,480 620 590 4,690 460 430 1,040 800 Hawaii 143.7 2,450 140 230 90 140 580 80 60 210 120 Idaho 162.8 2,730 80 180 210 130 80 670 90 60 210 180 Illinois 183.9 24,020 540 1,610 2,190 1,020 810 6,570 780 560 1,610 1,190 Indiana 192.6 13,370 310 860 1,090 550 380 4,140 440 310 840 580 Iowa 174.3 6,380 190 390 570 280 190 1,780 230 180 410 330 Kansas 174.7 5,460 150 370 480 260 170 1,560 200 140 370 250 Kentucky 209.5 10,130 210 590 850 370 280 3,570 300 200 570 390 Louisiana 201.3 9,040 200 640 840 330 400 2,650 260 190 600 400 Maine 187.7 3,300 90 190 250 130 110 970 100 60 200 160 Maryland 179.0 10,500 240 820 890 390 400 2,760 300 270 760 550 Massachusetts 177.6 12,810 310 790 990 510 550 3,500 400 320 920 630 Michigan 185.1 20,800 550 1,400 1,680 910 710 5,990 720 480 1,480 890 Minnesota 168.9 9,750 260 620 780 460 360 2,480 340 240 650 540 Mississippi 203.5 6,350 140 420 640 250 240 1,990 180 120 380 330 Missouri 189.2 12,870 310 910 1,090 540 450 3,950 390 250 860 550 Montana 166.3 2,000 50 130 170 90 50 520 70 60 130 130 Nebraska 170.7 3,480 100 210 340 140 100 900 130 80 240 200 Nevada 179.0 4,790 140 380 480 190 220 1,420 140 100 370 280 New Hampshire 177.3 2,670 70 170 200 100 80 750 80 60 190 130 New Jersey 175.0 16,350 350 1,290 1,510 630 600 3,970 510 440 1,220 760 New Mexico 155.5 3,600 90 260 350 140 170 790 110 90 240 220 New York 166.6 34,440 790 2,390 2,970 1,440 1,470 8,790 1,110 910 2,540 1,760 North Carolina 182.8 18,980 410 1,310 1,500 720 660 5,700 560 430 1,190 920 North Dakota 164.8 1,270 90 130 60 310 80 80 Ohio 192.4 25,260 600 1,720 2,140 990 790 7,370 810 570 1,730 1,200 Oklahoma 193.3 7,980 200 510 690 320 280 2,440 270 180 470 370 Oregon 176.3 7,940 230 510 660 320 340 2,090 280 220 550 440 Pennsylvania 184.5 28,670 610 1,940 2,490 1,200 980 7,600 1,010 730 1,990 1,370 Rhode Island 177.5 2,140 50 130 160 90 80 580 60 50 130 100 South Carolina 187.6 9,950 220 670 840 360 370 2,970 280 230 610 510 South Dakota 168.4 1,610 50 110 150 70 50 440 50 110 90 Tennessee 199.1 14,280 350 910 1,220 540 500 4,630 440 290 820 630 Texas 169.7 37,830 950 2,700 3,430 1,530 2,080 9,600 1,230 900 2,440 1,660 Utah 131.3 2,870 110 270 250 150 100 460 120 80 240 210 Vermont 177.9 1,340 80 100 50 60 390 90 70 Virginia 179.3 14,750 350 1,090 1,240 570 520 4,110 460 380 1,010 730 Washington 175.0 12,550 380 820 970 540 550 3,270 430 360 880 730 West Virginia 201.2 4,680 100 270 420 170 120 1,480 160 100 230 190 Wisconsin 175.6 11,360 310 710 860 550 390 3,000 400 300 800 630 Wyoming 167.8 990 60 90 70 250 80 40 United States 176.4 585,720 14,320 40,000 50,310 24,090 23,000 159,260 18,990 14,270 39,590 29,480 Rounded to the nearest 10. Rates are per 100,000 and age adjusted to the 2000 US standard population. Estimate is fewer than 50 deaths. Note: State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 deaths. Lifetime Probability of Developing Cancer The lifetime probability of being diagnosed with an invasive cancer is higher for men (44%) than for women (38%) (Table ). However, because of the earlier median age at diagnosis for breast cancer (61 years) compared with prostate (66 years) and other major cancers, women have a slightly higher probability of developing cancer than men before age 65 years. These estimates are 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. Probability (%) of Developing Invasive Cancers Within Selected Age Intervals by Sex, United States, 2008 to 2010 BIRTH TO 49 50 TO 59 60 TO 69 70 AND OLDER BIRTH TO DEATH All sites Male 3.5 (1 in 29) 6.8 (1 in 15) 15.4 (1 in 6) 36.9 (1 in 3) 43.9 (1 in 2) Female 5.4 (1 in 19) 6.0 (1 in 17) 10.1 (1 in 10) 26.7 (1 in 4) 38.0 (1 in 3) Kidney & renal pelvis Male 0.2 (1 in 480) 0.3 (1 in 289) 0.6 (1 in 154) 1.3 (1 in 75) 2.1 (1 in 49) Female 0.1 (1 in 753) 0.2 (1 in 586) 0.3 (1 in 317) 0.7 (1 in 134) 1.2 (1 in 83) Breast Female 1.9 (1 in 53) 2.3 (1 in 43) 3.5 (1 in 29) 6.7 (1 in 15) 12.3 (1 in 8) Colorectum Male 0.3 (1 in 305) 0.7 (1 in 144) 1.3 (1 in 76) 4.0 (1 in 25) 5.0 (1 in 20) Female 0.3 (1 in 334) 0.5 (1 in 189) 0.9 (1 in 109) 3.7 (1 in 27) 4.6 (1 in 22) Leukemia Male 0.2 (1 in 421) 0.2 (1 in 614) 0.4 (1 in 279) 1.3 (1 in 76) 1.7 (1 in 60) Female 0.2 (1 in 526) 0.1 (1 in 979) 0.2 (1 in 475) 0.8 (1 in 120) 1.2 (1 in 86) Lung & bronchus Male 0.2 (1 in 548) 0.7 (1 in 134) 2.1 (1 in 47) 6.7 (1 in 15) 7.6 (1 in 13) Female 0.2 (1 in 522) 0.6 (1 in 171) 1.6 (1 in 62) 4.9 (1 in 20) 6.3 (1 in 16) Melanoma of the skin Male 0.4 (1 in 284) 0.4 (1 in 134) 0.8 (1 in 129) 2.1 (1 in 48) 2.9 (1 in 34) Female 0.5 (1 in 206) 0.3 (1 in 313) 0.4 (1 in 243) 0.9 (1 in 113) 1.9 (1 in 53) Non‐Hodgkin lymphoma Male 0.3 (1 in 357) 0.3 (1 in 338) 0.6 (1 in 171) 1.8 (1 in 56) 2.4 (1 in 42) Female 0.2 (1 in 537) 0.2 (1 in 475) 0.4 (1 in 233) 1.4 (1 in 71) 1.9 (1 in 52) Prostate Male 0.3 (1 in 298) 2.3 (1 in 43) 6.4 (1 in 16) 11.2 (1 in 9) 15.3 (1 in 7) Uterine cervix Female 0.3 (1 in 348) 0.1 (1 in 812) 0.1 (1 in 824) 0.2 (1 in 619) 0.7 (1 in 154) Uterine corpus Female 0.3 (1 in 370) 0.6 (1 in 171) 0.9 (1 in 111) 1.3 (1 in 78) 2.7 (1 in 37) For people free of cancer at beginning of age interval. All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder. Probabilities for whites only. Trends in Cancer Incidence Figures and illustrate long‐term trends in cancer incidence rates for all cancers combined and for selected cancer sites by sex. Trends since 1992 are presented in Table in terms of the annual percent change in rates using 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. Trends in Cancer Incidence and Death Rates by Sex, United States, 1975 to 2010. Rates are age adjusted to the 2000 US standard population. Incidence rates are adjusted for delays in reporting. Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2010. Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting. *Includes intrahepatic bile duct. Trends in Cancer Incidence (Delay‐Adjusted) and Death Rates for Selected Cancers by Sex, United States, 1992 to 2010 TREND 1 TREND 2 TREND 3 TREND 4 2006–2010 YEARS APC YEARS APC YEARS APC YEARS APC AAPC All sites Incidence Overall 1992‐1994 ‐3.2 1994‐1998 0.4 1998‐2010 ‐0.4 ‐0.4 Male 1992‐1994 ‐5.6 1994‐2010 ‐0.6 ‐0.6 Female 1992‐1994 ‐0.4 1994‐1998 1.2 1998‐2003 ‐0.8 2003‐2010 0.1 0.1 Death Overall 1992‐2001 ‐1.0 2001‐2010 ‐1.5 ‐1.5 Male 1992‐2001 ‐1.4 2001‐2010 ‐1.8 ‐1.8 Female 1992‐1995 ‐0.2 1995‐1998 ‐1.2 1998‐2001 ‐0.4 2001‐2010 ‐1.4 ‐1.4 Lung & bronchus Incidence Male 1992‐2010 ‐1.9 ‐1.9 Female 1992‐1998 0.8 1998‐2001 ‐1.3 2001‐2005 0.7 2005‐2010 ‐1.2 ‐1.2 Death Male 1992‐2005 ‐1.9 2005‐2010 ‐2.9 ‐2.9 Female 1992‐1996 1.1 1996‐2004 0.2 2004‐2010 ‐1.4 ‐1.4 Colorectum Incidence Male 1992‐1995 ‐2.6 1995‐1998 1.4 1998‐2008 ‐2.5 2008‐2010 ‐4.2 ‐3.3 Female 1992‐1995 ‐1.8 1995‐1998 1.8 1998‐2008 ‐1.9 2008‐2010 ‐4.1 ‐3.0 Death Male 1992‐2002 ‐2.0 2002‐2005 ‐4.0 2005‐2010 ‐2.5 ‐2.5 Female 1992‐2001 ‐1.7 2001‐2010 ‐3.0 ‐3.0 Liver & intrahepatic bile duct Incidence Male 1992‐2010 3.7 3.7 Female 1992‐2010 2.9 2.9 Death Male 1992‐2010 2.3 2.3 Female 1992‐2010 1.4 1.4 Melanoma of skin Incidence Male 1992‐2010 2.4 2.4 Female 1992‐1997 3.9 1997‐2010 1.7 1.7 Death Male 1992‐2010 0.4 0.4 Female 1992‐2010 ‐0.5 ‐0.5 Thyroid Incidence Male 1992‐1996 ‐0.9 1996‐2010 5.4 5.4 Female 1992‐1998 3.9 1998‐2010 6.5 6.5 Death Male 1992‐2010 1.6 1.6 Female 1992‐1994 ‐6.4 1994‐2010 0.9 0.9 Female breast Incidence 1992‐1999 1.3 1999‐2004 ‐2.2 2004‐2010 0.2 0.2 Death 1992‐1995 ‐1.3 1995‐1998 ‐3.4 1998‐2010 ‐1.9 ‐1.9 Prostate Incidence 1992‐1995 ‐11.2 1995‐2000 2.2 2000‐2010 ‐2.0 ‐2.0 Death 1992‐1994 ‐1.0 1994‐2004 ‐3.8 2004‐2010 ‐3.1 ‐3.1 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. The APC or AAPC is significantly different from zero ( P < .05). Note: Trends analyzed by the Joinpoint Regression Program, version 4.0.3, allowing up to 3 joinpoints. Incidence trends based on Surveillance, Epidemiology, and End Results (SEER) 13 areas. The overall cancer incidence rate is 23% lower among women compared with men. However, during the past 5 years for which there are data (2006‐2010), the incidence rate decreased by 0.6% per year among males but remained stable in females (Table ). The decrease in men is driven by the rapid declines in colorectal (3.3% per year), prostate (2.0% per year), and lung (1.9% per year) cancers. Among women, although colorectal cancer declines are similar to those in men, the lung cancer rate has been slow to decline and breast cancer incidence rates have remained relatively flat since 2003 (Fig. ). Declines in incidence rates for the major cancers reflect improvements in cancer control and prevention. 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. However, the rapid declines in recent years (eg, greater than 4.0% per year from 2008‐2010) have been attributed to the increased uptake of colonoscopy, which prevents cancer by allowing for the removal of precancerous lesions. Prostate cancer incidence rates have been generally declining since around 2000, although rates have fluctuated widely from year to year (Fig. ), likely reflecting variation in the prevalence of prostate‐specific antigen testing for the detection of prostate cancer. Lung cancer incidence rates began declining in the mid‐1980s in men and in the late 1990s in women as a result of reduced smoking prevalence. Differences in lung cancer incidence patterns between men and women (Fig. ) reflect historical differences in tobacco use; cigarette smoking prevalence peaked about 20 years later in women than in men. In contrast to the stable or declining trends for most cancer types, incidence rates are increasing for melanoma of the skin; esophageal adenocarcinoma; cancers of the thyroid, liver, kidney, anus, and pancreas; and human papillomavirus‐positive oropharyngeal cancers. Among both men and women, the largest annual increases from 2006 to 2010 were for cancers of the thyroid (5.4% and 6.5% in men and women, respectively) and liver (3.7% and 2.9% in men and women, respectively) (Table ). Trends in Cancer Mortality The overall cancer death rate rose for most of the 20th century, peaking at 215.1 deaths per 100,000 population in 1991. This increase was largely driven by rapid increases in lung cancer deaths among men as a consequence of the tobacco epidemic. Over the past 2 decades, however, there has been a steady decline in the cancer death rate (to 171.8 in 2010) as a result of advances in prevention, early detection, and treatment, including the implementation of comprehensive tobacco control. As a result of this 20% decline, an estimated 1,340,400 cancer deaths (952,700 in men and 387,700 in women) that would have occurred had peak rates persisted have been averted (Fig. ). Total Number of Cancer Deaths Averted From 1991 to 2010 in Men and From 1992 to 2010 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. Overall declines in the cancer death rate from 1991 to 2010 occurred among white women (16%), black women (20%), white men (24%), and black men (33%). Figure illustrates the variation in the magnitude of the declines by race, sex, and 10‐year age group. Downturns occurred for black and white men and women of all ages with the exception of white women aged 80 years and older. Notably, black males experienced the largest drop in death rates in every age group. The sharpest decrease (44%–55%) occurred among black men aged 30 years to 59 years. In general, middle‐aged men and women experienced the largest declines, particularly compared with adults aged 70 years and older. The smaller declines among seniors reflect the lingering effects of the tobacco epidemic on older birth cohorts. Progress is more stunted among women than men in this generation because of the later onset and more protracted decline in smoking prevalence among women. Relative Decline in Cancer Death Rates From 1991 to 2010 by Age, Race, and Sex. The relative decline is the difference between the 2010 and 1991 rate expressed as a percentage of the 1991 rate. Figure depicts long‐term trends in cancer death rates among men and women overall and for selected cancer sites. 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. a). It is also interesting to note that prior to 1941, men had a lower risk of dying from cancer than women 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 2010, largely due to the widespread uptake of screening for the prevention and early detection of cervical cancer. A similar dramatic decline occurred for stomach cancer, which accounted for 30% and 20% of male and female cancer deaths, respectively, in the 1930s. By 2010, stomach cancer accounted for just 2% of cancer deaths. Rates of stomach cancer have declined worldwide due to improved hygiene, resulting in a lower prevalence of Helicobacter pylori , and advances in food preservation techniques (eg, refrigeration), which have led to lower salt intake and higher consumption of fresh fruits and vegetables. Trends in Death Rates Overall and for Selected Sites by Sex, United States, 1930 to 2010. 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, uterus, and ovary are affected by these changes. *Uterus includes uterine cervix and uterine corpus. During the most recent 5 years for which data are available, the average annual decline in cancer death rates was slightly larger among men (1.8%) than women (1.4%) (Fig. ) (Table ). These declines are driven by continued decreases in death rates for the 4 major cancer sites (Fig. ). Due to the reduction in tobacco use over the past 50 years, the lung cancer death rate declined 34% between 1991 and 2010 among males and 9% between 2002 and 2010 among females. Death rates for breast, prostate, and colorectal cancers are down from peak rates by 34%, 45%, and 46%, respectively, as a result of improvements in early detection and treatment. In contrast, joinpoint trend analysis for 2001 to 2010 indicates that death rates are rising for cancers of the oropharynx, anus, liver, pancreas, and soft tissue (including the heart), and for melanoma in men. The rate of death from thyroid cancer is also increasing according to joinpoint analysis (Table ), although the observed rates increased only slightly from 0.47 (per 100,000 population) to 0.50 among men and from 0.48 to 0.51 among women. Recorded Number of Deaths in 2010 A total of 2,468,435 deaths were recorded in the United States in 2010, of which 574,743 (23%) were from cancer. Overall, cancer is the second leading cause of death following heart disease. However, within 20‐year age groups, cancer is the leading cause of death among adults aged 40 years to 79 years (Table ). Among females, cancer is the first or second leading cause of death in every age group. Ten Leading Causes of Death by Age and Sex, United States, 2010 ALL AGES AGES 1 TO 19 AGES 20 TO 39 AGES 40 TO 59 AGES 60 TO 79 AGES ≥80 MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes 1,232,432 1,236,003 13,380 7,102 60,730 28,205 224,613 140,576 475,230 376,110 444,690 673,087 1 Heart diseases 307,384 Heart diseases 290,305 Accidents (unintentional injuries) 5,124 Accidents (unintentional injuries) 2,450 Accidents (unintentional injuries) 21,504 Accidents (unintentional injuries) 7,818 Cancer 54,440 Cancer 50,509 Cancer 156,723 Cancer 128,760 Heart diseases 131,682 Heart diseases 193,291 2 Cancer 301,037 Cancer 273,706 Assault (homicide) 1,978 Cancer 824 Intentional self‐harm (suicide) 9,463 Cancer 4,429 Heart diseases 52,472 Heart diseases 21,458 Heart diseases 117,385 Heart diseases 72,817 Cancer 84,636 Cancer 89,153 3 Accidents (unintentional injuries) 75,921 Cerebro‐vascular diseases 77,109 Intentional self‐harm (suicide) 1,510 Congenital anomalies 501 Assault (homicide) 7,098 Heart diseases 2,339 Accidents (unintentional injuries) 23,991 Accidents (unintentional injuries) 11,469 Chronic lower respiratory diseases 31,964 Chronic lower respiratory diseases31,397 Chronic lower respiratory diseases 27,899 Cerebro‐vascular disease 51,984 4 Chronic Chronic Cancer Assault Heart Intentional Intentional Chronic Cerebro‐ Cerebro‐ Cerebro‐ Alzheimer lower lower 1,039 (homicide) diseases self‐harm self‐harm lower vascular vascular vascular disease respiratory respiratory 500 5,202 (suicide) (suicide) respiratory disease disease disease 50,503 diseases diseases 2,297 12,253 diseases 19,703 19,261 25,130 65,423 72,657 5,172 5 Cerebro‐ Alzheimer Congenital Intentional Cancer Assault Chronic liver Cerebro‐ Diabetes Diabetes Alzheimer Chronic vascular disease anomalies self‐harm 4,163 (homicide) disease & vascular mellitus mellitus disease lower diseases 58,130 506 (suicide) 1,342 cirrhosis disease 16,718 13,431 19,934 respiratory 52,367 423 10,899 5,128 diseases 35,719 6 Diabetes Accidents Heart Heart HIV Pregnancy, Diabetes Chronic liver Accidents Nephritis, Influenza & Influenza & mellitus (unintentional diseases diseases disease childbirth & mellitus disease & (unintentional nephrotic pneumonia pneumonia 35,490 injuries) 427 259 1,016 puerperium 7,403 cirrhosis injuries) syndrome & 13,266 18,344 44,938 632 4,746 13,459 nephrosis 8,266 7 Intentional Diabetes Chronic lower Influenza & Chronic liver Diabetes Cerebro‐ Diabetes Nephritis, Accidents Nephritis, Diabetes self‐harm mellitus respiratory pneumonia disease & mellitus vascular mellitus nephrotic (unintentional nephrotic mellitus (suicide) 33,581 diseases 96 cirrhosis 587 disease 4,445 syndrome & injuries) syndrome & 15,082 30,277 154 828 6,675 nephrosis 7,937 nephrosis 9,581 12,217 8 Alzheimer Influenza & Cerebro‐ Cerebro‐ Diabetes Cerebro‐ Chronic Intentional Chronic liver Alzheimer Accidents Nephritis, disease pneumonia vascular vascular mellitus vascular lower self‐harm disease & disease (unintentional nephrotic 25,364 26,482 disease disease 779 disease respiratory (suicide) cirrhosis 7,431 injuries) syndrome & 133 93 diseases 3,793 7,734 11,195 nephrosis 576 5,027 14,891 9 Nephritis, Nephritis, Influenza & Chronic Cerebro‐ HIV HIV Septicemia Influenza & Septicemia Diabetes Accidents nephrotic nephrotic pneumonia lower vascular disease disease 2,269 pneumonia 6,715 mellitus (unintentional syndrome & syndrome & 114 respiratory disease 553 4,054 7,366 10,548 injuries) nephrosis nephrosis diseases 661 14,786 24,865 25,611 90 10 Influenza & Septicemia In situ, In situ, Congenital Chronic liver Viral Nephritis, Septicemia Influenza & Parkinson Hypertension pneumonia 18,743 benign, benign, anomalies disease & hepatitis nephrotic 6,768 pneumonia disease & hypertensive 23,615 & unknown & unknown 477 cirrhosis 3,306 syndrome & 5,919 8,291 renal disease* neoplasms neoplasms 466 nephrosis 10,756 97 90 2,087 HIV indicates human immunodeficiency virus. *Includes primary and secondary hypertension. 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. Source: US Final Mortality Data, 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2013. Table presents the number of deaths from all cancers combined and from the 5 most common sites for each 20‐year age group by sex. For all ages combined, men have a higher number of deaths for shared sites with the exception of pancreatic cancer, for which the burden is similar. Among males, leukemia is the leading cause of cancer death in those aged younger than 40 years, while lung cancer ranks first in men aged 40 years and older. Among females, leukemia is the leading cause of cancer death in children and adolescents (aged younger than 20 years), breast cancer ranks first in women aged 20 years to 59 years, and lung cancer causes the most cancer deaths in those aged 60 years and older. Five Leading Types of Cancer Death by Age and Sex, United States, 2010 ALL AGES <20 20 TO 39 40 TO 59 60 TO 79 ≥80 MALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 300,464 1,070 4,163 54,440 156,723 84,636 Lung & bronchus Leukemia Leukemia Lung & bronchus Lung & bronchus Lung & bronchus 87,699 293 550 14,687 52,233 20,504 Prostate Brain & ONS Brain & ONS* Colorectum Colorectum Prostate 28,561 272 503 5,645 13,272 15,188 Colorectum Bones & joints Colorectum Liver & bile duct Prostate Colorectum 27,074 92 442 4,458 11,949 7,708 Pancreas Soft tissue Non‐Hodgkin Pancreas Pancreas Urinary bladder 18,699 (including heart) lymphoma 3,748 10,371 4,766 83 276 Liver & intrahepatic Non‐Hodgkin Lung & bronchus Esophagus Liver & intrahepatic Pancreas bile duct lymphoma 266 2,737 bile duct 4,466 13,658 55 6,803 FEMALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 273,706 855 4,429 50,509 128,760 89,153 Lung & bronchus Leukemia Breast Breast Lung & bronchus Lung & bronchus 70,550 235 963 11,507 39,540 19,681 Breast Brain & ONS* Uterine cervix Lung & bronchus Breast Breast 40,996 226 430 11,082 17,375 11,151 Colorectum Bones & joints Leukemia Colorectum Colorectum Colorectum 24,972 74 395 4,185 9,855 10,588 Pancreas Soft tissue Colorectum Ovary Pancreas Pancreas 18,189 63 338 3,113 8,911 6,692 Ovary Liver & intrahepatic Brain & ONS* Pancreas Ovary Non‐Hodgkin 14,572 bile duct 309 2,506 7,338 lymphoma 25 4,144 ONS indicates other nervous system. Note: Ranking order excludes category titles that begin with “Other.” Regional Variations in Cancer Rates Tables and depict cancer incidence and death rates for selected cancers by state. Lung cancer shows the largest geographic variation in cancer occurrence by far, reflecting the large historical and continuing differences in smoking prevalence among states. For example, lung cancer incidence rates in Kentucky, which has historically had the highest smoking prevalence, are almost 4‐fold higher than those in Utah, which has the lowest smoking prevalence (126 vs 34 cases per 100,000 men). There is also a large range for prostate cancer incidence rates, from 112.7 in Arizona to 194.4 in the District of Columbia, which likely reflects state differences in PSA testing prevalence and racial distribution. In contrast, state variations for other cancer sites are smaller in both absolute and relative terms. For example, the breast cancer incidence rate ranges from 140 (per 100,000 population) in the District of Columbia to 109 in New Mexico, a difference of 28%. State variation in incidence rates reflects differences in the use of screening tests or detection practices in addition to differences in disease occurrence. Incidence Rates for Selected Cancers by State, United States, 2006 to 2010 ALL CANCERS BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PROSTATE URINARY BLADDER STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE MALE FEMALE Alabama 573.2 395.2 118.7 57.2 40.3 103.2 54.0 19.5 13.6 157.7 33.3 7.5 Alaska 521.0 430.3 127.7 53.1 44.5 83.8 60.4 21.8 16.1 137.3 38.0 9.8 Arizona 441.4 371.2 110.2 41.4 32.0 61.8 47.9 18.0 13.4 112.7 32.2 8.4 Arkansas 557.7 388.1 110.3 55.6 40.5 108.4 60.4 21.2 15.3 156.4 33.9 8.1 California 505.7 397.1 122.0 49.4 37.3 60.4 44.4 22.9 15.6 140.3 33.5 8.0 Colorado 483.1 396.4 125.3 43.6 33.6 56.1 44.2 22.5 15.9 142.7 31.2 8.2 Connecticut 576.2 456.9 136.3 51.3 39.2 75.5 59.5 25.2 17.3 160.0 46.8 12.6 Delaware 601.7 443.3 126.5 53.1 39.6 87.1 65.8 23.7 16.7 177.3 43.2 11.3 Dist. of Columbia 574.8 427.7 139.7 50.9 44.8 77.5 48.1 21.8 13.4 194.4 25.1 9.0 Florida 518.8 399.9 114.3 47.8 36.6 79.4 56.7 21.9 15.2 131.2 35.3 8.6 Georgia 568.7 403.1 121.5 52.1 38.4 93.3 55.0 21.5 14.8 165.7 33.9 7.9 Hawaii 484.4 393.4 123.1 56.9 38.0 64.3 38.7 20.7 13.7 119.9 25.8 6.3 Idaho 513.3 410.1 119.5 43.2 34.8 61.5 47.2 21.3 17.5 152.9 36.1 8.9 Illinois 566.6 440.3 126.4 59.1 43.4 86.7 60.9 24.0 16.4 153.9 39.4 9.9 Indiana 527.4 422.0 117.4 54.7 41.8 96.4 63.5 23.3 17.0 122.4 35.2 8.8 Iowa 555.7 437.1 123.4 56.9 44.3 84.7 54.9 26.8 18.9 137.2 41.7 8.8 Kansas 552.2 422.0 123.2 55.0 39.9 80.2 54.5 23.4 16.8 152.4 37.9 9.3 Kentucky 611.2 462.4 121.3 63.9 46.0 125.9 80.3 25.3 17.5 134.6 40.5 9.7 Louisiana 603.4 413.6 119.7 62.4 44.0 99.6 57.7 24.5 16.5 169.3 34.1 8.1 Maine 581.5 460.6 126.5 51.4 41.2 91.5 67.3 25.4 17.9 144.8 48.0 13.2 Maryland 529.1 415.0 128.0 47.6 36.7 74.4 55.8 21.3 15.0 157.2 33.4 9.2 Massachusetts 568.1 460.4 134.2 49.9 38.8 78.3 64.1 25.0 16.5 153.6 43.9 11.9 Michigan 574.1 433.5 120.0 51.0 39.3 86.1 61.6 24.9 17.7 163.7 41.3 10.7 Minnesota ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Mississippi 598.6 396.9 113.8 61.3 44.7 112.7 56.2 21.6 14.5 166.3 30.8 7.2 Missouri 530.8 423.3 121.5 55.3 40.8 95.6 64.3 22.3 16.0 126.2 34.8 8.4 Montana 520.8 421.9 124.1 51.1 39.0 68.9 56.3 22.8 15.0 155.2 36.4 9.9 Nebraska 526.2 420.9 122.3 57.7 44.4 74.6 51.2 23.5 17.7 143.0 35.0 8.6 Nevada 509.8 399.2 112.7 52.0 38.1 75.7 64.7 20.4 15.3 138.9 37.3 10.7 New Hampshire 580.3 452.1 132.0 46.7 38.0 80.1 62.2 25.1 17.1 155.4 49.1 13.2 New Jersey 582.6 450.6 129.3 54.7 41.2 72.8 55.3 25.2 17.8 169.2 43.6 11.6 New Mexico 461.9 362.5 108.8 44.1 33.6 52.9 38.1 18.2 13.8 134.1 26.2 6.2 New York 585.4 449.2 127.7 53.3 40.9 76.3 56.0 26.3 18.1 167.3 42.1 10.6 North Carolina 564.9 416.0 124.9 50.8 37.1 96.7 57.2 22.6 15.7 151.9 37.5 8.9 North Dakota 528.6 410.2 123.0 59.2 41.8 68.1 43.3 22.0 18.4 156.2 38.6 9.2 Ohio 548.1 425.4 120.5 55.5 42.2 92.6 60.7 23.0 16.1 145.2 38.7 9.6 Oklahoma 552.2 422.0 121.7 53.6 40.8 96.1 62.7 22.4 17.1 148.4 34.7 8.6 Oregon 508.8 429.2 129.5 45.5 36.8 70.6 57.6 22.8 15.3 139.3 37.1 9.5 Pennsylvania 573.6 454.8 126.0 56.0 42.8 84.4 57.9 25.2 17.8 149.5 44.1 11.0 Rhode Island 575.7 462.4 131.0 51.3 41.3 84.1 64.5 22.5 17.9 148.9 48.7 13.8 South Carolina 551.7 401.1 122.3 50.3 37.9 94.1 53.9 20.5 13.4 152.8 30.8 8.4 South Dakota 499.4 395.9 117.9 55.7 41.8 73.8 48.0 21.6 15.9 145.5 33.6 8.3 Tennessee 562.0 416.0 118.8 53.4 40.4 103.4 61.3 22.6 16.3 144.3 35.4 8.2 Texas 513.9 389.9 114.4 50.9 35.7 78.2 49.0 22.2 15.9 133.2 29.5 6.9 Utah 494.8 357.7 110.8 39.4 31.2 34.1 23.3 25.2 16.3 175.9 31.4 5.3 Vermont 539.8 453.8 131.4 44.8 38.3 81.2 65.6 24.1 17.7 139.9 40.5 12.2 Virginia 521.7 397.4 124.5 46.9 36.7 82.2 53.9 21.7 14.2 150.3 33.3 8.3 Washington 544.6 437.7 131.0 46.1 36.3 72.1 57.3 26.2 17.4 151.6 38.9 9.3 West Virginia 557.7 434.1 110.2 58.0 43.8 106.4 70.0 23.2 17.5 131.8 38.8 10.7 Wisconsin 530.8 419.2 122.5 48.4 37.5 73.6 53.4 24.3 17.3 142.9 39.2 9.7 Wyoming 497.1 384.2 110.8 47.5 37.7 57.3 46.0 19.8 15.0 152.2 38.7 9.9 United States 542.3 418.8 122.2 51.7 39.1 80.0 55.1 23.3 16.3 146.6 36.9 9.1 Rates are per 100,000 and age adjusted to the 2000 US standard population. 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 2006 to 2010 according to the North American Association of Central Cancer Registries (NAACCR). Rates are based on incidence data for 2006 to 2008. This state's registry did not submit cancer incidence data to the NAACCR. Rates are based on incidence data for 2006 to 2009. Death Rates for Selected Cancers by State, United States, 2006 to 2010 ALL SITES BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PANCREAS PROSTATE STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE Alabama 255.4 156.4 23.3 22.5 15.0 87.4 40.8 8.0 5.3 13.2 9.7 28.9 Alaska 210.5 161.0 24.2 19.6 15.1 61.8 45.8 7.6 5.5 12.9 9.8 22.5 Arizona 186.0 131.7 20.6 17.1 11.9 49.8 33.2 7.6 4.8 11.4 8.3 20.5 Arkansas 250.6 160.9 23.4 22.7 15.6 90.1 45.4 8.6 5.5 13.2 9.6 25.3 California 189.8 139.8 21.9 17.5 12.7 47.2 32.3 7.8 4.9 11.7 9.4 22.3 Colorado 181.4 133.2 19.6 16.7 12.4 44.2 31.3 7.8 4.4 10.8 9.0 22.9 Connecticut 199.5 144.7 21.6 16.2 12.1 52.7 38.2 7.5 4.9 13.9 9.9 22.3 Delaware 228.0 159.3 22.8 20.4 13.3 68.2 47.7 8.3 4.8 13.0 9.5 23.7 Dist. of Columbia 248.5 167.6 29.8 22.2 18.9 61.9 35.0 8.0 4.0 16.9 12.0 38.8 Florida 204.5 140.7 21.3 18.1 12.8 61.4 38.8 7.8 4.9 12.1 8.8 20.1 Georgia 228.3 147.8 23.4 20.2 13.8 73.1 38.7 7.6 4.5 12.5 9.1 27.1 Hawaii 178.4 117.1 16.4 17.3 10.9 48.8 25.9 7.2 4.3 12.3 9.7 15.7 Idaho 192.9 140.2 21.6 16.1 12.4 49.2 34.5 7.2 5.6 12.0 9.2 25.9 Illinois 223.3 158.5 23.6 21.7 15.4 65.8 41.9 8.5 5.3 13.0 10.1 24.3 Indiana 238.8 161.5 23.9 21.3 14.5 79.4 46.7 9.3 5.4 13.0 9.4 23.2 Iowa 212.6 148.4 21.3 20.0 15.2 64.1 38.3 8.9 5.5 12.2 8.8 22.7 Kansas 214.4 146.5 22.2 20.6 13.1 66.8 39.4 9.1 5.3 12.6 9.1 20.7 Kentucky 262.7 173.3 23.1 23.4 16.2 97.1 55.8 9.0 5.7 12.7 9.6 23.9 Louisiana 254.7 164.4 25.4 24.0 15.7 80.9 43.6 8.6 5.2 14.2 11.1 26.6 Maine 231.1 158.3 20.9 20.2 13.9 69.9 46.0 8.8 5.1 11.6 9.8 22.9 Maryland 216.9 154.0 24.5 20.5 14.0 61.7 40.8 7.4 4.5 12.9 10.3 25.0 Massachusetts 216.6 152.5 21.3 18.7 13.4 60.6 42.1 7.8 4.8 12.7 10.4 22.4 Michigan 223.0 159.5 24.0 19.4 14.2 68.2 43.9 8.9 5.8 13.9 10.2 21.8 Minnesota 203.9 145.0 20.9 17.6 12.6 53.3 37.0 9.4 5.2 11.9 9.3 23.9 Mississippi 270.6 159.1 24.7 24.8 16.5 95.4 42.0 8.3 4.7 14.1 10.1 31.2 Missouri 231.1 160.2 24.2 21.2 14.6 76.5 46.2 8.3 5.4 13.0 9.9 21.8 Montana 195.3 145.1 19.8 16.7 14.0 52.1 39.6 7.9 4.9 11.8 8.4 26.4 Nebraska 208.4 143.8 20.1 21.4 15.0 60.3 35.5 8.4 5.7 12.0 9.7 22.9 Nevada 211.4 153.6 23.0 21.0 14.9 59.7 46.5 7.1 4.6 12.6 9.7 23.9 New Hampshire 211.7 154.2 21.3 17.9 13.1 59.0 43.3 7.3 4.7 13.2 10.4 22.4 New Jersey 207.8 154.3 25.2 21.0 14.9 55.8 37.2 7.8 5.2 13.4 10.1 21.6 New Mexico 187.4 131.6 20.9 18.8 12.7 43.4 28.6 6.6 4.5 10.9 8.4 24.4 New York 199.7 145.4 22.3 19.2 13.8 54.3 36.1 7.9 4.9 12.8 9.9 21.8 North Carolina 232.2 149.9 23.1 19.4 13.1 76.6 40.7 7.5 5.0 12.0 9.6 25.8 North Dakota 203.6 137.2 21.6 21.2 13.9 54.1 32.2 6.7 5.1 12.6 8.3 23.6 Ohio 236.5 162.6 24.8 21.8 15.2 74.8 44.2 9.2 5.6 13.1 10.1 23.8 Oklahoma 238.8 161.0 23.9 22.1 14.5 79.6 46.6 9.0 6.0 12.2 8.9 23.5 Oregon 208.5 153.4 21.6 18.1 13.3 58.4 42.7 8.5 5.3 12.3 9.9 24.4 Pennsylvania 225.6 157.0 23.8 21.5 15.0 65.8 39.6 8.9 5.5 13.4 10.0 22.7 Rhode Island 221.8 149.6 20.8 18.6 13.2 64.9 42.6 8.3 4.4 12.2 8.9 20.6 South Carolina 240.1 151.7 23.5 20.2 14.2 77.1 39.9 7.8 4.7 12.7 9.8 27.5 South Dakota 206.8 141.3 20.3 19.8 13.9 61.9 34.1 7.8 5.3 11.1 9.3 23.4 Tennessee 256.4 160.4 23.3 21.8 15.3 89.5 46.6 9.2 5.4 13.1 9.4 25.2 Texas 209.3 141.8 21.8 20.0 13.1 60.7 35.4 7.9 4.9 11.8 8.8 21.3 Utah 157.1 112.3 21.8 14.3 10.7 27.5 16.8 7.7 4.7 10.0 8.4 25.9 Vermont 212.0 154.3 20.4 17.4 14.8 62.3 45.1 7.8 5.0 12.4 9.3 22.1 Virginia 221.1 151.4 24.0 19.2 14.0 67.1 40.0 8.2 4.8 12.7 9.7 24.7 Washington 207.2 152.2 21.5 17.1 12.5 57.0 42.1 8.6 5.4 12.7 10.0 24.2 West Virginia 246.9 168.6 22.1 23.4 16.1 84.3 50.9 8.7 6.6 11.3 7.8 20.9 Wisconsin 213.7 149.7 21.3 18.0 12.7 58.4 38.4 9.0 5.5 12.8 10.0 24.5 Wyoming 196.0 146.8 21.3 18.7 14.7 49.9 36.4 7.6 5.3 12.9 9.0 22.8 United States 215.3 149.7 22.6 19.6 13.9 63.5 39.2 8.2 5.1 12.5 9.6 23.0 Rates are per 100,000 and age adjusted to the 2000 US standard population. Cancer Occurrence by Race/Ethnicity Cancer incidence and death rates vary considerably between and within racial and ethnic groups. Of the 5 broadly defined groups in Table , black men have the highest cancer incidence and death rates–about double those of Asian Americans, who have the lowest rates. Cancer incidence and death rates are higher among black than white men for every site included in Table except kidney cancer mortality. Factors known to contribute to racial disparities vary by cancer site and include differences in exposure to underlying risk factors (eg, historical smoking prevalence for lung cancer), access to high‐quality screening (breast, cervical, and colorectal cancers), and timely diagnosis and treatment. It is notable that although white women have the highest breast cancer incidence rate, black women have the highest breast cancer mortality rate. The 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). The high breast cancer mortality rate among black women has been attributed to a higher prevalence of comorbidities, a longer time to follow‐up after an abnormal mammogram, less access to high‐quality treatment, and a higher prevalence of aggressive tumor characteristics. Incidence and Death Rates by Site, Race, and Ethnicity, United States, 2006 to 2010 NON‐HISPANIC WHITE BLACK ASIAN AMERICAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKA NATIVE HISPANIC Incidence All sites Male 548.6 601.0 326.1 441.1 426.8 Female 436.2 395.9 282.6 372.0 330.8 Breast (female) 127.3 118.4 84.7 90.3 91.1 Colorectum Male 50.9 62.5 40.8 51.7 47.3 Female 38.6 46.7 31.0 42.7 32.6 Kidney & renal pelvis Male 21.6 23.0 10.6 30.6 20.5 Female 11.2 12.2 5.1 17.5 11.5 Liver & intrahepatic bile duct Male 8.7 14.9 21.3 17.8 18.8 Female 2.9 4.4 8.0 8.0 6.9 Lung & bronchus Male 82.9 94.7 48.8 70.2 45.9 Female 59.9 50.4 28.0 52.1 26.6 Prostate 138.6 220.0 75.0 104.1 124.2 Stomach Male 7.8 15.7 15.6 13.1 13.9 Female 3.5 8.1 9.0 6.9 8.2 Uterine cervix 7.2 10.3 6.7 9.7 10.9 Mortality All sites Male 217.3 276.6 132.4 191.0 152.2 Female 153.6 171.2 92.1 139.0 101.3 Breast (female) 22.7 30.8 11.5 15.5 14.8 Colorectum Male 19.2 28.7 13.1 18.7 16.1 Female 13.6 19.0 9.7 15.4 10.2 Kidney & renal pelvis Male 5.9 5.7 3.0 9.5 5.1 Female 2.6 2.6 1.2 4.4 2.3 Liver & intrahepatic bile duct Male 7.1 11.8 14.4 13.2 12.3 Female 2.9 4.1 6.0 6.1 5.4 Lung & bronchus Male 65.7 78.5 35.5 49.6 31.3 Female 42.7 37.2 18.4 33.1 14.1 Prostate 21.3 50.9 10.1 20.7 19.2 Stomach Male 3.9 9.8 8.7 8.1 7.6 Female 1.9 4.7 5.1 3.8 4.4 Uterine cervix 2.1 4.2 1.9 3.5 2.9 Rates are per 100,000 population and age adjusted to the 2000 US standard population. Nonwhite race categories are not mutually exclusive of Hispanic origin. Data based on Indian Health Service Contract Health Service Delivery Areas. Cancer incidence and death rates are lower among Asian Americans/Pacific Islanders, American Indians/Alaska Natives, and Hispanics than 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 Asian American/Pacific Islander population as in whites, reflecting a higher prevalence of chronic infection with Helicobacter pylori and hepatitis B virus, respectively. Kidney cancer incidence and death rates are the highest among American Indians/Alaska Natives, which may be due in part to high rates of obesity and smoking in this population. Table presents trends in cancer incidence and death rates during the most recent 10 years for which there are data (2001‐2010) by race and ethnicity. These trends are based on rates that are not adjusted for reporting delays because the long‐term incidence data required for delay adjustment are not available for populations other than whites or blacks. Among men, incidence rates declined between 1.6% and 2.0% per year for all groups except American Indians/Alaska Natives. Declines in death rates among men were of a similar magnitude, and were highest among blacks (2.5% per year). Among women, incidence rate declines were smaller and were confined to non‐Hispanic whites (0.5% per year) and Hispanics (0.8% per year), though mortality declines of greater than 1.0% per year were experienced by all racial/ethnic groups except American Indians/Alaska Natives. As in men, black women had the largest annual decline in cancer death rates (1.7%). Average Annual Percent Change in Cancer Incidence and Mortality Rates From 2001 to 2010 by Race/Ethnicity, United States INCIDENCE MORTALITY MALE FEMALE MALE FEMALE All race/ethnicities ‐1.6 ‐0.3 ‐1.8 ‐1.4 Non‐Hispanic white ‐1.6 ‐0.5 ‐1.6 ‐1.3 Black ‐1.8 ‐0.1 ‐2.5 ‐1.7 Asian American/Pacific Islander ‐1.7 0.0 ‐1.6 ‐1.0 American Indian/Alaska Native ‐0.8 ‐0.2 ‐0.1 0.1 Hispanic ‐2.0 ‐0.8 ‐1.6 ‐1.4 Average annual percent change is statistically significant ( P < .05). Excludes deaths from Connecticut, District of Columbia, Maine, Maryland, Minnesota, New Hampshire, New York, North Dakota, Oklahoma, South Carolina, and Vermont due to unreliable Hispanic origin data for some years. Data based on Indian Health Service Contract Health Service Delivery Areas. Notes: Trends analyzed by the Joinpoint Regression Program, version 3.5.0, allowing up to 2 joinpoints. Incidence trends based on the North American Association of Central Cancer Registries (NAACCR) data. Nonwhite race categories are not mutually exclusive of Hispanic origin. Cancer Survival The stage‐specific 5‐year relative survival rate is lower for blacks than for whites for nearly every cancer type (Fig. ). Studies suggest that racial disparities in survival are primarily due to differences in treatment, stage at diagnosis, and comorbidities, as opposed to differences in cancer biology. As shown in Figure , blacks are less likely than whites to be diagnosed with cancer at a localized stage, when treatment is more successful. This disparity is particularly striking for cancers of the breast, cervix, uterine corpus, and oral cavity and pharynx. Lower socioeconomic status among blacks likely explains much of the stage disparity and is also associated with receipt of less aggressive treatment. Even among Medicare‐insured patients, blacks are less likely than whites to receive standard cancer therapies for lung, breast, colorectal, and prostate cancers. Five‐Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis, United States, 2003 to 2009. *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% for All Races, 97% for Whites, and 91% for blacks. Stage Distribution of Selected Cancers by Race, United States, 2003 to 2009. *The proportions of carcinoma in situ of the urinary bladder are 51% for All Races, 52% for Whites, and 38% for blacks. Stage categories do not sum to 100% because sufficient information is not available to assign a stage to all cancer cases. There have been notable improvements in survival over the past 3 decades for most cancers among both whites and blacks (Table ). Between 1975 and 1977 and 2003 and 2009, overall 5‐year relative survival rates increased 19 percentage points among whites and 22 percentage points among blacks. The largest improvements in survival have been for leukemia and non‐Hodgkin lymphoma, while lung and pancreatic cancers have shown the least improvement. Trends in 5‐Year Relative Survival Rates (%) by Race and Year of Diagnosis, United States, 1975 to 2009 ALL RACES WHITE BLACK 1975 TO 1977 1987 TO 1989 2003 TO 2009 1975 TO 1977 1987 TO 1989 2003 TO 2009 1975 TO 1977 1987 TO 1989 2003 TO 2009 All sites 49 55 68 50 57 69 39 43 61 Brain & other nervous system 22 29 35 22 28 33 25 32 41 Breast (female) 75 84 90 76 85 92 62 71 79 Colon 51 60 65 51 61 67 45 52 56 Esophagus 5 9 19 6 11 20 4 7 14 Hodgkin lymphoma 72 79 88 72 80 89 70 72 83 Kidney & renal pelvis 50 57 73 50 57 73 49 55 72 Larynx 66 66 63 67 67 64 58 56 52 Leukemia 34 43 59 35 44 60 33 35 53 Liver & intrahepatic bile duct 3 5 18 3 6 17 2 3 12 Lung & bronchus 12 13 18 12 13 18 11 11 14 Melanoma of the skin 82 88 93 82 88 93 57 79 77 Myeloma 25 27 45 24 27 45 30 30 44 Non‐Hodgkin lymphoma 47 51 71 47 51 72 48 46 64 Oral cavity 53 54 65 54 56 67 36 34 46 Ovary 36 38 44 35 38 44 42 34 36 Pancreas 2 4 6 3 3 7 2 6 6 Prostate 68 83 100 69 84 100 61 71 98 Rectum 48 58 68 48 59 68 44 52 62 Stomach 15 20 29 14 18 28 16 19 29 Testis 83 95 97 83 96 97 73 88 90 Thyroid 92 94 98 92 94 98 90 92 97 Urinary bladder 72 79 80 73 80 81 50 63 64 Uterine cervix 69 70 69 70 73 71 64 57 63 Uterine corpus 87 82 84 88 84 86 60 57 64 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 2003 to 2009, all followed through 2010. The difference in rates between 1975 to 1977 and 2003 to 2009 is statistically significant ( P < .05). The standard error of the survival rate is between 5 and 10 percentage points. Survival rate is for 1978 to 1980. Relative survival rates cannot be calculated for some minority populations because accurate life tables are not available. Comparison of cause‐specific survival rates for patients diagnosed from 2003 to 2009 indicates that Asian American/Pacific Islander women have the highest probability of surviving 5 years after a cancer diagnosis (69.5%), while American Indian/Alaska Native men have the lowest probability of surviving (56.8%). For both sexes combined, whites and Hispanics have the highest 5‐year cause‐specific survival (66.7%), while American Indians/Alaska Natives have the lowest (59.0%). Limitations The projected numbers of new cancer cases and cancer deaths should be interpreted with caution because they are model‐based estimates that may vary considerably from year to year for reasons other than changes in cancer occurrence. For instance, estimates are affected by changes in method, which are implemented regularly as modeling techniques improve and surveillance coverage becomes more complete. In addition, the model is sometimes oversensitive or undersensitive to abrupt or large changes in observed data. For these reasons, the projections are not an accurate measure of year‐to‐year changes in cancer occurrence and death. The data sources used for tracking cancer trends are age‐standardized or age‐specific cancer death rates from the NCHS and cancer incidence rates from SEER and/or the National Program of Cancer Registries. Nevertheless, the American Cancer Society projections of new cancer cases and deaths provide a reasonably accurate estimate of the current cancer burden in the United States. 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. It is also important to note that cancer data in the United States are primarily reported for broad racial and ethnic groups that are not homogenous, masking important differences in the cancer burden within these groups. Conclusions Cancer death rates have been continuously declining for the past 2 decades. Overall, the risk of dying from cancer decreased by 20% between 1991 and 2010. Progress has been most rapid for middle‐aged black men, among whom death rates have declined by approximately 50%. Despite this substantial progress, 5‐year survival rates among blacks continue to lag behind whites by as much as 22 percentage points for uterine cancer, 21 percentage points for cancer of the oral cavity, and 17 percentage points for urinary bladder cancer. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population, with an emphasis on those groups in the lowest socioeconomic bracket and other disadvantaged populations. ▪ http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png CA: A Cancer Journal for Clinicians Wiley

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Publisher
Wiley
Copyright
"© 2014 American Cancer Society, Inc."
ISSN
0007-9235
eISSN
1542-4863
DOI
10.3322/caac.21208
pmid
24399786
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Abstract

Introduction Cancer is a major public health problem in the United States and many other parts of the world. One in 4 deaths in the United States is due to cancer. In this article, we provide the expected numbers of new cancer cases and deaths in 2014 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 available. In addition, we estimate the total number of deaths averted since the early 1990s as a result of 2 decades of declining cancer death rates and present the actual number of deaths reported in 2010 by age for the 10 leading causes of death and the 5 leading causes of cancer death. Materials and Methods Incidence and Mortality Data Mortality data from 1930 to 2010 were obtained from the National Center for Health Statistics (NCHS). Population‐based cancer incidence data in the United States are collected both by the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) Program and the Centers for Disease Control and Prevention's (CDC's) National Program of Cancer Registries (NPCR). The SEER program reports long‐term (beginning in 1973), high‐quality incidence, prevalence, and survival data. Long‐term incidence and survival trends (1975‐2010) were based on data from the 9 oldest SEER areas (Connecticut, Iowa, Hawaii, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco‐Oakland, and Seattle‐Puget Sound), representing approximately 10% of the US population. As of 1992, SEER data have been available for 4 additional populations (Alaska Natives, Los Angeles County, San Jose‐Monterey, and rural Georgia) that increase the coverage of minority groups and allow for stratification by race and ethnicity. Data from these SEER 13 registries were the source for the annual percent change in incidence from 1992 to 2010. 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. Much of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review, 1975‐2010 . 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 or the NPCR. These data approach 100% coverage of the US population and were the source for incidence rates by state and race/ethnicity, as well as the projection of new cancer cases in 2014. Some of the data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2006‐2010 . All cancer cases were classified according to the International Classification of Diseases for Oncology . The lifetime probability of cancer was calculated using the NCI's DevCan software (version 6.7.0). 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 8.1.2). Cancer incidence rates in this report were adjusted for delays in reporting whenever possible. This adjustment, which is available only for SEER data, is based on historic patterns of case ascertainment and accounts for anticipated future corrections to registry data primarily due to a lag in case reporting. 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. For example, melanoma incidence rates adjusted for reporting delays are 14% higher than unadjusted rates in the most recent data year. Delay‐adjusted rates were obtained from the SEER Canques database ( surveillance.cancer.gov/delay/canques.html [accessed August 6, 2013]). Projected Cancer Cases and Deaths in 2014 The most recent year for which incidence and mortality data are available lags 3 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we project the numbers of new cancer cases and deaths in the United States in the current year in order to provide an estimate of the contemporary cancer burden. These estimates are not useful for tracking cancer occurrence over time because they are model‐based and because the calculation methodology changes every few years in order to take advantage of improvements in modeling techniques, increased cancer registration coverage, and updated risk factor surveillance. A 3‐step spatio‐temporal model was used to project the number of new invasive cancer cases that will be diagnosed in 2014 based on 1995 through 2010 high‐quality incidence data from 49 states and the District of Columbia, representing 89% population coverage. (All states did not meet high quality data standards for all years and Minnesota did not submit incidence data to NAACCR during the 2012 call for data.) This method accounts for expected delays in case reporting and considers geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence. First, complete incidence counts were estimated for each county from 1995 through 2010. Then these counts were adjusted to account for delays in cancer reporting. Finally, a temporal projection method (the vector autoregressive model) was applied to the last 15 years of data (1996‐2010) to estimate counts for 2014, which were then aggregated to obtain state‐level estimates. This method cannot estimate numbers of basal cell or squamous cell skin cancers because data on the occurrence of these cancers are not reported to cancer registries. For the complete details of the case projection methodology, please refer to Zhu et al. To estimate the number of in situ female breast and melanoma cases diagnosed in 2014, we first estimated the number of cases occurring annually from 2001 through 2010 by applying age‐specific SEER 13 incidence rates to the corresponding US population estimates provided in SEER*Stat. (Delay‐adjusted rates were available for in situ breast cancer but not for in situ melanoma.) We then projected the total number of cases in 2014 based on the average annual percent change in case counts from 2001 through 2010 generated by the joinpoint regression model. We estimated the number of cancer deaths expected to occur in 2014 in the United States overall and in each state using the joinpoint regression model based on the actual numbers of cancer deaths from 1995 through 2010 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al. Other Statistics The estimated number of cancer deaths averted in men and women due to the reduction in overall cancer death rates was calculated by first estimating the number of cancer deaths that would have occurred if 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 the subsequent years through 2010. Then the difference between the number of expected and recorded cancer deaths in each age group and calendar year was summed for men and women separately. Selected Findings Expected Numbers of New Cancer Cases Table presents the estimated numbers of new cases of invasive cancer expected among men and women in the United States in 2014. The overall estimate of 1,665,540 new cases is the equivalent of more than 4,500 new cancer diagnoses each day. About 62,570 cases of breast carcinoma in situ and 63,770 cases of melanoma in situ are expected to be newly diagnosed in 2014. The estimated numbers of new cancer cases by state for selected cancer sites are shown in Table . Estimated New Cancer Cases and Deaths by Sex, United States, 2014 ESTIMATED NEW CASES ESTIMATED DEATHS BOTH SEXES MALE FEMALE BOTH SEXES MALE FEMALE All sites 1,665,540 855,220 810,320 585,720 310,010 275,710 Oral cavity & pharynx 42,440 30,220 12,220 8,390 5,730 2,660 Tongue 13,590 9,720 3,870 2,150 1,450 700 Mouth 11,920 7,150 4,770 2,070 1,130 940 Pharynx 14,410 11,550 2,860 2,540 1,900 640 Other oral cavity 2,520 1,800 720 1,630 1,250 380 Digestive system 289,610 162,730 126,880 147,260 84,970 62,290 Esophagus 18,170 14,660 3,510 15,450 12,450 3,000 Stomach 22,220 13,730 8,490 10,990 6,720 4,270 Small intestine 9,160 4,880 4,280 1,210 640 570 Colon 96,830 48,450 48,380 50,310 26,270 24,040 Rectum 40,000 23,380 16,620 Anus, anal canal, & anorectum 7,210 2,660 4,550 950 370 580 Liver & intrahepatic bile duct 33,190 24,600 8,590 23,000 15,870 7,130 Gallbladder & other biliary 10,650 4,960 5,690 3,630 1,610 2,020 Pancreas 46,420 23,530 22,890 39,590 20,170 19,420 Other digestive organs 5,760 1,880 3,880 2,130 870 1,260 Respiratory system 242,550 130,000 112,550 163,660 90,280 73,380 Larynx 12,630 10,000 2,630 3,610 2,870 740 Lung & bronchus 224,210 116,000 108,210 159,260 86,930 72,330 Other respiratory organs 5,710 4,000 1,710 790 480 310 Bones & joints 3,020 1,680 1,340 1,460 830 630 Soft tissue (including heart) 12,020 6,550 5,470 4,740 2,550 2,190 Skin (excluding basal & squamous) 81,220 46,630 34,590 12,980 8,840 4,140 Melanoma‐skin 76,100 43,890 32,210 9,710 6,470 3,240 Other nonepithelial skin 5,120 2,740 2,380 3,270 2,370 900 Breast 235,030 2,360 232,670 40,430 430 40,000 Genital system 338,450 243,460 94,990 58,970 30,180 28,790 Uterine cervix 12,360 12,360 4,020 4,020 Uterine corpus 52,630 52,630 8,590 8,590 Ovary 21,980 21,980 14,270 14,270 Vulva 4,850 4,850 1,030 1,030 Vagina & other genital, female 3,170 3,170 880 880 Prostate 233,000 233,000 29,480 29,480 Testis 8,820 8,820 380 380 Penis & other genital, male 1,640 1,640 320 320 Urinary system 141,610 97,420 44,190 30,350 20,610 9,740 Urinary bladder 74,690 56,390 18,300 15,580 11,170 4,410 Kidney & renal pelvis 63,920 39,140 24,780 13,860 8,900 4,960 Ureter & other urinary organs 3,000 1,890 1,110 910 540 370 Eye & orbit 2,730 1,440 1,290 310 130 180 Brain & other nervous system 23,380 12,820 10,560 14,320 8,090 6,230 Endocrine system 65,630 16,600 49,030 2,820 1,300 1,520 Thyroid 62,980 15,190 47,790 1,890 830 1,060 Other endocrine 2,650 1,410 1,240 930 470 460 Lymphoma 79,990 43,340 36,650 20,170 11,140 9,030 Hodgkin lymphoma 9,190 5,070 4,120 1,180 670 510 Non‐Hodgkin lymphoma 70,800 38,270 32,530 18,990 10,470 8,520 Myeloma 24,050 13,500 10,550 11,090 6,110 4,980 Leukemia 52,380 30,100 22,280 24,090 14,040 10,050 Acute lymphocytic leukemia 6,020 3,140 2,880 1,440 810 630 Chronic lymphocytic leukemia 15,720 9,100 6,620 4,600 2,800 1,800 Acute myeloid leukemia 18,860 11,530 7,330 10,460 6,010 4,450 Chronic myeloid leukemia 5,980 3,130 2,850 810 550 260 Other leukemia 5,800 3,200 2,600 6,780 3,870 2,910 Other & unspecified primary sites 31,430 16,370 15,060 44,680 24,780 19,900 Rounded to the nearest 10; estimated new cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. About 62,570 carcinoma in situ of the female breast and 63,770 melanoma in situ will be newly diagnosed in 2014. Estimated deaths for colon and rectum cancers are combined. 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. Incidence Rates for All Cancers Combined (2006‐2010) and Estimated New Cases for Selected Cancers (2014) by State STATE INCIDENCE RATE ALL CASES FEMALE BREAST UTERINE CERVIX COLON & RECTUM UTERINE CORPUS LEUKEMIA LUNG & BRONCHUS MELANOMA OF THE SKIN NON‐HODGKIN LYMPHOMA PROSTATE URINARY BLADDER Alabama 469.6 26,770 3,660 210 2,350 650 690 4,160 1,320 990 3,760 990 Alaska 469.3 3,750 450 280 100 100 430 90 140 530 150 Arizona 401.1 32,830 4,520 210 2,560 910 950 4,280 1,430 1,320 4,390 1,490 Arkansas 460.6 16,520 2,050 140 1,500 400 480 2,660 490 660 2,240 640 California 442.2 171,730 26,130 1,550 13,930 5,650 5,650 18,780 8,440 7,770 23,010 7,210 Colorado 432.5 23,810 3,780 160 1,720 750 870 2,540 1,400 1,060 3,680 1,040 Connecticut 505.7 22,070 3,160 120 1,650 790 610 2,730 1,090 920 3,120 1,170 Delaware 511.7 5,320 760 420 180 150 790 290 220 800 260 Dist. of Columbia 486.9 2,840 430 250 100 60 320 80 100 510 80 Florida 452.0 114,560 15,480 960 10,230 3,410 3,810 17,960 5,320 5,050 16,590 5,800 Georgia 471.3 47,390 7,010 420 3,940 1,310 1,370 6,540 2,180 1,820 7,600 1,710 Hawaii 430.1 6,640 1,090 60 700 270 220 890 410 300 810 250 Idaho 455.6 7,990 1,100 50 610 230 290 960 450 360 1,320 390 Illinois 491.2 66,840 9,230 470 5,530 2,290 2,180 9,100 2,440 2,890 8,820 3,090 Indiana 464.0 35,560 4,590 260 3,020 1,070 1,060 5,540 1,550 1,480 4,390 1,600 Iowa 485.6 17,630 2,320 100 1,580 610 640 2,330 980 800 2,340 830 Kansas 476.8 14,630 2,090 100 1,120 470 490 1,900 780 650 1,980 620 Kentucky 523.2 25,770 3,370 200 2,170 720 790 4,690 1,540 1,070 3,280 1,100 Louisiana 494.1 24,300 3,160 200 2,270 540 720 3,470 750 960 3,720 940 Maine 511.1 9,270 1,220 50 700 340 310 1,400 440 380 1,160 540 Maryland 462.0 30,680 4,570 230 2,500 1,020 800 3,990 1,400 1,210 5,000 1,280 Massachusetts 503.3 37,940 5,560 200 2,800 1,320 1,140 4,930 1,800 1,600 5,600 2,030 Michigan 492.3 58,610 7,660 340 4,570 2,010 1,830 8,090 2,830 2,500 8,740 2,930 Minnesota ‐ 29,340 3,820 130 2,240 950 1,050 3,070 1,030 1,240 3,870 1,220 Mississippi 480.9 15,740 2,130 140 1,510 360 410 2,420 560 560 2,210 540 Missouri 467.7 33,890 4,610 240 2,970 1,090 1,040 5,370 1,510 1,430 4,010 1,530 Montana 466.3 5,850 860 500 180 200 760 290 260 1,010 300 Nebraska 464.5 9,550 1,360 60 880 320 330 1,220 460 440 1,250 430 Nevada 448.7 14,450 1,880 120 1,290 350 440 2,040 470 550 1,890 680 New Hampshire 507.2 8,450 1,150 600 300 250 1,110 400 350 1,160 460 New Jersey 503.7 51,130 7,290 380 4,280 1,820 1,560 6,130 2,590 2,250 7,320 2,510 New Mexico 405.9 10,210 1,450 80 830 300 370 1,060 470 400 1,400 400 New York 504.1 107,200 15,230 850 8,590 4,040 3,460 13,720 4,240 4,720 15,440 5,330 North Carolina 477.2 52,550 7,580 380 4,230 1,570 1,550 7,850 2,540 2,110 7,580 2,170 North Dakota 460.0 3,730 510 350 110 130 400 160 160 460 180 Ohio 474.7 67,000 8,710 400 5,450 2,280 1,890 9,760 3,170 2,860 8,690 3,110 Oklahoma 475.8 19,830 2,700 160 1,760 530 660 3,320 650 850 2,570 830 Oregon 462.2 22,530 3,320 130 1,540 720 640 2,950 1,440 960 3,200 1,080 Pennsylvania 502.6 79,920 10,660 500 6,790 2,840 2,420 10,290 3,820 3,420 10,930 4,070 Rhode Island 506.5 6,370 870 500 230 180 870 260 250 840 340 South Carolina 463.8 26,390 3,750 210 2,200 750 790 4,130 1,350 1,030 4,000 1,100 South Dakota 439.7 4,490 600 410 150 160 540 200 200 590 210 Tennessee 475.8 36,570 4,840 290 3,030 930 1,040 5,980 1,910 1,470 4,670 1,510 Texas 441.5 115,730 16,080 1,140 9,760 3,130 4,190 14,890 3,420 5,030 15,900 4,190 Utah 418.6 10,780 1,440 60 650 350 390 650 770 490 1,780 420 Vermont 489.8 4,130 560 290 140 110 550 220 160 580 210 Virginia 449.0 40,970 6,170 290 3,280 1,300 1,080 5,580 2,130 1,640 6,330 1,700 Washington 483.0 38,230 5,620 230 2,670 1,160 1,250 4,630 2,410 1,710 5,380 1,730 West Virginia 484.6 11,700 1,350 90 1,060 380 330 2,090 540 480 1,450 570 Wisconsin 466.0 32,480 4,330 190 2,520 1,140 1,150 4,020 1,440 1,410 4,630 1,580 Wyoming 435.0 2,890 420 240 90 90 330 150 120 490 140 United States 469.6 1,665,540 232,670 12,360 136,830 52,630 52,380 224,210 76,100 70,800 233,000 74,690 Rounded to the nearest 10; excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder. Rates are per 100,000 and age adjusted to the 2000 US standard population. US rate excludes cases from Arkansas, Minnesota, Nevada, Ohio, and Virginia. Estimate is fewer than 50 cases. High‐quality incidence data were not available for all 5 years. Arkansas rate is based on cases diagnosed during 2006 to 2008; Nevada and Ohio rates are based on 2006 to 2009. Incidence data were not available. Note: These model‐based estimates are offered as a rough guide and should be interpreted with caution. State estimates may not add to US total due to rounding. Figure indicates the most common cancers expected to occur in men and women in 2014. Among men, cancers of the prostate, lung and bronchus, and colorectum will account for about 50% of all newly diagnosed cancers. Prostate cancer alone will account for 27% (233,000) of incident cases in men. The 3 most commonly diagnosed types of cancer among women in 2014 will be breast, lung and bronchus, and colorectum, accounting for one‐half of all cases in women. Breast cancer alone is expected to account for 29% (232,670) of all new cancers among women. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2014. *Estimates are rounded to the nearest 10 and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. Expected Numbers of Cancer Deaths Table also shows the expected numbers of deaths from cancer projected for 2014. It is estimated that about 585,720 Americans will die from cancer this year, corresponding to about 1,600 deaths per day. Cancers of the lung and bronchus, prostate, and colorectum in men and cancers of the lung and bronchus, breast, and colorectum in women continue to be the most common causes of cancer death. These 4 cancers account for almost half of the total cancer deaths among men and women (Fig. ), with more than one‐quarter of all cancer deaths due to lung cancer. Table provides the estimated numbers of cancer deaths in 2014 by state for selected cancer sites. Death Rates for All Cancers Combined (2006‐2010) and Estimated Deaths for Selected Cancers (2014) by State STATE DEATH RATE ALL SITES BRAIN & OTHER NERVOUS SYSTEM FEMALE BREAST COLON & RECTUM LEUKEMIA LIVER & INTRAHEPATIC BILE DUCT LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA OVARY PANCREAS PROSTATE Alabama 196.4 10,510 270 690 950 410 350 3,310 310 280 630 540 Alaska 182.5 990 70 90 270 60 60 Arizona 155.2 11,400 310 780 990 500 470 2,840 390 310 790 640 Arkansas 198.0 6,730 150 420 620 270 210 2,200 200 140 400 310 California 160.3 57,950 1,590 4,270 5,150 2,510 3,140 12,590 2,000 1,560 4,150 3,380 Colorado 152.8 7,480 240 530 670 330 300 1,720 240 240 510 450 Connecticut 166.4 6,880 180 470 460 290 250 1,760 220 180 520 390 Delaware 187.7 1,980 120 160 70 90 600 60 50 130 90 Dist. of Columbia 199.0 1,010 80 100 60 230 80 80 Florida 168.4 42,740 920 2,770 3,560 1,760 1,620 12,050 1,430 940 2,890 2,170 Georgia 179.2 16,320 380 1,220 1,480 620 590 4,690 460 430 1,040 800 Hawaii 143.7 2,450 140 230 90 140 580 80 60 210 120 Idaho 162.8 2,730 80 180 210 130 80 670 90 60 210 180 Illinois 183.9 24,020 540 1,610 2,190 1,020 810 6,570 780 560 1,610 1,190 Indiana 192.6 13,370 310 860 1,090 550 380 4,140 440 310 840 580 Iowa 174.3 6,380 190 390 570 280 190 1,780 230 180 410 330 Kansas 174.7 5,460 150 370 480 260 170 1,560 200 140 370 250 Kentucky 209.5 10,130 210 590 850 370 280 3,570 300 200 570 390 Louisiana 201.3 9,040 200 640 840 330 400 2,650 260 190 600 400 Maine 187.7 3,300 90 190 250 130 110 970 100 60 200 160 Maryland 179.0 10,500 240 820 890 390 400 2,760 300 270 760 550 Massachusetts 177.6 12,810 310 790 990 510 550 3,500 400 320 920 630 Michigan 185.1 20,800 550 1,400 1,680 910 710 5,990 720 480 1,480 890 Minnesota 168.9 9,750 260 620 780 460 360 2,480 340 240 650 540 Mississippi 203.5 6,350 140 420 640 250 240 1,990 180 120 380 330 Missouri 189.2 12,870 310 910 1,090 540 450 3,950 390 250 860 550 Montana 166.3 2,000 50 130 170 90 50 520 70 60 130 130 Nebraska 170.7 3,480 100 210 340 140 100 900 130 80 240 200 Nevada 179.0 4,790 140 380 480 190 220 1,420 140 100 370 280 New Hampshire 177.3 2,670 70 170 200 100 80 750 80 60 190 130 New Jersey 175.0 16,350 350 1,290 1,510 630 600 3,970 510 440 1,220 760 New Mexico 155.5 3,600 90 260 350 140 170 790 110 90 240 220 New York 166.6 34,440 790 2,390 2,970 1,440 1,470 8,790 1,110 910 2,540 1,760 North Carolina 182.8 18,980 410 1,310 1,500 720 660 5,700 560 430 1,190 920 North Dakota 164.8 1,270 90 130 60 310 80 80 Ohio 192.4 25,260 600 1,720 2,140 990 790 7,370 810 570 1,730 1,200 Oklahoma 193.3 7,980 200 510 690 320 280 2,440 270 180 470 370 Oregon 176.3 7,940 230 510 660 320 340 2,090 280 220 550 440 Pennsylvania 184.5 28,670 610 1,940 2,490 1,200 980 7,600 1,010 730 1,990 1,370 Rhode Island 177.5 2,140 50 130 160 90 80 580 60 50 130 100 South Carolina 187.6 9,950 220 670 840 360 370 2,970 280 230 610 510 South Dakota 168.4 1,610 50 110 150 70 50 440 50 110 90 Tennessee 199.1 14,280 350 910 1,220 540 500 4,630 440 290 820 630 Texas 169.7 37,830 950 2,700 3,430 1,530 2,080 9,600 1,230 900 2,440 1,660 Utah 131.3 2,870 110 270 250 150 100 460 120 80 240 210 Vermont 177.9 1,340 80 100 50 60 390 90 70 Virginia 179.3 14,750 350 1,090 1,240 570 520 4,110 460 380 1,010 730 Washington 175.0 12,550 380 820 970 540 550 3,270 430 360 880 730 West Virginia 201.2 4,680 100 270 420 170 120 1,480 160 100 230 190 Wisconsin 175.6 11,360 310 710 860 550 390 3,000 400 300 800 630 Wyoming 167.8 990 60 90 70 250 80 40 United States 176.4 585,720 14,320 40,000 50,310 24,090 23,000 159,260 18,990 14,270 39,590 29,480 Rounded to the nearest 10. Rates are per 100,000 and age adjusted to the 2000 US standard population. Estimate is fewer than 50 deaths. Note: State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 deaths. Lifetime Probability of Developing Cancer The lifetime probability of being diagnosed with an invasive cancer is higher for men (44%) than for women (38%) (Table ). However, because of the earlier median age at diagnosis for breast cancer (61 years) compared with prostate (66 years) and other major cancers, women have a slightly higher probability of developing cancer than men before age 65 years. These estimates are 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. Probability (%) of Developing Invasive Cancers Within Selected Age Intervals by Sex, United States, 2008 to 2010 BIRTH TO 49 50 TO 59 60 TO 69 70 AND OLDER BIRTH TO DEATH All sites Male 3.5 (1 in 29) 6.8 (1 in 15) 15.4 (1 in 6) 36.9 (1 in 3) 43.9 (1 in 2) Female 5.4 (1 in 19) 6.0 (1 in 17) 10.1 (1 in 10) 26.7 (1 in 4) 38.0 (1 in 3) Kidney & renal pelvis Male 0.2 (1 in 480) 0.3 (1 in 289) 0.6 (1 in 154) 1.3 (1 in 75) 2.1 (1 in 49) Female 0.1 (1 in 753) 0.2 (1 in 586) 0.3 (1 in 317) 0.7 (1 in 134) 1.2 (1 in 83) Breast Female 1.9 (1 in 53) 2.3 (1 in 43) 3.5 (1 in 29) 6.7 (1 in 15) 12.3 (1 in 8) Colorectum Male 0.3 (1 in 305) 0.7 (1 in 144) 1.3 (1 in 76) 4.0 (1 in 25) 5.0 (1 in 20) Female 0.3 (1 in 334) 0.5 (1 in 189) 0.9 (1 in 109) 3.7 (1 in 27) 4.6 (1 in 22) Leukemia Male 0.2 (1 in 421) 0.2 (1 in 614) 0.4 (1 in 279) 1.3 (1 in 76) 1.7 (1 in 60) Female 0.2 (1 in 526) 0.1 (1 in 979) 0.2 (1 in 475) 0.8 (1 in 120) 1.2 (1 in 86) Lung & bronchus Male 0.2 (1 in 548) 0.7 (1 in 134) 2.1 (1 in 47) 6.7 (1 in 15) 7.6 (1 in 13) Female 0.2 (1 in 522) 0.6 (1 in 171) 1.6 (1 in 62) 4.9 (1 in 20) 6.3 (1 in 16) Melanoma of the skin Male 0.4 (1 in 284) 0.4 (1 in 134) 0.8 (1 in 129) 2.1 (1 in 48) 2.9 (1 in 34) Female 0.5 (1 in 206) 0.3 (1 in 313) 0.4 (1 in 243) 0.9 (1 in 113) 1.9 (1 in 53) Non‐Hodgkin lymphoma Male 0.3 (1 in 357) 0.3 (1 in 338) 0.6 (1 in 171) 1.8 (1 in 56) 2.4 (1 in 42) Female 0.2 (1 in 537) 0.2 (1 in 475) 0.4 (1 in 233) 1.4 (1 in 71) 1.9 (1 in 52) Prostate Male 0.3 (1 in 298) 2.3 (1 in 43) 6.4 (1 in 16) 11.2 (1 in 9) 15.3 (1 in 7) Uterine cervix Female 0.3 (1 in 348) 0.1 (1 in 812) 0.1 (1 in 824) 0.2 (1 in 619) 0.7 (1 in 154) Uterine corpus Female 0.3 (1 in 370) 0.6 (1 in 171) 0.9 (1 in 111) 1.3 (1 in 78) 2.7 (1 in 37) For people free of cancer at beginning of age interval. All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder. Probabilities for whites only. Trends in Cancer Incidence Figures and illustrate long‐term trends in cancer incidence rates for all cancers combined and for selected cancer sites by sex. Trends since 1992 are presented in Table in terms of the annual percent change in rates using 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. Trends in Cancer Incidence and Death Rates by Sex, United States, 1975 to 2010. Rates are age adjusted to the 2000 US standard population. Incidence rates are adjusted for delays in reporting. Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2010. Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting. *Includes intrahepatic bile duct. Trends in Cancer Incidence (Delay‐Adjusted) and Death Rates for Selected Cancers by Sex, United States, 1992 to 2010 TREND 1 TREND 2 TREND 3 TREND 4 2006–2010 YEARS APC YEARS APC YEARS APC YEARS APC AAPC All sites Incidence Overall 1992‐1994 ‐3.2 1994‐1998 0.4 1998‐2010 ‐0.4 ‐0.4 Male 1992‐1994 ‐5.6 1994‐2010 ‐0.6 ‐0.6 Female 1992‐1994 ‐0.4 1994‐1998 1.2 1998‐2003 ‐0.8 2003‐2010 0.1 0.1 Death Overall 1992‐2001 ‐1.0 2001‐2010 ‐1.5 ‐1.5 Male 1992‐2001 ‐1.4 2001‐2010 ‐1.8 ‐1.8 Female 1992‐1995 ‐0.2 1995‐1998 ‐1.2 1998‐2001 ‐0.4 2001‐2010 ‐1.4 ‐1.4 Lung & bronchus Incidence Male 1992‐2010 ‐1.9 ‐1.9 Female 1992‐1998 0.8 1998‐2001 ‐1.3 2001‐2005 0.7 2005‐2010 ‐1.2 ‐1.2 Death Male 1992‐2005 ‐1.9 2005‐2010 ‐2.9 ‐2.9 Female 1992‐1996 1.1 1996‐2004 0.2 2004‐2010 ‐1.4 ‐1.4 Colorectum Incidence Male 1992‐1995 ‐2.6 1995‐1998 1.4 1998‐2008 ‐2.5 2008‐2010 ‐4.2 ‐3.3 Female 1992‐1995 ‐1.8 1995‐1998 1.8 1998‐2008 ‐1.9 2008‐2010 ‐4.1 ‐3.0 Death Male 1992‐2002 ‐2.0 2002‐2005 ‐4.0 2005‐2010 ‐2.5 ‐2.5 Female 1992‐2001 ‐1.7 2001‐2010 ‐3.0 ‐3.0 Liver & intrahepatic bile duct Incidence Male 1992‐2010 3.7 3.7 Female 1992‐2010 2.9 2.9 Death Male 1992‐2010 2.3 2.3 Female 1992‐2010 1.4 1.4 Melanoma of skin Incidence Male 1992‐2010 2.4 2.4 Female 1992‐1997 3.9 1997‐2010 1.7 1.7 Death Male 1992‐2010 0.4 0.4 Female 1992‐2010 ‐0.5 ‐0.5 Thyroid Incidence Male 1992‐1996 ‐0.9 1996‐2010 5.4 5.4 Female 1992‐1998 3.9 1998‐2010 6.5 6.5 Death Male 1992‐2010 1.6 1.6 Female 1992‐1994 ‐6.4 1994‐2010 0.9 0.9 Female breast Incidence 1992‐1999 1.3 1999‐2004 ‐2.2 2004‐2010 0.2 0.2 Death 1992‐1995 ‐1.3 1995‐1998 ‐3.4 1998‐2010 ‐1.9 ‐1.9 Prostate Incidence 1992‐1995 ‐11.2 1995‐2000 2.2 2000‐2010 ‐2.0 ‐2.0 Death 1992‐1994 ‐1.0 1994‐2004 ‐3.8 2004‐2010 ‐3.1 ‐3.1 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. The APC or AAPC is significantly different from zero ( P < .05). Note: Trends analyzed by the Joinpoint Regression Program, version 4.0.3, allowing up to 3 joinpoints. Incidence trends based on Surveillance, Epidemiology, and End Results (SEER) 13 areas. The overall cancer incidence rate is 23% lower among women compared with men. However, during the past 5 years for which there are data (2006‐2010), the incidence rate decreased by 0.6% per year among males but remained stable in females (Table ). The decrease in men is driven by the rapid declines in colorectal (3.3% per year), prostate (2.0% per year), and lung (1.9% per year) cancers. Among women, although colorectal cancer declines are similar to those in men, the lung cancer rate has been slow to decline and breast cancer incidence rates have remained relatively flat since 2003 (Fig. ). Declines in incidence rates for the major cancers reflect improvements in cancer control and prevention. 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. However, the rapid declines in recent years (eg, greater than 4.0% per year from 2008‐2010) have been attributed to the increased uptake of colonoscopy, which prevents cancer by allowing for the removal of precancerous lesions. Prostate cancer incidence rates have been generally declining since around 2000, although rates have fluctuated widely from year to year (Fig. ), likely reflecting variation in the prevalence of prostate‐specific antigen testing for the detection of prostate cancer. Lung cancer incidence rates began declining in the mid‐1980s in men and in the late 1990s in women as a result of reduced smoking prevalence. Differences in lung cancer incidence patterns between men and women (Fig. ) reflect historical differences in tobacco use; cigarette smoking prevalence peaked about 20 years later in women than in men. In contrast to the stable or declining trends for most cancer types, incidence rates are increasing for melanoma of the skin; esophageal adenocarcinoma; cancers of the thyroid, liver, kidney, anus, and pancreas; and human papillomavirus‐positive oropharyngeal cancers. Among both men and women, the largest annual increases from 2006 to 2010 were for cancers of the thyroid (5.4% and 6.5% in men and women, respectively) and liver (3.7% and 2.9% in men and women, respectively) (Table ). Trends in Cancer Mortality The overall cancer death rate rose for most of the 20th century, peaking at 215.1 deaths per 100,000 population in 1991. This increase was largely driven by rapid increases in lung cancer deaths among men as a consequence of the tobacco epidemic. Over the past 2 decades, however, there has been a steady decline in the cancer death rate (to 171.8 in 2010) as a result of advances in prevention, early detection, and treatment, including the implementation of comprehensive tobacco control. As a result of this 20% decline, an estimated 1,340,400 cancer deaths (952,700 in men and 387,700 in women) that would have occurred had peak rates persisted have been averted (Fig. ). Total Number of Cancer Deaths Averted From 1991 to 2010 in Men and From 1992 to 2010 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. Overall declines in the cancer death rate from 1991 to 2010 occurred among white women (16%), black women (20%), white men (24%), and black men (33%). Figure illustrates the variation in the magnitude of the declines by race, sex, and 10‐year age group. Downturns occurred for black and white men and women of all ages with the exception of white women aged 80 years and older. Notably, black males experienced the largest drop in death rates in every age group. The sharpest decrease (44%–55%) occurred among black men aged 30 years to 59 years. In general, middle‐aged men and women experienced the largest declines, particularly compared with adults aged 70 years and older. The smaller declines among seniors reflect the lingering effects of the tobacco epidemic on older birth cohorts. Progress is more stunted among women than men in this generation because of the later onset and more protracted decline in smoking prevalence among women. Relative Decline in Cancer Death Rates From 1991 to 2010 by Age, Race, and Sex. The relative decline is the difference between the 2010 and 1991 rate expressed as a percentage of the 1991 rate. Figure depicts long‐term trends in cancer death rates among men and women overall and for selected cancer sites. 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. a). It is also interesting to note that prior to 1941, men had a lower risk of dying from cancer than women 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 2010, largely due to the widespread uptake of screening for the prevention and early detection of cervical cancer. A similar dramatic decline occurred for stomach cancer, which accounted for 30% and 20% of male and female cancer deaths, respectively, in the 1930s. By 2010, stomach cancer accounted for just 2% of cancer deaths. Rates of stomach cancer have declined worldwide due to improved hygiene, resulting in a lower prevalence of Helicobacter pylori , and advances in food preservation techniques (eg, refrigeration), which have led to lower salt intake and higher consumption of fresh fruits and vegetables. Trends in Death Rates Overall and for Selected Sites by Sex, United States, 1930 to 2010. 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, uterus, and ovary are affected by these changes. *Uterus includes uterine cervix and uterine corpus. During the most recent 5 years for which data are available, the average annual decline in cancer death rates was slightly larger among men (1.8%) than women (1.4%) (Fig. ) (Table ). These declines are driven by continued decreases in death rates for the 4 major cancer sites (Fig. ). Due to the reduction in tobacco use over the past 50 years, the lung cancer death rate declined 34% between 1991 and 2010 among males and 9% between 2002 and 2010 among females. Death rates for breast, prostate, and colorectal cancers are down from peak rates by 34%, 45%, and 46%, respectively, as a result of improvements in early detection and treatment. In contrast, joinpoint trend analysis for 2001 to 2010 indicates that death rates are rising for cancers of the oropharynx, anus, liver, pancreas, and soft tissue (including the heart), and for melanoma in men. The rate of death from thyroid cancer is also increasing according to joinpoint analysis (Table ), although the observed rates increased only slightly from 0.47 (per 100,000 population) to 0.50 among men and from 0.48 to 0.51 among women. Recorded Number of Deaths in 2010 A total of 2,468,435 deaths were recorded in the United States in 2010, of which 574,743 (23%) were from cancer. Overall, cancer is the second leading cause of death following heart disease. However, within 20‐year age groups, cancer is the leading cause of death among adults aged 40 years to 79 years (Table ). Among females, cancer is the first or second leading cause of death in every age group. Ten Leading Causes of Death by Age and Sex, United States, 2010 ALL AGES AGES 1 TO 19 AGES 20 TO 39 AGES 40 TO 59 AGES 60 TO 79 AGES ≥80 MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes 1,232,432 1,236,003 13,380 7,102 60,730 28,205 224,613 140,576 475,230 376,110 444,690 673,087 1 Heart diseases 307,384 Heart diseases 290,305 Accidents (unintentional injuries) 5,124 Accidents (unintentional injuries) 2,450 Accidents (unintentional injuries) 21,504 Accidents (unintentional injuries) 7,818 Cancer 54,440 Cancer 50,509 Cancer 156,723 Cancer 128,760 Heart diseases 131,682 Heart diseases 193,291 2 Cancer 301,037 Cancer 273,706 Assault (homicide) 1,978 Cancer 824 Intentional self‐harm (suicide) 9,463 Cancer 4,429 Heart diseases 52,472 Heart diseases 21,458 Heart diseases 117,385 Heart diseases 72,817 Cancer 84,636 Cancer 89,153 3 Accidents (unintentional injuries) 75,921 Cerebro‐vascular diseases 77,109 Intentional self‐harm (suicide) 1,510 Congenital anomalies 501 Assault (homicide) 7,098 Heart diseases 2,339 Accidents (unintentional injuries) 23,991 Accidents (unintentional injuries) 11,469 Chronic lower respiratory diseases 31,964 Chronic lower respiratory diseases31,397 Chronic lower respiratory diseases 27,899 Cerebro‐vascular disease 51,984 4 Chronic Chronic Cancer Assault Heart Intentional Intentional Chronic Cerebro‐ Cerebro‐ Cerebro‐ Alzheimer lower lower 1,039 (homicide) diseases self‐harm self‐harm lower vascular vascular vascular disease respiratory respiratory 500 5,202 (suicide) (suicide) respiratory disease disease disease 50,503 diseases diseases 2,297 12,253 diseases 19,703 19,261 25,130 65,423 72,657 5,172 5 Cerebro‐ Alzheimer Congenital Intentional Cancer Assault Chronic liver Cerebro‐ Diabetes Diabetes Alzheimer Chronic vascular disease anomalies self‐harm 4,163 (homicide) disease & vascular mellitus mellitus disease lower diseases 58,130 506 (suicide) 1,342 cirrhosis disease 16,718 13,431 19,934 respiratory 52,367 423 10,899 5,128 diseases 35,719 6 Diabetes Accidents Heart Heart HIV Pregnancy, Diabetes Chronic liver Accidents Nephritis, Influenza & Influenza & mellitus (unintentional diseases diseases disease childbirth & mellitus disease & (unintentional nephrotic pneumonia pneumonia 35,490 injuries) 427 259 1,016 puerperium 7,403 cirrhosis injuries) syndrome & 13,266 18,344 44,938 632 4,746 13,459 nephrosis 8,266 7 Intentional Diabetes Chronic lower Influenza & Chronic liver Diabetes Cerebro‐ Diabetes Nephritis, Accidents Nephritis, Diabetes self‐harm mellitus respiratory pneumonia disease & mellitus vascular mellitus nephrotic (unintentional nephrotic mellitus (suicide) 33,581 diseases 96 cirrhosis 587 disease 4,445 syndrome & injuries) syndrome & 15,082 30,277 154 828 6,675 nephrosis 7,937 nephrosis 9,581 12,217 8 Alzheimer Influenza & Cerebro‐ Cerebro‐ Diabetes Cerebro‐ Chronic Intentional Chronic liver Alzheimer Accidents Nephritis, disease pneumonia vascular vascular mellitus vascular lower self‐harm disease & disease (unintentional nephrotic 25,364 26,482 disease disease 779 disease respiratory (suicide) cirrhosis 7,431 injuries) syndrome & 133 93 diseases 3,793 7,734 11,195 nephrosis 576 5,027 14,891 9 Nephritis, Nephritis, Influenza & Chronic Cerebro‐ HIV HIV Septicemia Influenza & Septicemia Diabetes Accidents nephrotic nephrotic pneumonia lower vascular disease disease 2,269 pneumonia 6,715 mellitus (unintentional syndrome & syndrome & 114 respiratory disease 553 4,054 7,366 10,548 injuries) nephrosis nephrosis diseases 661 14,786 24,865 25,611 90 10 Influenza & Septicemia In situ, In situ, Congenital Chronic liver Viral Nephritis, Septicemia Influenza & Parkinson Hypertension pneumonia 18,743 benign, benign, anomalies disease & hepatitis nephrotic 6,768 pneumonia disease & hypertensive 23,615 & unknown & unknown 477 cirrhosis 3,306 syndrome & 5,919 8,291 renal disease* neoplasms neoplasms 466 nephrosis 10,756 97 90 2,087 HIV indicates human immunodeficiency virus. *Includes primary and secondary hypertension. 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. Source: US Final Mortality Data, 2010, National Center for Health Statistics, Centers for Disease Control and Prevention, 2013. Table presents the number of deaths from all cancers combined and from the 5 most common sites for each 20‐year age group by sex. For all ages combined, men have a higher number of deaths for shared sites with the exception of pancreatic cancer, for which the burden is similar. Among males, leukemia is the leading cause of cancer death in those aged younger than 40 years, while lung cancer ranks first in men aged 40 years and older. Among females, leukemia is the leading cause of cancer death in children and adolescents (aged younger than 20 years), breast cancer ranks first in women aged 20 years to 59 years, and lung cancer causes the most cancer deaths in those aged 60 years and older. Five Leading Types of Cancer Death by Age and Sex, United States, 2010 ALL AGES <20 20 TO 39 40 TO 59 60 TO 79 ≥80 MALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 300,464 1,070 4,163 54,440 156,723 84,636 Lung & bronchus Leukemia Leukemia Lung & bronchus Lung & bronchus Lung & bronchus 87,699 293 550 14,687 52,233 20,504 Prostate Brain & ONS Brain & ONS* Colorectum Colorectum Prostate 28,561 272 503 5,645 13,272 15,188 Colorectum Bones & joints Colorectum Liver & bile duct Prostate Colorectum 27,074 92 442 4,458 11,949 7,708 Pancreas Soft tissue Non‐Hodgkin Pancreas Pancreas Urinary bladder 18,699 (including heart) lymphoma 3,748 10,371 4,766 83 276 Liver & intrahepatic Non‐Hodgkin Lung & bronchus Esophagus Liver & intrahepatic Pancreas bile duct lymphoma 266 2,737 bile duct 4,466 13,658 55 6,803 FEMALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 273,706 855 4,429 50,509 128,760 89,153 Lung & bronchus Leukemia Breast Breast Lung & bronchus Lung & bronchus 70,550 235 963 11,507 39,540 19,681 Breast Brain & ONS* Uterine cervix Lung & bronchus Breast Breast 40,996 226 430 11,082 17,375 11,151 Colorectum Bones & joints Leukemia Colorectum Colorectum Colorectum 24,972 74 395 4,185 9,855 10,588 Pancreas Soft tissue Colorectum Ovary Pancreas Pancreas 18,189 63 338 3,113 8,911 6,692 Ovary Liver & intrahepatic Brain & ONS* Pancreas Ovary Non‐Hodgkin 14,572 bile duct 309 2,506 7,338 lymphoma 25 4,144 ONS indicates other nervous system. Note: Ranking order excludes category titles that begin with “Other.” Regional Variations in Cancer Rates Tables and depict cancer incidence and death rates for selected cancers by state. Lung cancer shows the largest geographic variation in cancer occurrence by far, reflecting the large historical and continuing differences in smoking prevalence among states. For example, lung cancer incidence rates in Kentucky, which has historically had the highest smoking prevalence, are almost 4‐fold higher than those in Utah, which has the lowest smoking prevalence (126 vs 34 cases per 100,000 men). There is also a large range for prostate cancer incidence rates, from 112.7 in Arizona to 194.4 in the District of Columbia, which likely reflects state differences in PSA testing prevalence and racial distribution. In contrast, state variations for other cancer sites are smaller in both absolute and relative terms. For example, the breast cancer incidence rate ranges from 140 (per 100,000 population) in the District of Columbia to 109 in New Mexico, a difference of 28%. State variation in incidence rates reflects differences in the use of screening tests or detection practices in addition to differences in disease occurrence. Incidence Rates for Selected Cancers by State, United States, 2006 to 2010 ALL CANCERS BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PROSTATE URINARY BLADDER STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE MALE FEMALE Alabama 573.2 395.2 118.7 57.2 40.3 103.2 54.0 19.5 13.6 157.7 33.3 7.5 Alaska 521.0 430.3 127.7 53.1 44.5 83.8 60.4 21.8 16.1 137.3 38.0 9.8 Arizona 441.4 371.2 110.2 41.4 32.0 61.8 47.9 18.0 13.4 112.7 32.2 8.4 Arkansas 557.7 388.1 110.3 55.6 40.5 108.4 60.4 21.2 15.3 156.4 33.9 8.1 California 505.7 397.1 122.0 49.4 37.3 60.4 44.4 22.9 15.6 140.3 33.5 8.0 Colorado 483.1 396.4 125.3 43.6 33.6 56.1 44.2 22.5 15.9 142.7 31.2 8.2 Connecticut 576.2 456.9 136.3 51.3 39.2 75.5 59.5 25.2 17.3 160.0 46.8 12.6 Delaware 601.7 443.3 126.5 53.1 39.6 87.1 65.8 23.7 16.7 177.3 43.2 11.3 Dist. of Columbia 574.8 427.7 139.7 50.9 44.8 77.5 48.1 21.8 13.4 194.4 25.1 9.0 Florida 518.8 399.9 114.3 47.8 36.6 79.4 56.7 21.9 15.2 131.2 35.3 8.6 Georgia 568.7 403.1 121.5 52.1 38.4 93.3 55.0 21.5 14.8 165.7 33.9 7.9 Hawaii 484.4 393.4 123.1 56.9 38.0 64.3 38.7 20.7 13.7 119.9 25.8 6.3 Idaho 513.3 410.1 119.5 43.2 34.8 61.5 47.2 21.3 17.5 152.9 36.1 8.9 Illinois 566.6 440.3 126.4 59.1 43.4 86.7 60.9 24.0 16.4 153.9 39.4 9.9 Indiana 527.4 422.0 117.4 54.7 41.8 96.4 63.5 23.3 17.0 122.4 35.2 8.8 Iowa 555.7 437.1 123.4 56.9 44.3 84.7 54.9 26.8 18.9 137.2 41.7 8.8 Kansas 552.2 422.0 123.2 55.0 39.9 80.2 54.5 23.4 16.8 152.4 37.9 9.3 Kentucky 611.2 462.4 121.3 63.9 46.0 125.9 80.3 25.3 17.5 134.6 40.5 9.7 Louisiana 603.4 413.6 119.7 62.4 44.0 99.6 57.7 24.5 16.5 169.3 34.1 8.1 Maine 581.5 460.6 126.5 51.4 41.2 91.5 67.3 25.4 17.9 144.8 48.0 13.2 Maryland 529.1 415.0 128.0 47.6 36.7 74.4 55.8 21.3 15.0 157.2 33.4 9.2 Massachusetts 568.1 460.4 134.2 49.9 38.8 78.3 64.1 25.0 16.5 153.6 43.9 11.9 Michigan 574.1 433.5 120.0 51.0 39.3 86.1 61.6 24.9 17.7 163.7 41.3 10.7 Minnesota ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Mississippi 598.6 396.9 113.8 61.3 44.7 112.7 56.2 21.6 14.5 166.3 30.8 7.2 Missouri 530.8 423.3 121.5 55.3 40.8 95.6 64.3 22.3 16.0 126.2 34.8 8.4 Montana 520.8 421.9 124.1 51.1 39.0 68.9 56.3 22.8 15.0 155.2 36.4 9.9 Nebraska 526.2 420.9 122.3 57.7 44.4 74.6 51.2 23.5 17.7 143.0 35.0 8.6 Nevada 509.8 399.2 112.7 52.0 38.1 75.7 64.7 20.4 15.3 138.9 37.3 10.7 New Hampshire 580.3 452.1 132.0 46.7 38.0 80.1 62.2 25.1 17.1 155.4 49.1 13.2 New Jersey 582.6 450.6 129.3 54.7 41.2 72.8 55.3 25.2 17.8 169.2 43.6 11.6 New Mexico 461.9 362.5 108.8 44.1 33.6 52.9 38.1 18.2 13.8 134.1 26.2 6.2 New York 585.4 449.2 127.7 53.3 40.9 76.3 56.0 26.3 18.1 167.3 42.1 10.6 North Carolina 564.9 416.0 124.9 50.8 37.1 96.7 57.2 22.6 15.7 151.9 37.5 8.9 North Dakota 528.6 410.2 123.0 59.2 41.8 68.1 43.3 22.0 18.4 156.2 38.6 9.2 Ohio 548.1 425.4 120.5 55.5 42.2 92.6 60.7 23.0 16.1 145.2 38.7 9.6 Oklahoma 552.2 422.0 121.7 53.6 40.8 96.1 62.7 22.4 17.1 148.4 34.7 8.6 Oregon 508.8 429.2 129.5 45.5 36.8 70.6 57.6 22.8 15.3 139.3 37.1 9.5 Pennsylvania 573.6 454.8 126.0 56.0 42.8 84.4 57.9 25.2 17.8 149.5 44.1 11.0 Rhode Island 575.7 462.4 131.0 51.3 41.3 84.1 64.5 22.5 17.9 148.9 48.7 13.8 South Carolina 551.7 401.1 122.3 50.3 37.9 94.1 53.9 20.5 13.4 152.8 30.8 8.4 South Dakota 499.4 395.9 117.9 55.7 41.8 73.8 48.0 21.6 15.9 145.5 33.6 8.3 Tennessee 562.0 416.0 118.8 53.4 40.4 103.4 61.3 22.6 16.3 144.3 35.4 8.2 Texas 513.9 389.9 114.4 50.9 35.7 78.2 49.0 22.2 15.9 133.2 29.5 6.9 Utah 494.8 357.7 110.8 39.4 31.2 34.1 23.3 25.2 16.3 175.9 31.4 5.3 Vermont 539.8 453.8 131.4 44.8 38.3 81.2 65.6 24.1 17.7 139.9 40.5 12.2 Virginia 521.7 397.4 124.5 46.9 36.7 82.2 53.9 21.7 14.2 150.3 33.3 8.3 Washington 544.6 437.7 131.0 46.1 36.3 72.1 57.3 26.2 17.4 151.6 38.9 9.3 West Virginia 557.7 434.1 110.2 58.0 43.8 106.4 70.0 23.2 17.5 131.8 38.8 10.7 Wisconsin 530.8 419.2 122.5 48.4 37.5 73.6 53.4 24.3 17.3 142.9 39.2 9.7 Wyoming 497.1 384.2 110.8 47.5 37.7 57.3 46.0 19.8 15.0 152.2 38.7 9.9 United States 542.3 418.8 122.2 51.7 39.1 80.0 55.1 23.3 16.3 146.6 36.9 9.1 Rates are per 100,000 and age adjusted to the 2000 US standard population. 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 2006 to 2010 according to the North American Association of Central Cancer Registries (NAACCR). Rates are based on incidence data for 2006 to 2008. This state's registry did not submit cancer incidence data to the NAACCR. Rates are based on incidence data for 2006 to 2009. Death Rates for Selected Cancers by State, United States, 2006 to 2010 ALL SITES BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PANCREAS PROSTATE STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE Alabama 255.4 156.4 23.3 22.5 15.0 87.4 40.8 8.0 5.3 13.2 9.7 28.9 Alaska 210.5 161.0 24.2 19.6 15.1 61.8 45.8 7.6 5.5 12.9 9.8 22.5 Arizona 186.0 131.7 20.6 17.1 11.9 49.8 33.2 7.6 4.8 11.4 8.3 20.5 Arkansas 250.6 160.9 23.4 22.7 15.6 90.1 45.4 8.6 5.5 13.2 9.6 25.3 California 189.8 139.8 21.9 17.5 12.7 47.2 32.3 7.8 4.9 11.7 9.4 22.3 Colorado 181.4 133.2 19.6 16.7 12.4 44.2 31.3 7.8 4.4 10.8 9.0 22.9 Connecticut 199.5 144.7 21.6 16.2 12.1 52.7 38.2 7.5 4.9 13.9 9.9 22.3 Delaware 228.0 159.3 22.8 20.4 13.3 68.2 47.7 8.3 4.8 13.0 9.5 23.7 Dist. of Columbia 248.5 167.6 29.8 22.2 18.9 61.9 35.0 8.0 4.0 16.9 12.0 38.8 Florida 204.5 140.7 21.3 18.1 12.8 61.4 38.8 7.8 4.9 12.1 8.8 20.1 Georgia 228.3 147.8 23.4 20.2 13.8 73.1 38.7 7.6 4.5 12.5 9.1 27.1 Hawaii 178.4 117.1 16.4 17.3 10.9 48.8 25.9 7.2 4.3 12.3 9.7 15.7 Idaho 192.9 140.2 21.6 16.1 12.4 49.2 34.5 7.2 5.6 12.0 9.2 25.9 Illinois 223.3 158.5 23.6 21.7 15.4 65.8 41.9 8.5 5.3 13.0 10.1 24.3 Indiana 238.8 161.5 23.9 21.3 14.5 79.4 46.7 9.3 5.4 13.0 9.4 23.2 Iowa 212.6 148.4 21.3 20.0 15.2 64.1 38.3 8.9 5.5 12.2 8.8 22.7 Kansas 214.4 146.5 22.2 20.6 13.1 66.8 39.4 9.1 5.3 12.6 9.1 20.7 Kentucky 262.7 173.3 23.1 23.4 16.2 97.1 55.8 9.0 5.7 12.7 9.6 23.9 Louisiana 254.7 164.4 25.4 24.0 15.7 80.9 43.6 8.6 5.2 14.2 11.1 26.6 Maine 231.1 158.3 20.9 20.2 13.9 69.9 46.0 8.8 5.1 11.6 9.8 22.9 Maryland 216.9 154.0 24.5 20.5 14.0 61.7 40.8 7.4 4.5 12.9 10.3 25.0 Massachusetts 216.6 152.5 21.3 18.7 13.4 60.6 42.1 7.8 4.8 12.7 10.4 22.4 Michigan 223.0 159.5 24.0 19.4 14.2 68.2 43.9 8.9 5.8 13.9 10.2 21.8 Minnesota 203.9 145.0 20.9 17.6 12.6 53.3 37.0 9.4 5.2 11.9 9.3 23.9 Mississippi 270.6 159.1 24.7 24.8 16.5 95.4 42.0 8.3 4.7 14.1 10.1 31.2 Missouri 231.1 160.2 24.2 21.2 14.6 76.5 46.2 8.3 5.4 13.0 9.9 21.8 Montana 195.3 145.1 19.8 16.7 14.0 52.1 39.6 7.9 4.9 11.8 8.4 26.4 Nebraska 208.4 143.8 20.1 21.4 15.0 60.3 35.5 8.4 5.7 12.0 9.7 22.9 Nevada 211.4 153.6 23.0 21.0 14.9 59.7 46.5 7.1 4.6 12.6 9.7 23.9 New Hampshire 211.7 154.2 21.3 17.9 13.1 59.0 43.3 7.3 4.7 13.2 10.4 22.4 New Jersey 207.8 154.3 25.2 21.0 14.9 55.8 37.2 7.8 5.2 13.4 10.1 21.6 New Mexico 187.4 131.6 20.9 18.8 12.7 43.4 28.6 6.6 4.5 10.9 8.4 24.4 New York 199.7 145.4 22.3 19.2 13.8 54.3 36.1 7.9 4.9 12.8 9.9 21.8 North Carolina 232.2 149.9 23.1 19.4 13.1 76.6 40.7 7.5 5.0 12.0 9.6 25.8 North Dakota 203.6 137.2 21.6 21.2 13.9 54.1 32.2 6.7 5.1 12.6 8.3 23.6 Ohio 236.5 162.6 24.8 21.8 15.2 74.8 44.2 9.2 5.6 13.1 10.1 23.8 Oklahoma 238.8 161.0 23.9 22.1 14.5 79.6 46.6 9.0 6.0 12.2 8.9 23.5 Oregon 208.5 153.4 21.6 18.1 13.3 58.4 42.7 8.5 5.3 12.3 9.9 24.4 Pennsylvania 225.6 157.0 23.8 21.5 15.0 65.8 39.6 8.9 5.5 13.4 10.0 22.7 Rhode Island 221.8 149.6 20.8 18.6 13.2 64.9 42.6 8.3 4.4 12.2 8.9 20.6 South Carolina 240.1 151.7 23.5 20.2 14.2 77.1 39.9 7.8 4.7 12.7 9.8 27.5 South Dakota 206.8 141.3 20.3 19.8 13.9 61.9 34.1 7.8 5.3 11.1 9.3 23.4 Tennessee 256.4 160.4 23.3 21.8 15.3 89.5 46.6 9.2 5.4 13.1 9.4 25.2 Texas 209.3 141.8 21.8 20.0 13.1 60.7 35.4 7.9 4.9 11.8 8.8 21.3 Utah 157.1 112.3 21.8 14.3 10.7 27.5 16.8 7.7 4.7 10.0 8.4 25.9 Vermont 212.0 154.3 20.4 17.4 14.8 62.3 45.1 7.8 5.0 12.4 9.3 22.1 Virginia 221.1 151.4 24.0 19.2 14.0 67.1 40.0 8.2 4.8 12.7 9.7 24.7 Washington 207.2 152.2 21.5 17.1 12.5 57.0 42.1 8.6 5.4 12.7 10.0 24.2 West Virginia 246.9 168.6 22.1 23.4 16.1 84.3 50.9 8.7 6.6 11.3 7.8 20.9 Wisconsin 213.7 149.7 21.3 18.0 12.7 58.4 38.4 9.0 5.5 12.8 10.0 24.5 Wyoming 196.0 146.8 21.3 18.7 14.7 49.9 36.4 7.6 5.3 12.9 9.0 22.8 United States 215.3 149.7 22.6 19.6 13.9 63.5 39.2 8.2 5.1 12.5 9.6 23.0 Rates are per 100,000 and age adjusted to the 2000 US standard population. Cancer Occurrence by Race/Ethnicity Cancer incidence and death rates vary considerably between and within racial and ethnic groups. Of the 5 broadly defined groups in Table , black men have the highest cancer incidence and death rates–about double those of Asian Americans, who have the lowest rates. Cancer incidence and death rates are higher among black than white men for every site included in Table except kidney cancer mortality. Factors known to contribute to racial disparities vary by cancer site and include differences in exposure to underlying risk factors (eg, historical smoking prevalence for lung cancer), access to high‐quality screening (breast, cervical, and colorectal cancers), and timely diagnosis and treatment. It is notable that although white women have the highest breast cancer incidence rate, black women have the highest breast cancer mortality rate. The 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). The high breast cancer mortality rate among black women has been attributed to a higher prevalence of comorbidities, a longer time to follow‐up after an abnormal mammogram, less access to high‐quality treatment, and a higher prevalence of aggressive tumor characteristics. Incidence and Death Rates by Site, Race, and Ethnicity, United States, 2006 to 2010 NON‐HISPANIC WHITE BLACK ASIAN AMERICAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKA NATIVE HISPANIC Incidence All sites Male 548.6 601.0 326.1 441.1 426.8 Female 436.2 395.9 282.6 372.0 330.8 Breast (female) 127.3 118.4 84.7 90.3 91.1 Colorectum Male 50.9 62.5 40.8 51.7 47.3 Female 38.6 46.7 31.0 42.7 32.6 Kidney & renal pelvis Male 21.6 23.0 10.6 30.6 20.5 Female 11.2 12.2 5.1 17.5 11.5 Liver & intrahepatic bile duct Male 8.7 14.9 21.3 17.8 18.8 Female 2.9 4.4 8.0 8.0 6.9 Lung & bronchus Male 82.9 94.7 48.8 70.2 45.9 Female 59.9 50.4 28.0 52.1 26.6 Prostate 138.6 220.0 75.0 104.1 124.2 Stomach Male 7.8 15.7 15.6 13.1 13.9 Female 3.5 8.1 9.0 6.9 8.2 Uterine cervix 7.2 10.3 6.7 9.7 10.9 Mortality All sites Male 217.3 276.6 132.4 191.0 152.2 Female 153.6 171.2 92.1 139.0 101.3 Breast (female) 22.7 30.8 11.5 15.5 14.8 Colorectum Male 19.2 28.7 13.1 18.7 16.1 Female 13.6 19.0 9.7 15.4 10.2 Kidney & renal pelvis Male 5.9 5.7 3.0 9.5 5.1 Female 2.6 2.6 1.2 4.4 2.3 Liver & intrahepatic bile duct Male 7.1 11.8 14.4 13.2 12.3 Female 2.9 4.1 6.0 6.1 5.4 Lung & bronchus Male 65.7 78.5 35.5 49.6 31.3 Female 42.7 37.2 18.4 33.1 14.1 Prostate 21.3 50.9 10.1 20.7 19.2 Stomach Male 3.9 9.8 8.7 8.1 7.6 Female 1.9 4.7 5.1 3.8 4.4 Uterine cervix 2.1 4.2 1.9 3.5 2.9 Rates are per 100,000 population and age adjusted to the 2000 US standard population. Nonwhite race categories are not mutually exclusive of Hispanic origin. Data based on Indian Health Service Contract Health Service Delivery Areas. Cancer incidence and death rates are lower among Asian Americans/Pacific Islanders, American Indians/Alaska Natives, and Hispanics than 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 Asian American/Pacific Islander population as in whites, reflecting a higher prevalence of chronic infection with Helicobacter pylori and hepatitis B virus, respectively. Kidney cancer incidence and death rates are the highest among American Indians/Alaska Natives, which may be due in part to high rates of obesity and smoking in this population. Table presents trends in cancer incidence and death rates during the most recent 10 years for which there are data (2001‐2010) by race and ethnicity. These trends are based on rates that are not adjusted for reporting delays because the long‐term incidence data required for delay adjustment are not available for populations other than whites or blacks. Among men, incidence rates declined between 1.6% and 2.0% per year for all groups except American Indians/Alaska Natives. Declines in death rates among men were of a similar magnitude, and were highest among blacks (2.5% per year). Among women, incidence rate declines were smaller and were confined to non‐Hispanic whites (0.5% per year) and Hispanics (0.8% per year), though mortality declines of greater than 1.0% per year were experienced by all racial/ethnic groups except American Indians/Alaska Natives. As in men, black women had the largest annual decline in cancer death rates (1.7%). Average Annual Percent Change in Cancer Incidence and Mortality Rates From 2001 to 2010 by Race/Ethnicity, United States INCIDENCE MORTALITY MALE FEMALE MALE FEMALE All race/ethnicities ‐1.6 ‐0.3 ‐1.8 ‐1.4 Non‐Hispanic white ‐1.6 ‐0.5 ‐1.6 ‐1.3 Black ‐1.8 ‐0.1 ‐2.5 ‐1.7 Asian American/Pacific Islander ‐1.7 0.0 ‐1.6 ‐1.0 American Indian/Alaska Native ‐0.8 ‐0.2 ‐0.1 0.1 Hispanic ‐2.0 ‐0.8 ‐1.6 ‐1.4 Average annual percent change is statistically significant ( P < .05). Excludes deaths from Connecticut, District of Columbia, Maine, Maryland, Minnesota, New Hampshire, New York, North Dakota, Oklahoma, South Carolina, and Vermont due to unreliable Hispanic origin data for some years. Data based on Indian Health Service Contract Health Service Delivery Areas. Notes: Trends analyzed by the Joinpoint Regression Program, version 3.5.0, allowing up to 2 joinpoints. Incidence trends based on the North American Association of Central Cancer Registries (NAACCR) data. Nonwhite race categories are not mutually exclusive of Hispanic origin. Cancer Survival The stage‐specific 5‐year relative survival rate is lower for blacks than for whites for nearly every cancer type (Fig. ). Studies suggest that racial disparities in survival are primarily due to differences in treatment, stage at diagnosis, and comorbidities, as opposed to differences in cancer biology. As shown in Figure , blacks are less likely than whites to be diagnosed with cancer at a localized stage, when treatment is more successful. This disparity is particularly striking for cancers of the breast, cervix, uterine corpus, and oral cavity and pharynx. Lower socioeconomic status among blacks likely explains much of the stage disparity and is also associated with receipt of less aggressive treatment. Even among Medicare‐insured patients, blacks are less likely than whites to receive standard cancer therapies for lung, breast, colorectal, and prostate cancers. Five‐Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis, United States, 2003 to 2009. *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% for All Races, 97% for Whites, and 91% for blacks. Stage Distribution of Selected Cancers by Race, United States, 2003 to 2009. *The proportions of carcinoma in situ of the urinary bladder are 51% for All Races, 52% for Whites, and 38% for blacks. Stage categories do not sum to 100% because sufficient information is not available to assign a stage to all cancer cases. There have been notable improvements in survival over the past 3 decades for most cancers among both whites and blacks (Table ). Between 1975 and 1977 and 2003 and 2009, overall 5‐year relative survival rates increased 19 percentage points among whites and 22 percentage points among blacks. The largest improvements in survival have been for leukemia and non‐Hodgkin lymphoma, while lung and pancreatic cancers have shown the least improvement. Trends in 5‐Year Relative Survival Rates (%) by Race and Year of Diagnosis, United States, 1975 to 2009 ALL RACES WHITE BLACK 1975 TO 1977 1987 TO 1989 2003 TO 2009 1975 TO 1977 1987 TO 1989 2003 TO 2009 1975 TO 1977 1987 TO 1989 2003 TO 2009 All sites 49 55 68 50 57 69 39 43 61 Brain & other nervous system 22 29 35 22 28 33 25 32 41 Breast (female) 75 84 90 76 85 92 62 71 79 Colon 51 60 65 51 61 67 45 52 56 Esophagus 5 9 19 6 11 20 4 7 14 Hodgkin lymphoma 72 79 88 72 80 89 70 72 83 Kidney & renal pelvis 50 57 73 50 57 73 49 55 72 Larynx 66 66 63 67 67 64 58 56 52 Leukemia 34 43 59 35 44 60 33 35 53 Liver & intrahepatic bile duct 3 5 18 3 6 17 2 3 12 Lung & bronchus 12 13 18 12 13 18 11 11 14 Melanoma of the skin 82 88 93 82 88 93 57 79 77 Myeloma 25 27 45 24 27 45 30 30 44 Non‐Hodgkin lymphoma 47 51 71 47 51 72 48 46 64 Oral cavity 53 54 65 54 56 67 36 34 46 Ovary 36 38 44 35 38 44 42 34 36 Pancreas 2 4 6 3 3 7 2 6 6 Prostate 68 83 100 69 84 100 61 71 98 Rectum 48 58 68 48 59 68 44 52 62 Stomach 15 20 29 14 18 28 16 19 29 Testis 83 95 97 83 96 97 73 88 90 Thyroid 92 94 98 92 94 98 90 92 97 Urinary bladder 72 79 80 73 80 81 50 63 64 Uterine cervix 69 70 69 70 73 71 64 57 63 Uterine corpus 87 82 84 88 84 86 60 57 64 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 2003 to 2009, all followed through 2010. The difference in rates between 1975 to 1977 and 2003 to 2009 is statistically significant ( P < .05). The standard error of the survival rate is between 5 and 10 percentage points. Survival rate is for 1978 to 1980. Relative survival rates cannot be calculated for some minority populations because accurate life tables are not available. Comparison of cause‐specific survival rates for patients diagnosed from 2003 to 2009 indicates that Asian American/Pacific Islander women have the highest probability of surviving 5 years after a cancer diagnosis (69.5%), while American Indian/Alaska Native men have the lowest probability of surviving (56.8%). For both sexes combined, whites and Hispanics have the highest 5‐year cause‐specific survival (66.7%), while American Indians/Alaska Natives have the lowest (59.0%). Limitations The projected numbers of new cancer cases and cancer deaths should be interpreted with caution because they are model‐based estimates that may vary considerably from year to year for reasons other than changes in cancer occurrence. For instance, estimates are affected by changes in method, which are implemented regularly as modeling techniques improve and surveillance coverage becomes more complete. In addition, the model is sometimes oversensitive or undersensitive to abrupt or large changes in observed data. For these reasons, the projections are not an accurate measure of year‐to‐year changes in cancer occurrence and death. The data sources used for tracking cancer trends are age‐standardized or age‐specific cancer death rates from the NCHS and cancer incidence rates from SEER and/or the National Program of Cancer Registries. Nevertheless, the American Cancer Society projections of new cancer cases and deaths provide a reasonably accurate estimate of the current cancer burden in the United States. 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. It is also important to note that cancer data in the United States are primarily reported for broad racial and ethnic groups that are not homogenous, masking important differences in the cancer burden within these groups. Conclusions Cancer death rates have been continuously declining for the past 2 decades. Overall, the risk of dying from cancer decreased by 20% between 1991 and 2010. Progress has been most rapid for middle‐aged black men, among whom death rates have declined by approximately 50%. Despite this substantial progress, 5‐year survival rates among blacks continue to lag behind whites by as much as 22 percentage points for uterine cancer, 21 percentage points for cancer of the oral cavity, and 17 percentage points for urinary bladder cancer. Further progress can be accelerated by applying existing cancer control knowledge across all segments of the population, with an emphasis on those groups in the lowest socioeconomic bracket and other disadvantaged populations. ▪

Journal

CA: A Cancer Journal for CliniciansWiley

Published: Jan 1, 2014

Keywords: ; ; ; ; ;

References

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