Cancer Statistics, 2015

Rebecca L. Siegel, MPH1*; Kimberly D. Miller, MPH2; Ahmedin Jemal, DVM, PhD3

Each year the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the National Cancer Institute (Surveillance, Epidemiology, and End Results [SEER] Program), the Centers for Disease Control and Prevention (National Program of Cancer Registries), and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. A total of 1,658,370 new cancer cases and 589,430 cancer deaths are projected to occur in the United States in 2015. During the most recent 5 years for which there are data (2007-2011), delay-adjusted cancer incidence rates (13 oldest SEER registries) declined by 1.8% per year in men and were stable in women, while cancer death rates nationwide decreased by 1.8% per year in men and by 1.4% per year in women. The overall cancer death rate decreased from 215.1 (per 100,000 population) in 1991 to 168.7 in 2011, a total relative decline of 22%. However, the magnitude of the decline varied by state, and was generally lowest in the South (�15%) and highest in the Northeast (�20%). For example, there were declines of 25% to 30% in Maryland, New Jersey, Massachusetts, New York, and Delaware, which collectively averted 29,000 cancer deaths in 2011 as a result of this progress. Further gains can be accelerated by applying existing cancer control knowledge across all segments of the population. CA Cancer J Clin 2015;000:000

C

000. V2015 American Cancer Society.

Keywords: cancer statistics, incidence, trends, survival, mortality, death rates, cancer cases

Introduction

Cancer is a major public health problem in the United States and many other parts of the world. It is currently the second leading cause of death in the United States, and is expected to surpass heart diseases as the leading cause of death in the next few years. In this article, we provide the expected numbers of new cancer cases and deaths in 2015 in the United States nationally and for each state, as well as a comprehensive overview of cancer incidence, mortality, and survival rates and trends using the most current population-based data. In addition, we estimate the total number of deaths averted nationally during the past 2 decades and by state in 2011 as a result of the continual decline in cancer death rates. We also present the actual number of deaths reported in 2011 by age for the 10 leading causes of death and for the 5 leading causes of cancer death.

Materials and Methods

Incidence and Mortality Data

Mortality data from 1930 to 2011 were obtained from the National Center for Health Statistics (NCHS).1 Forty-seven states and the District of Columbia met data quality requirements for reporting to the national vital statistics system in 1930. Texas, Alaska, and Hawaii began reporting mortality data in 1933, 1959, and 1960, respectively. The methods for abstraction and age adjustment of mortality data are described elsewhere.2,3

Population-based cancer incidence data in the United States have been collected by the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology, and End Results (SEER) Program since 1973 and by the Centers for Disease Control and Prevention’s National Program of Cancer Registries (NPCR) since 1995. The SEER program is the only source for long-term, delay-adjusted, population-based incidence data. Long-term incidence and survival trends (1975-2011) were based on data from the 9 oldest SEER areas (Connecticut, Hawaii, Iowa, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco-Oakland, and Seattle-Puget Sound), representing approximately 9% of the US population.4

1Director, Surveillance Information, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA; 2Epidemiologist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA; 3Vice President, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA

Corresponding author: Rebecca L. Siegel, MPH, Surveillance and Health Services Research, American Cancer Society, 250 Williams St, NW, Atlanta, GA 30303-1002; Rebecca.siegel@cancer.org

DISCLOSURES: The authors report no conflicts of interest.

doi: 10.3322/caac.21254. Available online at cacancerjournal.com

TABLE 1. Estimated New Cancer Cases and Deaths by Sex, United States, 2015*

BOTH SEXES ESTIMATED NEW CASES MALE FEMALE BOTH SEXES ESTIMATED DEATHS MALE FEMALE
All sites 1,658,370 848,200 810,170 589,430 312,150 277,280
Oral cavity & pharynx 45,780 32,670 13,110 8,650 6,010 2,640
Tongue 14,320 10,310 4,010 2,190 1,500 690
Mouth 12,920 7,750 5,170 2,120 1,200 920
Pharynx 15,520 12,380 3,140 2,660 2,010 650
Other oral cavity 3,020 2,230 790 1,680 1,300 380
Digestive system 291,150 163,050 128,100 149,300 86,540 62,760
Esophagus 16,980 13,570 3,410 15,590 12,600 2,990
Stomach 24,590 15,540 9,050 10,720 6,500 4,220
Small intestine 9,410 4,960 4,450 1,260 670 590
Colon† 93,090 45,890 47,200 49,700 26,100 23,600
Rectum 39,610 23,200 16,410
Anus, anal canal, & anorectum 7,270 2,640 4,630 1,010 400 610
Liver & intrahepatic bile duct 35,660 25,510 10,150 24,550 17,030 7,520
Gallbladder & other biliary 10,910 4,990 5,920 3,700 1,660 2,040
Pancreas 48,960 24,840 24,120 40,560 20,710 19,850
Other digestive organs 4,670 1,910 2,760 2,210 870 1,340
Respiratory system 240,390 130,260 110,130 162,460 89,750 72,710
Larynx 13,560 10,720 2,840 3,640 2,890 750
Lung & bronchus 221,200 115,610 105,590 158,040 86,380 71,660
Other respiratory organs 5,630 3,930 1,700 780 480 300
Bones & joints 2,970 1,640 1,330 1,490 850 640
Soft tissue (including heart) 11,930 6,610 5,320 4,870 2,600 2,270
Skin (excluding basal & squamous) 80,100 46,610 33,490 13,340 9,120 4,220
Melanoma of the skin 73,870 42,670 31,200 9,940 6,640 3,300
Other nonepithelial skin 6,230 3,940 2,290 3,400 2,480 920
Breast 234,190 2,350 231,840 40,730 440 40,290
Genital system 329,330 231,050 98,280 58,670 28,230 30,440
Uterine cervix 12,900 12,900 4,100 4,100
Uterine corpus 54,870 54,870 10,170 10,170
Ovary 21,290 21,290 14,180 14,180
Vulva 5,150 5,150 1,080 1,080
Vagina & other genital, female 4,070 4,070 910 910
Prostate 220,800 220,800 27,540 27,540
Testis 8,430 8,430 380 380
Penis & other genital, male 1,820 1,820 310 310
Urinary system 138,710 96,580 42,130 30,970 21,110 9,860
Urinary bladder 74,000 56,320 17,680 16,000 11,510 4,490
Kidney & renal pelvis 61,560 38,270 23,290 14,080 9,070 5,010
Ureter & other urinary organs 3,150 1,990 1,160 890 530 360
Eye & orbit 2,580 1,360 1,220 270 140 130
Brain & other nervous system 22,850 12,900 9,950 15,320 8,940 6,380
Endocrine system 64,860 16,520 48,340 2,890 1,350 1,540
Thyroid 62,450 15,220 47,230 1,950 870 1,080
Other endocrine 2,410 1,300 1,110 940 480 460
Lymphoma 80,900 44,950 35,950 20,940 12,140 8,800
Hodgkin lymphoma 9,050 5,100 3,950 1,150 660 490
Non-Hodgkin lymphoma 71,850 39,850 32,000 19,790 11,480 8,310
Myeloma 26,850 14,090 12,760 11,240 6,240 5,000
Leukemia 54,270 30,900 23,370 24,450 14,210 10,240
Acute lymphocytic leukemia 6,250 3,100 3,150 1,450 800 650
Chronic lymphocytic leukemia 14,620 8,140 6,480 4,650 2,830 1,820
Acute myeloid leukemia 20,830 12,730 8,100 10,460 6,110 4,350
Chronic myeloid leukemia 6,660 3,530 3,130 1,140 590 550
Other leukemia‡ 5,910 3,400 2,510 6,750 3,880 2,870
Other & unspecified primary sites‡ 31,510 16,660 14,850 43,840 24,480 19,360

*Rounded to the nearest 10; estimated new cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. About 60,290 cases of carcinoma in situ of the female breast and 63,440 cases of melanoma in situ will be newly diagnosed in 2015.

†Estimated deaths for colon and rectum cancers are combined due to a high percentage of misclassification.

‡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.

TABLE 2. Estimated New Cases for Selected Cancers by State, 2015*

ALL FEMALE UTERINE COLON & UTERINE LUNG & MELANOMA NON-HODGKIN URINARY
STATE CASES BREAST CERVIX RECTUM CORPUS LEUKEMIA BRONCHUS OF THE SKIN LYMPHOMA PROSTATE BLADDER
Alabama 26,150 3,680 230 2,150 660 730 4,150 1,380 1,020 3,590 1,000
Alaska 3,700 470 † 290 100 110 420 100 140 490 180
Arizona 32,440 4,750 200 2,440 940 950 3,740 1,400 1,300 4,090 1,580
Arkansas 15,830 2,090 150 1,420 420 480 2,620 360 670 2,050 630
California 172,090 25,270 1,490 14,510 5,800 5,970 18,430 8,560 7,870 21,060 7,150
Colorado 24,540 3,640 170 1,800 740 870 2,560 1,400 1,090 3,600 1,080
Connecticut 21,970 3,190 130 1,580 810 660 2,870 780 920 3,170 1,140
Delaware 5,280 780 † 400 180 160 860 280 220 740 250
Dist. of Columbia 2,800 430 † 230 100 70 310 80 100 490 80
Florida 114,040 15,470 980 9,330 3,550 3,930 16,810 5,480 5,340 15,480 5,670
Georgia 48,070 7,170 430 3,820 1,330 1,430 6,460 2,350 1,870 7,450 1,720
Hawaii 6,730 1,140 50 720 280 230 890 420 310 710 220
Idaho 8,080 1,070 † 620 240 300 910 470 380 1,270 410
Illinois 65,460 9,570 550 5,720 2,470 2,200 8,920 2,380 2,890 8,140 2,970
Indiana 35,620 4,600 280 2,890 1,180 1,100 5,510 1,460 1,490 4,040 1,590
Iowa 17,140 2,390 100 1,490 640 640 2,440 1,070 830 2,170 800
Kansas 14,440 2,130 90 1,080 500 480 1,930 850 640 1,860 620
Kentucky 26,490 3,300 220 2,090 730 820 4,680 1,530 1,030 3,040 1,070
Louisiana 24,100 2,900 220 2,150 570 690 3,380 540 950 3,980 910
Maine 8,810 1,010 50 610 340 320 1,360 320 390 1,100 540
Maryland 30,050 4,730 230 2,360 1,080 780 3,980 1,410 1,230 4,620 1,250
Massachusetts 37,790 5,890 210 2,550 1,460 1,130 5,150 1,310 1,620 5,420 2,000
Michigan 57,420 7,780 350 4,190 2,090 1,870 8,350 2,630 2,500 8,110 2,870
Minnesota 29,730 3,900 130 2,140 990 1,120 3,250 1,190 1,330 3,740 1,270
Mississippi 16,260 2,050 140 1,460 390 450 2,340 540 550 2,150 500
Missouri 34,680 4,610 260 2,840 1,120 1,100 5,380 1,510 1,450 3,900 1,500
Montana 5,950 830 † 500 190 200 760 300 270 1,000 310
Nebraska 9,540 1,230 60 850 340 320 1,200 500 450 1,190 440
Nevada 13,640 1,690 120 1,110 350 440 1,770 470 530 1,640 660
New Hampshire 8,090 1,120 † 540 310 260 1,140 280 350 1,080 450
New Jersey 51,410 7,310 410 4,260 1,850 1,610 5,830 2,520 2,310 7,270 2,530
New Mexico 9,970 1,320 80 820 300 360 990 480 410 1,290 390
New York 107,840 14,900 870 8,010 4,250 3,630 13,180 4,270 4,800 14,850 5,200
North Carolina 50,420 7,820 390 3,980 1,630 1,660 7,750 2,600 2,150 7,210 2,170
North Dakota 3,840 510 † 350 110 140 440 180 170 490 190
Ohio 65,010 8,950 450 5,430 2,410 1,930 10,000 2,790 2,790 8,150 3,040
Oklahoma 19,280 2,770 170 1,690 540 670 3,220 480 840 2,480 830
Oregon 22,410 3,280 130 1,510 740 720 2,830 1,480 960 3,110 1,090
Pennsylvania 81,540 9,990 540 6,300 3,000 2,560 10,540 3,880 3,410 10,050 4,080
Rhode Island 6,040 730 † 470 230 180 880 180 250 760 330
South Carolina 25,550 3,820 220 2,130 780 820 4,040 1,420 1,070 3,870 1,090
South Dakota 4,520 600 † 360 150 170 570 210 210 550 220
Tennessee 38,300 4,770 320 3,060 1,000 1,110 6,200 1,940 1,500 4,410 1,510
Texas 113,630 16,510 1,240 10,050 3,240 4,360 13,650 2,410 5,080 15,020 4,080
Utah 11,050 1,460 70 670 360 390 660 800 510 1,750 430
Vermont 4,020 530 † 280 150 110 570 150 170 470 210
Virginia 41,170 6,090 320 2,970 1,340 1,100 5,740 2,230 1,680 6,120 1,670
Washington 38,180 5,480 230 2,700 1,250 1,300 4,790 2,460 1,770 5,430 1,790
West Virginia 11,730 1,430 90 1,080 400 380 2,080 550 480 1,370 550
Wisconsin 32,700 4,310 190 2,460 1,160 1,190 4,370 1,330 1,460 4,310 1,610
Wyoming 2,860 390 † 230 90 100 320 160 120 460 140
United States 1,658,370 231,840 12,900 132,700 54,870 54,270 221,200 73,870 71,850 220,800 74,000

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

†Estimate is fewer than 50 cases.

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

FIGURE 1. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2015.

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

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, allowing for stratification by race and ethnicity.5 Delay-adjusted data from these (SEER 13) registries, which represent 14% of the US population, were the source for the annual percent change in incidence from 1992 to 2011. The SEER program added 5 additional catchment areas beginning with cases diagnosed in 2000 (greater California, greater Georgia, Kentucky, Louisiana, and New Jersey), achieving 28% population coverage. Data from all 18 SEER areas were the source for cancer stage distribution, stage-specific survival, and the lifetime probability of developing cancer.6 Much of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review, 1975

7

2011.

The North American Association of Central Cancer Registries (NAACCR) compiles and reports incidence data from 1995 onward for cancer registries that participate in the SEER program and/or the NPCR. (Five states receive funding from both programs). These data approach 100% coverage of the US population in the most recent time period and were the source for the projected new cancer cases in 2015, incidence rates by state and race/ethnicity, and the 5-year average annual percent change in incidence rates by race/ethnicity and for childhood and adolescent cancers.8,9 Some of the data presented herein were previously published in volumes 1 and 2 of Cancer in North

10,11

America: 2007-2011.

All cancer cases were classified according to the International Classification of Diseases for Oncology except childhood and adolescent cancers, for which the International Classification of Childhood Cancer (ICCC) was used.12 The lifetime

TABLE 3. Estimated Deaths for Selected Cancers by State, 2015*

STATE ALL SITES BRAIN & OTHER NERVOUS SYSTEM FEMALE BREAST COLON & RECTUM LEUKEMIA LIVER & INTRAHEPATIC BILE DUCT LUNG & BRONCHUS NON-HODGKIN LYMPHOMA OVARY PANCREAS PROSTATE
Alabama 10,560 290 680 930 420 360 3,280 330 270 660 580
Alaska 1,040 † 70 90 † 50 290 † † 70 50
Arizona 11,540 330 770 990 510 530 2,800 410 310 830 600
Arkansas 6,760 160 410 620 260 270 2,180 210 140 410 290
California 58,180 1,690 4,320 5,180 2,550 3,250 12,370 2,070 1,530 4,240 3,180
Colorado 7,590 260 540 650 330 350 1,710 250 240 530 430
Connecticut 6,840 190 460 440 300 270 1,730 220 170 540 360
Delaware 2,010 50 120 150 80 90 600 60 † 140 100
Dist. of Columbia 990 † 80 100 † 60 210 † † 80 70
Florida 43,050 1,000 2,830 3,520 1,790 1,710 11,920 1,440 940 2,980 2,030
Georgia 16,460 430 1,240 1,500 630 660 4,640 470 430 1,040 750
Hawaii 2,470 † 130 230 100 140 580 90 60 220 110
Idaho 2,790 90 190 220 130 90 670 100 60 210 170
Illinois 23,940 570 1,640 2,090 990 860 6,550 810 560 1,640 1,080
Indiana 13,420 340 870 1,080 570 400 4,060 450 300 850 540
Iowa 6,440 190 390 570 270 210 1,770 250 170 410 300
Kansas 5,510 170 350 480 260 190 1,540 200 140 380 240
Kentucky 10,200 230 590 850 370 310 3,550 320 200 600 350
Louisiana 9,040 210 630 810 330 440 2,610 280 180 620 380
Maine 3,300 90 180 240 140 100 970 110 70 210 150
Maryland 10,470 260 810 860 400 440 2,700 320 250 780 500
Massachusetts 12,710 330 770 930 530 580 3,420 410 330 930 570
Michigan 20,920 580 1,410 1,670 890 730 6,010 740 470 1,480 810
Minnesota 9,820 270 620 760 490 370 2,450 380 240 660 510
Mississippi 6,360 140 410 640 250 260 1,950 170 110 390 300
Missouri 12,830 310 900 1,050 530 480 3,910 400 240 860 500
Montana 2,020 60 130 170 90 60 540 70 60 140 120
Nebraska 3,480 110 210 340 140 120 890 130 70 240 180
Nevada 4,880 150 380 470 190 220 1,410 150 110 370 260
New Hampshire 2,730 80 170 200 110 80 770 80 70 200 120
New Jersey 16,250 380 1,290 1,480 640 630 3,900 510 450 1,240 720
New Mexico 3,620 100 270 350 150 180 760 120 110 250 210
New York 34,600 840 2,420 2,890 1,470 1,520 8,740 1,300 900 2,590 1,640
North Carolina 19,310 460 1,340 1,490 750 730 5,780 590 430 1,200 860
North Dakota 1,280 † 80 130 60 † 320 † † 90 70
Ohio 25,400 620 1,740 2,090 1,010 850 7,370 850 560 1,720 1,130
Oklahoma 8,100 220 520 680 320 310 2,460 260 180 490 350
Oregon 8,040 240 510 670 330 370 2,070 280 220 560 420
Pennsylvania 28,640 650 1,950 2,400 1,240 1,020 7,520 1,030 700 2,050 1,280
Rhode Island 2,120 50 130 160 90 90 570 60 † 120 100
South Carolina 10,130 240 690 840 350 380 2,970 300 230 640 460
South Dakota 1,630 50 110 140 80 50 450 50 † 100 90
Tennessee 14,370 360 890 1,220 540 550 4,600 450 290 840 580
Texas 38,520 1,010 2,710 3,470 1,620 2,260 9,580 1,260 930 2,550 1,570
Utah 2,900 120 270 240 140 120 460 120 90 240 200
Vermont 1,360 † 80 100 50 60 400 † † 90 70
Virginia 14,830 370 1,090 1,180 580 570 4,070 480 380 1,040 670
Washington 12,700 400 830 990 540 590 3,220 440 350 900 690
West Virginia 4,710 110 270 410 190 130 1,460 160 100 250 170
Wisconsin 11,550 350 720 850 540 400 3,050 410 300 830 590
Wyoming 1,000 † 70 80 60 † 240 † † 70 †
United States 589,430 15,320 40,290 49,700 24,450 24,550 158,040 19,790 14,180 40,560 27,540

*Rounded to the nearest 10.

†Estimate is fewer than 50 deaths.

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

TABLE 4. Probability (%) of Developing Invasive Cancer Within Selected Age Intervals by Sex, United States, 2009 to 2011*

BIRTH TO 49 50 TO 59 60 TO 69 �70 BIRTH TO DEATH
All sites† Male 3.4 (1 in 29) 6.7 (1 in 15) 15.1 (1 in 7) 36.0 (1 in 3) 43.3 (1 in 2)
Female 5.4 (1 in 19) 6.0 (1 in 17) 10.0 (1 in 10) 26.4 (1 in 4) 37.8 (1 in 3)
Breast Colorectum Female Male 1.9 (1 in 53) 0.3 (1 in 300) 2.3 (1 in 44) 0.7 (1 in 148) 3.5 (1 in 29) 1.3 (1 in 80) 6.7 (1 in 15) 3.9 (1 in 26) 12.3 (1 in 8) 4.8 (1 in 21)
Female 0.3 (1 in 326) 0.5 (1 in 193) 0.9 (1 in 112) 3.5 (1 in 28) 4.5 (1 in 22)
Kidney & renal pelvis Male Female 0.2 (1 in 468) 0.1 (1 in 752) 0.3 (1 in 292) 0.2 (1 in 586) 0.6 (1 in 157) 0.3 (1 in 321) 1.3 (1 in 76) 0.7 (1 in 134) 2.0 (1 in 49) 1.2 (1 in 84)
Leukemia Male 0.2 (1 in 419) 0.2 (1 in 598) 0.4 (1 in 271) 1.3 (1 in 75) 1.7 (1 in 59)
Lung & bronchus Female Male 0.2 (1 in 516) 0.2 (1 in 578) 0.1 (1 in 968) 0.7 (1 in 140) 0.2 (1 in 464) 2.0 (1 in 49) 0.9 (1 in 117) 6.6 (1 in 15) 1.2 (1 in 84) 7.4 (1 in 13)
Female 0.2 (1 in 541) 0.6 (1 in 173) 1.6 (1 in 64) 4.9 (1 in 20) 6.2 (1 in 16)
Melanoma of the skin‡ Male Female 0.3 (1 in 294) 0.5 (1 in 207) 0.4 (1 in 240) 0.3 (1 in 323) 0.8 (1 in 129) 0.4 (1 in 246) 2.1 (1 in 47) 0.9 (1 in 112) 3.0 (1 in 34) 1.9 (1 in 53)
Non-Hodgkin lymphoma Male 0.3 (1 in 366) 0.3 (1 in 347) 0.6 (1 in 173) 1.8 (1 in 55) 2.4 (1 in 42)
Prostate Female Male 0.2 (1 in 543) 0.3 (1 in 304) 0.2 (1 in 483) 2.3 (1 in 44) 0.4 (1 in 233) 6.3 (1 in 16) 1.4 (1 in 72) 10.9 (1 in 9) 1.9 (1 in 52) 15.0 (1 in 7)
Thyroid Male Female 0.2 (1 in 585) 0.7 (1 in 135) 0.1 (1 in 827) 0.3 (1 in 288) 0.2 (1 in 653) 0.3 (1 in 306) 0.2 (1 in 464) 0.4 (1 in 263) 0.6 (1 in 174) 1.7 (1 in 60)
Uterine cervix Female 0.3 (1 in 358) 0.1 (1 in 840) 0.1 (1 in 842) 0.2 (1 in 565) 0.6 (1 in 154)
Uterine corpus Female 0.3 (1 in 367) 0.6 (1 in 170) 0.9 (1 in 109) 1.3 (1 in 76) 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 are for whites.

probability of developing cancer was calculated using NCI’s DevCan software (version 6.7.1).13 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 8.1.5).14 The annual percent change in rates was quantified using NCI’s Joinpoint Regression Program (version 4.1.1).15

Whenever possible, cancer incidence rates presented in this report were adjusted for delays in reporting, which can occur because of a lag in case capture or data corrections. This adjustment is only available for data from the 13 oldest SEER registries because historic patterns of case ascertainment are required to anticipate future corrections to registry data. 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.16 For example, leukemia incidence rates adjusted for reporting delays are 13% higher than unadjusted rates in the most recent data year.4 Delay-adjusted rates were obtained from SEER*Stat databases.17,18

Projected Cancer Cases and Deaths in 2015

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 4-year-ahead projections are not useful for tracking cancer occurrence over time because they are model-based and because the methodology varies over time as we continually strive to achieve the most accurate estimates by taking advantage of improved modeling techniques, increased cancer registration coverage, and updated covariates.

A 3-step spatio-temporal model was used to estimate the number of new invasive cancer cases that will be diagnosed in 2015 based on high-quality incidence data from 49 states (Minnesota data were unavailable) and the District of Columbia during 1995 through 2011. Case coverage represents approximately 89% of the population because, in addition to lacking Minnesota, many states did not achieve high-quality data standards every year. In the first step, complete incidence counts were estimated for each county from 1995 through 2011 using geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of incidence.19 Then these counts were adjusted to account for delays in cancer reporting and aggregated to obtain national-and state-level estimates. Finally, a temporal projection method (the vector autoregressive model) was applied to the last 15 years of data to estimate counts for 2015. This method cannot estimate numbers of basal cell or squamous cell skin cancers because data on the occurrence of these cancers are not required to be reported to cancer registries. For the complete details of the case projection methodology, please refer to Zhu et al.20

To estimate the number of cases of female breast carcinoma in situ and melanoma in situ diagnosed in 2015, we first estimated the number of cases occurring annually from 2002 through 2011 by applying age-specific NAACCR incidence rates (data from 44 states with high-quality data every year) to the corresponding US population estimates provided in SEER*Stat.8,14 SEER 13-based delay-adjustment ratios, accessed from NCI’s Cancer Query System,21 were applied to in situ breast cancer counts to account for delays in reporting. (Delay-adjustment ratios are not available for in situ melanoma.) Then the total number of cases in 2015 was projected based on the average annual percent change in case counts from 2002 through 2011 generated by the joinpoint regression model.15

We estimated the number of cancer deaths expected to occur in 2015 in the United States overall and in each state using the joinpoint regression model based on the actual numbers of cancer deaths from 1997 through 2011 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al.22

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 subsequent years through 2011. The difference between the number of expected and recorded cancer deaths in each age group and calendar year was then summed. Averted deaths by state in 2011 were calculated similarly using state-and age-specific average annual crude rates for 5 age groups during 1990 through 1992. An aggregate rate was used instead of a single year because peak years varied across states, with a majority of states reaching peak rates during 1990 to 1992.

Selected Findings

Expected Numbers of New Cancer Cases

Table 1 presents the estimated numbers of new cases of invasive cancer expected in the United States in 2015 by sex. The overall estimate of 1,658,370 new cases is the equivalent of more than 4,500 new cancer diagnoses each day. In addition, about 60,290 cases of female breast carcinoma in situ and 63,440 cases of melanoma in situ are expected to be diagnosed in 2015. The estimated numbers of new cases by state for selected cancer sites are shown in Table 2.

Figure 1 indicates the most common cancers expected to occur in men and women in 2015. Prostate, lung and bronchus, and colorectal cancers will account for about one-half of all cases in men, with prostate cancer alone accounting for about one-quarter of new diagnoses. The 3 most commonly diagnosed cancers in women 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% of all new cancers in women.

Expected Numbers of Cancer Deaths

Table 1 also shows the expected numbers of deaths from cancer in 2015. It is estimated that about 589,430 Americans

FIGURE 3. Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2011.

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

will die from cancer this year, corresponding to about 1,600 deaths per day. The most common causes of cancer death are cancers of the lung and bronchus, prostate, and colorectum in men and cancers of the lung and bronchus, breast, and colorectum in women. These 4 cancers account for almost one-half of all cancer deaths (Fig. 1), with more than one-quarter (27%) of all cancer deaths due to lung cancer. Table 3 provides the estimated numbers of deaths in 2015 by state for selected cancer sites.

Lifetime Probability of Developing Cancer

The lifetime probability of being diagnosed with an invasive cancer is higher for men (43%) than for women (38%) (Table 4). The reasons for increased susceptibility in men are not well understood, but to some extent likely reflect differences in environmental exposures, endogenous hormones, and complex interactions between these influences. Recent studies suggest that height may also be afactor.23,24 For adults aged younger than 50 years, however, cancer risk is higher for women (5.4%) than for men (3.4%) because of the higher occurrence of breast, genital, and thyroid cancers in young women. The current cancer incidence rate among individuals aged birth to 49 years is 78.6 (per 100,000 population) in males and 125.1 in females, compared with 1732.8 and 1188.9, respectively, among adults aged 50 years and older.8 The estimated probability of developing cancer is based on the average experience of the general population and may over-or underestimate individual risk because of differences in exposure (eg, smoking history), medical history, and/or genetic susceptibility.

Trends in Cancer Incidence

Figures 2 and 3 illustrate long-term trends in cancer incidence rates for all cancers combined and for selected cancer sites by sex. Cancer incidence patterns in the United States reflect behavioral trends and improvements in cancer prevention and control, as well as changes in medical practice. Trends in overall incidence are heavily influenced by the 4 major cancers (lung, breast, prostate, and colorectal). For example, the steady increase in incidence rates in men from 1975 to the early 1990s (Fig. 2) was driven by a surge in prostate cancer incidence largely due to the increased detection of asymptomatic disease, first through the use of transurethral prostatectomy and then through widespread prostate-specific antigen (PSA) testing (Fig. 3).25,26 The

TABLE 5. Trends in Cancer Incidence (Delay-Adjusted) and Death Rates for Selected Cancers by Sex, United States, 1992 to 2011

TREND 1 TREND 2 TREND 3 TREND 4
2007-2011
YEARS APC YEARS APC YEARS APC YEARS APC AAPC
All sites
Incidence
Overall 1992-1994 23.1 1994-1999 0.3 1999-2011 20.5* 20.5*
Male 1992-1994 25.9* 1994-2007 20.5* 2007-2011 21.8* 21.8*
Female 1992-1998 0.8* 1998-2003 20.7 2003-2011 0.0 0.0
Death
Overall 1992-2001 21.0* 2001-2011 21.5* 21.5*
Male 1992-2001 21.4* 2001-2011 21.8* 21.8*
Female 1992-1995 20.2 1995-1998 21.2* 1998-2001 20.4 2001-2011 21.4* 21.4*
Female breast
Incidence 1992-1999 1.3* 1999-2004 22.2* 2004-2011 0.3 0.3
Death 1992-1995 21.3* 1995-1998 23.4* 1998-2011 21.9* 21.9*
Colorectum
Incidence
Male 1992-1995 22.6* 1995-1998 1.4 1998-2008 22.5* 2008-2011 24.0* 23.6*
Female 1992-1995 21.8* 1995-1998 1.8 1998-2008 21.9* 2008-2011 24.2* 23.6*
Death
Male 1992-2002 22.0* 2002-2005 23.9* 2005-2011 22.6* 22.6*
Female 1992-2001 21.7* 2001-2011 23.0* 23.0*
Liver & intrahepatic bile duct
Incidence
Male 1992-2011 3.6* 3.6*
Female 1992-2011 2.9* 2.9*
Death
Male 1992-2007 2.2* 2007-2011 3.3* 3.3*
Female 1992-2008 1.3* 2008-2011 3.1* 2.6*
Lung & bronchus
Incidence
Male 1992-2009 21.9* 2009-2011 24.0* 23.0*
Female 1992-2007 0.0 2007-2011 22.2* 22.2*
Death
Male 1992-2005 21.9* 2005-2011 22.9* 22.9*
Female 1992-1995 1.4* 1995-2003 0.3* 2003-2007 20.8 2007-2011 21.9* 21.9*
Melanoma of skin
Incidence
Male 1992-2011 2.3* 2.3*
Female 1992-1997 4.1* 1997-2011 1.5* 1.5*
Death
Male 1992-2011 0.3* 0.3*
Female 1992-2011 20.5* 20.5*
Pancreas
Incidence
Male 1992-2001 0.0 2001-2011 1.2* 1.2*
Female 1992-1999 20.1 1999-2011 1.1* 1.1*
Death
Male 1992-1996 21.0* 1996-2011 0.3* 0.3*
Female 1992-1997 20.4 1997-2011 0.4* 0.4*
Prostate
Incidence 1992-1995 211.2* 1995-2000 2.3 2000-2011 22.1* 22.1*
Death 1992-1994 21.0 1994-2004 23.8* 2004-2011 23.2* 23.2*
Thyroid
Incidence
Male 1992-1995 23.1 1995-2011 5.3* 5.3*
Female 1992-1999 4.2* 1999-2009 6.9* 2009-2011 2.2 4.5*
Death
Male 1992-2011 1.6* 1.6*
Female 1992-1994 26.0 1994-2011 0.8* 0.8*

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 4.1.1, allowing up to 3 joinpoints. Incidence trends based on Surveillance, Epidemiology, and End Results (SEER) 13 areas.

TABLE 6. Trends in 5-Year Relative Survival Rates* (%) by Race and Year of Diagnosis, United States, 1975 to 2010

1975 TO ALL RACES 1987 TO 2004 TO 1975 TO WHITE 1987 TO 2004 TO 1975 TO BLACK 1987 TO 2004 TO
1977 1989 2010 1977 1989 2010 1977 1989 2010
All sites 49 55 68† 50 57 69† 39 43 62†
Brain & other nervous system 22 29 35† 22 28 33† 25 32 42†
Breast (female) 75 84 91† 76 85 92† 62 71 80†
Colon 51 60 65† 51 61 67† 45 52 56†
Esophagus 5 9 20† 6 11 21† 4 7 13†
Hodgkin lymphoma 72 79 88† 72 80 88† 70 72 85†
Kidney & renal pelvis 50 57 74† 50 57 74† 49 55 72†
Larynx 66 66 63† 67 67 64 58 56 52
Leukemia 34 43 60† 35 44 61† 33 35 54†
Liver & intrahepatic bile duct 3 5 18† 3 6 17† 2 3 13†
Lung & bronchus 12 13 18† 12 13 18† 11 11 15†
Melanoma of the skin 82 88 93† 82 88 93† 57‡ 79‡ 75
Myeloma 25 27 47† 24 27 47† 30 30 47†
Non-Hodgkin lymphoma 47 51 71† 47 51 73† 48 46 63†
Oral cavity & pharynx 53 54 66† 54 56 67† 36 34 45†
Ovary 36 38 45† 35 38 44† 42 34 36
Pancreas 3 4 7† 3 3 7† 2 6 7†
Prostate 68 83 >99† 69 84 >99† 61 71 98†
Rectum 48 58 68† 48 59 68† 44 52 63†
Stomach 15 20 29† 14 18 28† 16 19 28†
Testis 83 95 97† 83 96 97† 73‡§ 88‡ 90
Thyroid 92 94 98† 92 94 98† 90 92 96†
Urinary bladder 72 79 79† 73 80 80† 50 63 64†
Uterine cervix 69 70 70 70 73 71 65 57 62
Uterine corpus 87 82 83† 88 84 85† 60 57 65†

*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 2004 to 2010, all followed through 2011.

†The difference in rates between 1975 to 1977 and 2004 to 2010 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.

increase in incidence in women during the 1980s reflects the increase in lung cancer as a result of the tobacco epidemic and the increase in breast cancer because of changes in female reproductive patterns, as well as increased detection of asymptomatic disease during the rapid uptake of mammography screening.27

Table 5 presents the annual percent change in delay-adjusted incidence rates in the SEER 13 registries during 1992 through 2011 based on joinpoint regression analysis. Joinpoint is a tool used to describe and quantify trends by fitting observed rates to lines connected at “joinpoints” where trends change in direction or magnitude.7,28 During the past 5 years for which there are data (2007-2011), the overall incidence rate remained stable in women and declined by 1.8% per year in men. The decrease in men is driven by the rapid declines in colorectal (3.6% per year), lung (3.0% per year), and prostate (2.1% per year) cancers. Among women, although the recent rates of decline for colorectal and lung cancers have been similar to those in men, breast cancer incidence rates remained flat and thyroid cancer incidence rates increased dramatically, by an average of 4.5% per year from 2007 to 2011. Although thyroid cancer incidence is also increasing rapidly in men, the 3-fold higher rates in women have a larger influence on overall trends.8

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 colorectal cancer screening.29 However, the rapid declines in recent years (4.0% or greater per year from 2008-2011) likely reflect the increased uptake of screening, primarily in the form of colonoscopy, which can prevent cancer by allowing for the removal of precancerous lesions.30,31 Among adults aged 50 to 75 years, colonoscopy use increased from 19.1% in 2000 to 54.5% in 2013.32

Lung cancer incidence rates began declining in the mid-1980s in men and in the late 1990s in women as a result of reductions in smoking prevalence that began decades earlier. Contemporary differences in lung cancer incidence patterns between men and women (Fig. 3) reflect historical differences in tobacco use. Women took up smoking in large numbers decades later than men, first

TABLE 7. Relative Decline in Cancer Death Rates by State Since the Early 1990s and Potential Deaths Averted in 2011

1990 TO 2011 RELATIVE 2011 OBSERVED 2011 EXPECTED 2011 AVERTED
1992 RATE RATE DECLINE COUNTS* COUNTS† DEATHS‡
Alabama 220.2 187.4 15% 10,233 12,122 1,889
Alaska 219.3 176.1 20% 935 1,204 269
Arizona 197.8 148.4 25% 10,690 14,363 3,673
Arkansas 221.8 191.1 14% 6,497 7,625 1,128
California 202.2 151.8 25% 56,448 76,129 19,681
Colorado 187.5 143.9 23% 7,051 9,416 2,365
Connecticut 206.9 157.9 24% 6,837 8,948 2,111
Delaware 240.9 179.7 25% 1,905 2,583 678
Dist. of Columbia 269.7 180.6 33% 1,070 1,629 559
Florida 208.0 160.2 23% 41,681 53,723 12,042
Georgia 214.8 171.0 20% 15,602 20,184 4,582
Hawaii 172.5 138.2 20% 2,278 2,841 563
Idaho 187.0 157.6 16% 2,573 3,111 538
Illinois 222.9 174.8 22% 24,006 31,036 7,030
Indiana 221.0 185.2 16% 13,180 15,966 2,786
Iowa 198.5 172.4 13% 6,481 7,502 1,021
Kansas 197.2 169.9 14% 5,440 6,343 903
Kentucky 236.3 200.9 15% 9,733 11,726 1,993
Louisiana 240.4 193.5 20% 9,233 11,646 2,413
Maine 230.5 181.7 21% 3,201 4,087 886
Maryland 237.3 165.9 30% 10,249 14,865 4,616
Massachusetts 225.1 166.4 26% 12,895 17,531 4,636
Michigan 220.2 177.4 19% 20,420 25,597 5,177
Minnesota 197.8 160.5 19% 9,489 11,849 2,360
Mississippi 224.2 196.8 12% 6,278 7,233 955
Missouri 217.5 179.4 18% 12,473 15,311 2,838
Montana 203.4 164.4 19% 2,022 2,547 525
Nebraska 192.9 164.2 15% 3,410 4,052 642
Nevada 226.7 170.3 25% 4,605 6,308 1,703
New Hampshire 224.0 178.0 21% 2,740 3,510 770
New Jersey 229.6 165.6 28% 16,708 23,332 6,624
New Mexico 182.5 146.6 20% 3,328 4,200 872
New York 215.4 159.6 26% 35,469 47,934 12,465
North Carolina 213.9 174.8 18% 18,284 22,694 4,410
North Dakota 199.1 160.5 19% 1,321 1,644 323
Ohio 224.2 184.4 18% 25,140 30,880 5,740
Oklahoma 209.6 191.2 9% 7,997 8,859 862
Oregon 209.2 172.2 18% 7,802 9,668 1,866
Pennsylvania 223.6 177.3 21% 28,895 36,398 7,503
Rhode Island 222.7 168.3 24% 2,170 2,888 718
South Carolina 219.7 182.2 17% 9,543 11,662 2,119
South Dakota 195.9 168.6 14% 1,665 1,930 265
Tennessee 220.6 189.1 14% 13,562 16,015 2,453
Texas 211.3 162.6 23% 37,351 49,696 12,345
Utah 157.4 125.6 20% 2,746 3,469 723
Vermont 218.9 175.6 20% 1,347 1,735 388
Virginia 222.1 170.7 23% 14,374 19,125 4,751
Washington 205.9 166.6 19% 12,002 15,194 3,192
West Virginia 226.8 199.6 12% 4,782 5,569 787
Wisconsin 208.1 174.9 16% 11,608 13,950 2,342
Wyoming 193.2 156.1 19% 936 1,192 256

Rates are per 100,000 and age adjusted to the 2000 US standard population. *Excludes unknown age.

†Expected counts were estimated by applying age-specific crude rates for 1990–1992 to 2011 population estimates.

‡Deaths averted is the difference between the number of expected and observed deaths in 2011.

initiated smoking at older ages, and were slower to quit, The decline in prostate cancer incidence rates that including recent upturns in smoking prevalence in some began in the mid-1990s likely reflects the diminishing birth cohorts.33,34 proportion of men receiving an initial PSA test.35

TABLE 8. Ten Leading Causes of Death by Age and Sex, United States, 2011

ALL AGES MALE FEMALE All Causes All Causes 1,254,978 1,260,480 AGES 1 TO 19 MALE FEMALE All Causes All Causes 13,202 7,039 AGES 20 TO 39 MALE FEMALE All Causes All Causes 61,744 28,555 AGES 40 TO 59 MALE FEMALE All Causes All Causes 226,700 143,234 AGES 60 TO 79 MALE FEMALE All Causes All Causes 484,159 382,212 AGES �80 MALE FEMALE All Causes All Causes 455,747 688,747
1 Heart diseases 308,398 Heart diseases 288,179 Accidents (unintentional injuries) 4,916 Accidents (unintentional injuries) 2,394 Accidents (unintentional injuries) 22,459 Accidents (unintentional injuries) 8,122 Cancer 54,172 Cancer 50,445 Cancer 158,118 Cancer 129,632 Heart diseases 132,189 Heart diseases 191,463
2 Cancer 302,231 Cancer 274,460 Assault (homicide) 1,862 Cancer 797 Intentional self-harm (suicide) 9,708 Cancer 4,407 Heart diseases 52,247 Heart diseases 21,470 Heart diseases 118,232 Heart diseases 72,365 Cancer 84,860 Cancer 89,145
3 Accidents (unintentional injuries) 79,257 Cerebrovascular disease 76,597 Intentional self-harm (suicide) 1,633 Assault (homicide) 513 Assault (homicide) 7,051 Heart diseases 2,446 Accidents (unintentional injuries) 25,372 Accidents (unintentional injuries) 12,132 Chronic lower respiratory diseases 32,493 Chronic lower respiratory diseases 31,990 Chronic lower respiratory diseases 29,122 Alzheimer disease 51,567
4 Chronic lower respiratory diseases 67,521 Chronic lower respiratory diseases 75,422 Cancer 1,055 Congenital anomalies 464 Heart diseases 5,143 Intentional self-harm (suicide) 2,409 Intentional self-harm (suicide) 12,287 Chronic lower respiratory diseases 5,428 Cerebrovascular disease 19,925 Cerebrovascular disease 19,350 Cerebrovascular disease 25,029 Cerebrovascular disease 51,528
5 Cerebrovascular disease 52,335 Alzheimer disease 59,297 Congenital anomalies 594 Intentional self-harm (suicide) 456 Cancer 3,984 Assault (homicide) 1,359 Chronic liver disease & cirrhosis 11,123 Chronic liver disease & cirrhosis 5,298 Diabetes mellitus 18,200 Diabetes mellitus 14,392 Alzheimer disease 20,171 Chronic lower respiratory diseases 37,645
6 Diabetes mellitus 38,324 Accidents (unintentional injuries) 47,181 Heart diseases 403 Heart diseases 283 HIV disease 879 Pregnancy, childbirth & puerperium 684 Diabetes mellitus 7,795 Cerebrovascular disease 4,994 Accidents (unintentional injuries) 14,138 Accidents (unintentional injuries) 8,345 Influenza & pneumonia 14,189 Influenza & pneumonia 19,413
7 Intentional self-harm (suicide) 31,003 Diabetes mellitus 35,507 Chronic lower respiratory diseases 172 Influenza & pneumonia 138 Diabetes mellitus 842 Diabetes mellitus 593 Cerebrovascular disease 6,557 Diabetes mellitus 4,867 Nephritis, nephrotic syndrome & nephrosis 8,596 Nephritis, nephrotic syndrome & nephrosis 7,589 Accidents (unintentional injuries) 11,706 Accidents (unintentional injuries) 15,671
8 Alzheimer disease 25,677 Influenza & pneumonia 28,425 Influenza & pneumonia 158 Chronic lower respiratory diseases 86 Chronic liver disease & cirrhosis 821 Cerebrovascular disease 581 Chronic lower respiratory diseases 5,393 Intentional self-harm (suicide) 3,981 Chronic liver disease & cirrhosis 8,264 Alzheimer disease 7,530 Diabetes mellitus 11,443 Diabetes mellitus 15,616
9 Influenza & pneumonia 25,401 Nephritis, nephrotic syndrome & nephrosis 22,942 Cerebrovascular disease 114 Septicemia 86 Cerebrovascular disease 634 HIV disease 522 HIV disease 3,567 Septicemia 2,409 Influenza & pneumonia 7,741 Septicemia 6,897 Nephritis, nephrotic syndrome & nephrosis 11,184 Nephritis, nephrotic syndrome & nephrosis 13,284
10 Nephritis, nephritic syndrome & nephrosis 22,649 Septicemia 19,264 Septicemia 86 Cerebrovascular disease 84 Influenza & pneumonia 556 Chronic liver disease & cirrhosis 471 Viral hepatitis 3,347 Influenza & pneumonia 1,947 Septicemia 7,001 Influenza & pneumonia 6,408 Parkinson disease 8,744 Hypertension & hypertensive renal disease* 11,615

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, 2011, National Center for Health Statistics, Centers for Disease Control and Prevention, 2014.

FIGURE 4. Geographic Patterns in Cancer Death Rates in 2011 (A) and in the Relative Decline (%) in Cancer Death Rates from 1990–1992 to 2011 (B).

Rates are per 100,000 and age adjusted to the 2000 US standard population.

Routine screening with the PSA test is no longer rec-declined in recent years among men aged younger than ommended because of growing concerns about high 50 years, as well as in those aged 75 years or older, rates of overdiagnosis, estimated at 23% to 42% for but remain high for older men with a limited life

36 37–39

screen-detected cancers. PSA testing rates may have expectancy.

FIGURE 5. Trends in Death Rates Overall and for Selected Sites by Sex, United States, 1930 to 2011.

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. *Mortality rates for pancreatic and liver cancers are increasing.

† Uterus includes uterine cervix and uterine corpus.

In contrast to the stable or declining trends for most cancers, incidence rates in the SEER 13 registries increased from 2007 through 2011 among both men and women for cancers of the small intestine, anus, liver, pancreas, soft tissue (including the heart), and thyroid; melanoma of the skin; myeloma; and leuke

mia.7,17

In addition, incidence rates increased in men for breast cancer, non-Hodgkin lymphoma, and human papillomavirus-positive oropharyngeal cancers and in women for esophageal adenocarcinoma and uterine cancer. The largest annual increases were for cancers of the thyroid (5.3% and 4.5% in men and women, respectively) and liver (3.6% and 2.9% in men and women, respectively) (Table 5).

TABLE 9. Five Leading Types of Cancer Death by Age and Sex, United States, 2011

ALL AGES <20 20 TO 39 40 TO 59 60 TO 79 �80
MALE
ALL SITES 302,231 Lung & bronchus 86,738 Prostate 27,970 Colorectum 26,804 Pancreas 18,881 Liver* 14,626 ALL SITES 1,094 Brain & ONS 308 Leukemia 293 Bones & joints 107 Soft tissue (including heart) 80 NHL 44 ALL SITES 3,984 Leukemia 529 Brain & ONS 491 Colorectum 442 NHL 278 Soft tissue (including heart) 225 ALL SITES 54,172 Lung & bronchus 14,347 Colorectum 5,789 Liver* 4,754 Pancreas 3,676 Esophagus 2,691 ALL SITES 158,118 Lung & bronchus 51,951 Colorectum 13,088 Prostate 11,732 Pancreas 10,594 Liver* 7,467 ALL SITES 84,860 Lung & bronchus 20,216 Prostate 14,956 Colorectum 7,480 Urinary bladder 4,785 Pancreas 4,510
FEMALE
ALL SITES 274,460 Lung & bronchus 70,219 Breast 40,931 Colorectum 24,979 Pancreas 18,463 Ovary 14,346 ALL SITES 828 Brain & ONS 242 Leukemia 226 Soft tissue (including heart) 68 Bones & joints 67 Kidney & renal pelvis 23 ALL SITES 4,407 Breast 1,041 Uterine cervix 417 Leukemia 356 Colorectum 344 Brain & ONS 303 ALL SITES 50,445 Breast 11,340 Lung & bronchus 11,043 Colorectum 4,209 Ovary 3,064 Pancreas 2,578 ALL SITES 129,632 Lung & bronchus 39,287 Breast 17,538 Colorectum 10,084 Pancreas 9,076 Ovary 7,192 ALL SITES 89,145 Lung & bronchus 19,694 Breast 11,010 Colorectum 10,338 Pancreas 6,747 Leukemia 4,111

NHL indicates Non-Hodgkin lymphoma; ONS, other nervous system. *Liver includes intrahepatic bile duct. Note: Ranking order excludes category titles that begin with “Other.”

Trends in Cancer Survival

There have been notable improvements in survival over the past 3 decades for most cancer types in both blacks and whites (Table 6). The 5-year relative survival rate for all sites combined has increased 19 percentage points among whites and 23 percentage points among blacks. Progress has been most rapid for hematopoietic and lymphoid malignancies due to improvements in treatment protocols, including the discovery of targeted therapies. For example, the 5-year survival for acute lymphocytic leukemia increased from 41% during the mid-1970s to 70% during 2004 to 2010. The use of BCR-ABL tyrosine kinase inhibitors (eg, imatinib) doubled survival for patients with chronic myeloid leukemia in less than 2 decades, from 31% in the early 1990s to 60% in 2004 through 2010.40

In contrast to the steady increase in survival for most cancers, advances have been slow for lung and pancreatic cancers, for which the 5-year relative survival is currently 18% and 7%, respectively. These low rates are partly because more than one-half of cases are diagnosed at a distant stage, for which 5-year survival is 4% and 2%, respectively. There is promise for improving lung cancer survival rates because of earlier detection through screening with spiral computed tomography, which has been shown to reduce lung cancer deaths by 16% to 20% among adults with at least a 30-packyear smoking history.41,42 However, it is important to realize that screening, as well as other changes in detection practices, introduces lead time bias in survival rates, thereby reducing their usefulness in measuring progress against cancer. 43 Advances against cancer are best measured using age-standardized mortality rates.

Trends in Cancer Mortality

The overall cancer death rate rose during most of the 20th century, peaking 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

TABLE 10. Incidence and Death Rates by Site, Race, and Ethnicity, United States, 2007 to 2011

NON-HISPANIC WHITE NON-HISPANIC BLACK ASIAN/PACIFIC ISLANDER AMERICAN INDIAN/ ALASKA NATIVE* HISPANIC
Incidence
All sites Male Female Breast (female) Colorectum Male Female Kidney & renal pelvis Male Female Liver & intrahepatic bile duct Male Female Lung & bronchus Male Female Prostate Stomach Male Female Uterine cervix 540.8 435.8 127.6 49.2 37.4 21.6 11.3 8.9 3.0 81.3 59.3 133.2 7.8 3.5 7.1 606.2 406.3 123.0 61.9 45.6 24.1 12.9 16.0 4.6 95.4 51.7 219.8 15.4 8.1 10.2 322.3 283.7 86.0 39.9 30.0 10.7 5.0 21.2 8.0 48.0 28.0 72.5 15.3 8.6 6.4 432.2 368.3 91.7 50.9 41.1 30.1 17.8 18.4 8.6 68.5 52.5 97.9 12.0 6.5 9.5 420.9 330.1 91.6 45.9 31.6 20.6 11.6 19.1 6.9 45.0 26.3 120.2 13.8 7.9 10.5
Mortality
All sites Male Female Breast (female) Colorectum Male Female Kidney & renal pelvis Male Female Liver & intrahepatic bile duct Male Female Lung & bronchus Male Female Prostate Stomach Male Female Uterine cervix 214.0 151.2 22.2 18.7 13.2 5.9 2.6 7.3 3.0 63.9 42.1 20.7 3.8 1.9 2.0 275.5 173.0 31.4 28.4 18.9 5.8 2.7 12.4 4.3 77.5 37.4 49.8 9.8 4.6 4.2 131.0 91.5 11.3 13.1 9.5 3.0 1.3 14.5 6.0 34.7 18.4 10.0 8.3 4.8 1.8 190.0 135.2 15.2 19.2 15.6 9.5 4.4 13.8 6.0 50.0 32.4 21.2 7.0 3.8 3.4 150.1 99.9 14.5 15.8 9.9 5.1 2.3 12.6 5.5 30.5 14.0 18.5 7.5 4.2 2.8

Rates are per 100,000 population and age adjusted to the 2000 US standard population. Nonwhite and nonblack race categories are not mutually exclusive of Hispanic origin.

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

rate as a result of fewer Americans smoking and advances in cancer prevention, early detection, and treatment. The 22% drop in cancer death rates from 1991 (215.1 per 100,000 population) to 2011 (168.7 per 100,000 population) translates into the avoidance of an estimated 1,519,300 cancer deaths (1,071,600 in men and 447,700 in women) that would have occurred if peak rates had persisted.

Although cancer death rates have declined in every state, there is much variation in the magnitude of the declines. Table 7 shows the relative decline in cancer death rates by state from the early 1990s to 2011 and the estimated number of cancer deaths averted in 2011 as a result. The decline was calculated from an average annual baseline rate during 1990 to 1992 because the death rate did not peak in 1991 in all states. Declines ranged from 9% in Oklahoma to 33% in the District of Columbia, and were generally largest in northeastern states. The declines of 25% to 30% in Maryland,

FIGURE 6. Stage Distribution of Selected Cancers by Race, United States, 2004 to 2010.

Stage categories do not sum to 100% because sufficient information is not available to stage all cases. *The proportion of cases of carcinoma in situ of the urinary bladder is 51% in all races combined, 52% in whites, and 39% in blacks.

New Jersey, Massachusetts, New York, and Delaware resulted in 29,000 fewer cancer deaths, collectively, in 2011. Almost 20,000 deaths were averted in California because of a 25% drop. In general, Southern states had the slowest declines and the highest current death rates, whereas western states had the lowest death rates (Fig. 4). For example, 2011 cancer death rates ranged from 125.6 (per 100,000 population) in Utah to 200.9 in Kentucky. The large geographic variation in cancer death rates and trends reflects differences in risk factor patterns, such as smoking and obesity, as well as disparities in the national distribution of poverty and access to health care, which have increased over

time.44,45

FIGURE 7. Five-Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis, United States, 2004 to 2010.

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

†

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

Figure 5 depicts trends in cancer death rates since 1930 among men and women overall and for selected cancer sites by sex. In contrast to male cancer death rates, which rose continuously prior to 1990, female cancer death rates fell from the late 1940s to the mid-1970s (Fig. 5A). It is also interesting to note that prior to 1941, death rates were higher in women than in men due to the high death rate for uterine cancer (uterine corpus and uterine cervix combined), which was the leading cause of cancer death among women in the early 20th century. Uterine cancer death rates declined by more than 80% between 1930 and 2011, largely due to the widespread uptake of screening
18 CA: A Cancer Journal for Clinicians

TABLE 11. Average Annual Percent Change in Cancer Incidence and Mortality Rates From 2007 to 2011 by Race/Ethnicity, United States

MALE INCIDENCE FEMALE 5-YEAR AAPC MALE MORTALITY FEMALE
Non-Hispanic white 22.9* 20.8 21.6* 21.3*
Non-Hispanic black 23.0* 20.4* 22.5* 21.1*
Asian/Pacific Islander 21.6* 0.1 21.3* 20.8*
American Indian/Alaska Native† 24.3* 22.3 20.5 21.6*
Hispanic 23.2* 20.6* 21.6* 21.2*

*Average annual percent change is statistically significant (P < .05).

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

Notes: Trends analyzed from 2002 to 2011 using the Joinpoint Regression Program, version 4.1.1, allowing up to 2 joinpoints. Incidence trends based on44 states, representing 92% of the US population.

for the prevention and early detection of cervical cancer. A similarly dramatic decline occurred for stomach cancer, which accounted for 30% and 20% of male and female cancer deaths, respectively, in the 1930s, but just 2% for each in 2011. Although reasons for the decline in the United States and most other parts of the world are complex and not completely understood, contributors are thought to include a lower prevalence of Helicobacter pylori because of improved hygiene and lower salt intake and a higher consumption of fresh fruits and vegetables because of advances in food preservation techniques (eg, refrigeration).46 Recent studies indicate that incidence rates for certain subtypes of stomach cancer are increasing for some subsets of the US population.47,48

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%) (Table 5). These declines are driven by continued decreases in death rates for the 4 major cancer sites (lung, breast, prostate, and colorectum). Lung cancer death rates declined 36% between 1990 and 2011 among males and 11% between 2002 and 2011 among females due to reduced tobacco use as a result of increased awareness of the health hazards of smoking and the implementation of comprehensive tobacco control.7,49 Researchers recently estimated that tobacco control efforts adopted in the wake of the first Surgeon General’s report on smoking and health in 1964 have resulted in 8 million fewer premature smoking-related deaths, one-third of which are due to cancer.50,51 Death rates for female breast cancer are down 35% from peak rates, and those from prostate and colorectal cancers are each down 47% as a result of improvements in early detection and treatments.7,29,52,53

In contrast to declining trends for the major cancers, joinpoint analysis indicates that death rates are rising in both sexes for cancers of the oropharynx, anus, liver, pancreas, and soft tissue (including the heart).7 Death rates are also increasing for tonsil cancer and melanoma in men and for uterine cancer in women. Thyroid cancer death rates also increased, but only slightly, from 0.51 (per 100,000 population) in 2007 to 0.52 in 2011 among men and from

0.48 to 0.49 among women.

Recorded Number of Deaths in 2011

A total of 2,515,458 deaths were recorded in the United States in 2011, of which 576,691 (23%) were from cancer. Overall, cancer is the second leading cause of death following heart disease, which accounted for 24% of total deaths. However, cancer is expected to overtake heart disease as the leading cause of death within the next several years. In 2011, cancer was the leading cause of death among adults aged 40 to 79 years and was the first or second leading cause of death in every age group among women (Table 8).

Table 9 presents the number of deaths from all cancers combined and from the 5 most common sites for each 20year age group by sex. More cancer deaths occur in men than in women except for those aged 20 to 39 years and 80 years or older. Breast cancer is the leading cause of cancer death in women aged 20 to 59 years, but is replaced by lung cancer in women aged 60 years or older. Among men, leukemia is the leading cause of cancer death for those aged 20 to 39 years, whereas lung cancer ranks first among men aged 40 years or older.

Cancer Occurrence by Race/Ethnicity

Cancer incidence and death rates vary considerably between and within racial and ethnic groups. Of the 5 broadly defined population groups in Table 10, black men have the highest overall cancer incidence and death rates—about double those of Asian/Pacific Islander (API) men, who have the lowest rates. Cancer incidence and death rates are higher among

TABLE 12. Incidence Rates for Selected Cancers by State, United States, 2007 to 2011

LUNG & NON-HODGKIN URINARY
STATE ALL CANCERS MALE FEMALE BREAST FEMALE COLORECTUM MALE FEMALE BRONCHUS MALE FEMALE LYMPHOMA MALE FEMALE PROSTATE MALE BLADDER MALE FEMALE
Alabama 568.8 396.5 118.4 55.6 38.7 100.6 54.8 19.7 13.7 153.7 33.4 7.8
Alaska 501.4 424.1 127.3 50.9 41.4 79.4 59.5 21.3 14.9 126.0 37.5 11.0
Arizona 432.8 373.5 111.6 41.1 31.4 60.7 47.7 18.7 13.6 100.9 32.7 8.4
Arkansas*† 552.7 385.1 109.8 55.2 38.7 106.7 60.2 21.9 14.8 149.6 33.7 7.8
California 499.2 396.3 122.4 47.9 36.3 58.0 43.1 23.0 15.6 136.4 33.1 7.9
Colorado 490.7 397.2 125.3 41.8 32.8 54.7 44.0 22.5 15.9 147.6 32.8 8.4
Connecticut 567.4 455.7 136.6 49.4 37.4 74.3 58.2 25.3 17.4 152.4 47.1 12.3
Delaware 589.5 444.9 128.0 49.1 37.5 86.0 63.4 23.4 16.9 168.1 43.1 11.4
Dist. of Columbia 579.8 435.7 143.4 51.2 43.7 75.3 47.2 21.0 12.9 198.2 25.1 9.1
Florida 514.2 400.5 114.6 46.6 35.4 77.4 56.0 21.9 15.1 128.3 35.0 8.6
Georgia 564.4 407.8 123.8 50.8 37.6 91.0 54.8 22.1 14.8 161.0 34.2 7.9
Hawaii 477.9 398.1 126.0 56.5 37.4 62.6 38.4 21.3 14.4 113.9 24.5 6.1
Idaho 526.2 411.2 118.8 44.9 34.5 61.2 47.1 22.5 17.0 155.0 38.7 9.0
Illinois 560.6 441.3 127.4 57.2 41.9 84.9 60.4 23.9 16.6 149.4 39.3 9.8
Indiana 522.5 424.5 118.5 52.9 41.1 95.0 62.9 23.5 16.8 117.4 35.9 8.8
Iowa 552.1 438.9 124.8 55.8 42.1 83.0 54.7 27.0 18.7 133.3 41.1 8.7
Kansas 552.5 424.7 122.5 52.4 38.5 78.2 54.0 23.6 16.3 152.6 38.7 9.3
Kentucky 604.0 464.2 120.7 62.4 45.0 122.9 80.7 24.9 17.2 128.8 40.4 9.8
Louisiana 601.6 416.6 121.3 60.8 43.5 96.9 57.0 24.3 16.6 168.9 34.3 8.1
Maine 563.6 454.9 126.4 48.4 39.3 88.1 66.2 25.3 17.5 133.9 48.1 13.0
Maryland 526.8 420.7 130.3 46.2 35.9 72.2 54.9 21.5 15.2 152.1 33.7 9.2
Massachusetts 558.7 460.0 135.6 47.6 37.6 77.1 63.6 24.8 16.4 148.9 42.8 11.9
Michigan 567.4 432.3 120.7 48.9 37.5 83.6 61.2 24.6 17.4 161.5 41.2 10.6
Minnesota‡ -- - -- -- -- - --
Mississippi 593.4 402.7 116.0 60.3 44.0 110.2 56.8 21.3 14.6 161.4 30.7 7.3
Missouri 519.8 423.3 122.6 53.2 39.4 93.0 63.7 22.1 15.9 121.8 34.0 8.5
Montana 519.6 425.3 125.8 48.6 38.5 68.8 54.7 23.0 15.3 147.2 37.6 10.1
Nebraska 513.6 421.4 121.8 54.9 42.9 72.2 50.8 23.7 17.8 136.6 35.0 8.5
Nevada*§ 494.8 394.5 112.7 50.2 35.8 72.2 61.3 19.7 15.0 133.9 36.8 10.6
New Hampshire 573.2 454.4 134.1 45.1 38.0 78.8 62.8 25.3 17.5 151.7 49.6 13.5
New Jersey 576.6 450.0 129.5 52.6 39.9 71.4 55.1 25.1 17.9 166.1 42.7 11.4
New Mexico 447.8 362.2 110.0 43.0 32.2 51.2 37.7 17.9 13.4 124.4 25.7 6.2
New York 580.6 451.2 128.5 51.6 39.8 75.4 55.6 26.4 18.1 163.3 41.9 10.6
North Carolina 560.9 417.9 126.6 48.4 35.7 94.4 56.7 22.7 15.6 149.1 36.9 9.0
North Dakota 524.8 411.1 121.8 57.2 41.1 68.9 44.3 23.2 18.5 149.0 37.8 9.3
Ohio 531.6 421.6 120.0 51.8 38.9 89.4 59.9 22.6 15.6 135.8 38.5 9.4
Oklahoma 539.1 414.8 120.4 51.5 39.5 93.5 61.1 22.1 16.2 142.7 34.0 8.2
Oregon 505.2 429.6 129.4 44.5 35.3 69.1 57.8 22.5 15.5 134.4 37.8 9.5
Pennsylvania 571.5 456.9 126.8 54.3 41.1 83.2 57.6 25.6 17.8 145.9 44.3 11.1
Rhode Island 559.0 455.8 130.1 47.1 38.9 82.7 63.1 23.3 17.6 143.1 46.4 14.0
South Carolina 544.6 402.9 123.0 48.2 36.7 92.5 53.8 20.1 13.4 146.7 31.6 8.5
South Dakota 501.8 411.7 122.0 55.9 41.4 70.9 49.1 22.4 16.3 142.0 34.2 8.8
Tennessee 562.5 417.9 119.7 51.7 38.9 101.0 61.4 22.4 16.1 143.7 35.3 8.1
Texas 504.7 387.1 113.7 49.7 34.6 75.7 47.4 22.1 15.6 126.9 28.8 6.8
Utah 492.1 361.1 112.0 38.1 30.4 34.2 23.3 24.9 15.7 170.6 31.3 5.6
Vermont 528.9 441.4 129.1 43.3 36.1 77.2 64.0 24.7 17.2 133.4 39.5 11.1
Virginia 508.6 398.1 125.0 45.0 35.1 79.7 53.1 21.3 14.6 143.2 33.0 8.3
Washington 534.9 438.8 132.5 44.6 35.5 70.1 56.1 25.9 17.2 144.3 38.0 9.4
West Virginia 555.1 437.2 110.5 57.5 42.5 104.7 68.8 23.2 16.8 126.3 39.1 10.8
Wisconsin 532.9 426.8 124.8 47.4 37.1 73.2 54.1 24.7 17.3 139.2 40.0 10.0
Wyoming 488.5 387.1 112.1 44.0 35.5 56.3 45.6 20.1 14.5 143.4 37.8 10.6
United States 535.8 419.1 122.8 50.0 37.8 78.6 54.6 23.2 16.1 142.1 36.7 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 2007 to 2011 according to the North American Association of Central Cancer Registries (NAACCR).

†Rates are based on incidence data for 2007 to 2009.

‡This state’s registry did not submit cancer incidence data to the NAACCR. §Rates are based on incidence data for 2007 to 2010.

TABLE 13. Death Rates for Selected Cancers by State, United States, 2007 to 2011

LUNG & NON-HODGKIN
STATE ALL SITES MALE FEMALE BREAST FEMALE COLORECTUM MALE FEMALE BRONCHUS MALE FEMALE LYMPHOMA MALE FEMALE PANCREAS MALE FEMALE PROSTATE MALE
Alabama 251.6 154.3 22.9 21.5 14.4 85.5 40.7 8.2 5.2 13.3 9.8 28.2
Alaska 215.4 155.0 22.7 19.6 13.9 62.8 45.3 8.2 4.7 13.4 9.2 22.6
Arizona 182.6 130.0 20.1 16.5 11.7 47.9 32.2 7.3 4.8 11.3 8.6 20.1
Arkansas 248.7 159.8 22.8 22.9 15.6 88.1 45.3 8.3 5.6 13.3 9.5 24.3
California 186.8 137.3 21.5 17.2 12.4 45.5 31.5 7.7 4.7 11.7 9.4 21.9
Colorado 177.7 130.5 19.3 15.8 12.0 42.8 30.3 7.4 4.3 10.8 9.1 22.8
Connecticut 195.7 141.3 20.8 15.3 11.4 51.3 37.2 7.3 4.8 13.8 9.9 21.5
Delaware 222.8 158.9 22.9 19.0 13.5 67.3 45.9 7.4 4.8 12.9 10.1 23.6
Dist. of Columbia 234.8 166.8 29.4 20.6 18.8 57.1 35.4 6.5 3.9 16.4 12.4 37.6
Florida 200.3 138.8 21.0 17.6 12.4 59.2 38.1 7.6 4.6 12.0 8.9 19.5
Georgia 222.9 146.3 23.1 19.8 13.5 70.1 38.1 7.5 4.3 12.3 9.1 26.0
Hawaii 175.8 115.6 15.2 17.6 10.7 46.7 25.5 7.4 4.3 12.8 9.7 15.6
Idaho 192.2 138.6 21.9 16.0 12.3 48.0 33.9 7.8 5.4 12.1 8.8 25.8
Illinois 218.9 156.4 23.4 20.7 14.8 64.2 41.6 8.3 5.1 13.0 10.0 23.3
Indiana 235.8 159.0 23.2 20.8 14.2 77.3 45.5 9.1 5.4 12.8 9.5 22.7
Iowa 211.1 147.1 20.7 20.0 14.8 63.2 38.1 8.8 5.3 12.3 8.9 21.7
Kansas 211.3 145.0 21.4 19.8 13.1 64.3 38.8 9.2 5.2 12.5 9.3 20.4
Kentucky 257.5 172.2 22.8 22.6 16.1 94.5 55.5 8.6 5.8 12.9 9.5 22.3
Louisiana 250.7 162.2 25.0 23.3 15.4 79.1 43.1 8.6 5.0 14.3 11.4 25.1
Maine 227.7 156.5 20.0 19.4 13.7 67.6 44.5 9.1 5.3 12.1 9.9 22.1
Maryland 211.8 150.2 23.9 19.6 13.2 58.9 39.7 7.5 4.5 13.2 10.1 23.7
Massachusetts 210.8 149.2 20.4 17.7 12.7 58.0 41.2 7.7 4.6 12.7 10.4 21.4
Michigan 219.4 157.1 23.5 19.1 13.7 66.5 43.5 8.9 5.6 13.8 10.0 21.1
Minnesota 201.1 143.0 20.7 17.2 12.1 51.9 36.1 9.4 5.2 12.0 9.2 23.4
Mississippi 264.7 157.0 24.2 24.6 16.5 92.0 41.3 8.0 4.6 13.8 10.0 29.6
Missouri 225.9 157.8 23.8 20.9 14.1 74.2 45.5 8.3 5.3 12.9 9.8 20.7
Montana 192.5 142.2 20.1 15.8 12.7 52.3 39.4 7.8 4.5 11.9 8.0 24.8
Nebraska 204.2 142.5 19.8 20.4 15.0 57.9 35.5 8.3 5.5 11.3 9.6 22.6
Nevada 206.9 151.7 23.5 21.0 14.3 58.0 45.2 6.9 4.4 12.8 9.6 22.8
New Hampshire 211.1 152.1 21.2 16.6 13.3 59.2 43.1 7.4 4.6 13.5 9.9 21.4
New Jersey 203.7 151.0 24.6 20.2 14.3 53.9 36.5 7.5 5.0 13.6 10.1 21.2
New Mexico 183.8 129.8 20.8 18.7 12.5 42.2 27.9 6.2 4.3 11.0 8.3 23.0
New York 196.6 143.4 22.0 18.5 13.3 52.9 35.8 7.7 4.8 12.9 9.9 21.4
North Carolina 227.7 147.2 22.7 18.8 12.7 74.4 39.9 7.5 4.8 11.8 9.4 24.6
North Dakota 200.0 133.1 21.1 20.8 13.1 52.7 31.4 6.7 4.6 12.8 8.1 22.6
Ohio 232.8 160.4 24.2 21.4 14.6 72.8 43.9 9.2 5.5 13.3 10.1 23.2
Oklahoma 238.2 159.7 23.5 22.1 14.3 78.4 46.2 8.8 5.6 12.3 9.2 23.1
Oregon 206.6 151.4 21.1 18.2 13.3 56.4 41.8 8.4 5.0 12.3 9.8 23.9
Pennsylvania 222.2 154.9 23.5 20.7 14.6 63.9 39.3 8.9 5.4 13.3 10.1 22.0
Rhode Island 217.5 147.5 20.6 18.1 13.4 63.9 42.6 7.7 4.2 12.3 8.7 21.3
South Carolina 236.1 150.0 23.5 19.9 13.7 74.9 39.0 7.7 4.6 13.1 10.0 26.3
South Dakota 201.4 143.9 21.1 18.9 13.6 60.0 35.0 7.6 5.1 10.4 9.7 22.1
Tennessee 251.1 158.1 22.7 21.7 15.3 86.5 45.7 8.9 5.1 13.1 9.6 24.0
Texas 205.2 139.7 21.3 19.4 12.8 58.6 34.5 7.8 4.7 11.8 8.9 20.4
Utah 154.6 109.1 20.8 14.0 10.3 26.5 16.2 7.3 4.6 10.3 8.0 24.6
Vermont 213.6 153.2 19.7 16.8 14.5 61.3 45.4 8.3 4.7 12.9 9.7 22.4
Virginia 216.7 149.1 23.5 18.3 13.5 64.7 39.1 8.2 4.7 12.7 9.6 23.9
Washington 205.7 149.7 21.1 16.7 12.6 55.6 41.0 8.6 5.1 12.8 10.1 23.4
West Virginia 246.1 167.8 22.5 23.7 15.6 82.3 49.8 8.4 6.2 11.9 7.8 20.7
Wisconsin 212.6 148.4 21.0 17.9 12.4 57.8 38.6 8.7 5.4 13.0 9.8 24.3
Wyoming 192.3 143.4 21.1 19.1 12.8 48.9 34.6 7.3 5.3 11.9 8.5 21.3
United States 211.6 147.4 22.2 19.1 13.5 61.6 38.5 8.1 5.0 12.5 9.6 22.3

Rates are per 100,000 and age adjusted to the 2000 US standard population.

black than white men for every site included in Table 10 with the exception of kidney cancer mortality, for which rates are similar. The largest disparities are for stomach and prostate cancers, for which death rates in black men are about 2.5 times those in white men. Factors known to contribute to racial disparities vary by cancer site and include differences in risk factor prevalence and access to high-quality health care, including cancer prevention and early detection, timely
VOLUME 00 _ NUMBER 00 _ MONTH 2015 21

TABLE 14. Trends in 5-Year Relative Survival Rates* (%) for Children (Birth to 14 Years) by Year of Diagnosis, United States, 1975 to 2010

1975 TO 1978 TO 1981 TO 1984 TO 1987 TO 1990 TO 1993 TO 1996 TO 1999 TO 2004 TO
1977 1980 1983 1986 1989 1992 1995 1998 2003 2010
All sites 58 62 67 68 72 76 77 79 81 83†
Acute lymphocytic leukemia 57 66 71 72 78 83 84 87 90 92†
Acute myeloid leukemia 19 26 27‡ 31‡ 37‡ 42 41‡ 49 58 66†
Bones & joints 50‡ 48 57‡ 57‡ 67‡ 67 74 70 71 79†
Brain & other nervous system 57 58 57 62 64 64 71 75 74 74
Hodgkin lymphoma 81 87 88 90 87 97 95 96 95 98†
Neuroblastoma 53 57 55 52 63 76 67 66 72 77†
Non-Hodgkin lymphoma 43 53 67 70 71 77 81 83 90 86†
Soft tissue 61 74 69 73 66 80 77 71 79 81†
Wilms tumor 73 79 87 91 92 92 92 92 92 92†

*Survival rates are adjusted for normal life expectancy and are based on follow-up of patients through 2011.

†The difference in rates between 1975 to 1977 and 2004 to 2010 is statistically significant (P < .05).

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

54,55

diagnosis, and optimal treatment.Even among Medicare-insured patients, blacks are less likely than whites to receive standard-cancer therapies for lung, breast, colorectal, and prostate cancers. 56 A major source of these inequalities is the disproportionately high burden of poverty in the black community. According to the US Census Bureau, 27% of blacks lived in poverty and 19% were without health insurance in 2012, compared with 10% and 11%, respectively, of non-Hispanic whites.57

Higher mortality rates among blacks compared with whites partly reflect a later stage of disease at diagnosis. This disparity is particularly striking for cancers of the uterine corpus, oral cavity, female breast, and cervix (Fig. 6). Moreover, black patients have lower stage-specific survival for most cancer types (Fig. 7). As a result, although black women have a lower breast cancer incidence rate than white women, they have a higher breast cancer death rate (Table 10). 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).58 The higher risk of death from breast cancer among black women is thought to reflect a higher prevalence of comorbidities, a longer time to follow-up after an abnormal mammogram, less receipt of high-quality treatment, and a higher prevalence of aggressive tumor characteristics.59–61 However, an analysis of clinical trial data showed that black women were less likely than white women to survive their breast cancer despite uniform treatment, even after controlling for stage of disease, tumor characteristics, follow-up, and socioeconomic status.62

Cancer incidence and death rates are lower among APIs, American Indians/Alaska Natives (AI/ANs), and Hispanics than non-Hispanic whites for all cancer sites combined and for the 4 most common cancer sites. However, cancers associated with infectious agents (eg, those of the uterine cervix, stomach, and liver) are generally more common in nonwhite populations. For example, stomach and liver cancer incidence and death rates are twice as high in the API population as in whites, reflecting a higher prevalence of chronic infection with Helicobacter pylori and hepatitis B virus, respectively, in immigrant countries of origin.63 Kidney cancer incidence and death rates are the highest among AI/ANs, which may be due in part to high rates of obesity, smoking, and hypertension in this population. Regional variation in the prevalence of these risk factors may contribute to striking geographic differences in kidney cancer death rates among AI/AN men, which are highest in the Southern and Northern Plains and lowest in the East and Pacific Coast.64

Table 11 shows the variation in trends in cancer incidence and death rates during the most recent 5 data years by race and ethnicity. These trends are based on incidence data from 2002 to 2011 covering 92% of the US population, but are not adjusted for reporting delays. Among men, the magnitude of decline for incidence rates is larger than that for death rates, while the opposite is generally true for women. Significant declines in incidence rates in women were confined to blacks (0.4% per year) and Hispanics (0.6% per year). Black men continue to have the largest decline in death rates (2.5% per year).

Regional Variations in Cancer Rates

Tables 12 and 13 depict current cancer incidence and death rates for selected cancers by state. The largest geographic variation in cancer occurrence by far is for lung cancer, reflecting the large historical and continuing differences in smoking prevalence among states.49 For example, lung cancer incidence rates in Kentucky, which has historically had the highest smoking prevalence, are

3.5 times higher than those in Utah, which has the lowest smoking prevalence. There is a 2-fold difference for prostate cancer incidence rates, which range from 100.9 (per 100,000 population) in Arizona to 198.2 in the District of Columbia, likely reflecting both state differences in PSA testing prevalence and population demographics.26 In contrast, state variations for other cancer types are smaller in both absolute and relative terms. For example, breast cancer incidence rates range from 109.8 (per 100,000 population) in Arkansas to 143.4 in the District of Columbia, arelativedifferenceofjust23%.Someofthisvariation is attributable to differences in mammography prevalence.65 State variation in cancer incidence rates reflects differences in the use of screening tests and diagnostic practices in addition to differences in the prevalence of risk factors, while the variation in death rates reflects differences in cancer occurrence and survival.

Cancer in Children

Cancer is the second most common cause of death among children aged 1 to 14 years in the United States, surpassed only by accidents. In 2015, an estimated 10,380 children (0-14 years) will be diagnosed with cancer (excluding benign/borderline brain tumors) and 1,250 will die from the disease. Benign and borderline brain tumors are not included in the estimated new cases for 2015 because the calculation method requires historic data and these tumors were not reportable until 2004. Leukemia (77% of which are lymphoid leukemias) accounts for 30% of all childhood cancers (including benign brain tumors). Cancers of the brain and other nervous system are the second most common cancer type (26%), followed by neuroblastoma (6%), soft tissue sarcomas (6%, one-half of which are rhabdomyosarcoma), renal (Wilms) tumors (5%), non-Hodgkin lymphomas (including Burkitt lymphoma) (5%), and Hodgkin lymphomas (3%).8

Cancers in adolescents (aged 15-19 years) differ somewhat from those in children in terms of type and distribution. For example, a smaller proportion of the cancers diagnosed in adolescents are leukemias and a larger proportion are lymphomas. Cancers of the brain and other nervous system are most common (20%), followed by leukemia (13%), Hodgkin lymphoma (13%), thyroid carcinoma (10%), and gonadal germ cell tumors (9%). Melanoma accounts for 5% of the cancers diagnosed in this age group.

From 2007 to 2011, the overall incidence rate for cancer increased by 0.6% per year in children and was stable in adolescents. In contrast, death rates have been declining for decades. From 1970 to 2011, the death rate for childhood cancer decreased 67% (from 6.3 to 2.1 per 100,000 population) and the death rate for adolescents decreased by 58% (from 7.2 to 3.0). Table 14 provides trends in survival rates for the most common childhood cancers. The 5-year relative survival rate for all cancer sites combined improved from 58% for children diagnosed during 1975-1977 to 83% for those diagnosed during 2004-2010. The substantial progress for all of the major childhood cancers reflects both improvements in treatment and high levels of participation in clinical trials.

Limitations

The projected numbers of cancer cases and deaths in 2015 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 under-sensitive to abrupt or large changes in observed data. Therefore, while these estimates provide a reasonably accurate portrayal of the contemporary cancer burden, they should not be used to track cancer occurrence over time. Age-standardized or age-specific cancer death rates from the NCHS and cancer incidence rates from SEER, NPCR, and/or NAACCR are the most informative indicators of cancer trends.

Errors in reporting race/ethnicity in medical records and on death certificates may result in underestimates of cancer incidence and mortality rates in nonwhite and nonblack populations. This is particularly relevant for AI/AN populations. It is also important to note that cancer data in the United States are primarily reported for broad 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 22% between 1991 and 2011. Regionally, progress has been most rapid for residents of the Northeast, among whom death rates have declined by 25% to 30%, and slowest in the South, where rates declined by about 15%. Further reductions in cancer death rates can be accelerated by applying existing cancer control knowledge across all segments of the population, with an emphasis on those in the lowest socioeconomic bracket and other disadvantaged populations. �

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