Proposal:Breast Cancer in Hispanic Populations

Cancer Statistics for African Americans, 2016: Progress and Opportunities in Reducing Racial Disparities

Carol E. DeSantis, MPH 1 ; Rebecca L. Siegel, MPH

2 ; Ann Goding Sauer, MPH

3 ;

Kimberly D. Miller, MPH 4 ; Stacey A. Fedewa, MPH

5 ; Kassandra I. Alcaraz, PhD, MPH

6 ;

Ahmedin Jemal, DVM, PhD 7

In this article, the American Cancer Society provides the estimated number of new cancer cases and deaths for blacks in the

United States and the most recent data on cancer incidence, mortality, survival, screening, and risk factors for cancer. Inci-

dence data are from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American

Association of Central Cancer Registries, and mortality data are from the National Center for Health Statistics. Approximately

189,910 new cases of cancer and 69,410 cancer deaths will occur among blacks in 2016. Although blacks continue to have

higher cancer death rates than whites, the disparity has narrowed for all cancers combined in men and women and for lung and

prostate cancers in men. In contrast, the racial gap in death rates has widened for breast cancer in women and remained level

for colorectal cancer in men. The reduction in overall cancer death rates since the early 1990s translates to the avoidance of

more than 300,000 deaths among blacks. In men, incidence rates from 2003 to 2012 decreased for all cancers combined (by

2.0% per year) as well as for the top 3 cancer sites (prostate, lung, and colorectal). In women, overall rates during the corre-

sponding time period remained unchanged, reflecting increasing trends in breast cancer combined with decreasing trends in

lung and colorectal cancer rates. Five-year relative survival is lower for blacks than whites for most cancers at each stage of

diagnosis. The extent to which these disparities reflect unequal access to health care versus other factors remains an active

area of research. Progress in reducing cancer death rates could be accelerated by ensuring equitable access to prevention,

early detection, and high-quality treatment. CA Cancer J Clin 2016;66:290-308. VC 2016 American Cancer Society.

Keywords: cancer statistics, health disparities, incidence, mortality, survival, risk factors, trends

Introduction

In the United States, African Americans bear a disproportionate share of the cancer burden, having the highest death rate

and shortest survival of any racial or ethnic group for most cancers. The causes of these inequalities are complex and reflect

social and economic disparities more than biological differences. For example, in 2014, 26% of blacks, compared with 10%

of non-Hispanic whites, were living below the federal poverty level, and 22% of blacks had completed 4 years of college

compared with 36% of non-Hispanic whites.1,2 Persons with lower socioeconomic status are more likely to engage in behav-

iors that increase cancer risk, in part because of marketing strategies that target these populations as well as environmental

and community factors, such as fewer opportunities for physical activity and less access to fresh fruits and vegetables. We

recognize that race is a social construct; however, because much US health data are reported by race, racial classification

remains useful for describing general patterns of health within the nation. Although we use the terms African Americans

and blacks interchangeably, the data provided herein are for those identified by black race and exclude those of Hispanic

ethnicity when possible. A report on cancer statistics for Hispanics was published previously in this journal.3 Herein, we

provide cancer incidence, survival, and mortality statistics for blacks, including the estimated numbers of new cases and

deaths in 2016, as well as the prevalence of cancer risk factors and screening uptake. We also estimate the total number of

cancer deaths averted among blacks as a result of the decline in cancer death rates since the early 1990s.

1 Director, Breast and Gynecological Cancer Surveillance, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA;

2 Strategic

Director, Surveillance Information Services, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA; 3 Epidemiologist, Surveil-

lance and Health Services Research, American Cancer Society, Atlanta, GA; 4 Epidemiologist, Surveillance and Health Services Research, American Can-

cer Society, Atlanta, GA; 5 Director, Risk Factor and Screening Surveillance, Surveillance and Health Services Research, American Cancer Society,

Atlanta, GA; 6 Strategic Director, Health Equities Research, Behavioral Research Center, American Cancer Society, Atlanta, GA;

7 Vice President, Surveil-

lance and Health Services Research, American Cancer Society, Atlanta, GA.

Corresponding author: Carol E. DeSantis, MPH, Surveillance and Health Services Research, American Cancer Society, 250 Williams Street NW, Atlanta, GA 30303; [email protected]

DISCLOSURES: The authors report no conflicts of interest.

doi: 10.3322/caac.21340. Available online at cacancerjournal.com

290 CA: A Cancer Journal for Clinicians

Cancer Statistics for African Americans, 2016

Materials and Methods

Incidence and Mortality Data

There are two sources for cancer incidence data reported

in this article. The Surveillance, Epidemiology, and End

Results (SEER) program of the National Cancer Institute

(NCI) reports long-term, high-quality, population-based

incidence data covering up to 28% of the US population.

Long-term incidence trends (1975-2012) were based

upon data from the SEER 9 registries (Connecticut,

Hawaii, Iowa, New Mexico, Utah, and the metropolitan

areas of Atlanta, Detroit, San Francisco-Oakland, and

Seattle-Puget Sound), representing approximately 9% of

the US population.4 As of 1992, SEER data have been

available for 4 additional SEER registries (Alaska

Natives, Los Angeles County, San Jose-Monterey, and

rural Georgia), which increase coverage of minority

groups, allowing for stratification by race and ethnicity.

Delay-adjusted data from these (SEER 13) registries,

which represent 14% of the US population, were the

source for the annual percent change in incidence from

2003 to 2012.5 Five-year relative survival rates, stage at

diagnosis, and the lifetime probability of developing can-

cer were based upon data from the SEER 18 registries,

which also include data from Greater California, Greater

Georgia, Kentucky, Louisiana, and New Jersey and are

available from 2000 onward.6 The probability of develop-

ing cancer was calculated using NCI’s DevCan software

(version 6.7.3).7 Much of the statistical information pre-

sented here was previously published in the SEER Cancer

Statistics Review 1975-2012.8

The North American Association of Central Cancer

Registries (NAACCR) compiles and reports incidence data

for 1995 forward from cancer registries that participate in the

SEER program or from the Centers for Disease Control and

Prevention’s National Program of Cancer Registries. These

data approach 100% coverage of the US population in the

most recent time period and were the source for the projected

new cancer cases in 2016 and incidence rates in the most

recent time period (2008-2012).9 Overall US rates based on

data from NAACCR include all states except Arkansas,

Minnesota, and Nevada, because these states did not submit

data or failed to meet NAACCR high-quality standards for 1

or more years during 2008 through 2012. Some of the data

presented here were previously published in volumes 1 and 2

of Cancer in North America: 2008-2012.10,11

Mortality data were obtained from the National Center

for Health Statistics as reported by the SEER program.12

Data are available for whites and blacks beginning in 1969

and by Hispanic ethnicity since 1990. When available, data

are presented for non-Hispanic blacks and non-Hispanic

whites. All cancer cases and deaths were accessed using

SEER*Stat software (version 8.2.1).13 Population data

were obtained from the US Census Bureau. Incidence and

death rates were age-standardized to the 2000 US standard

population and expressed per 100,000 persons.

FIGURE 1. Leading Sites of New Cancer Cases and Deaths Among Blacks, 2016 Estimates. Estimates are rounded to the nearest 10 cell and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.

CA CANCER J CLIN 2016;66:290–308

VOLUME 66 _ NUMBER 4 _ JULY/AUGUST 2016 291

All cancer cases were classified according to the Interna-

tional Classification of Diseases for Oncology.14 Causes of

death were classified according to the International Classi-

fication of Diseases.15 The annual percent change in rates

was quantified using NCI’s Joinpoint Regression Program

(version 4.2.0.2).16

Projected Cancer Cases and Deaths in 2016

The most recent year for which incidence and mortality data

are available lags 2 to 4 years behind the current year because

of the time required for data collection, compilation, quality

control, and dissemination. Therefore, we projected the num-

bers of new cancer cases and deaths for blacks in the United

States in 2016 to provide an estimate of the contemporary

cancer burden. The number of invasive cancer cases that

occurred each year during 1998 through 2012 was estimated

using a 3-step spatiotemporal model based on high-quality

incidence data from 49 states and the District of Columbia,

representing approximately 94% population coverage (data

were lacking for all years for Minnesota and for some years

for other states). This method accounts for expected delays in

case reporting and considers geographic variations in sociode-

mographic and lifestyle factors, medical settings, and cancer

screening behaviors as predictors of incidence. 17

Finally, a

temporal projection method (vector autoregression) was

applied to all 15 years of data to estimate counts for 2016. For

complete details of the case projection methodology, please

refer to Zhu et al.18

The number of cancer deaths expected to occur in 2016

among blacks in the United States was estimated based on

the annual percent change in the actual number of cancer

deaths from 1998 through 2012 as reported to the National

Center for Health Statistics. For the complete details of

this methodology, please refer to Chen et al.19

Estimated Cancer Deaths Averted

The estimated numbers of cancer deaths averted in black

men and women because of the reduction in overall

TABLE 1. Lifetime Probability (%) of Developing or Dying From Invasive Cancers by Race/Ethnicity and Sex, United States, 2010-2012*

DEVELOPING DYING

BLACK NH WHITE BLACK NH WHITE

All sites† Male 40.8 (1 in 2) 42.4 (1 in 2) 23.4 (1 in 4) 22.8 (1 in 4) Female 34.3 (1 in 3) 39.0 (1 in 3) 19.4 (1 in 5) 19.5 (1 in 5)

Prostate Male 18.2 (1 in 6) 13.3 (1 in 8) 4.4 (1 in 23) 2.4 (1 in 42)

Breast Female 11.1 (1 in 9) 13.1 (1 in 8) 3.3 (1 in 31) 2.7 (1 in 37)

Lung & bronchus Male 7.5 (1 in 13) 7.5 (1 in 13) 6.4 (1 in 16) 6.6 (1 in 15) Female 5.4 (1 in 19) 6.7 (1 in 15) 4.2 (1 in 24) 5.3 (1 in 19)

Colon & rectum Male 4.9 (1 in 21) 4.6 (1 in 22) 2.4 (1 in 42) 1.9 (1 in 52) Female 4.7 (1 in 21) 4.3 (1 in 23) 2.1 (1 in 47) 1.8 (1 in 56)

Uterine corpus Female 2.5 (1 in 39) 2.9 (1 in 35) 0.9 (1 in 108) 0.5 (1 in 184)

Kidney Male 2.0 (1 in 51) 2.1 (1 in 48) 0.5 (1 in 204) 0.6 (1 in 158) Female 1.3 (1 in 79) 1.2 (1 in 83) 0.3 (1 in 328) 0.3 (1 in 288)

Urinary bladder Male 1.9 (1 in 54) 4.4 (1 in 23) 0.5 (1 in 194) 1.0 (1 in 100) Female 0.8 (1 in 124) 1.3 (1 in 79) 0.4 (1 in 285) 0.4 (1 in 284)

Pancreas Male 1.5 (1 in 67) 1.5 (1 in 65) 1.4 (1 in 74) 1.4 (1 in 72) Female 1.7 (1 in 58) 1.4 (1 in 69) 1.5 (1 in 66) 1.3 (1 in 76)

Non-Hodgkin lymphoma Male 1.4 (1 in 70) 2.5 (1 in 40) 0.5 (1 in 201) 0.9 (1 in 110) Female 1.2 (1 in 84) 2.0 (1 in 50) 0.4 (1 in 239) 0.7 (1 in 140)

Uterine cervix Female 0.8 (1 in 130) 0.6 (1 in 176) 0.4 (1 in 265) 0.2 (1 in 506)

Thyroid Male 0.3 (1 in 368) 0.7 (1 in 148) <0.1 (1 in 2,908) 0.1 (1 in 1,783) Female 1.0 (1 in 98) 1.9 (1 in 54) 0.1 (1 in 1,556) 0.1 (1 in 1,581)

Liver & bile duct Male 1.5 (1 in 69) 1.0 (1 in 99) 1.1 (1 in 88) 0.8 (1 in 123) Female 0.5 (1 in 195) 0.4 (1 in 249) 0.5 (1 in 193) 0.4 (1 in 237)

Leukemia Male 1.14 (1 in 88) 1.84 (1 in 53) 0.7 (1 in 147) 1.1 (1 in 92) Female 0.92 (1 in 109) 1.28 (1 in 77) 0.6 (1 in 176) 0.7 (1 in 134)

NH indicates non-Hispanic.

*For people who have not been previously diagnosed with cancer.

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

Note: Percentages and “1 in” numbers may not be equivalent due to rounding.

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.7.3. 7

Cancer Statistics for African Americans, 2016

292 CA: A Cancer Journal for Clinicians

cancer death rates were determined by subtracting the

number of recorded cancer deaths from the number

that would have been expected if cancer death rates had

remained at their peak. The expected numbers of deaths

were calculated by applying the 5-year age-specific can-

cer death rates in the peak year for age-standardized

cancer death rates (1990 in men, 1991 in women) to

the corresponding age-specific populations in the subse-

quent years through 2012. We then summed the differ-

ence between the number of expected and observed

deaths in each age group and calendar year for men and

women separately.

Risk Factors and Screening Data

Data on behavioral risk factors (cigarette smoking, obesity,

and physical inactivity) and receipt of cancer screening

were obtained from two national surveys: the National

Health Interview Survey (NHIS) 20

and the National

Health and Nutrition Examination Survey (NHANES).21

NHANES is the preferred source of information for obe-

sity prevalence in the United States, because height and

weight are measured rather than reported by participants.

All surveys were analyzed using SUDAAN statistical soft-

ware (version 11.0.1; RTI International, Research Triangle

Park, NC) to obtain weighted prevalence estimates, which

are considered representative of the noninstitutionalized civil-

ian population.

Selected Findings

Overall Cancer Occurrence

Incidence

About 189,910 new cancer cases are expected to be diag-

nosed among blacks in 2016, including 93,990 cases in men

and 95,920 cases in women (Fig. 1). Prostate cancer is

expected to be the most commonly diagnosed cancer in

men, and breast cancer is expected to be the most com-

monly diagnosed cancer in women. Cancers of the lung and

colorectum will be the second-most and third-most com-

monly diagnosed cancers in both black men and black

women. The four most common cancers (breast, prostate,

colorectal, and lung) account for more than half of all

TABLE 2. Comparison of Cancer Incidence Rates Between Non-Hispanic (NH) Blacks and Whites, United States, 2008–2012

MALE FEMALE

CANCER

NH BLACK RATE*

NH WHITE RATE*

ABSOLUTE DIFFERENCE†

RATE RATIO‡ CANCER

NH BLACK RATE*

NH WHITE RATE*

ABSOLUTE DIFFERENCE†

RATE RATIO‡

Kaposi sarcoma 1.7 0.5 1.2 3.57§ Kaposi sarcoma 0.2 <0.1 0.1 3.96§ Myeloma 14.8 7.0 7.8 2.11§ Myeloma 11.1 4.3 6.8 2.58§ Stomach 15.1 7.8 7.3 1.93§ Stomach 8.0 3.5 4.5 2.30§ Liver & IHB 16.5 9.3 7.2 1.77§ Liver & IHB 4.8 3.2 1.6 1.52§ Prostate 208.7 123.0 85.7 1.70§ Uterine cervix 10.0 7.1 2.9 1.41§ Larynx 9.3 6.3 3.0 1.48§ Pancreas 14.4 10.6 3.8 1.36§ Breast 2.0 1.4 0.6 1.45§ Esophagus 2.5 1.8 0.7 1.34§ Colon & rectum 60.3 47.4 12.9 1.27§ Colon & rectum 44.1 36.2 7.9 1.22§ Pancreas 17.2 14.0 3.2 1.23§ Kidney & renal pelvis 13.0 11.3 1.7 1.15§ Lung & bronchus 93.4 79.3 14.1 1.18§ Breast 124.3 128.1 23.8 0.97§ Kidney & renal pelvis 24.2 21.8 2.4 1.11§ Uterine corpus 23.0 25.5 22.5 0.90§ Hodgkin lymphoma 3.2 3.4 20.2 0.95§ Hodgkin lymphoma 2.4 2.7 20.3 0.88§ Esophagus 8.0 8.8 20.8 0.90§ Lung & bronchus 51.4 58.7 27.3 0.87§ Oral cavity & pharynx 15.3 18.1 22.8 0.84§ Leukemia 8.6 10.7 22.1 0.80§ Leukemia 13.2 17.7 24.5 0.75§ Oral cavity & pharynx 5.2 6.7 21.5 0.78§ Non-Hodgkin lymphoma 17.2 24.1 26.9 0.71§ Ovary 9.6 12.4 22.8 0.77§ Brain & ONS 4.9 8.8 23.9 0.56§ Non-Hodgkin lymphoma 12.0 16.6 24.6 0.72§ Urinary bladder 19.8 40.2 220.4 0.49§ Urinary bladder 6.7 9.9 23.2 0.68§ Thyroid 3.7 7.7 24.0 0.48§ Thyroid 12.9 21.9 29.0 0.59§ Testis 1.4 6.8 25.4 0.21§ Brain & ONS 3.6 6.3 22.7 0.58§ Melanoma of the skin 1.1 31.3 230.2 0.04§ Melanoma of the skin 1.0 20.6 219.6 0.05§ All sites 592.3 528.9 63.4 1.12§ All sites 408.1 436.2 228.1 0.94§

IHB indicates intrahepatic bile duct; ONS, other nervous system.

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

†The absolute difference is the rate in blacks minus the rate in whites.

‡The rate ratio is the unrounded rate in blacks divided by the unrounded rate in whites.

§The rate ratio is significantly different from one (P < .05).

Note: Sites are listed in descending order by rate ratio.

Source: North American Association of Central Cancer Registries. 9

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VOLUME 66 _ NUMBER 4 _ JULY/AUGUST 2016 293

cancer cases. The lifetime probability of being diagnosed

with cancer among black men and black women is 41% and

34%, respectively, compared with 42% and 39%, respec-

tively, among whites (Table 1).

Differences in cancer incidence rates between blacks and

whites in the United States are described in Table 2.

Among black males, incidence rates are higher for all can-

cers combined (12% higher) and for the most common can-

cers, including cancers of the prostate, lung, colorectum,

kidney, and pancreas. In contrast, black females have a 6%

lower overall incidence rate for all cancers combined and

for many cancers, including lung, breast (only 3% lower),

and uterine cancers.

Incidence rates for Kaposi sarcoma (KS), stomach can-

cer, and multiple myeloma are about 2 to 4 times higher in

blacks than in whites (Table 2). Although it is a relatively

rare cancer, incidence rates of KS are 4 times higher in

black men and women than in their white counterparts. In

the United States, KS primarily occurs among people

infected with human immunodeficiency virus (HIV). The

burden of HIV is disproportionately high among blacks,

which may in part reflect less access to advanced antiretro-

viral therapies as well as higher rates of transmission

among men who have sex with men. 22

In 2013, the rate

of new HIV cases among blacks was 55.9 per 100,000

population compared with 6.6 per 100,000 population

among whites.23 Higher rates of stomach cancer in blacks

are limited to noncardia gastric cancers. This disparity may

reflect higher rates of Helicobacter pylori infection among

blacks, which is the most important risk factor for noncar-

dia tumors. 24

High consumption of salt and grilled meat

also increase risk for this type of stomach cancer.25 The

reasons for higher rates of myeloma among blacks are not

currently known. 26

Incidence rates for all cancers combined increased in

blacks from the mid-1970s to the early 1990s; with a

steeper slope in males than in females (Fig. 2). However,

during the most recent time period (2003-2012), incidence

rates decreased by 2.0% per year in black males but were

stable in females, similar to the pattern in whites (Table 3).

The declines in men are largely driven by cancers of the

lung and prostate.

Mortality

About 69,410 blacks are expected to die from cancer in

2016, including 35,660 men and 33,750 women. Cancer is

the second leading cause of death in blacks, accounting for

23% of all deaths in 2012 (Table 4). Lung cancer accounts

for the largest number of cancer deaths among both men

(27%) and women (22%), followed by prostate cancer in

men (12%), and breast cancer in women (19%) (Fig. 1).

For both men and women, colorectal cancer (CRC) is

expected to be the third leading cause of cancer death.

TABLE 3. Fixed-Interval Trends (Annual Percent Change) in Cancer Incidence and Death Rates, 2003 to 2012

MALE FEMALE

BLACK WHITE BLACK WHITE

All sites Incidence 22.0* 21.2* 0.1 0.1 Death 22.5* 21.6* 21.5* 21.3*

Lung & bronchus Incidence 22.5* 22.3* 21.1* 21.0* Death 23.3* 22.5* 21.6* 21.2*

Prostate Incidence 23.4* 24.2* — Death 23.6* 23.4*

Female breast Incidence — 0.3* 20.1 Death 21.4* 21.8*

Colorectum Incidence 23.0* 23.3* 23.1* 22.9* Death 22.5* 23.0* 23.3* 22.9*

Uterine cervix Incidence — 23.8* 22.6* Death 22.6* 20.9*

*The annual percent change from 2003 to 2012 is significantly different from zero.

Sources: Incidence: Surveillance, Epidemiology, and End Results (SEER) Program, SEER 13 registries, National Cancer Institute.

5 Mortality:

National Center for Health Statistics, Centers for Disease Control and Pre- vention.

12 Death rates for blacks and whites exclude those of Hispanic

ethnicity.

FIGURE 2. Trends in Cancer Incidence and Death Rates Among Blacks, United States, 1975 to 2012. Rates are age adjusted, 2-year moving averages. Incidence rates are adjusted for reporting delay. Sources: Incidence: Surveillance, Epidemiology, and End Results (SEER) Program, SEER 9 registries, National Cancer Institute.

4 Mortality: National

Center for Health Statistics, Centers for Disease Control and Prevention. 12

Cancer Statistics for African Americans, 2016

294 CA: A Cancer Journal for Clinicians

Death rates are higher in blacks than in whites for most

cancers (Table 5).

Death rates among blacks for all cancers combined have

been decreasing since the early 1990s, with larger declines

in men than in women (Fig. 2). The reduction in overall

cancer death rates since 1990 in men and since 1991 in

women translates to the avoidance of more than 300,000

deaths from cancer (Fig. 3). In fact, since the mid-1990s,

death rates have declined faster among blacks than among

whites (Table 3). As a result, the overall racial gap is nar-

rowing, particularly among men. In 1990, the cancer

death rate in males was 47% higher in blacks than in

whites, but was 24% higher in 2012. Among females, the

disparity decreased from 19% higher in 1991 to 14%

higher in 2012.

Notably, the higher death rate in black women compared

with white women occurs despite their lower incidence

rate. Higher death rates in blacks are due largely to cancers

of the breast and colorectum in women and to cancers of

the prostate, lung and bronchus, and colorectum in men.

However, in recent years, death rates for lung and prostate

cancer have decreased faster in black men than in white

men, contributing to the recent narrowing of the overall

racial disparity (Fig. 4). In addition, lung (male and female)

and cervical cancer death rates have converged for young

blacks and whites. 27,28

In contrast, the racial disparity

continues to widen for breast cancer in women and remains

level for CRC in men (Fig. 4): cancers for which incidence

and mortality are largely influenced by access to screening and

treatment.

Variations in cancer incidence and death rates for

selected cancers by state are presented in Tables 6 and 7.

There is wide variation in rates by state, particularly for

cancers closely tied to behavioral factors like smoking.

For example, the lung cancer incidence rate in black men

in Kentucky (136 per 100,000) is double that in Colorado

(64 per 100,000) due to historic differences in smoking

prevalence.

Survival and stage distribution

The 5-year relative survival rate is lower in blacks than

in whites for every stage of diagnosis for most cancer

sites (Fig. 5). Much of the difference in survival is

believed to be due to barriers that limit access to timely,

appropriate, and high-quality medical care. 29-33

Fur-

thermore, blacks are more likely to be diagnosed at later

stages of the disease for most cancer sites (Fig. 6) when

treatment choices are more limited and often less effec-

tive. It is recognized that these issues largely reflect soci-

oeconomic disparities. Some studies suggest that blacks

who receive cancer treatment and medical care similar to

TABLE 4. Leading Causes of Death Among Non-Hispanic (NH) Blacks and Whites, 2012

ALL AGES

NH BLACK NH WHITE

CAUSE OF DEATH RANK NUMBER PERCENT OF

TOTAL DEATHS DEATH RATE* RANK NUMBER PERCENT OF

TOTAL DEATHS DEATH RATE*

Heart diseases 1 69,139 24% 216.8 1 481,976 24% 171.2 Cancer 2 66,560 23% 199.2 2 462,493 23% 170.2 Cerebrovascular diseases 3 15,712 5% 50.7 4 100,152 5% 35.5 Diabetes 4 12,835 4% 39.8 7 50,442 3% 18.5 Accidents (unintentional injuries) 5 12,447 4% 32.5 5 99,284 5% 43.7

All causes 291,148 889.0 2,016,830 742.3

CHILDREN AGES 1–14

NH BLACK NH WHITE

CAUSE OF DEATH RANK NUMBER PERCENT OF

TOTAL DEATHS DEATH RATE* RANK NUMBER PERCENT OF

TOTAL DEATHS DEATH RATE*

Accidents 1 617 29% 7.1 1 1,543 32% 5.0 Homicide 2 233 11% 2.7 4 279 6% 0.9 Cancer 3 204 10% 2.4 2 703 15% 2.3 Congenital anomalies (birth defects) 4 181 8% 2.1 3 395 8% 1.3 Chronic lower respiratory diseases 5 104 5% 1.2 11 36 1% 0.1

All causes 2,144 24.6 4,761 15.4

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

Source: National Center for Health Statistics, Centers for Disease Control and Prevention. 12

CA CANCER J CLIN 2016;66:290–308

VOLUME 66 _ NUMBER 4 _ JULY/AUGUST 2016 295

FIGURE 3. Total Number of Cancer Deaths Averted From 1991 to 2012 in Black Men and From 1992 to 2012 in Black Women. The blue line represents the actual number of cancer deaths recorded in each year, and the red line represents the expected number of cancer deaths if can- cer death rates had remained at peak rates.

TABLE 5. Comparison of Cancer Death Rates Between Non-Hispanic (NH) Blacks and Whites, United States, 2008– 2012

MALE FEMALE

CANCER

NH BLACK RATE*

NH WHITE RATE*

ABSOLUTE DIFFERENCE†

RATE RATIO‡ CANCER

NH BLACK RATE*

NH WHITE RATE*

ABSOLUTE DIFFERENCE†

RATE RATIO‡

Stomach 9.4 3.6 5.8 2.58§ Stomach 4.5 1.8 2.7 2.48§ Prostate 47.2 19.9 27.3 2.38§ Myeloma 5.4 2.4 3.0 2.22§ Larynx 3.7 1.8 1.9 2.02§ Uterine cervix 4.1 2.0 2.1 2.00§ Myeloma 7.8 4.0 3.8 1.95§ Uterine corpus 7.8 4.1 3.7 1.92§ Liver & IHB 12.8 7.6 5.2 1.69§ Liver & IHB 4.4 3.1 1.3 1.43§ Colon & rectum 27.6 18.2 9.4 1.52§ Breast 31.0 21.9 9.1 1.42§ Oral cavity & pharynx 5.2 3.8 1.4 1.36§ Colon & rectum 18.2 12.9 5.3 1.41§ Pancreas 15.4 12.7 2.7 1.21§ Pancreas 12.6 9.5 3.1 1.32§ Lung & bronchus 74.9 62.2 12.7 1.20§ Esophagus 2.0 1.6 0.4 1.28§ Kidney & renal pelvis 5.7 5.9 20.2 0.97 Urinary bladder 2.6 2.3 0.3 1.12§ Hodgkin lymphoma 0.4 0.5 20.1 0.94 Kidney & renal pelvis 2.6 2.6 0.0 1.02 Esophagus 7.1 8.0 20.9 0.89§ Lung & bronchus 36.7 41.1 24.4 0.89§ Leukemia 8.1 9.9 21.8 0.82§ Leukemia 4.8 5.4 20.6 0.89§ Non-Hodgkin lymphoma 5.9 8.3 22.4 0.71§ Hodgkin lymphoma 0.3 0.3 0.0 0.89 Urinary bladder 5.4 8.4 23.0 0.65§ Ovary 6.8 8.2 21.4 0.83§ Brain & ONS 3.2 6.0 22.8 0.53§ Non-Hodgkin lymphoma 3.6 5.0 21.4 0.71§ Melanoma of the skin 0.5 5.0 24.5 0.09§ Brain & ONS 2.2 3.9 21.7 0.55§

Melanoma of the skin 0.4 2.1 21.7 0.18§ All sites 267.7 210.6 57.1 1.27§ All sites 170.4 149.2 21.2 1.14§

IHB indicates intrahepatic bile duct; ONS, other nervous system.

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

†The absolute difference is the rate in blacks minus the rate in whites.

‡The rate ratio is the unrounded rate in blacks divided by the unrounded rate in whites.

§The rate ratio is significantly different from one (P < .05).

Note: Sites are listed in descending order by rate ratio.

Source: National Center for Health Statistics, Centers for Disease Control and Prevention. 12

Cancer Statistics for African Americans, 2016

296 CA: A Cancer Journal for Clinicians

that of whites experience similar outcomes.31,34 However,

other studies report that racial disparities persist even

after controlling for socioeconomic factors and access

to care.35-39 Higher rates of comorbid health condi-

tions (eg, obesity, diabetes, and hypertension) among

black patients can affect the delivery of optimal treatment and

are also thought to contribute to differences in survival.40-42

Although there is limited evidence that differing responses to

cancer therapy contribute to racial disparities in survival,

blacks and other racial minorities are underrepresented in

clinical trials, which makes it more difficult to assess the effi-

cacy of cancer therapies in these groups. 43,44

The overall 5-year relative survival rate among blacks

has improved from approximately 27% during 1960

through 1963 to 62% during 2005 through 2011. 8

Sur-

vival during the corresponding period in whites increased

from 39% to 70%. Increases in survival over time reflect

earlier diagnoses and improvements in treatment;

FIGURE 4. Trends in Cancer Death Rates and Mortality Rate Ratios by Site and Race/Ethnicity, United States, 1990 to 2012. Note: Vertical scales (death rates and rate ratios) differ by site. NH indicates non-Hispanic. Source: National Center for Health Statistics, Centers for Disease Control and Prevention.

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however, not all persons have benefited equally from

these advances. Importantly, improvements in survival

do not always indicate progress against cancer, such as

when they result from the detection of indolent cancers

(overdiagnosis) or when early diagnosis does not extend

lifespan (lead time bias).

TABLE 6. Incidence Rates* for Selected Cancers in Non-Hispanic Black Males and Females by State, 2008–2012

ALL CANCERS LUNG AND BRONCHUS

COLON AND RECTUM

PROSTATE BREAST UTERINE CERVIX

MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE FEMALE

Alabama 602.3 379.8 103.6 38.2 65.9 46.5 220.9 125.9 10.3 Alaska 564.8 360.8 91.6 † † † 201.0 141.7 † Arizona 423.1 347.9 65.9 51.4 45.2 37.3 132.0 103.2 8.2 Arkansas‡§ 597.8 357.5 115.4 49.1 62.2 48.9 205.1 101.3 11.4 California 572.3 417.5 79.7 51.7 61.3 47.3 197.2 129.1 8.2 Colorado 502.1 374.2 64.3 47.1 48.9 36.7 187.9 120.2 5.9 Connecticut 592.8 408.8 77.7 47.9 62.0 42.5 217.2 122.1 7.5 Delaware 612.3 414.9 87.5 53.4 47.9 36.8 231.5 127.5 8.9 District of Columbia 654.2 453.3 99.4 57.4 63.2 48.4 215.9 137.9 11.3 Florida 533.2 365.9 75.1 36.9 54.4 39.1 197.0 109.7 12.0 Georgia 609.0 392.0 91.7 42.4 60.3 44.5 235.3 124.1 9.2 Hawaii 473.6 360.2 † † 39.6 † 184.2 134.0 † Idaho 468.7 366.6 † † † † † † † Illinois 622.5 437.7 102.1 65.3 71.3 50.5 211.7 126.8 12.7 Indiana 544.0 421.3 109.5 63.6 58.8 47.5 150.2 123.7 8.8 Iowa 586.9 453.6 99.8 86.4 58.5 51.2 164.6 111.6 † Kansas 621.0 450.7 104.0 64.8 62.8 51.5 214.5 131.4 † Kentucky 636.8 458.4 135.6 81.6 65.9 52.5 170.3 133.2 7.4 Louisiana 655.9 422.6 113.1 52.0 72.6 51.8 223.4 130.0 12.0 Maine 425.8 272.8 † † † † 161.9 † † Maryland 547.1 402.3 76.4 49.3 50.7 39.6 203.1 130.2 8.3 Massachusetts 568.2 387.1 72.9 41.5 49.3 37.0 218.9 115.1 8.3 Michigan 636.1 429.3 104.0 63.1 59.4 44.5 223.1 122.7 8.8 Minnesota‡k - - - - - - - - - Mississippi 648.8 408.5 116.2 47.7 75.8 55.8 225.3 124.0 12.5 Missouri 582.1 450.2 106.5 70.8 67.2 49.1 171.5 135.6 10.5 Montana 489.9 † † † † † † † † Nebraska 594.6 456.2 107.6 61.0 80.8 57.7 177.9 134.2 † Nevada‡¶ 468.9 379.9 69.6 48.0 57.8 47.4 141.7 116.8 9.9 New Hampshire 497.5 288.9 † † † † 190.9 † † New Jersey 606.7 415.0 80.6 50.4 59.7 44.9 234.1 124.4 11.2 New Mexico 405.6 320.6 81.8 32.7 28.5 31.5 141.4 107.2 † New York 613.1 406.2 74.6 45.0 57.5 41.2 247.3 119.2 11.4 North Carolina 609.1 403.2 103.6 47.2 58.4 41.2 213.7 128.1 8.7 North Dakota 541.0 † † † † † † † † Ohio 572.1 405.7 102.8 64.2 56.1 38.9 190.7 121.0 7.7 Oklahoma 613.2 421.0 104.8 56.4 55.3 46.4 229.1 131.3 9.4 Oregon 531.3 392.2 87.8 59.1 63.4 39.4 174.3 121.6 † Pennsylvania 624.6 467.1 104.3 71.8 60.9 43.6 198.7 131.1 11.3 Rhode Island 505.3 380.6 67.6 66.2 31.9 33.1 170.0 104.8 † South Carolina 583.8 388.0 94.4 41.0 57.1 40.6 207.2 125.1 9.3 South Dakota 315.2 309.8 † † † † † † † Tennessee 602.8 407.3 109.6 53.1 64.0 45.9 203.8 126.2 10.9 Texas 572.4 406.8 99.9 52.3 63.9 45.1 175.8 120.3 11.1 Utah 551.7 386.1 † † † † 210.9 108.6 † Vermont 325.9 † † † † † † † † Virginia 578.8 392.8 95.1 49.5 54.2 41.0 208.9 129.8 7.6 Washington 573.1 417.1 80.9 55.8 47.4 36.0 196.2 127.3 6.9 West Virginia 565.2 369.3 99.5 47.1 65.6 38.2 192.2 115.5 † Wisconsin 684.9 458.7 127.8 74.1 69.4 44.1 217.8 126.0 11.3 Wyoming 264.2 236.7 † † † † † † †

United States 592.3 408.1 93.4 51.4 60.3 44.1 208.7 124.3 10.0

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

†Rates are suppressed when they are based on fewer than 25 cases.

‡This state’s data are not included in US combined rates.

§Rates are based on incidence data for 2008–2009.

kIncidence data not submitted to North American Association of Central Cancer Registries. ¶Rates are based on incidence data for 2008–2010.

Source: North American Association of Central Cancer Registries. 9

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298 CA: A Cancer Journal for Clinicians

Selected Cancer Sites

Female breast

Breast cancer is the most common cancer among black

women and is the second leading cause of cancer death,

with an estimated 30,700 new cases of breast cancer and

6310 deaths expected to occur in 2016. During 2008

through 2012, the overall breast cancer incidence rate in

black women was 124.3 cases per 100,000 women, which

was 3% lower than that in white women (128.1 per

100,000 women) (Table 2). However, rates were higher in

TABLE 7. Death Rates* for Selected Cancers in Non-Hispanic Black Males and Females by State, 2008–2012

ALL CANCERS LUNG AND BRONCHUS

COLON AND RECTUM

PROSTATE BREAST UTERINE CERVIX

MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE FEMALE

Alabama 298.3 167.5 87.3 29.8 31.2 19.7 56.7 30.7 4.7 Alaska 247.4 128.8 † † † † † † † Arizona 204.9 152.8 47.7 32.5 24.3 17.8 32.1 29.7 † Arkansas 304.6 183.2 99.3 38.7 32.3 21.7 53.0 31.4 6.4 California 250.3 181.4 63.4 38.8 26.3 19.9 48.4 33.1 3.6 Colorado 219.9 154.5 54.6 35.5 22.8 15.0 51.2 26.0 † Connecticut 224.6 148.2 55.7 31.0 19.1 13.5 39.7 24.6 † Delaware 248.5 168.6 68.9 37.4 16.5 15.3 39.8 26.5 † District of Columbia 291.7 190.3 74.2 41.0 26.2 20.3 48.0 34.0 4.0 Florida 232.0 147.2 59.8 25.1 23.5 16.4 46.2 28.5 4.9 Georgia 264.7 155.6 71.0 29.5 27.1 17.6 52.6 29.5 3.9 Hawaii 194.6 125.3 † † † † † † † Idaho † † † † † † † † † Illinois 284.6 188.4 80.8 45.6 30.8 20.5 48.8 32.8 5.5 Indiana 282.1 190.9 90.6 48.1 26.8 19.1 43.9 31.0 3.5 Iowa 291.9 190.2 71.6 52.6 26.4 25.7 48.7 25.6 † Kansas 270.5 197.9 80.1 54.9 27.1 22.1 44.3 29.4 † Kentucky 292.9 191.4 102.1 56.8 26.2 20.7 40.4 32.7 3.2 Louisiana 303.5 182.0 94.0 40.0 31.3 19.6 45.2 34.8 4.5 Maine † † † † † † † † † Maryland 250.5 166.0 66.2 36.7 26.6 17.4 43.4 30.6 3.3 Massachusetts 223.4 146.9 51.1 26.9 19.7 14.0 42.5 23.7 2.5 Michigan 271.7 183.1 82.0 45.1 28.0 17.4 38.8 33.1 3.8 Minnesota 226.2 151.0 53.0 30.4 15.4 9.3 33.6 21.7 † Mississippi 323.1 175.7 98.4 35.1 33.8 22.2 59.6 33.3 5.6 Missouri 272.8 188.2 79.6 47.1 28.8 18.6 41.4 33.7 4.5 Montana † † † † † † † † † Nebraska 287.6 186.8 86.2 48.5 40.4 19.2 38.7 29.0 † Nevada 218.6 154.4 59.2 39.5 23.6 19.6 37.4 29.3 † New Hampshire 146.1 † † † † † † † † New Jersey 263.2 170.9 65.7 34.9 30.2 18.8 49.4 32.5 4.1 New Mexico 218.6 157.2 73.6 † † † † 30.2 † New York 226.7 154.4 54.6 30.0 23.8 15.6 44.8 28.4 4.4 North Carolina 282.7 160.3 83.2 32.7 27.2 17.2 52.3 28.8 3.3 North Dakota † † † † † † † † † Ohio 278.4 181.8 86.8 47.8 28.0 16.5 44.6 30.9 3.6 Oklahoma 287.4 188.5 84.5 40.6 33.2 22.5 55.9 35.4 4.8 Oregon 261.3 170.4 69.5 48.7 27.3 † 47.9 28.5 † Pennsylvania 288.4 193.3 80.9 49.1 29.7 18.1 52.6 33.1 4.1 Rhode Island 203.2 127.3 47.5 36.9 † † † 28.1 † South Carolina 286.2 162.6 75.6 30.0 28.0 17.5 52.8 29.2 4.1 South Dakota † † † † † † † † † Tennessee 321.3 186.3 97.3 41.0 34.8 21.4 53.0 33.9 5.2 Texas 274.6 177.4 81.4 38.5 30.5 19.9 39.5 33.7 4.2 Utah 162.6 148.8 † † † † † † † Vermont † † † † † † † † † Virginia 271.1 165.3 76.1 35.9 26.9 17.1 47.3 31.7 2.9 Washington 241.2 157.8 61.0 36.8 20.6 13.3 48.4 25.0 † West Virginia 282.7 173.2 89.8 40.2 35.2 17.5 56.0 26.6 † Wisconsin 307.8 195.0 102.7 50.1 28.0 18.2 42.6 32.1 3.8 Wyoming † † † † † † † † †

United States 267.7 170.4 74.9 36.7 27.6 18.2 47.2 31.0 4.1

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

†Rates are suppressed when they are based on fewer than 25 deaths.

Source: National Center for Health Statistics, Centers for Disease Control and Prevention. 12

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black women than in white women in 7 states (Alabama,

Kentucky, Louisiana, Mississippi, Missouri, Oklahoma,

and Tennessee) and were not significantly different in 24

states.45 Breast cancer incidence rates are also higher among

blacks than whites for women under age 45. The median

age of diagnosis is 58 years for black women, compared

with 62 years for white women.8 One in 9 black women is

expected to be diagnosed with breast cancer in her lifetime,

compared with 1 in 8 white women (Table 1).

Long-term breast cancer incidence trends are shown in

Figure 7. Similar to the pattern among white women, rates

among black women increased rapidly during the 1980s,

largely because of increased detection due to mammog-

raphy screening uptake. However, rates stabilized in white

women (since 2004) but continued to increase in black

women from 1986 to 2012 by 0.5% per year.8 As a

result, incidence rates in black and white women con-

verged in 2012. The continued increase in breast cancer

FIGURE 5. Five-year Relative Survival Rates for Selected Cancers by Race and Stage, United States, 2005 to 2011. Survival rates are based on patients who were diagnosed between 2005 and 2011 and followed through 2012. Source: Surveillance, Epidemiology, and End Results (SEER) Program, SEER 18 registries, National Cancer Institute.

6

Cancer Statistics for African Americans, 2016

300 CA: A Cancer Journal for Clinicians

incidence rates in black women may in part reflect the obesity epidemic. The prevalence of obesity (body mass index �30 kg/m2) increased from 38% during 1988 through 1994 to 57% in 2013 and 2014 for black women and from 23% to 38% over the same period for white women (Fig. 8).

Prior to the mid-1980s, breast cancer death rates for white

and black women were similar. However, a larger increase in

black than in white women from the mid-1970s to the early

1990s, followed by a slower decline in black women, has

resulted in a widening disparity. Since 1990, breast cancer

death rates dropped 23% in black women and 37% in white

women (Fig. 4). As a result, breast cancer death rates in the

most recent time period (2008-2012) are 42% higher in

black women compared with white women, despite histori-

cally lower incidence rates. Higher death rates among black

women likely reflect a combination of factors, including dif-

ferences in stage at diagnosis, obesity, comorbidities, and

tumor characteristics as well as access, adherence, and

response to high-quality cancer treatment.46-52

The 5-year relative survival rate for breast cancer

diagnosed in 2005 through 2011 among black women was

80%, compared with 91% among white women (Fig. 5).

This difference can be attributed to both later stage at

detection and poorer stage-specific survival among black

women. Despite similar reported mammography screening

rates (Table 8), only about half (52%) of breast cancers are

diagnosed at a local stage among black women, compared

with 63% among white women (Fig. 6).

Later stage at diagnosis among black women has been

largely attributed to lower frequency of and longer intervals

between mammograms and lack of timely follow-up of

abnormal results. 53-55

Lower stage-specific survival has

been explained in part by unequal access to and receipt of

prompt, high-quality treatment among black women

compared with white women. 48,56-59

Aggressive tumor

characteristics are more common in breast cancers diag-

nosed in black women than in other racial/ethnic

groups.45,60-62 For example, 22% of breast cancers in black

women are triple negative (estrogen receptor-negative, pro-

gesterone receptor-negative, and human epidermal growth

factor receptor 2-negative) compared with 10% to 12% of

those among women of other races/ethnicities in the

United States.45 These proportions are even higher among

premenopausal black breast cancer patients.63 Triple-

negative breast cancers, which include the basal-type subset

FIGURE 6. Stage Distribution for Selected Cancers in Non-Hispanic (NH) Blacks and Whites, United States, 2005 to 2011. Percentages may not total 100% because of rounding. Source: North American Association of Central Cancer Registries.

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of breast cancers, are more aggressive and have a poorer

prognosis, in part because there are currently no targeted

therapies for these tumors.64,65 Some studies suggest that

black women are more likely to be diagnosed with

triple-negative and basal-like breast cancers as a result of

shared African ancestry.60,66 A recent analysis from the

African American Breast Cancer Epidemiology and Risk

(AMBER) Consortium identified eight genes that may

be involved in the etiology of breast cancer in black

women, including three linked to estrogen receptor-

negative disease.67 Other studies have found that risk

factors vary for breast cancer subtypes and that obesity

and certain reproductive patterns (including multi-

party, early age at first pregnancy, and lower rates of

breastfeeding) which are more common in black women,

are linked to increased risk for aggressive breast cancer

subtypes. 63,68-72

Colon and rectum

CRC is the third most common cancer diagnosed among

both black men and women and the second most common

for both sexes combined, with 17,240 new cases expected to

be diagnosed in 2016 (Fig. 1). The median age of diagnosis

for CRC is 66 years for black men and 70 years for black

women, compared with ages 72 and 77 years for white men

and women, respectively.8 CRC is also the third leading

cause of cancer death in black men and women, with 7030

CRC deaths expected in 2016.

Incidence rates for CRC are 27% higher in black men

and 22% higher in black women compared with white men

and women, respectively (Table 2). Blacks have higher rates

of obesity and higher rates of physical inactivity (Table 9),

which are known risk factors for CRC. Results from the

National Institutes of Health-AARP Diet and Health

Study suggest that health behaviors (diet, physical activity,

and smoking) and body mass index explain more than a

third (36%) of the increased risk for CRC associated with

low socioeconomic status, for which blacks are dispropor-

tionately represented. 73

In addition, uptake of CRC screen-

ing, which can prevent cancer through the removal of

precancerous polyps as well as detect cancer at an early

stage, has been slower in blacks than in whites and remains

slightly lower. From 2000 to 2013, CRC screening

increased from 32% to 59% in blacks and from 40% to

61% in whites.20 Before 1989, incidence rates were

FIGURE 7. Trends in Cancer Incidence Rates Among Blacks, United States, 1975 to 2012. Rates are delay adjusted and age adjusted to the 2000 US standard popula- tion and are 2-year moving averages. Source: SEER Program, SEER 9 registries, National Cancer Institute.

4

FIGURE 8. Trends in Adult Obesity (Body Mass Index �30 kg/m

2 ) Prevalence (%) by Sex and Race/Ethnicity, United

States, 1988 to 2014. NH indicates non-Hispanic. Sources: 1988-2012: Health, United States, 2014: With Special Feature on Adults Ages 55-64. 2013-2014: Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey, 2014. Public use data file.

21

Cancer Statistics for African Americans, 2016

302 CA: A Cancer Journal for Clinicians

predominantly higher in white men than in black men and

were similar for women of both races. Since 1989, however,

incidence rates have been higher for blacks than for whites

in both men and women. This crossover likely reflects racial

differences in risk factor trends and/or greater access to and

utilization of recommended screening tests by whites.74

From 2003 to 2012, incidence rates decreased by 3.0% per

year in black men and by 3.1% per year in black women,

similar to declines in whites (Table 3).

The racial disparity is more striking for CRC death rates:

rates are 52% higher in black men and 41% higher in black

women (Table 5). One model-based study estimated that

19% of the racial disparity in CRC mortality rates can be

attributed to lower screening rates and 36% can be attributed

to lower stage-specific survival among blacks.75 Similar to

the pattern for incidence rates, CRC mortality rates were

historically higher in whites compared with blacks, with the

crossover occurring around 1979 for women and 1984 for

men. From 2003 through 2012, annual declines in mortality

rates were higher in black women than white women (3.3%

vs 2.9%) but were lower in black men than in white men

(2.5% vs 3.0%) (Table 3). As a result, the racial gap appears

to be shrinking in women, whereas rates in men have

remained about 50% higher in blacks than in whites since

2005 (Fig. 4). Smaller declines in death rates for distant-

stage disease in blacks than in whites (5% vs 33%) appear to

be driving the overall mortality differential.76

The 5-year relative survival rate for CRC among blacks

improved from 45% during 1975 through 1977 to 59% dur-

ing 2005 through 2011; however, this improvement was

smaller than that in whites (from 50% to 67% over the same

period). 8

Some of the racial disparity in survival is because of

later stage at diagnosis—37% of CRCs in blacks are diag-

nosed at a localized stage compared with 40% in whites (Fig.

6). However, lower 5-year relative survival rates are also seen

in black CRC patients within each stage at diagnosis (Fig.

5). Racial disparities in CRC survival largely reflect differen-

ces in treatment, socioeconomic status, and comorbid-

ities. 35,77-80

Numerous studies document that black CRC

patients are less likely than white patients to receive recom-

mended surgical treatment and adjuvant chemotherapy.81-83

Notably, a recent study reported that, when black and white

stage III CRC patients received similar adjuvant chemother-

apy (combined folinic acid, fluorouracil, and oxaliplatin

TABLE 8. Human Papillomavirus Vaccination (2014) and Use of Cancer Screening Examinations and Tests (2013), United States

NH BLACK (%)

NH WHITE (%)

HPV vaccination* (youth 13-17 years) Girls � 1 dose 66 56 � 3 doses 39 38

Boys � 1 dose 42 36 � 3 doses 20 19

Breast cancer (women 40 years and older) Mammogram in the past 2 years 66 66

Cervical cancer (women ages 21–65 years)† Pap test in the past 3 years 82 83

Colorectal cancer (adults 50 years and older) FOBT in the past year 9 7 Endoscopy‡ 57 58 FOBT or endoscopy§ 59 61

Prostate cancer (men 50 years and older) PSA test in the past year 33 37

NH indicates non-Hispanic; Pap, Papanicolaou; FOBT, fecal occult blood test; PSA, prostate-specific antigen.

*Complete vaccination series consists of 3 doses.

†Among women with intact uteri.

‡Sigmoidoscopy in the past 5 years or colonoscopy in the past 10 years.

§FOBT in the past year, sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years.

Note: Estimates for screening are age-adjusted to the 2000 US standard population.

Sources: Vaccination: National Immunization Survey-Teen, 2014. 118

Screen- ing: Centers for Disease Control and Prevention. National Health Interview Survey, 2013. Public use data file.

20

TABLE 9. Risk Factors for Cancer by Sex and Race/ Ethnicity, Adults, United States, 2013–2014

NH BLACK (%)

NH WHITE (%)

Obesity (BMI � 30.0)* All 48 36 Men 38 35 Women 57 38

Overweight (BMI 25.0–29.9)* All 28 33 Men 31 40 Women 25 26

No leisure-time physical activity† All 38 26 Men 34 25 Women 41 27

Met recommendations for aerobic activity†,‡ All 44 54 Men 51 56 Women 38 52

Current cigarette smoking†,§ All 18 19 Men 22 20 Women 14 18

NH indicates non-Hispanic; BMI, body mass index, kg/m 2 .

*Among adults 20 years and older.

†Among adults 18 years and older.

‡Includes 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity each week.

§Ever smoked 100 cigarettes in lifetime and smoking every day or some days at time of survey.

Note: Estimates are age-adjusted to the 2000 US standard population.

Sources: BMI: Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey, 2013–2014. Public use data file.

21 Physical

activity and smoking: Centers for Disease Control and Prevention. National Health Interview Survey, 2014. Public use data file.

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[FOLFOX]) in a phase 3 clinical trial, those aged 50 years

and older had similar outcomes; however, younger blacks

had shorter disease-free survival (hazard ratio, 1.80; 95%

confidence interval, 1.21-2.66) and time to recurrence (haz-

ard ratio, 1.77; 95% confidence interval, 1.18-2.65) com-

pared with whites. 84

Lung and bronchus

Lung cancer is the second leading cause of cancer in black

men and women, with 13,720 men and 11,010 women

expected to be newly diagnosed in 2016 (Fig. 1). Lung cancer

is also the leading cause of cancer death in blacks, with 9710

men and 7340 women expected to die from this disease in

2016. Black men have higher lung cancer rates than white

men, but the reverse is true for women, reflecting race and sex

differences in historic smoking patterns (Fig. 9). The lung

cancer incidence rate is 18% higher in black men compared

with white men; however, among women, the rate is 13%

lower among blacks (Table 2). Lung cancer trends are similar

in blacks and whites. In black men, lung cancer incidence

rates increased rapidly until the mid-1980s, but have since

been steadily declining (Fig. 7). In contrast, in black women,

rates increased until the early 2000s and have subsequently

begun to decline. From 2003 to 2012, lung cancer incidence

rates decreased slightly faster in black men and women than

in white men and women (Table 3).

The lung cancer mortality rate is higher for black men

than for any other racial or ethnic group. After increasing for

decades, lung cancer death rates in men began to decline in

1990, with acceleration in the decline beginning in 1994.

Similar to the pattern for incidence trends, the decline in

lung cancer death rates has been faster in black men and

women (3.3% per year and 1.6% per year from 2003-2012,

respectively) compared with white men (2.5% per year) and

women (1.2% per year) (Table 3). The disparity in lung can-

cer death rates between black and white men has been sub-

stantially reduced overall (from an excess of 40% in the early

1990s to 20% in 2012) (Fig. 4) and has been eliminated in

adults younger than 40 years. 28

The declines in lung cancer

death rates are the result of decreases in smoking prevalence

over the previous 40 years, which have been more rapid in

blacks than in whites (Fig. 9). Furthermore, black adoles-

cents initiate smoking at a much lower rate than their white

counterparts. 85

If black youths continue to have lower smok-

ing prevalence as they age, racial differences in lung cancer

death rates should be eliminated in the next 40 to 50 years.28

The 5-year overall relative survival rate for lung cancer

is lower in blacks than in whites; 14% versus 18%,

respectively (Fig. 5). When lung cancer is detected at a local

stage, the 5-year relative survival rate in blacks is 47%; how-

ever, only 15% of lung cancer cases in blacks are detected at

this early stage, because symptoms generally do not appear

until the disease is advanced. Studies have shown that even

when lung cancer is diagnosed early, blacks are less likely

than whites to receive curative-intent surgery, even after

accounting for socioeconomic factors. 86-88

Other studies

have found that, among lung cancer patients treated at Vet-

erans Affairs or US Military Health System facilities, racial

disparities in lung cancer outcomes diminished, although

differences in receipt of treatment remained.89-91

Prostate

Prostate cancer is the most commonly diagnosed cancer

among black men and the second leading cause of cancer

death. In 2016, approximately 29,530 cases of prostate can-

cer will be newly diagnosed and 4450 prostate cancer deaths

will occur among black men. The median age of diagnosis

for prostate cancer is 63 years for black men compared with

66 years for white men.8 It is estimated that 1 in 6 black

men will be diagnosed with prostate cancer in their lifetime

compared with 1 in 8 white men (Table 1).

During 2008 through 2012, the average annual prostate

cancer incidence rate was 208.7 cases per 100,000 black

men, which was 70% higher than the rate in white men

(Table 2). Similar to the pattern in white men, incidence

rates in black men increased sharply between 1989 and

1992—reflecting increased use of the prostate-specific anti-

gen (PSA) blood test for the detection of prostate cancer—

but have generally decreased thereafter (Fig. 7). During

2003 through 2012, prostate cancer incidence rates declined

on average by 3.4% per year in black men and 4.2% per year

in white men (Table 3). The decrease in incidence was

driven by declines in early stage disease, and a recent study

noted that the sharpest drop occurred after the release of

FIGURE 9. Trends in Adult Smoking Prevalence (%) by Sex and Race, 1965 to 2014. Sources: 1965-2013: Health, United States, 2014: With Special Feature on Adults Aged 55-64. 2014: Centers for Disease Control and Prevention. National Health Interview Survey, 2014. Public use data file.

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Cancer Statistics for African Americans, 2016

304 CA: A Cancer Journal for Clinicians

the US Preventive Services Task Force draft recommenda-

tion against PSA screening for men of all ages in 2011.92

The only well established risk factors for prostate cancer

are age, race, and family history of the disease. Men who

have a first-degree relative with a history of prostate cancer

are 2 to 3 times more likely to be diagnosed with the dis-

ease than men without a family history.93 Black men and

Jamaican men of African descent have the highest prostate

cancer incidence rates worldwide, which may reflect differ-

ences in inherited genetic susceptibility.94-97

Similarly, black men have the highest mortality rate for

prostate cancer of any racial or ethnic group in the United

States, 2.4 times higher than the rate in white men (Table

5), in part reflecting higher incidence rates among black

men. After a long period of increase, prostate cancer

death rates in black men peaked in 1993 and declined

steadily thereafter. Rates have been declining since 1996,

by 3.6% per year in blacks and by 3.4% in whites, resulting

in a narrowing disparity (Fig. 4). The decrease in prostate

cancer mortality has been attributed to improved surgical

and radiologic treatment and dissemination of hormonal

therapy for advanced-stage disease. 98-101

The contribution

of PSA testing is not clear. Results from a US-based

randomized trial indicated no reduction in prostate cancer

mortality as a result of PSA testing, while two European

trials showed a modest benefit.102-104 Studies also suggest

that black men are less likely to receive surgical treatment

than white men with similar disease characteristics. 105-108

Furthermore, a recent analysis of SEER-Medicare data

concluded that, among localized prostate cancer patients

who underwent radical prostatectomy, blacks were more

likely to experience treatment delays and postoperative

complications and were less likely to receive lymph node

dissection compared with whites, although prostate cancer-

specific and all-cause mortality were similar in both

groups.105 The lack of a difference in outcome despite

treatment differences suggests that some patients with early

stage disease may be overtreated. 109

The overall 5-year relative survival rate for prostate cancer

is 97% among blacks and 99% among whites (Fig. 5). Eighty-

eight percent of prostate cancers in black men are diagnosed

at a local or regional stage (Fig. 6), for which the 5-year rela-

tive survival rate approaches 100%. Five-year survival rates

drop to 28% when the cancer is diagnosed at distant stage.

Uterine cervix

An estimated 2290 new cases of invasive cervical cancer and

750 deaths are expected to occur among black women in 2016.

The incidence rate of cervical cancer is 41% higher in black

women than in white women (Table 2). However, a recent

study suggests that the racial disparity may be even wider after

adjusting incidence rates to account for women who have had

a hysterectomy and thus are not at risk for cervical cancer. 110

Nevertheless, the racial disparity has narrowed substantially, as

rates have dropped faster among black women than among

white women in recent years (Table 3). Notably, among

women under age 50 years, incidence rates of cervical cancer

converged between black and white women in the mid-

2000s. 27

The median age of cervical cancer diagnosis is 51 years

for black women compared with 48 years for white women. 8

The overall 5-year relative survival rate for cervical cancer

among black women is 58%, compared with 69% among

white women (Fig. 5), partly because black women are more

likely than white women to be diagnosed with regional-

stage or distant-stage disease (Fig. 6) despite similar screen-

ing rates (Table 8). Racial differences in stage at diagnosis

may be because of differences in the quality of screening and

follow-up after abnormal results. 111,112

Lower socioeco-

nomic status is also associated with lower screening rates,

later stage at diagnosis, and poorer survival. 113-115

Virtually all cervical cancers are caused by persistent

human papillomavirus (HPV) infection, particularly HPV

types 16 and 18.116 The US Food and Drug Administra-

tion has approved and three vaccines are recommended for

the prevention of the most common HPV genotypes. Two

of the vaccines provide protection against HPV types caus-

ing approximately 70% of cervical cancers, while the third

provides protection against HPV types associated with

approximately 90% of invasive cervical cancers. 117

Data

from the 2014 National Immunization Survey-Teen found

that, although HPV vaccine initiation was higher among

black girls (66%) than among white girls (56%), completion

of the three-vaccine series was similar (blacks, 39%; whites,

38%) (Table 8).118 Vaccinated women need to continue to

receive recommended cervical cancer screening, because

these vaccines only target the most common strains of

HPV, and they also do not provide protection for those

women who are already infected with HPV.119,120

Data Limitations

The projected numbers of new cancer cases and cancer

deaths should be interpreted cautiously, because these esti-

mates are model-based and may vary considerably from year

to year for reasons other than changes in cancer occurrence,

including changes in methodology. Therefore, we discour-

age the use of these estimates to track year-to-year changes

in cancer occurrence and death. The preferred data sources

used for tracking cancer trends are age-standardized or age-

specific cancer death rates from the National Center for

Health Statistics and cancer incidence rates from SEER or

NAACCR, although these data are 2 to 4 years old by the

time they become available. Nevertheless, the American

Cancer Society projections of the number of new cancer

cases and deaths provide a reasonably accurate estimate of

the current cancer burden in the United States.

CA CANCER J CLIN 2016;66:290–308

VOLUME 66 _ NUMBER 4 _ JULY/AUGUST 2016 305

Conclusions

Substantial progress has been made over the last several

decades to reduce the disproportionate burden of cancer in

blacks in the United States. The black-white disparity in

cancer death rates has narrowed for all cancers combined in

men and women and for lung and prostate cancer in men.

However, the racial gap in death rates has widened for

breast cancer in women and remained level for CRC in

men, likely because of suboptimal screening and treatment

for blacks. Accelerating progress in eliminating racial dis-

parities requires equitable access to services for prevention,

early detection, and high-quality treatment. �

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Cancer Statistics for African Americans, 2016

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