Evaluation of a National Cancer Registry National Study.
Kaydence347
cncr.31551.pdf
Annual Report to the Nation on the Status of Cancer, Part I: National Cancer Statistics
Kathleen A. Cronin, PhD, MPH1; Andrew J. Lake, BS2; Susan Scott, MPH 1; Recinda L. Sherman, MPH, PhD, CTR3;
Anne-Michelle Noone, MS1; Nadia Howlader, MS, PhD1; S. Jane Henley, MSPH4; Robert N. Anderson, PhD5;
Albert U. Firth, BS2; Jiemin Ma, PhD, MHS6; Betsy A. Kohler, MPH, CTR3; and Ahmedin Jemal, DVM, PhD 6
BACKGROUND: The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer
Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate to provide annual updates
on cancer occurrence and trends in the United States. METHODS: Incidence data were obtained from the CDC-funded and NCI-
funded population-based cancer registry programs and compiled by NAACCR. Data on cancer deaths were obtained from the
National Center for Health Statistics National Vital Statistics System. Trends in age-standardized incidence and death rates for all can-
cers combined and for the leading cancer types by sex, race, and ethnicity were estimated by joinpoint analysis and expressed as the
annual percent change. Stage distribution and 5-year survival by stage at diagnosis were calculated for breast cancer, colon and rec-
tum (colorectal) cancer, lung and bronchus cancer, and melanoma of the skin. RESULTS: Overall cancer incidence rates from 2008 to
2014 decreased by 2.2% per year among men but were stable among women. Overall cancer death rates from 1999 to 2015
decreased by 1.8% per year among men and by 1.4% per year among women. Among men, incidence rates during the most recent 5-
year period (2010-2014) decreased for 7 of the 17 most common cancer types, and death rates (2011-2015) decreased for 11 of the 18
most common types. Among women, incidence rates declined for 7 of the 18 most common cancers, and death rates declined for 14
of the 20 most common cancers. Death rates decreased for cancer sites, including lung and bronchus (men and women), colorectal
(men and women), female breast, and prostate. Death rates increased for cancers of the liver (men and women); pancreas (men and
women); brain and other nervous system (men and women); oral cavity and pharynx (men only); soft tissue, including heart (men
only); nonmelanoma skin (men only); and uterus. Incidence and death rates were higher among men than among women for all racial
and ethnic groups. For all cancer sites combined, black men and white women had the highest incidence rates compared with other
racial groups, and black men and black women had the highest death rates compared with other racial groups. Non-Hispanic men
and women had higher incidence and mortality rates than those of Hispanic ethnicity. Five-year survival for cases diagnosed from
2007 through 2013 ranged from 100% (stage I) to 26.5% (stage IV) for female breast cancer, from 88.1% (stage I) to 12.6% (stage IV)
for colorectal cancer, from 55.1% (stage I) to 4.2% (stage IV) for lung and bronchus cancer, and from 99.5% (stage I) to 16% (stage IV)
for melanoma of the skin. Among children, overall cancer incidence rates increased by 0.8% per year from 2010 to 2014, and overall
cancer death rates decreased by 1.5% per year from 2011 to 2015. CONCLUSIONS: For all cancer sites combined, cancer incidence
rates decreased among men but were stable among women. Overall, there continue to be significant declines in cancer death rates
among both men and women. Differences in rates and trends by race and ethnic group remain. Progress in reducing cancer mortality
has not occurred for all sites. Examining stage distribution and 5-year survival by stage highlights the potential benefits associated
with early detection and treatment. Cancer 2018;124:2785-800. VC 2018 The Authors. Cancer published by Wiley Periodicals, Inc. on
behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial
License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used
for commercial purposes.
KEYWORDS: Annual Report to the Nation, cancer, incidence, mortality, National Program of Cancer Registries (NPCR), National Vital
Statistics System (NVSS), North American Association of Central Cancer Registries (NAACCR), Surveillance, Epidemiology, and End
Results (SEER), survival, trends.
Corresponding author: Kathleen A. Cronin, PhD, MPH, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 4E454, Bethesda, MD 20892-9765; [email protected]
1 Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland;
2 Information Management Services, Inc., Rockville, Maryland;
3 North American Association of Central Cancer Registries, Springfield, Illinois;
4 Division of Cancer Prevention and Control, National Center for Chronic Disease Pre-
vention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; 5National Center for Health Statistics, Centers for Disease Control
and Prevention, Hyattsville, Maryland; 6 Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
See companion article on pages 2801-14, this issue.
This article has been contributed to by US Government employees, and their work is in the public domain in the United States.
We gratefully acknowledge the contributions of the state and regional cancer registry staff for their work in collecting the data used in this report. In addition,
we thank Daniel Miller, Joe Zou, and Steve Scoppa of Information Management Services, Inc., for assistance in compiling the data used in this report. We thank
Alyssa Wang, MPH, for assistance with preparation of the graphics and Trish Murphy, MS, for editorial assistance.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official positions of the author’s agencies (the Centers
for Disease Control and Prevention, the National Cancer Institute, the American Cancer Society, or the North American Association of Central Cancer Registries).
DOI: 10.1002/cncr.31551, Received: March 22, 2018; Revised: April 23, 2018; Accepted: April 26, 2018, Published online May 22, 2018 in Wiley Online Library (wileyonlinelibrary.com)
Cancer July 1, 2018 2785
Original Article
INTRODUCTION The American Cancer Society (ACS), Centers for Disease Control and Prevention (CDC), National Cancer Insti- tute (NCI), and North American Association of Central Cancer Registries (NAACCR) have collaborated annually since 1998 to provide updates on cancer incidence and mortality patterns in the United States.1-19 This report uses a single database to estimate delay-adjusted incidence to monitor population-based cancer trends. In addition to reporting on incidence and mortality trends overall and for common cancer sites, this year’s report highlights 4 cancer sites (female breast, colon and rectum [colorectal], lung and bronchus, and melanoma of the skin) by pre- senting the percentage of cases by stage at diagnosis and 5- year survival estimates by stage at diagnosis.
MATERIALS AND METHODS
Data Sources Cancer incidence data
Population-based cancer incidence data by age, sex, and race/ethnicity were obtained from 42 state registries that participate in the CDC’s National Program of Cancer Registries (NPCR) and/or the NCI’s Surveillance, Epi- demiology, and End Results (SEER) Program. The data satisfied the NAACCR’s data quality criteria and repre- sented cases diagnosed from 1999 through 2014,20 cover- ing 89% of the US population. Information on incident cases came primarily from the abstracts of inpatient and outpatient medical records but also from a variety of other sources, including pathology reports and death certifi- cates. This database of 42 registries was used to derive all incidence statistics presented in this report.
Anatomic site and histology were coded according to the International Classification of Diseases for Oncol- ogy (ICD-O) edition in use at the time of diagnosis and were converted to the third edition (ICD-O-3) coding21
and categorized according to SEER site groups.22 Only cases defined as malignant under ICD-O-2 and ICD-O-3 were included in this report, with the exception of bladder cancer. In situ and malignant cancers were combined when reporting bladder cancer incidence rates. All case counts and rates were adjusted for delay in reporting.23
After adjusting for reporting delay, the 5-year fixed inter- val incidence rates are based on 3.6 million male cases and 3.5 million female cases diagnosed between 2010 and 2014.
Cancer mortality data
Although cancer incidence data were available through 2014, an additional year of data was available for analysis
of mortality. Cause of death by age, sex, and race/ethnicity (1999-2015) came from the National Vital Statistics Sys- tem and was based on death certificate information reported to state vital statistics offices and compiled into a national file covering all states in the United States by the National Center for Health Statistics (NCHS).24 Catego- rization methods for cause of death have been described in previous reports.19
Race/ethnicity data
In this report, information on race and ethnicity was based on medical records for incidence or death certifi- cates from the NCHS for mortality. Race was categorized as white, black, Asian/Pacific Islander (API), and Ameri- can Indian/Alaska Native (AI/AN). Race information for AI/AN, however, was considered reliable only for geo- graphic areas covered by the Indian Health Service Con- tract Health Service Delivery Areas (CHSDA)10,25,26; therefore, incidence and mortality data for AI/AN were based only on these areas. Overall, 83% of the AI/AN population lived in CHSDA areas between the years 2010 and 2014. This percentage varied by geographic area, with 100% or close to 100% of the AI/AN population liv- ing in CHSDA areas in Alaska, the Pacific Coast, the Southern Plains, and the East; 67% living in the Northern Plains; and 60% living in the Southwest. Hispanic ethnic- ity included individuals from all races identified as His- panic. Although the accuracy of race and ethnicity reporting has improved over time, recent studies have demonstrated that reporting of race in medical records remains less accurate for API, Hispanic, and AIs/ANs than for whites and blacks.27,28 We present incidence and mortality data separately by race and by Hispanic ethnic- ity. The number of cases included in the 5-year incidence rate calculation ranged from 12,000 male and 13,500 female AIs/ANs residing in CHSDA areas to almost 3 million white men and women.
Population data
The population estimates used as the denominators to cal- culate incidence and death rates were a modification of the intercensal and Vintage 2015 annual times series of July 1, county population estimates by age, sex, race, and Hispanic origin produced by the US Census Bureau’s Population Estimates Program in collaboration with the NCHS and with support from the NCI.29 The estimates incorporate intercensal (for July 1, 2000-2009) and Vin- tage 2015 (for July 1, 2010-2015) bridged, single-race estimates that are derived from the original multiple-race categories in the 2000 and 2010 Censuses, as specified in
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2786 Cancer July 1, 2018
the 1997 Office of Management and Budget standards for the collection of data on race and ethnicity.30,31 Some
additional adjustments were made to refine the July 1 population estimates, as with previous reports.19
Survival data
Estimates for 5-year relative survival were calculated for cases diagnosed from 2007 through 2013. We used 34
central cancer registries (33 states and 1 metropolitan area, referenced hereafter as states) compiled by the NAACCR (covering 70% of the US population) to examine survival differences by sex and cancer stage at diagnosis for cancers of the lung and bronchus, breast,
colon and rectum, and melanoma of the skin.32 These 34 states were considered to have sufficient vital status follow-up to conduct survival analyses, because they either conducted recent National Death Index linkages
or they routinely conduct active vital status follow-up of all cases.33 Cancers that were identified by death certifi- cate or autopsy only were excluded from the survival analysis, as were patients who died so soon after diagno- sis that their survival time was not measurable. The first
site-specific cancer of the analysis period (2007-2013) was used in the analysis. Patients were followed for vital status through December 31, 2013, because not all regis- tries had complete information on vital status through
December 31, 2014.
Statistical Methods Cancer incidence and death rates and trends
Cross-sectional incidence (2010-2014) and death (2011- 2015) rates for all ages combined were calculated for all cancer sites combined and for the most common cancer
sites by sex, race, and ethnicity. These rates were calcu- lated with their 95% confidence intervals using SEER*- Stat software, version 8.3.4.34,35 Incidence rates were adjusted for delay in reporting.36 Similarly, we calculated overall cancer incidence and death rates for children (ages
0-14 years). All rates were age-standardized to the 2000 US standard population and were expressed per 100,000 persons.34 Rates based on fewer than 16 cases were deemed to be statistically unstable and were suppressed.
Temporal trends in age-standardized, delay-adjusted cancer incidence (1999-2014) and death (1999-2015) rates were estimated using joinpoint regression,37,38 with a maximum of 2 joinpoints (3 line segments) allowed in
each model for incidence and 3 joinpoints (4 line seg- ments) allowed in each model for mortality. The maxi- mum number of joinpoints is based on the number of data points in the series.39 The resultant trends were
described by the annual percent change (APC). The 5- year average APCs (AAPCs) for 2010 through 2014 (inci- dence) and for 2011 through 2015 (mortality) were calcu- lated using a weighted average of the slope coefficients of the underlying joinpoint regression line, with the weights equal to the length of each segment over the interval. The AAPC was equal to the APC when the AAPC was entirely within the last joinpoint segment.40 Two-sided statistical significance (P < .05) for the APC and the AAPC was determined using a t test for the APC and for the AAPC when it lay entirely within the last joinpoint segment; and a Z test was used when the AAPC extended beyond the last joinpoint segment.39
In describing trends, the terms increase and decrease are used when the slope of the trend (APC or AAPC) was statistically significant; otherwise, the term stable is used. Trends based on fewer than 10 cases in any of the data years (1999-2014 for incidence and 1999-2015 for mor- tality) were considered statistically unstable and were suppressed.
RESULTS
Cancer Incidence Rates for All Sites Combined and for the Most Common Cancers
Figure 1 illustrates trends from 1999 to 2014 in age- standardized, delay-adjusted incidence rates for all cancer sites combined among men and among women. Incidence rates among men decreased throughout the study period, with the decrease accelerating from 0.6% (on average) per year during 1999 to 2008 to 2.2% (on average) per year during 2008 to 2014. In contrast, over the same 15-year period, incidence rates among women were stable.
Figure 2 presents average annual incidence rates and 5-year AAPCs (2010-2014) for the 17 most common can- cers among men and the 18 most common cancers among women. Among men, incidence rates decreased for 7 of the 17 most common cancers: prostate (5-year AAPC, 27.6%), lung and bronchus (22.4%), colon and rec- tum (colorectal) (21.9%), urinary bladder (bladder) (20.8%), esophagus (21.6%), brain and other nervous system (20.2%), and larynx (22.3%) (Table 1 and Fig. 2). In contrast, incidence rates among men increased for 8 cancers: melanoma of the skin (5-year AAPC, 2.3%), kidney and renal pelvis (kidney) (1.1%), leukemia (1.6%), oral cavity and pharynx (1.3%), pancreas (1.0%), liver and intrahepatic bile duct (liver) (2.8%), myeloma (2.5%), and thyroid (2.4%). Incidence rates were stable for non-Hodgkin lymphoma (NHL) and stomach cancer.
Among women, incidence rates decreased for 7 of the 18 most common cancers: lung and bronchus (5-year
Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2787
AAPC, 21.2%), colorectal (21.7%), NHL (20.4%), ovary (21.6%), bladder (20.8%), cervix uteri (cervix) (21.0%), and brain and other nervous system (20.7%). However, incidence rates increased for 10 cancers: breast (0.4%), corpus and uterus not otherwise specified (uterus) (1.2%), thyroid (1.9%), melanoma of the skin (1.2%), leukemia (1.4%), kidney (0.4%), pancreas (1.1%), oral cavity and pharynx (0.8%), myeloma (1.6%), and liver (3.8%). Incidence rates remained unchanged for stomach cancer (Table 1 and Fig. 2). Liver cancer replaced thyroid cancer as the most rapidly increasing incident cancer among women. For most cancer sites, the increasing or decreasing trends from 2010 to 2014 among men and among women were continuations of past trends (Sup- porting Table 1).
At the end of this Results section, incidence and mortality trends for female breast cancer, colorectal can- cer, lung and bronchus cancer, and melanoma of the skin are discussed in greater detail—along with stage at diagnosis and survival by stage. Prostate cancer inci- dence and mortality are examined in detail in Part II of this report.
Cancer Death Rates for All Sites Combined and for the Most Common Cancers
Figure 1 illustrates trends in death rates from 1999 to
2015 for all cancer sites combined, by sex. Death rates
decreased during this period by 1.8% on average per year
among men and by 1.4% on average per year among
women. Figure 3 presents average annual death rates and 5-
year AAPCs (2011-2015) for the 18 most common can-
cers among men and the 20 most common cancers among
women. Among men, death rates during this period
decreased for 11 of the 18 cancers: lung and bronchus (5-
year AAPC, 23.8%), prostate (22.2%), colorectal
(22.5%), leukemia (22.2%), NHL (22.0%), esophagus
(21.1%), kidney (20.5%), stomach (21.6%), myeloma
(20.9%), melanoma of the skin (23.0%), and larynx
(22.5%). In contrast, death rates among men increased
for cancers of the pancreas (0.2%), liver (1.6%), brain and
other nervous system (0.5%), oral cavity and pharynx
(1.0%), nonmelanoma skin (2.8%), and soft tissue
(including heart) (0.8%). The death rate among men was
stable for bladder cancer (Fig. 3 and Table 2).
Figure 1. Trends in age-standardized incidence (1999-2014) and mortality rates (1999-2015) are illustrated for all cancer sites combined, all races/ethnicities combined, and by sex. An asterisk indicates that the annual percent change (APC) or the average APC (AAPC) is statistically significantly different from zero (2-sided t test; P <.05). UNK indicates unknown. Rates were age- standardized to the 2000 US standard population (19 age groups; Bureau of the Census. Current Population Reports, Publication 25-1130. Washington, DC: US Government Printing Office; 2000 [Census 25-1130]). Scattered points indicate observed rates, and lines are fitted rates according to joinpoint regression. Incidence rates were delay-adjusted and covered 89% of the US popula- tion, and mortality covered the entire United States. The following registries were included for incidence: Alabama, Alaska, Ari- zona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming. The AAPC is a weighted average of the APCs over the fixed interval (2010-2014 for inci- dence; 2011-2015 for mortality) using the underlying Joinpoint model for the period from 1999 to 2014 for incidence and the period from 1999 to 2015 for mortality. Joinpoint models with up to 2 joinpoints for incidence and up to 3 joinpoints for mortality are based on rates per 100,000 persons age standardized to the 2000 US standard population (19 age groups; Census P25- 1130). For joinpoint analysis, the Joinpoint Regression Program was used (version 4.5.01; Bethesda, MD: Statistical Research and Applications Branch, National Cancer Institute; June 2017).
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2788 Cancer July 1, 2018
Among women, during the same time period, death rates decreased for 14 of the 20 most common cancer types: lung and bronchus (5-year AAPC, 22.4%), breast
(21.6%), colorectal (22.7%), ovary (22.3%), leukemia (22.3%), NHL (22.7%), kidney (21.4%), stomach (21.8%), cervix (20.7%), bladder (20.5%), melanoma of the skin (22.6%), esophagus (21.6%), oral cavity and pharynx (21.3%), and gallbladder (21.3%) (Fig. 3 and Table 2). In contrast, death rates among women increased for cancers of the pancreas (0.2%), uterus (1.9%), liver (2.7%), and brain and other nervous system (0.5%). Death rates among women were stable for myeloma and soft tissue (including heart). Like the incidence trends, increases or decreases in death rates for most cancers among men and women were continuations of past trends (Supporting Table 2).
Current Cancer Incidence Rates and Trends by Sex, Race, and Ethnicity
Table 1 lists average annual age-standardized, delay- adjusted incidence rates and trends for the most recent 5- year period (2010-2014) by cancer site, sex, race, and eth- nicity. For all cancer sites combined, rates were higher among men than among women overall (all races/ethnici- ties combined; 502.0 vs 420.6 per 100,000 persons) and among persons in every racial/ethnic group. Black men and white women had higher overall cancer incidence rates than other racial groups. Non-Hispanic men and women had higher incidence rates than those of Hispanic ethnicity. API men and API women had the lowest rates relative to other racial and ethnic groups. In every racial and ethnic group, prostate cancer among men and breast cancer among women were the most frequent incident cancers, followed by lung and bronchus cancer, and colo- rectal cancer, except among Hispanics. Among Hispanic men and Hispanic women, colorectal cancer was more frequent than lung and bronchus cancer. Rankings for several other cancers varied substantially by race and eth- nicity among both men and women. Among men, for example, melanoma of the skin ranked fifth in whites and 19th in blacks; and liver cancer ranked 11th in whites, sixth in blacks, and fourth in APIs.
Among men in each racial/ethnic group, incidence trends during 2010 to 2014 for all cancer sites combined and for each of the 17 most common cancers were gener- ally similar in direction (decrease or increase) to those for all races/ethnicities combined (Table 1). Incidence rates among men in each racial and ethnic group decreased for all cancers combined and for each of the 3 most common cancers (prostate, lung and bronchus, colorectal), except that the rate was stable for lung and bronchus cancer among AIs/ANs. Rates also decreased among men in each racial/ethnic group for cancers of the bladder, stomach,
Figure 2. Age-standardized, delay-adjusted incidence rates and recent trends (2010-2014) are illustrated for the 17 most common cancers in men and the 18 most common cancers in women for all races/ethnicities combined and by sex. The 5- year average annual percent change (AAPC) is based on the joinpoint trend from 1999 to 2014. An asterisk indicates that the AAPC is statistically significantly different from zero (2- sided t test or Z test; P <.05). Rates were age-standardized to the 2000 US standard population (19 age groups; Census P25- 1130), were delay-adjusted, and covered 89% of the US popula- tion. The following registries were included in the analyses: Ala- bama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachu- setts, Michigan, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Caro- lina, Texas, Utah, Vermont, Washington, West Virginia, Wiscon- sin, and Wyoming. The AAPC is a weighted average of the annual percent changes (APCs) over the fixed interval (2010- 2014) using the underlying joinpoint model for the period from 1999 to 2014. Joinpoint models with up to 2 joinpoints are based on rates per 100,000 persons age standardized to the 2000 US standard population (19 age groups; Census P25- 1130). For joinpoint analysis, the Joinpoint Regression Program was used (version 4.5.0.1; Bethesda, MD: Statistical Research and Applications Branch, National Cancer Institute; June 2017).
Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2789
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2 0 .2
.8 5
K id
n e y
a n d
re n a l p
e lv
is 7
2 2 .3
1 .1
h .0
0 1
7 2 2 .5
0 .7
h .0
0 1
4 2 4 .7
1 .0
h .0
3 9
1 1 .4
2 .3
h <
.0 0 1
4 3 1 .9
2 .1
h .0
0 2
4 2 1 .5
1 .0
.2 1
7 2 2 .5
1 .2
h .0
0 1
L e u k e m
ia 8
1 9 .0
1 .6
h <
.0 0 1
8 1 9 .8
1 .6
h <
.0 0 1
1 1
1 4 .7
1 .0
h <
.0 0 1
1 0
1 0 .4
0 .8
h .0
3 9
1 4 .0
0 .5
.5 5
8 1 4 .1
0 .5
h .0
3 8
1 9 .3
1 .7
h <
.0 0 1
O ra
l c a v it y
a n d
p h a ry
n x
9 1 7 .7
1 .3
h <
.0 0 1
9 1 8 .3
1 .6
h <
.0 0 1
1 0
1 4 .8
2 1 .9
h <
.0 0 1
8 1 1 .7
0 .5
.1 3
8 1 7 .1
1 .3
.0 7
1 1
1 0 .9
2 0 .9
h .0
0 3
9 1 8 .6
1 .6
h <
.0 0 1
P a n c re
a s
1 0
1 4 .5
1 .0
h <
.0 0 1
1 0
1 4 .4
1 .1
h <
.0 0 1
8 1 7 .0
0 .6
h .0
0 3
1 1
1 0 .3
0 .5
h .0
4 1 0
1 2 .6
1 .3
.1 9
1 0
1 2 .3
0 .5
h .0
3 1 0
1 4 .7
1 .1
h <
.0 0 1
L iv
e r
a n d
in tr
a h e p
a ti c
b ile
d u c t
1 1
1 2 .5
2 .8
h <
.0 0 1
1 1
1 1 .3
3 .3
h <
.0 0 1
6 1 7 .7
2 .6
h .0
0 2
4 2 0 .6
2 1 .7
h .0
0 3
6 2 0 .7
4 .6
h <
.0 0 1
6 2 0 .4
1 .1
.1 8
1 1
1 1 .7
2 .9
h <
.0 0 1
S to
m a c h
1 2
9 .4
2 0 .3
.1 3
1 2
8 .6
0 .0
.9 5
1 2
1 4 .3
2 1 .8
h <
.0 0 1
7 1 4 .3
2 2 .8
h <
.0 0 1
1 1
1 1 .9
2 2 .2
h .0
1 9
1 3 .1
2 2 .1
h <
.0 0 1
1 2
9 .0
2 0 .1
.7 0
M y e lo
m a
1 3
8 .7
2 .5
h <
.0 0 1
1 5
8 .0
2 .3
h <
.0 0 1
9 1 6 .9
2 .2
h <
.0 0 1
1 3
5 .2
2 .6
h <
.0 0 1
1 3
8 .7
1 .8
.1 1
1 2
8 .5
1 .5
h <
.0 0 1
1 3
8 .7
2 .5
h <
.0 0 1
E s o
p h a g
u s
1 4
8 .1
2 1 .6
h <
.0 0 1
1 4
8 .4
2 1 .3
h .0
0 2
1 4
7 .0
2 4 .7
h <
.0 0 1
1 5
3 .8
2 1 .0
.1 0
1 4
8 .1
2 0 .8
.5 0
1 7
4 .9
2 3 .6
h <
.0 0 1
1 4
8 .4
2 0 .9
.2 1
B ra
in a n d
o th
e r
n e rv
o u s
s y s te
m
1 5
7 .9
2 0 .2
h .0
0 3
1 3
8 .5
2 0 .1
.0 8
1 5
5 .0
0 .3
.2 4
1 4
4 .4
0 .3
.3 2
1 5
6 .1
1 .0
.3 4
1 3
6 .1
2 0 .5
h .0
0 3
1 5
8 .3
0 .0
.9 5
T h y ro
id 1 6
7 .3
2 .4
h <
.0 0 1
1 6
7 .8
2 .3
h .0
0 1
1 6
3 .9
4 .9
h <
.0 0 1
1 2
7 .1
5 .6
h <
.0 0 1
1 8
4 .8
4 .2
h .0
1 1 4
5 .5
4 .5
h <
.0 0 1
1 6
7 .7
2 .3
h <
.0 0 1
L a ry
n x
1 7
6 .1
2 2 .3
h <
.0 0 1
1 8
6 .0
2 2 .1
h <
.0 0 1
1 3
8 .5
2 3 .2
h <
.0 0 1
1 6
2 .2
2 2 .9
h .0
0 1
1 7
5 .1
2 1 .9
h .0
4 1 6
5 .0
2 3 .0
h <
.0 0 1
1 7
6 .2
2 2 .2
h <
.0 0 1
F e m
a le
s
B re
a s t
1 1 2 5 .6
0 .4
h .0
0 8
1 1 2 6 .9
0 .4
h .0
3 1
1 2 5 .6
0 .7
h .0
3 1
9 4 .9
1 .7
h <
.0 0 1
1 1 0 8 .8
1 .9
h .0
0 1
1 9 5 .3
0 .4
h .0
3 1
1 2 9 .5
0 .5
h .0
0 2
L u n g
a n d
b ro
n c h u s
2 5 3 .3
2 1 .2
h <
.0 0 1
2 5 5 .1
2 1 .1
h <
.0 0 1
2 4 9 .8
2 0 .9
h .0
0 1
2 2 8 .6
0 .2
.0 7
2 5 8 .1
2 2 .0
h .0
2 3
2 5 .6
2 0 .8
h <
.0 0 1
2 5 6 .2
2 1 .0
h <
.0 0 1
C o
lo n
a n d
re c tu
m 3
3 5 .2
2 1 .7
h .0
0 4
3 3 4 .5
2 1 .7
h .0
2 3
4 1 .5
2 2 .0
h .0
1 3
2 7 .8
2 3 .5
h <
.0 0 1
3 4 4 .1
2 0 .8
h .0
4 2
3 0 .0
2 1 .1
.1 1
3 3 5 .9
2 1 .7
h .0
1
C o
rp u s
a n d
u te
ru s ,
N O
S 4
2 6 .3
1 .2
h <
.0 0 1
4 2 6 .8
1 .1
h <
.0 0 1
4 2 5 .9
2 .4
h <
.0 0 1
5 1 8 .9
2 .2
h <
.0 0 1
4 2 3 .5
1 .5
h .0
0 5
4 2 2 .7
2 .7
h <
.0 0 1
4 2 6 .7
1 .2
h <
.0 0 1
T h y ro
id 5
2 1 .6
1 .9
h <
.0 0 1
5 2 2 .7
1 .6
h <
.0 0 1
6 1 4 .1
2 .7
h .0
5 4
2 1 .8
1 .5
.2 2
6 1 6 .2
5 .9
h <
.0 0 1
5 2 0 .5
2 .5
h .0
0 2
5 2 1 .9
1 .8
h .0
0 1
M e la
n o
m a
o f
th e
s k in
6 1 6 .8
1 .2
h .0
0 2
6 1 9 .6
1 .4
h <
.0 0 1
2 1
1 .0
0 .4
.3 8
1 8
1 .3
2 0 .3
.6 6
1 6
6 .5
1 .7
h .0
4 1 7
4 .4
0 .2
.5 1
6 1 8 .7
1 .4
h .0
0 1
N o
n -H
o d
g k in
ly m
p h o
m a
7 1 6 .3
2 0 .4
h .0
0 2
7 1 6 .9
2 0 .5
h .0
0 1
8 1 2 .5
0 .7
h <
.0 0 1
6 1 1 .1
0 .2
.4 4
7 1 4 .7
0 .2
.8 0
6 1 5 .7
0 .1
.4 2
7 1 6 .4
2 0 .4
h .0
0 2
O v a ry
8 1 1 .8
2 1 .6
h <
.0 0 1
8 1 2 .2
2 1 .6
h <
.0 0 1
1 0
9 .5
2 0 .6
h .0
0 2
7 9 .6
2 0 .2
.3 0
8 1 1 .5
2 0 .5
.5 8
8 1 0 .6
2 1 .3
h <
.0 0 1
8 1 1 .9
2 1 .6
h <
.0 0 1
L e u k e m
ia 9
1 1 .5
1 .4
h <
.0 0 1
9 1 2 .0
1 .1
h <
.0 0 1
1 1
9 .4
2 .1
h <
.0 0 1
1 1
6 .7
1 .1
h .0
0 2
1 0
9 .8
0 .6
.5 3
1 1
9 .7
0 .5
h .0
2 9
1 1 .6
1 .4
h <
.0 0 1
K id
n e y
a n d
re n a l p
e lv
is 1 0
1 1 .5
0 .4
h .0
3 1 0
1 1 .7
0 .4
h .0
3 7
1 2 .7
2 0 .1
.8 9
1 4
5 .1
2 0 .2
.7 9
5 1 8 .9
1 .7
h .0
1 7
1 2 .4
2 .0
h <
.0 0 1
1 0
1 1 .4
0 .3
.0 9
P a n c re
a s
1 1
1 1 .2
1 .1
h <
.0 0 1
1 1
1 0 .9
1 .1
h <
.0 0 1
5 1 4 .6
0 .8
h <
.0 0 1
8 9 .0
0 .8
h .0
0 3
9 1 1 .1
0 .8
.3 2
9 1 0 .6
0 .6
h <
.0 0 1
1 1
1 1 .3
1 .1
h <
.0 0 1
U ri n a ry
b la
d d
e r
1 2
9 .1
2 0 .8
h <
.0 0 1
1 2
9 .6
2 0 .7
h <
.0 0 1
1 4
6 .8
2 0 .3
.1 9
1 5
4 .0
2 0 .4
.4 2
1 5
6 .6
1 .8
h .0
5 1 5
5 .2
2 1 .3
h .0
0 1
1 2
9 .5
2 0 .6
h <
.0 0 1
C e rv
ix u te
ri 1 3
7 .7
2 1 .0
h <
.0 0 1
1 3
7 .5
2 0 .7
h .0
0 4
1 2
9 .4
2 3 .7
h .0
0 1
1 2
6 .2
2 2 .8
h <
.0 0 1
1 1
9 .4
2 6 .3
h .0
3 1 0
9 .9
2 1 .6
.1 0
1 3
7 .4
2 0 .8
h .0
0 1
O ra
l c a v it y
a n d
p h a ry
n x
1 4
6 .5
0 .8
h <
.0 0 1
1 4
6 .7
1 .0
h <
.0 0 1
1 5
5 .2
2 0 .8
h .0
0 1
1 3
5 .3
2 0 .7
.0 9
1 4
6 .6
0 .7
.5 3
1 8
4 .3
2 0 .2
.6 0
1 4
6 .8
0 .9
h <
.0 0 1
Original Article
2790 Cancer July 1, 2018
T A
B L
E 1.
C o
n ti
n u
e d
A ll
R a c e s
c W
h it e
c B
la c k
c A
P Ic
A I/
A N
(C H
S D
A )c
H is
p a n ic
c N
o n -H
is p
a n ic
c
S e x /C
a n c e r
S it e
o r
T y p
e d
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
R a n k
R a te
e
2 0 1 0 -2
0 1 4
A A
P C
f P
M y e lo
m a
1 5
5 .7
1 .6
h .0
0 3
1 6
5 .0
2 .3
h <
.0 0 1
9 1 2 .5
2 .0
h <
.0 0 1
1 6
3 .4
1 .0
.0 6
1 7
5 .8
2 1 .0
.3 5
1 4
5 .7
2 .0
h .0
0 3
1 6
5 .7
1 .6
h .0
0 4
B ra
in a n d
o th
e r
n e rv
o u s
s y s te
m
1 6
5 .7
2 0 .7
h .0
0 8
1 5
6 .1
2 0 .7
h .0
1 1 7
3 .6
0 .1
.7 1
1 7
3 .4
3 .7
h .0
0 1
1 8
3 .9
0 .1
.9 5
1 6
4 .6
2 1 .1
h <
.0 0 1
1 5
5 .9
2 0 .6
h .0
3
S to
m a c h
1 7
4 .7
0 .1
h .7
7 1 7
4 .1
0 .5
.3 2
1 3
8 .0
2 1 .3
h <
.0 0 1
9 8 .3
2 2 .5
h <
.0 0 1
1 3
6 .7
2 1 .5
.0 9
1 2
7 .9
2 1 .5
h <
.0 0 1
1 7
4 .4
2 0 .8
h <
.0 0 1
L iv
e r
a n d
in tr
a h e p
a ti c
b ile
d u c t
1 8
4 .3
3 .8
h <
.0 0 1
1 8
4 .0
4 .5
h <
.0 0 1
1 6
5 .2
3 .6
h <
.0 0 1
1 0
7 .8
2 0 .5
.0 5
1 2
9 .2
3 .9
h .0
0 2
1 3
7 .8
2 .3
h <
.0 0 1
1 8
4 .0
4 .1
h <
.0 0 1
A b
b re
v ia
ti o
n s :
A A
P C
, a v e ra
g e
a n n u a l
p e rc
e n t
c h a n g
e ;
A I/
A N
, A
m e ri c a n
In d
ia n /A
la s k a
N a ti v e ;
A P
C ,
a n n u a l
p e rc
e n t
c h a n g
e ;
A P
I, A
s ia
n /P
a c if ic
Is la
n d
e r;
C H
S D
A ,
In d
ia n
H e a lt h
S e rv
ic e
C o
n tr
a c t
H e a lt h
S e rv
ic e s
D e liv
e ry
A re
a ;
N O
S ,
n o
t o
th e rw
is e
s p
e c if ie
d .
a S
o u rc
e :
N a ti o
n a l
P ro
g ra
m o
f C
a n c e r
R e g
is tr
ie s
a n d
S u rv
e ill
a n c e ,
E p
id e m
io lo
g y,
a n d
E n d
R e s u lt s
a re
a s
re p
o rt
e d
b y
th e
N o
rt h
A m
e ri c a n
A s s o
c ia
ti o
n o
f C
e n tr
a l
C a n c e r
R e g
is tr
ie s
a s
m e e ti n g
h ig
h -q
u a lit
y in
c i-
d e n c e
d a ta
s ta
n d
a rd
s fo
r th
e s p
e c if ie
d ti m
e p
e ri o
d s .
b T
h e
fo llo
w in
g re
g is
tr ie
s w
e re
in c lu
d e d
in th
e in
c id
e n c e
ra te
s (2
0 1 0 -2
0 1 4 )
a n d
J o
in p
o in
t m
o d
e ls
(1 9 9 9 -2
0 1 4 )
fo r
a ll
ra c e s /e
th n ic
it ie
s ,
w h it e ,
b la
c k ,
A I/
A N
, A
P I,
H is
p a n ic
, a n d
n o
n -H
is p
a n ic
(4 2
s ta
te s ):
A la
b a m
a ,
A la
s k a ,
A ri z o
n a ,
A rk
a n s a s ,
C a lif
o rn
ia ,
C o
lo ra
d o
, C
o n n e c ti c u t,
D e la
w a re
, F
lo ri d
a ,
G e o
rg ia
, H
a w
a ii,
Id a h o
, Il lin
o is
, In
d ia
n a ,
Io w
a ,
K e n tu
c k y,
L o
u is
ia n a ,
M a in
e ,
M a ry
la n d
, M
a s s a c h u s e tt
s ,
M ic
h ig
a n ,
M is
s o
u ri ,
M o
n -
ta n a ,
N e b
ra s k a ,
N e w
H a m
p s h ir e ,
N e w
J e rs
e y,
N e w
Y o
rk ,
N o
rt h
C a ro
lin a ,
N o
rt h
D a k o
ta ,
O h io
, O
k la
h o
m a ,
O re
g o
n ,
P e n n s y lv
a n ia
, R
h o
d e
Is la
n d
, S
o u th
C a ro
lin a ,
T e x a s ,
U ta
h ,
V e rm
o n t,
W a s h in
g to
n ,
W e s t
V ir g
in ia
,
W is
c o
n s in
, a n d
W y o
m in
g .
c W
h it e ,
b la
c k ,
A P
I, a n d
A I/
A N
(C H
S D
A 2 0 1 2
c o
u n ti e s )
in c lu
d e
H is
p a n ic
a n d
n o
n -H
is p
a n ic
; th
e ra
c e
a n d
e th
n ic
it y
c a te
g o
ri e s
a re
n o
t m
u tu
a lly
e x c lu
s iv
e .
A I/
A N
(C H
S D
A 2 0 1 2 )
s ta
ti s ti c s
e x c lu
d e
d a ta
fr o
m K
a n s a s .
d C
a n c e rs
a re
s o
rt e d
in d
e s c e n d
in g
o rd
e r
a c c o
rd in
g to
s e x -s
p e c if ic
ra te
s fo
r a ll
ra c e s /e
th n ic
it ie
s .
M o
re th
a n
1 5
c a n c e rs
m a y
a p
p e a r
u n d
e r
m a le
s a n d
fe m
a le
s to
in c lu
d e
th e
to p
1 5
c a n c e rs
in e v e ry
ra c e /e
th n ic
it y
g ro
u p
. e
R a te
s a re
p e r
1 0 0 ,0
0 0
p e rs
o n s
a n d
w e re
a g
e s ta
n d
a rd
iz e d
to th
e 2 0 0 0
U S
s ta
n d
a rd
p o
p u la
ti o
n (1
9 a g
e g
ro u p
s ;
U S
B u re
a u
o f
th e
C e n s u s ,
C u rr
e n t
P o
p u la
ti o
n R
e p
o rt
s ,
P u b
lic a ti o
n 2 5 -1
1 3 0 .
W a s h in
g to
n ,
D C
:
U S
G o
v e rn
m e n t
P ri n ti n g
O ff
ic e ;
2 0 0 0
[C e n s u s
P 2 5 -1
1 3 0 ]) .
f T
h e
A A
P C
is th
e a v e ra
g e
A P
C a n d
is a
w e ig
h te
d a v e ra
g e
o f
th e
A P
C s
o v e r
th e
fi x e d
in te
rv a l
fr o
m 2 0 1 0
to 2 0 1 4
u s in
g th
e u n d
e rl y in
g J o
in p
o in
t m
o d
e l
fo r
th e
p e ri o
d fr
o m
1 9 9 9
to 2 0 1 4 .
J o
in p
o in
t m
o d
e ls
w it h
u p
to 2
jo in
p o
in ts
a re
b a s e d
o n
ra te
s p
e r
1 0 0 ,0
0 0
p e rs
o n s
a n d
a g
e s ta
n d
a rd
iz e d
to th
e 2 0 0 0
U S
s ta
n d
a rd
p o
p u la
ti o
n (1
9 a g
e g
ro u p
s ;
C e n s u s
P 2 5 -1
1 3 0 ).
F o
r jo
in p
o in
t a n a ly
s is
, th
e J o
in p
o in
t R
e g
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Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2791
and larynx, except that rates were stable for bladder cancer among AIs/ANs, were stable for stomach cancer among whites and non-Hispanics, and increased for bladder
Figure 3. Age-standardized death rates and recent fixed- interval trends (2011-2015) are illustrated for the 18 most common cancers in men and the 20 most common cancers in women, for all races/ethnicities combined, and by sex. The 5-year average annual percent change (AAPC) is based on the joinpoint trend from 1999 to 2015. An asterisk indicates that the AAPC is statistically significantly different from zero (2-sided t test or Z test; P <.05). Rates were age- standardized to the 2000 US standard population (19 age groups; Bureau of the Census. Current Population Reports, Publication 25-1130. Washington, DC: US Government Printing Office; 2000 [Census P25-1130]). The AAPC is a weighted average of the annual percent changes over the fixed interval (2011-2015) using the underlying joinpoint model for the period from 1999 to 2015. Joinpoint models with up to 3 join- points are based on rates per 100,000 persons age standard- ized to the 2000 US standard population (19 age groups; Census P25-1130). For joinpoint analysis, the Joinpoint Regression Program was used (version 4.5.0.1; Bethesda, MD: Statistical Research and Applications Branch, National Cancer Institute; June 2017).
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Original Article
2792 Cancer July 1, 2018
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Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2793
cancer among blacks. Incidence rates among men increased in each racial and ethnic group for leukemia, myeloma, and cancers of the kidney, thyroid, pancreas, and liver, except that rates were stable for kidney and liver cancers among Hispanics and for leukemia, myeloma, and pancreas cancer among AIs/ANs.
Among women, overall cancer incidence rates inc- reased during 2010 to 2014 among blacks, APIs, and AIs/ ANs but remained stable in whites, Hispanics, and non- Hispanics. Incidence rates increased for female breast can- cer in each racial and ethnic group (Table 1). Incidence rates among women also increased for cancers of the thy- roid, liver, and uterus in each racial and ethnic group, except that rates remained stable for thyroid cancer and liver cancer among APIs. Incidence rates among women decreased for lung and bronchus cancer and colorectal cancer in each racial and ethnic group, except that rates were stable for lung and bronchus cancer among APIs and for colorectal cancer among Hispanics. As with men, for most cancer sites incidence trends for women in each racial and ethnic group were similar in direction to those for all women combined.
Current Cancer Death Rates and Trends by Sex, Race, and Ethnicity
Average annual death rates and trends from 2011 to 2015 are presented by cancer site, sex, race, and ethnicity in Table 2. For all cancer sites combined, similar to inci- dence rates, death rates (per 100,000 persons) were higher among men than among women overall (196.7 vs 139.5 for all races/ethnicities combined) and in every racial and ethnic group. Black men and black women had the high- est cancer death rates of any racial group for all cancer sites combined, for 8 of the most common cancers in men, and for 9 of the most common cancers in women. Non- Hispanic men and women had higher overall cancer death rates than those of Hispanic ethnicity. Among men, lung and bronchus cancer was the leading cause of cancer death in every racial and ethnic group, followed by prostate and colorectal cancer in black, white, and Hispanic men; liver and colorectal cancer in API men; and colorectal and prostate cancer in AI/AN men. Among women, lung and bronchus, breast, and colorectal cancers were the leading causes of cancer death in every racial and ethnic group except Hispanics, in whom breast cancer replaced lung and bronchus cancer as the leading cause.
During 2011 to 2015, death rates declined overall and for the most common cancers (lung and bronchus, prostate, colorectal, breast) among men and women in all racial and ethnic groups, except that breast cancer death
rates were stable among API and AI/AN women, colorec- tal cancer death rates were stable among AI/AN men and women, and prostate cancer death rates were stable among AI/AN men (Table 2). Death rates for most of the other cancer sites declined or were stable among men and women in each racial and ethnic group. However, death rates increased for some cancers in some racial and ethnic groups: liver cancer in white men and women, black women, AI/AN men, Hispanic women, and non- Hispanic men and women; pancreas cancer in white men and women and non-Hispanic men and women; uterus cancer in white, black, API, Hispanic, and non-Hispanic women; brain cancer in white men and women, non- Hispanic men and women, and API women; oral cavity and pharynx cancer in white men and non-Hispanic men; nonmelanoma skin cancer in white men and non- Hispanic men; and soft tissue (including heart) cancer in white men and non-Hispanic men and women.
Incidence and Mortality Trends, Survival by Stage, and Stage at Diagnosis for Female Breast Cancer, Colorectal Cancer, Lung and Bronchus Cancer, and Melanoma of the Skin
Figure 4 illustrates delay-adjusted incidence (1999-2014) and mortality (1999-2015) trends, 5-year survival esti- mates by stage (2007-2013), and the stage distribution at diagnosis for female breast cancer, colorectal cancer, lung and bronchus cancer, and melanoma of the skin. We focus on these 4 cancer sites because they are among the 5 sites that have the highest number of expected cases in 2017.41
In addition to these 4 cancer sites, prostate cancer is among the top 5 sites based on the number of expected cases, but we do not include prostate cancer here because it is examined in detail in Part II of this report.
Female breast cancer incidence had been declining before 2004 but has increased since then at an average rate of 0.4% per year (Supporting Table 1). Female breast can- cer mortality decreased during 1999 to 2015 (Supporting Table 2). Seventy-eight percent of cases were diagnosed at stage I or II, for which 5-year survival was high (100% and 92%, respectively) (Fig. 4). Approximately 6% of cases were diagnosed at stage IV, for which 5-year survival was 26.5%.
Colorectal cancer incidence rates decreased during 1999 to 2012 among men and women, although rates have been stable since 2012 (Supporting Table 1). Colo- rectal cancer mortality decreased during 1999 to 2015 among men and women (Supporting Table 2). Five-year survival for colorectal cancer (men and women combined) varied from 88.1% for cases diagnosed at stage I (23% of
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2794 Cancer July 1, 2018
cases) to 12.6% for cases diagnosed at stage IV (20% of cases) (Fig. 4).
Lung and bronchus cancer incidence and mortality rates remain higher among men than among women, but men have experienced a longer and more pronounced decrease in both rates over time (Fig. 4, Supporting Tables 1 and 2). Among women, lung and bronchus cancer inci- dence decreased during 2006 to 2014, and lung and bron- chus cancer mortality decreased during 2002 to 2015 (Supporting Tables 1 and 2). Lung and bronchus cancer survival (men and women combined) was low, ranging from 55.1% for stage I (21% of cases) to 4.2% for cases diagnosed at stage IV (44% of cases) (Fig. 4).
The incidence of melanoma of the skin increased substantially since 1999 among men and among women, although the rates of increase among women began slowing in 2005 (Fig. 4 and Supporting Table 1). Melanoma mortality was stable during 1999 to 2015 in women; in men, it was stable during 2009 to 2013 and decreased during 2013 to 2015 (Supporting Table 2). Sixty-two percent of cases were diagnosed with stage I disease and 12% were diagnosed with stage II disease, for which the 5-year survival rates were 99.5% and 75%, respectively. Four percent were diag- nosed at stage IV, for which the 5-year survival rate was 16% (Fig. 4).
Figure 4. Delay-adjusted incidence (1999-2014) and mortality (1999-2015) trends, 5-year survival estimates by stage (2007- 2013), and stage distribution at diagnosis are illustrated for (A) female breast cancer, (B) colon and rectum cancer, (C) lung and bronchus cancer, and (D) melanoma of the skin. Rates were age-standardized to the 2000 US standard population (19 age groups; Bureau of the Census. Current Population Reports, Publication 25-1130. Washington, DC: US Government Printing Office; 2000 [Census P25-1130]). Scattered points indicate observed rates, and lines are fitted rates according to joinpoint regression. Incidence rates were delay-adjusted and covered 89% of the US population, and mortality covered the entire United States. The following registries were included for incidence: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylva- nia, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming. Joinpoint models with up to 2 joinpoints for incidence and up to 3 joinpoints for mortality are based on rates per 100,000 persons age standard- ized to the 2000 US standard population (19 age groups; Census P25-1130). For joinpoint analysis, the Joinpoint Regression Pro- gram was used (version 4.5.0.1; Bethesda, MD: Statistical Research and Applications Branch, National Cancer Institute; June 2017). Five-year relative survival rates covered 69.5% of the US population. The following registries were included for survival: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Ken- tucky, Louisiana, Maine, Maryland, Michigan, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Pennsyl- vania, Rhode Island, South Carolina, Utah, Vermont, Seattle, West Virginia, Wisconsin, and Wyoming.
Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2795
Cancer Incidence and Mortality Among Children
The most common cancer sites for children vary by age. Overall, the most common sites are leukemia, brain and other nervous system, soft tissue, NHL, and kidney and renal pelvis. Bone and joint cancer and Hodgkin lym- phoma are more common in older children. Among chil- dren ages birth to 14 years, the average annual, age- standardized, delay-adjusted incidence rates (all cancer types combined; per 100,000 persons) during 2010 to 2014 ranged from 12.6 among AIs/ANs to 17.3 among whites (both sexes combined) (Table 3). The average, annual age-standardized death rates during 2011 to 2015 ranged from 1.7 among APIs to 2.2 among whites. Inci- dence rates increased during 2010 to 2014 for all racial/ ethnic groups combined (0.8% per year) and among chil- dren in 4 racial/ethnic groups (APIs, 1.1% per year; non- Hispanics, 1.0% per year; whites, 0.7% per year; and His- panics, 0.4% per year). Among AI/AN and black chil- dren, incidence rates were stable. In contrast, death rates among children during 2011 to 2015 decreased overall (21.5% per year; all races/ethnicities combined) and among children in every racial and ethnic group, except that the AAPC for AIs/ANs could not be calculated
because of sparse data (Table 3). The greatest decrease in cancer mortality was observed among API children (22.4%), and the smallest decreases were among white children and non-Hispanic children (21.4% in each group).
DISCUSSION Cancer incidence rates for all races/ethnicities combined continued to decline among men and were stable among women. Incidence rates from 2010 to 2014 decreased for 7 of the 17 most common cancers among men and for 7 of the 18 most common cancers among women, and rates increased for 8 cancer sites among men and 10 sites among women.
The largest increases in incidence rates were ob- served for liver cancer, myeloma, melanoma of the skin, thyroid cancer, and leukemia. Additional cancers with ris- ing incidence trends during the most recent years include kidney and female breast. The increase in thyroid cancer incidence rates is largely thought to be caused by increased detection of small and indolent tumors through imag- ing42,43; however, the rates increased for both small and large tumors, suggesting a role for unidentified risk factors
TABLE 3. Delay-Adjusted Childhood Cancer Incidence Rates for Areas With High-Quality Data and US Childhood Cancer Death Rates by Race/Ethnicity, Both Sexes Combined, and Their Fixed-Interval Trendsa,b
Children: Ages 0-14 Yearsc
Incidence (2010-2014) Mortality (2011-2015)
Race/Ethnicityd Ratee AAPCf 95% CI P Ratee AAPCf 95% CI P
All races 16.6 0.8g 0.6, 1.0 < .001 2.1 21.5g 21.8, 21.2 < .001
White 17.3 0.7g 0.5, 0.9 < .001 2.2 21.4g 21.7, 21.0 < .001
Black 12.9 21.1 23.7, 1.3 .30 2.0 21.6g 22.1, 21.0 < .001
API 13.7 1.1g 0.4, 1.7 .004 1.7 22.4g 23.9, 21.0 .003
AI/AN CHSDA 12.6 20.1 21.4, 1.2 .84 1.9 —h
Hispanic 16.1 0.4g 0.1, 0.6 .02 2.1 22.0g 22.5, 21.5 < .001
Non-Hispanic 16.8 1.0g 0.8, 1.1 < .001 2.1 21.4g 21.7, 21.0 < .001
Abbreviations: AAPC, average annual percent change; AI/AN, American Indian/Alaska Native; API, Asian/Pacific Islander; CHSDA, Indian Health Service Con-
tract Health Services Delivery Area; CI, confidence interval. a Source: National Program of Cancer Registries and Surveillance, Epidemiology, and End Results areas reported by the North American Association of Central
Cancer Registries as meeting high-quality incidence data standards for the specified time periods. b The following registries were included in the incidence rates (2010-2014) and Joinpoint models (1999-2014) for all race/ethnicities, white, black, AI/AN, API,
Hispanic, and non-Hispanic (42 states): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illi-
nois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York,
North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, Wis-
consin, and Wyoming. c For incidence, AI/AN (CHSDA 2012) statistics exclude data from Kansas. d White, black, API, and AI/AN (CHSDA 2012 counties) include Hispanic and non-Hispanic; the race and ethnicity categories are not mutually exclusive. e Rates are per 100,000 persons and were age standardized to the 2000 US standard population (19 age groups US Bureau of the Census. Current Population
Reports, Publication 25-1130. Washington, DC: US Government Printing Office; 2000 [Census P25-1130]). f The AAPC is the average APC and is a weighted average of the APCs over the fixed interval (2009-2013 for incidence; 2010-2014 for mortality) using the
underlying Joinpoint model for the period from 1999 to 2014 for incidence and the period from 1999 to 2015 for mortality. Joinpoint models with up to 2 join-
points for incidence and up to 3 joinpoints for mortality were based on rates per 100,000 persons that were age standardized to the 2000 US standard popula-
tion (19 age groups; Census P25-1130). For joinpoint analysis, the Joinpoint Regression Program was used (version 4.5.0.1; Bethesda, MD: Statistical
Research and Applications Branch, National Cancer Institute; June 2017). g The AAPC is statistically significantly different from zero (2-sided P <.05). h The statistic could not be calculated. The average APC is based on <10 cases for at least 1 year within the time interval.
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2796 Cancer July 1, 2018
in the rising trend.44,45 It is believed that the increase in kidney cancer incidence rates in part reflects increased detection resulting from wider application of imaging techniques46 as well as the obesity epidemic.14 For all can- cer sites combined, men had higher incidence rates than women within every racial and ethnic group. Overall, black men and white women had higher rates than other racial groups, and non-Hispanic men and women had higher rates than Hispanic individuals. These racial and ethnic differences were driven largely by the incidence of prostate cancer, female breast cancer, and lung cancer.
The increase in the breast cancer incidence rate con- tinues the 0.4% increase observed in last year’s report.19
After decreasing in the early 2000s after cessation of hormone-replacement therapy,47,48 the increase from 2004 to 2014 may in part reflect the obesity epidemic.17
Increased detection through mammography is unlikely to have contributed to the recent trend, because mammogra- phy rates remained unchanged during the corresponding period.49 The continued increase in melanoma incidence rates is thought to reflect increased harmful recreational sun exposure and tanning bed use, as well as increased detection.50 The survival rates for early stage breast cancer and melanoma of the skin are extremely high (100% and 99.5% for stage I breast cancer and melanoma, respec- tively), suggesting the influence of screening on survival. These high survival rates may result from a combination of better prognosis because of early detection, some level of overdiagnosis associated with screening, and individu- als with screen-detected disease being healthier than the general population.51
Overall cancer death rates have continued to dec- rease among both men and women for all major racial and ethnic groups, with the greatest decrease among black men and the smallest among AI/AN men. From 2011 to 2015, death rates for all races/ethnicities combined decreased for 11 of the 18 most common cancers among men and for 14 of the 20 most common cancers among women, including lung and bronchus (men and women), colorectal (men and women), female breast, and prostate. In contrast, cancer death rates increased for liver, pan- creas, and brain and other nervous system among men and women; for oral cavity and pharynx, nonmelanoma skin, and soft tissue (including heart) among men; and for uterus among women. Black men and black women had the highest cancer death rates of any racial group during the most recent 5-year period. Except for female lung can- cer, black men and black women had the highest death rates for cancer sites with the highest mortality in the over- all population: lung, prostate, female breast, colorectal,
and pancreas. Non-Hispanic men and women had higher overall cancer death rates than men and women of His- panic ethnicity.
Factors that have contributed to the continued decreases in cancer death rates for the 4 most common cancers have been discussed in previous reports.14-19
Briefly, the sustained decrease in lung and bronchus can- cer death rates since the early 1990s among men and since the early 2000s among women has been attributed to the reduction in cigarette smoking over the past 5 decades.11
Between 1964 and 2012, cigarette smoking decreased by about 50% because of public health policies against tobacco use (eg, increased excise taxes on cigarette smok- ing, smoke-free air laws) and increased awareness about the health hazards of smoking.52 However, cigarette smoking still accounts for over one-quarter of cancer deaths in the United States.53-55
The continued decreases in death rates for female breast cancer, prostate cancer, and colorectal cancer largely reflect improved early detection and more effective treat- ments.14-19 Because mammography use has been stable since the early 2000s,48 the recent decrease in breast cancer death rates may largely reflect improvement in treatments, such as targeted therapies.56 The use of prostate-specific antigen testing has substantially decreased following the US Preventive Services Task Force recommendations against routine testing for men aged 75 and older in 2008 and for all ages in 2012,57,58 which may have contributed to the less rapid decline in prostate cancer death rates dur- ing the most recent years compared with the previous period. See Part II of this report for details on prostate cancer rates and prostate-specific antigen testing patterns. In contrast, it is believed that the rapid decrease in colorec- tal cancer death rates over the past decades is because of increased colonoscopy use59,60 after reimbursement of the procedure was granted by Medicare for high-risk individu- als in 1998 and for all eligible persons in 2001.61 Unlike increases in breast cancer screening, which resulted in a large percentage of cases being diagnosed with stage I dis- ease, increased colorectal cancer screening—because it detects precancerous polyps so they can be removed before becoming cancer—has instead resulted in decreases in incidence.
In addition to the decreases for the 4 most common cancers, death rates decreased for many other cancers. These include larynx (men), bladder (women), and esoph- agus (men and women)—mainly because of reductions in cigarette smoking and other tobacco use—and leukemia (men and women) and NHL (men and women) because of improved treatments.19
Annual Report National Cancer Statistics/Cronin et al
Cancer July 1, 2018 2797
We have observed that death rates continued to increase for several cancers, including liver (both sexes), pancreas (both sexes), uterus, and oral cavity and pharynx cancer (men only). The increase in liver cancer death rates has been associated with the high prevalence of hepatitis C virus infection among Baby Boomers caused by sharing of contaminated needles for intravenous drug use from the 1960s through the 1980s, as well as the obesity epi- demic.18 It is also believed that the obesity epidemic has contributed to the increase in endometrial (uterus lining) and pancreas cancer death rates.14 It is estimated that obe- sity accounts for 25% and 68% of pancreas and uterus cancer deaths, respectively, in the United States.62 The recent increase in oral cavity and pharynx cancer death rates among men, confined to whites, is thought to be associated with an increase in human papillomavirus infection.63 A recent study estimated that approximately 11 million men and 3.2 million women have oral human papillomavirus infection in the United States.64
The incidence of childhood cancers continues to increase, whereas mortality is decreasing. The cancers occurring in children represent a heterogeneous group of cancer sites that vary by age. To better understand the fac- tors influencing the rates, a careful examination of specific cancer sites within this age group would be necessary.
Limitations
A limitation of this report is misclassification of race/eth- nicity information in medical records (incidence), death certificates, and the Census. Since 2000, the Census has given respondents the option to self-select multiple race/ ethnicity categories; this has created incompatibility with race/ethnicity information in medical records and death certificates, which often have single race/ethnicity catego- ries. To address this problem, the US Census Bureau, in collaboration with the CDC’s NCHS and the NCI, have developed methods to generate single-race population estimates—but with some uncertainties about the popula- tion estimates and resultant rates.65 Furthermore, race/ ethnicity information on death certificates is underascer- tained for AI/AN, API, and Hispanic populations,27,28
leading to an underestimation of cancer rates. In addition, cancer rates for broad racial and ethnic groups (eg, His- panics and APIs) may mask important variations in cancer burden by country of origin.
Conclusions
For all cancer sites combined, cancer incidence rates decreased among men but were stable among women. Overall, there continue to be significant declines in cancer
death rates among both men and women. Differences in
rates and trends by race and ethnic group remain. Progress
in reducing cancer mortality has not occurred for all sites, the most notable exceptions being liver cancer and uterus
cancer. Examining stage distribution and 5-year survival by stage highlights the potential benefits associated with
early detection and treatment. The continued monitoring
of national statistics identifies areas for potential interven- tion and control to reduce the burden of cancer in the US
population.
FUNDING SUPPORT This work was supported by the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries.
CONFLICT OF INTEREST DISCLOSURES Jiemin Ma and Ahmedin Jemal are employed by the American Cancer Society, which received a grant from Merck, Inc., for intra- mural research outside the submitted work; however, their salaries are solely funded through American Cancer Society funds. The remaining authors made no disclosures.
AUTHOR CONTRIBUTIONS Kathleen A. Cronin: Conceptualization, supervision, visualization, writing–original draft, and writing–review and editing. Andrew J. Lake: Software, validation, formal analysis, data curation, writing– original draft, writing–review and editing, and visualization. Susan Scott: Writing–original draft and project administration. Recinda L. Sherman: Conceptualization, methodology, writing–original draft, writing–review and editing, and visualization. Anne- Michelle Noone: Conceptualization, methodology, writing–origi- nal draft, and writing–review and editing. Nadia Howlader: Con- ceptualization, methodology, writing–original draft, and writing– review and editing. S. Jane Henley: Writing–review and editing. Robert N. Anderson: Writing–review and editing. Albert U. Firth: Software, validation, formal analysis, data curation, writing– original draft, writing–review and editing, and visualization. Jiemin Ma: Writing–review and editing. Betsy A. Kohler: Conceptualiza- tion, data curation, resources, and writing–review and editing. Ahmedin Jemal: Conceptualization, writing–original draft, and writing–review and editing.
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