Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.
Cancer is a major public health problem worldwide and is the second leading cause of death in the United States. In this article, we provide the estimated numbers of new cancer cases and deaths in 2019 in the United States nationally and for each state, as well as a comprehensive overview of cancer occurrence based on the most current population-based data for cancer incidence through 2015 and for mortality through 2016. We also estimate the total number of deaths averted because of the continuous decline in cancer death rates since the early 1990s and analyze cancer mortality rates by county-level poverty.
Materials and Methods
Incidence and Mortality Data
Mortality data from 1930 to 2016 were provided by the National Center for Health Statistics (NCHS).1-3 Forty-seven states and the District of Columbia met data quality requirements for reporting to the national vital statistics system in 1930, and Texas, Alaska, and Hawaii began reporting in 1933, 1959, and 1960, respectively. The methods for abstraction and age adjustment of historic mortality data are described elsewhere.3, 4 Five-year mortality rates (2011-2015) for Puerto Rico were previously published in volume 3 of the North American Association of Central Cancer Registries’ (NAACCR’s) Cancer in North America: 2011-2015.5
Population-based cancer incidence data in the United States have been collected by the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology, and End Results (SEER) Program since 1973 and by the Centers for Disease Control and Prevention's (CDC’s) National Program of Cancer Registries (NPCR) since 1995. The SEER program is the only source for historic population-based incidence data. Long-term (1975–2015) incidence and survival trends were based on data from the 9 oldest SEER areas (Connecticut, Hawaii, Iowa, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco–Oakland, and Seattle–Puget Sound), representing approximately 9% of the US population.6, 7 The lifetime probability of developing cancer and contemporary stage distribution and survival statistics were based on data from all 18 SEER registries (the SEER 9 registries plus Alaska Natives, California, Georgia, Kentucky, Louisiana, and New Jersey), covering 28% of the US population.8 The probability of developing cancer was calculated using NCI’s DevCan software (version 6.7.6).9 Some of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975-2015.10
The NAACCR compiles and reports incidence data from 1995 onward for registries that participate in the SEER program and/or the NPCR. These data approach 100% coverage of the US population for the most recent years and were the source for the projected new cancer cases in 2019 and cross-sectional incidence rates by state and race/ethnicity.11, 12 Some of the incidence data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2011-2015.13, 14
All cancer cases were classified according to the International Classification of Diseases for Oncology except childhood and adolescent cancers, which were classified according to the International Classification of Childhood Cancer (ICCC).15, 16 Causes of death were classified according to the International Classification of Diseases.17 All incidence and death rates were age standardized to the 2000 US standard population and expressed per 100,000 population, as calculated by NCI’s SEER*Stat software (version 8.3.5).18 The annual percent change in rates was quantified using NCI’s Joinpoint Regression Program (version 4.6.0).19
Whenever possible, cancer incidence rates were adjusted for delays in reporting, which occur because of a lag in case capture or data corrections. Delay-adjustment has the largest effect on the most recent data years for cancers that are frequently diagnosed in outpatient settings (eg, melanoma, leukemia, and prostate cancer) and provides the most accurate portrayal of cancer occurrence in the most recent time period.20 For example, the leukemia incidence rate for 2015 in the 9 oldest SEER registries was 12% higher after adjusting for reporting delays (15.2 vs 13.6 per 100,000 population).10
Projected Cancer Cases and Deaths in 2019
The most recent year for which reported incidence and mortality data are available lags 2 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we projected the numbers of new cancer cases and deaths in the United States in 2019 to provide an estimate of the contemporary cancer burden.
To calculate the number of invasive cancer cases, a generalized linear mixed model was used to estimate complete counts for each county (or health service area for rare cancers) from 2001 through 2015 using delay-adjusted, high-quality incidence data from 48 states and the District of Columbia (96% population coverage) and geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors.21 (Data were unavailable for all years for Kansas and Minnesota, as well as for a few sporadic years for a handful of states.) Modeled counts were aggregated to the national and state level for each year, and a time series projection method (vector autoregression) was applied to all 15 years to estimate cases for 2019. Basal cell and squamous cell skin cancers cannot be estimated because incidence data are not collected by most cancer registries. For complete details of the case projection methodology, please refer to Zhu et al.22
New cases of in situ female breast carcinoma and melanoma of the skin diagnosed in 2019 were estimated by first approximating the number of cases occurring annually from 2006 through 2015 based on age-specific NAACCR incidence rates (data from 46 states with high-quality data for all 10 years) and US Census Bureau population estimates obtained via SEER*Stat. Counts were then adjusted for delays in reporting using SEER delay factors for invasive disease (delay factors are unavailable for in situ cases) and projected to 2019 based on the average annual percent change generated by the joinpoint regression model.
The number of cancer deaths expected to occur in 2019 was estimated based on the most recent joinpoint-generated annual percent change in reported cancer deaths from 2002 through 2016 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al.23
The number of cancer deaths averted in men and women due to the reduction in cancer death rates since the early 1990s was estimated by summing the difference between the annual number of recorded cancer deaths from the number that would have been expected if cancer death rates had remained at their peak. The expected number of deaths was estimated by applying the 5-year age- and sex-specific cancer death rates in the peak year for age-standardized cancer death rates (1990 in men and 1991 in women) to the corresponding age- and sex-specific populations in subsequent years through 2016.
Temporal trends in socioeconomic disparities in cancer mortality were examined using county-level poverty as a proxy for socioeconomic status. Cancer death rates by county-level poverty quintile were calculated using linked attributes from the US Census Bureau American Community Survey 2012–2016 available through SEER*Stat. The total resident population in each quintile was 73,559,180 persons (1.81%-10.84% poverty); 62,695,449 persons (10.85%-14.10% poverty); 74,157,401 persons (14.11%-17.16% poverty); 76,945,467 persons (17.17%-21.17% poverty); and 35,770,016 persons (21.18%-53.95% poverty), respectively. County-level poverty in the United States has shifted slightly from the South to the West since 1970, although the highest concentration remains in the South.24
Expected Numbers of New Cancer Cases
Table 1 presents the estimated numbers of new cases of invasive cancer in the United States in 2019 by sex and cancer type. In total, there will be approximately 1,762,450 cancer cases diagnosed, which is the equivalent of more than 4,800 new cases each day. In addition, there will be approximately 62,930 new cases of female breast carcinoma in situ and 95,830 new cases of melanoma in situ of the skin. The estimated numbers of new cases by state are shown in Table 2.
|ESTIMATED NEW CASES||ESTIMATED DEATHS|
|BOTH SEXES||MALE||FEMALE||BOTH SEXES||MALE||FEMALE|
|Oral cavity & pharynx||53,000||38,140||14,860||10,860||7,970||2,890|
|Other oral cavity||3,760||2,710||1,050||1,650||1,290||360|
|Anus, anal canal, & anorectum||8,300||2,770||5,530||1,280||520||760|
|Liver & intrahepatic bile duct||42,030||29,480||12,550||31,780||21,600||10,180|
|Gallbladder & other biliary||12,360||5,810||6,550||3,960||1,610||2,350|
|Other digestive organs||7,220||2,990||4,230||2,860||1,230||1,630|
|Lung & bronchus||228,150||116,440||111,710||142,670||76,650||66,020|
|Other respiratory organs||5,880||4,070||1,810||1,080||720||360|
|Bones & joints||3,500||2,030||1,470||1,660||960||700|
|Soft tissue (including heart)||12,750||7,240||5,510||5,270||2,840||2,430|
|Skin (excluding basal & squamous)||104,350||62,320||42,030||11,650||8,030||3,620|
|Melanoma of the skin||96,480||57,220||39,260||7,230||4,740||2,490|
|Other nonepithelial skin||7,870||5,100||2,770||4,420||3,290||1,130|
|Vagina & other genital, female||5,350||5,350||1,430||1,430|
|Penis & other genital, male||2,080||2,080||410||410|
|Kidney & renal pelvis||73,820||44,120||29,700||14,770||9,820||4,950|
|Ureter & other urinary organs||3,930||2,630||1,300||980||600||380|
|Eye & orbit||3,360||1,860||1,500||370||200||170|
|Brain & other nervous system||23,820||13,410||10,410||17,760||9,910||7,850|
|Acute lymphocytic leukemia||5,930||3,280||2,650||1,500||850||650|
|Chronic lymphocytic leukemia||20,720||12,880||7,840||3,930||2,220||1,710|
|Acute myeloid leukemia||21,450||11,650||9,800||10,920||6,290||4,630|
|Chronic myeloid leukemia||8,990||5,250||3,740||1,140||660||480|
|Other leukemia ‡||4,690||2,860||1,830||5,350||3,130||2,220|
|Other & unspecified primary sites ‡||31,480||16,750||14,730||45,140||24,240||20,900|
- * Rounded to the nearest 10; cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. Approximately 62,930 cases of carcinoma in situ of the female breast and 95,830 cases of melanoma in situ will be newly diagnosed in 2019.
- † Deaths for colon and rectal cancers are combined because a large number of deaths from rectal cancer are misclassified as colon.
- ‡ More deaths than cases may reflect a lack of specificity in recording the underlying cause of death on death certificates and/or an undercount in the case estimate.
- Note: These are model-based estimates that should be interpreted with caution and not compared with those for previous years.
|STATE||ALL CASES||FEMALE BREAST||UTERINE CERVIX||COLON & RECTUM||UTERINE CORPUS||LEUKEMIA||LUNG & BRONCHUS||MELANOMA OF THE SKIN||NON-HODGKIN LYMPHOMA||PROSTATE||URINARY BLADDER|
|Dist. of Columbia||3,190||510||†||260||120||80||340||80||120||300||80|
- * Rounded to the nearest 10; excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder. Estimates for Puerto Rico are not available.
- † Estimate is fewer than 50 cases.
- Note: These are model-based estimates that should be interpreted with caution and not compared with those for previous years. State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 cases.
Figure 1 depicts the most common cancers expected to be diagnosed in men and women in 2019. Prostate, lung and bronchus (referred to as lung hereafter), and colorectal cancers (CRCs) account for 42% of all cases in men, with prostate cancer alone accounting for nearly 1 in 5 new diagnoses. For women, the 3 most common cancers are breast, lung, and colorectum, which collectively represent one-half of all new diagnoses; breast cancer alone accounts for 30% of all new cancer diagnoses in women.
The lifetime probability of being diagnosed with invasive cancer is slightly higher for men (39.3%) than for women (37.7%) (Table 3). The reasons for the excess risk in men are not fully understood, but partly reflect differences in environmental exposures, endogenous hormones, and probably complex interactions between these influences. Recent research suggests that sex differences in immune function and response may also play a role.25 Adult height, which is determined by genetics and childhood nutrition, is positively associated with cancer incidence and mortality in both men and women,26 and has been estimated to account for one-third of the sex disparity.27
|BIRTH TO 49||50 TO 59||60 TO 69||≥70||BIRTH TO DEATH|
|All sites †||Male||3.4 (1 in 30)||6.1 (1 in 16)||13.2 (1 in 8)||31.9 (1 in 3)||39.3 (1 in 3)|
|Female||5.6 (1 in 18)||6.2 (1 in 16)||10.0 (1 in 10)||26.0 (1 in 4)||37.7 (1 in 3)|
|Breast||Female||2.0 (1 in 51)||2.3 (1 in 43)||3.5 (1 in 29)||6.7 (1 in 15)||12.4 (1 in 8)|
|Colorectum||Male||0.4 (1 in 272)||0.7 (1 in 143)||1.2 (1 in 87)||3.3 (1 in 30)||4.4 (1 in 23)|
|Female||0.3 (1 in 292)||0.5 (1 in 190)||0.8 (1 in 123)||3.0 (1 in 33)||4.1 (1 in 25)|
|Kidney & renal pelvis||Male||0.2 (1 in 440)||0.4 (1 in 280)||0.6 (1 in 155)||1.3 (1 in 73)||2.1 (1 in 47)|
|Female||0.2 (1 in 665)||0.2 (1 in 575)||0.3 (1 in 319)||0.7 (1 in 135)||1.2 (1 in 82)|
|Leukemia||Male||0.3 (1 in 396)||0.2 (1 in 570)||0.4 (1 in 259)||1.4 (1 in 72)||1.8 (1 in 56)|
|Female||0.2 (1 in 508)||0.1 (1 in 876)||0.2 (1 in 434)||0.9 (1 in 112)||1.3 (1 in 80)|
|Lung & bronchus||Male||0.1 (1 in 719)||0.6 (1 in 158)||1.8 (1 in 56)||6.0 (1 in 16)||6.7 (1 in 15)|
|Female||0.1 (1 in 673)||0.6 (1 in 178)||1.4 (1 in 72)||4.7 (1 in 21)||5.9 (1 in 17)|
|Melanoma of the skin ‡||Male||0.5 (1 in 215)||0.5 (1 in 186)||1.0 (1 in 104)||2.7 (1 in 37)||3.7 (1 in 27)|
|Female||0.7 (1 in 150)||0.4 (1 in 238)||0.5 (1 in 191)||1.1 (1 in 87)||2.5 (1 in 40)|
|Non-Hodgkin lymphoma||Male||0.3 (1 in 382)||0.3 (1 in 350)||0.6 (1 in 176)||1.8 (1 in 54)||2.4 (1 in 42)|
|Female||0.2 (1 in 548)||0.2 (1 in 484)||0.4 (1 in 247)||1.4 (1 in 74)||1.9 (1 in 54)|
|Prostate||Male||0.2 (1 in 437)||1.7 (1 in 59)||4.6 (1 in 22)||7.9 (1 in 13)||11.2 (1 in 9)|
|Thyroid||Male||0.2 (1 in 513)||0.1 (1 in 764)||0.2 (1 in 584)||0.2 (1 in 417)||0.6 (1 in 156)|
|Female||0.8 (1 in 122)||0.4 (1 in 268)||0.3 (1 in 286)||0.4 (1 in 262)||1.8 (1 in 55)|
|Uterine cervix||Female||0.3 (1 in 366)||0.1 (1 in 835)||0.1 (1 in 938)||0.2 (1 in 628)||0.6 (1 in 162)|
|Uterine corpus||Female||0.3 (1 in 333)||0.6 (1 in 164)||1.0 (1 in 102)||1.3 (1 in 75)||2.9 (1 in 35)|
- * For people without a history of cancer at beginning of age interval.
- † All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder.
- ‡ Probabilities for non-Hispanic whites only.
Expected Number of Cancer Deaths
An estimated 606,880 Americans will die from cancer in 2019, corresponding to almost 1,700 deaths per day (Table 1). The greatest number of deaths are from cancers of the lung, prostate, and colorectum in men and the lung, breast, and colorectum in women (Fig. 1). One-quarter of all cancer deaths are due to lung cancer. Table 4 provides the estimated numbers of cancer deaths in 2019 by state.
|STATE||ALL SITES||BRAIN & OTHER NERVOUS SYSTEM||FEMALE BREAST||COLON & RECTUM||LEUKEMIA||LIVER & INTRAHEPATIC BILE DUCT||LUNG & BRONCHUS||NON-HODGKIN LYMPHOMA||OVARY||PANCREAS||PROSTATE|
|Dist. of Columbia||1,020||†||100||100||†||90||180||†||†||90||70|
- * Rounded to the nearest 10. Estimates for Puerto Rico are not available.
- † Estimate is fewer than 50 deaths.
- Note: These are model-based estimates that should be interpreted with caution and not compared with those for previous years. State estimates may not add to US total due to rounding and the exclusion of states with fewer than 50 deaths.
Trends in Cancer Incidence
Figure 2 illustrates long-term trends in cancer incidence rates for all cancers combined by sex. Cancer incidence patterns reflect trends in behaviors associated with cancer risk and changes in medical practice, such as the use of cancer screening tests. The volatility in incidence for males reflects rapid changes in prostate cancer incidence rates, which spiked in the late 1980s and early 1990s (Fig. 3) due to a surge in the detection of asymptomatic disease as a result of widespread prostate-specific antigen (PSA) testing among previously unscreened men.28
Over the past decade of data, the overall cancer incidence rate in men declined by approximately 2% per year (Table 5). This trend reflects accelerated declines during the past 5 data years (2011-2015) of approximately 3% per year for cancers of the lung and colorectum, and 7% per year for prostate cancer. The sharp drop in prostate cancer incidence has been attributed to decreased PSA testing from 2008 to 2013 in the wake of US Preventive Services Task Force recommendations against the routine use of the test to screen for prostate cancer (Grade D) in men aged 75 years and older in 2008 and in all men in 2011 because of growing concerns about overdiagnosis and overtreatment.29, 30 Although PSA testing prevalence stabilized from 2013 to 2015,31 the effect of the reduction in screening on the occurrence of advanced disease is being watched closely. Based on analysis of cancer registry data covering 89% of the US population, Negoita et al recently reported that the overall decline in prostate cancer incidence masks an increase in distant stage diagnoses since around 2010 across age and race, although improved staging may have contributed to this trend.32 The Task Force has revised their recommendation for men aged 55 to 69 years to informed decision making (Grade C) based on an updated evidence review, noting that “screening offers a small potential benefit” of reduced prostate cancer mortality “in some men.”33-35
|TREND 1||TREND 2||TREND 3||TREND 4||TREND 5||TREND 6||2006-2015||2011-2015|
|Liver & intrahepatic bile duct|
|Lung & bronchus|
|Melanoma of skin|
- AAPC indicates average annual percent change; APC, annual percent change based on delay-adjusted incidence rates age adjusted to the 2000 US standard population.
- Note: Trends analyzed by the Joinpoint Regression Program, version 4.6, allowing up to 5 joinpoints. Trends are based on Surveillance, Epidemiology, and End Results (SEER) 9 areas.
- * The APC or AAPC is significantly different from zero (P < .05).
The overall cancer incidence rate in women has remained generally stable over the past few decades. Declines have continued for lung cancer, but tapered in recent years for CRC, whereas rates for other common cancers are increasing or stable (Table 5). Breast cancer incidence rates increased from 2006 to 2015 by approximately 0.3% to 0.4% per year among non-Hispanic white (NHW) and Hispanic women, by 0.7% to 0.8% per year among black (non-Hispanic) and American Indian/Alaska Native women, and by 1.8% per year among Asian/Pacific Islander women.36 This trend may in part be a consequence of the obesity epidemic, as well as declining parity.37, 38
Lung cancer incidence continues to decline twice as fast in men as in women, reflecting historical differences in tobacco uptake and cessation, as well as upturns in female smoking prevalence in some birth cohorts.39, 40 However, smoking patterns do not appear to explain the higher lung cancer incidence rates recently reported in young women compared with men born around the 1960s.41 In contrast, CRC incidence patterns are generally similar in men and women (Fig. 3), although in the past 5 data years rates have continued to decline by approximately 3% per year in men, but appear to have stabilized in women (Table 5). Reductions in CRC incidence prior to 2000 are attributed equally to changes in risk factors and the use of screening, which allows for the removal of premalignant lesions.42 However, more recent rapid declines are thought to primarily reflect the increased uptake of colonoscopy, which now is the predominant screening test.43, 44 Colonoscopy use among US adults aged 50 years and older tripled from 21% in 2000 to 60% in 2015.45 The rapid declines in overall CRC incidence rates mask an increase in adults aged younger than 55 years of almost 2% per year since the mid-1990s.7
Incidence rates continue to increase for melanoma and cancers of the liver, thyroid, uterine corpus, and pancreas. Liver cancer incidence is rising faster than that for any other cancer in both men and women.38 Notably, however, the majority (71%) of cases in the United States are potentially preventable because most risk factors are modifiable (eg, obesity, excess alcohol consumption, cigarette smoking, and hepatitis B and C viruses).46 Approximately 24% of cases are caused by chronic hepatitis C virus (HCV) infection, which confers the largest relative risk and is also the most common chronic blood-borne infection in the United States.47 Although there is exciting potential to avert much of the future burden of HCV-associated disease because of new, well-tolerated, antiviral therapies that achieve cure rates of greater than 90%,48 most infected individuals are undiagnosed. One-time screening has been recommended for baby boomers (those born between 1945 and 1965), who account for three-fourths of affected individuals,49, 50 since 2012 and is now even mandated in several states.51 However, only 14% of the more than 76 million boomers reported having received HCV testing in 2015.52 Compounding the challenge is a 3-fold spike in acute HCV infections reported to the CDC from 2010 through 2016, after a decade of stable/declining rates, that is attributed to the opioid epidemic.53, 54 Fewer than 10% of new infections are reported and the CDC estimates the actual number of acute infections in 2016 to be 41,200 (95% confidence interval, 32,600-140,600), approximately 75% to 85% of which will progress to chronic infection.
The 5-year relative survival rate for all cancers combined diagnosed during 2008 through 2014 was 67% in whites and 62% in blacks.10 Figure 4 shows 5-year relative survival rates by cancer type, stage at diagnosis, and race. For all stages combined, survival is highest for prostate cancer (98%), melanoma of the skin (92%), and female breast cancer (90%) and lowest for cancers of the pancreas (9%), liver (18%), esophagus (19%), and lung (19%). Black patients have lower survival rates than whites for every cancer type shown in Figure 4 except for cancers of the kidney and pancreas, with the absolute difference being 10% or higher for most. The largest disparities are for melanoma (26%) and cancers of the uterine corpus (21%) and oral cavity and pharynx (18%), in part reflecting a much later stage at diagnosis in black patients (Fig. 5). However, blacks also have lower stage-specific survival for most cancer types. After adjusting for sex, age, and stage at diagnosis, the relative risk of death after a cancer diagnosis is 33% higher in black patients than in white patients.55 The disparity is even larger for American Indians/Alaska Natives, who are 51% more likely than whites to die from their cancer.
Cancer survival has improved since the mid-1970s for all of the most common cancers except those of the uterine cervix and uterine corpus,55 although for some cancer types (eg, breast and prostate) this partly reflects lead time bias because of changes in detection practice. Progress has been especially rapid for hematopoietic and lymphoid malignancies due to improvements in treatment protocols, including the discovery of targeted therapies. For example, the 5-year relative survival rate for chronic myeloid leukemia increased from 22% for patients diagnosed in the mid-1970s to 69% for those diagnosed during 2008 through 2014,10 and most patients treated with tyrosine kinase inhibitors experience nearly normal life expectancy.56
In contrast to the steady increase in survival for most cancer types, advances have been slow for lung and pancreatic cancers, partly because greater than one-half of cases are diagnosed at a distant stage (Fig. 5). There is a potential for earlier lung cancer diagnosis through screening with low-dose computed tomography, which has demonstrated a 20% reduction in lung cancer mortality in current/former smokers with a history of 30 or more pack-years.57 However, the translation of this benefit from clinical trial participants to the general population remains challenging. In 2015, only 4% of the 6.8 million eligible Americans reported being screened for lung cancer with low-dose computed tomography.58 Another study found that more individuals who did not meet guideline-recommended criteria for lung cancer screening had received a recent test than those who did meet criteria.59 Broad implementation of guideline-recommended lung cancer screening will require new systems to facilitate unique aspects of the process, such as identifying eligible patients and acquainting physicians with information that should be delivered during the shared decision-making conversation, which is recommended by the American Cancer Society and US Preventive Services Task Force and required by the Centers for Medicare and Medicaid Services. A recent small study suggests stark failure in the practice of shared decision making by primary care and pulmonary physicians.60
Trends in Cancer Mortality
Mortality rates are a better indicator of progress against cancer than incidence or survival rates because they are less affected by biases resulting from changes in detection practices.61 The cancer death rate rose during most of the 20th century, largely driven by rapid increases in lung cancer deaths among men as a consequence of the tobacco epidemic. However, since its peak of 215.1 deaths (per 100,000 population) in 1991, the cancer death rate has dropped steadily by approximately 1.5% per year, resulting in an overall decline of 27% as of 2016 (156.0 per 100,000 population). This translates to an estimated 2,629,200 fewer cancer deaths (1,804,000 in men and 825,200 in women) than what would have occurred if mortality rates had remained at their peak (Fig. 6). The number of averted deaths is larger for men than for women because the total decline in cancer mortality has been steeper for men (34% vs 24%).
The decline in cancer mortality over the past 2 decades is primarily the result of steady reductions in smoking and advances in early detection and treatment, which are reflected in the rapid declines for the 4 major cancers (lung, breast, prostate, and colorectum) (Fig. 7). Specifically, the death rate for lung cancer dropped by 48% from 1990 to 2016 among males and by 23% from 2002 to 2016 among females, whereas the death rate for breast cancer dropped by 40% from 1989 to 2016, that for prostate cancer dropped by 51% from 1993 to 2016, and that for CRC dropped by 53% from 1970 to 2016. During the most recent data years, declines in mortality from lung cancer have accelerated whereas those for CRC have slowed (Table 6). Prostate cancer mortality stabilized during 2013 through 2016 after 2 decades of steep (4% per year) reductions that are attributed to an earlier stage at diagnosis due to PSA testing and advances in treatments.62, 63 The leveling of rates is temporally associated with both declines in PSA testing and an uptick in distant stage disease diagnoses.32 Death rates rose from 2012 through 2016 for cancers of the liver, pancreas, and uterine corpus (Table 6), as well as for cancers of the brain and other nervous system, soft tissue (including heart), and sites within the oral cavity and pharynx associated with the human papillomavirus (HPV).1
|TREND 1||TREND 2||TREND 3||TREND 4||TREND 5||TREND 6||2007-2016||2012-2016|
|Liver & intrahepatic bile duct|
|Lung & bronchus|
|Melanoma of skin|
- AAPC indicates average annual percent change; APC, annual percent change based on mortality rates age adjusted to the 2000 US standard population.
- Note: Trends analyzed by the Joinpoint Regression Program, version 4.6, allowing up to 5 joinpoints.
- a The APC or AAPC is significantly different from zero (P <.05).
Recorded Number of Deaths in 2016
A total of 2,744,248 deaths were recorded in the United States in 2016, 22% of which were from cancer (Table 7). Cancer is the second leading cause of death after heart disease in both men and women nationally, but is the leading cause of death in many states,64 in Hispanic and Asian Americans,65, 66 and in people younger than 80 years. However, those 80 years and older are nearly 2 times more likely to die from heart disease than from cancer. Among females, cancer is the first or second leading cause of death for every age group shown in Table 8, whereas among males, accidents, assault, and suicide predominate before age 40 years.
|2015||2016||RELATIVE CHANGE IN RATE|
|RANK (2016)||All causes||2,712,630||733.0||2,744,248||729.1||−0.5%|
|3||Accidents (unintentional injuries)||146,571||5%||43.1||161,374||6%||47.3||9.7%|
|4||Chronic lower respiratory diseases||155,041||6%||41.8||154,596||6%||40.8||−2.4%|
|8||Influenza and pneumonia||57,062||2%||15.2||51,537||2%||13.6||−10.5%|
|9||Nephritis, nephrotic syndrome, & nephrosis||49,959||2%||13.4||50,046||2%||13.2||−1.5%|
|10||Intentional self-harm (suicide)||44,193||2%||13.3||44,965||2%||13.4||0.8%|
- Death counts include unknown age.
- Rates are per 100,000 population and age adjusted to the 2000 US standard population. Rank is based on number of deaths.
- Source: National Center for Health Statistics, Centers for Disease Control and Prevention.
|ALL AGES||AGES 1 TO 19||AGES 20 TO 39||AGES 40 TO 59||AGES 60 TO 79||AGES ≥80|
|All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes||All Causes|
|1||Heart disease||Heart disease||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Heart disease||Cancer||Cancer||Cancer||Heart disease||Heart disease|
|2||Cancer||Cancer||Assault (homicide)||Cancer||Intentional self-harm (suicide)||Cancer||Cancer||Heart disease||Heart disease||Heart disease||Cancer||Cancer|
|3||Accidents (unintentional injuries)||Cerebro-vascular disease||Intentional self-harm (suicide)||Intentional self-harm (suicide)||Assault (homicide)||Intentional self-harm (suicide)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Chronic lower respiratory diseases||Chronic lower respiratory diseases||Chronic lower respiratory diseases||Alzheimer disease|
|4||Chronic lower respiratory diseases||Chronic lower respiratory diseases||Cancer||Assault (homicide)||Heart disease||Heart disease||Intentional self-harm (suicide)||Chronic lower respiratory diseases||Cerebro-vascular disease||Cerebro-vascular disease||Cerebro-vascular disease||Cerebro-vascular disease|
|5||Cerebro-vascular disease||Alzheimer disease||Congenital anomalies||Congenital anomalies||Cancer||Assault (homicide)||Chronic liver disease & cirrhosis||Chronic liver disease & cirrhosis||Diabetes mellitus||Diabetes mellitus||Alzheimer disease||Chronic lower respiratory diseases|
|6||Diabetes mellitus||Accidents (unintentional injuries)||Heart disease||Heart disease||Chronic liver disease & cirrhosis||Pregnancy, childbirth & puerperium||Diabetes mellitus||Cerebro-vascular disease||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)|
|7||Alzheimer disease||Diabetes mellitus||Chronic lower respiratory diseases||Influenza & pneumonia||Diabetes mellitus||Chronic liver disease & cirrhosis||Cerebro-vascular disease||Diabetes mellitus||Chronic liver disease & cirrhosis||Alzheimer disease||Influenza & pneumonia||Influenza & pneumonia|
|8||Intentional self-harm (suicide)||Influenza & pneumonia||Influenza & pneumonia||Chronic lower respiratory diseases||Cerebro-vascular disease||Diabetes mellitus||Chronic lower respiratory diseases||Intentional self-harm (suicide)||Nephritis, nephrotic syndrome & nephrosis||Nephritis, nephrotic syndrome & nephrosis||Diabetes mellitus||Diabetes mellitus|
|9||Chronic liver disease & cirrhosis||Nephritis, nephrotic syndrome & nephrosis||Cerebro-vascular disease||Septicemia||HIV disease||Cerebro-vascular disease||Assault (homicide)||Septicemia||Influenza & pneumonia||Septicemia||Nephritis, nephrotic syndrome & nephrosis||Nephritis, nephrotic syndrome & nephrosis|
|10||Nephritis, nephrotic syndrome & nephrosis||Septicemia||Septicemia||Cerebro-vascular disease||Influenza & pneumonia||Influenza & pneumonia||Septicemia||Influenza & pneumonia||Septicemia||Influenza & pneumonia||Parkinson disease||Hypertension & hypertensive renal diseasea|
- HIV indicates human immunodeficiency virus.
- Note: Deaths within each age group do not sum to all ages combined due to the inclusion of unknown ages. In accordance with the National Center for Health Statistics’ cause-of-death ranking, "Symptoms, signs, and abnormal clinical or laboratory findings" and categories that begin with "Other" and "All other" were not ranked.
- Source: US Final Mortality Data, 2016, National Center for Health Statistics, Centers for Disease Control and Prevention, 2018.
- a Includes primary and secondary hypertension.
Table 9 presents the number of deaths in 2016 for the 5 leading cancer types by age and sex. Brain and other nervous system tumors are the leading cause of cancer death among men aged younger than 40 years and women aged younger than 20 years, whereas breast cancer leads among women aged 20 to 59 years. Lung cancer leads in cancer deaths among men aged 40 years and older and women aged 60 years and older, causing more deaths in 2016 than breast cancer, prostate cancer, CRC, and leukemia combined. There were approximately 20% more lung cancer deaths in men (80,775) than in women (68,095) in 2016, but this pattern is projected to reverse by 2045 if current smoking trends continue.67 Cervical cancer continues to be the second leading cause of cancer death in women aged 20 to 39 years, causing 9 deaths per week in this age group. This finding underscores the need for increased HPV vaccination uptake in adolescents and guideline-adherent screening in young women. Notably, the percentage of women aged 22 to 30 years who had never been screened for cervical cancer increased between 2000 and 2010.68 In addition, an estimated 14 million screening-aged women (ages 21-65 years) had not been tested in the past 3 years in 2015.69
|ALL AGES||<20||20 TO 39||40 TO 59||60 TO 79||≥ 80|
|ALL SITES||ALL SITES||ALL SITES||ALL SITES||ALL SITES||ALL SITES|
|Lung & bronchus||Brain & ONS||Brain & ONS||Lung & bronchus||Lung & bronchus||Lung & bronchus|
|Colorectum||Bones & joints||Colorectum||Liver*||Prostate||Colorectum|
|Pancreas||Soft tissue (including heart)||Non-Hodgkin lymphoma||Pancreas||Pancreas||Urinary bladder|
|Liver*||Non-Hodgkin lymphoma||Soft tissue (including heart)||Brain & ONS||Liver*||Pancreas|
|ALL SITES||ALL SITES||ALL SITES||ALL SITES||ALL SITES||ALL SITES|
|Lung & bronchus||Brain & ONS||Breast||Breast||Lung & bronchus||Lung & bronchus|
|Breast||Leukemia||Uterine cervix||Lung & bronchus||Breast||Breast|
|Colorectum||Bone & joints||Colorectum||Colorectum||Pancreas||Colorectum|
|Pancreas||Soft tissue (including heart)||Brain & ONS||Ovary||Colorectum||Pancreas|
- ONS indicates other nervous system.
- Note: Ranking order excludes category titles that begin with the word “Other.”
- * Includes intrahepatic bile duct.
Cancer Disparities by Socioeconomic Status
Lower socioeconomic status (SES), whether measured at the individual or area level, is associated with numerous health disadvantages and higher mortality across race and ethnicity.70-72 A recent study estimated that approximately one-third (34%) of cancer deaths in Americans aged 25 to 74 years could be averted with the elimination of socioeconomic disparities.72 Notably, socioeconomic deprivation was associated with lower cancer mortality prior to the mid-1980s because of the later development of effective treatment and the historically elevated risk of lung and colorectal cancers among individuals with high SES.73, 74
County-level SES indicators only indirectly reflect individual SES, but are valuable because the county is the smallest geographic unit for which policy is legislated. In addition, county-level indicators potentially capture some of the complex environmental influences on health. Figure 8 depicts the distribution of county-level poverty by quintile across the United States during 2012-2016, when the overall cancer death rate was approximately 20% higher among residents of the poorest compared with the most affluent counties. Socioeconomic inequalities in cancer mortality widened over the past 3 decades overall, but there is substantial variation by cancer type. Consistent with socioeconomic inequalities for cancer incidence,75 the largest gaps are for the most preventable cancers. For example, cervical cancer mortality among women in poor counties is twice that of women in affluent counties, and lung and liver cancer mortality among men is >40% higher (Table 10). The most striking socioeconomic shift occurred for CRC mortality; rates in men in the poorest counties were approximately 20% lower than those in affluent counties in the early 1970s, but are now 35% higher (Fig. 9). This reversal reflects changes in dietary and smoking patterns that influence CRC risk,73 as well as the slower dissemination of screening and treatment advances among disadvantaged populations.76 A similar crossover occurred earlier for male lung cancer mortality because historically, men of higher SES were much more likely to smoke.73
|1970 TO 1974||2012 TO 2016|
|RATE RATIO (95% CI)||RATE RATIO (95% CI)|
|POOR||AFFLUENT||POOR VS AFFLUENT||POOR||AFFLUENT||POOR VS AFFLUENT|
|Both sexes||199.7||198.8||1.00 (1.00-1.01)||176.7||149.7||1.18 (1.18-1.19)|
|Male||259.0||250.4||1.03 (1.03-1.04)||217.5||177.3||1.23 (1.22-1.23)|
|Female||157.5||164.4||0.96 (0.95-0.97)||147.6||130.2||1.13 (1.13-1.14)|
|Brain & ONS|
|Both sexes||3.7||4.1||0.90 (0.86-0.93)||4.0||4.6||0.89 (0.86-0.91)|
|Male||4.6||4.9||0.93 (0.88-0.97)||4.9||5.6||0.87 (0.84-0.91)|
|Female||3.0||3.4||0.87 (0.82-0.92)||3.4||3.7||0.91 (0.87-0.95)|
|All races||29.0||34.0||0.85 (0.84-0.87)||22.5||19.5||1.16 (1.14-1.17)|
|White||28.8||34.4||0.84 (0.82-0.85)||20.9||19.7||1.06 (1.04-1.09)|
|Black||30.1||30.8||0.97 (0.90-1.05)||28.8||25.7||1.12 (1.08-1.16)|
|Both sexes||25.5||30.9||0.83 (0.81-0.84)||16.5||12.7||1.30 (1.28-1.32)|
|Male||28.6||35.6||0.81 (0.79-0.82)||20.2||14.9||1.35 (1.33-1.38)|
|Female||23.3||27.8||0.84 (0.82-0.86)||13.6||10.9||1.25 (1.23-1.28)|
|Both sexes||3.9||3.3||1.19 (1.14-1.24)||4.0||3.9||1.02 (0.99-1.04)|
|Male||6.7||5.5||1.20 (1.14-1.26)||7.1||6.9||1.03 (1.00-1.06)|
|Female||1.8||1.6||1.15 (1.06-1.25)||1.5||1.5||0.99 (0.93-1.05)|
|Both sexes||8.1||8.3||0.97 (0.94-1.00)||6.4||6.4||1.00 (0.97-1.02)|
|Male||10.5||11.1||0.94 (0.91-0.98)||8.6||8.7||0.99 (0.97-1.02)|
|Female||6.3||6.4||0.99 (0.95-1.04)||4.8||4.8||1.00 (0.97-1.04)|
|Liver & intrahepatic bile duct|
|Both sexes||3.5||2.8||1.27 (1.21-1.33)||7.7||5.6||1.37 (1.35-1.40)|
|Male||4.8||3.8||1.29 (1.21-1.37)||11.5||8.2||1.41 (1.37-1.44)|
|Female||2.5||2.0||1.22 (1.13-1.31)||4.5||3.5||1.31 (1.27-1.36)|
|Lung & bronchus|
|Both sexes||41.2||37.3||1.11 (1.09-1.12)||47.7||37.2||1.28 (1.27-1.29)|
|Male||76.3||66.8||1.14 (1.13-1.16)||63.0||44.2||1.42 (1.41-1.44)|
|Female||14.2||14.7||0.96 (0.94-0.99)||36.1||32.0||1.13 (1.12-1.14)|
|Both sexes||2.8||2.8||1.00 (0.96-1.05)||3.7||3.1||1.17 (1.14-1.21)|
|Male||3.4||3.4||1.00 (0.93-1.07)||4.6||4.0||1.14 (1.09-1.19)|
|Female||2.3||2.3||1.01 (0.94-1.08)||3.0||2.5||1.22 (1.17-1.28)|
|Both sexes||4.9||6.0||0.83 (0.80-0.85)||5.6||5.5||1.02 (1.00-1.05)|
|Male||6.2||7.3||0.85 (0.81-0.89)||7.2||7.1||1.02 (0.98-1.05)|
|Female||4.0||5.0||0.80 (0.76-0.84)||4.4||4.2||1.03 (0.99-1.06)|
|All races||9.0||10.6||0.84 (0.81-0.87)||7.0||7.0||1.00 (0.97-1.03)|
|White||9.3||10.8||0.86 (0.83-0.90)||7.3||7.3||1.00 (0.97-1.04)|
|Black||7.6||8.5||0.89 (0.77-1.04)||6.4||6.1||1.05 (0.97-1.14)|
|Both sexes||10.8||10.5||1.03 (1.01-1.06)||11.4||10.8||1.06 (1.04-1.07)|
|Male||14.3||13.3||1.07 (1.04-1.11)||13.0||12.5||1.04 (1.02-1.07)|
|Female||8.3||8.4||0.98 (0.95-1.02)||10.1||9.4||1.07 (1.05-1.10)|
|All races||32.6||30.2||1.08 (1.05-1.11)||22.5||17.9||1.26 (1.23-1.28)|
|White||28.1||29.9||0.94 (0.91-0.97)||18.2||17.7||1.03 (1.00-1.05)|
|Black||51.4||52.8||0.97 (0.90-1.06)||42.9||33.7||1.27 (1.21-1.34)|
|Both sexes||5.2||5.9||0.87 (0.84-0.91)||4.2||4.3||0.96 (0.94-0.99)|
|Male||8.5||10.4||0.82 (0.78-0.86)||7.2||7.6||0.95 (0.92-0.98)|
|Female||2.9||3.0||0.97 (0.91-1.04)||2.2||2.1||1.03 (0.98-1.08)|
|All races||5.9||5.5||1.08 (1.04-1.13)||5.3||4.6||1.15 (1.11-1.19)|
|White||5.2||5.4||0.96 (0.92-1.01)||4.3||4.5||0.96 (0.92-1.00)|
|Black||9.0||8.6||1.04 (0.90-1.22)||8.9||8.2||1.08 (1.01-1.16)|
|All races||8.9||5.1||1.73 (1.66-1.80)||3.2||1.6||2.00 (1.90-2.10)|
|White||6.7||4.9||1.36 (1.30-1.43)||2.9||1.6||1.86 (1.75-1.98)|
|Black||16.9||12.4||1.37 (1.22-1.54)||4.3||2.4||1.76 (1.57-1.99)|
- 95% CI indicates 95% confidence interval; ONS, other nervous system.
- "Poor" and "affluent" refer to extreme county-level poverty categories: 21.18% to 53.95% and 1.81% to 10.84%, respectively.
- Rates are per 100,000 population and age adjusted to the 2000 US standard population. Rate ratio is the unrounded rate in poor counties divided by the corresponding unrounded rate in affluent counties.
In contemporary times, the prevalence of behaviors that increase cancer incidence and mortality are vastly higher among residents of the poorest counties, including double the prevalence of smoking and obesity compared to residents of the wealthiest counties.70 Poverty is also associated with lower cancer screening prevalence,77 later stage diagnosis,78 and a lower likelihood of optimal treatment. Although lack of health care capacity in economically challenged areas likely contributes to these disparities, some states are home to both the poorest and most affluent counties, suggesting an opportunity for improvement in the distribution of services. Increasing access to care weakens the link between SES and health.79 Numerous states have reduced inequalities through various strategies that removed barriers to prevention, early detection, and treatment.80-82
Socioeconomic inequalities in cancer mortality are small or absent for malignancies that are less amenable to prevention or treatment. For example, mortality for leukemia and non-Hodgkin lymphoma was equivalent across poverty levels, despite a higher incidence in more affluent counties,75 likely reflecting survival disparities.83-85 Inferior survival among those with low SES is predominantly driven by a later stage of disease at diagnosis and less aggressive treatment.86 Disparities are also minimal or nonexistent for pancreatic and ovarian cancers, for which early detection is lacking and even optimal treatment has a nominal influence on survival. The inequality for prostate cancer mortality was largely confined to black men, even after accounting for Hispanic ethnicity among whites (data not shown). This finding is consistent with previous studies showing a stronger association between SES and prostate cancer mortality among blacks.87, 88 The slight excess mortality for brain/other nervous system tumors and urinary bladder cancer in affluent counties is in agreement with incidence studies and may partly reflect detection bias.75, 89
Cancer Disparities by Race/Ethnicity
Cancer occurrence and outcomes vary considerably between racial and ethnic groups, largely because of inequalities in wealth that lead to differences in risk factor exposures and barriers to high-quality cancer prevention, early detection, and treatment,90, 91 as discussed in the previous section. Cancer incidence and mortality are generally highest among non-Hispanic blacks (NHBs) and lowest among Asian/Pacific Islanders (Table 11). The overall cancer incidence rate in NHB men during 2011 through 2015 was 84% higher than that in Asian/Pacific Islander men and 9% higher than that in NHW men. Notably, NHB women had 7% lower cancer incidence than NHW women (because of lower rates of breast and lung cancer), but 13% higher cancer mortality. In men and women combined, the black-white disparity in overall cancer mortality has declined from a peak of 33% in 1993 (279.0 vs 210.5 per 100,000 population) to 14% in 2016 (183.6 vs 160.7 per 100,000 population). This progress is largely due to the steep drop in smoking prevalence unique among black teens from the late 1970s through the early 1990s.92
|ALL RACES COMBINED||NON-HISPANIC WHITE||NON-HISPANIC BLACK||ASIAN/PACIFIC ISLANDER||AMERICAN INDIAN/ ALASKA NATIVE *||HISPANIC|
|Colon & rectum||39.3||39.0||46.6||30.7||44.4||34.4|
|Kidney & renal pelvis||16.4||16.6||18.4||7.8||23.2||16.2|
|Liver & intrahepatic bile duct||8.1||6.7||10.7||13.0||14.8||13.3|
|Lung & bronchus||60.5||64.7||63.8||34.9||61.5||30.7|
|Colon & rectum||14.2||14.0||19.4||9.9||15.9||11.2|
|Kidney & renal pelvis||3.8||3.9||3.7||1.8||5.8||3.5|
|Liver & intrahepatic bile duct||6.5||5.7||8.6||9.4||10.8||9.3|
|Lung & bronchus||41.9||45.0||45.6||22.8||35.4||18.3|
- Rates are per 100,000 population and age adjusted to the 2000 US standard population. Nonwhite and nonblack race categories are not mutually exclusive of Hispanic origin.
- * Data based on Indian Health Service Contract Health Service Delivery Areas (CHSDA) counties.
Geographic Variation in Cancer Occurrence
Tables 12 and 13 show cancer incidence and mortality rates for selected cancers by state. State variation in cancer incidence results from differences in medical detection practices and the prevalence of risk factors, such as smoking, obesity, and other health behaviors. For example, up-to-date HPV vaccination coverage among adolescent (ages 13-17 years) boys and girls ranged widely in 2017, from just 29% in Mississippi to 78% in Rhode Island and the District of Columbia.93 This variation may contribute to future differential patterns in HPV-associated cancers across states.94, 95 Geographic health disparities, which have increased over time,96, 97 often reflect the national distribution of poverty.98 This trend may be exacerbated by widening inequalities in access to health care because of state/territory differences in Medicaid expansion and other initiatives to improve insurance coverage.99, 100
|STATE||ALL SITES||BREAST||COLORECTUM||LUNG & BRONCHUS||NON-HODGKIN LYMPHOMA||PROSTATE||URINARY BLADDER|
|Dist. of Columbia* †||527.8||444.3||144.6||50.1||38.7||65.4||49.5||22.6||12.9||154.1||23.2||8.5|
|Puerto Rico ‡||404.9||319.3||93.2||52.5||35.1||24.7||12.3||17.0||12.8||146.6||16.9||4.7|
- Rates are per 100,000 population and age adjusted to the 2000 US standard population.
- — Data unavailable.
- * Data for these states are not included in the US combined rates because either the registry did not consent or high-quality incidence data were not available for all years during 2011 through 2015 according to the North American Association of Central Cancer Registries (NAACCR).
- † Rates are based on cases diagnosed during 2011 through 2014.
- ‡ Data for Puerto Rico are not included in the US combined rates for comparability to previously published US rates.
|STATE||ALL SITES||BREAST||COLORECTUM||LUNG & BRONCHUS||NON-HODGKIN LYMPHOMA||PANCREAS||PROSTATE|
|Dist. of Columbia||200.2||155.6||28.3||18.4||13.5||44.3||30.7||6.3||3.3||15.8||11.8||31.0|
- Rates are per 100,000 population and age adjusted to the 2000 US standard population.
- a Rates for Puerto Rico are for 2011 through 2015 and are not included in the overall US combined rates.
The largest geographic variation in cancer occurrence by far is for lung cancer, reflecting the large historical and continuing differences in smoking prevalence between states.101 For example, lung cancer incidence rates during 2011 through 2015 in Kentucky (113 per 100,000 population in men and 79 per 100,000 population in women), where smoking prevalence continues to be highest, were approximately 3.5 times higher than those in Utah (32 per 100,000 population in men and 24 per 100,000 population in women), where smoking prevalence is lowest. In 2016, 1 in 4 residents of Kentucky and West Virginia were current smokers compared with 1 in 10 in Utah, Puerto Rico, and California.102
Cancer in Children and Adolescents
Cancer is the second most common cause of death among children aged 1 to 14 years in the United States, surpassed only by accidents. In 2019, an estimated 11,060 children (birth to 14 years) will be diagnosed with cancer and 1,190 will die from the disease. Benign and borderline malignant brain tumors are not included in the 2019 case estimates because the calculation method requires historical data and these tumors were not required to be reported to cancer registries until 2004.
Leukemia is the most common childhood cancer, accounting for 28% of cases (including benign and borderline malignant brain tumors). Brain and other nervous system tumors, approximately one-quarter of which are benign/borderline malignant, are second most common (26%) (Table 14). The distribution of cancers that occur in adolescents (aged 15 to 19 years) differs somewhat from that in children. For example, brain and other nervous system tumors (21%), greater than one-half of which (58%) are benign/borderline malignant, and lymphoma (20%) are the most common cancers, whereas leukemia accounts for just 13% of cases. Thyroid carcinoma and melanoma of the skin account for 11% and 4%, respectively, of cancers in adolescents, but only 2% and 1%, respectively, in children.
|BIRTH TO 14||15 TO 19|
|PERCENTAGE OF CASES||5-YEAR SURVIVAL, %||PERCENTAGE OF CASES||5-YEAR SURVIVAL, %|
|All ICCC groups combined||83.4||84.6|
|Acute myeloid leukemia||4%||66.4||4%||64.2|
|Non-Hodgkin lymphoma (including Burkitt lymphoma)||5%||90.2||7%||89.1|
|Central nervous system neoplasms||26%||72.9||21%||77.9|
|Neuroblastoma & other peripheral nervous cell tumors||6%||80.2||<1%||54.1 †|
|Nephroblastoma & other nonepithelial renal tumors||5%||92.7||<1%||—|
|Hepatic tumors||2%||80.4||<1%||52.4 †|
|Ewing tumor & related bone sarcomas||1%||77.7||2%||64.3|
|Germ cell & gonadal tumors||3%||91.6||11%||92.6|
- ICCC indicates International Classification of Childhood Cancer.
- Survival rates are adjusted for normal life expectancy and are based on follow-up of patients through 2015.
- — Statistic could not be calculated due to fewer than 25 cases diagnosed during 2008 to 2014.
- * Benign and borderline brain tumors were excluded from survival calculations, but were included in the denominator for case distribution.
- † The standard error of the survival rate is between 5 and 10 percentage points.
The overall cancer incidence rate in children and adolescents has been increasing slightly (by 0.7% per year) since 1975. In contrast, death rates have declined continuously for many decades, from 6.5 per 100,000 population in 1970 to 2.3 per 100,000 population in 2016, an overall reduction of 65% (65% in children and 61% in adolescents). Much of this progress reflects the dramatic 78% decline in leukemia mortality, from 2.7 per 100,000 children and adolescents in 1970 to 0.6 in 2016. Improved remission rates of 90% to 100% for childhood acute lymphocytic leukemia over the past 4 decades have been achieved primarily through the optimization of established chemotherapeutic agents as opposed to the development of new therapies.103 The 5-year relative survival rate for all cancers combined improved from 58% during the mid-1970s to 83% during 2008 through 2014 for children and from 68% to 85% for adolescents.10 However, survival varies substantially by cancer type and age at diagnosis (Table 14).
Although the estimated numbers of new cancer cases and deaths expected to occur in 2019 provide a reasonably accurate portrayal of the contemporary cancer burden, they are model-based, 3-year- and 4-year-ahead projections that should be interpreted with caution and not be used to track trends over time. First, the estimates may be affected by changes in methodology as we take advantage of improvements in modeling techniques and cancer surveillance coverage. Second, although the models are robust, they can only account for trends through the most recent data year (currently 2015 for incidence and 2016 for mortality) and cannot anticipate abrupt fluctuations for cancers affected by changes in detection practice (eg, PSA testing and prostate cancer). Third, the model can be oversensitive to sudden or large changes in observed data. The most informative metrics for tracking cancer trends are age-standardized or age-specific cancer death rates from the NCHS and cancer incidence rates from SEER, NPCR, and/or NAACCR.
Errors in reporting race/ethnicity in medical records and on death certificates may result in underestimates of cancer incidence and mortality in nonwhite and nonblack populations, particularly American Indian/Alaska Native populations. It is also important to note that cancer data in the United States are primarily reported for broad, heterogeneous racial and ethnic groups, masking important differences in the cancer burden within these populations. For example, lung cancer incidence is equivalent in Native Hawaiian and NHW men, but approximately 50% lower in Asians/Pacific Islanders overall.66
The continuous decline in cancer death rates since 1991 has resulted in an overall drop of 27%, translating to approximately 2.6 million fewer cancer deaths. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with residents of the poorest counties experiencing an increasingly disproportionate burden of the most preventable cancers. These counties are low-hanging fruit for locally focused cancer control efforts, including increased access to basic health care and interventions for smoking cessation, healthy living, and cancer screening programs. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.
All authors are employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the submitted work. The authors are not funded by or key personnel for any of these grants and their salary is solely funded through American Cancer Society funds.
- 1 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Mortality-All COD, Total US (1969–2016) <Early release with Vintage 2016 Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Surveillance Systems Branch; 2018; underlying mortality data provided by National Center for Health Statistics 2018.
- 2 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Mortality-All COD, Total US (1990–2016) <Early release with Vintage 2016 Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program; 2018; underlying mortality data provided by National Center for Health Statistics 2018.
- 3, , , et al. Long-term trends in cancer mortality in the United States, 1930–1998. Cancer. 2003; 97(suppl 12): 3133-3275.
- 4, , , . Deaths: Final Data for 2012. National Vital Statistics Reports. Vol 63. No. 9. Hyattsville, MD: National Center for Health Statistics; 2015.
- 5, , , et al. Cancer In North America, 2011–2015. Vol 3. Registry-Specific Cancer Mortality in the United States and Canada. Springfield, IL: North American Association of Central Cancer Registries Inc; 2018.
- 6 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence-SEER 9 Regs Research Data, Nov. 2017 Sub (1973–2015) <Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program; 2018.
- 7 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence-SEER 9 Regs Research Data with Delay-Adjustment, Malignant Only, Nov. 2017 Sub (1975–2015) <Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Surveillance Systems Branch; 2018.
- 8 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence-SEER 18 Regs Research Data + Hurricane Katrina Impacted Louisiana Cases, Nov. 2017 Sub (2000–2015) <Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Surveillance Systems Branch; 2018.
- 9 Statistical Research and Applications Branch, National Cancer Institute. DevCan: Probability of Developing or Dying of Cancer Software. Version 6.7.6. Bethesda, MD: Surveillance Research Program, Statistical Methodology and Applications, National Cancer Institute; 2018.
- 10, , , et al. SEER Cancer Statistics Review, 1975-2015. Bethesda, MD: National Cancer Institute; 2018.
- 11 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: North American Association of Central Cancer Registries (NAACCR) Incidence Data-CiNA Analytic File, 1995-2015, for Expanded Races, Custom File With County, ACS Facts and Figures Projection Project (Which Includes Data From CDC’s National Program of Cancer Registries [NPCR], CCCR’s Provincial and Territorial Registries, and the NCI’s Surveillance, Epidemiology, and End Results [SEER] Registries). Bethesda, MD: North American Association of Central Cancer Registries; 2018.
- 12 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: North American Association of Central Cancer Registries (NAACCR) Incidence Data-CiNA Analytic File, 1995-2015, for NHIAv2 Origin, Custom File With County, ACS Facts and Figures Projection Project (Which Includes Data From CDC’s National Program of Cancer Registries [NPCR], CCCR’s Provincial and Territorial Registries, and the NCI’s Surveillance, Epidemiology, and End Results [SEER] Registries). Bethesda, MD: North American Association of Central Cancer Registries; 2018.
- 13, , , et al. Cancer in North America: 2011-2015. Vol 1. Combined Cancer Incidence for the United States, Canada and North America. Springfield, IL: North American Association of Central Cancer Registries Inc; 2018.
- 14, , , et al. Cancer in North America: 2011–2015. Vol 2. Registry-Specific Cancer Incidence in the United States and Canada. Springfield, IL: North American Association of Central Cancer Registries Inc; 2018.
- 15, , , . International Classification of Childhood Cancer, third edition. Cancer. 2005; 103: 1457-1467.
- 16, , , et al. International Classification of Diseases for Oncology. 3rd ed. Geneva: World Health Organization; 2000.
- 17 World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th Rev. Vols I-III. Geneva: World Health Organization; 2011.
- 18 Surveillance Research Program, National Cancer Institute. SEER*Stat Software. Version 8.3.5. Bethesda, MD: Surveillance Research Program, National Cancer Institute; 2018.
- 19 Statistical Research and Applications Branch, National Cancer Institute. Joinpoint Regression Program, Version 18.104.22.168. Bethesda, MD: Statistical Research and Applications Branch, National Cancer Institute; 2018.
- 20, , , , . Impact of reporting delay and reporting error on cancer incidence rates and trends. J Natl Cancer Inst. 2002; 94: 1537-1545.
- 21, , , et al. A new method of estimating United States and state-level cancer incidence counts for the current calendar year. CA Cancer J Clin. 2007; 57: 30-42.
- 22, , , et al. Predicting US- and state-level cancer counts for the current calendar year: Part II: evaluation of spatiotemporal projection methods for incidence. Cancer. 2012; 118: 1100-1109.
- 23, , , et al. Predicting US- and state-level cancer counts for the current calendar year: Part I: evaluation of temporal projection methods for mortality. Cancer. 2012; 118: 1091-1099.
- 24, , , et al. Poverty in the United States: 50-Year Trends and Safety Net Impacts. aspe.hhs.gov/system/files/pdf/154286/50YearTrends.pdf. Accessed October 10, 2018.
- 25, . Sex differences in immune responses. Nat Rev Immunol. 2016; 16: 626-638.
- 26, , , et al. Pooled cohort study on height and risk of cancer and cancer death. Cancer Causes Control. 2014; 25: 151-159.
- 27, , , , . Height as an explanatory factor for sex differences in human cancer. J Natl Cancer Inst. 2013; 105: 860-868.
- 28, , , . The role of increasing detection in the rising incidence of prostate cancer. JAMA. 1995; 273: 548-552.
- 29, , . Cancer statistics, 2016. CA Cancer J Clin. 2016; 66: 7-30.
- 30; US Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012; 157: 120-134.
- 31, , , . Recent patterns of prostate-specific antigen testing for prostate cancer screening in the United States. JAMA Intern Med. 2017; 177: 1040-1042.
- 32, , , et al. Annual Report to the Nation on the Status of Cancer, part II: recent changes in prostate cancer trends and disease characteristics. Cancer. 2018; 124: 2801-2814.
- 33 U.S. Preventive Services Task Force. Draft Recommendation Statement: Screening for Prostate Cancer. screeningforprostatecancer.org. Accessed September 27, 2017.
- 34, , , , , . Prostate-specific antigen–based screening for prostate cancer: a systematic evidence review for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Pub. No. 17–05229-EF-1.
- 35 US Preventive Services Task Force, , , et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018; 319: 1901-1913.
- 36 Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence-SEER 18 Regs Research Data with Delay-Adjustment, Malignant Only, Nov. 2017 Sub (2000–2015)<Katrina/Rita Population Adjustment>-Linked To County Attributes-Total US, 1969–2016 Counties. Bethesda, MD: National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Surveillance Systems Branch; 2018.
- 37, , , et al. Annual Report to the Nation on the Status of Cancer, 1975–2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. J Natl Cancer Inst. 2015; 107: djv048.
- 38, , , et al. Annual Report to the Nation on the Status of Cancer, part I: national cancer statistics. Cancer. 2018; 124: 2785-2800.
- 39. Cigarette smoking among successive birth cohorts of men and women in the United States during 1900–80. J Natl Cancer Inst. 1983; 71: 473-479.
- 40, , , , . Increasing lung cancer death rates among young women in southern and midwestern states. J Clin Oncol. 2012; 30: 2739-2744.
- 41, , , et al. Higher lung cancer incidence in young women than young men in the United States. N Engl J Med. 2018; 378: 1999-2009.
- 42, , , et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010; 116: 544-573.
- 43, , , . Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992–2001. Cancer. 2006; 107(suppl 5): 1142-1152.
- 44, , . Trends in colorectal cancer incidence rates in the United States by tumor location and stage, 1992–2008. Cancer Epidemiol Biomarkers Prev. 2012; 21: 411-416.
- 45 National Center for Health Statistics, Centers for Disease Control and Prevention. National Health Interview Surveys 2000 and 2015. Public Use Data Files 2001. Atlanta, GA: National Center for Health Statistics, Centers for Disease Control and Prevention; 2016.
- 46, , , et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable factors in the United States in 2014. CA Cancer J Clin. 2018; 68: 31-54.
- 47, , , , . Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015; 62: 1353-1363.
- 48. New hepatitis C virus (HCV) drugs and the hope for a cure: concepts in anti-HCV drug development. Semin Liver Dis. 2014; 34: 22-29.
- 49, , , et al. Centers for Disease Control and Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012; 61: 1-32.
- 50; US Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013; 159: 349-357.
- 51, , , et al. Evaluation of the impact of mandating health care providers to offer hepatitis C virus screening to all persons born during 1945–1965–New York, 2014. MMWR Morb Mortal Wkly Rep. 2017; 66: 1023-1026.
- 52, . Recent hepatitis C virus testing patterns among baby boomers. Am J Prev Med. 2017; 53: e31-e33.
- 53 National Center for HIV/AIDS, Viral Hepatitis , STD, and TB Prevention, Centers for Disease Control and Prevention. Viral hepatitis surveillance, United States, 2016. cdc.gov/hepatitis/statistics/2016surveillance/index.htm. Accessed September 30, 2018.
- 54, , , et al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018; 108: 175-181.
- 55, , , et al. Annual Report to the Nation on the Status of Cancer, 1975–2014, featuring survival. J Natl Cancer Inst. 2017; 109(9).
- 56, , , et al. Relative survival in patients with chronic-phase chronic myeloid leukaemia in the tyrosine-kinase inhibitor era: analysis of patient data from six prospective clinical trials. Lancet Haematol. 2015; 2: e186-e193.
- 57 National Lung Screening Trial Research Team, , , et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011; 365: 395-409.
- 58, . Lung cancer screening with low-dose computed tomography in the United States–2010 to 2015. JAMA Oncol. 2017; 3: 1278-1281.
- 59, , , . Use of CT and chest radiography for lung cancer screening before and after publication of screening guidelines: intended and unintended uptake. JAMA Intern Med. 2017; 177: 439-441.
- 60, , , et al. Evaluating shared decision making for lung cancer screening. JAMA Intern Med. 2018; 178: 1311-1316.
- 61, , . Are increasing 5-year survival rates evidence of success against cancer?JAMA. 2000; 283: 2975-2978.
- 62, , , et al. Quantifying the role of PSA screening in the US prostate cancer mortality decline. Cancer Causes Control. 2008; 19: 175-181.
- 63, , , et al. Reconciling the effects of screening on prostate cancer mortality in the ERSPC and PLCO trials. Ann Intern Med. 2017; 167: 449-455.
- 64, . Changes in the Leading Cause of Death: Recent Patterns in Heart Disease and Cancer Mortality. Hyattsville, MD: National Center for Health Statistics; 2016. NCHS Data Brief No. 254.
- 65, , , et al. Cancer statistics for Hispanics/Latinos, 2015. CA Cancer J Clin. 2015; 65: 457-480.
- 66, , , , , . Cancer statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2016: converging incidence in males and females. CA Cancer J Clin. 2016; 66: 182-202.
- 67, , , et al. Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach [published online ahead of print October 9, 2018]. Ann Intern Med. https://doi.org/10.7326/M18-1250.
- 68 Centers for Disease Control and Prevention (CDC). Cervical cancer screening among women aged 18-30 years–United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2013; 61: 1038-1042.
- 69, , , , . National assessment of HPV and Pap tests: changes in cervical cancer screening, National Health Interview Survey. Prev Med. 2017; 100: 243-247.
- 70, , , , . Health and social conditions of the poorest versus wealthiest counties in the United States. Am J Public Health. 2017; 107: 130-135.
- 71, , . Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010; 51(suppl): S28-S40.
- 72, , , , , . An assessment of progress in cancer control. CA Cancer J Clin. 2018; 68: 329-339.
- 73, , . Changing area socioeconomic patterns in U.S. cancer mortality, 1950–1998: Part II–Lung and colorectal cancers. J Natl Cancer Inst. 2002; 94: 916-925.
- 74, . Socioeconomic and racial/ethnic disparities in cancer mortality, incidence, and survival in the United States, 1950–2014: over six decades of changing patterns and widening inequalities. J Environ Public Health. 2017; 2017: 2819372.
- 75, , , , , . The relationship between area poverty rate and site-specific cancer incidence in the United States. Cancer. 2014; 120: 2191-2198.
- 76, , , , . Fundamental causes of colorectal cancer mortality: the implications of informational diffusion. Milbank Q. 2012; 90: 592-618.
- 77, , , . Cancer screening delivery in persistent poverty rural counties. J Prim Care Community Health. 2011; 2: 240-249.
- 78, , , , , . The joint effects of census tract poverty and geographic access on late-stage breast cancer diagnosis in 10 US states. Health Place. 2013; 21: 110-121.
- 79, , , et al. Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: a longitudinal analysis. Lancet. 2016; 388: 684-695.
- 80, , , et al. Eliminating racial disparities in colorectal cancer in the real world: it took a village. J Clin Oncol. 2013; 31: 1928-1930.
- 81, , . Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012; 367: 1025-1034.
- 82, , . Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014; 160: 585-593.
- 83, , , , , . Effects of poverty and race on outcomes in acute myeloid leukemia. Am J Clin Oncol. 2011; 34: 297-304.
- 84, , , et al. Socioeconomic disparities in survival from childhood leukemia in the United States and globally: a meta-analysis. Ann Oncol. 2015; 26: 589-597.
- 85, , , , . Ethnic variations in diagnosis, treatment, socioeconomic status, and survival in a large population-based cohort of elderly patients with non-Hodgkin lymphoma. Cancer. 2008; 113: 3231-3241.
- 86, , , et al.: Patterns of Care Study Group. The impact of socioeconomic status on survival after cancer in the United States: findings from the National Program of Cancer Registries Patterns of Care Study. Cancer. 2008; 113: 582-591.
- 87, , , et al. Cancer mortality in the United States by education level and race. J Natl Cancer Inst. 2007; 99: 1384-1394.
- 88, , , , , . Geographic patterns of prostate cancer mortality and variations in access to medical care in the United States. Cancer Epidemiol Biomarkers Prev. 2005; 14: 590-595.
- 89, , , et al. Socioeconomic position and the risk of brain tumour: a Swedish national population-based cohort study. J Epidemiol Community Health. 2016; 70: 1222-1228.
- 90, , , et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004; 54: 78-93.
- 91, , , , , . Survival of blacks and whites after a cancer diagnosis. JAMA. 2002; 287: 2106-2113.
- 92, , , et al. Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications. Am J Public Health. 2008; 98: 905-915.
- 93, , , et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years–United States, 2017. MMWR Morb Mortal Wkly Rep. 2018; 67: 909-917.
- 94, , , et al. HPV-IMPACT Working Group. Reduction in HPV 16/18–associated high grade cervical lesions following HPV vaccine introduction in the United States–2008-2012. Vaccine. 2015; 33: 1608-1613.
- 95, , , et al. Surveillance of high-grade cervical cancer precursors (CIN III/AIS) in four population-based cancer registries, United States, 2009–2012. Prev Med. 2017; 103: 60-65.
- 96, , , . The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Medicine. 2008; 5: e66.
- 97, , , et al. Trends and patterns of disparities in cancer mortality among US counties, 1980–2014. JAMA. 2017; 317: 388-406.
- 98, , , . Where can colorectal cancer screening interventions have the most impact?Cancer Epidemiol Biomarkers Prev. 2015; 24: 1151-1156.
- 99, , , . Diet quality, risk factors and access to care among low-income uninsured American adults in states expanding Medicaid vs. states not expanding under the Affordable Care Act. Prev Med. 2016; 91: 169-171.
- 100, , . Health insurance coverage and health–what the recent evidence tells us. N Engl J Med. 2017; 377: 586-593.
- 101, , , et al. Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst. 2008; 100: 1672-1694.
- 102 State Tobacco Activities Tracking and Evaluation (STATE) System, Centers for Disease Control and Prevention. Map of current cigarette use among adults: current cigarette use among adults (Behavior Risk Factor Surveillance System) 2016. cdc.gov/statesystem/cigaretteuseadult.html. Accessed October 15, 2018.
- 103, , . Toward the potential cure of leukemias in the next decade [published online ahead of print October 6, 2018]. Cancer. https://doi.org/10.1002/cncr.31669.