Cancer Statistics, 2021
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2017) 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 (through 2018) were collected by the National Center for Health Statistics. In 2021, 1,898,160 new cancer cases and 608,570 cancer deaths are projected to occur in the United States. After increasing for most of the 20th century, the cancer death rate has fallen continuously from its peak in 1991 through 2018, for a total decline of 31%, because of reductions in smoking and improvements in early detection and treatment. This translates to 3.2 million fewer cancer deaths than would have occurred if peak rates had persisted. Long-term declines in mortality for the 4 leading cancers have halted for prostate cancer and slowed for breast and colorectal cancers, but accelerated for lung cancer, which accounted for almost one-half of the total mortality decline from 2014 to 2018. The pace of the annual decline in lung cancer mortality doubled from 3.1% during 2009 through 2013 to 5.5% during 2014 through 2018 in men, from 1.8% to 4.4% in women, and from 2.4% to 5% overall. This trend coincides with steady declines in incidence (2.2%-2.3%) but rapid gains in survival specifically for nonsmall cell lung cancer (NSCLC). For example, NSCLC 2-year relative survival increased from 34% for persons diagnosed during 2009 through 2010 to 42% during 2015 through 2016, including absolute increases of 5% to 6% for every stage of diagnosis; survival for small cell lung cancer remained at 14% to 15%. Improved treatment accelerated progress against lung cancer and drove a record drop in overall cancer mortality, despite slowing momentum for other common cancers.
Cancer is a major public health problem worldwide and is the second leading cause of death in the United States. In 2020, the diagnosis and treatment of cancer was hampered by the coronavirus disease 2019 (COVID-19) pandemic. For example, reduced access to care because of health care setting closures resulted in delays in diagnosis and treatment that may lead to a short-term drop in cancer incidence followed by an uptick in advanced stage disease and ultimately increased mortality. However, this secondary consequence of the pandemic will take several years to quantify because of the lag in dissemination of population-based surveillance data.
In this article, we provide the estimated numbers of new cancer cases and deaths in 2021 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 2017 and for mortality through 2018. We also estimate the total number of cancer deaths averted due to the decline in cancer mortality since the early 1990s.
Materials and Methods
Incidence, Survival, and Mortality Data
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 (1975-2017) 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.1, 2 Contemporary stage distribution and survival statistics were based on data from the 18 SEER registries (SEER 9 plus the Alaska Native Tumor Registry, California, Georgia, Kentucky, Louisiana, and New Jersey).3 Contemporary incidence trends were based on all 21 SEER registries (SEER 18 plus Idaho, Massachusetts, and New York)4 unless otherwise specified, as was the probability of developing cancer, which was calculated using the NCI's DevCan software, version 220.127.116.11 Some of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975-2017.6
The North American Association of Central Cancer Registries (NAACCR) compiles and reports incidence data from 1995 forward 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 2021 and cross-sectional incidence rates by state and race/ethnicity.7, 8 Some of the incidence data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2013-2017.9, 10
Mortality data from 1930 to 2018 were provided by the National Center for Health Statistics (NCHS).11, 12 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.12, 13 Mortality rates (2013-2017) for Puerto Rico were previously published in volume 3 of the NAACCR's Cancer in North America: 2013-2017.14
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.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 persons, as calculated using the NCI's SEER*Stat software, version 18.104.22.168 The annual percent change in rates was quantified using the NCI's Joinpoint Regression Program (version 22.214.171.124).19 All tests of statistical significance were 2-sided, and a P value <.05 was considered statistically significant.
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 2017 in the 9 oldest SEER registries was 10% higher after adjusting for reporting delays (15.3 vs 13.9 per 100,000).6
Projected Cancer Cases and Deaths in 2021
The most recent year for which incidence and mortality data are available lags 2 to 4 years behind the current year because of the time required for data collection, compilation, quality control, and dissemination. Therefore, we project the numbers of new cancer cases and deaths in the United States in 2021 to provide an estimate of the contemporary cancer burden. The methodology for calculating contemporary cases and deaths was revised for 2021 to take advantage of advances in statistical modeling and improved cancer registration coverage. Basal cell and squamous cell skin cancers cannot be estimated because incidence data are not collected by most cancer registries. The 2021 projections are based on currently available incidence and mortality data and thus do not reflect the impact of COVID-19 on cancer cases and deaths.
The first step in calculating the number of invasive cancer cases expected in 2021 was to estimate complete counts in every state from 2003 through 2017 using delay-adjusted, high-quality NAACCR incidence data from 50 states and the District of Columbia (98% population coverage; data were unavailable for a few sporadic years for a limited number of states). A generalized linear mixed model (Liu et al., unpublished data) was used that accounted for geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors.21 Modeled state- and national-level counts were projected forward using a novel, data-driven joinpoint algorithm to estimate cases for 2021 (Miller et al., unpublished data).
New cases of ductal carcinoma in situ (DCIS) of the female breast and in situ melanoma of the skin diagnosed in 2021 were estimated by first approximating the number of cases occurring annually from 2008 through 2017 based on age-specific NAACCR incidence rates (data from 49 states with high-quality data available for all 10 years) and US Census Bureau population estimates obtained using SEER*Stat.7, 22 Counts were then adjusted for delays in reporting using SEER 21 delay factors for invasive disease (delay factors are unavailable for in situ cases) and projected to 2021 based on the average annual percent change generated by the joinpoint regression model.4
The number of cancer deaths expected to occur in 2021 was estimated by applying the data-driven joinpoint algorithm described for the invasive cases methodology to reported cancer deaths from 2004 through 2018 at the state and national levels as reported to the NCHS (Miller et al., unpublished data).
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-specific and sex-specific cancer death rates in the peak year for age-standardized cancer death rates (1990 in men, 1991 in women) to the corresponding age-specific and sex-specific populations in subsequent years through 2018.
Expected Numbers of New Cancer Cases and the Probability of Cancer
Table 1 presents the estimated numbers of new invasive cancer cases in the United States in 2021 by sex and cancer type. In total, there will be approximately 1,898,160 cancer cases diagnosed, the equivalent of 5200 new cases each day. In addition, there will be about 49,290 new cases of DCIS diagnosed in women and 101,280 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||54,010||38,800||15,210||10,850||7,620||3,230|
|Other oral cavity||3,290||2,370||920||1,460||1,110||350|
|Anus, anal canal, & anorectum||9,090||3,020||6,070||1,430||560||870|
|Liver & intrahepatic bile duct||42,230||29,890||12,340||30,230||20,300||9,930|
|Gallbladder & other biliary||11,980||5,730||6,250||4,310||1,770||2,540|
|Other digestive organs||7,650||3,380||4,270||3,300||1,460||1,840|
|Lung & bronchus||235,760||119,100||116,660||131,880||69,410||62,470|
|Other respiratory organs||5,790||3,870||1,920||1,390||910||480|
|Bones & joints||3,610||2,100||1,510||2,060||1,190||870|
|Soft tissue (including heart)||13,460||7,720||5,740||5,350||2,840||2,510|
|Skin (excluding basal & squamous)||115,320||68,120||47,200||11,540||7,660||3,880|
|Melanoma of the skin||106,110||62,260||43,850||7,180||4,600||2,580|
|Other nonepithelial skin||9,210||5,860||3,350||4,360||3,060||1,300|
|Vagina & other genital, female||8,180||8,180||1,530||1,530|
|Penis & other genital, male||2,210||2,210||460||460|
|Kidney & renal pelvis||76,080||48,780||27,300||13,780||8,790||4,990|
|Ureter & other urinary organs||4,190||2,690||1,500||960||590||370|
|Eye & orbit||3,320||1,750||1,570||400||220||180|
|Brain & other nervous system||24,530||13,840||10,690||18,600||10,500||8,100|
|Acute lymphocytic leukemia||5,690||3,000||2,690||1,580||900||680|
|Chronic lymphocytic leukemia||21,250||13,040||8,210||4,320||2,620||1,700|
|Acute myeloid leukemia||20,240||11,230||9,010||11,400||6,620||4,780|
|Chronic myeloid leukemia||9,110||5,150||3,960||1,220||680||540|
|Other & unspecified primary sites c||32,880||16,270||16,610||47,230||25,610||21,620|
- These are model-based estimates that should be interpreted with caution and not compared with those for previous years.
- a Rounded to the nearest 10; cases exclude basal cell and squamous cell skin cancer and in situ carcinoma except urinary bladder. Approximately 49,290 cases of female breast ductal carcinoma in situ and 101,280 cases of melanoma in situ will be diagnosed in 2021.
- b Deaths for colon and rectal cancers are combined because a large number of deaths from rectal cancer are misclassified as colon.
- c More deaths than cases may reflect a lack of specificity in recording underlying cause of death on death certificates and/or an undercount in the case estimate.
|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||3,450||630||b||270||140||80||360||120||110||550||110|
- These are model-based estimates that should be interpreted with caution. State estimates may not sum to US total due to rounding and the exclusion of states with fewer than 50 cases.
- a 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.
- b Estimate is fewer than 50 cases.
Figure 1 depicts the most common cancers diagnosed in men and women in 2021. Prostate, lung and bronchus (lung hereafter), and colorectal cancers (CRCs) account for 46% of all incident cases in men, with prostate cancer alone accounting for 26% of diagnoses. For women, breast cancer, lung, and CRCs account for 50% of all new diagnoses, with breast cancer alone accounting for 30% of female cancers.
The probability of being diagnosed with invasive cancer is slightly higher for men (40.5%) than for women (38.9%) (Table 3), reflecting differences in life expectancy as well as cancer risk.23 The sex disparity in overall cancer incidence has narrowed over time, with the male-to-female incidence rate ratio (IRR) dropping from 1.39 (95% CI, 1.38-1.40) in 1995 to 1.14 (95% CI, 1.13-1.14) in 2017 This is because incidence rates declined during this time period by 2% overall among women versus 20% among men, largely driven by differences in lung cancer trends. (See section on incidence trends for more information.)
|BIRTH TO 49||50 TO 59||60 TO 69||70 AND OLDER||BIRTH TO DEATH|
|All sites b|
|Male||3.5 (1 in 29)||6.2 (1 in 16)||13.6 (1 in 7)||33.2 (1 in 3)||40.5 (1 in 2)|
|Female||5.8 (1 in 17)||6.4 (1 in 16)||10.3 (1 in 10)||26.8 (1 in 4)||38.9 (1 in 3)|
|Female||2.1 (1 in 49)||2.4 (1 in 42)||3.5 (1 in 28)||7.0 (1 in 14)||12.9 (1 in 8)|
|Male||0.4 (1 in 254)||0.7 (1 in 143)||1.1 (1 in 92)||3.2 (1 in 32)||4.3 (1 in 23)|
|Female||0.4 (1 in 266)||0.5 (1 in 191)||0.8 (1 in 128)||2.9 (1 in 34)||4.0 (1 in 25)|
|Kidney & renal pelvis|
|Male||0.2 (1 in 410)||0.4 (1 in 263)||0.7 (1 in 151)||1.4 (1 in 73)||2.2 (1 in 46)|
|Female||0.2 (1 in 647)||0.2 (1 in 541)||0.3 (1 in 310)||0.8 (1 in 133)||1.3 (1 in 80)|
|Male||0.3 (1 in 391)||0.2 (1 in 549)||0.4 (1 in 255)||1.4 (1 in 69)||1.8 (1 in 55)|
|Female||0.2 (1 in 500)||0.1 (1 in 834)||0.2 (1 in 427)||0.9 (1 in 110)||1.3 (1 in 78)|
|Lung & bronchus|
|Male||0.1 (1 in 776)||0.6 (1 in 163)||1.7 (1 in 58)||5.9 (1 in 17)||6.6 (1 in 15)|
|Female||0.1 (1 in 679)||0.6 (1 in 172)||1.4 (1 in 70)||4.9 (1 in 21)||6.0 (1 in 17)|
|Melanoma of the skin c|
|Male||0.4 (1 in 230)||0.5 (1 in 198)||0.9 (1 in 109)||2.7 (1 in 37)||3.7 (1 in 27)|
|Female||0.6 (1 in 156)||0.4 (1 in 241)||0.5 (1 in 187)||1.2 (1 in 86)||2.5 (1 in 40)|
|Male||0.3 (1 in 375)||0.3 (1 in 345)||0.6 (1 in 177)||1.9 (1 in 54)||2.4 (1 in 42)|
|Female||0.2 (1 in 523)||0.2 (1 in 463)||0.4 (1 in 242)||1.4 (1 in 73)||1.9 (1 in 52)|
|Male||0.2 (1 in 451)||1.8 (1 in 55)||5.0 (1 in 20)||8.7 (1 in 12)||12.1 (1 in 8)|
|Male||0.2 (1 in 447)||0.1 (1 in 703)||0.2 (1 in 571)||0.2 (1 in 412)||0.7 (1 in 146)|
|Female||0.9 (1 in 114)||0.4 (1 in 258)||0.4 (1 in 283)||0.4 (1 in 263)||1.9 (1 in 53)|
|Female||0.3 (1 in 362)||0.1 (1 in 837)||0.1 (1 in 916)||0.2 (1 in 590)||0.6 (1 in 158)|
|Female||0.3 (1 in 322)||0.6 (1 in 157)||1.1 (1 in 94)||1.5 (1 in 67)||3.1 (1 in 32)|
- a For people free of cancer at beginning of age interval.
- b All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder.
- c Probabilities for non-Hispanic Whites only.
However, these overall sex differences mask variation in risk in both direction and size among younger age groups. For example, during childhood (ages 0-14 years), incidence is about 10% higher in boys than in girls (IRR, 1.11; 95% CI, 1.09-1.13),24 whereas, during early adulthood (ages 20-49 years), it is 44% lower in men (IRR, 0.56; 95% CI, 0.558-0.563), largely because of breast cancer occurrence in young women.25 Reasons for sex differences are not fully understood but probably largely reflect differences in exposure to environmental risk factors and endogenous hormones, as well as complex interactions between these influences. Sex differences in immune function and response may also play a role.26
Expected Number of Cancer Deaths
An estimated 608,570 Americans will die from cancer in 2021, corresponding to more than 1600 deaths per day (Table 1). The greatest number of deaths are from cancers of the lung, prostate, and colorectum in men and cancers of the lung, breast, and colorectum in women (Fig. 1). Table 4 provides estimated number of deaths for these and other common cancers by state.
Almost one-quarter of all cancer deaths are due to lung cancer, 82% of which is directly caused by cigarette smoking.27 This translates to approximately 107,870 smoking-attributable lung cancer deaths in 2021, with an additional 3590 due to second-hand smoke exposure, leaving a residual 20,420 lung cancer deaths. Thus nonsmoking-related lung cancer accounts for a substantial burden, ranking among the top 10 causes of cancer death among sexes combined.
Women have a larger fraction of nonsmoking-related lung cancer than men,27 despite an equivalent relative risk associated with smoking,28 because they have not smoked to the same extent as men. Similarly, the proportion of nonsmoking-related lung cancer is slowly increasing in both sexes because of continuous declines in smoking prevalence.29 (Temporal trends in the incidence of nonsmoking-related lung cancer are unknown because data on smoking status have only recently begun to be collected by cancer registries.) Nevertheless, even among recently diagnosed lung cancer patients (2011-2016), 84% of women and 90% of men had ever smoked, including 72% and 81%, respectively, of those aged 20 to 49 years.30 Smoking continues to be the leading preventable cause of death in the United States, costing more than $300 billion annually. As a result, CDC has redoubled efforts to increase cessation, including publication of a new Surgeon General's report this year.31, 32 Smokers who quit by age 40 years reduce their risk of death from smoking-related disease by about 90% compared with continued smoking.33
|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||70||100||90||b||50||140||b||b||100||70|
- These are model-based estimates that should be interpreted with caution. State estimates may not sum to US total due to rounding and exclusion of states with fewer than 50 deaths.
- a Rounded to the nearest 10. Estimates for Puerto Rico are not available.
- b Estimate is fewer than 50 deaths.
Trends in Cancer Incidence
Figure 2 illustrates long-term trends in overall cancer incidence rates, which reflect both patterns in behaviors associated with cancer risk and changes in medical practice, such as the use of cancer screening tests. For example, the spike in incidence for males during the early 1990s reflects rapid changes in prostate cancer incidence rates due to a surge in detection of asymptomatic disease as a result of widespread prostate-specific antigen (PSA) testing among previously unscreened men.34
The overall cancer incidence rate in men generally decreased from the early 1990s until around 2013 but has since remained stable (through 2017), reflecting slowing declines for CRC and a halt in the decline for prostate cancer (Fig. 3). The sharp drop in prostate cancer incidence rates from 2007 to 2014 is attributed to decreased PSA testing in the wake of US Preventive Services Task Force recommendations against routine use of the test to screen for prostate cancer (grade D) because of growing concerns about overdiagnosis and overtreatment.35, 36 However, this decision was largely based on clinical trial data that have been criticized for widespread screening among control subjects and insufficient follow-up time.37 Since around 2010, there has been an increase in distant-stage prostate cancer diagnoses across age and race,38-40 and, in 2017 the US Preventive Services Task Force upgraded their recommendation for men aged 55 to 69 years to informed decision making (grade C).41-43 There is some evidence that the long-term benefit of screening is underappreciated, particularly given recent advances in mitigating over detection through more stringent diagnostic criteria and reducing overtreatment via active surveillance for low-risk disease.37, 44, 45
Overall cancer incidence in women has ticked up slightly in recent years after stable rates over the past couple of decades.46 This partly reflects a slowing decline for CRC coupled with increasing rates for breast and uterine corpus cancers (Fig. 3). Breast cancer incidence rates continue to increase by about 0.5% per year, which is attributed at least in part to continued declines in the fertility rate and increased body weight.47 These factors may also contribute to the continued increase in uterine corpus cancer incidence of about 1% per year,48 although a recent study indicated that this trend is driven by nonendometrioid subtypes, which are not as strongly associated with obesity as endometrioid carcinoma.49 Thyroid cancer incidence has begun to decline in women (although not yet in men) after the implementation of more conservative diagnostic practices in response to the sharp uptick in largely indolent tumors in recent decades.50, 51
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.52, 53 However, smoking patterns do not appear to fully explain higher lung cancer incidence in women than in men among individuals born since circa 1960.54 In contrast, CRC incidence patterns are generally similar in men and women, with both experiencing rapid declines during the 2000s in the wake of widespread colonoscopy uptake that have slowed in recent years (Fig. 3). Importantly, declines in overall CRC incidence mask increasing rates among adults aged <65 years.55
Incidence continues to increase in both men and women for cancers of the kidney, pancreas, and oral cavity and pharynx (non-Hispanic Whites [NHWs]) and melanoma of the skin, although melanoma has begun to decline in recent birth cohorts.25, 56 Liver cancer incidence has stabilized in men after decades of steep increase but continues to rise in women by >2% annually. The majority (71%) of these cases are potentially preventable because most liver cancer risk factors are modifiable (eg, obesity, excess alcohol consumption, cigarette smoking, and hepatitis B virus and hepatitis C virus [HCV]).27 Chronic HCV infection, the most common chronic blood-borne infection in the United States, confers the largest relative risk and accounts for 1 in 4 liver cancer cases.57 Although well tolerated antiviral therapies achieve >90% cure rates and could potentially avert much of the future burden of HCV-associated disease,58 most infected individuals are undiagnosed and thus untreated. Compounding the challenge is a greater than 3-fold spike in acute HCV infections reported to the CDC between 2010 and 2017 as a consequence of the opioid epidemic, 75% to 85% of which will progress to chronic infection.59 In a renewed attempt to mitigate the rising HCV-associated disease burden, the CDC and the US Preventive Services Task Force issued new recommendations in 2020 for one-time HCV testing of all adults aged ≥18 years.60-62
The 5-year relative survival rate for all cancers combined diagnosed during 2010 through 2016 was 67% overall, 68% in White individuals, and 63% in Black individuals.6 Figure 4 shows 5-year relative survival rates for selected cancer types by stage at diagnosis and race. For all stages combined, survival is highest for prostate cancer (98%), melanoma of the skin (93%), and female breast cancer (90%) and lowest for cancers of the pancreas (10%), liver (20%), esophagus (20%), and lung (21%). Survival rates are lower for Black patients than for Whites for every cancer type illustrated in Figure 4 except pancreas and kidney, for which they are the same. For kidney cancer, however, these overall statistics are misleading because they reflect the higher proportion in Black patients of papillary and chromophobe renal cell carcinomas (RCCs), which have a better prognosis than clear cell RCC, which is more common among Whites; indeed, Black patients have lower survival for every RCC subtype.63 The largest Black-White survival differences in absolute terms are for melanoma (25%) and cancers of the uterine corpus (21%), oral cavity and pharynx (18%), and urinary bladder (13%). Although these disparities partly reflect later stage diagnosis in patients who are Black (Fig. 5), Black individuals also have lower stage-specific survival for most cancer types (Fig. 4). After adjusting for sex, age, and stage at diagnosis, the relative risk of death is 33% higher in Black than in White patients with cancer.64 The disparity is even larger for American Indian/Alaska Native patients, among whom the risk of cancer death is 51% higher than in White patients.
Cancer survival has improved since the mid-1970s for all of the most common cancers except uterine cervix and uterine corpus,64 largely reflecting the absence of major treatment advances for these cancers.65, 66 For cervical cancer, it may also reflect an increasing proportion of adenocarcinoma over time because of widespread cytology screening, which mostly detects squamous precancerous lesions and invasive squamous cell carcinomas.67 Screening also hinders the utility of tracking trends in survival to measure progress against breast and prostate cancers because of lead-time bias and the detection of indolent cancers.68 Gains in survival have been especially rapid for hematopoietic and lymphoid malignancies due to improvements in treatment protocols, including the development of targeted therapies. For example, the 5-year relative survival rate for chronic myeloid leukemia increased from 22% in the mid-1970s to 72% for those diagnosed during 2010 through 2016,6 and most patients treated with tyrosine kinase inhibitors experience near-normal life expectancy.69
Low lung cancer survival rates reflect the large proportion of patients (57%) diagnosed with metastatic disease (Fig. 5), for which the 5-year relative survival rate is 6% (Fig. 4). However, the 5-year survival for localized stage disease is 59%, and there is potential for earlier diagnoses through annual screening with low-dose computed tomography, which demonstrated a 20% reduction in lung cancer mortality in ≥30 pack-year current and former smokers compared with chest radiography in the National Lung Screening Trial.70 More recently, the Multicentric Italian Lung Detection trial, which included more screening rounds, longer follow-up, and a more moderate risk pool (≥20 pack-years), reported a 39% reduction in lung cancer mortality compared with no intervention.71 As a result, the US Preventive Services Task Force updated their 2013 screening recommendation in a draft statement issued in July 2020 that expanded the eligibility pool from adults 55 to 80 years with a 30 pack-year smoking history to ages 50 to 80 years with a 20 pack-year history. However, the implementation of widespread screening within the general population remains challenging and inappropriate testing is not uncommon.72, 73 Broad implementation of recommended lung cancer screening will require new systems to facilitate unique aspects of the process, including the identification of eligible patients and education of physicians about the details of shared decision making, which is required for reimbursement by the Centers for Medicaid and Medicare Services.
Trends in Cancer Mortality
Mortality rates are a better indicator of progress against cancer than incidence or survival because they are less affected by biases resulting from changes in detection practices.74 The cancer death rate rose during most of the 20th century, largely because of a rapid increase in lung cancer deaths among men as a consequence of the tobacco epidemic. However, reductions in smoking as well as improvements in early detection and treatment for some cancers have resulted in a continuous decline in the cancer death rate since its peak of 215.1 (per 100,000) in 1991. The overall drop of 31% as of 2018 (149.0 per 100,000) translates to an estimated 3,188,500 fewer cancer deaths (2,170,700 in men and 1,017,800 in women) than what would have occurred if mortality rates had remained at their peak (Fig. 6). The number of averted deaths is twice as large for men than for women because the death rate in men peaked higher and declined faster (Fig. 7).
The progress against cancer reflects large decreases in mortality for the 4 major sites (lung, breast, prostate, and colorectal) (Fig. 7). Specifically, as of 2018, the death rate had dropped from its peak for lung cancer by 54% among males (since 1990) and by 30% among females (since 2002); for female breast cancer by 41% (since 1989); for prostate cancer by 52% (since 1993); and for CRC by 53% among males (since 1980) and by 59% among females (since 1969). (Although CRC death rates were declining in women before 1969, earlier data years are not exclusive of deaths from small intestine cancer.) However, in recent years, mortality declines have slowed for female breast cancer and CRC and have halted for prostate cancer (Table 5). During the late 1990s and 2000s, the prostate cancer death rate declined by 4% per year on average because of advances in treatment and earlier stage diagnosis through PSA testing.75, 76 However, PSA testing dropped by about 10 percentage points in absolute terms from 2008 to 2013,77, 78 which coincided with an uptick in distant-stage diagnoses38, 40 followed by a stable mortality trend from 2013 to 2018.
|TREND 1||TREND 2||TREND 3||TREND 4||TREND 5||TREND 6||AAPC|
|Liver & intrahepatic bile duct|
|Lung & bronchus|
|Melanoma of skin|
|Oral cavity and pharynx|
|Tongue, tonsil, oropharynx||1975-2000||−1.6a||2000-2009||−0.1||2009-2018||1.9a||1.9a||1.9a||1.9a|
|Other oral cavity||1975-1992||−1.6a||1992-2006||−2.9a||2006-2018||−0.8a||−0.8a||−0.8a||−0.8a|
- Abbreviations: AAPC, 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 4.7, allowing up to 5 joinpoints.
- a The APC or AAPC is significantly different from zero (P < .05).
In contrast, declines in mortality for melanoma and lung cancer have accelerated in recent years, likely due to improvements in treatment.79, 80 For example, the death rate for melanoma was stable from 2009 to 2013, but decreased over the next 5 years (2014-2018) by 5.7% annually. Over the same time period, the pace of the annual decline for lung cancer doubled from 3.1% to 5.5% in men, from 1.8% to 4.4% in women, and from 2.4% to 5% overall (Table 5). Lung cancer accounted for almost one-half (46%) of the total decline in cancer mortality from 2014 to 2018 of 7.7%, which is reduced to 4.1% with the exclusion of lung cancer. Expedited progress in lung cancer mortality likely reflects improved treatment because incidence rates decreased steadily from 2008 to 2017 by about 2.2% to 2.3% per year based on cancer registry data covering 69% of the US population.7 These findings are also consistent with a recent SEER analysis by Howlader et al, who also examined stage at diagnosis and found no evidence of a shift to earlier diagnosis, suggesting little impact of lung cancer screening on population-based mortality trends, likely due to low adherence.80, 81 In contrast to steady incidence trends, the 2-year relative survival rate for lung cancer increased from 30% during 2009 through 2010 to 36% during 2015 through 2016. This progress is confined to the 80% of individuals diagnosed with nonsmall cell lung cancer (NSCLC), for whom 2-year survival increased from 34% to 42%, with absolute gains of 5% to 6% for every stage of diagnosis (Fig. 8). Meanwhile, survival for small cell lung cancer remained low and steady at 14% to 15%. Increased survival for regional-stage small cell lung cancer coincides with a steep decline for unstaged cancers and thus likely reflects improved staging (Fig. 8).
Therapeutic advances that likely contributed to survival gains include epidermal growth factor receptor tyrosine kinase inhibitors that are targeted against the most common NSCLC driver mutations.82 Immunotherapy (ie, programmed cell death protein-1/programmed death ligand-1 inhibitors) may have played a small role,83 although these drugs were not approved by the US Food and Drug Administration for second-line treatment until 2015.84 Notably these therapies are directed at metastatic disease, so the comparable survival improvements for earlier stage cancers likely reflect advances in diagnostic and surgical procedures, such as pathologic staging and video-assisted thoracoscopic surgery.85, 86 In addition, increased access to care for many individuals after the 2014 implementation of the Patient Protection and Affordable Care Act and Medicaid expansion was recently found to be independently associated with survival gains for NSCLC.87
Despite the steady progress in mortality for most cancers, rates continue to increase for some common sites. The increase in death rates for uterine corpus cancer has accelerated from 0.3% per year from 1997 through 2008 to 1.9% per year from 2008 through 2018 (Table 5), twice the pace of the increase in incidence.6, 46 This may reflect the increase in nonendometrioid carcinoma, which is associated with a poor prognosis.49 Death rates are also increasing for cancers of the oral cavity and pharynx overall by 0.5% per year from 2009 to 2018, although, consistent with incidence,6, 88, 89 this trend is confined to subsites associated with HPV; the death rate rose by about 2% per year for cancers of the tongue, tonsil, and oropharynx but continued to decline by about 1% per year for other oral cavity cancers (Table 5). Pancreatic cancer death rates continued to increase slowly in men (0.3% annually since 2000) but remained stable in women, despite incidence rising by about 1% per year in both sexes. Recent liver cancer trends are promising as the long-term rise in mortality slowed among women and stabilized among men.
Recorded Number of Deaths in 2018
In total, 2,813,503 deaths were recorded in the United States in 2018, 21% of which were from cancer (Table 6). The death rate for all causes combined decreased steadily from 1975 to 2010 but remained stable through 2018 because of slowing declines for heart and cerebrovascular diseases and a sharp uptick for accidents (Table 7). In contrast, the decline in cancer mortality accelerated from about 1% annually in the 1990s to 1.5% in the 2000s and early 2010s to 2.3% during 2016 through 2018, partly driven by lung cancer (see Trends in Cancer Mortality, above). From 2017 to 2018, the cancer death rate dropped by 2.4%, the largest single-year drop since rates began declining in 1992.
|All causes||2017||2018||RELATIVE CHANGE IN RATE|
|3||Accidents (unintentional injuries)||169,936||6%||49.4||167,127||6%||47.9||−3.0%|
|4||Chronic lower respiratory diseases||160,201||6%||41.1||159,486||6%||39.8||−3.2%|
|8||Influenza and pneumonia||55,672||2%||14.3||59,120||2%||14.9||4.2%|
|9||Nephritis, nephrotic syndrome, & nephrosis||50,633||2%||13.0||51,386||2%||12.9||−0.8%|
|10||Intentional self-harm (suicide)||47,173||2%||14.0||48,344||2%||14.2||1.4%|
- Rates are per 100,000 and age adjusted to the 2000 US standard population.
|TREND 1||TREND 2||TREND 3||TREND 4||TREND 5||TREND 6||AAPC|
|Accidents (unintentional injuries)||1975-1992||−2.1a||1992-2000||−0.0||2000-2006||2.0a||2006-2012||−0.8||2012-2018||4.7a||0.5||4.7a||2.8a|
|Chronic lower respiratory diseases||1975-1986||3.7a||1986-2000||1.7a||2000-2018||−0.5a||−0.5a||−0.5a||−0.5a|
- Abbreviations: AAPC, 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 126.96.36.199, allowing up to 5 joinpoints.
- a The APC or AAPC is significantly different from zero (P < .05).
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 states90 and in people who are Hispanic, Asian American,91, 92 or Alaska Native. Cancer is the first or second leading cause of death for every age group shown in Table 8 among females, whereas, among males aged <40 years, accidents, suicide, and homicide predominate. Table 9 presents the number of deaths in 2018 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 <40 years and women aged <20 years, whereas breast cancer leads among women aged 20 to 59 years. CRC overtook leukemia in 2018 as the second leading cause of cancer death in men aged 20 to 39 years, and it is the leading cause in men <50 years, reflecting increasing trends in CRC in this age group, as well as declining mortality for leukemia. Lung cancer is the leading cause of cancer death in men aged ≥40 years and women aged ≥60 years, causing far more deaths than breast cancer, prostate cancer, and CRC combined.
|ALL AGES||1 TO 19||20 TO 39||40 TO 59||60 TO 79||≥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|
|Heart diseases||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Heart diseases||Cancer||Cancer||Cancer||Heart diseases||Heart diseases|
|Cancer||Intentional self-harm (suicide)||Cancer||Intentional self-harm (suicide)||Cancer||Cancer||Heart diseases||Heart diseases||Heart diseases||Cancer||Cancer|
Accidents (unintentional injuries)
|Chronic lower respiratory diseases||Assault (homicide)||Intentional self-harm (suicide)||Assault (homicide)||Intentional self-harm (suicide)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Chronic lower respiratory diseases||Chronic lower respiratory diseases||Cerebrovascular disease||Alzheimer disease|
Chronic lower respiratory diseases
|Cerebrovascular disease||Cancer||Assault (homicide)||Heart diseases||Heart diseases||Intentional self-harm (suicide)||Chronic liver disease & cirrhosis||Cerebrovascular disease||Cerebrovascular disease||Chronic lower respiratory diseases||Cerebrovascular disease|
|Alzheimer disease||Congenital abnormalities||Congenital abnormalities||Cancer||Assault (homicide)||Chronic liver disease & cirrhosis||Chronic lower respiratory diseases||Diabetes mellitus||Diabetes mellitus||Alzheimer disease||Chronic lower respiratory diseases|
|Accidents (unintentional injuries)||Heart diseases||Heart diseases||Chronic liver disease & cirrhosis||Chronic liver disease & cirrhosis||Diabetes mellitus||Diabetes mellitus||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)||Accidents (unintentional injuries)|
|Diabetes mellitus||Influenza & pneumonia||Influenza & pneumonia||Diabetes mellitus||Diabetes mellitus||Cerebrovascular disease||Cerebrovascular disease||Chronic liver disease & cirrhosis||Alzheimer disease||Influenza & pneumonia||Influenza & pneumonia|
Intentional self-harm (suicide)
|Influenza & pneumonia||Chronic lower respiratory diseases||Chronic lower respiratory diseases||Cerebrovascular disease||Cerebrovascular disease||Chronic lower respiratory diseases||Intentional self-harm (suicide)||Nephritis, nephrotic syndrome, & nephrosis||Nephritis, nephrotic syndrome, & nephrosis||Diabetes mellitus||Diabetes mellitus|
Influenza & pneumonia
|Nephritis, nephrotic syndrome, & nephrosis||Cerebrovascular disease||Cerebrovascular disease||HIV disease||Pregnancy, childbirth, & puerperium||Assault (homicide)||Septicemia||Influenza & pneumonia||Influenza & pneumonia||Parkinson disease||Nephritis, nephrotic syndrome, & nephrosis|
Chronic liver disease & cirrhosis
|Septicemia||Septicemia||Septicemia||Influenza & pneumonia||Influenza & pneumonia||Influenza & pneumonia||Influenza & pneumonia||Septicemia||Septicemia||Nephritis, nephrotic syndrome, & nephrosis||Hypertension & hypertensive renal diseasesa|
- Abbreviation: HIV, human immunodeficiency virus.
- Note: Deaths within each age group do not sum to all ages combined because of 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.
- a Includes primary and secondary hypertension.
|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||Leukemia||Pancreas||Pancreas||Colorectum|
|Pancreas||Soft tissue (including heart)||Non-Hodgkin lymphoma||Livera||Colorectum||Urinary bladder|
|Livera||Non-Hodgkin lymphoma||Soft tissue (including heart)||Brain & ONS||Livera||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||Soft tissue (including heart)||Colorectum||Colorectum||Pancreas||Colorectum|
|Pancreas||Bones & joints||Brain & ONS||Ovary||Colorectum||Pancreas|
|Ovary||Kidney & renal pelvis||Leukemia||Pancreas||Ovary||Leukemia|
- Abbreviation: ONS, other nervous system.
- Note: Ranking order excludes category titles that begin with the word "other."
- a Includes intrahepatic bile duct.
Despite being one of the most preventable cancers through screening, cervical cancer took the lives of 4138 women in 2018; this is the equivalent of 11 women per day, one-half of whom were aged ≤58 years at death. It also continues to be the second leading cause of cancer death in women aged 20 to 39 years. Although cervical cancer incidence has declined for decades overall, distant-stage disease and cervical adenocarcinoma, which is often undetected by cytology, are increasing, largely driven by trends in young women.93 These findings underscore the need for more targeted efforts to increase both HPV vaccination among all individuals aged ≤26 years and primary HPV testing or HPV/cytology cotesting every 5 years among women beginning at age 25 years, as recommended by the American Cancer Society in updated guidelines published in 2020.94, 95
Screening rates are lowest among women who have less educational attainment (high school or less), are uninsured, or do not have a primary care provider,96 consistent with cervical cancer death rates, which are 2 times higher in high-poverty versus low-poverty areas.97 HPV vaccination in the United States falls far behind that in other high-income countries.98 Among female adolescents, for example, up-to-date coverage in 2019 was 57% in the United States99 compared with 67% in Canada,100 >80% in Australia (ncci.canceraustralia.gov.au/), and >90% in the United Kingdom-Scotland.98 In 2020, the first population-based evaluation of the efficacy of the quadrivalent vaccine for preventing invasive cervical cancer reported adjusted incidence rate ratios of 0.12 (95% CI, 0.00-0.34) and 0.47 (95% CI, 0.27-0.75) for women who had been vaccinated before age 17 years and between ages 17 and 30 years, respectively, compared with women who had not been vaccinated.101
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.102, 103 These inequalities ultimately stem from hundreds of years of structural racism, including residential, educational, and occupational segregation and discriminatory policies in criminal justice and housing that have altered the balance of prosperity, security, and health.104 One of many examples is redlining, a previously legal form of lending discrimination whereby credit-worthy applicants who lived in predominantly Black neighborhoods were denied loans for home ownership or improvement, preventing people of color from integrating into suburban White neighborhoods. A recent study found that women who lived in areas of redlining had breast cancer mortality rates 2 times higher than those who did not reside in these areas.105
Overall cancer incidence rates are highest among NHWs because of their high rates of lung and female breast cancers (Table 10). However, sex-specific incidence is highest in non-Hispanic Black (NHB) men, among whom rates during 2013 through 2017 were 81% higher than those in Asian/Pacific Islander men, who have the lowest rates, and 7% higher than NHW men, who rank second. Among women, those who are NHW have the highest incidence—9% higher than those who are NHB (who rank second); however, NHB women have the highest sex-specific cancer mortality rates—12% higher than NHW women. The mortality disparity among men is larger, with the death rate in NHB men double that in Asian/Pacific Islander men and 19% higher than that in NHW men. Notably, the Black-White disparity in overall cancer mortality among men and women combined has declined from a peak of 33% in 1993 (279.0 vs 210.5 per 100,000, respectively) to 13% in 2018 (174.2 vs 154.1 per 100,000, respectively). This progress is largely due to more rapid declines in deaths from smoking-related cancers among Blacks because of the steep drop in smoking prevalence unique to Black teens from the late 1970s to the early 1990s.106
|ALL RACES COMBINED||ASIAN/PACIFIC ISLANDER||AMERICAN INDIAN/ALASKA NATIVEa||HISPANIC|
|NON-HISPANIC WHITE||NON-HISPANIC BLACK|
|Incidence, 2013 to 2017|
|Colon & rectum b||36.9||36.6||43.6||29.2||42.3||32.9|
|Kidney & renal pelvis||16.9||17.1||18.9||8.0||23.9||16.7|
|Liver & intrahepatic bile duct||8.5||7.1||11.0||12.6||15.7||13.5|
|Lung & bronchus||58.4||62.6||60.9||34.4||52.7||29.7|
|Mortality rates, 2014 to 2018|
|Colon & rectum||13.7||13.6||18.5||9.4||15.1||10.9|
|Kidney & renal pelvis||3.6||3.8||3.6||1.7||5.5||3.4|
|Liver & intrahepatic bile duct||6.6||5.8||8.6||8.8||10.6||9.3|
|Lung & bronchus||38.5||41.7||41.3||21.2||32.1||16.8|
- Rates are per 100,000 population and age adjusted to the 2000 US standard population and exclude data from Puerto Rico.
- a Data based on Purchased/Referred Care Delivery Area (PRCDA) counties.
- b Colorectal cancer incidence rates exclude appendix.
Geographic Variation in Cancer Occurrence
Tables 11 and 12 show cancer incidence and mortality rates for selected cancers by state. State variation reflects differences in detection practices and the prevalence of risk factors, such as smoking, obesity, and other health behaviors. The largest geographic variation is for cancers that are most preventable,27 such as lung cancer, cervical cancer, and melanoma of the skin.56 For example, lung cancer incidence and mortality rates in Kentucky, where smoking prevalence was historically highest, are 3 to 5 times higher than those in Utah and Puerto Rico, where it was lowest. Even in 2018, 1 in 4 residents of Kentucky, Arkansas, and West Virginia were current smokers compared with 1 in 10 residents of Utah and California.107
|STATE||ALL SITES||BREAST||COLON & RECTUMa||LUNG & BRONCHUS||NON-HODGKIN LYMPHOMA||PROSTATE||UTERINE CERVIX|
|Dist. of Columbia||452.8||417.8||139.4||38.9||34.7||49.8||44.5||19.2||12.1||127.4||8.8|
- Rates are per 100,000, age adjusted to the 2000 US standard population.
- a Colorectal cancer incidence rates exclude appendix, with the exception of Nevada.
- b Data for this state are not included in US combined rates because either the registry did not consent or incidence data did not meet inclusion standards for all years during 2013 to 2017 according to the North American Association of Central Cancer Registries (NAACCR). Rates for this state are based on data published in NAACCR's Cancer in North America, Volume II.
- c Data for Puerto Rico are not included in US combined rates for comparability to previously published US rates. Puerto Rico incidence data for 2017 reflect diagnoses that occurred January through June only.
|STATE||ALL SITES||BREAST||COLORECTUM||LUNG & BRONCHUS||NON-HODGKIN LYMPHOMA||PANCREAS||PROSTATE|
|Dist. of Columbia||183.5||146.3||26.2||17.9||13.1||36.4||25.8||6.0||3.4||15.6||12.2||28.2|
- Rates are per 100,000 and age adjusted to the 2000 US standard population.
- a Rates for Puerto Rico are for 2013 to 2017 and are not included in US combined rates.
Similarly, cervical cancer incidence and mortality currently vary 2-fold to 3-fold, with incidence rates ranging from <5 per 100,000 in Vermont and New Hampshire, to 10 per 100,000 in Arkansas and Kentucky, and 13 per 100,000 in Puerto Rico (Table 11). Ironically, advances in cancer control often exacerbate disparities, and state gaps for cervical and other HPV-associated cancers may widen in the wake of unequal uptake of the HPV vaccine. In 2019, up-to-date HPV vaccination among adolescents (aged 13-17 years) ranged from 32% in Mississippi to 78% in Rhode Island among girls and from 29% in Mississippi to 80% in Rhode Island among boys.108 The HPV vaccine was recently confirmed to reduce the risk of invasive cervical cancer by 88% among women who were inoculated with the quadrivalent vaccine before age 17 years.101 State/territory differences in other initiatives to improve health, including Medicaid expansion, may also contribute to future geographic disparities.109, 110
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 2021, an estimated 10,500 children (aged birth to 14 years) and 5090 adolescents (aged 15-19 years) will be diagnosed with cancer, and 1190 and 590, respectively, will die from the disease. These estimates require 15 years of historical incidence data (see Methods), and thus exclude benign and borderline malignant brain tumors, which were not required to be reported to cancer registries until 2004.
Leukemia is the most common childhood cancer, accounting for 28% of cases, followed by brain and other nervous system tumors (27%), more than one-quarter of which are benign/borderline malignant (Table 13). Cancer types and their distribution in adolescents differ from those in children; for example, brain and other nervous system tumors, more than one-half of which are benign/borderline malignant, are most common (21%), followed closely by lymphoma (19%). In addition, there are almost twice as many cases of Hodgkin as non-Hodgkin lymphoma among adolescents, whereas among children it is the reverse. Thyroid carcinoma and melanoma of the skin account for 11% and 3% of cancers, respectively, in adolescents, but only 2% and 1%, respectively, in children.
|BIRTH TO 14||15 TO 19|
|CASES, %||5-YEAR SURVIVAL, %||CASES, %||5-YEAR SURVIVAL, %|
|All ICCC groups combined||84||85|
|Leukemias, myeloproliferative & myelodysplastic diseases||28||87||13||73|
|Acute myeloid leukemia||4||68||4||66|
|Lymphomas and reticuloendothelial neoplasms||12||93||19||94|
|Non-Hodgkin lymphoma (including Burkitt)||6||90||7||89|
|Central nervous system neoplasms||27||74||21||76|
|Benign/borderline malignant tumorsa||8||97||13||98|
|Neuroblastoma & other peripheral nervous cell tumors||6||81||<1||63b|
|Nephroblastoma & other nonepithelial renal tumors||5||93||<1||c|
|Malignant bone tumors||4||73||5||68|
|Ewing tumor & related bone sarcomas||1||75||2||58|
|Germ cell & gonadal tumors||3||90||10||93|
- Abbreviation: ICCC, International Classification of Childhood Cancer.
- Survival rates are adjusted for normal life expectancy and are based on follow-up of patients through 2017.
- a Benign and borderline brain tumors were excluded from survival calculations for overall central nervous system tumors but were included in the denominator for case distribution.
- b The standard error of the survival rate is between 5 and 10 percentage points.
- c Statistic could not be calculated due to fewer than 25 cases during 2010 through 2016.
The overall cancer incidence rate in children and adolescents has been increasing slightly (by 0.6% and 0.7% per year in children and adolescents, respectively) since 1975 for reasons that remain unclear. In contrast, death rates have declined continuously from 6.3 per 100,000 in children and 7.1 per 100,000 in adolescents in 1970 to 2.0 and 2.9 per 100,000, respectively, in 2018, for overall reductions of 68% in children and 59% in adolescents. Much of this progress reflects dramatic declines in leukemia mortality of 83% and 68%, respectively. Remission rates of 90% to 100% have been achieved for childhood acute lymphocytic leukemia over the past 4 decades, primarily through the optimization of established chemotherapeutic agents as opposed to the development of new therapies.111 However, progress among adolescents has lagged behind that among children for reasons that are complex but include differences in tumor biology, treatment protocols, and tolerance and compliance with treatment.112 Mortality reductions from 1970 to 2018 are also lower in adolescents for other common cancers, including lymphoma (91% in children and 85% in adolescents) and brain and other nervous system tumors (37% and 29%, respectively). The 5-year relative survival rate for all cancers combined improved from 58% during the mid-1970s to 86% during 2010 through 2016 in children and from 68% to 86% in adolescents.6 However, survival varies substantially by cancer type and age at diagnosis (Table 13).
The estimated numbers of new cancer cases and deaths expected to occur in 2021 provide a reasonably accurate portrayal of the contemporary cancer burden, but they are model-based 3-year (mortality) or 4-year (incidence) ahead projections that should not be used to track trends over time for several reasons. First, a new methodology has been employed as of the 2021 estimates to 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, 2017 for incidence and 2018 for mortality) and thus do not reflect the impact of the COVID-19 pandemic on reduced health care access and subsequent diagnosis delays. Similarly, the models 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 incidence rates from SEER, NPCR, and/or NAACCR and cancer death rates from the NCHS.
Errors in reporting race/ethnicity in medical records and on death certificates may result in underestimates of cancer incidence and mortality in persons who are not White or Black, particularly Native American 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 is approximately 50% lower in Asians/Pacific Islanders overall.92
The continuous decline in the cancer mortality rate since 1991 has resulted in an overall drop of 31%, translating to approximately 3.2 million fewer cancer deaths. This steady progress is largely due to reductions in smoking and subsequent declines in lung cancer mortality, which have accelerated in recent years because of improved management of NSCLC. Treatment breakthroughs are also responsible for rapid reductions in mortality from hematopoietic and lymphoid malignancies in both children and adults and, more recently, certain difficult-to-treat cancers, such as metastatic melanoma. Yet progress is slowing or halting for cancers amenable to early detection through screening, such as breast cancer, prostate cancer, and CRC. More concerning are the persistent racial, socioeconomic, and geographic disparities for highly preventable cancers, such as cervix and lung. Increased investment for both the equitable and broad application of existing cancer control interventions and basic and clinical research to further knowledge and advance treatment options would undoubtedly accelerate progress against cancer.
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