Key Points Cancer death rates for all racial and ethnic populations combined have decreased by 1.1 percent per year from 1993 to 2002. (Question 4) Incidence rates for all cancers combined among men were stable from 1995 through 2002, but the rates among women have increased by 0.3 percent annually since 1987. (Question 6) For the period 1992 to 2002, prostate, lung, colon/rectum in men and breast, colon/rectum, and lung in women continue to be the leading types of cancer for incidence and mortality for each racial and ethnic group. (Question 7) The authors note that one strategy for reducing death and improving survival for cancer patients is to ensure that evidence-based treatment services are available and accessible. (Question 9)

1. What is the purpose of this report and who created it?

   This report provides an update of cancer death rates, incidence rates (new cases), and trends in the United States. It also features an analysis of trends in cancer treatment. The Centers for Disease Control and Prevention (CDC), the American Cancer Society (ACS), the National Cancer Institute (NCI), which is part of the National Institutes of Health, and the North American Association of Central Cancer Registries (NAACCR) collaborated to create this report. These reports have been issued annually since 1998.

   This report describes cancer incidence and death rates for white, black, Asian/Pacific Islander, American Indian/Alaska Native, and Hispanic persons (Hispanic persons are not mutually exclusive from persons who are white, black, Asian/Pacific Islander, or American Indian/Alaska Native).

2. What are the sources of the data?

   Cancer mortality information in the United States is based on causes of death reported by physicians on death certificates and filed by state vital statistics offices. The mortality information is processed and consolidated in a national database by CDC through the National Vital Statistics System, which covers the entire United States.

   Information on newly diagnosed cancer cases occurring in the United States is based on data collected by registries in NCI's Surveillance, Epidemiology, and End Results (SEER) Program and CDC's National Program of Cancer Registries (NPCR). NAACCR evaluates and publishes data annually from registries in both programs. Incidence rates are for invasive cancers (cancer that has spread beyond where it first developed to involve adjacent tissues), except for bladder cancer, which includes in situ cancer (early cancer that has not spread to neighboring tissue).

   Long-term (1975-2002) incidence trends are reported by SEER and cover 10 percent of the U.S. population. Trend data (1992-2002) for the five major racial and ethnic populations (non-Hispanic white, Hispanic white, black, Asian/Pacific Islander, and American Indian/Alaska Native) are also from SEER and cover 14 percent of the U.S. population.

3. Which reporting periods were chosen as a main focus of the report?

   The period from 1992 through 2002 was used for describing the cancer burden and trends among the five major racial and ethnic populations. The period from 1975 through 2002 was chosen to represent the best perspective on long-term trends in cancer incidence and death rates among all races combined. All rates are adjusted to the 2000 U.S. standard population as determined by the U.S. Census Bureau.

   Update on Incidence and Mortality Trends for All Cancer Sites Combined and the Top 15 Cancers

4. What is happening with cancer death rates overall?

   Cancer death rates for all racial and ethnic populations combined have decreased by 1.1 percent per year from 1993 to 2002. The decline was more pronounced in men (1.5 percent per year from 1993-2002) than in women (0.8 percent decline from 1992 to 2002). Death rates decreased for 12 of the top 15 cancers in men and nine of the top 15 cancers in women. Death rates are the best indicator of our progress against cancer.

5. What is happening with lung cancer in women?

   For female lung cancer, death rates increased from 1995 through 2002, but incidence rates stabilized from 1998 through 2002. The slight, but statistically significant, increase in the overall female lung cancer death rate during that period represents a change from last year's annual report, when the rates were reported to be level. This change may reflect random variations in the rates as the trend stabilizes before possibly showing a steady decline.

6. What is happening with cancer incidence rates overall?

   Incidence rates for all cancers combined among men were stable from 1995 through 2002, but the rates among women have increased by 0.3 percent annually since 1987. The persistent increase in overall cancer incidence rates for women can be attributed to increases in rates for breast and six other cancers (non-Hodgkin lymphoma, melanoma, thyroid, leukemia, bladder and kidney). However, according to more recent data from 1998 to 2002, female lung cancer incidence rates have stabilized after increasing for many years, which is good news.

   Changes in incidence also may result from changes in prevalence of risk factors and changes in detection practices due to introduction or increased use of screening and/or diagnostic techniques. Cancer incidence rates may not be a good marker of cancer risk, as early detection of cancer due to higher screening rates may influence incidence rates.

   Of note, the incidence and death rates of liver cancer are increasing for most population groups examined, suggesting that this once relatively rare cancer is becoming more common in the United States.

7. What is happening with incidence and death rates for some of the top 15 cancers?

   For the period 1992 to 2002, prostate, lung, and colon/rectum cancer in men and breast, colon/rectum, and lung cancer in women continue to be the leading types of cancer for incidence and mortality for each racial and ethnic group. Men and women of different racial and ethnic populations showed considerably different rates and trends for each of the top 15 cancer sites.

   Incidence rates for lung and prostate cancer decreased among men in all populations, while colon/rectum cancer incidence rates decreased only for white men. Among women, breast cancer incidence rates increased in Asian/Pacific Islander women, decreased among American Indian/Alaska Native women, and were stable for other women. Colon/rectum incidence rates decreased only for white women.

   Trends in Cancer Treatment

8. What are some general trends in cancer treatment?

   The authors found that much of contemporary cancer treatment was consistent with evidence-based National Institutes of Health Consensus Development Statements (http://consensus.nih.gov/), which are considered a "gold standard" for care recommendations. By examining the care patients received from 1993 to 1996, the authors found that fewer cancer patients died in acute-care hospitals and more patients were using hospice services.

9. What are some trends in treatment for the top cancers?

   The authors note that one strategy for reducing death and improving survival of cancer is to ensure that evidence-based treatment services are available and accessible. Using data from Patterns of Care/Quality of Care studies, as well as SEER-Medicare databases and other resources, the authors looked at several of the most prevalent cancers and examined whether evidence-based care was delivered uniformly to diverse populations and how rapidly changes in evidence-based guidelines resulted in changes in cancer care. These Patterns of Care/Quality of Care studies supplement routine data collection from NCI's SEER Program. They include more detailed data on treatment patterns, as well as SEER-Medicare databases that link data from SEER registries to Medicare claims data to assess treatment histories for those over age 65.

   • For breast cancer, data on trends in the treatment of early-stage disease show that the proportion of women diagnosed with stage I or II (earlier stage) breast cancer who received breast-conserving surgery with radiation treatment increased during the 1990s, but the proportion of women who only received breast-conserving surgery increased more modestly. In a separate analysis, the authors note that between 1987 and 2000, the use of concurrent chemotherapy and the hormone-inhibiting drug tamoxifen increased substantially for women being treated for early-stage disease. However, use of concurrent therapy remained relatively low among women age 65 and older, who were more likely to receive tamoxifen only.
   • For colorectal cancer, adjuvant (additional treatment that follows initial surgery) chemotherapy for stage III colon cancer patients increased rapidly between 1987 and 1992. However, dissemination of this therapy was uneven across age groups, with much lower rates of treatment among older patients. Also noted was the fact that the number of patients who received treatment decreased with the increasing number of pre-existing medical conditions, but the likelihood of receiving adjuvant therapy decreased with age even after taking other medical conditions into account.
   • For lung cancer, one analysis found that 22 percent of late-stage (stage IV) non-small cell lung cancer patients diagnosed between 1991 and 1993 received chemotherapy, although evidence-based guidelines recommend that chemotherapy may be beneficial for patients who are well enough to withstand the treatment. A study of patients diagnosed in 1996 found similar low levels of treatment among patients age 65 and older. However, more recent studies have found increasing trends in the late 1990s in the use of chemotherapy among late- stage non-small cell lung cancer patients.
   • For ovarian cancer, one study found a major shift in the type of chemotherapy that women with ovarian cancer received between 1991 and 1996. Specifically, the use of cyclophosphamide decreased while the use of the FDA-recommended paclitaxel increased rapidly.
   • Unlike breast and lung cancers, treatment for prostate cancer is more controversial. The authors indicate that the most notable trend in prostate cancer treatment from 1986 to 1999 was the decreasing proportion of cases that received watchful waiting, surgical or chemical castration, or hormonal deprivation therapy as primary treatment while more aggressive treatments, including newer radiation techniques, were on the rise. Additionally, black men were found to have received substantially less aggressive treatment than white men.

   Update on Disparities in Overall Cancer Burden

10. How does the overall cancer burden differ among racial and ethnic groups or populations?

    Differences in cancer incidence and death persist, especially among black men, who have 25 percent higher incidence rates and 43 percent higher death rates than white men for all cancer sites combined. The rates are more than 50 percent higher in black men than in white men for myeloma and cancers of the prostate, lung, stomach, liver, esophagus, and larynx. Subpopulations within these racial and ethnic groups also may have varying rates.

    Similar differences were found in death rates. The rate for all sites combined is 43 percent higher in black men than in white men, with rates for myeloma and cancers of the prostate and stomach more than 200 percent higher, and rates for cancers of the esophagus and oral cavity more than 75 percent higher.

    In general, cancer rates for Asian/Pacific Islander, American Indian/Alaska Native, and Hispanic/Latino populations are lower than rates among black and white populations. All three of these populations have higher rates of stomach and liver cancer than the white population, with Asian/Pacific Islanders having the highest rates among the populations studied. However, selected populations within each of these groups may have higher cancer rates than the overall groups, and there are cancers that disproportionately affect these populations.

    The American Indian/Alaska Native population has the highest rate of cancer of the gallbladder, even though the effects of under-counting and misclassification of the American Indian/Alaska Native race are well-documented. Finally, Hispanic/Latina women have the highest rates of cancers of the cervix uteri and gallbladder among the populations studied.

11. What about racial and ethnic disparities in death rates?

    Death trends for cancer sites other than the top three cancers also varied by race/ethnicity and gender. Death rates for liver cancer increased among white, black, and Hispanic/Latino men and among white and Hispanic/Latina women from 1992 through 2002. Stomach cancer death rates decreased in men and women of all racial and ethnic populations except for American Indian/Alaska Native men and women.

    Similarly, reductions in death rates for oral cavity cancers were observed among men and women in most populations, except for American Indian/Alaska Native men and women, Asian/Pacific Islander women, and Hispanic/Latina women. Finally, death rates for cancers of the gall bladder decreased among white, Asian/Pacific Islander, and Hispanic/Latina women, and cervical cancer death rates decreased in all populations.

12. Do incidence rates vary geographically?

    There is substantial variation from one geographical area to another. Using a new technique, the authors present incidence rates for all cancer sites combined per 100,000 people for white and black men and women by state (including the District of Columbia). The technique, called linked micromap plots, links age-adjusted incidence rates for all cancer sites combined from 1998 to 2002. Information on microplots can be found on the Web supplement to the Report at http://jncicancerspectrum.oupjournals.org/jnci/content/vol97/issue19. One factor that can be observed when comparing plots is that the range of incidence rates is broader among black men and women than among white men and women. Even for the largest population group, there was substantial variation in rates from one geographic area to another. However, variation is seen even for the largest population group, with incidence rates per 100,000 people ranging from 468 to 636 in white men and from 355 to 462 in white women.

    The median (middle value when all rates are ranked from highest to lowest) incidence rate of 634 in black males is higher than the median rate of 557 in white males. Among women, the median incidence rate is higher for white women (422) than black women (390). Southwestern states tend to have lower incidence rates, regardless of race.

    How to Read This Report

13. How are cancer incidence and death rates presented?

    Cancer incidence rates and death rates are measured as the number of cases or deaths per 100,000 people per year and are age-adjusted to the 2000 U.S. standard population. When a cancer affects only one gender--for example, prostate cancer--then the number is per 100,000 persons of that gender.

14. What is an annual percent change or APC?

    The annual percent change (APC) is the average rate of change in a cancer rate per year in a given time frame (i.e., how fast or slowly a cancer rate has increased or decreased each year over a period of years). Annual percent change was calculated for both incidence and death rates. The number is given as a percent, such as the approximate one percent per year decrease.

    A negative APC describes a decreasing trend, and a positive APC describes an increasing trend. In this report, trends are reported as increasing and decreasing only if they are statistically significant. The rates are age-adjusted, which allows for comparison of rates from different populations with varying age composition over time and regions.

    Data Adjustments

15. Why were rates adjusted for delays in reporting incidence data to SEER?

    This report presents analyses of long-term trends in cancer incidence rates with and without adjustment for reporting delays and more complete information. Adjusting for these delays provides the basis for a potentially more accurate assessment of incidence rates and trends in the most recent years for which data are available. Cancer registries routinely take two to three years to compile their current cancer statistics. An additional one to two years may be required to have more complete incidence data on certain cancers, such as prostate and breast cancers, particularly when they are diagnosed in outpatient settings. Cancer registries continue to update incidence rates to include these cases. Consequently, the initial data reported for certain cancer incidence rates may be an underestimate. Long-term reporting patterns in SEER registries have been analyzed, and it is now possible to adjust site-specific incidence rates and incidence rates for all cancers combined incidence to correct for expected reporting delays and more complete information.

16. What is joinpoint analysis and how does it account for the different time periods used for trends analysis in this report?

    Joinpoint analysis is a statistical method that describes changing trends over successive segments of time and the amount of increase or decrease within each segment. This statistical method chooses the best-fitting point or points, which are called joinpoints; these points are where the rate of increase or decrease changes significantly.

    Joinpoint regression analysis involves fitting a series of joined straight lines to the age-adjusted rates, and each line segment is described by an annual percent change that is based on the slope of the line segment. Each joinpoint denotes a statistically significant change in trend. Thus, for death rates for all cancers combined in men, the slope, or trend, changes in 1993 and is reported as a 1.5 percent per year decline from 1993 to 2002. However, for women, the trend changes in 1992 and is reported as a 0.8 percent per year decline from 1992 to 2002 in this report.

    Joinpoint analyses were performed for incidence and mortality trends for 1975 to 2002.

17. Where is this report published?

    The report was published on October 5, 2005, in the Journal of the National Cancer Institute: "Annual Report to the Nation on the Status of Cancer, 1975-2002, Featuring Population-Based Trends in Cancer Treatment," (Vol. 97, Number 19). The authors of this year's report are Brenda K. Edwards, Ph.D. (NCI), Martin L. Brown, Ph.D. (NCI), Phyllis A. Wingo, Ph.D. (CDC), Holly L. Howe, Ph.D. (NAACCR), Elizabeth Ward, Ph.D. (ACS), Lynn A.G. Ries, M.S. (NCI), Deborah Schrag, M.D., (Memorial Sloan-Kettering), Patricia M. Jamison, M.P.H. (CDC), Ahmedin Jemal, Ph.D. (ACS), Xiao Cheng Wu, M.D. (NAACCR), Carol Friedman, D.O. (CDC), Linda Harlan, Ph.D. (NCI), Joan Warren, Ph.D. (NCI), Robert N. Anderson, Ph.D. (CDC), and Linda Pickle, Ph.D. (NCI).

18. Where can I find out more about the report?

    For more information, visit the following Web sites:

    'Report to the Nation' press release: http://www.nci.nih.gov/newscenter/pressreleases/ReportNation2005release

    To view the full report, go to the Journal of the National Cancer Institute online: http://jncicancerspectrum.oupjournals.org/. For supplemental material, please go to http://jncicancerspectrum.oupjournals.org/jnci/content/vol97/issue19

    ACS: http://www.cancer.org

    CDC (Division of Cancer Prevention and Control): http://www.cdc.gov/cancer

    CDC (National Center for Health Statistics' mortality report): http://www.cdc.gov/nchs/about/major/dvs/mortdata.htm

    NAACCR: http://www.naaccr.org/

    NCI: http://www.cancer.gov and the SEER Homepage: http://www.seer.cancer.gov. Click on the icon "1975-2002 Report to the Nation."

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