Cancer

Goal

Reduce the number of new cancer cases as well as the illness, disability, and death caused by cancer.

Overview

Cancer is the second leading cause of death in the United States. During 2000, an estimated 1,220,100 persons in the United States were expected to be diagnosed with cancer; 552,200 persons were expected to die from cancer.[1] These estimates did not include most skin cancers, and new cases of skin cancer are estimated to exceed 1 million per year. One-half of new cases of cancer occur in people aged 65 years and over.[2]

About 491,400 persons who get cancer in a given year, or 4 in 10 patients, are expected to be alive 5 years after diagnosis. When adjusted for normal life expectancy (accounting for factors such as dying of heart disease, injuries, and diseases of old age), a relative 5-year survival rate of 60 percent is seen for all cancers.1 This rate means that the chance of a person recently diagnosed with cancer being alive in 5 years is 60 percent of the chance of someone not diagnosed with cancer. Five-year relative survival rates commonly are used to monitor progress in the early detection and treatment of cancer and include persons who are living 5 years after diagnosis, whether in remission, disease free, or under treatment.

Issues and Trends

Cancer death rates for all sites combined decreased an average of 0.6 percent per year from 1990 to 1996.[3] This decrease occurred after rates had increased by 0.4 percent per year from 1973 to 1990.[4] Death rates for male lung, female breast, prostate, and colorectal cancers decreased significantly during the 1990–96 period.3 The lung and bronchus, prostate, female breast, and colon and rectum were the most common cancer sites for all racial and ethnic populations in the United States and together accounted for approximately 54 percent of all newly diagnosed cancers.1

In addition to the human toll of cancer, the financial costs of cancer are substantial.[5] The overall annual costs for cancer are estimated at $107 billion, with $37 billion for direct medical costs (the total of all health expenditures), $11 billion for costs of illness (the cost of low productivity due to illness), and $59 billion for costs of death (the cost of lost productivity due to death). Treatment for lung, breast, and prostate cancers alone accounts for more than half of the direct medical costs.

Disparities

Cancer death rates vary by gender, race, and ethnicity.3 Male cancer death rates peaked in 1990 at 220.8 per 100,000, and female death rates peaked a year later at 142.2 per 100,000. After the peak year, through 1996, male cancer deaths for all sites decreased on average by 1 percent per year, and female deaths decreased on average by 0.4 percent per year. There were significant decreases in death for lung, prostate, brain, and other nervous system cancers in males and a significant decrease in breast cancer death for females.3 Among males, lung cancer death rates have declined since 1990. In contrast, lung cancer death rates have continued to increase among females. Since 1987, more females have died from lung cancer than breast cancer.

African Americans are about 34 percent more likely to die of cancer than are whites and more than two times more likely to die of cancer than are Asian or Pacific Islanders, American Indians, and Hispanics.1 African American women are more likely to die of breast and colon cancers than are women of any other racial and ethnic group, and they have approximately the same lung cancer death rates as white women. African American men have the highest death rates of colon and rectum, lung, and prostate cancers. Age-adjusted lung cancer death rates are approximately 40 percent higher among African American males than white males. Little difference in age-adjusted lung cancer death rates has been observed between African American females and white females. Hispanics have higher rates of cervical, esophageal, gallbladder, and stomach cancers. Similarly, some specific forms of cancer affect other ethnic groups at rates higher than the national average (for example, stomach and liver cancers among Asian American populations and colorectal [CRC] cancer among Alaska Natives). Certain racial and ethnic groups have lower survival rates than whites for most cancers.1

Differences among the races represent both a challenge to understand the reasons and an opportunity to reduce illness and death and to improve survival rates.

The Hispanic cancer experience also differs from that of the non-Hispanic white population, with Hispanics having higher rates of cervical, esophageal, gallbladder, and stomach cancers. New cases of female breast and lung cancers are increasing among Hispanics, who are diagnosed at later stages and have lower survival rates than whites.

The recent decrease in deaths from breast cancer in white females is attributed to greater use of breast cancer screening in regular medical care. However, deaths due to breast cancer in African American females continue to increase, in part, because breast cancer is diagnosed at later stages in African American females.1

Data on CRC show a decline in new cases and death rates in white males and females, stable new case rates in African Americans, and a continued rise in death rates in African American males. Five-year survival rates for the 1989–94 period are 64 percent in whites and 52 percent in African Americans.3 Early detection and treatment play a key role in these survival rates.

New cases of prostate cancer peaked in 1992 at 190.8 per 100,000 people and declined on average by 8.5 percent each year from 1992 to 1996. Prostate cancer death rates peaked in 1991 at 26.7 per 100,000 people; rates decreased on average by 2.1 percent each year from 1991 to 1995.3 Causes of the trends are unclear but may be attributed to a number of factors that are under investigation.

Possible disparities regarding the health status of lesbian women and possible barriers to access to health services by lesbians have been identified by the Institute of Medicine as a research priority.[6]

Opportunities

Evidence suggests that several types of cancer can be prevented and that the prospects for surviving cancer continue to improve. The ability to reduce cancer death rates depends, in part, on the existence and application of various types of resources. First, the means to provide culturally and linguistically appropriate information on prevention, early detection, and treatment to the public and to health care professionals are essential. Second, mechanisms or systems must exist for providing people with access to state-of-the-art preventive services and treatment. Where suitable, participation in clinical trials also should be encouraged. Third, a mechanism for maintaining continued research progress and for fostering new research is essential. Genetic information that can be used to improve disease prevention strategies is emerging for many cancers and may provide the foundation for improved effectiveness in clinical and preventive medicine services.

To provide new opportunities for cancer prevention and control in the future, there is a continuing and vital need to foster new, innovative research on both the causes of cancer (including genetic and environmental causes) and on methods to translate biologic and epidemiologic findings into effective prevention and control programs for use by government and community organizations to reduce further the Nation’s cancer burden.

These needs can be met, in part, with the network of cancer control resources now in place. This network has the organizational and personnel capabilities for various cancer interventions. Despite the extent of these resources, they alone are insufficient to reduce deaths from cancer. Gaps exist in information transfer, optimal practice patterns, research capabilities, and other areas. These gaps must be recognized and filled to meet cancer prevention and control needs.

It is estimated that as much as 50 percent or more of cancer can be prevented through smoking cessation and improved dietary habits, such as reducing fat consumption and increasing fruit and vegetable consumption.[7], [8] Physical activity and weight control also can contribute to cancer prevention.[9], [10]

Scientific data from randomized trials of cancer screening together with expert opinions indicate that adherence to screening recommendations for cancers of the breast, cervix, and colon/rectum reduces deaths from these cancers.

To reduce breast cancer deaths in the United States, a high percentage of females aged 40 years and older need to comply with screening recommendations. A reduction in breast cancer deaths could be expected to occur after a delay of roughly 7 years.[11] To reduce cervical cancer deaths, a high percentage of females in the United States who are aged 18 years and older need to comply with screening recommendations. Evidence from randomized preventive trials is unavailable, but expert opinion suggests that a beneficial impact on cervical cancer death rates would be expected to occur after a delay of a few years.

Evidence shows that a reduction in CRC deaths can be achieved through detection and removal of precancerous polyps and treatment of CRC in its earliest stages. The findings from three randomized controlled trials indicate that biennial screening with fecal occult blood tests (FOBT) can reduce deaths from CRC by 15 to 21 percent in people aged 45 to 80 years.[12], [13], [14] One trial[15] reported a 33 percent reduction in deaths with annual screening in the same age groups, and a simulation model showed a 56 percent reduction.[16] The efficacy of sigmoidoscopy has been supported by three case-control studies[17], [18], [19] that showed 59 to 79 percent reductions in CRC deaths from cancers within reach of the sigmoidoscope in age groups 45 years and older.

Prostate cancer prevention strategies are not available at this time. Race and age are the only clearly identified risk factors for prostate cancer. African Americans and older men are at higher risk. There is no scientific agreement on the benefits of screening for prostate cancer, and screening is not recommended in the general population or in high-risk groups because it is unclear if screening and treatment do more good than harm.[20] Clinical trials currently are under way to assess the benefits and risks of screening and treatments, and additional research is needed to identify modifiable risk factors for prostate cancer.

Melanoma and other skin cancers were expected to claim the lives of almost 9,600 persons in 2000.1 Insufficient evidence exists to determine whether routine skin examinations (self or physician) decrease deaths from melanoma or other skin cancers. However, many of the skin cancers diagnosed each year could be prevented by limiting exposure to the sun, by wearing protective clothing, and by using sunscreen.

For all cancers, treatments designed to increase survival are needed along with improved access to state-of-the-art care. In addition to measurements of survival, indices of quality of life for both the short term and long term are regarded as important considerations.

Interim Progress Toward Year 2000 Objectives

The Healthy People 2000 objective for total cancer deaths was achieved for the total population by 1995. Lung cancer deaths declined for the first time in 50 years in 1991, declined again in 1992, remained level in 1993, and then dropped again in 1994, 1995, and 1996. The decline in the age-adjusted death rate for CRC for the total population has gone beyond the year 2000 target, but declines in death rates have not been as substantial for the black population. Improvements were observed in cancer risk factors, such as tobacco use and dietary fat intake. Data also showed some improvement in the proportion of women receiving mammograms and Pap tests. In addition, for both mammograms and Pap tests, the disparity in use rates for most of the population subgroups and those for all women either has been reduced or eliminated.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Cancer

Goal: Reduce the number of new cancer cases as well as the illness, disability, and death caused by cancer.

Healthy People 2010 Objectives

3-1.		Reduce the overall cancer death rate.

Target: 159.9 deaths per 100,000 population.

Baseline: 202.4 cancer deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 21 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Cancer Deaths
	Rate per 100,000
TOTAL	202.4
Race and ethnicity
American Indian or Alaska Native	129.3
Asian or Pacific Islander	124.2
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	255.1
White	199.3
Hispanic or Latino	123.7
Not Hispanic or Latino	206.6
Black or African American	261.8
White	203.0
Gender
Female	169.2
Male	252.4
Education level (aged 25 to 64 years)
Less than high school	137.8
High school graduate	139.7
At least some college	79.6

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

3-2.

Reduce the lung cancer death rate.

Target: 44.9 deaths per 100,000 population.

Baseline: 57.6 lung cancer deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 22 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Lung Cancer Deaths
	Rate per 100,000
TOTAL	57.6
Race and ethnicity
American Indian or Alaska Native	38.2
Asian or Pacific Islander	29.3
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	66.7
White	57.5
Hispanic or Latino	22.7
Not Hispanic or Latino	59.6
Black or African American	68.6
White	59.6
Gender
Female	41.5
Male	79.9
Education level (aged 25 to 64 years)
Less than high school	49.0
High school graduate	41.8
At least some college	17.6

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Lung cancer is the most common cause of cancer death among both females and males in the United States. Estimates indicated that 164,100 (74,600 females and 89,500 males) new cases of lung cancer would be diagnosed in 2000; 156,900 persons (67,600 females and 89,300 males) would die from lung cancer in 2000, accounting for 28 percent of all cancer deaths.1

Cigarette smoking is the most important risk factor for lung cancer, accounting for 68 to 78 percent of lung cancer deaths among females and 88 to 91 percent of lung cancer deaths among males.[21] Other risk factors include occupational exposures (radon, asbestos) and indoor and outdoor air pollution (radon, environmental tobacco smoke).[22] One to two percent of lung cancer deaths are attributable to air pollution.[23] After 10 years of abstinence, smoking cessation decreases the risk of lung cancer to 30 to 50 percent of that of continuing smokers.7

3-3.		Reduce the breast cancer death rate.

Target: 22.3 deaths per 100,000 females.

Baseline: 27.9 breast cancer deaths per 100,000 females occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 20 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Females, 1998	Breast Cancer Deaths
	Rate per 100,000
TOTAL	27.9
Race and ethnicity
American Indian or Alaska Native	14.2
Asian or Pacific Islander	13.1
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	35.7
White	27.3
Hispanic or Latino	16.8
Not Hispanic or Latino	28.5
Black or African American	36.7
White	27.9
Education level (aged 25 to 64 years)
Less than high school	20.0
High school graduate	28.4
At least some college	22.0

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Breast cancer is the most common cancer among women in the United States. An estimated 184,200 new cases were expected to be diagnosed in 2000. About 40,800 U.S. women were expected to die from breast cancer in 2000, accounting for about 15.2 percent of cancer deaths among women.1 Death from breast cancer can be reduced substantially if the tumor is discovered at an early stage. Mammography is the most effective method for detecting these early malignancies. Clinical trials have demonstrated that mammography screening can reduce breast cancer deaths by 20 to 39 percent in women aged 50 to 74 years and about 17 percent in women aged 40 to 49 years.[24] Breast cancer deaths can be reduced through increased adherence with recommendations for regular mammography screening.

Many breast cancer risk factors, such as age, family history of breast cancer, reproductive history, mammographic densities, previous breast disease, and race and ethnicity, are not subject to intervention.[25], [26] However, being overweight is a well-established breast cancer risk for postmenopausal women that can be addressed.25 Avoiding weight gain is one method by which older women may reduce their risk of developing breast cancer.

3-4.		Reduce the death rate from cancer of the uterine cervix.

Target: 2.0 deaths per 100,000 females.

Baseline: 3.0 cervical cancer deaths per 100,000 females occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Females, 1998	Cervical Cancer Deaths
	Rate per 100,000
TOTAL	3.0
Race and ethnicity
American Indian or Alaska Native	2.5
Asian or Pacific Islander	3.3
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	6.0
White	2.7
Hispanic or Latino	3.3
Not Hispanic or Latino	3.0
Black or African American	6.2
White	2.6
Education level (aged 25 to 64 years)
Less than high school	7.2
High school graduate	4.8
At least some college	2.1

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Cervical cancer is the 10th most common cancer among females in the United States, with an estimated 12,800 new cases in 2000. The number of new cases of cervical cancer is higher among females from racial and ethnic groups than among white females. An estimated 4,600 U.S. females were expected to die from cervical cancer in 2000.1 Cervical cancer accounts for about 1.7 percent of cancer deaths among females. Infections of the cervix with certain types of sexually transmitted human papilloma virus increase risk of cervical cancer and may be responsible for most cervical cancer in the United States.[27]

Considerable evidence suggests that screening can reduce the number of deaths from cervical cancer. Invasive cervical cancer is preceded in a large proportion of cases by precancerous changes in cervical tissue that can be identified with a Pap test. If cervical cancer is detected early, the likelihood of survival is almost 100 percent with appropriate treatment and followup; that is, almost all cervical cancer deaths could be avoided if all females complied with screening and followup recommendations.[28] Risk is substantially decreased among former smokers in comparison to continuing smokers.7

3-5.		Reduce the colorectal cancer death rate.

Target: 13.9 deaths per 100,000 population.

Baseline: 21.2 colorectal cancer deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 34 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Colorectal Cancer Deaths
	Rate per 100,000
TOTAL	21.2
Race and ethnicity
American Indian or Alaska Native	13.3
Asian or Pacific Islander	13.7
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	28.2
White	20.8
Hispanic or Latino	12.8
Not Hispanic or Latino	21.7
Black or African American	28.9
White	21.1
Gender
Female	18.2
Male	25.4
Education level (aged 25 to 64 years)
Less than high school	10.4
High school graduate	12.0
At least some college	7.5

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Colorectal cancer is the second leading cause of cancer-related deaths in the United States. An estimated 130,200 cases (66,600 females and 63,600 males) of CRC and 56,300 deaths (28,500 females and 27,800 males) from CRC were expected to occur in 2000. When cancer-related deaths are estimated separately for males and females, however, CRC becomes the third leading cause of cancer death behind lung and breast cancers for females and behind lung and prostate cancers for males.1

Risk factors for CRC may include age, personal and family history of polyps or colorectal cancer, inflammatory bowel disease, inherited syndromes, physical inactivity (colon only), obesity, alcohol use, and a diet high in fat and low in fruits and vegetables.[29] Detecting and removing precancerous colorectal polyps and detecting and treating the disease in its earliest stages will reduce deaths from CRC. FOBT and sigmoidoscopy are widely used to screen for CRC, and barium enema and colonoscopy are used as diagnostic tests.

3-6.		Reduce the oropharyngeal cancer death rate.

Target: 2.7 deaths per 100,000 population.

Baseline: 3.0 oropharyngeal cancer deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Oropharyngeal Cancer Deaths
	Rate per 100,000
TOTAL	3.0
Race and ethnicity
American Indian or Alaska Native	2.1
Asian or Pacific Islander	2.2
Asian	DNC
Native Hawaiian and other Pacific lslander	DNC
Black or African American	4.5
White	2.8
Hispanic or Latino	1.8
Not Hispanic or Latino	3.1
Black or African American	4.7
White	2.9
Gender
Female	1.7
Male	4.5
Education level (aged 25 to 64 years)
Less than high school	3.6
High school graduate	3.0
At least some college	1.2

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Oral and pharyngeal (oropharyngeal) cancers comprise a diversity of malignant tumors that affect the oral cavity and pharynx; the overwhelming majority of these tumors are squamous cell carcinomas. In 2000, 30,200 new cases of oropharyngeal cancer were expected to be diagnosed, and approximately 7,800 deaths were expected to occur from the disease. Oropharyngeal cancer is the 10th most common cancer among U.S. men and the 14th most common among U.S. women.1 Its 5-year survival rate is only 53 percent. The risk of oral cancer is increased in current smokers. Alcohol consumption is an independent risk factor, and when alcohol is combined with use of tobacco products, 90 percent of all oral cancers are explained.[30]

3-7.		Reduce the prostate cancer death rate.

Target: 28.8 deaths per 100,000 males.

Baseline: 32.0 prostate cancer deaths per 100,000 males occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 10 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Males, 1998	Prostate Cancer Deaths
	Rate per 100,000
TOTAL	32.0
Race and ethnicity
American Indian or Alaska Native	15.9
Asian or Pacific Islander	12.4
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	68.7
White	29.4
Hispanic or Latino	20.9
Not Hispanic or Latino	32.4
Black or African American	70.2
White	29.7
Education level (aged 25 to 64 years)
Less than high school	4.4
High school graduate	5.0
At least some college	2.8

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Prostate cancer is the most commonly diagnosed form of cancer (other than skin cancer) in males and the second leading cause of cancer death among males in the United States. Prostate cancer was expected to account for an estimated 180,400 cases and 31,900 deaths in 2000, or about 29 percent and 11 percent of the cases and deaths due to all cancers, respectively.1 Prostate cancer is most common in men aged 65 years and older, who account for approximately 80 percent of all cases of prostate cancer.

Digital rectal examination (DRE) and the prostate-specific antigen (PSA) test are two commonly used methods for detecting prostate cancer. Clinical trials of the benefits of DRE and PSA screening are under way, with results expected in the early 21st century.

Although several treatment alternatives are available for prostate cancer, their impact on reducing death from prostate cancer when compared with no treatment in patients with operable cancer is uncertain.[31], [32], [33] Efforts aimed at reducing deaths through screening and early detection remain controversial because of the uncertain benefits and potential risks of screening, diagnosis, and treatment.

3-8.		Reduce the rate of melanoma cancer deaths.

Target: 2.5 deaths per 100,000 population.

Baseline: 2.8 melanoma cancer deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 11 percent improvement.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Melanoma Cancer Deaths
	Rate per 100,000
TOTAL	2.8
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander