Surveillance for Cancer Incidence and Mortality — United States, 2011

Simple D. Singh, MD

S. Jane Henley, MSPH

A. Blythe Ryerson, PhD

Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Simple Singh, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-4292; e-mail: sdsingh@cdc.gov.

Preface

This report provides, in tabular and graphic form, official federal statistics on the occurrence of cancer for 2011 and trends for 1999–2011 as reported by CDC and the National Cancer Institute (NCI) (1). Cancer incidence data are from population-based cancer registries that participate in CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results (SEER) program reported as of November 2013. Cancer mortality data are from death certificate information reported to state vital statistics offices through 2011 and compiled into a national file for the entire United States by CDC's National Center for Health Statistics' (NCHS) National Vital Statistics System (NVSS). This report is a part of the first-ever Summary of Notifiable Noninfectious Conditions and Disease Outbreaks, which encompasses various surveillance years but is being published in 2015 (2). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (3).

This report presents information on new cancer cases and deaths for 2011. The number and rate of cancer cases and deaths are stratified by the primary cancer sites as reported for 2011; information is provided by demographic characteristic (e.g., sex, age, race, and ethnicity) and primary cancer site (68 selected sites among men and 72 selected sites among women) (Tables 1–12). Age-adjusted cancer incidence and death rates for the most common sites are shown by race, sex, and ethnicity for 2011, the most recent diagnosis year (Figure 1). Maps of the United States display age-adjusted cancer incidence and death rates, presented by quartiles, for 2011, the most recent diagnosis year (Figures 2 and 3). Time trends in age-adjusted cancer incidence and death rates during 1999–2011 are shown for all sites combined by race, sex, and ethnicity (Figures 4–7). Age-adjusted cancer incidence and death rates are shown by primary site and year for the period 1999–2011 (Tables 13–16).

Background

Cancer comprises a diverse mix of diseases occurring in every part of the body and is a leading cause of death in the United States, second only to heart disease (4). More than half of cancer cases could be prevented (5). Surveillance of cancer incidence and mortality can help public health officials target areas for control efforts (6) and track progress toward meeting the national health objectives set forth in Healthy People 2020 (7). Because cancer is a reportable disease in every state, hospitals, physician's offices, pathology laboratories, and other medical facilities are required to submit data on all cancer diagnoses to a central cancer registry at the state or territorial level. A cancer registry is a database that contains individual records of all cancer cases in a defined population and includes patient demographics, tumor characteristics (e.g., cancer site and pathology), and information about the notifying health provider or facility. In 1992, Congress established NPCR by enacting the Cancer Registries Amendment Act, Public Law 102-515 (8). Administered by CDC, NPCR collects data on the occurrence of cancer, and the type, extent, and location of the cancer. Before NPCR was established, 10 states had no registry, and most states with registries lacked the resources and state legislation needed to gather complete data (9). Presently, NPCR supports central cancer registries in 45 states, the District of Columbia, Puerto Rico, and the U.S. Pacific Island Jurisdictions. NPCR data represent 96% of the overall U.S. population. Together, NPCR and NCI's SEER Program collect data for the entire U.S. population. Cancer control planners and others can identify variations in cancer rates by population subgroups and monitor trends over time to guide the planning and evaluation of cancer prevention and control programs and allocation of health resources.

Data Sources

Data about cancer incidence and mortality in the Summary (Noninfectious) come from the official federal statistics on cancer, the U.S. Cancer Statistics (USCS) dataset (1). The USCS dataset includes cancer incidence data from NPCR registries in 45 states and the District of Columbia (cancer incidence data from Puerto Rico and the U.S. Pacific Island Jurisdictions were not available for this analysis) and SEER program registries in the remaining five states (Connecticut, Hawaii, Iowa, New Mexico, and Utah) and cancer mortality data from NVSS.

Incidence Data

The primary source of data on cancer incidence is medical records. Staff at health care facilities abstract data from patients' medical records, enter it into the facility's own cancer registry if it has one, and then send the data to the regional or state registry. Both NPCR and SEER registries collect data using uniform data items and codes as documented by the North American Association of Central Cancer Registries (NAACCR). This uniformity ensures that data items collected by the two federal programs are comparable (10,11). Information on primary site and histology is coded according to the International Classification of Diseases for Oncology, Third Edition (ICD-O-3) and categorized according to the revised SEER recodes dated January 27, 2003, which define standard groupings of primary cancer sites (http://seer.cancer.gov/siterecode) (12). Beginning with 2010 diagnoses, cases were first classified by anatomic site using ICD-O-3; cases with hematopoetic histologies were further classified by using the 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (13). Data from the NPCR registries provided in this report were reported to CDC as of November 30, 2013. Data from SEER registries were reported to NCI as of November 1, 2013.

NPCR and SEER cancer registries consider as reportable all incident cases with a behavior code of 2 (in situ, noninvasive) or 3 (invasive, primary site only) in ICD-O-3, except for in situ cancer of the cervix. Basal and squamous cell carcinomas of the skin also are excluded, except for those on the skin of the genital organs. (12). Several cancers that are coded as malignant in ICD-O-3 (beginning with 2001 diagnoses) were not coded as malignant in ICD-O-2 (10). Additional information is provided in the USCS technical notes (available at http://www.cdc.gov/cancer/npcr/uscs/2011/technical_notes/data_sources/incidence.htm).

Mortality Data

Cancer mortality statistics are based on information from all death certificates filed in the 50 states and the District of Columbia and processed by NVSS at NCHS (14). The cancer mortality data were compiled in accordance with World Health Organization regulations, which specify that member nations classify and code causes of death in accordance with the current revision of the International Classification of Diseases (ICD) (15). For consistency with the data on cancer incidence, the cancer sites in mortality data were grouped according to the revised SEER recodes dated January 27, 2003 (available at http://seer.cancer.gov/codrecode). Additional information is provided in the USCS technical notes (available at http://www.cdc.gov/cancer/npcr/uscs/2011/technical_notes/data_sources/mortality.htm).

Population Estimates

Population denominators are race-specific, ethnicity-specific, and sex-specific county population estimates from the 2010 U.S. Census, modified by SEER and aggregated to the state and national level. Additional details about SEER are available at http://seer.cancer.gov/popdata/index.html.

Interpreting Data

Incidence Data

Each year, state cancer registries submit cancer cases for a new diagnosis year and an updated version of the previous years' cancer cases to CDC or NCI. Therefore, each year when U.S. Cancer Statistics is published, updates to the previous year's data are published, using the most recent data submission and the most recent population data. Users of cancer incidence data published by federal agencies should be mindful of the data submission dates for all data used in their analyses.

Mortality Data

Cancer mortality statistics in USCS are influenced by the accuracy of information on the death certificate. Unlike incidence data, mortality data for a calendar year are not updated after the data file is released. Mortality data for the entire United States refer to only deaths that occurred within the United States; data for geographic areas are provided by the decedent's place of residence.

Race and Ethnicity Data

For cancer incidence, race and ethnicity data are abstracted from medical records and grouped into categories (11). When reporting cancer mortality, race and Hispanic origin are recorded separately on the death certificate by the funeral director as provided by an informant or, in the absence of an informant, on the basis of observation (16).

Differences in rates among racial and ethnic (Hispanic origin) populations should be interpreted with caution. A recent study using SEER incidence data suggests that the quality of data on race in cancer registries is considered excellent for whites, blacks, and Asians/Pacific Islanders, good for Hispanics, and poor for American Indians/Alaska Natives (17). Recent studies involving cancer mortality data demonstrate that death rates for whites and blacks generally are estimated accurately whereas death rates for Asians/Pacific Islanders, American Indians/Alaska Natives, and Hispanics are underestimated (18). For this reason, incidence and mortality data provided in this report might be underestimated for these groups, possibly because of misclassification of race or Hispanic ethnicity.

Four NPCR registries (Delaware, Kentucky, Missouri, and South Carolina) opted not to present state-specific Asian/Pacific Islander counts and rates. Six NPCR registries (Delaware, Kentucky, Massachusetts, Missouri, Pennsylvania, and South Carolina) opted not to present state-specific Hispanic (classified by the NAACCR Hispanic Identification [NHIA] Algorithm) counts and rates. Nine NPCR registries (Delaware, Georgia, Illinois, Kansas, Kentucky, Missouri, New Jersey, New York, and South Carolina) opted not to present state-specific American Indian/Alaska Native counts and rates. However, in each of these cases, the aggregate national rates presented in this report include data for these registries.

Methods for Identifying Cancer

Medical facilities such as hospitals, doctor's offices, and pathology laboratories send information about cancer cases to their cancer registry. Most information comes from hospitals, where highly trained cancer registrars transfer the information from the patient's medical record to the registry's computer software using standardized codes. The data are then sent to the central cancer registry. Every year the central cancer registries electronically submit incidence, demographic, and clinical data to NPCR or SEER.

Population Coverage

The population coverage for incidence data varies by diagnosis year. Population coverage might be affected by the suppression of state incidence data, if a state did not meet the publication criteria or did not submit data. In addition, state incidence data might be suppressed if <16 cases were reported or if the state requested that the data be suppressed. Additional information is provided by the USCS technical notes (available at http://www.cdc.gov/cancer/npcr/uscs/2011/data/00_pop_coverage.htm). Mortality data from malignant neoplasms (i.e., cancers) as recorded in the NVSS from the 50 states and the District of Columbia are available in USCS, and thus 100% of the U.S. population is covered each year.

Suppression of Rates and Counts

When the numbers of cases or deaths used to compute rates are small, those rates tend to have poor reliability. Therefore, in an effort to discourage misinterpretation or use of rates or counts that are unstable because case or death counts are small, incidence and death rates and counts of <16 are not shown in tables and figures. The use of a threshold value for suppressing cells helps protect the confidentiality of patients by reducing or eliminating the risk for disclosure of their identity. Additional information is provided in the USCS technical notes (available at http://www.cdc.gov/cancer/npcr/uscs/2011/technical_notes/stat_methods/suppression.htm).

Publication Criteria

Cancer incidence data that appear in this report are derived from state cancer registries that have high-quality cancer incidence data for individual (e.g., 2011) and combined (e.g., 1999–2011) years as demonstrated by meeting all of the following criteria on data quality for all cancer sites combined:

• case ascertainment is ≥90% (margin of error ±5%) complete,
• ≤5% of cases are ascertained solely on the basis of a death certificate,
• ≤3% of cases are missing information on sex,
• ≤3% of cases are missing information on age,
• ≤5% of cases are missing information on race, and
• ≥97% of the registry's records passed a set of single-field and inter-field computerized edits that test the validity and logic of data components.

Additional information about USCS is available at available at http://www.cdc.gov/uscs.

Highlights

Incidence and Death Rates

In 2011, approximately 1.5 million invasive cancers were diagnosed in the United States, an annual incidence rate of 451 cases per 100,000 persons. In the same year, approximately 576,000 persons died of cancer nationally, an annual death rate of 169 deaths per 100,000 persons. Differing rates of cancer by race, ethnicity, and state of residence indicate that for some populations, Healthy People 2020 objectives have already been achieved, whereas objectives for other populations have not been met, and these populations might benefit from targeted cancer prevention and control efforts.

Cancer incidence and death rates increase with age. In 2011, among persons in the youngest age group (<15 years), 10,063 new cancer cases (rate: 17 cases per 100,000 persons) and 1,283 cancer deaths (rate: two deaths per 100,000 persons) were reported. Among persons aged ≥65 years, 822,548 new cancer cases (rate: 2,005 cases per 100,000 persons) and 397,106 cancer deaths (rate: 960 deaths per 100,000 persons) were reported. Overall, 54% of cancer cases and 69% of cancer deaths in 2011 occurred among persons aged ≥65 years.

Among men in 2011, blacks had the highest cancer incidence and death rates in the United States, and American Indians/Alaska Natives and Asians/Pacific Islanders had the lowest cancer incidence and death rates. Among women in 2011, whites had the highest cancer incidence rates and blacks had the highest cancer death rates. American Indians/Alaska Natives had the lowest cancer incidence rates, and Asians/Pacific Islanders had the lowest cancer death rates. Differences in cancer rates by race and ethnicity might reflect differences in risk factors, screening, and treatment although rates among some populations might be underestimated because of problems ascertaining race or ethnicity. By state, overall (all cancer sites combined) cancer incidence rates in 2011 ranged from 374 to 509 cases per 100,000 persons, and overall cancer death rates ranged from 126 to 201 deaths per 100,000 persons.

Four cancer sites accounted for half of all cases diagnosed in 2011, including 209,292 prostate cancers, 220,097 female breast cancers, 207,339 lung and bronchus cancers (110,322 among men and 97,017 among women), and 135,260 colon and rectum cancers (70,099 among men and 65,161 among women). These four sites also accounted for half of cancer deaths in 2011, including 156,953 lung cancer deaths, 51,783 colon and rectum cancer deaths, 40,931 female breast cancer deaths, and 27,970 prostate cancer deaths.

Time Trends in Incidence and Death Rates

On the basis of data from registries meeting data quality criteria during 1999–2011, cancer incidence rates declined from 485 cancer cases per 100,000 population in 1999 to 444 cases in 2011. Although lung cancer incidence declined steadily among men from 1999 to 2011, it increased among women from 1999 to 2005 and has since declined from 2005 to 2011. Prostate cancer incidence declined from 170 cases per 100,000 men in 1999 to 128 cases in 2011. Colorectal cancer incidence declined from 57 cases per 100,000 persons in 1999 to 40 cases in 2011. Female breast cancer incidence declined from 135 cases per 100,000 women in 1999 to 121 cases in 2005, increased to 125 cases in 2009, and declined again to 122 cases in 2011. During 1999–2011, cancer death rates declined from 201 deaths per 100,000 persons in 1999 to 169 deaths in 2011; during the same period, death rates declined for each of the top four cancers.

National cancer surveillance data help public health officials track progress toward achieving the national cancer objectives set forth in Healthy People 2020 (19). For the national cancer burden to be reduced and Healthy People 2020 targets to be met, behavioral and environmental factors that increase cancer risk must be reduced, and high-quality screening services and evidence-based treatments must be available and accessible to all persons. Several effective primary and secondary prevention measures, such as vaccination against infectious agents that cause cancer (i.e., hepatitis B virus and human papilloma virus), help with smoking cessation, and cancer screening, when effectively implemented and sustained, could reduce the number of new cancer cases and prevent many cancer-related deaths (20). Evidence-based interventions can be implemented at both the individual level and the population level to reduce cancer risk factors, promote healthy living, and encourage cancer screening (5).

Acknowledgment

Data were provided by state and regional cancer registry personnel.

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