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Centers for Disease Control and
Prevention National Institutes of Health |
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.
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.
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]
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.
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Cancer: A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissue and can spread through the bloodstream and lymphatic system to other parts of the body.
Cancer screening: Checking for changes in tissue, cells, or fluids that may indicate the possibility of cancer when there are no symptoms.
Carcinoma: Cancer that begins in the epithelial tissue that lines or covers an organ.
Clinical trials: Research studies that evaluate the effectiveness of new treatment or disease prevention methods on patients.
Colonoscopy: An examination of the rectum and entire colon using a lighted instrument called a colonoscope. A colonoscope allows the physician to remove polyps or other abnormal tissue for examination under a microscope.
Digital rectal exam (DRE): A test in which the health care provider inserts a lubricated, gloved finger into the rectum to feel for abnormal areas.
Fecal occult blood test (FOBT): A test to check for small amounts of hidden blood in stool.
Grade: A system for classifying cancer cells in terms of how abnormal they appear under a microscope. The grading system provides information about the probable growth rate of the tumor and its tendency to spread. The systems used to grade tumors vary with each type of cancer. Grading plays a role in treatment decisions.
Invasive cervical cancer: Cancer that has spread from the surface of the cervix to tissue deeper in the cervix or to other parts of the body.
Malignant: Cancerous.
Mammogram: An x ray of the breast.
Melanoma: Cancer of the cells that produce pigment in the skin.
Pap (Papanicolaou) test: Microscopic examination of cells collected from the cervix. The Pap test is used todetect cancer, changes in the cervix that may lead to cancer, and noncancerous conditions, such as infection or inflammation.
PSA (prostate-specific antigen) test: A test that measures the level of an enzyme (PSA) in the blood that increases due to diseases of the prostate gland, including prostate cancer.
Risk factor: Something that increases a person’s chance of developing a disease.
Sigmoidoscopy: A procedure in which the physician or health care provider looks inside the rectum and the lower part of the colon (sigmoid colon) through a flexible lighted tube. During the procedure, the physician or health care provider may collect samples of tissues or cells for closer examination.
Squamous cells: Flat cells that look like fish scales. These cells are found in the tissue that forms the surface of the skin, the lining of the hollow organs of the body, and the passages of the respiratory and digestive tracts.
Stage: The size and extent of a cancer, including whether the disease has spread from the original site into surrounding tissue and other parts of the body.
[1] Landis, S.H.; Murray, T.; Bolden, S.; et al. Cancer statistics, 2000. CA: A Cancer Journal for Clinicians 50(1):2398-2424, 2000.
[2] Ries, L.A.G.; Kosary, C.L.; Hankey, B.F.; et al. SEER Cancer Statistics Review, 1973–1996. Bethesda, MD: National Cancer Institute, 1999.
[3] Wingo, P.A.; Ries, L.A.G.; Giovino, G.A.; et al. Annual report to the nation on the status of cancer, 1973–1996, with a special section on lung cancer and tobacco smoking. Journal of the National Cancer Institute 91(8):675-690, 1999.
[4] Wingo, P.A.; Ries, L.A.; Rosenberg, H.M.; et al. Cancer incidence and mortality 1973–1995: A report card for the U.S. Cancer 82(6):1197-1207, 1998.
[5] Brown, M.L.; Hodgson, T.A.; and Rice, D.P. Economic impact of cancer in the United States. In: Schottenfeld, D., and Fraumeni, Jr., J.F.; eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996.
[6] Solarz, A., ed. Lesbian Health: Current Assessment and Directions for the Future 1999. Washington, DC: National Academy Press, 1999.
[7] U.S. Department of Health and Human Services (HHS). The Health Benefits of Smoking Cessation. DHHS Publication No. CDC 90-8416. Atlanta, GA: Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990.
[8] Willet, W. Diet and nutrition. In: Schottenfeld, D., and Fraumeni, Jr., J.F.; eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996, 438-461.
[9] Greenwald, P.; Kramer, B.; and Weed, D.L.; eds. Cancer Prevention and Control. New York, NY: Marcel Dekker, 1995, 303-327.
[10] HHS. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 1996.
[11] Fletcher, S.W.; Black, W.; Harris, R.; et al. Report of the International Workshop on Screening for Breast Cancer. Journal of the National Cancer Institute 85(20):1644-1656, 1993.
[12] Kronborg, O.; Fenger, C.; Olsen, J.; et al. Randomized study of screening for colorectal cancer with faecal-occult-blood test. Lancet 348(9640):1467-1471, 1996.
[13] Hardcastle, J.D.; Chamberlain, J.O.; Robinson, M.H.E.; et al. Randomized controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 348(9040):1472-1477, 1996.
[14] Mandel, J.S. Reducing mortality from colorectal cancer by screening for fecal occult blood. Journal of the National Cancer Institute 91(5): 434-437, 1999.
[15] Mandel, J.S.; Bond, J.H.; Church, T.R.; et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. New England Journal of Medicine 328(19):1365-1371, 1993.
[16] Winawer, S.; Fletcher, R.; Miller, L.; et al. Colorectal cancer screening: Clinical guidelines and rationale. Gerontology 112:594-642, 1997.
[17] Selby, J.V.; Freidman, G.D.; Quesenberry, Jr., C.P.; et al. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine 326(10):653-657, 1992.
[18] Muller, A.D., and Sonnenberg, A. Protection by endoscopy against death from colorectal cancer—A case-control study among veterans. Archives of Internal Medicine 155:1741-1748, 1995.
[19] Newcomb, P.A.; Norfleet, R.G.; Storer, B.E.; et al. Screening sigmoidoscopy and colorectal cancer mortality. Journal of the National Cancer Institute 84(20):1572-1575, 1992.
[20] Alexander, F.E.; Edinburgh, G.L.; Andriole, G.L.; et al. Rationale for randomized trials of prostate cancer screening. European Journal of Cancer 35(2):262-271, 1999.
[21] CDC. Cigarette smoking-attributable mortality and years of potential life lost—United States, 1990. Morbidity and Mortality Weekly Report 42(33):645-649, 1993.
[22] Greenwald, P.; Kramer, B.S.; and Weed, D.L.; eds. Cancer Prevention and Control. New York, NY: Marcel Dekker, 1995, 568-569.
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[25] Henderson, B.E.; Pike, M.C.; Bernstein, L.; et al. Breast cancer. In: Schottenfeld, D., and Fraumeni, Jr., J.F., eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996, 1022-1039.
[26] Harvard report on cancer prevention. Vol. 1. Causes of human cancer. Cancer Causes & Control 7(Suppl. 1):53-59, 1996.
[27] National Institutes of Health. Cervical cancer. NIH Consensus Statement 14(1):1-38, 1996.
[28] Schiffman, M.H.; Brinton, L.A.; Devesa, S.S.; et al. Cervical cancer. In: Schottenfeld, D., and Fraumeni, Jr., J.F., eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996, 1090-1116.
[29] Schottenfeld, D., and Winawer, S.J. Cancers of the large intestine. In: Schottenfeld, D., and Fraumeni, Jr., J.F., eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996, 813-840.
[30] Silverman, S. Oral Cancer. 4th ed. Hamilton, Ontario, Canada: American Cancer Society, B.C. Decker, Inc., 1998.
[31] Chodak, G.W.; Thisted, R.A.; Gerber, G.S.; et al. Results of conservative management of clinically localized prostate cancer. New England Journal of Medicine 330(4):242-248, 1994.
[32] Gerber, G.S.; Thisted, R.A.; Scardino, P.T.; et al. Results of radical prostatectomy in men with clinically localized prostate cancer: Multi-institutional pooled analysis. Journal of the American Medical Association 276(8):615-619, 1996.
[33] U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: HHS, 1996.
[34] Armstrong, B.K., and English, D.R. Cutaneous malignant melanoma. In: Schottenfeld, D., and Fraumeni, Jr., J.F., eds. Cancer Epidemiology and Prevention. 2nd ed. New York, NY: Oxford University Press, 1996, 1282-1312.