cancer progress report

U.S. Department of Health and Human ServicesPublic Health ServiceNational Institutes of HealthNational Cancer Institute

CANCER PROGRESS REPORT

2001

Cancer Progress Report 2001, with links to related information, is online at

http://progressreport.cancer.govNIH Publication No. 02-5045

U.S. Department of Health and Human ServicesPublic Health ServiceNational Institutes of HealthNational Cancer Institute

C A N C E RP R O G R E S SR E P O R T

2001

Director’s Message ........................................................................................6

Highlights ......................................................................................................8

I. INTRODUCTION ..................................................................................18

II. PREVENTION ......................................................................................21

A. BEHAVIORAL FACTORS ..............................................................22

Tobacco Use ....................................................................................22

Adult Smoking............................................................................22

Youth Smoking ..........................................................................24

Age of Smoking Initiation..........................................................26

Quitting ......................................................................................28

Alcohol Consumption ......................................................................30

Diet and Nutrition ............................................................................31

Fruit and Vegetable Consumption ..............................................31

Fat Consumption ........................................................................33

Weight ..............................................................................................35

Physical Activity ..............................................................................37

Sun Protection ..................................................................................38

B. ENVIRONMENTAL FACTORS......................................................40

Secondhand Smoke ..........................................................................40

Radon in the Home ..........................................................................42

Benzene in the Air............................................................................43

III. EARLY DETECTION ..........................................................................44

Breast Cancer Screening ..................................................................45

Mammography............................................................................45

Cervical Cancer Screening ..............................................................46

Pap Smear ..................................................................................46

Colorectal Cancer Screening............................................................47

Fecal Occult Blood Test ..............................................................47

Sigmoidoscopy............................................................................47

Contents

IV. DIAGNOSIS..........................................................................................49

Incidence ..........................................................................................50

Stage at Diagnosis............................................................................53

V. TREATMENT ........................................................................................55

VI. LIFE AFTER CANCER........................................................................56

Survival ............................................................................................57

Costs of Cancer Care ......................................................................59

VII. END OF LIFE......................................................................................61

Mortality ..........................................................................................62

Person-Years of Life Lost ................................................................65

Appendixes

A. Acknowledgments............................................................................67

B. Dictionary of Terms ........................................................................69

C. References ........................................................................................70

D. Methodology for Characterizing Trends ..........................................73

E. Cancer Incidence and Mortality Rates Age-Adjusted

to the 1970 and 2000 Standards, United States 1998 ......................74

Figure 1: Percent of Adults (Ages 18+) Who Were Current Cigarette Smokers—1992-1998. . . . . . . . . . . . . . 23

Figure 2: Percent of High School Students (Grades 9-12) Who Were Current Users of Cigarettes or Smokeless Tobacco—1991-1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Figure 3: Average Age at First Use of Cigarettes for Respondents Ages 12+, 12-17, and 18-25—1990-1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Figure 4: Percent of Daily Smokers (Ages 25+) Who Tried to Quit or Quit for 3 Months or Longer—1992-1993, 1995-1996, and 1998-1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Figure 5: Per Capita Alcohol Consumption (Ages 14+)—1990-1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figure 6: Average Daily Servings of Fruits and Vegetables (Ages 2+)—1989-1991 to 1994-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Figure 7: Trends in Fat Intakes as a Percentage of Total Calories—1989-1991 to 1994-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Figure 8: Percent of Adults (Ages 20-74) Who Were at a Healthy Weight, Overweight, or Obese—1971-1974, 1976-1980, and 1988-1994. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Figure 9: Percent of Adults (Ages 18+) Reporting No Physical Activity in Their Leisure Time—1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Figure 10: Percent of Adults (Ages 18+) Very Likely to Protect Themselves From the Sun—1992 and 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Figure 11: States With Smoke-Free Indoor Air Laws in State Government Worksites, Private Worksites, Restaurants, and Day Care Centers—1990-2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Figure 12: Percent of People Who Have Heard of Radon Who Live in Homes Tested for Radon—1991-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Figure 13: National Trend in Annual/Average Benzene Concentrations in Metropolitan Areas (micrograms per cubic meter)—1993-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Figure 14: Percent of Women (Ages 40+) Who Had Mammography Within the Past 2 Years, by Race/Ethnicity—1987, 1992, and 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Figure 15: Percent of Women (Ages 18+) Who Had a Pap Smear Test Within the Past 3 Years—1987, 1992, and 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Figures and Tables

Figure 16: Percent of Adults (Ages 50+) Who Had an FOBT Test Within the Past 2 Years, by Race/Ethnicity—1987, 1992, and 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Figure 17: Percent of Men and Women (Ages 50+) Who Ever Had a Sigmoidoscopy—1987, 1992, and 1998. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Figure 18: Rates of New Cases of All Cancers—1973-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Figure 19: Rates of New Cases of the Four Most Common Cancers—1973-1998 . . . . . . . . . . . . . . . . . . . . . . . . 51

Figure 20: Rates of New Cases of All Cancers, by Race/Ethnicity—1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . 52

Figure 21: Rates of Some Common Cancers That Are Increasing—1973-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Figure 22: Rates of New Cases of Late-Stage Disease, by Site—1980-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Figure 23: 5-Year Relative Survival Rates, by Site—1975-1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Figure 24: Rates of Deaths for All Cancers—1973-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Figure 25: Cancer Death Rates for Common Cancers—1973-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Figure 26: Rates of Deaths for All Cancers, by Race/Ethnicity—1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Figure 27: Person-Years of Life Lost Due to Major Causes of Death in U.S.—1998 . . . . . . . . . . . . . . . . . . . . . . 65

Figure 28: Person-Years of Life Lost Due to Cancer—1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Table 1: National Cancer Treatment Expenditures in Billions of Dollars—1963-1995 . . . . . . . . . . . . . . . . . . . 59

Table 2: Estimates of National Expenditures for Medical Treatment for the 13 Most Common Cancers—Based on Cancer Prevalence in 1996 and Cancer-Specific Costs for 1995-1998, Expressed in 1996 Dollars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

The beginning of a new century is a fitting time to take stock of

our Nation’s progress against cancer and to establish a readily

accessible, authoritative tool to track this progress over time. The

National Cancer Institute’s (NCI) Cancer Progress Report 2001 aims to

do just that. This report tracks progress, or lack of it, across the full cancer

continuum—from prevention and early detection to diagnosis, treatment,

life after cancer, and the end of life. It also compares this progress with the

cancer-related targets set forth in the Department of Health and Human

Services’ Healthy People 2010, the national set of health objectives for the

first decade of the 21st century.

As a national report, Cancer Progress Report 2001 goes beyond the work

of NCI. It also reflects efforts by other Federal agencies, foundations,

and State and local governments and health departments, as well as medical

providers and researchers, cancer patients and advocates, and all those

concerned with making cancer an uncommon and easily treated disease.

The main message of this report is that, overall, the Nation is making

progress against cancer. In the last decade, for the first time since we have

been keeping records of cancer statistics, the rates of both new cancers and

deaths from cancer have fallen. Behind the numbers are declines in certain

behaviors that cause cancer, especially cigarette smoking by adults. More

people are getting screened for breast, cervical, and colorectal cancers, and

more practitioners are adopting state-of-the-art cancer treatments. Some of

these favorable trends are modest and need to be accelerated—for example,

the still distressingly low rates of colorectal cancer screening.

Much work remains if we are to meet the Healthy People 2010 targets.

In some areas, we are making no progress or even losing ground. The rates

of some cancers, such as melanoma skin cancer, are rising and need

attention. Greater efforts also are needed to reduce tobacco use, weight

gain, and sun exposure, and to increase physical activity. It also is critical

that we develop better measures of progress, especially for cancer treatment

and quality of cancer care.

Director’s Message

6 http://progressreport.cancer.gov

Finally, some racial and ethnic groups and disadvantaged people continue to

suffer an unequal burden of cancer. For example, Blacks have higher overall

rates of new cancers and deaths from cancer than any other group. We

must redouble our efforts to eliminate these cancer-related health disparities.

Although the Cancer Progress Report is filled with data, it is not just about

the numbers. Behind every number are people. This report is about cancer

patients and survivors, their families, communities, and those at risk of

getting cancer. Taking control of cancer—through research and its

dissemination and application—includes giving millions of people the

chance to take greater control over their own lives.

Richard D. Klausner, M.D.DirectorNational Cancer Institute1995-2001

Cancer Progress Report 7

Highlights

Cancer Progress Report 2001 is the first in a new series of reports todescribe progress in reducing theU.S. cancer burden through cancerresearch and its dissemination.

Major Conclusions

The Nation is making progresstoward major cancer-relatedHealthy People 2010 targets.

• The rates of both new cancer cases and cancer deaths are falling overall.

• Some prevention behaviors haveshown improvement. Adultsmoking is down dramaticallysince the 1960s, although rates fell only slightly in the 1990s.Alcohol and fat consumption isheaded down, while fruit andvegetable consumption is up.

• The use of screening tests forbreast, cervical, and colorectalcancers is increasing. Screeningfor colorectal cancer, however,remains low.

The Nation is losing ground in other important areas thatdemand attention.

• Some cancers are risingdramatically, such as cancer of the esophagus and melanoma skincancer. Lung cancer in womencontinues to rise, but not as rapidly as before.

• Youth smoking has been on therise, though data show there maybe a recent, promising decline.

• People are doing less to protectthemselves from the sun.

• More people are overweight andobese, and physical activity isincreasing only slightly.

• Cancer treatment spending continues to rise along with total health care spending.

• Unexplained cancer-related health disparities remain amongpopulation subgroups. Forexample, Blacks and people withlow socioeconomic status have thehighest overall rates for both newcancers and deaths.

What’s in This Report

Cancer Progress Report 2001includes key measures in the areasof prevention, early detection,diagnosis, life after cancer, and endof life. These are based on scientificevidence and, in most cases, areproducts of long-term national datacollection efforts. We have includedthe most recent data available fromthe National Cancer Institute (NCI),the Centers for Disease Control andPrevention, and other Federalagencies, professional groups, andcancer researchers.

The Progress Report tracks progressover time, usually beginning in 1990and up to the most recent data available. This progress is thenmeasured against certain cancer-related targets of Healthy People2010: a comprehensive set of 10-year national health objectives developed through a public-private effort sponsored by the U.S.Department of Health and HumanServices (of which NCI is a part).These targets reflect where theNation should be in 10 years relativeto where we are now. In preparingthis Progress Report, NCI used onlythose HP 2010 cancer-related targetsthat reflect measures for which long-term data are available.



The Cancer Progress Report is notan official government assessmentof progress toward Healthy People2010 targets. These assessmentswill be published by the U.S.Department of Health and HumanServices.

What’s Not in This Report

Not all measures for all relevantareas of cancer progress could beincluded in this report. In somecases, trend information on anational level was not available. In other cases, there are no reliable numbers at this time.Regarding treatment measures,although dramatic advances havebeen made in the treatment of many cancers, we currently lack a national data system for tracking and assessing these successes over time. In the future, we intend to include more population-levelmeasures like the one in this edition describing State laws onsmoke-free air.

NCI and its partners are workinghard to improve current measuresand to develop new ones. Future editions of the Cancer ProgressReport will reflect these developments.

The following eight-page chart summarizes some of the measuresthat are described at greater lengthin the body of this report. Specialgraphics address two questions:

Is the trend good or bad?

• A graph shows the direction of the trend for each measure in the chart. Below the graph is anarrow showing the desired direction(up or down) of the trend.

• Each graph line is color-coded toindicate whether the trend is:

For example, this graph shows thatmammography use is rising and thatthis is the desired direction.

How does the Nation’s progresscompare to the Healthy People2010 target?

• Progress toward the relevantHealthy People 2010 target isdisplayed by two bars—the firstindicating where we started, andthe second, where we are now.

• The first (baseline) bar is white.The second bar is either green orred, depending on the direction ofthe trend.

• A black horizontal line shows theHealthy People 2010 target.

For example, this bar chart showsthat mammography use hasincreased from 29 percent in 1987 to 67 percent in 1998, a level closeto the Healthy People 2010 target of 70 percent.

Per

cent

0

10

20

30

40

50

60

70

1987 1990 1993 1996 1999

Headed in the right direction

Headed in the wrong direction

Stable

1987 1998

70%

2010Target

67%29%

How To Use the Summary Chart

1992 1998

12%

2010Target

26% 24%

Adult Smoking Youth Smoking Age That Smoking Begins

Measure

Period

Desired Direction

Trend

Most RecentEstimate

Target From HealthyPeople 2010 Report

Progress Relative to Healthy People2010 Target

Percent of adults whoare current cigarettesmokers (ages 18 andolder)

Average age at first use ofcigarettes (ages 12-17)

Percent of high schoolstudents who are current cigarette smokers

1992-1998 1991-1999 1990 -1999

1998: 24% of adults were current smokers.

1999: 12.4 was the average age 12- to 17- year-olds start-ed smoking.

1999: 35% of youth were current smokers.

12% 16% 14 years

PREVENTION-Summary

Falling slightly

More Information

Per

cent

020

25

30

1990 1993 1996 1999

Per

cent

0

10

20

30

40

1990 1993 1996 1999

1991 1999

16%

2010Target

28% 35%

1990 1999

14 Years

2010Target

11.5Years

12.4Years

Ave

rage

Age

at F

irst U

se

0

11

12

13

14

15

1990 1993 1996 1999

Rising Rising slightly

Page 22 Page 26Page 24


Quitting Smoking

Alcohol Fruits FatsVegetables

Percent of daily cigarette smokerswho were able tostay off cigarettes 3months or longer(ages 25 and older)

Estimated gallons ofalcohol drunk perperson, per year(ages 14 and older)

Average daily servings (ages 2 and older)

Intake of total fatas a percentage oftotal calories (ages2 and older)

Average daily servings (ages 2 and older)

1992 -1999 1990-1998 1989 -1996 1989 -19961989 -1996

1998-1999: 5% ofdaily smokers quitfor 3 months orlonger.

1998: 2.19 gallonswere consumed perperson.

1994-1996: 1.5 dailyservings were consumed.

1994-1996: 33% oftotal calories camefrom fat.

1994-1996: 3.4 dailyservings were consumed.

This report uses datadifferent from thatused in HealthyPeople 2010.

2 gallons per year At least 2 daily servings

People should consume no morethan 30% of dailycalories from fat.

At least 3 daily servings with at least 1/3 dark-green/deep-yellow

PREVENTION-Summary

No comparison possible

Falling, then rising RisingFalling slightly Rising slightly Falling slightly

Num

ber

of S

ervi

ngs

0

1

2

3

4

1990 1993 1996 1999

Num

ber

of S

ervi

ngs

0

1

2

3

4

1990 1993 1996 1999 Per

cent

age

of T

otal

Cal

orie

s

0

35

40

1990 1993 1996 1999

30

1990 1998

2Gallons

2010Target

2.5Gallons

2.2Gallons

1989 1996

2Servings

2010Target

1.3Servings

1.5Servings

1989 1996

3Servings

2010Target

3.2Servings

3.4Servings

1989 1996

30%

2010Target

34% 33%

Per

cent

0

2

4

6

8

10

1990 1993 1996 1999

Gal

lons

0

1

2

3

1990 1993 1996 1999

Right direction Wrong direction StableTrends:


Page 28 Page 30 Page 31 Page 31 Page 33

Weight No Leisure-TimePhysical Activity

Sun Protection

Measure

Period

Desired Direction

Trend

Target From HealthyPeople 2010 Report

Progress Relative to Healthy People2010 Target

Percent of adults at a healthy weight,overweight, or obese(ages 20-74)(Example: Obese)

Percent of adults very likelyto protect themselves fromthe sun if outside for morethan 1 hour (ages 18 andolder)

Percent of adults withno leisure-time physicalactivity during the pastmonth (ages 18 andolder)

1971-1994 1990-1998 1992 and 1998

1988-1994: 23% ofadults were obese.

1998: 47% of adults werevery likely to protect themselves from the sun.

1998: 29% of adults hadno leisure-time physicalactivity.

15% 20% 75%

Most RecentEstimate

PREVENTION-Summary

Rising slightly, then rising Falling slightly Falling

More Information

1971 1994

15%

2010Target

15% 23%

1990 1998

20%

2010Target31% 29%

1992 1998

75%

2010Target

54% 47%

Per

cent

0

10

20

30

1974 1979 1984 1989 1994 1999

Per

cent

25

30

35

1990 1993 1996 19990

Per

cent

0

30

40

50

60

1990 1993 1996 1999


Page 35 Page 37 Page 38

Laws on Smoke-Free Air

Radon Testing Benzene

States (and D.C.) with laws on smoke-free air for publicplaces and worksites(Example: Day carecenters)

Percent of U.S. population who heardof radon who lived inhomes tested forradon

National yearly average concentra-tions of benzene in metropolitan areas, measured inmicrograms per cubic meter (µg/m3)

1990-2000 1991-1998 1993-1998

2000: 25 States hadsmoke-free day carecenters.

1998: 17.5% of Americanswho heard of radon livedin homes tested for it.

1998: 1.85 µg/m3 of benzene were in the air in metropolitanareas.

51 States 20% No target


Rising Rising Falling

PREVENTION-Summary

1990 2000

51States

2010Target

25States

5States

1991 1998

20%

2010Target

17.5%8.7%

Num

ber

of S

tate

s

0

5

10

15

20

25

1990 1993 1996 1999

Per

cent

0

5

10

15

20

1990 1993 1996 1999 Mic

rogr

ams

per

Cub

ic M

eter

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1990 1993 1996 1999



Page 40 Page 42 Page 43

Cervical CancerScreening

Colorectal Cancer Screening

Measure

Period

Desired Direction

Trend

Most RecentEstimate

Target FromHealthy People2010 ReportProgressRelative toHealthy People2010 Target

Percent of womenwho had a Papsmear within thepast 3 years (ages18 and older)

Percent of adultswho ever had a sigmoidoscopy (ages 50 and older)

Percent of adultswho had a fecaloccult blood testwithin the past 2years (ages 50 and older)

1987-1998 1987-1998 1987-1998

1998: 79% of womenhad a Pap smearwithin the past 3years.

1998: 37% of olderadults ever had a sigmoidoscopy.

1998: 34% of olderadults had a fecaloccult blood testwithin the past 2years.

90% 50% 50%

Rising slightly Rising Rising

EARLY DETECTION-SummaryBreast CancerScreening

Percent of womenwho had a mammo-gram within thepast 2 years (ages40 and older)

1987-1998

1998: 67% of womenhad a mammogramwithin the past 2years.

70%

Rising

More Information

Per

cent

0

10

20

30

40

50

60

70

1987 1990 1993 1996 1999

Per

cent

0

60

70

80

90

1987 1990 1993 1996 1999

Per

cent

0

10

20

30

40

1987 1990 1993 1996 1999

Per

cent

0

20

30

40

50

1987 1990 1993 1996 1999

1987 1998

70%

2010Target

67%29%

1987 1998

90%

2010Target

79%74%

1987 1998

50%

2010Target

34%27%

1987 1998

50%

2010Target

37%27%


Page 45 Page 46 Page 47 Page 47

Incidence Stage atDiagnosis

Number of new cancer cases per100,000 people

New cancercases that arediagnosed late,per 100,000 people (Example:Colon cancer)

1973 -1998 1980-1998

1998: 471 per 100,000 people were diagnosed with cancer.

1998: 7 per 100,000people were diagnosed withcolon cancer thathad spread.

No target No target



DIAGNOSIS-Summary

Falling slightly

Rat

e pe

r 10

0,00

0

0

350

400

450

500

550

1974 1979 1984 1989 1994 1999

Rat

e pe

r 10

0,00

0

0

5

10

15

1984 1989 1994 1999

Rising, then fallingslightly



Page 50 Page 53

Measure

Period

Desired Direction

Trend

Most RecentEstimate

Target FromHealthy People2010 Report

ProgressRelative toHealthy People2010 Target

LIFE AFTER CANCER-Summary

Survival Costs of CancerCare

Percent of cancerpatients survivingcancer 5 yearsafter theirdiagnosis

Cancer treatmentspending as a percent of totalU.S. treatmentspending

1975-1993 1963-1995

1993: 62% of cancerpatients survivedcancer 5 years aftertheir diagnosis.

1995: 4.7% of totalU.S. treatmentspending was forcancer treatment.

70% No target

Rising Stable


More Information

1975 1993

70%

2010Target

62%50%

Per

cent

Sur

vivi

ng

01974 1979 1984 1989 1994 1999

20

40

60

80

Per

cent

0

2

4

6

8

10

1963 1971 1979 1987 1995


Page 57 Page 59

Mortality Person-Years of Life Lost

Number of cancerdeaths per 100,000people

The differencebetween the actualage of death due to a cancer and the expected age of death

1973-1998 1998

1998: 202.6 per100,000 people diedfrom cancer.

1998: 8 million person-years of lifewere lost due tocancer.

No target159.9 per 100,000

No comparisonpossible

END OF LIFE-Summary

No trend data available

1973 1998

159.9

2010Target

202.6198.7

Rat

e pe

r 10

0,00

0

0

100

150

200

250

1974 1979 1984 1989 1994 1999


Stable, then falling slightly


Page 62 Page 65

Introduction

The Nation’s investment in cancer research is making a difference:

• Many people are adopting good health habits that reduce the chancesof getting cancer.

• The rates of new cancers are going down.

• Overall, cancer death rates have dropped.

• Many people who have had cancer live longer, with the opportunity toenjoy a better quality of life than was possible years ago.

Yet cancer remains a major public health problem—one that profoundlyaffects the more than 1 million people diagnosed each year, as well as theirfamilies and friends:

• Not all cancer rates are going down. For example, the rates of new lung cancers in females have continued to rise. The rates of new casesand deaths from non-Hodgkin’s lymphoma also continued to rise, as have the rates of new cases of melanoma.

• The burden of some types of cancer weighs more heavily on somegroups than others. The rates of both new cases and deaths from cancer vary by cancer site, socioeconomic status, sex, and racial andethnic group.

• The economic burden of cancer also is taking its toll. As our Nation’spopulation grows and ages, more people will get cancer. Meanwhile, thecosts of cancer diagnosis and treatment are on the rise. The combinationof these trends will accelerate the overall national costs of cancer treatment.

Why a Progress Report Is Needed

For the past 30 years, our country has vigorously fought the devastatingeffects of cancer. Now it is time to see how far we have come. CancerProgress Report 2001 is the first in a new series of reports to describe theNation’s progress against cancer through research and related efforts. Thereport is based on the most recent data from the National Cancer Institute,the Centers for Disease Control and Prevention, other Federal agencies,professional groups, and cancer researchers.

The Cancer Progress Report was designed to help policymakers review past efforts and plan future ones. The public can use the report to better


understand the nature and results of strategies to fight cancer. Researchers,clinicians, and public health providers can focus on the gaps andopportunities identified in the report, paving the way to future progressagainst cancer.

What’s in the Report

Cancer Progress Report 2001 includes key measures of progress along thecancer continuum:

• Prevention. The measures in this section cover behaviors that can helppeople prevent cancer—the most important of which is not using tobacco.This section also covers exposures to chemicals in the environment.

• Early Detection. Screening tests are ways to find cancers early, whenthere is the best chance for cure. This section describes the proportion ofpeople using recommended screening tests and who they are.

• Diagnosis. We can learn much about progress against cancer by lookingat the rates of new cancer cases (incidence) and of cancers diagnosed atlate stages. This section describes both.

• Treatment. Few treatment measures have been tracked at a nationallevel. This section explains the current status of treatment measures anddescribes the kinds of measures that are emerging from ongoing researchand monitoring activities.

• Life After Cancer. Trends in the proportion of cancer patients alive 5 years after their diagnosis and the costs of cancer care are addressed inthis section.

• End of Life. This section includes the rate of deaths (mortality) fromcancer and the estimated number of years of life lost (person-years of lifelost) due to cancer.

Where possible, the Cancer Progress Report shows changes in these dataover time (trends). Most of the trend graphs were made using a newstatistical method that illustrates real changes in direction instead of merelyconnecting one dot to another. This report also shows whether the trendsare “rising” or “falling” using standard definitions, and it explains whychanges might have occurred (Appendix D). For some measures,differences in the cancer burden between some U.S. racial and ethnic groups also are presented. We were not able to present information on all demographic groups for all measures because of space limitations.


Most of the measures in this report are identical to those in Healthy People2010—a comprehensive set of 10-year health objectives for the Nation—sponsored by the U.S. Department of Health and Human Services. This enabled us to show the Nation’s progress relative to Healthy People cancer-related targets for 2010.

How Data Were Selected

In selecting measures that would be meaningful to readers of this report, we relied on those that are based on scientific evidence and long-termnational, rather than State or local, data collection efforts. The reportincludes more measures for prevention, because more data on trends areavailable in that area. Some measures such as “quality of life” were notincluded in this report, even though they are important in assessing thecancer burden, because there simply is no consensus on how best to trackthese measures at this time.

The data in Cancer Progress Report 2001 come from a variety of systemsand surveys with different collection techniques and reporting times, sotime periods may vary. Where possible, 1990 was used as the starting pointor baseline against which to measure how well the Nation is progressingtoward the Healthy People 2010 targets.

Online Version

This report presents summary data in a concise manner so that manymeasures could be included. More detailed information on these andrelated topics can be found at: http://progressreport.cancer.gov.

The online version includes links to published reports, databases, articles,and other background information. Use the key words that appearthroughout this printed report to locate information at the Cancer ProgressReport site.

Introduction (continued)


Key Word: Prevention

P R E V E N T I O N

Prevention

This section of Cancer ProgressReport 2001 focuses on two kindsof factors that can affect a person’srisk of getting cancer: behaviors andexposures to chemicals in theenvironment. Choosing the rightbehaviors and preventing exposuresto certain chemicals may help toprevent cancers before they can start.

Behavioral FactorsScientists estimate that as many as50 percent to 75 percent of cancerdeaths in the United States arecaused by human behaviors such assmoking and dietary choices. Thefirst part of the Prevention sectiondescribes trends in the followingbehaviors that can help to preventcancer:

• Not using cigarettes or othertobacco products

• Not drinking too much alcohol

• Eating five or more daily servingsof fruits and vegetables

• Eating a low-fat diet

• Maintaining or reaching a healthyweight

• Being physically active

• Protecting skin from sunlight

Smoking causes about 30 percent of all U.S. deaths from cancer.Avoiding tobacco use is the singlemost important step Americans cantake to reduce the cancer burden in this country.

Additional important steps aremaintaining a healthy weight, being physically active, eating alow-fat diet and enough fruits andvegetables, avoiding too muchalcohol, and protecting skin fromsunlight.

Environmental FactorsCertain chemicals in theenvironment are known to causecancer. The second part of thePrevention section covers:

• Secondhand smoke (also knownas environmental tobacco smoke)

• Radon in the home

• Benzene in the air

These environmental measures werechosen because of the availability ofreliable national data showing trendsover time. Additional environmentalmeasures will be available for futureeditions of this report.


Key Words: Adult Smoking

PREVENTION: Behavioral

Adult SmokingCigarette smoking by adults has fallen slightly since 1990.

Smoking and CancerCigarette smoking is the mostpreventable cause of death in theUnited States. It causes nearly one-third (163,000) of all U.S. cancer deaths each year and is theleading cause of lung cancer deaths.Cigarette smoking also causescancers of the larynx, mouth,esophagus, pharynx, and bladder. In addition, it plays a role in cancersof the pancreas, kidney, and cervix.

Cigar smoking has been found tocause cancers of the larynx, oralcavity (lip, tongue, mouth, and throat),esophagus, and lung.

MeasurePercent of adults who were currentcigarette smokers: Adults ages 18 and older who reported smoking 100 or more cigarettes in their lifetime and who, at the time of the interview, continued to smokeevery day or some days.

Period – 1992-1998

Trends – Falling slightly

Adult cigarette smoking is fallingslightly for men and women and for both combined, although the trend for women is notstatistically significant.

Most Recent EstimatesIn 1998, 24 percent of adults—26percent of men and 22 percent ofwomen—were current cigarettesmokers.

Also in 1998, 2.5 percent ofadults—5 percent of men and 0.2percent of women—were currentcigar smokers, an increase from earli-er in the decade. Current cigarsmokers have had at least 50 cigarsin their lifetime and, at the time ofthe interview, continued to smokeevery day or some days.

Healthy People 2010 TargetsReduce to 12 percent the proportionof adult current cigarette smokers.

Reduce to 1.2 percent the proportionof adult current cigar smokers.

Groups at High Risk forSmokingMen—especially American Indian/Alaska Natives and Blacks—aremore likely than women to smokecigarettes. Other high-risk groupsinclude American Indian/AlaskaNative women, people living belowthe poverty level, and those with 9 to 11 years of education.



Cigar use is increasing among young and middle-aged (ages 18-44) White men with higher thanaverage incomes and education, andamong women.

Key IssuesAlthough the rate of smoking hasdropped by nearly half since theSurgeon General’s first report onsmoking in 1964 (42 percent ofadults were current smokers in1965), progress has slowed in recentyears. Further decreases in tobaccouse could vastly improve the public’shealth.

From 1993 to 1997, U.S. cigar salessoared by almost 50 percent, mostlydue to increased sales of large cigars.This followed new cigar marketingapproaches that began in 1992.

Key Words: Adult Smoking


Figure 1: Percent of Adults (Ages 18+) Who WereCurrent Cigarette Smokers—1992-1998

Per

cent

Year

Both SexesMenWomen

20

25

30

1990 1993 1996 19990

Source: Centers for Disease Control and Prevention, National Center for HealthStatistics. National Health Interview Survey.Age-adjusted to the year 2000 standard population.

PREVENTION: BehavioralKey Words: Youth Smoking

Youth SmokingCigarette smoking by high schoolers is rising, with recent suggestionsof a turnaround. Smokeless tobacco use appears to be falling.

Youth Tobacco Use and CancerFor most of the 1990s, about 3,000youth under 18 became regular cigarette smokers each day. This hasdeclined recently to just over 2,000each day. Of these 2,000, nearly 700will die early due to lung cancer orother tobacco-related diseases.

Other forms of tobacco used byyoung people include smokelesstobacco (chewing tobacco and snuff,also known as spit tobacco), cigars,and bidis (small, brown, hand-rolled,flavored cigarettes). Each of thesealso can cause cancer.

MeasurePercent of high school students whowere current cigarette or smokelesstobacco users: Students (grades 9-12) who reported having used cigarettes or smokeless tobacco inthe 30 days before the survey.

Period – 1991-1999

Trends Cigarettes:The data show that current cigarettesmoking among youth is rising.There appears to be a downwardtrend beginning in 1997, but more data are needed before this can be verified.

Smokeless tobacco:Current smokeless tobacco use isfalling, although the trend is not statistically significant.

The source of trend data used in thisreport does not provide data for useof either “any tobacco” or cigarsbefore 1997.

Most Recent EstimatesAmong high school students in 1999:

• 35 percent were current cigarettesmokers.

• 8 percent were current users ofsmokeless tobacco.

• 18 percent were current cigarsmokers.

• 40 percent were current users of“any tobacco.”

Healthy People 2010 TargetsDecrease the proportion of highschool students who currently:

• Smoke cigarettes to 16 percent.

• Use smokeless tobacco to 1 percent.

• Smoke cigars to 8 percent.

• Use any tobacco to 21 percent.


Groups at High Risk forTobacco UseWhite, non-Hispanic students aremore likely to smoke cigarettes thanare Hispanic students, who in turnare more likely to smoke than Blacknon-Hispanic students.

High school boys are much morelikely than girls to use smokelesstobacco, cigars, pipes, and bidis. Overall, White high school studentsare much more likely than Blackhigh school students to report current cigar use.

Among middle school students,Blacks are much more likely thanWhites to smoke cigars.

Key IssuesSince 1997, current smoking leveledoff or possibly began to declineamong 9th-11th graders. However, it has risen steadily among 12thgraders since 1991.

In 1999, 13 percent of middle schoolstudents (grades 6 to 8) reportedusing some form of tobacco in thepast month. Cigarettes were themost popular, followed by cigars.

Bidis—increasingly popular amongyoung people—can be even moredangerous than cigarettes. Bidisproduce higher levels of carbonmonoxide, nicotine, and tar than cigarettes. Also, bidi smokers tendto inhale more often and moredeeply than cigarette smokers.

Per

cent

Year

CigarettesSmokless Tobacco

0

10

20

30

40

1990 1993 1996 1999

PREVENTION: BehavioralKey Words: Youth Smoking


Figure 2: Percent of High School Students (Grades 9-12) Who Were Current Users of Cigarettes or SmokelessTobacco—1991-1999

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Youth Risk BehaviorSurveillance System.

Key Words: Smoking Initiation


Age of Smoking InitiationThe average age at which people first begin smoking has been relatively stable in recent years.

Age of Initiation and CancerThe younger a person starts smok-ing, the greater the lifelong risk ofdeveloping smoking-related cancers.That is because young smokers aremore likely to become addicted, andthe more years one smokes, thegreater the risk of cancer.

MeasureAverage age of first use of cigarettes,based on responses from people ages12 and older, 12 to 17, and 18 to 25.

Period – 1990-1999

Trends12 +: Rising slightly in the

early 1990s, then stable

12-17: Rising slightly

18-25: Rising until 1997, then stable

Most Recent EstimatesIn 1999, the average age at first useamong people ages 12 and older was 15.4 years. Among 12- to 17-year-olds, the average age was12.4. Among those 18 to 25, theaverage age was 14.8.

Healthy People 2010 TargetsIncrease the average age at first useof cigarettes to:

• 14 years of age for 12- to 17-year-olds.

• 17 years of age for 18- to 25-year-olds.

There is no Healthy People 2010 tar-get for ages 12 and older as a group.


Key Words: Smoking Initiation


Ave

rage

Age

at F

irst U

se

Year

Ages 12+Ages 12-17Ages 18-25

10

11

12

13

14

15

16

17

18

1990 1993 1996 19990


Figure 3: Average Age at First Use of Cigarettesfor Respondents Ages 12+, 12-17, and 18-25—1990-1999

Source: Substance Abuse and Mental Health Services Administration,Office of Applied Studies. National Household Survey on Drug Abuse.

Groups at High Risk forBeginning SmokingYoung people who come from low-income families with less educationare more likely to smoke. So are those who have less success andinvolvement in school and fewerskills to resist the pervasive pres-sures to use tobacco. Tendencies totake risks and rebel are among theother risk factors for beginningsmoking.

Key IssuesMost smokers try their first cigarette before the age of 18 and become addicted during adolescence.

Efforts to help young people delay or avoid smoking may help to prevent some cancers.

PREVENTION: BehavioralKey Words: Quit Smoking

QuittingAdult quitting rates are improving after a decline in the early 1990s.

The Effects of QuittingSmoking on CancerTen years after quitting smoking, aperson’s risk of getting lung canceris about one-third to one-half that ofpeople who continue to smoke. Thelonger the time off cigarettes, thelower the risk. Quitting also reducesthe risk of getting cancers of thelarynx, esophagus, pancreas,bladder, and cervix.

Also, the sooner one quits smoking,the better. Long-term smokers who stop smoking at around 50 or60 years of age are less likely to get lung cancer than are people who continue to smoke. Quitting at around age 30 lowers this riskeven more.

The quickest non-cancer healthbenefit of quitting is a lower risk ofcoronary heart disease. This risk iscut in half after one year of quitting.After 15 years, the chance of gettingthe disease is similar to that ofpeople who never smoked.

MeasuresDaily cigarette smokers (ages 25 and older) who showed somequitting activity.

Daily cigarette smokers (ages 25 and older) who were able to stay off cigarettes 3 months or longer.

Period – 1992-1993, 1995-1996, and 1998-1999

Trends – Falling, then rising

Between 1992-1993 and 1995-1996,there was a clear decline in attemptsto quit smoking as well as insuccessful longer-term quitting.From 1995-1996 to 1998-1999, both of these activities increased.

Most Recent EstimatesIn 1998-1999, at least 36 percent of daily smokers 25 years of age andolder made some attempt to quit.Five percent of daily smokers wereable to stay off cigarettes 3 monthsor longer.

Also, in 1998, 41 percent of adultsmokers (ages 18 and older) stoppedsmoking for a day or longer becausethey were trying to quit. Trend dataare not available for this measure.

Healthy People 2010 TargetIncrease to 75 percent the proportionof adult smokers (ages 18 and older)who stopped smoking for a day or longer because they were tryingto quit.

There are no targets in HealthyPeople 2010 for the other quitmeasures in this report.


PREVENTION: BehavioralKey Words: Quit Smoking

Groups at High Risk for Not QuittingOlder smokers (ages 65 years andolder) are much less likely to try to quit. However, once they do quit,this group is more likely to besuccessful for 3 months or longer.

Blacks have higher rates of trying toquit than Whites, but lower rates of successfully quitting for 3 months or longer.

Smokers with lower levels ofeducation and income are less likelyto be successful quitters.

Key IssuesStudies show that most smokerswant to quit.

Efforts to reduce smoking are mosteffective when multiple techniquesare used, including educational,clinical, regulatory, and economicinterventions (for example,increasing excise taxes), along withmedia campaigns and other socialstrategies.


Per

cent

Year

Some Quitting ActivityQuitting for 3 Months or More

0

10

20

30

40

1990 1993 1996 1999

Figure 4: Percent of Daily Smokers (Ages 25+)Who Tried to Quit or Quit for 3 Months orLonger—1992-1993, 1995-1996, and 1998-1999

Source: Tobacco Use Supplement to the Current Population Survey, sponsored by the National Cancer Institute.Age-adjusted to the year 2000 standard population.

PREVENTION: BehavioralKey Word: Alcohol

Alcohol ConsumptionPer capita alcohol consumption is falling slightly.

Alcohol and CancerDrinking alcohol increases the riskof cancers of the mouth, esophagus,pharynx, larynx, and liver in men andwomen, and breast cancer in women.In general, these risks increase afterabout one daily drink for women andtwo daily drinks for men. (A drinkis defined as 12 ounces of regular beer, 5 ounces of wine, or1.5 ounces of 80-proof liquor.)

Two drinks daily increase the risk of getting breast cancer by about 25 percent. The chances of gettingliver cancer increase with five ormore daily drinks.

The earlier that long-term, heavyalcohol use begins, the greater thecancer risk. Also, using alcohol withtobacco is riskier than using eitherone alone, because it further increas-es the chances of getting cancers ofthe mouth, throat, and esophagus.

MeasurePer capita alcohol consumption: Theestimated number of gallons of purealcohol drunk per person (ages 14and older), per year. This measureaccounts for the varying alcoholcontent of wine, beer, and liquor.People as young as 14 are includedbecause a large number of adoles-cents begin drinking at an early age.

Period – 1990-1998

Trend – Falling slightly

Most Recent EstimateIn 1998, per capita alcohol con-sumption was 2.19 gallons for allbeverages, including beer, wine, andliquor.

Healthy People 2010 TargetReduce per capita alcohol consumption to 2 gallons.

Groups at High Risk forUsing AlcoholMany people start drinking as early as middle school (13- to 14-year-olds).

Among 12- to 17-year-olds, Whitesand Hispanics are more likely thanBlacks to use alcohol.

Among alcohol drinkers, those ages18 to 25 consume greater quantitiesthan any other group.

Key IssuesPeople who drink and smoke mayfind it harder to stop either of thesebehaviors.

Drinking low levels of alcohol canhave both negative and positivehealth effects: It raises the risk ofgetting breast cancer and lowers the risk of getting heart disease.Therefore, women who already areat low risk for heart disease couldreduce their risk of breast cancer byavoiding regular alcohol use.

Gal

lons

Year

0

1

2

3

4

1990 1993 1996 1999


Figure 5: Per Capita Alcohol Consumption(Ages 14+)—1990-1998

Source: National Institute on Alcohol Abuse and Alcoholism.

PREVENTION: BehavioralKey Words: Fruits and Vegetables

Fruit and Vegetable ConsumptionAmericans are eating only slightly more fruits and vegetables than a decade ago.

Fruits and VegetablesReduce Cancer RiskPeople whose diets are rich in fruitsand vegetables have a lower risk ofgetting cancers of the lung, mouth,pharynx, esophagus, stomach, colon,and rectum. They also are less likelyto get cancers of the breast, pan-creas, larynx, and bladder.

To help prevent these cancers andother chronic diseases, experts rec-ommend 5-9 servings of fruits andvegetables daily. This includes 2-4servings of fruits and 3-5 servings of vegetables, with dark-green anddeep-yellow vegetables making up about one-third (about 1 to 2servings) of the vegetable servings.There is no direct evidence thatAmerica’s favorite vegetable, thewhite potato, protects against cancer.

MeasureAverage daily servings of fruits andvegetables for people ages 2 andolder. This measure includes fruitsand vegetables from all sources.

Period – 1989-1991 and 1994-1996

Trends Fruits: Rising

Vegetables: Rising slightly

Total average daily servings of fruits and vegetables increased from4.5 servings in 1989-1991 to 4.9servings in 1994-1996. Fruit serv-ings rose from 1.3 to 1.5 servings.Vegetable servings rose from 3.2 to3.4 servings.

Most Recent EstimatesIn 1994-1996, people ages 2 andolder had, on average, 1.5 servingsof fruits and 3.4 servings of vegeta-bles, for a total 4.9 servings of fruitsand vegetables. Total vegetableservings included:

• Dark-green/deep-yellow: 0.4servings.

• Starchy: 1.5 servings (mostly fried potatoes).

• Tomatoes and other vegetables:1.5 servings.

Among racial and ethnic groups,Blacks had 4.5 total servings; Whites and Hispanics, 5;Asian/Pacific Islanders, 5.6; andNative Americans, 6.

Healthy People 2010 Targets At least two daily servings of fruits.

At least three daily servings of veg-etables, with at least one-third beingdark-green/deep-yellow.

(The Healthy People 2010 targetscall for 75 percent of the populationto consume the minimum servingsof fruits and 50 percent to consumethe minimum servings of vegetables.)


Groups at High Risk for Not Eating Enough Fruits and VegetablesYoung children (ages 2-11 years),teenage girls, and young women eatthe fewest numbers of servings offruits and vegetables—about fourper day. People with lower levels ofincome and education tend to eatfewer fruits and vegetables. Amongracial and ethnic groups, Blackshave the lowest intake.

Key IssuesAlthough, on average, people con-sume more than the recommendedthree daily servings of vegetables,they do not consume enough dark-green/deep-yellow varieties.

Consumers—especially those livingin low-income and urban areas—need access to affordable fruits andvegetables. However, between 1982and 1997, fruits and vegetables hadmore retail price increases than allother food categories.

While five servings of fruits andvegetables is the minimum daily recommendation, estimates based oncaloric needs suggest that Americansactually need an average of sevendaily servings. These additionalservings should replace sources of“empty calories” in the diet, such as added sugars and fats, to avoidtaking in too many calories.

Num

ber

of S

ervi

ngs

Year

FruitsVegetables

0

1

2

3

4

5

1990 1993 1996 1999

Figure 6: Average Daily Servings of Fruits andVegetables (Ages 2+)—1989-1991 to 1994-1996

Source: U.S. Department of Agriculture. Continuing Survey of Food Intakes by Individuals.Age-adjusted to the year 2000 standard population.

Key Words: Fruits and Vegetables


Fruit and Vegetable Consumption (continued)


Key Word: Fats


Fat ConsumptionAmericans are getting a smaller portion of their calories from fat.

Fat Consumption and CancerSome studies have linked high-fatdiets and different types of fat in thediet to several cancers, includingcancers of the colon, prostate, lung,and endometrium. Saturated fattyacids are thought to be the mostharmful kind. While earlier studiessuggested similar results for breastcancer, more recent evidence hasraised doubts about the importanceof dietary fat in the development ofbreast cancer.

More research is needed to betterunderstand which types of fat andwhat amounts alter cancer risk.Although monounsaturated andpolyunsaturated fatty acids havebeen studied for a number of years,their effects are still unclear. Morerecent research on the effects oftrans fatty acids also has yet to reachdefinite conclusions.

The U.S. Dietary Guidelinesrecommend getting less than 10percent of calories from saturatedfatty acids for general health and theprevention of chronic disease,including cancer and heart disease.The Guidelines also recommend nomore than 30 percent of caloriesfrom total fat.

MeasureIntakes of total fat, and of the majorfatty acids—saturated, monounsaturated,and polyunsaturated—all as apercentage of total calories.

Period – 1989-1991 and 1994-1996

Trends – Falling slightly overall

Total fat: Falling slightly

Saturated: Falling

Monounsaturated: Stable

Polyunsaturated: Falling slightly

Most Recent EstimatesData collected from 1994-1996 showthat total fat made up one-third (33percent) of the calories peopleconsumed, a slightly higher level

than recommended. In the sameperiod, saturated fatty acidsaccounted for 11 percent of calories;monounsaturated, 13 percent; andpolyunsaturated, 7 percent.

Healthy People 2010 TargetNo more than 30 percent of dailycalories from fat.

(The Healthy People 2010 targetcalls for 75 percent of the populationto reach this level.)


Groups at High Risk forEating Too Much FatIntake of fat and the major fattyacids does not vary in the U.S. population by major racial or ethnic groups. Total fat intakes tend to decrease as education levels increase.

Key IssuesResearchers are studying how fatand fatty acids alter cancer risk.Precise and reliable measures of theamount and type of fat are needed—especially biological indicators of fat intake that might be determinedfrom a blood test.

Per

cent

age

of T

otal

Cal

orie

s

Year

Total FatMonounsaturated Fatty AcidsSaturated Fatty AcidsPolyunsaturated Fatty Acids

0

10

20

30

40

1990 1993 1996 1999

PREVENTION: BehavioralKey Word: Fats

Fat Consumption (continued)


Figure 7: Trends in Fat Intakes as a Percentageof Total Calories—1989-1991 to 1994-1996

Source: U.S. Department of Agriculture. Continuing Survey of Food Intakesby Individuals.Age-adjusted to the year 2000 standard population.


WeightMore adults are becoming overweight and obese.

Overweight, Obesity, andCancerBeing overweight increases thechances of health problems, includ-ing heart disease, stroke, diabetes,and some cancers.

In women, overweight and obesity,weight gain, and increased amountsof fat at the waist or around thebody’s mid-section double to triplethe chances of getting endometrialcancer. These factors also doublethe chances of getting breast cancerafter menopause.

Obesity and increased body fat raisethe risk of getting colorectal cancer.Overweight and obesity are linked toan increased risk of some types ofesophageal and kidney cancers.

MeasuresPercent of adults (ages 20-74) whoare at a healthy weight, overweight,or obese.

These weight groups are defined bya measurement called body massindex (BMI). BMI is found bydividing weight (in kilograms) byheight (in meters) squared.

Healthy weight in adults: BMIgreater than or equal to 18.5 and lessthan 25

Overweight in adults: BMI of 25 ormore

Obesity in adults: BMI of 30 ormore

Period – 1971-1974, 1976-1980,and 1988-1994

Trends Healthy weight: Stable, then fallingslightly

Overweight: Stable, then risingslightly

Obesity: Rising slightly (though notstatistically significant), then rising

Early data from 1999 show even fur-ther increases in overweight and obesity.

Most Recent EstimatesAmong adults in 1988-1994:

• 42 percent were at a healthy weight.

• 56 percent were overweight.

• 23 percent were obese.

Healthy People 2010 TargetsIncrease to 60 percent the proportionof adults who are at a healthyweight.

There is no Healthy People 2010 target for overweight.

Decrease to 15 percent the proportionof obese adults.

Key Word: Weight


PREVENTION: BehavioralKey Word: Weight

Groups at High Risk forBeing Overweight or ObeseOverweight and obesity are mostcommon among Black and Mexican-American women. The same pat-terns are seen for children and teensin these groups.

Overweight children are more likelyto become overweight adults and tosuffer from the illnesses that comewith it as well as premature death.As with adults, the trend towardexcess weight among children hasgreatly increased in recent years.

Key IssuesDaily physical activity balanced withappropriate calorie intake is one ofthe most effective ways to avoidweight gain. Lack of activity isbelieved to be one of the major rea-sons for the increase in overweightamong U.S. youth and adults.

Increased TV watching is linkedwith excess weight.

See page 37 for trends in physicalactivity.

Weight (continued)

Per

cent

Year

Healthy WeightOverweightObese

0

10

20

30

40

50

60

1974 1979 1984 1989 1994 1999


Figure 8: Percent of Adults (Ages 20-74) Who Wereat a Healthy Weight, Overweight, or Obese—1971-1974, 1976-1980, and 1988-1994

Source: National Center for Health Statistics. National Health and NutritionExamination Survey.Age-adjusted to the year 2000 standard population.

PREVENTION: BehavioralKey Words: Physical Activity

Physical ActivityOnly about two-thirds of adults get any physical activity in theirleisure time.

Physical Activity ReducesCancer RiskPhysical activity at work or duringleisure time is linked to a 50 percentlower risk of getting colon cancer.Both vigorous and moderate levelsof physical activity appear to reducethis risk. Physical activity probablyis connected with a lower risk ofbreast cancer and possibly prostatecancer. Studies continue to look atwhether physical activity has a rolein reducing the chances of gettingother cancers.

MeasurePercent of adults ages 18 and olderwho had no leisure-time physicalactivity during the past month.

Period – 1990-1998

Trend – Falling slightly

This means that only slightly moreadults have any physical activity intheir leisure time. However, thistrend is not statistically significant.

Most Recent EstimatesResults from the Behavioral RiskFactor Surveillance System (BRFSS)show that in 1998, 29 percent ofadults ages 18 and older reported nophysical activity in their leisure time.BRFSS, a telephone survey, wasused for Cancer Progress Report2001 because data have been available in a consistent form over time.

The 1998 National Health InterviewSurvey (NHIS), a household survey

that used different questions toassess physical activity, indicatesthat 40 percent of adults 18 andolder reported no physical activity in their leisure time.

Healthy People 2010 TargetReduce to 20 percent the percent ofadults who engage in no leisure-timephysical activity (based on NHIS data).

Groups at High Risk forBeing Inactive in TheirLeisure TimeWomen are more likely than men,and Blacks and Hispanics are morelikely than Whites to report noleisure-time physical activity. Lackof physical activity also is morecommon among those with less education.

For youth, physical activity is loweramong females, especially Blacks.Also, physical activity decreases aschildren get older.

Key IssuesSince the mid-1980s, fewer highschool students have taken part inphysical education classes.

Removing barriers (such as lack ofphysical education classes) and set-ting up supports (such as bicycle andwalking paths) can help to promotephysically active lifestyles.


Per

cent

Year

025

30

35

1990 1993 1996 1999

Figure 9: Percent of Adults (Ages 18+) Reporting NoPhysical Activity in Their Leisure Time—1990-1998

Source: Centers for Disease Control and Prevention, National Center for ChronicDisease Prevention and Health Promotion. Behavioral Risk Factor SurveillanceSystem.Age-adjusted to the year 2000 standard population.

Key Word: Sun


Sun Protection Fewer than half of adults say they are likely to protect themselvesfrom the sun.

Sun Protection ReducesCancer RiskSkin cancers are most common inlight-skinned people, although theyalso occur in people with darkerskin. Studies suggest that reducinglong-term exposure to the sun, totanning booths, and to sunlamps canlower the risk of nonmelanoma skincancer. Avoiding burns from thesesources—especially by children andteens—may reduce the chances ofgetting melanoma skin cancer. The

rates of new cases of melanomaincreased from 1973 to 1998,although the rate of increase hasslowed since 1981.

MeasurePercent of adults ages 18 and olderwho reported they were “very likely”to practice at least one of three sun-protection behaviors—use sunscreen,wear protective clothing, or seekshade—if they were outside on asunny day for more than 1 hour.

Per

cent

Year

20

30

40

50

60

1990 1993 1996 1999

Very likely to use sunscreen, wear protective clothing, or seek shadeVery likely to use sunscreenVery likely to wear protective clothingVery likely to seek shade

0


Figure 10: Percent of Adults (Ages 18+) Very Likely toProtect Themselves From the Sun—1992 and 1998

Source: Centers for Disease Control and Prevention, National Center forHealth Statistics. National Health Interview Survey.Age-adjusted to the year 2000 standard population.

Key Word: Sun


Period – 1992 and 1998

Trends – Falling overall

The percent of people very likely touse at least one sun protection methodis falling, as are the percents ofpeople very likely to wear protectiveclothing and to seek shade. Thepercent of people very likely to usesunscreen is rising slightly.

Most Recent EstimatesIn 1998, 47 percent of adults saidthey were very likely to practice atleast one of three sun protectionbehaviors:

• 31 percent were very likely to usesunscreen.

• 24 percent were very likely towear protective clothing.

• 28 percent were very likely toseek shade.

Healthy People 2010 TargetIncrease to 75 percent the proportionof adults who are very likely to usesunscreen, wear protective clothing,or seek shade.

Groups at High Risk forGetting Too Much SunYounger adults and men are lesslikely to use some form of sunprotection. Adults with lowerincomes and less education are lesslikely to use sunscreen.

Youths (ages 11-18) also are lesslikely to protect themselves from thesun. A 1998 survey found that fewyoung people routinely practicedthese behaviors on sunny days:wearing long pants (21 percent),staying in the shade (22 percent),and using sunscreen (31 percent).

Key IssuesIn general, increased exposure to thesun—especially without adequateuse of sunscreen and protectiveclothing—increases the chances ofgetting skin cancer.

Some research suggests that peopleapply less than an adequate amountof sunscreen and fail to reapply itappropriately.


Key Words: Secondhand Smoke

PREVENTION: Environmental

Num

ber

of S

tate

s

Year

State Government WorksitesRestaurantsPrivate WorksitesDay Care Centers

0

5

10

15

20

25

30

1990 1993 1996 1999

Secondhand SmokeProgress is slow in efforts to enact State laws on smoke-free air.

Secondhand Smoke and CancerSecondhand smoke—also known asenvironmental tobacco smoke—iswhat comes from a burning cigarette,pipe, or cigar, plus what the smokerexhales. Tobacco smoke is known to contain at least 60 carcinogens.People who are exposed to second-hand smoke inhale these chemicals,just as smokers do, although at lower levels.

In 1993, the U.S. EnvironmentalProtection Agency (EPA) reportedthat secondhand smoke is a "knownhuman carcinogen." The EPA alsoreported that secondhand smokecauses some 3,000 lung cancer deathseach year among U.S. nonsmokers.

MeasuresStates (and the District of Columbia)with laws on smoke-free air in Stategovernment worksites, private work-sites, restaurants, and day care centers.


Figure 11: States With Smoke-Free Indoor Air Laws in StateGovernment Worksites, Private Worksites, Restaurants, andDay Care Centers—1990-2000

Source: National Cancer Institute. State Cancer Legislative Database.Age-adjusted to the year 2000 standard population.

Key Words: Secondhand Smoke


Period – 1990-2000

Trends – Rising in day care centers, but still low. Stable and very low at other sites.

Most Recent EstimatesIn 2000, the number of States with smoke-free indoor air laws, asmeasured in four types of sites, were as follows:

• State government worksites: 4

• Private worksites: 2

• Restaurants: 3

• Day care centers: 25

Results of another survey show thatin 1998-1999, 69 percent of theworkforce (ages 18 and older)reported there was a smoke-free policy at their workplace. Also during that time, 61 percent of people ages 18 and older reportedthat smoking is not allowed in theirhome. These represent significantincreases since 1992-1993.

Healthy People 2010 TargetIncrease to 51 the number of States(and the District of Columbia) withsmoke-free indoor air laws for public places and worksites.

Groups at High Risk for Exposure to SecondhandSmokePeople with lower income and edu-cation levels are more likely to beexposed to smoking in their work-places and homes. Men andyounger adults are more likely towork in places that allow smoking.

Key IssuesAlthough secondhand smokeremains a major public health con-cern, nonsmokers’ exposure totobacco smoke declined more than75 percent from 1988-1991 to 1999.

In 1999, nearly 7 out of 10 U.S.workers reported a smoke-free policyin their workplace.

State laws that protect against sec-ondhand smoke slowly became morecommon in the past decade. Itappears that greater improvementcame from voluntary or local effortsduring that time.


Key Word: Radon


Radon in the HomeMore people live in homes tested for radon.

Radon and CancerRadon—an invisible, odorless,tasteless gas that is released fromrocks and soil—enters homes throughcracks and holes in the foundation.Indoor radon is the most seriousenvironmental cancer-causing agentto which the general public is exposed.The Environmental ProtectionAgency estimates that as many as 8 million homes in the United Stateshave high levels of radon. Statesurveys show that one out of fivehomes have high levels.

Radon is second only to tobacco as the leading cause of lung cancer.Radon found in homes may contributeto as many as 20,000 lung cancerdeaths each year. It is a moreserious health threat to under-ground miners.

People who are exposed to bothradon gas and tobacco smoke aremore likely to get lung cancer thanare people who are exposed to eitherone alone. Most radon-relateddeaths from lung cancer occuramong smokers.

MeasureThe percent of people who live in homes tested for radonconcentrations, among those whohave heard of radon.

Period – 1991-1998

Trend – Rising

Most Recent EstimateIn 1998, 17.5 percent of Americanswho have heard of radon lived inhomes tested for radon.

Healthy People 2010 TargetIncrease to 20 percent the proportionof people who have heard of radonwho live in homes tested for radon.

Groups at High Risk for Not Testing for RadonPeople who live in homes with asmoker are less likely to test forradon than are those who live inhomes without smokers.

Key IssuesResearchers estimate that loweringindoor radon exposure would preventabout 30 percent of lung cancerdeaths from radon. Of these, 86percent would be among smokers or former smokers.

Per

cent

Year

0

5

10

15

20

1990 1993 1996 1999


Figure 12: Percent of People Who Have Heard of RadonWho Live in Homes Tested for Radon—1991-1998

Source: Centers for Disease Control and Prevention, National Center for HealthStatistics. National Health Interview Survey.

Key Word: Benzene


Benzene in the AirBenzene concentrations in the air are going down.

Benzene and CancerBenzene is a natural part of crude oil,gasoline, and cigarette smoke. It is alsoused as a gasoline additive and in themanufacture of a number of products.

The general population’s main exposure to benzene is inhaling airthat contains it. About half of humanexposures to benzene come fromsmoking and secondhand smoke.Other sources include vapors fromheavy traffic and gas stations.Long-term exposure to high levels of benzene in the air can cause leukemia.

MeasureNational yearly average concentra-tions of benzene in the air in metropolitan areas, measured inmicrograms per cubic meter.

Period – 1993-1998

Trend – Falling

From 1993 to 1998, the averageyearly concentrations of benzenedeclined by 37 percent.

Most Recent EstimateIn 1998, the average concentrationof benzene was 1.85 micrograms percubic meter.

Healthy People 2010 TargetThere is no Healthy People 2010 target for this measure.

Groups at High Risk forBenzene ExposurePeople who are exposed to benzeneinclude those who work around

or with benzene, smokers, and people who are exposed to secondhand smoke.

Key IssuesThe Environmental Protection Agencysays that benzene concentrations in the air have declined becausereformulated gasoline is being usedin many parts of the United States.This is an example of how changesto the environment can help to lowercancer risk.

More measures of environmentalchemical carcinogen exposures—such as those reported by theNational Center for EnvironmentalHealth, Centers for Disease Controland Prevention—need to be trackedover time.

Mic

rogr

ams

per

Cub

ic M

eter

Year

0

1

2

3

4

5

1990 1993 1996 1999


Figure 13: National Trend in Annual/Average BenzeneConcentrations in Metropolitan Areas (micrograms percubic meter)—1993-1998

Source: Environmental Protection Agency. National Air Quality and EmissionsTrends Report, 1998. March 2000.

Key Words: Early Detection

E A R LY D E T E C T I O N

Early Detection

The use of screening tests to detectcancers early often leads to moreeffective treatment with fewer sideeffects. Patients whose cancers arefound early also are less likely to diefrom these cancers than are thosewhose cancers are not found untilsymptoms appear.

This section describes trends in theuse of the following screening tests,each of which has been found todetect cancers accurately and todecrease the chances of dying fromcancer:

• Mammography (for breast cancer)

• Pap smear (for cervical cancer)

• Fecal occult blood test (forcolorectal cancer)

• Sigmoidoscopy (for colorectalcancer)

Trends for newer ways to detectcancer, such as the prostate specificantigen (PSA) test, may be includedin future editions of the CancerProgress Report. PSA use has notyet been proven to reduce deathsfrom prostate cancer. There is alsoconcern about possible harm causedby unnecessary treatments, becausethe test can find very early cancersthat might not cause any harm if leftuntreated—especially in older men.Other screening methods, such asnew imaging techniques to detectlung cancer, or ways to detect earlycancer in the blood, also requiremore research.


Key Word: Mammography


Breast Cancer ScreeningMammography use has increased steadily in women ages 40 and older.

Benefits of ScreeningMammographyRegular use of screeningmammograms can help reduce thechances of dying from breast cancer.For women between the ages of 50and 69, there is strong evidence thatscreening lowers this risk by 30percent. For women in their 40s, therisk can be reduced by about 17percent. For women ages 70 and older, mammography may be helpful, although firm evidence is lacking.

MeasurePercent of women ages 40 years and older who reported they had amammogram within the past 2 years,by racial/ethnic group.

Period – 1987, 1992, and 1998

Trends – Rising

Mammography use is increasingamong Hispanic, Black, and Whitewomen ages 40 and older.

Most Recent EstimatesIn 1998, 67 percent of women ages40 and older had a mammogramwithin the past 2 years. Amongracial and ethnic groups, 60 percentof Hispanics, 66 percent of Blacks,and 68 percent of Whites had amammogram within the past 2 years.Notably, differences between thesegroups were minimal.

Healthy People 2010 TargetIncrease to 70 percent the proportionof women ages 40 and older whohave received a mammogram withinthe past 2 years.

Groups at High Risk for Not Being ScreenedPoor, less educated women who lackhealth insurance or a usual source ofcare are less likely to get screeningmammograms.

Key IssuesThe barriers that prevent high-riskgroups from getting regularmammograms need to be removed.

While millions of women have hadat least one screening mammogram,many women still have not. Also,even among those women who had arecent screening mammogram, manydo not do so on a regular basis.

Per

cent

Year

10

20

30

40

50

60

70

1987 1990 1993 1996 1999

HispanicBlackWhiteAverage Rate

0


Figure 14: Percent of Women (Ages 40+) Who HadMammography Within the Past 2 Years, byRace/Ethnicity—1987, 1992, and 1998


Key Words: Pap Smear

E A R LY D E T E C T I O NCervical Cancer ScreeningPap smear use is rising slightly among women ages 18 and older.

Benefits of Pap SmearTestingRegular use of the Pap smear testreduces deaths from cervical cancer.Women who have not been screenedface a 3 to 10 times greater risk ofdeveloping invasive cervical cancer.

MeasurePercent of women ages 18 years andolder who reported they had a Papsmear within the past 3 years.

Period – 1987, 1992, and 1998

Trend – Rising slightly

Most Recent EstimateIn 1998, 79 percent of women ages18 and older had a Pap smear withinthe past 3 years.

Healthy People 2010 TargetIncrease to 90 percent the proportionof women ages 18 and older whohave received a Pap smear within thepast 3 years.

Groups at High Risk for NotBeing ScreenedOlder, poor, less educated womenare less likely to be screened for cervical cancer. At the same time,older women are at greater risk than younger women of dying fromcervical cancer.

Key IssuesRegular Pap smear testing needs tobe encouraged for all women.Special efforts are needed for thefollowing groups: older, poor, lesseducated women; women who haveemigrated to this country; and sexu-ally active women, who are morelikely to be exposed to the humanpapillomavirus and the humanimmunodeficiency virus, both of which can increase the risk ofdeveloping cervical cancer.

Promising new techniques are morelikely to detect cancer cells in thecervix and to detect viruses knownto cause this cancer.

Per

cent

Year

0

60

70

80

90

1987 1990 1993 1996 1999


Figure 15: Percent of Women (Ages 18+) Who Had aPap Smear Test Within the Past 3 Years—1987, 1992, and 1998


Key Word: Colorectal


Colorectal Cancer ScreeningColorectal cancer screening rates have risen but remain low amongpeople ages 50 and older.

Benefits of Screening Testsfor Colorectal CancerResearch supports the use of twoscreening tests for colorectal cancer:

• The fecal occult blood test(FOBT). When done every 1 to 2years in people ages 50-80, theFOBT can decrease the number ofdeaths due to colorectal cancer.

• Sigmoidoscopy (also known asproctosigmoidoscopy). Regularsigmoidoscopies can reducecolorectal cancer deaths. More

research is needed to learn thebest timing between exams.

MeasuresFOBT: Percent of people ages 50and older who reported they had anFOBT within the past 2 years, byracial/ethnic group.

Sigmoidoscopy: Percent of men and women ages 50 and older who reported they ever had a sigmoidoscopy.

Per

cent

Year

HispanicBlackWhiteAverage Rate

0

10

20

30

40

1987 1990 1993 1996 1999


Figure 16: Percent of Adults (Ages 50+) Who Had anFOBT Test Within the Past 2 Years, byRace/Ethnicity—1987, 1992, and 1998


Key Word: Colorectal


Period – 1987, 1992, and 1998

Trends – Rising overall

FOBT: Rising overall. In Whites,rising slightly (though not statisticallysignificant), then rising. Rising inBlacks, though not statistically sig-nificant. Rising, then rising slightlyin Hispanics, though neither of thesetrends is statistically significant. (Figure 16.)

Sigmoidoscopy: Rising overall and in men. Rising, then risingslightly in women, though the lattertrend for women is not statisticallysignificant. (Figure 17.)

Most Recent EstimatesIn 1998, 34 percent of people 50 andolder had an FOBT within the past 2years. This includes 23 percent ofHispanics, 30 percent of Blacks, and36 percent of Whites. (Figure 16.)

In 1998, 37 percent of people 50 andolder had ever had a sigmoidoscopy.This includes 43 percent of men and33 percent of women. (Figure 17.)

Healthy People 2010 TargetsIncrease to 50 percent the proportionof adults ages 50 and older whohave had an FOBT within the past 2 years.

Increase to 50 percent the proportionof adults ages 50 and older whohave ever had a sigmoidoscopy.

Groups at High Risk for Not Being ScreenedPeople with lower incomes, less education, and no health care coverage are less likely to bescreened for colorectal cancer.

Key IssuesDespite some improvements overtime, colorectal cancer screeningrates remain low. It is important to understand and overcome doctor and patient barriers to these life-saving tests.

Newer screening methods, such as colonoscopy, are promising and need further evaluation.

A substantial proportion of reported FOBT and sigmoidoscopyprocedures may be for diagnosticrather than screening purposes.

Per

cent

Year

MenWomenBoth Sexes

020

30

40

50

1987 1990 1993 1996 1999

Colorectal Cancer Screening (continued)


Figure 17: Percent of Men and Women (Ages50+) Who Ever Had a Sigmoidscopy—1987,1992, and 1998

Source: Centers for Disease Control and Prevention, NationalCenter for Health Statistics. National Health Interview Survey.Age-adjusted to the year 2000 standard population.

Key Word: Diagnosis

D I A G N O S I SDiagnosis

The rates of newly diagnosed cancercases (incidence) are one way tomeasure progress against cancer.The lower the rates, the better.

Another important measure is theproportion of cancers diagnosed at alate stage. The stage of a cancershows how far the disease has pro-gressed. The lower the stage at diag-nosis, the better the chances for cure.Downward trends in the proportionof late cancer diagnoses are a signthat screening is working for thecancers for which early detectionmethods are available.

This section of Cancer ProgressReport 2001 provides data on therates of new cancers in the UnitedStates—by cancer site and by racialand ethnic group. Also included aredata on the proportion of cancersdiagnosed at the late stage for five ofthe major cancer sites: breast, colon,rectum, cervix, and prostate.


Key Word: Incidence

D I A G N O S I S

IncidenceAfter several decades of steady increases, rates of new cancers beganto decline in 1992.

Measuring New CancerCasesIn 1998, more than half of all newcancers were cancers of the prostate,breast, lung, and colon/rectum. It is projected that there will be1,268,000 new cases of cancer in2001, including 198,100 prostatecancers; 192,200 female breastcancers; 169,500 lung cancers; and135,400 cancers of the colon/rectum.

Cancer incidence usually is measuredas the number of new cases eachyear for every 100,000 people.

MeasureIncidence rate: The number of new cancer cases per 100,000 people per year.

Period – 1973-1998

Trends – Rising, then fallingslightly overall

U.S. cancer incidence for all sitescombined was on the rise until early1992, when it began to decline(Figure 18).

For the four most common cancers(Figure 19):

• The incidence of prostate cancerrose sharply beginning around1988, peaked in 1992, and began asharp decline until around 1995,after which it became stable.

• The incidence of breast cancersteadily increased between 1980and 1987, and has remained stablesince then. For ages 50-64, thereappears to be a slight increase inrecent years.

• The incidence of lung cancerincreased until 1992, after whichit declined slightly. However, forwomen the rates continue toincrease, although not as rapidlyas earlier.

• The incidence of colorectal cancerincreased slightly until 1985. Ithas declined steadily since then,except for a slight rise since 1995,though this recent trend is notstatistically significant.

Rat

e pe

r 10

0,00

0

Year of Diagnosis

0

250

300

350

400

450

500

550

1974 1979 1984 1989 1994 1999


Figure 18: Rates of New Cases of All Cancers—1973-1998

Source: SEER Program, National Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groups tothe 2000 U.S. standard million.

Most Recent EstimateIn 1998, the rate of new cases of all cancers was 471 per 100,000people (Figure 18).

Healthy People 2010 TargetThere is no Healthy People 2010target for this measure.

Groups at High Risk forGetting New CancersBlacks have the highest rate of newcancers. Rates are very low amongAmerican Indians/Alaska Natives.(Figure 20.) These disparities arenot likely to be due to differences inpeople’s genes or body makeup.Rather, they are more likely to dowith social, cultural, behavioral, andenvironmental factors.

Key Word: Incidence

D I A G N O S I S

Rat

e pe

r 10

0,00

0

Year of Diagnosis

ProstateFemale BreastColorectalLung and Bronchus

0

50

100

150

200

250

1974 1979 1984 1989 1994 1999


Figure 19: Rates of New Cases of the Four MostCommon Cancers—1973-1998

Source: SEER Program, National Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year agegroups to the 2000 U.S. standard million.

Key Word: Incidence

D I A G N O S I S

Incidence (continued)

Key IssuesThe rising lung cancer rate inwomen illustrates the need for moretobacco control efforts. This isespecially important for teenagegirls and young women, who are athigher risk than older women forstarting to smoke and becomingaddicted.

The recent increase in new breastcancers is unexplained and needsfurther study.

Although most major cancers areoccurring less frequently, some areon the rise and require greaterefforts at control. These includebreast and lung cancer in women, aswell as non-Hodgkin’s lymphomaand melanoma in men and women(Figure 21). The incidence of somerare cancers, including liver andesophagus, also is increasing.

Rat

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r 10

0,00

0

Year of Diagnosis

0

200

300

400

500

600

1990 1993 1996 1999

HispanicBlackWhiteAmerican Indian/Alaska NativeAsian/Pacific Islander

Rat

e pe

r 10

0,00

0

Year of Diagnosis

Female BreastFemale Lung

Non-Hodgkin’s LymphomaMelanoma (White)

25

50

75

100

125

150

1974 1979 1984 1989 1994 19990

5

10

15

25

1974 1979 1984 1989 1994 1999

20

0


Figure 20: Rates of New Cases of All Cancers, byRace/Ethnicity—1990-1998

Source: SEER Program, National Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groups tothe 2000 U.S. standard million.

Figure 21: Rates of Some Common Cancers That AreIncreasing—1973-1998

Source: SEER Program, National Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groupsto the 2000 U.S. standard million.

Late-Stage Diagnosis of Cancer Cancers can be diagnosed at differentstages of their development. Stagesat diagnosis may be expressed asnumbers (I, II, III, or IV, for exam-ple) or by terms such as “localized,”“regional,” and “distant.” The lowerthe number or the more localized thecancer, the better a person’s chancesof benefiting from treatment andbeing cured.

Tracking the rates of distant, or late,cancers is a good way to monitor theimpact of cancer screening. Whenmore cancers are detected in theearly stages, fewer should be detectedin the late stages.

MeasureLate-stage diagnosis rate: The numberof new cancer cases diagnosed at alate stage, per 100,000 people peryear. This report shows the rates forcancers of the prostate, colon, breast,rectum, and cervix.

Period – 1980-1998

Trends Prostate: Falling. Late-stageprostate cancer has fallen dramati-cally since the early 1990s, follow-ing the introduction of the prostate-specific antigen (PSA) test.

Colon: Falling slightly

Breast: Stable

Rectum: Falling

Cervix: Falling

Most Recent EstimatesIn 1998, these major cancers were diagnosed at a late stage at the following rates:

Prostate: 8 new cases per 100,000people

Colon: 7 new cases per 100,000people

Breast (female): 7 new cases per100,000 people

Rectum: 2 new cases per 100,000people

Cervix: 0.7 new cases per 100,000people


Key Word: Stage

D I A G N O S I S

Stage at Diagnosis There are fewer late-stage diagnoses for five major cancers.

Rat

e pe

r 10

0,00

0

Year of Diagnosis

0

5

10

15

20

25

1979 1984 1989 1994 1999

ColonFemale BreastRectumCervixProstate


Figure 22: Rates of New Cases of Late-Stage Disease,by Site—1980-1998

Source: SEER Program, National Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groupsto the 2000 U.S. standard million.

Key Word: Stage

D I A G N O S I S

Groups at High Risk for Late-Stage DiagnosisPeople who do not have regular, recommended cancer screening tests are at highest risk of beingdiagnosed with late-stage cancer.

Key IssuesA lower rate of diagnosis at latestages is an early sign of the effec-tiveness of screening efforts. Theselower rates can be expected to occurbefore decreases in death rates areseen. For example, the drop in newcases of late-stage prostate cancerprobably was an early indicator of lower death rates observed forthis disease.

Important differences that existamong racial and ethnic groups inthe percent of cases diagnosed at a late stage contribute to disparitiesin cancer mortality.

Stage at Diagnosis (continued)


Key Word: Treatment

T R E A T M E N TTreatment

Cancer treatment is improving—saving lives and extending survivalfor people with cancers at manysites, including the breast and colon,and for people with leukemias,lymphomas, and pediatric cancers.Clinical trials are the major avenuefor discovering, developing, andevaluating new therapies. However,only about 3 percent of all adultcancer patients participate in clinicaltrials. It is important to increasephysician and patient awareness of,and participation in, clinical trials if we are to test new treatments more rapidly, find more effectivetreatments, and broaden the options available to patients.

Regarding treatments already in use,the United States lacks a nationaldata system for tracking those that reflect the best quality of care. Therefore, for most cancerswe cannot yet illustrate with nationaldata the extent to which cancerpatients and their doctors are usingthe best treatments. This situationwill begin to change in the near future.

NCI is working with many Federaland private partners to developmethods and data systems to facilitatetracking the quality of cancer care.This requires developing and reachingagreement by all major interestedparties, public and private, on thebest measures of cancer outcomes,such as survival and quality of life,as well as on measures of qualitycare, such as the receipt of effectivetreatment in a timely manner.

The research to generate suchmeasures is underway. For prostatecancer, a major study on the quality-of-life outcomes among 3,500 menfollowing diagnosis has providedimportant new information that will help men, their families, andphysicians make better informeddecisions about treatment. Researchresults on breast cancer treatmentshow that the use of breast-conservingsurgery and radiation for olderwomen increased markedly beginningin 1990. A new NCI initiative, theCancer Care Outcomes Researchand Surveillance Consortium, willprovide more detailed informationon how to link measures of qualitycare to outcomes important topatients as we develop systems forevaluating quality of care. Similarstudies are being supported by majorprofessional organizations as well as NCI.

These and other ongoing studies willprovide much new information ontreatment. Future editions of theCancer Progress Report will includetreatment trends for several cancersites, including breast and colorectalcancer, where there are definitivetreatment guidelines based onrigorous evidence of benefit topatients.


Key Words: Life After Cancer

L I F E A F T E R C A N C E RLife After Cancer

More and more people are benefit-ing from the early detection of can-cer and its successful treatment.These medical advances are improv-ing both quality of life and length ofsurvival, permitting many survivorsto continue full and productive livesat home and at work.

Nevertheless, national data regardinglife after cancer are limited. Theyinclude:

• Survival rates for cancer by eachstage at diagnosis

• The estimated total number ofsurvivors

• The economic impact of cancer

Few national measures are availablethat reflect health-related quality oflife for cancer survivors, such as:

• The ability of cancer survivors toperform daily tasks

• The impact of cancer onemployment and insurability

• The effects of cancer on familyand loved ones

These and other measures related tolife after cancer are subjects ofintense research interest as well asmatters of great concern to cancersurvivors themselves. Future edi-tions of the Cancer Progress Reportwill include additional measures inthis area.


Key Word: Survival

L I F E A F T E R C A N C E R

SurvivalFive-year survival rates have improved for all sites combined.

Cancer SurvivalAdvances in the ways cancer is diag-nosed and treated have increased thenumber of people who are cured ofcancer or who live long periods oftime free of their disease. Thisreport looks at trends in 5-year sur-vival rates for cancer, the time peri-od traditionally associated with cure.However, we know that some peoplehave a recurrence of their cancerafter 5 years.

In 1997, more than 7 millionAmericans were alive who had beendiagnosed with cancer and had sur-vived for up to 20 years. Of these,more than 1.5 million had beendiagnosed with breast cancer, andmore than 1 million had been diag-nosed with prostate cancer. Anadditional unknown number of peo-ple—perhaps around 1 million—were alive in 1997 who had survivedmore than 20 years after cancer.

MeasureFive-year relative cancer survivalrate: The proportion of patients surviving cancer 5 years after their diagnosis. This report showssurvival rates for cancers of theprostate, breast, colon/rectum, andlung, and for all cancers combined.

Period – 1975-1993 (year diagnosed)

Trends – Rising overall

All sites: Rising slightly, then rising

Prostate: Rising slightly, then rising

Breast: Stable, rising slightly, rising,then stable

Colorectal: Rising, then fallingslightly, though the latter trend is notstatistically significant

Lung: Rising slightly

Five-year survival rates are highestfor prostate and breast cancers andlowest for lung cancer.

Most Recent EstimateFor people diagnosed with cancer(all sites) in 1993, 62 percent sur-vived cancer after 5 years.

Healthy People 2010 TargetIncrease to 70 percent the proportionof cancer survivors who are living 5years or longer after diagnosis.


Key Word: Survival


Survival (continued)

Groups at High Risk for Poor SurvivalPeople with cancers diagnosed atlate stages have the worst chance ofsurvival.

Some cancers, like pancreatic cancerand lung cancer, are especiallyaggressive and have poor survival nomatter what the stage at diagnosis.

For other cancers that have goodresults from treatment, such asbreast and colorectal cancers,patients who had not taken advantage of screening opportunitiesor who have poor access to healthcare are at highest risk.

Key IssuesImproved survival rates result fromboth early detection and better treat-ments. It is difficult to separate outthe contribution of each factor.

Despite the positive trends in 5-yearsurvival for three of the most common cancers, lung cancer survival rates are low.

Per

cent

Sur

vivi

ng

Year of Diagnosis

0

20

40

60

80

100

1974 1979 1984 1989 1994 1999

All SitesProstateFemale BreastColorectalLung and Bronchus


Figure 23: 5-Year Relative Survival Rates, by Site—1975-1993

Source: SEER Program, National Cancer Institute.

Key Word: Costs

L I F E A F T E R C A N C E RCosts of Cancer CareCancer treatment spending has risen but remains stable in proportionto total U.S. treatment spending.

The financial costs of cancer treat-ment are a burden to people diag-nosed with cancer, their families,and society as a whole. Cancertreatment accounted for about $41 billion in 1995, the most recentyear for which there is information.This is just under 5 percent of totalU.S. spending for medical treatment.In the 10 years from 1985 to 1995,the overall costs of treating cancermore than doubled.

High-quality cancer care is not necessarily the most expensive care.It would be desirable to see the overall costs of cancer treatmentdecrease relative to total health carecosts. In the near future, however,these costs may increase as the population ages and the absolutenumber of people treated for cancerincreases. Costs also are likely to increase at the individual level asnew, more advanced, and more

expensive treatments are adopted as standards of care.

NCI will continue to monitor cancer costs and track the percentage of total medical costsaccounted for by cancer care. Over the last three decades, this percentage has remainedremarkably constant.

As total spending for medical treatment rose between 1963 and 1995,so did spending for cancer treatment.

Percent of Cancer Treatment Total Health Care Cancer Treatment

Year Spending (billions) Spending (billions) Spending to Total

1963 $1.3 $29.4 4.4%1972 $3.9 $78.0 5.0%1980 $13.1 $217.0 6.0%1985 $18.1 $376.4 4.8%1990 $27.5 $614.7 4.5%1995 $41.2 $879.3 4.7%

Table 1: National Cancer Treatment Expenditures in Billions of Dollars–1963-1995

Source: Brown, ML, Riley, GF, Schussler, N, Etzioini, R. Estimating health care cost fromSEER-Medicare data. Submitted to Medical Care.


Source: Brown ML, Lipscomb J, Snyder C. The burden of illness of cancer: economiccost and quality of life. Annual Review of Public Health 2001;22:91-113.

As total spending for medical treatment rose between 1963 and1995, so did spending for cancer treatment.

Spending for each year is expressedin current dollars for that year.While cancer treatment costsincreased dramatically between1963 and 1995, the proportion of

these to all health care expendituresremained stable. Cancer spendingin this chart does not include screen-ing, which cost an additional $5 billion to $10 billion in 2000.

Key Word: Costs


Costs of Cancer Care (continued)

The first-year costs for lung and colorectal cancer are higher becausescreening is not commonly used inthe detection of these cancers. Ifscreening for colorectal cancer wereperformed as recommended, the proportion of cases presenting atadvanced stages—when treatment is more extensive and costly—would be reduced.

Medicare does not cover certain cancer care expenses, such as oralmedicines commonly used to treatcancers of the breast and prostate.These out-of-pocket costs may addas much as 10 percent to the esti-mates shown above.

Direct medical expenditures are onlyone component of the total econom-ic burden of cancer. The indirect

costs include losses in time and eco-nomic productivity resulting fromcancer-related illness and death.Based on 1990 data, the total economic burden of cancer in 1996was an estimated $143.5 billion.

Treatment expenditures for each of the four most common cancersare remarkably similar. However, individual costs for other cancers

based on Medicare data show wide variation by type of cancer.

Average MedicarePercent of all payments per

Percent of all Expenditures cancer individual in firstnew cancers (In billions of treatment year following

(1998) 1996 dollars) expenditures diagnosis

Breast 18.2% $5.4 13.1% $9,230Colorectal 11.7% $5.4 13.1% $21,608Lung 12.5% $4.9 12.1% $20,340Prostate 13.6% $4.6 11.3% $8,869Lymphoma 4.2% $2.6 6.3% $17,217Bladder 4.0% $1.7 4.2% $10,770Cervix 2.3% $1.7 4.1% $13,083Head/Neck 3.3% $1.6 4.0% $14,788Leukemia 2.1% $1.2 2.8% $11,882Ovary 1.7% $1.5 3.7% $32,340Melanoma 5.2% $0.7 1.7% $3,177Pancreas 2.1% $0.6 1.5% $23,504Esophagus 0.9% $0.4 0.9% $25,886All Other 18.1% $8.7 21.2% $17,201

Total 100.0% $41.0 100%

Table 2: Estimates of National Expenditures for Medical Treatment for the 13 MostCommon Cancers–Based on Cancer Prevalence in 1996 and Cancer-Specific Costsfor 1995-1998, Expressed in 1996 Dollars.Source: SEER-Medicare data base.


Source: Brown ML, Riley GF, Schussler N, Etzioni R. Estimating health care cost fromSEER-Medicare data. Submitted to Medical Care.

Treatment expenditures for each of the four most common cancersare remarkably similar. However, individual costs for other cancersbased on Medicare data show wide variation by type of cancer.

Key Words: End of Life

E N D O F L I F E

End of Life

The ultimate measure of ourNation’s success against cancer ishow far we can lower the death ratefrom this group of dread diseases.This final section of CancerProgress Report 2001 providesnational data not only on cancermortality by major sites, but also in terms of years of life lost to cancer—a measure that emphasizesthe tragedy of common cancers that strike people at a relativelyyoung age.

As highlighted at the beginning ofthis report, the news is good. Forthe first time since the Governmentbegan collecting mortality data earlyin the last century, cancer death ratesbegan to decline in 1992. It is ourjob as a Nation to maintain andaccelerate this trend. Future editionsof this report will continue to docu-ment how we are doing in the ongo-ing battle against deaths from can-cer.


Key Word: Mortality

E N D O F L I F E

MortalityAfter several decades of steady increases, cancer death rates began todecline in the early 1990s.

Measuring Cancer DeathsIn 1998, cancers of the breast,prostate, lung, and colon/rectumaccounted for more than half of allcancer deaths in the United States.Lung cancer alone claimed morethan one-fourth of the lives lost tocancer. It is projected that in 2001,there will be 553,400 cancer deathsoverall, including 157,400 deathsfrom lung cancer; 56,700 fromcancers of the colon/rectum; 40,200from female breast cancer; and31,500 from prostate cancer.

Cancer mortality usually ismeasured as the annual number ofdeaths from cancer for every100,000 people.

MeasureMortality rate: The number ofcancer deaths per 100,000 peopleper year.

Period – 1973-1998

Rat

e pe

r 10

0,00

0

Year of Death

0

150

175

200

225

250

1974 1979 1984 1989 1994 1999


Figure 24: Rates of Deaths for All Cancers—1973-1998

Source: National Center for Health Statistics data as analyzed by theNational Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groups to the 2000 U.S. standard million.

Trends – Falling slightly

Cancer death rates rose over the longterm until the mid-1980s, when they became stable. The ratesbegan falling in the early 1990s.(Figure 24.)

Death rates for the four mostcommon cancers began to fallbetween 1984 and 1991 (Figure 25).

Most Recent EstimateIn 1998, the death rate for allcancers was 202.6 per 100,000people (Figure 24).

Healthy People 2010 TargetReduce the overall cancer death rateto 159.9 cancer deaths per 100,000people.

Key Word: Mortality

E N D O F L I F E

Rat

e pe

r 10

0,00

0

Year of Diagnosis

ProstateFemale BreastColorectalLung and Bronchus

0

10

20

30

40

50

60

70

1974 1979 1984 1989 1994 1999


Figure 25: Cancer Death Rates for Common Cancers—1973-1998

Source: National Center for Health Statistics data as analyzed by the NationalCancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groups to the 2000 U.S. standard million.

Year of Death

Key Word: Mortality

E N D O F L I F E

Mortality (continued)

Rat

e pe

r 10

0,00

0

Year of Diagnosis

0

50

100

150

200

250

300

1990 1993 1996 1999

HispanicBlackWhiteAmerican Indian/Alaska NativeAsian/Pacific Islander


Figure 26: Rates of Deaths for All Cancers, byRace/Ethnicity—1990-1998

Source: National Center for Health Statistics data as analyzed by theNational Cancer Institute.Rates are per 100,000 population and age-adjusted by 5-year age groups to the 2000 U.S. standard million.

Groups at High Risk forCancer DeathsBlacks have the highest overallrates for cancer deaths, followed byWhites (Figure 26).

Key IssuesAlthough overall death rates are on the decline, deaths from somecancers, such as esophageal and non-Hodgkin’s lymphoma, areincreasing. Death rates amongAmerican Indians/Alaska Nativesalso are increasing.

Year of Death

Key Word: PYLL

E N D O F L I F E

Person-Years of Life LostCancer is responsible for more estimated years of life lost than anyother cause of death.

Person-Years of Life Lost to CancerMortality rates alone do not give acomplete picture of the burden ofcancer deaths. Another useful measure is person-years of life lost(PYLL)—the years of life lost dueto early death from a particularcause. PYLL helps to describe theextent to which life is cut short bycancer. On average, each personwho dies from cancer loses an esti-mated 15 years of life.

MeasurePYLL due to cancer: The differencebetween the actual age of death due to a cancer and the expected age of death.

Period – 1998

Trend – No trend data are available.

Most Recent EstimatesIn 1998, cancer deaths were respon-sible for 8 million PYLL. This ismore than heart disease or any othercause of death. (Figure 27.)

Also in 1998, among cancers, lungcancer accounted for 2 millionPYLL, the most by far of any can-cer. In contrast, prostate cancer,which primarily affects older men,accounted for fewer than 300,000PYLL. (Figure 28.)

Years in Thousands

Cancer

Heart Disease

All Other Causes

Accidents

Cerebrovascular

Bronchitis, Emphysema, and Asthma

Suicide & Self-Inflicted Injury

Diabetes Mellitus

Pneumonia & Influenza

Homicide

Cirrhosis

HIV

Septicemia

Nephritis & Nephrosis

Aortic Aneurysm & Dissection

Atherosclerosis

0 1000 2000 3000 4000 5000 6000 7000 8000 9000

8158

8034

3075

1297

1030

311

288

192

115

487

547

820

868

895

1627

6661


Figure 27: Person-Years of Life Lost Due to Major Causesof Death in U.S.—1998

Source: National Center for Health Statistics (NCHS) public-use file andNCHS 1997 Life Tables.

Key Word: PYLL

E N D O F L I F E

Person-Years of Life Lost (continued)

Years in Thousands

Lung

Breast

Colorectum

Pancreas

Non-Hodgkin’s

Leukemias

Prostate

Brain & ONS

Ovary

Stomach

Kidney/Renal

Esophagus

Multiple Myeloma

Melanomas of the Skin

Oral Cavity & Pharynx

Bladder

Cervix Uteri

Childhood

Corpus & Uterus, NOS

Hodgkin’s Disease

Testis

0 500 1000 1500 2000 2500

2272

790

758

394

358

345

289

280

227

186

179

177

139

139

130

128

113

101

95

34

13


Groups at High Risk for theMost PYLLCancers that are both common andfrom which there is poor survival areresponsible for the most PYLL.Breast and colorectal cancers arealso common cancers that strikepeople at a relatively young age andcause many years of life lost.

Deaths from childhood cancers,which are uncommon, lead to themost years of life lost for the indi-vidual child, but contribute only asmall percentage to total PYLL.

Key IssuesThe greatest impact on reducing thenumber of years lost to cancer willcome from progress against commoncancers—especially lung, breast, andcolorectal cancers.


Figure 28: Person-Years of Life Lost Due to Cancer—1998

Source: National Center for Health Statistics (NCHS) public-use file andNCHS 1997 Life Tables.

Appendix A: Acknowledgments

NCI wishes to acknowledge the fol-lowing Federal agencies as sourcesfor the data used in this report:

Environmental Protection Agency

National Center for Chronic DiseasePrevention and Health Promotion,Centers for Disease Control andPrevention

National Center for Health Statistics,Centers for Disease Control andPrevention

National Institute on Alcohol Abuseand Alcoholism

Office of Disease Prevention andHealth Promotion, U.S. Departmentof Health and Human Services

Substance Abuse and Mental HealthServices Administration

U.S. Department of Agriculture

The preparation of this reportinvolved the efforts of many individ-uals who provided direction and con-tent by serving on the internalWorking Group or external AdvisoryGroup, or who otherwise providedsignificant content or productionassistance.

NCI Working Group

Robert A. Hiatt, M.D., Ph.D.,Working Group ChairDeputy Director, Division of CancerControl and Population Sciences(DCCPS)

Rachel Ballard-Barbash, M.D.,M.P.H., Associate DirectorApplied Research Program, DCCPS

Martin Brown, Ph.D., ChiefHealth Services and EconomicsBranch, DCCPS

Lynn Ries, M.S., Health StatisticianSurveillance Research Program,DCCPS

Paula Zeller, M.A., Medical WriterOffice of the Director, DCCPS

External Advisory Group

David B. Abrams, Ph.D.,Professor and DirectorCenters for Behavioral andPreventive Medicine,Brown Medical School and TheMiriam Hospital

Ross H. Arnett, III, Former DirectorCenter for Cost and FinancingStudies, Agency for HealthcareResearch and Quality

Ralph Coates, Ph.D., AssociateDirector for Science, Division ofCancer Prevention and Control,National Center for Chronic DiseasePrevention and Health Promotion,Centers for Disease Control andPrevention

Bruce Cohen, Ph.D., DirectorResearch and EpidemiologyBureau of Health Statistics,Massachusetts Department of PublicHealth

Steven B. Cohen, Ph.D., DirectorCenter for Cost and FinancingStudies, Agency for HealthcareResearch and Quality

Gregg Meyer, M.D., M.Sc., DirectorCenter for Quality Improvement and Patient Safety, Agency forHealthcare Research and Quality

Maryann Napoli, Associate DirectorCenter for Medical Consumers

Elsie Pamuk, Ph.D., Acting DirectorDivision of Epidemiology,National Center for Health Statistics,Centers for Disease Control andPrevention

Phyllis Wingo, Ph.D., ChiefCancer Surveillance Branch,National Center for Chronic DiseasePrevention and Health Promotion,Centers for Disease Control andPrevention(Formerly with the American Cancer Society)

continued on page 68


Appendix A: Acknowledgments (continued)

NCI Staff

Michael B. Ahmadi, UsabilityEngineer/AnalystCommunication TechnologiesBranch, Office of Communications

Kelly Blake, M.S., CHES,Writer/EditorOffice of the Director, DCCPS

Nancy Breen, Ph.D., EconomistApplied Research Program, DCCPS

William W. Davis, Ph.D.,Mathematical StatisticianSurveillance Research Program,DCCPS

Kevin Dodd, Ph.D., MathematicalStatisticianSurveillance Research Program,DCCPS

Regina El Arculli, Director State Cancer Legislative DatabaseProgram, Office of Legislation andCongressional Activities

Michael Fay, Ph.D., MathematicalStatisticianSurveillance Research Program,DCCPS

Eric J. Feuer, Ph.D., ChiefStatistical Research ApplicationsBranch, Surveillance ResearchProgram, DCCPS

Dan J. Grauman, M.A., ComputerSpecialistOffice of the Director, DCCPS

Anne Hartman, M.S., HealthStatisticianApplied Research Program, DCCPS

Susan M. Krebs-Smith, Ph.D., ChiefRisk Factor Monitoring and MethodsBranch, Applied Research Program,DCCPS

Deirdre Lawrence, Ph.D., M.P.H.,EpidemiologistApplied Research Program, DCCPS

Stephen Marcus, Ph.D.,EpidemiologistBehavioral Research Program,DCCPS

Janice Nall, DirectorCommunication TechnologiesBranch, Office of Communications

Linda Pickle, Ph.D., MathematicalStatisticianSurveillance Research Program,DCCPS

Barbara K. Rimer, Dr.P.H., Director,DCCPS

Richard Troiano, Ph.D.,EpidemiologistApplied Research Program, DCCPS

Stacey Vandor, M.P.A., PlanningOfficerOffice of the Director, DCCPS

Other Contributors

Important contributions from otherFederal agencies were made by com-menting on drafts of the report,including, in particular, commentsfrom the Centers for Disease Controland Prevention’s Terry F. Pechacek,Ph.D., Associate Director forScience, Office on Smoking andHealth, and Deborah A. Galuska,Ph.D., Acting Associate Director forScience, Division of Nutrition andPhysical Activity.

Contractors

Information Management Services,Inc.: Data support

Matthews Media Group, Inc.:Editing and design

Redish & Associates, Inc.:Consultation on special graphics andassistance with usability testing

VSB Associates: Graph design

Cynthia A. Brewer, AssociateProfessor, Department of Geography,The Pennsylvania State University:Color consultation


Appendix B: Dictionary of Terms

cancer continuumThe spectrum of cancer-relatedexperience, including prevention,early detection, diagnosis, treatment,life after cancer, and end of life.

carcinogenAny substance that causes cancer.

clinical trialA research study that tests how wellnew medical treatments or otherinterventions work in people.

esophagusThe tube through which food passesfrom the mouth to the stomach.

fecal occult blood test (FOBT) An exam of the stool that can findhidden blood, a sign of possible col-orectal cancer. The FOBT also canfind bleeding from other disorders.

incidence rate (for cancer)The number of new cancer cases per100,000 people, per year.

invasive cancerCancer that has spread beyond thelayer of tissue in which it developedinto surrounding, healthy tissue.

larynxThe voice box.

leukemiaCancer of the blood-forming tissue.

mammographyThe use of x-rays to create a pictureof the breast (mammogram) that canshow signs of breast cancer before itcan be felt.

mortality rate (for cancer)The number of cancer deaths per100,000 people, per year.

outcomesThe outcomes of cancer care are theend results of interventions to pre-vent, detect, and treat cancer on thehealth and well-being of people andpopulations. Such outcomes includesurvival and disease-free survival,health-related quality of life (includ-ing ability to carry out usual activi-ties), patient symptoms (such as painand shortness of breath), economicburden, and patient and family expe-rience and satisfaction with care.

Pap smearThe collection of cells from thecervix (the lower, narrow end of theuterus that forms a canal betweenthe uterus and vagina) and theirexamination under a microscope.The Pap smear (or Pap test) is usedto detect changes that may be canceror may lead to cancer.

pharynxThe throat.

screeningUsing tests to check for a disease inits early stage, when there are nosymptoms. For example, mammog-raphy is a screening test that canfind breast cancer before it can befelt.

sigmoidoscopy An exam of the rectum and thelower part of the colon with a thin,flexible, lighted tube to find polyps,abnormal areas, and tumors. Alsocalled proctosigmoidoscopy.

socioeconomic statusA measure of a person's relativestanding in society, frequently basedon a combination of income, educa-tion, and occupation.

statistical significance (of a trend)Results of a test to find out if a trendreally is rising or falling, or whetherany apparent rise or fall can beexplained by random variation in themeasurement.

survival (cancer)As used in this report, the proportionof cancer patients surviving cancer 5years after their diagnosis.

trend The general direction (for example,rising, falling, or stable) of changeover time.


Appendix C: References

Following are selected major refer-ences used in preparing this report.See the online version for links tomore references and backgroundinformation. http://progressreport.cancer.gov

The data referenced here will notalways match the data in the CancerProgress Report. That is becausemost of this report’s data were age-adjusted to the year 2000 standardpopulation in order to be compatiblewith data presented in HealthyPeople 2010.

GeneralCenters for Disease Control andPrevention, National Center forHealth Statistics. National HealthInterview Survey, 1987, 1990, 1991,1992, 1993, 1994, and 1998.http://www.cdc.gov/nchs/nhis.htm.

Ries LAG, Eisner MP, Kosary CL,Hankey BF, Miller BA, Clegg L,Edwards BK (eds). SEER cancerstatistics review, 1973-1998.Bethesda, MD: National CancerInstitute, 2001.http://seer.cancer.gov/Publications/CSR1973_1998/.

U.S. Department of Health andHuman Services. Healthy People2010. 2nd ed. With Understandingand Improving Health and Objectivesfor Improving Health. 2 vols.Washington, DC: U.S. GovernmentPrinting Office, November 2000.http://www.health.gov/healthypeople/document/.

PreventionDoll R, Peto R. The causes of cancer. New York: Oxford UniversityPress, 1981.

Harvard Report on CancerPrevention, Volume 1: Causes ofHuman Cancer, Cancer Causes &Control, Volume 7 Supplement,November 1996.

Harvard Report on CancerPrevention, Volume 2: Prevention ofHuman Cancer, Cancer Causes &Control, Volume 8 Supplement,November 1997.

McGinnis JM, Foege WH. Actualcauses of death in the United States.JAMA 270:2207-2212, 1993.

National Cancer Institute, Divisionof Cancer Prevention and Control,Cancer Statistics Branch. Cancerrates and risks. 4th edition, 1996.NIH Publication No. 96-691, May1996.http://seer.cancer.gov/Publications/raterisk/.

Peto J. Cancer epidemiology in thelast century and the next decade.Nature 2001;411:390-395.

Behavioral FactorsCenters for Disease Control andPrevention, National Center forHealth Statistics. National Healthand Nutrition Examination Survey,1971-1974, 1976-1980, and 1988-1994.http://www.cdc.gov/nchs/about/major/nhanes/overweight.pdf.

Centers for Disease Control andPrevention, National Center forHealth Statistics. National HealthInterview Survey, 1992 and 1998.http://www.cdc.gov/nchs/nhis.htm.

Centers for Disease Control andPrevention. Youth risk behavior surveillance—United States, 1991,1993, 1995, 1997, and 1999.http://www.cdc.gov/nccdphp/dash/yrbs/index.htm.

Centers for Disease Control andPrevention, National Center forChronic Disease Prevention andHealth Promotion. Behavioral RiskFactor Surveillance System, 1990,1991, 1992, 1994, 1996, and 1998.http://www.cdc.gov/nccdphp/brfss.

IARC Working Group on theEvaluation of Cancer-PreventiveAgents (ed). Weight control andphysical activity (IARC Handbooksof Cancer Prevention, Vol. 6). Lyon,IARC. (in press).

National Center for Health Statistics.Health, United States 2000, withadolescent health chartbook.Hyattsville, Maryland: 2000.http://www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm.


National Institute on Alcohol Abuseand Alcoholism, Division ofBiometry and Epidemiology.Apparent per capita ethanol con-sumption for the United States,1850-1998, 2001.http://www.niaaa.nih.gov/databases/consum01.txt.

Substance Abuse and Mental HealthServices Administration, Office ofApplied Studies. NationalHousehold Survey on Drug AbuseMain Findings Reports, 1990-1999.http://www.samhsa.gov/statistics/statistics.html (1994-1999).

Tobacco Use Supplement to theCurrent Population Survey, spon-sored by the National CancerInstitute.http://appliedresearch.cancer.gov/RiskFactor/tobacco/whereget.html(1992-1993, 1995-1996, and 1998-1999).

U.S. Department of Agriculture.Continuing Survey of Food Intakesby Individuals, 1989-1991 and 1994-1996.http://www.barc.usda.gov/bhnrc/foodsurvey/Products.html.

World Cancer Research Fund inAssociation with American Institutefor Cancer Research. Food, nutritionand the prevention of cancer: a glob-al perspective. Menasha, WI:BANTA Book Group. 1997.

Environmental FactorsCenters for Disease Control andPrevention, National Center forHealth Statistics. National HealthInterview Survey, 1990, 1991, 1993,1994, and 1998.http://www.cdc.gov/nchs/nhis.htm.

Environmental Protection Agency.National air quality and emissionstrends report, 1998. March 2000.http://www.epa.gov/oar/aqtrnd98/.

National Cancer Institute. StateCancer Legislative Database, 1990-2000. http://www.scld-nci.net/.

Early DetectionCenters for Disease Control andPrevention, National Center forHealth Statistics. National HealthInterview Survey, 1987, 1992 and1998.http://www.cdc.gov/nchs/nhis.htm.

Ries LA, Wingo PA, Miller DS,Howe HL, Weir HK, RosenbergHM, Vernon SW, Cronin K, EdwardsBK. The annual report to the Nationon the status of cancer, 1973-1997,with a special section on colorectalcancer. Cancer 2000;88:2398-2424.

DiagnosisAmerican Cancer Society. Cancerfacts & figures 2001. Atlanta:American Cancer Society, 2001.http://cancer.org/downloads/STT/F&F2001.pdf.


Treatment Ballard-Barbash R, Potosky A,Harlan L, Kessler L, Nayfield S.Factors associated with surgical andradiation therapy for early stagebreast cancer in older women. J NatlCancer Inst 1996;88:716-726.

Legler J, Potosky AL, Gilliland FD,Eley JW, Stanford JL. Validationstudy of retrospective recall of dis-ease-targeted function: results fromthe prostate cancer outcomes study.Med Care 2000 Aug;38(8):847-857.

Potosky AL, Harlan LC, StanfordJL, et al. Prostate cancer practicepatterns and quality of life: theProstate Cancer Outcomes Study. JNatl Cancer Inst 1999;91:1719-1724.

Young WW, Marks SM, Kohler SA,Hsu AY. Dissemination of clinicalresults: mastectomy versus lumpec-tomy and radiation therapy. MedCare 1996;34:1003-1017.

continued on page 72


Life After Cancer

Brown ML, Lipscomb J, Snyder C.The burden of illness of cancer: economic cost and quality of life.Annual Review of Public Health2001;22:91-113.

Brown ML, Riley GF, Schussler N,Etzioni R. Estimating health carecost from SEER-Medicare data.Submitted to Medical Care.

Hodgson TA, Cohen AJ. Medicalexpenditures for major diseases,1995. Health Care Financing Review1999;21:119-164.


Warren JL, Klabunde CN, Schrag D,Bach PB, Riley GF. An overview ofSEER-Medicare data: content, struc-ture, and research applications.Submitted to Medical Care.

End of Life

American Cancer Society. Cancerfacts & figures 2001. Atlanta:American Cancer Society, 2001.http://cancer.org/downloads/STT/F&F2001.pdf.



Appendix C: References (continued)

Appendix D: Methodology for Characterizing Trends

In order to obtain a consistent char-acterization of population trends infactors related to the prevention,early detection, or treatment of can-cer, the joinpoint statistical method-ology was used in this report (Kimet al., 2000). This methodologycharacterizes a trend using joinedlinear segments on a logarithmicscale, and has proven useful in char-acterizing trends in cancer incidenceand mortality rates (e.g., Cancer statistics review: 1973-1997).

The joinpoint software (JoinpointVersion 2.5, 2000) uses statisticalcriteria to determine the fewest num-ber of segments that are necessary tocharacterize a trend, where the seg-ments begin and end, and the annualpercent change (APC) for each seg-ment (a linear trend on a log scaleimplies a constant annual percentchange). In addition, a 95 percentconfidence interval around the APCwas used to determine if the APCfor each segment differed signifi-cantly from zero. For the purposesof this report the maximum numberof possible segments was limited tothree. To avoid statistical anomalies,segments had to contain at leastthree observed data points, and nosegment could begin or end closerthan three data points from thebeginning or end of the data series.For factors related to the prevention,early detection, or treatment of can-cer, the data points within eachseries were not differentially weight-ed because they arose from surveysor other data sources that did nothave dramatically different samplesizes across the years, and in somecases the weights would be difficult

to obtain. When characterizingtrends in cancer incidence or mortal-ity, weights were used that arederived from the standard Poissonassumption. Using the results ofthese analyses we characterizetrends with respect to both theirpublic health importance and statis-tical significance. If a trend was:

• Changing less than 0.5 percent peryear, we characterized it asSTABLE (-0.5 < APC < 0.5).

• Changing more than 0.5 percentper year but less than 1.5 percentper year, we characterized it asRISING OR FALLINGSLIGHTLY (-1.5 < APC ≤ -0.5 or0.5 ≤ APC < 1.5).

• Changing more than 1.5 percentper year, we characterized it asRISING OR FALLING(APC ≤ -1.5 or APC ≥ 1.5).

• Rising or falling at 0.5 percent peryear or more, but the APC was notstatistically different from zero,we noted that the trend was notstatistically significant.

While these characterizations aresomewhat arbitrary, they at leastprovide a consistent method to char-acterize the trends across disparatemeasures. By definition (since weconstrained the joinpoint models tothose where no segment could beginor end closer than three data pointsfrom the beginning or end of thedata series), for situations in whichthere were four or fewer data pointsin the series, only one segment (i.e.,a model with no joinpoints) could befit, and for five data points only one

possible joinpoint could be fit at themiddle data point. To avoid these sit-uations, for four or five data pointswe simply fit a regression line onthe log of the response to determinethe APC and its statistical signifi-cance. In one case the fit of such aline to the observed data was notgood and may have been misleading.This was for “percent of high schoolstudents (grades 9-12) who werecurrent users of cigarettes (1991-1999),” where the 1999 data pointappeared to show a decline after along-term rise. Thus the trend linewas only fit through the first fourdata points (1991-1997). The dottedline connecting the trend line from1991 through 1997 to the 1999 datapoint suggests a change in trend,which must be verified as more dataaccumulates. For two or three datapoints we connected the data pointsto determine the APC for each timeperiod, and then employed a two-sample test using the survey weightsto determine the statistical signifi-cance of the change in period.

References:

Kim HJ, Fay MP, Feuer EJ,Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000;19:335-351.

Joinpoint Regression Program,Version 2.5, March 2000, National Cancer Institute.http://srab.cancer.gov/joinpoint/index.html


Appendix E: Cancer Incidence andMortality Rates Age-Adjusted to the 1970and 2000 Standards, United States 1998

Incidence

All sites

Lung

Breast

Cervix uteri

Colorectal

Prostate

Melanoma

Mortality

All sites

Lung

Breast

Cervix uteri

Colorectal

Prostate

Melanoma

All Male Female White male White female Black male Black female

AA 1970 AA 2000 AA 1970 AA 2000 AA 1970 AA 2000 AA 1970 AA 2000 AA 1970 AA 2000 AA 1970 AA 2000 AA 1970 AA 2000

Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate

395.3 471.4 452.2 544.4 355.9 424.1 447.7 539.9 362.4 431.3 543.8 642.1 334.1 398.0

54.8 64.9 69.8 84.2 43.4 50.9 68.4 82.8 44.8 52.5 100.6 118.8 47.9 56.0

63.8 76.0 0.9 1.1 118.1 139.1 1.0 1.2 121.3 142.8 0.7 0.8 99.2 117.1

— — 0.0 0.0 7.5 9.0 0.0 0.0 6.7 8.1 0.0 0.0 10.5 12.8

44.1 55.4 51.7 65.0 38.2 48.3 51.3 64.8 37.6 47.7 54.9 67.4 43.8 53.6

— — 137.3 161.4 0.0 0.0 130.9 153.9 0.0 0.0 216.2 251.1 0.0 0.0

14.3 16.9 17.3 20.8 12.0 14.2 19.3 23.1 13.6 16.0 1.1 1.4 1.0 1.2

Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate

161.5 202.6 198.5 253.5 135.3 169.0 193.6 247.8 133.9 167.4 277.3 348.6 163.0 201.6

47.9 57.6 65.4 80.1 34.6 41.5 64.2 78.7 35.3 42.2 88.8 106.5 34.7 41.2

12.6 15.8 0.2 0.3 22.7 27.9 0.2 0.3 22.2 27.3 0.4 0.5 29.6 36.0

— — 0.0 0.0 2.5 3.0 0.0 0.0 2.2 2.7 0.0 0.0 4.9 6.0

16.3 21.4 19.6 25.6 13.7 18.3 19.2 25.1 13.2 17.7 26.2 33.4 19.4 25.3

— — 21.5 32.2 0.0 0.0 19.6 29.6 0.0 0.0 48.7 70.6 0.0 0.0

2.3 2.8 3.3 4.1 1.4 1.8 3.7 4.6 1.6 2.0 0.3 0.4 0.4 0.6

Source: Incidence is for 9% of the U.S. population from the National Cancer Institute SEER Program, and mortality is for the total U.S. population from the National Center for Health Statistics. Rates are per 100,000 and are age-adjusted to 1970 or 2000 U.S. standard million population as specified.


NIH Publication No: 02-5045Printed December 2001 T905

cancer progress report

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