Trends in Mortality Due to Cancer in the United States by Age and County-Level Income, 1999-2015

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

Global patterns of cancer transitions: A modelling study

Cancer is a major contributor to global disease burden. Many countries experienced or are experiencing the transition that non-infection-related cancers replace infection-related cancers. We aimed to characterise burden changes for major types of cancers and identify global transition patterns. We focused on 10 most common cancers worldwide and extracted age-standardised incidence and mortality in 204 countries and territories from 1990 to 2019 through the Global Burden of Disease Study. Two-stage modelling design was used. First, we applied growth mixture models (GMMs) to identify distinct trajectories for incidence and mortality of each cancer type. Next, we performed latent class analysis to detect cancer transition patterns based on the categorisation results from GMMs. Kruskal-Wallis H tests were conducted to evaluate associations between transition patterns and socioeconomic indicators. Three distinct patterns were identified as unfavourable, intermediate and favourable stages. Trajectories of lung and breast cancers had the strongest association with transition patterns among men and women. The unfavourable stage was characterised by rapid increases in lung, breast and colorectal cancers alongside stable or decreasing burden of gastric, cervical, oesophageal and liver cancers. In contrast, the favourable stage exhibited rapid declines in most cancers. The unfavourable stage was associated with lower sociodemographic index, health expenditure, gross domestic product per capita and higher maternal mortality ratio (P < .001 for all associations). Our findings suggest that unfavourable, intermediate and favourable transition patterns exist. Countries and territories in the unfavourable stage tend to be socioeconomically disadvantaged, and tailored intervention strategies are needed in these resource-limited settings.

Proximity to Radiotherapy Center, Population, Average Income, and Health Insurance Status as Predictors of Cancer Mortality at the County Level in the United States

PURPOSE

Sufficient radiotherapy (RT) capacity is essential to delivery of high-quality cancer care. However, despite sufficient capacity, universal access is not always possible in high-income countries because of factors beyond the commonly used parameter of machines per million people. This study assesses the barriers to RT in a high-income country and how these affect cancer mortality.

METHODS

This cross-sectional study used US county-level data obtained from Center for Disease Control and Prevention and the International Atomic Energy Agency Directory of Radiotherapy Centres. RT facilities in the United States were mapped using Geographic Information Systems software. Univariate analysis was used to identify whether distance to a RT center or various socioeconomic factors were predictive of all-cancer mortality-to-incidence ratio (MIR). Significant variables (P ≤ .05) on univariate analysis were included in a step-wise backward elimination method of multiple regression analysis.

RESULTS

Thirty-one percent of US counties have at least one RT facility and 8.3% have five or more. The median linear distance from a county's centroid to the nearest RT center was 36 km, and the median county all-cancer MIR was 0.37. The amount of RT centers, linear accelerators, and brachytherapy units per 1 million people were associated with all-cancer MIR (P < .05). Greater distance to RT facilities, lower county population, lower average income per county, and higher proportion of patients without health insurance were associated with increased all-cancer MIR (R-squared, 0.2113; F, 94.22; P < .001).

CONCLUSION

This analysis used unique high-quality data sets to identify significant barriers to RT access that correspond to higher cancer mortality at the county level. Geographic access, personal income, and insurance status all contribute to these concerning disparities. Efforts to address these barriers are needed.

Opportunities for Achieving the Cancer Moonshot Goal of a 50% Reduction in Cancer Mortality by 2047

On February 2, 2022, President Biden and First Lady Dr. Biden reignited the Cancer Moonshot, setting a new goal to reduce age-standardized cancer mortality rates by at least 50% over the next 25 years in the United States. We estimated trends in U.S. cancer mortality during 2000 to 2019 for all cancers and the six leading types (lung, colorectum, pancreas, breast, prostate, liver). Cancer death rates overall declined by 1.4% per year from 2000 to 2015, accelerating to 2.3% per year during 2016 to 2019, driven by strong declines in lung cancer mortality (-4.7%/year, 2014 to 2019). Recent declines in colorectal (-2.0%/year, 2010-2019) and breast cancer death rates (-1.2%/year, 2013-2019) also contributed. However, trends for other cancer types were less promising. To achieve the Moonshot goal, progress against lung, colorectal, and breast cancer deaths needs to be maintained and/or accelerated, and new strategies for prostate, liver, pancreatic, and other cancers are needed. We reviewed opportunities to prevent, detect, and treat these common cancers that could further reduce population-level cancer death rates and also reduce disparities.

SIGNIFICANCE

We reviewed opportunities to prevent, detect, and treat common cancers, and show that to achieve the Moonshot goal, progress against lung, colorectal, and breast cancer deaths needs to be maintained and/or accelerated, and new strategies for prostate, liver, pancreatic, and other cancers are needed. See related commentary by Bertagnolli et al., p. 1049. This article is highlighted in the In This Issue feature, p. 1027.

National trends and disparities in retail food environments in the USA between 1990 and 2014

OBJECTIVE

To describe national disparities in retail food environments by neighbourhood composition (race/ethnicity and socio-economic status) across time and space.

DESIGN

We examined built food environments (retail outlets) between 1990 and 2014 for census tracts in the contiguous USA (n 71 547). We measured retail food environment as counts of all food stores, all unhealthy food sources (including fast food, convenience stores, bakeries and ice cream) and healthy food stores (including supermarkets, fruit and vegetable markets) from National Establishment Time Series business data. Changes in food environment were mapped to display spatial patterns. Multi-level Poisson models, clustered by tract, estimated time trends in counts of food stores with a land area offset and independent variables population density, racial composition (categorised as predominantly one race/ethnicity (>60 %) or mixed), and inflation-adjusted income tertile.

SETTING

The contiguous USA between 1990 and 2014.

PARTICIPANTS

All census tracts (n 71 547).

RESULTS

All food stores and unhealthy food sources increased, while the subcategory healthy food remained relatively stable. In models adjusting for population density, predominantly non-Hispanic Black, Hispanic, Asian and mixed tracts had significantly more destinations of all food categories than predominantly non-Hispanic White tracts. This disparity increased over time, predominantly driven by larger increases in unhealthy food sources for tracts which were not predominantly non-Hispanic White. Income and food store access were inversely related, although disparities narrowed over time.

CONCLUSIONS

Our findings illustrate a national food landscape with both persistent and shifting spatial patterns in the availability of establishments across neighbourhoods with different racial/ethnic and socio-economic compositions.

Cancer Disparities among Pacific Islanders: A Review of Sociocultural Determinants of Health in the Micronesian Region

It is well appreciated that the social determinants of health are intimately related with health outcomes. However, there is a paucity of literature that explores these themes comprehensively for the indigenous people within Micronesia. Certain Micronesia-specific factors, such as transitions from traditional diets, the consumption of betel nut, and exposure to radiation from the nuclear bomb testing in the Marshall Islands, have predisposed certain Micronesian populations to an increased risk of developing a variety of malignancies. Furthermore, severe weather events and rising sea levels attributed to climate change threaten to compromise cancer care resources and displace entire Micronesian populations. The consequences of these risks are expected to increase the strain on the already challenged, disjointed, and burdened healthcare infrastructure in Micronesia, likely leading to more expenses in off-island referrals. A general shortage of Pacific Islander physicians within the workforce reduces the number of patients that can be seen, as well as the quality of culturally competent care that is delivered. In this narrative review, we comprehensively underscore the health disparities and cancer inequities faced by the underserved communities within Micronesia.

Increased Mortality Trends in Patients With Chronic Non-communicable Diseases and Comorbid Hypertension in the United States, 2000–2019

Background

According to the Sustainable Development Goals (SDGs), countries are required to reduce the mortality rates of four main non-communicable diseases (NCDs), including cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs), and cancer (CA), by one-third in 2030 from the 2015 level. However, progress fell short of expectations, partly attributed to the high rates of hypertension-related NCD mortality. This study aimed to investigate the mortality trends of SDG-targeted NCDs with comorbid hypertension. In addition, the disparities in mortality rates among different demographic subgroups were further explored.

Methods

Mortality data from 2000 to 2019 were acquired from the Centers for Disease Control and Prevention in the United States. SDG-targeted NCDs were considered the underlying causes of death, and hypertension was considered a multiple cause of death. Permutation tests were performed to determine the time points of Joinpoints for mortality trends. The annual percent changes and average annual percent changes (AAPCs), as well as 95% confidence intervals (CIs), were calculated to demonstrate the temporary trend of mortality rates overall and by age, sex, ethnicity, and region.

Results

The hypertension-related DM, CRD, and CA mortality rates increased over the 20 years, of which the AAPCs were 2.0% (95% CI: 1.4%, 2.6%), 3.2% (95% CI: 2.8%, 3.6%), and 2.1% (95% CI: 1.6%, 2.6%), respectively. Moreover, despite decreasing between 2005 and 2015, the hypertension-related CVD mortality rate increased from 2015 to 2019 [APC: 1.3% (95% CI: 0.7%, 1.9%)]. The increased trends were consistent across most age groups. Mortality rates among men were higher and increased faster than those among women. The hypertension-related CVD, DM, and CA mortality rates among African American people were higher than those among White people. The increased mortality rates in rural areas, especially in rural south, were higher than those in urban areas.

Conclusion

In the United States, the hypertension-related DM, CRD, and CA mortality rates increased between 2000 and 2019, as well as hypertension-related CVD mortality between 2015 and 2019. Disparities existed among different sexes, ethnicities, and areas. Actions to prevent and manage hypertension among patients with NCDs are required to reduce the high mortality rates and minimize disparities.

Changes in breast cancer screening rates among 32 community health centers during the COVID-19 pandemic

Background

Breast cancer screening utilization steeply dropped at the start of the coronavirus disease 2019 (COVID‐19) pandemic. However, the effects on breast cancer screening in lower income populations are unknown. This study examined changes in breast cancer screening rates (BCSRs) during the pandemic among 32 community health centers (CHCs) that provided health care to lower income populations.

Methods

Secondary data from 32 CHCs participating in an American Cancer Society grant program to increase breast cancer screening services were used. BCSRs were defined as the percentage of women aged 50 to 74 years who had a medical visit in the past 12 months (142,207 in 2018, 142,003 in 2019, and 150,630 in 2020) and received a screening mammogram within the last 27 months. BCSRs in July 2020, July 2019, and June 2018 were compared with screening rate ratios (SRRs) and corresponding 95% confidence intervals (CIs).

Results

BCSRs significantly rose by 18% between 2018 and 2019 (from 45.8% to 53.9%; SRR, 1.18; 95% CI, 1.17‐1.18) and then declined by 8% between 2019 and 2020 (from 53.9% to 49.6%; SRR, 0.92; 95% CI, 0.92‐0.93). If the 2018‐2019 BCSR trends had continued through 2020, 63.3% of women would have been screened in 2020 in contrast to the 49.6% who were; this potentially translated into 47,517 fewer mammograms and 242 missed breast cancer diagnoses in this population.

Conclusions

In this study of 32 CHCs, BCSRs declined by 8% from July 2019 to 2020, and this reversed an 18% improvement between July 2018 and 2019. Declining BCSRs among CHCs during the COVID‐19 pandemic call for policies to support and resources to identify women in need of screening.

In this study of 32 community health centers, breast cancer screening rates declined by 8% from July 2019 to 2020. This reverses an 18% improvement between July 2018 and 2019.

The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri

Background

Rural residence is commonly thought to be a risk factor for poor cancer outcomes. However, a number of studies have reported seemingly conflicting information regarding cancer outcome disparities with respect to rural residence, with some suggesting that the disparity is not present and others providing inconsistent evidence that either urban or rural residence is associated with poorer outcomes. We suggest a simple explanation for these seeming contradictions: namely that rural cancer outcome disparities are related to factors that occur differentially at a local level, such as environmental exposures, lack of access to care or screening, and socioeconomic factors, which differ by type of cancer.

Methods

We conducted a retrospective cohort study examining ten cancers treated at the University of Kansas Medical Center from 2011 to 2018, with individuals from either rural or urban residences. We defined urban residences as those in a county with a U.S. Department of Agriculture Urban Influence Code (UIC) of 1 or 2, with all other residences defines a rural. Inverse probability of treatment weighting was used to create a pseudo-sample balanced for covariates deemed likely to affect the outcomes modeled with cumulative link and weighted Cox-proportional hazards models.

Results

We found that rural residence is not a simple risk factor but rather appears to play a complex role in cancer outcome disparities. Specifically, rural residence is associated with higher stage at diagnosis and increased survival hazards for colon cancer but decreased risk for lung cancer compared to urban residence.

Conclusion

Many cancers are affected by unique social and environmental factors that may vary between rural and urban residents, such as access to care, diet, and lifestyle. Our results show that rurality can increase or decrease risk, depending on cancer site, which suggests the need to consider the factors connected to rurality that influence this complex pattern. Thus, we argue that such disparities must be studied at the local level to identify and design appropriate interventions to improve cancer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12190-w.

Are NCCN Resource-Stratified Guidelines for Breast Cancer Systemic Therapy Achievable? A Population-Based Study of Global Need and Economic Impact

PURPOSE

Resource-stratified guidelines (RSG) for cancer provide a hierarchy of interventions, based on resource availability. We quantify treatment need and cost if National Comprehensive Cancer Network (NCCN) RSGs for breast cancer (BC) are adopted globally.

METHODS

We developed decision trees for first-course systemic therapy, merged with SEER and Global Cancer Observatory 2018 incidence data to estimate treatment need and cost if NCCN RSG are implemented globally based on country-level income. Simulations were used to quantify need and cost of globally scaling up services to Maximal.

RESULTS

Based on NCCN RSG, first-course chemotherapy is indicated in 0% (Basic), 87% (Core), and 86% (Enhanced) but declined to 50% (Maximal) because of incorporation of genomic profiling. First-course endocrine therapy (ET) is indicated in 80% in all settings. In 2018, treatment need was 1.4 million people for chemotherapy, 183,943 for human epidermal growth factor receptor 2 (HER2) therapies and 1.6 million for ET. The cost per person for chemotherapy or HER2 or immunotherapy increased by 17-fold from Core to Maximal ($1,278-$22,313 Australian dollars [AUD]). The cost of ET per person rose eight-fold from Basic to Maximal ($1,236-$9,809 AUD). If all patients with BC globally were treated with Maximal resources, the need for chemotherapy would decline by 28%, whereas cost of first-course treatment would rise by 1.8-fold ($21-$37 billion AUD) because of more costly therapies.

CONCLUSION

NCCN RSGs for BC could result in chemotherapy overtreatment in Core and Enhanced settings. The absence of chemotherapy in Basic settings should be reconsidered, and future iterations of RSG should perform cross-tumor comparisons to ensure equitable resource distribution and maximize population-level outcomes. Our model is flexible and can be tailored to the costs, population attributes, and resource availability of any institution or country for health-services planning.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018

BACKGROUND

This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types.

METHODS

Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types.

RESULTS

CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health.

CONCLUSIONS

SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types.

IMPACT

Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States

INTRODUCTION

Many sociodemographic factors affect women's ability to meet cancer screening guidelines. Our objective was to examine which sociodemographic characteristics were associated with women meeting US Preventive Services Task Force (USPSTF) guidelines for breast, cervical, and colorectal cancer screening.

METHODS

We used 2018 Behavioral Risk Factor Surveillance System data to examine the association between sociodemographic variables, such as race/ethnicity, rurality, education, and insurance status, and self-reported cancer screening for breast, cervical, and colorectal cancer. We used multivariable log-binomial regression models to estimate adjusted prevalence ratios and 95% CIs.

RESULTS

Overall, the proportion of women meeting USPSTF guidelines for breast, cervical, and colorectal cancer screening was more than 70%. The prevalence of meeting screening guidelines was 6% to 10% greater among non-Hispanic Black women than among non-Hispanic White women across all 3 types of cancer screening. Women who lacked health insurance had a 26% to 39% lower screening prevalence across screening types than women with health insurance. Compared with women with $50,000 or more in annual household income, women with less than $50,000 in annual household income had a 3% to 8% lower screening prevalence across all 3 screening types. For colorectal cancer, the prevalence of screening was 7% less among women who lived in rural counties than among women in metropolitan counties.

CONCLUSION

Many women still do not meet current USPSTF guidelines for breast, cervical, and colorectal cancer screening. Screening disparities are persistent among socioeconomically disadvantaged groups, especially women with low incomes and without health insurance. To increase the prevalence of cancer screening and reduce disparities, interventions must focus on reducing economic barriers and improving access to care.

Differences Related to Cancer Screening by Minority and Rural/Urban Status in the Deep South: Population-based Survey Results

Objective: Cancer mortality in the U.S. Deep South exceeds national levels. A cross-sectional survey was undertaken across Alabama to discern cancer beliefs and screening practices, and compare data from racial/ethnic minority versus majority and rural versus urban respondents. Methods: Using population-based methods, we approached 5,633 Alabamians (ages 50-80) to complete a 58-item survey (administered in-person, via telephone, or the web). Descriptive statistics were used to summarize findings; two-tailed, chi-square and t-tests (α<0.05) were used to compare minority-majority and rural-urban subgroups. Results: The response rate was 15.2%; respondents identified as minority (n=356) or majority (n=486), and rural (n=671) or urban (n=183). Mean (SD) age was 63.7 (10.2) and >90% indicated stable housing, and healthcare coverage and access. Rural and minority versus urban and majority respondents were significantly more likely to have lower education, employment, and income, respectively. Most respondents equated cancer as a "death sentence" and were unable to identify the age at which cancer screening should begin. Few rural-urban subgroup differences were noted, though significant differences were observed between minority versus majority subgroups for mammography (36.7% versus 49.6%, p<.001) and colorectal cancer screening (34.5% vs. 47.9%, p<0.001). Furthermore, while minorities were significantly more likely to report ever having a colonoscopy (82.1% versus 76.1%, p=0.041) and to have received fecal occult blood testing within the past year (17.2% versus 12.2%, p=0.046), routine adherence to screening was <20% across all subgroups. Discussion: Cancer early detection education is needed across Alabama to improve cancer screening, and particularly needed among racial/ethnic minorities to raise cancer awareness.

Factors Associated With County-Level Variation in Premature Mortality Due to Noncommunicable Chronic Disease in the United States, 1999-2017

IMPORTANCE

Progress against premature death due to noncommunicable chronic disease (NCD) has stagnated. In the United States, county-level variation in NCD premature mortality has widened, which has impeded progress toward mortality reduction for the World Health Organization (WHO) 25 × 25 target.

OBJECTIVES

To estimate variations in county-level NCD premature mortality, to investigate factors associated with mortality, and to present the progress toward achieving the WHO 25 × 25 target by analyzing the trends in mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study focused on NCD premature mortality and its factors from 3109 counties using US mortality data for cause of death from the Centers for Disease Control and Prevention WONDER databases and county-level characteristics data from multiple databases. Data were collected from January 1, 1999, through December 31, 2017, and analyzed from April 1 through October 28, 2019.

EXPOSURES

County-level factors, including demographic composition, socioeconomic features, health care environment, and population health status.

MAIN OUTCOMES AND MEASURES

Variations in county-level, age-adjusted NCD mortality in the US residents aged 25 to 64 years and associations between mortality and the 4 sets of county-level factors.

RESULTS

A total of 6 794 434 deaths due to NCD were recorded during the study period (50.58% women; 16.49% aged 65 years or older). Mortality decreased by 4.30 (95% CI, -4.54 to -4.08) deaths per 100 000 person-years annually from 1999 to 2010 (P < .001) and decreased annually at a rate of 0.90 (95% CI, -1.13 to -0.73) deaths per 100 000 person-years annually from 2010 to 2017 (P < .001). Mortality in the county with the highest mortality was 10.40 times as high as that in the county with the lowest mortality (615.40 vs 59.20 per 100 000 population) in 2017. Geographic inequality was decomposed by between-state and within-state differences, and within-state differences accounted for most inequality (57.10% in 2017). County-level factors were associated with 71.83% variation in NCD mortality. Association with intercounty mortality was 19.51% for demographic features, 23.34% for socioeconomic composition, 16.40% for health care environment, and 40.75% for health-status characteristics.

CONCLUSIONS AND RELEVANCE

Given the stagnated trend of decline and increasing variations in NCD premature mortality, these findings suggest that the WHO 25 × 25 target appears to be unattainable, which may be related to broad failure by United Nations members to follow through on commitments of reducing socioeconomic inequalities. The increasing inequalities in mortality are alarming and warrant expanded multisectoral efforts to ameliorate socioeconomic disparities.