Report highlights are categorized into one of the three following groups: Making Progress, Areas of Concern, and Other Trends to Consider.
The nation is making progress toward major cancer-related targets for Healthy People 2020, a comprehensive set of 10-year health objectives sponsored by the U.S. Department of Health and Human Services.
- Cigarette smoking prevalence among adults has declined steadily since 1992. In 2018, 13.9% of adults aged 18 and over were current cigarette smokers.
- Cigarette smoking prevalence among adolescents has declined since the late 1990s, with 8.8% of high school students in 2017 having smoked cigarettes in the past 30 days.
- Initiation of the use of cigarettes among children and adolescents aged 12-17 started falling more rapidly in 2010, reaching the Healthy People 2020 target of 4.3% in 2013. As of 2018, it is 2.3%.
- Cigarette smoking cessation among adult smokers has risen since 2003. In 2018, 8.3% became former cigarette smokers who had quit 6-12 months previously, exceeding the Healthy People 2020 target of 8%. However, some subgroups have not achieved this reduction, such as non-Hispanic blacks and people with less than a high school education.
- Female teen indoor tanning has decreased significantly among high school students since 2013. Many states have enacted policies to control the indoor tanning industry, and some are restricting minors’ access to indoor tanning facilities. The most recent estimate (2017) of the percentage of female adolescents in grades 9 through 12 who used an indoor tanning device in the past year is 7.5% (5.6% for both sexes), further dropping below the overall Healthy People 2020 target of 14% for both sexes for adolescents.
- Recent trends for inorganic arsenic exposure have been decreasing. Inorganic arsenic compounds are more toxic than organic arsenic compounds, and inorganic arsenic has been linked to bladder, lung, skin, prostate, liver and intrahepatic bile duct, and some kidney cancers. Inorganic arsenic compounds are found in industry, in building products (in some “pressure-treated” woods), and in arsenic-contaminated water and soil. We typically take in small amounts of inorganic arsenic in the food we eat (in particular, rice and fish), the water we drink, and the air we breathe.
- The percentage of adolescents aged 13-17 who are up to date on recommended HPV vaccinations (based on the guidelines set for by the Centers for Disease Control and Prevention’s [CDC] Advisory Committee on Immunization Practices [ACIP]) has been increasing, and in 2018 was 53.7% for females and 48.7% for males.
- Lung cancer incidence rates (new cases) in men have continued to fall since 1982 and, for women, since 2006.
- Recent trends show a decline in the incidence of esophageal squamous cell, ovarian, and larynx cancers at 2% or more a year, with smaller but still statistically significant decreases in urinary bladder, stomach, and brain cancers, and Hodgkin and non-Hodgkin lymphoma.
- Trends for distant-stage colon cancer have been decreasing since the late 1980s.
- Colorectal cancer incidence rates have mostly been decreasing through 2011 and reached the Healthy People 2020 target in 2011. Since then the trend has flattened somewhat. The declines in colorectal cancer incidence can be attributed to increased screening, which not only contributes to reduced incidence through the identification and removal of precancerous lesions but also improves the detection of cancer at an earlier stage.
- Since 2002, more females with early-stage breast cancer have been treated with breast-conserving surgery (BCS) with radiation than with mastectomy.
- Between 1990 and 2015, there was a significant increase in receipt of guideline chemotherapy treatment among patients aged 65+ with stage III colon cancer and stages II and III rectal cancer, with 57% receiving guideline therapy in 2015.
Life After Cancer
- The length of cancer survival has increased slowly for all cancers combined. Five-year relative survival for all cancer sites is 69.3% and is approaching the Healthy People 2020 target of 71.7%. Improving survival reflects real changes due to improved early detection and treatment, which can extend life. However, sometimes early detection does not extend the date that someone would die of cancer, but it produces a perceived improvement in survival by increasing the length of time since diagnosis.
- The proportion of adult cancer survivors who are current smokers continues to decline, with the greatest improvement seen among survivors aged 18-44.
- The percentage of cancer survivors aged 18 years and older reporting no physical activity in their leisure time has been declining steadily over the past 20 years. Likewise, the percentage of survivors who meet current Federal guidelines for aerobic and muscle-strengthening physical activity continues to rise.
End of Life
- The rate of death from cancer continues to decline among both men and women in all major racial and ethnic groups.
- Mortality for three of the most common types of cancer (colorectal, female breast, and lung) continues to fall.
- Recent trends show a decline in the mortality of ovarian and larynx cancers, non-Hodgkin and Hodgkin lymphoma, and leukemia of 2% or more a year, with smaller but still statistically significant decreases in myeloma and esophagus, kidney and renal pelvis, and stomach cancers.
Areas of Concern
The nation is losing ground in other important areas that demand attention.
- Although the percentage of smokers making a quit attempt in the past year has been rising since 2005 and was 54.1% in 2018, it is still far below the Healthy People 2020 target of 80%.
- Although progress has been made in reducing exposure to secondhand smoke among all populations, non-Hispanic blacks still have higher rates of exposure than other racial/ethnic groups; those living at less than 200% of the federal poverty level still have higher rates of exposure than those living at 200% or greater than the federal poverty level; and those aged 25 years and older with a high school education or less still have higher rates than those with more education.
- E-cigarette use among high school students rose sharply between 2017 and 2018. In 2018, 20.8% of high school students reported current use of e-cigarettes.
- In 2019, the U.S. experienced an outbreak of e-cigarette and vaping associated lung injury (EVALI). As of January 21, 2020, a total of 2,711 EVALI cases or deaths were reported to the Centers for Disease Control and Prevention (CDC). The U.S. Food and Drug Administration (FDA), CDC, and state health authorities have determined that tetrahydrocannabinol (THC)-containing e-cigarettes are linked to most EVALI cases; however, the involvement of other toxicants in EVALI cannot yet be ruled out.
- Tobacco advertising and promotion are causally related to increased tobacco initiation and use. The U.S. Federal Trade Commission reports cigarette and smokeless tobacco advertising and promotion expenditures for the largest cigarette companies and major smokeless tobacco product manufacturers. In 2017, the combined annual expenditure for advertising and promotion (adjusted to 2017 dollars) was $8.6 billion for cigarettes (which has stabilized since 2009) and $718.3 million for smokeless tobacco products (which has been rising rapidly) —amounting to about $26 million every day.
- Although more than 70% of adults reported practicing sun-protective behaviors in 2015, more than 35% reported having had one or more sunburns in the past 12 months, which is just above the Heathy People Goal of 33.8%. An even higher rate of sunburn (57.2% in 2017) was reported among teens. Sunburn is a primary modifiable risk factor for melanoma skin cancer, and the rate has changed very little from 2000-2015 for adults and between 2015-2017 among teens. While non-Hispanic Whites were more likely to experience sunburn than other racial/ethnic groups, sunburn occurs across all groups, and the rate has remained relatively steady.
- Sun sensitivity occurs in all racial/ethnic groups. Sun-sensitive individuals, who are at greatest risk for melanoma, continue to report slightly higher tanning bed use and higher sunburn incidence than those without sun sensitivity.
- Per capital alcohol consumption, which can increase the risk of some cancers, has risen slightly since the mid-1990s.
- Excess weight or obesity, physical inactivity, and poor nutrition are preventable conditions that are associated with elevated cancer risk. Obesity prevalence continues to increase, with 39.5% of adults estimated to be obese and an additional 31.8% overweight. Despite modest increases over time, only 23.8% of adults report meeting federal guidelines for aerobic and muscle-strengthening physical activity. Rates among low-income and low-education groups of any race were well below the Healthy People 2020 target. Overall diet quality has not improved for years; Americans are not meeting recommendations for intake of fruits and vegetables, which have been linked to prevention of several cancer types.
- The Cancer Trends Progress Report has tracked triennial Pap testing since 1987. To accommodate the addition of HPV testing as a recommended approach to cervical cancer screening, the current report tracks the percentage of women who were up to date with cervical cancer screening recommendations. In 2018, 81% of women aged 21-65 were up to date with respect to their cervical screening recommendations, which is below the Healthy People 2020 target of 93%.
- Uptake of lung cancer screening with CT since 2010 has been fairly stable – but limited. In 2015, 5.9% of adults aged 55-80 years who met the U.S. Preventive Services Task Force criteria for lung cancer screening had a CT scan to check for lung cancer within the past year. The US Preventive Services Task first recommended CT screening for lung cancer in 2013.
- The incidence of several cancers, including leukemia, myeloma, melanoma of the skin, and oral cavity and pharynx, testis, and esophageal adenocarcinoma cancers, has been increasing annually.
- Although age-specific trends in incidence and mortality are not generally covered in this report, it should be noted that incidence trends of colorectal cancer for those under 50 have been rising and are of enough concern that some guideline setting organizations either have, or are considering, lowering the age to initiate screening.
Life After Cancer
- Even for patients with health insurance, out-of-pocket costs for cancer care often pose a significant financial burden. Estimates of national expenditures for cancer care in 2018 for the top five cancer sites were $19.7, $16.6, $15.3, $14.6, and $14.2 billion for female breast, colorectal, prostate, lymphoma, and lung, respectively. As the U.S. population ages and newer technologies and treatments become available, national expenditures for cancer will continue to rise, and cancer costs may increase at a faster rate than overall medical expenditures.
- The proportion of adult cancer survivors who are obese has been rising and is now 32.5%, exceeding the Healthy People 2020 target of 30.5% for all adults. Efforts are needed to help cancer survivors adopt or maintain a healthy lifestyle after cancer, which has the potential to reduce both cancer- and non-cancer-related morbidity.
End of Life
- Recent trends in the death rates for several cancers, including thyroid, liver and intrahepatic bile duct, brain and other nervous system, and corpus and uterine cancers, have been increasing.
Other Trends to Consider
While this report provides trends in cancer rates, and factors that influence cancer rates, for some trends it is not possible to characterize the direction of the trend as either progress or an area of concern.
- Prostate cancer: After a long decline, the incidence rates and death rates for prostate cancer are no longer declining. Prostate cancer incidence rates are very sensitive to changes in PSA screening rates and subsequent referral for biopsy. Screening rates declined recently, probably partly in reaction to a 2012 U.S. Preventive Services Task Force recommendation against PSA screening (this recommendation was partially reversed in 2018). Mortality rates are a function of many factors including changes in screening rates and advances in treatment. While PSA screening may reduce mortality for some patients, it must be balanced against a significant number of patients who are diagnosed with disease that is relatively indolent and may not have progressed prior to the person eventually dying of other unrelated causes.