Cancer is a major public health problem worldwide and is the second leading cause of death in the United States. In this article, we provide the estimated numbers of new cancer cases and deaths in 2020 in the United States nationally and for each state, as well as a comprehensive overview of cancer occurrence based on the most current population‐based data for cancer incidence through 2016 and for mortality through 2017. We also estimate the total number of cancer deaths averted because of the continuous decline in cancer death rates since the early 1990s.

The number of cancer deaths averted in men and women due to the reduction in cancer death rates since the early 1990s was estimated by summing the difference between the annual number of recorded cancer deaths from the number that would have been expected if cancer death rates had remained at their peak. The expected number of deaths was estimated by applying the 5‐year age‐ and sex‐specific cancer death rates in the peak year for age‐standardized cancer death rates (1990 in men and 1991 in women) to the corresponding age‐ and sex‐specific populations in subsequent years through 2017.

The number of cancer deaths expected to occur in 2020 was estimated based on the most recent joinpoint‐generated annual percent change in reported cancer deaths from 2003 through 2017 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al. 23

New cases of ductal carcinoma in situ of the female breast and in situ melanoma of the skin diagnosed in 2020 were estimated by first approximating the number of cases occurring annually from 2007 through 2016 based on age‐specific NAACCR incidence rates (data from 49 states with high‐quality data for all 10 years) and US Census Bureau population estimates obtained via SEER*Stat. 9 , 21 Counts were then adjusted for delays in reporting using SEER delay factors for invasive disease (delay factors are unavailable for in situ cases) and projected to 2020 based on the average annual percent change generated by the joinpoint regression model. 22

To calculate the number of invasive cancer cases, a generalized linear mixed model was used to estimate complete counts for each county (or health service area for rare cancers) from 2002 through 2016 using delay‐adjusted, high‐quality incidence data from 49 states and the District of Columbia (98% population coverage) and geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors. 19 (Data were unavailable for all years for Kansas and for a few sporadic years for a limited number of other states.) Modeled counts were aggregated to the national and state level for each year, and a time series projection method (vector autoregression) was applied to all 15 years to estimate cases for 2020. Basal cell and squamous cell skin cancers cannot be estimated because incidence data are not collected by most cancer registries. For complete details of the case projection methodology, please refer to Zhu et al. 20

The most recent year for which reported incidence and mortality data are available lags 2 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we projected the numbers of new cancer cases and deaths in the United States in 2020 to provide an estimate of the contemporary cancer burden.

Whenever possible, cancer incidence rates were adjusted for delays in reporting, which occur because of a lag in case capture or data corrections. Delay‐adjustment has the largest effect on the most recent data years for cancers that are frequently diagnosed in outpatient settings (eg, melanoma, leukemia, and prostate cancer) and provides the most accurate portrayal of cancer occurrence in the most recent time period. 18 For example, the leukemia incidence rate for 2016 in the 9 oldest SEER registries was 10% higher after adjusting for reporting delays (15.2 vs 13.8 per 100,000 population). 8

All cancer cases were classified according to the International Classification of Diseases for Oncology except childhood and adolescent cancers, which were classified according to the International Classification of Childhood Cancer (ICCC). 13 , 14 Causes of death were classified according to the International Classification of Diseases . 15 All incidence and death rates were age standardized to the 2000 US standard population and expressed per 100,000 population, as calculated by the NCI's SEER*Stat software (version 8.3.6). 16 The annual percent change in rates was quantified using the NCI's Joinpoint Regression Program (version 4.7.0.0). 17

The NAACCR compiles and reports incidence data from 1995 onward for registries that participate in the SEER program and/or the NPCR. These data approach 100% coverage of the US population for the most recent years and were the source for the projected new cancer cases in 2020 and cross‐sectional incidence rates by state and race/ethnicity. 9 , 10 Some of the incidence data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2012‐2016 . 11 , 12

Population‐based cancer incidence data in the United States have been collected by the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program since 1973 and by the Centers for Disease Control and Prevention's (CDC's) National Program of Cancer Registries (NPCR) since 1995. The SEER program is the only source for historic population‐based incidence data. Long‐term (1975‐2016) incidence and survival trends were based on data from the 9 oldest SEER areas (Connecticut, Hawaii, Iowa, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco–Oakland, and Seattle–Puget Sound), representing approximately 9% of the US population. 5 Contemporary stage distribution and survival statistics were based on data from all 18 SEER registries (the SEER 9 registries plus Alaska Natives, California, Georgia, Kentucky, Louisiana, and New Jersey). 6 The probability of developing cancer was based on all 21 SEER registries (the SEER 18 registries plus Idaho, Massachusetts, and New York) and calculated using the NCI's DevCan software (version 6.7.7). 7 Some of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975‐2016 . 8

Mortality data from 1930 to 2017 were provided by the National Center for Health Statistics (NCHS). 1 , 2 Forty‐seven states and the District of Columbia met data quality requirements for reporting to the national vital statistics system in 1930, and Texas, Alaska, and Hawaii began reporting in 1933, 1959, and 1960, respectively. The methods for abstraction and age adjustment of historic mortality data are described elsewhere. 2 , 3 Five‐year mortality rates (2012‐2016) for Puerto Rico were previously published in volume 3 of the North American Association of Central Cancer Registries' (NAACCR's) Cancer in North America: 2012‐2016 . 4

Selected Findings

Expected Numbers of New Cancer Cases Table 1 presents the estimated numbers of new invasive cancer cases in the United States in 2020 by sex and cancer type. In total, there will be approximately 1,806,590 cancer cases diagnosed, which is the equivalent of approximately 4,950 new cases each day. In addition, there will be approximately 48,530 new cases of ductal carcinoma in situ of the breast diagnosed in women and 95,710 new cases of melanoma in situ of the skin. The estimated numbers of new cases by state are shown in Table 2. Table 1. Estimated New Cancer Cases and Deaths by Sex, United States, 2020 ESTIMATED NEW CASES ESTIMATED DEATHS BOTH SEXES MALE FEMALE BOTH SEXES MALE FEMALE All sites 1,806,590 893,660 912,930 606,520 321,160 285,360 Oral cavity & pharynx 53,260 38,380 14,880 10,750 7,760 2,990 Tongue 17,660 12,960 4,700 2,830 1,980 850 Mouth 14,320 8,430 5,890 2,660 1,690 970 Pharynx 17,950 14,630 3,320 3,640 2,820 820 Other oral cavity 3,330 2,360 970 1,620 1,270 350 Digestive system 333,680 187,620 146,060 167,790 97,560 70,230 Esophagus 18,440 14,350 4,090 16,170 13,100 3,070 Stomach 27,600 16,980 10,620 11,010 6,650 4,360 Small intestine 11,110 6,000 5,110 1,700 940 760 Colonb 104,610 52,340 52,270 53,200 28,630 24,570 Rectum 43,340 25,960 17,380 Anus, anal canal, & anorectum 8,590 2,690 5,900 1,350 540 810 Liver & intrahepatic bile duct 42,810 30,170 12,640 30,160 20,020 10,140 Gallbladder & other biliary 11,980 5,600 6,380 4,090 1,700 2,390 Pancreas 57,600 30,400 27,200 47,050 24,640 22,410 Other digestive organs 7,600 3,130 4,470 3,060 1,340 1,720 Respiratory system 247,270 130,340 116,930 140,730 76,370 64,360 Larynx 12,370 9,820 2,550 3,750 3,000 750 Lung & bronchus 228,820 116,300 112,520 135,720 72,500 63,220 Other respiratory organs 6,080 4,220 1,860 1,260 870 390 Bones & joints 3,600 2,120 1,480 1,720 1,000 720 Soft tissue (including heart) 13,130 7,470 5,660 5,350 2,870 2,480 Skin (excluding basal & squamous) 108,420 65,350 43,070 11,480 8,030 3,450 Melanoma of the skin 100,350 60,190 40,160 6,850 4,610 2,240 Other nonepithelial skin 8,070 5,160 2,910 4,630 3,420 1,210 Breast 279,100 2,620 276,480 42,690 520 42,170 Genital system 317,260 203,740 113,520 67,830 34,210 33,620 Uterine cervix 13,800 13,800 4,290 4,290 Uterine corpus 65,620 65,620 12,590 12,590 Ovary 21,750 21,750 13,940 13,940 Vulva 6,120 6,120 1,350 1,350 Vagina & other genital, female 6,230 6,230 1,450 1,450 Prostate 191,930 191,930 33,330 33,330 Testis 9,610 9,610 440 440 Penis & other genital, male 2,200 2,200 440 440 Urinary system 159,120 110,230 48,890 33,820 23,540 10,280 Urinary bladder 81,400 62,100 19,300 17,980 13,050 4,930 Kidney & renal pelvis 73,750 45,520 28,230 14,830 9,860 4,970 Ureter & other urinary organs 3,970 2,610 1,360 1,010 630 380 Eye & orbit 3,400 1,890 1,510 390 210 180 Brain & other nervous system 23,890 13,590 10,300 18,020 10,190 7,830 Endocrine system 55,670 14,160 41,510 3,260 1,600 1,660 Thyroid 52,890 12,720 40,170 2,180 1,040 1,140 Other endocrine 2,780 1,440 1,340 1,080 560 520 Lymphoma 85,720 47,070 38,650 20,910 12,030 8,880 Hodgkin lymphoma 8,480 4,690 3,790 970 570 400 Non‐Hodgkin lymphoma 77,240 42,380 34,860 19,940 11,460 8,480 Myeloma 32,270 17,530 14,740 12,830 7,190 5,640 Leukemia 60,530 35,470 25,060 23,100 13,420 9,680 Acute lymphocytic leukemia 6,150 3,470 2,680 1,520 860 660 Chronic lymphocytic leukemia 21,040 12,930 8,110 4,060 2,330 1,730 Acute myeloid leukemia 19,940 11,090 8,850 11,180 6,470 4,710 Chronic myeloid leukemia 8,450 4,970 3,480 1,130 670 460 Other leukemiac 4,950 3,010 1,940 5,210 3,090 2,120 Other & unspecified primary sites c 30,270 16,080 14,190 45,850 24,660 21,190 Table 2. Estimated New Cases for Selected Cancers by State, 2020 STATE ALL CASES FEMALE BREAST UTERINE CERVIX COLON & RECTUM UTERINE CORPUS LEUKEMIA LUNG & BRONCHUS MELANOMA OF THE SKIN NON‐HODGKIN LYMPHOMA PROSTATE URINARY BLADDER Alabama 28,570 4,120 240 2,460 780 810 4,230 1,550 1,000 3,530 1,090 Alaska 2,960 510 b 320 120 90 400 120 120 340 160 Arizona 36,730 5,630 260 3,010 1,240 990 4,200 2,380 1,500 3,830 1,810 Arkansas 17,200 2,430 140 1,540 500 630 2,760 800 650 1,860 760 California 172,040 30,650 1,630 15,530 7,030 6,060 18,040 10,980 8,200 20,160 7,780 Colorado 27,290 4,530 190 2,040 920 910 2,550 1,920 1,150 3,140 1,250 Connecticut 20,300 3,590 130 1,520 910 400 2,650 1,110 930 2,320 1,080 Delaware 6,660 960 b 470 220 230 890 420 260 770 320 Dist. of Columbia 3,600 510 b 250 120 110 300 90 130 370 80 Florida 150,500 19,900 1,130 11,310 4,460 3,370 18,150 8,750 7,170 13,950 6,780 Georgia 55,190 8,340 440 4,660 1,710 1,550 7,240 3,190 2,280 6,840 2,110 Hawaii 6,800 1,300 60 730 330 230 870 520 290 700 300 Idaho 8,540 1,340 60 730 310 340 990 740 390 1,160 470 Illinois 71,990 11,020 540 6,240 2,850 2,400 9,210 3,700 2,920 8,000 3,310 Indiana 37,940 5,410 270 3,410 1,430 1,290 5,700 2,370 1,590 3,570 1,720 Iowa 18,460 2,710 110 1,600 700 840 2,440 1,150 800 1,920 870 Kansas 16,170 2,390 110 1,320 560 620 2,020 890 650 1,730 640 Kentucky 26,500 3,800 200 2,440 870 920 4,890 1,330 1,040 2,440 1,130 Louisiana 26,480 3,910 260 2,370 690 930 3,700 1,030 1,110 2,970 1,050 Maine 8,180 1,370 50 670 390 160 1,430 520 390 800 520 Maryland 34,710 5,500 250 2,570 1,300 820 3,930 1,780 1,330 4,410 1,360 Massachusetts 36,990 6,690 220 2,650 1,630 580 5,150 2,190 1,670 3,890 1,970 Michigan 61,770 8,800 360 4,620 2,380 2,060 8,140 3,290 2,450 6,820 2,890 Minnesota 33,210 4,670 140 2,320 1,200 1,600 3,580 1,750 1,350 2,880 1,460 Mississippi 17,190 2,390 160 1,730 450 500 2,510 620 570 2,050 630 Missouri 37,540 5,360 270 3,090 1,290 1,370 5,540 1,820 1,410 3,540 1,580 Montana 5,850 960 b 500 220 250 770 450 250 680 330 Nebraska 10,560 1,580 70 940 390 480 1,270 610 450 980 470 Nevada 16,540 2,310 130 1,480 480 520 1,850 840 650 1,780 780 New Hampshire 8,060 1,350 b 590 370 180 1,220 530 370 910 510 New Jersey 53,340 8,260 440 4,250 2,240 2,100 6,100 2,770 2,340 6,010 2,640 New Mexico 9,800 1,570 80 890 370 340 1,040 610 410 920 410 New York 117,910 17,540 930 8,910 4,840 4,600 13,370 4,980 5,120 11,470 5,590 North Carolina 59,620 9,340 430 4,540 2,030 1,640 8,470 3,680 2,480 7,200 2,510 North Dakota 4,060 590 b 360 140 190 460 230 170 400 200 Ohio 71,850 10,350 440 5,910 2,790 2,280 10,110 4,100 2,820 7,030 3,190 Oklahoma 20,530 3,130 170 1,870 620 860 3,200 940 860 2,130 920 Oregon 23,330 3,880 160 1,740 910 740 2,930 1,730 1,000 2,470 1,150 Pennsylvania 80,240 12,180 530 6,520 3,390 3,050 10,710 4,410 3,480 8,300 4,350 Rhode Island 5,930 1,020 b 430 260 100 920 340 270 650 320 South Carolina 31,710 4,790 230 2,550 970 1,220 4,460 1,900 1,300 3,390 1,270 South Dakota 4,960 720 b 430 170 230 590 270 200 520 240 Tennessee 39,360 5,760 330 3,540 1,220 1,280 6,300 2,110 1,580 3,990 1,700 Texas 129,770 19,590 1,410 11,430 4,120 5,260 14,830 4,530 5,650 12,110 4,590 Utah 11,900 1,780 80 840 450 500 730 1,230 550 1,380 460 Vermont 3,740 630 b 270 170 90 570 270 170 330 210 Virginia 47,550 7,410 320 3,530 1,660 1,370 5,960 2,920 1,940 6,200 2,010 Washington 36,290 6,690 250 2,970 1,480 1,430 4,790 2,800 1,740 4,040 1,930 West Virginia 12,380 1,680 80 1,040 440 480 2,030 680 500 1,110 620 Wisconsin 35,280 5,120 200 2,540 1,410 1,420 4,290 2,190 1,460 3,560 1,740 Wyoming 2,880 430 b 260 100 110 320 220 120 400 150 United States 1,806,590 276,480 13,800 147,950 65,620 60,530 228,820 100,350 77,240 191,930 81,400 Figure 1 depicts the most common cancers expected to be diagnosed in men and women in 2020. Prostate, lung and bronchus (referred to as lung hereafter), and colorectal cancers (CRCs) account for 43% of all cases in men, with prostate cancer alone accounting for more than 1 in 5 new diagnoses. For women, the 3 most common cancers are breast, lung, and colorectal, accounting for 50% of all new diagnoses; breast cancer alone accounts for 30% of female cancers. Figure 1 Open in figure viewer PowerPoint Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, United States, 2020. Estimates are rounded to the nearest 10 and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder. Ranking is based on modeled projections and may differ from the most recent observed data. The lifetime probability of being diagnosed with invasive cancer is slightly higher for men (40.1%) than for women (38.7%) (Table 3). The reasons for the excess risk in men are not fully understood, but probably largely reflect differences in environmental exposures and endogenous hormones, as well as complex interactions between these influences. Recent research suggests that sex differences in immune function and response may also play a role.24 Adult height, which is determined by genetics and childhood nutrition, is positively associated with cancer incidence and mortality in both men and women,25 and has been estimated to account for one‐third of the sex disparity.26 Notably, the gender gap varies by age. For example, cancer incidence during childhood (ages birth‐14 years) is approximately 10% higher in males than in females (18.2 vs 16.4 per 100,000 population),27 whereas during early adulthood (ages 20‐49 years) it is 77% higher in females (203.4 vs 114.9 per 100,000 population), largely because of breast cancer incidence in young women.28 Table 3. Probability (%) of Developing Invasive Cancer Within Selected Age Intervals by Sex, United States, 2014 to 2016 BIRTH TO 49 50 TO 59 60 TO 69 ≥70 BIRTH TO DEATH All sites b Male 3.5 (1 in 29) 6.2 (1 in 16) 13.3 (1 in 8) 32.7 (1 in 3) 40.1 (1 in 2) Female 5.8 (1 in 17) 6.4 (1 in 16) 10.2 (1 in 10) 26.7 (1 in 4) 38.7 (1 in 3) Breast Female 2.0 (1 in 49) 2.4 (1 in 42) 3.5 (1 in 28) 7.0 (1 in 14) 12.8 (1 in 8) Colorectum Male 0.4 (1 in 262) 0.7 (1 in 143) 1.1 (1 in 90) 3.3 (1 in 30) 4.4 (1 in 23) Female 0.4 (1 in 274) 0.5 (1 in 190) 0.8 (1 in 126) 3.0 (1 in 33) 4.1 (1 in 25) Kidney & renal pelvis Male 0.2 (1 in 415) 0.4 (1 in 266) 0.7 (1 in 153) 1.4 (1 in 74) 2.2 (1 in 46) Female 0.2 (1 in 661) 0.2 (1 in 551) 0.3 (1 in 317) 0.7 (1 in 136) 1.2 (1 in 82) Leukemia Male 0.3 (1 in 391) 0.2 (1 in 550) 0.4 (1 in 249) 1.5 (1 in 69) 1.9 (1 in 54) Female 0.2 (1 in 499) 0.1 (1 in 838) 0.2 (1 in 433) 0.9 (1 in 109) 1.3 (1 in 77) Lung & bronchus Male 0.1 (1 in 730) 0.6 (1 in 158) 1.8 (1 in 57) 6.0 (1 in 17) 6.7 (1 in 15) Female 0.2 (1 in 659) 0.6 (1 in 169) 1.4 (1 in 70) 4.8 (1 in 21) 6.0 (1 in 17) Melanoma of the skin c Male 0.4 (1 in 228) 0.5 (1 in 197) 0.9 (1 in 109) 2.6 (1 in 38) 3.6 (1 in 28) Female 0.6 (1 in 156) 0.4 (1 in 245) 0.5 (1 in 194) 1.2 (1 in 86) 2.5 (1 in 41) Non‐Hodgkin lymphoma Male 0.3 (1 in 367) 0.3 (1 in 340) 0.6 (1 in 176) 1.9 (1 in 53) 2.4 (1 in 41) Female 0.2 (1 in 529) 0.2 (1 in 463) 0.4 (1 in 238) 1.4 (1 in 72) 1.9 (1 in 52) Prostate Male 0.2 (1 in 441) 1.8 (1 in 57) 4.7 (1 in 21) 8.2 (1 in 12) 11.6 (1 in 9) Thyroid Male 0.2 (1 in 449) 0.1 (1 in 694) 0.2 (1 in 558) 0.2 (1 in 405) 0.7 (1 in 144) Female 0.9 (1 in 112) 0.4 (1 in 252) 0.4 (1 in 273) 0.4 (1 in 251) 1.9 (1 in 52) Uterine cervix Female 0.3 (1 in 367) 0.1 (1 in 831) 0.1 (1 in 921) 0.2 (1 in 595) 0.6 (1 in 159) Uterine corpus Female 0.3 (1 in 323) 0.6 (1 in 157) 1.0 (1 in 95) 1.5 (1 in 69) 3.1 (1 in 33)

Expected Number of Cancer Deaths An estimated 606,520 Americans will die from cancer in 2020, corresponding to more than 1,600 deaths per day (Table 1). The greatest number of deaths are from cancers of the lung, prostate, and colorectum in men and the lung, breast, and colorectum in women (Fig. 1). Almost one‐quarter of all cancer deaths are due to lung cancer. Table 4 provides the estimated numbers of cancer deaths in 2020 by state. Table 4. Estimated Deaths for Selected Cancers by State, 2020 STATE ALL SITES BRAIN & OTHER NERVOUS SYSTEM FEMALE BREAST COLON & RECTUM LEUKEMIA LIVER & INTRAHEPATIC BILE DUCT LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA OVARY PANCREAS PROSTATE Alabama 10,530 340 690 960 370 520 2,790 290 230 790 520 Alaska 1,090 b 70 120 b 50 190 b b 90 60 Arizona 12,580 400 900 1,120 520 680 2,590 410 310 1,070 760 Arkansas 6,730 190 410 610 240 290 1,890 190 140 450 280 California 60,660 1,980 4,620 5,480 2,400 3,880 10,210 2,140 1,590 4,840 3,890 Colorado 8,220 290 640 700 330 410 1,450 260 210 620 590 Connecticut 6,390 210 430 460 260 310 1,370 230 160 520 480 Delaware 2,130 60 150 160 90 120 510 80 50 190 90 Dist. of Columbia 1,020 b 100 100 b 80 180 b b 90 70 Florida 45,300 1,290 3,040 3,930 1,800 2,200 10,580 1,500 1,000 3,570 2,800 Georgia 17,990 540 1,380 1,730 600 760 4,210 530 400 1,300 990 Hawaii 2,540 60 160 240 90 180 520 90 b 240 130 Idaho 3,100 100 230 260 110 160 590 120 90 260 210 Illinois 24,220 670 1,720 2,160 900 1,080 5,710 750 560 1,780 1,560 Indiana 13,630 370 880 1,170 510 550 3,570 450 290 990 640 Iowa 6,440 190 380 560 250 260 1,530 240 150 500 340 Kansas 5,520 170 350 500 240 250 1,300 180 120 410 290 Kentucky 10,540 290 630 870 370 440 2,910 330 180 670 430 Louisiana 9,300 240 640 880 320 580 2,330 280 160 750 450 Maine 3,350 100 180 240 120 120 870 110 70 240 180 Maryland 10,790 300 850 920 410 580 2,310 340 260 870 580 Massachusetts 12,430 410 780 910 480 640 2,810 390 310 1,020 660 Michigan 21,000 600 1,380 1,700 770 890 5,220 720 480 1,720 1,030 Minnesota 10,040 330 630 790 430 420 2,210 390 210 820 590 Mississippi 6,700 180 460 670 220 320 1,740 160 120 520 360 Missouri 13,010 340 850 1,090 480 570 3,250 390 250 940 570 Montana 2,140 70 140 190 70 100 460 70 50 160 150 Nebraska 3,520 120 240 320 150 120 800 120 80 280 190 Nevada 5,460 210 400 590 200 240 1,230 170 150 400 310 New Hampshire 2,830 90 170 290 110 120 700 90 70 200 150 New Jersey 15,710 480 1,230 1,440 620 700 3,230 560 390 1,340 810 New Mexico 3,730 110 280 360 120 250 670 120 110 280 230 New York 34,710 960 2,430 2,950 1,370 1,610 6,510 1,230 870 2,890 1,850 North Carolina 20,410 570 1,440 1,640 710 850 5,020 610 430 1,500 1,010 North Dakota 1,260 b 80 110 60 b 280 50 b 100 70 Ohio 25,380 700 1,710 2,170 930 1,090 6,460 850 550 1,930 1,200 Oklahoma 8,430 230 560 800 330 410 2,180 270 190 570 430 Oregon 8,280 260 550 660 310 480 1,750 270 240 680 500 Pennsylvania 27,860 780 1,910 2,440 1,070 1,270 6,460 950 640 2,270 1,390 Rhode Island 2,120 60 120 160 80 110 540 70 b 170 110 South Carolina 10,780 310 750 910 390 520 2,610 320 210 830 590 South Dakota 1,690 60 110 170 70 70 400 60 b 130 90 Tennessee 14,780 380 950 1,260 530 730 3,990 460 310 1,010 660 Texas 41,810 1,260 3,060 4,070 1,620 2,740 8,420 1,350 930 3,130 2,310 Utah 3,350 140 290 300 170 160 430 130 110 280 240 Vermont 1,450 60 70 130 50 50 350 50 b 110 70 Virginia 15,220 450 1,140 1,400 540 730 3,450 490 370 1,180 800 Washington 13,020 440 900 1,050 490 720 2,740 450 330 1,000 750 West Virginia 4,750 120 290 440 180 200 1,300 150 90 310 190 Wisconsin 11,610 380 720 920 470 450 2,690 400 250 950 660 Wyoming 960 b 60 80 50 60 190 b b 70 50 United States 606,520 18,020 42,170 53,200 23,100 30,160 135,720 19,940 13,940 47,050 33,330

Trends in Cancer Incidence Figure 2 illustrates long‐term trends in cancer incidence rates for all cancers combined by sex. Cancer incidence patterns reflect trends in behaviors associated with cancer risk and changes in medical practice, such as the use of cancer screening tests. For example, the spike in incidence for males during the early 1990s reflects rapid changes in prostate cancer incidence rates due to a surge in the detection of asymptomatic disease as a result of widespread prostate‐specific antigen (PSA) testing among previously unscreened men.29 The overall cancer incidence rate in men declined rapidly from 2007 to 2014, but stabilized through 2016, reflecting slowing declines for CRC and stabilizing rates for prostate cancer (Fig. 3). The sharp drop in prostate cancer incidence from 2007 to 2014 has been attributed to decreased PSA testing in the wake of US Preventive Services Task Force recommendations against the routine use of the test to screen for prostate cancer (Grade D) because of growing concerns about overdiagnosis and overtreatment.30, 31 However, Negoita et al recently reported that the overall decline in prostate cancer incidence masks an increase in distant stage diagnoses since around 2010 across age and race, although improved staging may have contributed.32 In 2017, the Task Force revised their recommendation for men aged 55 to 69 years to informed decision making (Grade C) based on an updated evidence review, noting that “screening offers a small potential benefit” of reduced prostate cancer mortality “in some men.”33-35 Figure 2 Open in figure viewer PowerPoint Trends in Cancer Incidence (1975 to 2016) and Mortality Rates (1975 to 2017) by Sex, United States. Rates are age adjusted to the 2000 US standard population. Incidence rates also are adjusted for delays in reporting. Figure 3 Open in figure viewer PowerPoint Trends in Incidence Rates for Selected Cancers by Sex, United States, 1975 to 2016. Rates are age adjusted to the 2000 US standard population and adjusted for delays in reporting. *Includes intrahepatic bile duct. The overall cancer incidence rate in women has remained generally stable over the past few decades because lung cancer declines have been offset by a tapering decline for CRC and increasing or stable rates for other common cancers (Fig. 3). The slight rise in breast cancer incidence rates (by approximately 0.3% per year) since 2004 has been attributed at least in part to continued declines in the fertility rate as well as increased obesity,36 factors that may also contribute to the continued increase in incidence for uterine corpus cancer (1.3% per year from 2007‐2016).37 However, a recent study indicated that the rise in uterine cancer is driven by nonendometrioid subtypes, which are less strongly associated with obesity than endometrioid carcinoma.38 Thyroid cancer incidence has stabilized after the implementation of more conservative diagnostic practices in response to the sharp uptick in the diagnosis of largely indolent tumors in recent decades.39, 40 Lung cancer incidence continues to decline twice as fast in men as in women, reflecting historical differences in tobacco uptake and cessation, as well as upturns in female smoking prevalence in some birth cohorts.41, 42 However, smoking patterns do not fully explain the higher lung cancer incidence rates recently reported in young women compared with men born around the 1960s.43 In contrast, CRC incidence patterns are generally similar in men and women, with the rapid declines noted during the 2000s in the wake of widespread colonoscopy uptake appearing to taper in more recent years (Fig. 3). Notably, declines in the overall CRC incidence rate mask an increase in adults aged younger than 55 years of 2% per year since the mid‐1990s. Incidence also continues to increase for cancers of the kidney, pancreas, liver, and oral cavity and pharynx (among non‐Hispanic whites) and melanoma of the skin, although melanoma has begun to decline in recent birth cohorts.28, 44 Liver cancer is increasing most rapidly, by 2% to 3% annually during 2007 through 2016, although the pace has slowed from previous years.8 The majority of these cases (71%) are potentially preventable because most liver cancer risk factors are modifiable (eg, obesity, excess alcohol consumption, cigarette smoking, and hepatitis B and C viruses).45 Chronic hepatitis C virus (HCV) infection, the most common chronic blood‐borne infection in the United States, confers the largest relative risk and accounts for 1 in 4 cases.46 Although well‐tolerated antiviral therapies achieve cure rates of >90% and could potentially avert much of the future burden of HCV‐associated disease,47 most infected individuals are undiagnosed, and thus untreated. Only 14% of the more than 76 million individuals born during 1945 through 1965 (baby boomers) had received the recommended one‐time HCV test in 2015.48 Compounding the challenge is a greater than 3‐fold spike in acute HCV infections reported to the CDC between 2010 and 2017 as a consequence of the opioid epidemic, of which 75% to 85% of cases will progress to chronic infection.49

Cancer Survival The 5‐year relative survival rate for all cancers combined diagnosed during 2009 through 2015 was 67% overall, 68% in whites, and 62% in blacks.8 Figure 4 shows 5‐year relative survival rates by cancer type, stage at diagnosis, and race. For all stages combined, survival is highest for prostate cancer (98%), melanoma of the skin (92%), and female breast cancer (90%) and lowest for cancers of the pancreas (9%), liver (18%), lung (19%), and esophagus (20%). Survival rates are lower for black patients than for whites for every cancer type shown in Figure 4 except for cancers of the kidney and pancreas, for which they are the same. The largest black‐white differences in absolute terms are for melanoma (25%) and cancers of the uterine corpus (22%), oral cavity and pharynx (19%), and urinary bladder (14%). Although these disparities partly reflect a later stage of disease at diagnosis in black patients (Fig. 5), blacks also have lower stage‐specific survival for most cancer types (Fig. 4). After adjusting for sex, age, and stage at diagnosis, the relative risk of death after a cancer diagnosis is 33% higher in black patients than in white patients.50 The disparity is even larger for American Indians/Alaska Natives, among whom the risk of cancer death is 51% higher than that for whites. Figure 4 Open in figure viewer PowerPoint Five‐Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis, United States, 2009 to 2015. *The standard error of the survival rate is between 5 and 10 percentage points. †The survival rate for carcinoma in situ of the urinary bladder is 95% in all races, 95% in whites, and 91% in blacks. Figure 5 Open in figure viewer PowerPoint Stage Distribution for Selected Cancers by Race, United States, 2009 to 2015. Stage categories do not sum to 100% because sufficient information was not available to stage all cases. Cancer survival has improved since the mid‐1970s for all of the most common cancers except uterine cervix and uterine corpus.50 Stagnant survival rates for these cancers largely reflect a lack of major treatment advances for patients with recurrent and metastatic disease.51, 52 For cervical cancer, it may also reflect an increasing proportion of adenocarcinoma over time due to the removal of slow‐growing squamous lesions through long‐term widespread screening.53 On the contrary, survival rates for breast and prostate cancer are likely to be artificially inflated in the screening era due to lead time bias and the detection of indolent cancers in the absence of the capacity to detect and remove premalignant lesions.54 Progress for hematopoietic and lymphoid malignancies has been especially rapid due to improvements in treatment protocols, including the development of targeted therapies. For example, the 5‐year relative survival rate for chronic myeloid leukemia increased from 22% in the mid‐1970s to 70% for those diagnosed during 2009 through 2015,8 and most patients treated with tyrosine kinase inhibitors experience nearly normal life expectancy.55 Low lung cancer survival rates reflect the large proportion of patients (57%) diagnosed with metastatic disease, for which the 5‐year relative survival rate is 5%.8 However, the 5‐year survival rate for localized stage disease is 57%, and there is potential for earlier diagnoses among those at high risk through screening with low‐dose computed tomography. The National Lung Screening Trial, the largest trial to date, demonstrated a 20% reduction in lung cancer mortality in current/former smokers with a ≥30 pack‐year history compared with chest radiography.56 More recently, the Multicentric Italian Lung Detection (MILD) trial, which included more screening rounds, longer follow‐up, and a more moderate risk pool (those with a smoking history of ≥20 pack‐years) reported a 39% reduction in lung cancer mortality compared with no intervention.57 Although the American Cancer Society and US Preventive Services Task Force recommend low‐dose computed tomography lung cancer screening for select current/former heavy smokers, the translation of this benefit to the general population remains challenging. Recent studies have found that millions of individuals are inappropriately screened whereas fewer than 500,000 are screened according to guidelines.58, 59 Broad implementation of recommended lung cancer screening will require new systems to facilitate unique aspects of the process, including the identification of eligible patients and the education of physicians regarding details of the shared decision‐making conversation required by the Centers for Medicaid and Medicare Services.

Recorded Number of Deaths in 2017 A total of 2,820,034 deaths were recorded in the United States in 2017, 21% of which were from cancer (Table 6). In contrast to stable or increasing trends for most leading causes of death, the cancer death rate declined by 2.2% from 2016 to 2017, the largest single‐year drop since rates began declining in 1992. This progress is largely driven by recent rapid declines in lung cancer mortality. Cancer is the second leading cause of death after heart disease in both men and women nationally, but is the leading cause of death in many states,69 in Hispanic and Asian Americans,70, 71 and in individuals aged younger than 80 years. However, those aged 80 years and older are nearly 2 times more likely to die from heart disease than from cancer. Among females, cancer is the first or second leading cause of death for every age group shown in Table 7, whereas among males, accidents and suicide predominate before age 40 years. Table 6. Ten Leading Causes of Death in the United States, 2016 and 2017 RANK (2016) All causes 2016 2017 RELATIVE CHANGE IN RATE NO. PERCENT RATE NO. PERCENT RATE 2,744,248 728.7 2,820,034 731.7 0.4% 1 Heart disease 635,260 23% 165.5 647,457 23% 165.0 −0.3% 2 Cancer 598,038 22% 155.9 599,108 21% 152.4 −2.2% 3 Accidents (unintentional injuries) 161,374 6% 47.3 169,936 6% 49.3 4.2% 4 Chronic lower respiratory diseases 154,596 6% 40.7 160,201 6% 41.0 0.7% 5 Cerebrovascular disease 142,142 5% 37.4 146,383 5% 37.6 0.5% 6 Alzheimer disease 116,103 4% 30.3 121,404 4% 31.1 2.6% 7 Diabetes mellitus 80,058 3% 21.0 83,564 3% 21.4 1.9% 8 Influenza and pneumonia 51,537 2% 13.5 55,672 2% 14.3 5.9% 9 Nephritis, nephrotic syndrome, & nephrosis 50,046 2% 13.2 50,633 2% 13.0 −1.5% 10 Intentional self‐harm (suicide) 44,965 2% 13.4 47,173 2% 14.0 4.5% Source: National Center for Health Statistics, Centers for Disease Control and Prevention. Table 7. Ten Leading Causes of Death in the United States by Age and Sex, 2017 ALL AGES AGES 1 TO 19 AGES 20 TO 39 AGES 40 TO 59 AGES 60 TO 79 AGES ≥80 MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes 1,439,111 1,374,392 13,350 6,987 81,908 36,347 228,878 146,257 594,384 454,632 508,032 720,264 1 Heart disease Heart disease Accidents (unintentional injuries) Accidents (unintentional injuries) Accidents (unintentional injuries) Accidents (unintentional injuries) Heart disease Cancer Cancer Cancer Heart disease Heart disease 347,879 299,578 4,510 2,283 34,903 12,610 51,071 46,700 174,590 142,987 144,806 189,291 2 Cancer Cancer Intentional self‐harm (suicide) Cancer Intentional self‐harm (suicide) Cancer Cancer Heart disease Heart disease Heart disease Cancer Cancer 315,147 283,961 2,290 769 12,324 4,563 47,008 22,307 145,974 84,855 88,575 88,908 3 Accidents (unintentional injuries) Chronic lower respiratory diseases Assault (homicide) Intentional self‐harm (suicide) Assault (homicide) Intentional self‐harm (suicide) Accidents (unintentional injuries) Accidents (unintentional injuries) Chronic lower respiratory diseases Chronic lower respiratory diseases Chronic lower respiratory diseases Alzheimer disease 109,722 85,196 1,956 723 8,832 3,107 33,368 14,712 38,540 38,153 30,543 72,172 4 Chronic lower respiratory diseases Cerebro‐vascular disease Cancer Assault (homicide) Heart disease Heart disease Intentional self‐harm (suicide) Chronic lower respiratory diseases Cerebro‐vascular disease Cerebro‐vascular disease Cerebro‐vascular disease Cerebro‐vascular disease 75,005 84,738 971 514 5,474 2,722 12,367 6,025 24,391 22,389 29,653 56,685 5 Cerebro‐vascular disease Alzheimer disease Congenital anomalies Congenital anomalies Cancer Assault (homicide) Chronic liver disease & cirrhosis Chronic liver disease & cirrhosis Diabetes mellitus Diabetes mellitus Alzheimer disease Chronic lower respiratory diseases 61,645 84,079 524 447 3,971 1,710 11,063 5,873 23,780 16,711 29,246 40,607 6 Diabetes mellitus Accidents (unintentional injuries) Heart disease Heart disease Chronic liver disease & cirrhosis Pregnancy, childbirth, & puerperium Diabetes mellitus Diabetes mellitus Accidents (unintentional injuries) Alzheimer disease Accidents (unintentional injuries) Accidents (unintentional injuries) 46,302 60,214 372 241 1,317 869 8,795 5,254 21,301 11,660 14,865 18,479 7 Alzheimer disease Diabetes mellitus Influenza & pneumonia Influenza & pneumonia Diabetes mellitus Chronic liver disease & cirrhosis Cerebro‐vascular disease Cerebro‐vascular disease Chronic liver disease & cirrhosis Accidents (unintentional injuries) Influenza & pneumonia Influenza & pneumonia 37,325 37,262 148 138 1,082 850 6,627 4,940 12,267 11,572 13,764 18,362 8 Intentional self‐harm (suicide) Influenza & pneumonia Chronic lower respiratory diseases Cerebro‐vascular disease Cerebro‐vascular disease Diabetes mellitus Chronic lower respiratory diseases Intentional self‐harm (suicide) Nephritis, nephrotic syndrome, & nephrosis Nephritis, nephrotic syndrome, & nephrosis Diabetes mellitus Diabetes mellitus 36,782 29,114 144 97 783 747 5,377 4,226 10,837 9,254 12,581 14,496 9 Influenza & pneumonia Nephritis, nephrotic syndrome, & nephrosis Cerebro‐vascular disease Chronic lower respiratory diseases HIV disease Cerebro‐vascular disease Assault (homicide) Septicemia Influenza & pneumonia Septicemia Parkinson Nephritis, nephrotic syndrome, & nephrosis 26,558 24,889 132 86 700 584 3,510 2,419 9,585 8,816 12,258 13,264 10 Chronic liver disease & cirrhosis Septicemia Septicemia In situ/benign neoplasms Congenital anomalies Septicemia Septicemia Nephritis, nephrotic syndrome, & nephrosis Septicemia Influenza & pneumonia Nephritis, nephrotic syndrome, & nephrosis Hypertension & hypertensive renal diseasea 26,451 21,319 78 72 504 410 2,924 2,074 8,966 8,117 11,683 12,861 Source: US Final Mortality Data, 2017, National Center for Health Statistics, Centers for Disease Control and Prevention, 2019. Table 8 presents the number of deaths in 2017 for the 5 leading cancer types by age and sex. Brain and other nervous system tumors and leukemia are the first and second leading causes of cancer death among men aged younger than 40 years and women aged younger than 20 years, whereas breast cancer leads among women aged 20 to 59 years. Lung cancer leads in cancer deaths among men aged 40 years and older and women aged 60 years and older, causing 145,849 total deaths in 2017, more than breast, prostate, colorectal, and brain cancers combined. There were 17% more lung cancer deaths in men (78,694) than in women (67,155) in 2017, but this pattern is projected to reverse by 2045 if current smoking trends continue.72 Table 8. Five Leading Causes of Cancer Death by Age and Sex, United States, 2017 ALL AGES <20 20 TO 39 40 TO 59 60 TO 79 ≥80 MALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 315,147 996 3,971 47,008 174,590 88,575 Lung & bronchus Brain & ONS Brain & ONS Lung & bronchus Lung & bronchus Lung & bronchus 78,694 270 546 10,498 49,230 18,750 Prostate Leukemia Leukemia Colorectum Colorectum Prostate 30,488 266 469 5,939 14,156 15,298 Colorectum Bones & joints Colorectum Livera Prostate Colorectum 27,797 99 463 3,752 13,923 7,234 Pancreas Soft tissue (including heart) Soft tissue (including heart) Pancreas Pancreas Urinary bladder 22,919 89 239 3,676 13,923 5,697 Livera Non‐Hodgkin lymphoma Non‐Hodgkin lymphoma Brain & ONS Livera Pancreas 18,246 44 237 2,438 11,473 5,182 FEMALE ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES 283,961 801 4,563 46,700 142,987 88,908 Lung & bronchus Brain & ONS Breast Breast Lung & bronchus Lung & bronchus 67,155 249 1,063 10,283 39,115 18,800 Breast Leukemia Uterine cervix Lung & bronchus Breast Breast 42,000 194 513 9,088 19,256 11,398 Colorectum Soft tissue (including heart) Colorectum Colorectum Pancreas Colorectum 24,750 75 396 4,329 11,315 9,516 Pancreas Bones & joints Brain & ONS Ovary Colorectum Pancreas 21,093 72 358 2,748 10,506 7,062 Ovary Kidney & renal pelvis Leukemia Pancreas Ovary Leukemia 14,193 26 317 2,643 7,741 4,183 Cervical cancer continues to be the second leading cause of cancer death in women aged 20 to 39 years, causing 10 premature deaths per week in this age group. This finding, coupled with increasing trends for distant stage diagnoses and cervical adenocarcinoma,73 which is often undetected by cytology, underscores the need for increased HPV vaccination uptake and Papanicolaou/HPV DNA cotesting, which is the preferred screening method for women aged 30 to 65 years.74 Approximately one‐half of adolescent girls have not been fully vaccinated,75 and only 43% of women in their 30s received recent Papanicolaou/HPV DNA screening tests in 2015.76

Cancer Disparities by Race/Ethnicity Cancer occurrence and outcomes vary considerably between racial and ethnic groups, largely because of inequalities in wealth that lead to differences in risk factor exposures and barriers to high‐quality cancer prevention, early detection, and treatment.77, 78 Overall cancer incidence rates are highest among non‐Hispanic whites (NHWs) because of their high rate of lung and female breast cancer (Table 9). However, sex‐specific incidence is highest in non‐Hispanic black (NHB) men, among whom rates during 2012 through 2016 were 85% higher than those in Asian/Pacific Islander men, who have the lowest rates, and 8% higher than those in NHW men, who rank second. Among women, NHWs have the highest incidence, 8% higher than NHBs (who rank second); however, NHB women have the highest cancer mortality rates–13% higher than those for NHW women. The mortality disparity among men is likewise larger, with the death rate in NHB men double that in Asian/Pacific Islander men and 20% higher than that in NHW men. However, the black‐white disparity in overall cancer mortality among men and women combined has declined from a peak of 33% in 1993 (279.0 vs 210.5 per 100,000 population) to 13% in 2017 (178.5 vs 157.5 per 100,000 population). This progress is largely due to more rapid declines in deaths from smoking‐related cancers among blacks because of the steep drop in smoking prevalence unique to black teens from the late 1970s to early 1990s.79 Table 9. Incidence and Mortality Rates for Selected Cancers by Race and Ethnicity, United States, 2012 to 2017 ALL RACES COMBINED NON‐HISPANIC WHITE NON‐HISPANIC BLACK ASIAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKA NATIVEa HISPANIC Incidence, 2012‐2016 All sites 448.4 464.6 460.4 288.4 380.7 346.4 Male 489.4 501.2 540.0 292.3 399.2 372.9 Female 421.1 440.7 407.2 289.5 370.9 333.4 Breast (female) 125.2 130.8 126.7 93.3 94.7 93.9 Colon & rectum 38.7 38.6 45.7 30.0 43.3 34.1 Male 44.4 44.0 53.8 35.3 48.5 40.8 Female 33.9 33.9 39.9 25.7 39.1 28.7 Kidney & renal pelvis 16.6 16.8 18.7 7.7 23.1 16.4 Male 22.5 22.8 25.9 11.0 29.7 21.6 Female 11.5 11.5 13.2 5.1 17.5 12.2 Liver & intrahepatic bile duct 8.3 6.9 10.9 12.7 15.1 13.4 Male 12.7 10.5 17.9 19.4 21.6 20.0 Female 4.4 3.7 5.4 7.3 9.4 7.8 Lung & bronchus 59.3 63.5 62.4 34.4 53.6 30.2 Male 69.3 72.4 82.7 43.5 60.1 37.9 Female 51.7 56.7 48.6 27.6 48.8 24.6 Prostate 104.1 97.1 173.0 52.9 68.0 86.8 Stomach 6.6 5.4 10.1 10.3 8.8 9.6 Male 9.0 7.6 13.9 13.3 11.6 12.1 Female 4.6 3.5 7.5 7.9 6.7 7.7 Uterine cervix 7.6 7.1 9.1 6.0 8.7 9.6 Mortality, 2013‐2017 All sites 158.2 162.9 186.4 98.1 144.0 111.8 Male 189.3 193.8 233.2 116.4 172.6 135.6 Female 135.5 139.9 157.5 85.0 122.9 95.1 Breast (female) 20.3 20.3 28.4 11.4 14.6 14.0 Colon & rectum 13.9 13.8 19.0 9.5 15.8 11.1 Male 16.6 16.3 23.8 11.4 19.4 14.1 Female 11.7 11.7 15.6 8.1 13.0 8.7 Kidney & renal pelvis 3.7 3.8 3.7 1.7 5.5 3.4 Male 5.4 5.6 5.6 2.6 8.2 5.0 Female 2.3 2.4 2.3 1.1 3.4 2.2 Liver & intrahepatic bile duct 6.6 5.8 8.6 9.0 10.6 9.3 Male 9.6 8.4 13.5 13.4 14.8 13.2 Female 4.0 3.5 4.9 5.6 7.1 6.0 Lung & bronchus 40.2 43.4 43.5 22.0 33.3 17.5 Male 49.3 51.8 60.4 29.0 40.0 24.1 Female 33.2 36.8 31.9 16.8 28.3 12.6 Prostate 19.1 18.0 38.7 8.6 18.7 15.7 Stomach 3.1 2.3 5.4 5.1 4.8 5.0 Male 4.1 3.2 8.0 6.6 6.3 6.4 Female 2.2 1.6 3.7 4.0 3.6 4.0 Uterine cervix 2.3 2.1 3.6 1.7 2.5 2.6

Geographic Variation in Cancer Occurrence Tables 10 and 11 show cancer incidence and mortality rates for selected cancers by state. State variation in cancer incidence reflects differences in medical detection practices and the prevalence of risk factors, such as smoking, obesity, and other health behaviors. The largest geographic variation in cancer occurrence is for cancers that are potentially the most preventable,45 such as lung cancer, cervical cancer, and melanoma of the skin.44 For example, lung cancer incidence and mortality rates in Kentucky, where smoking prevalence was historically highest, are 3 to 4 times higher than those in Utah, where it was lowest. Even in 2018, 1 in 4 residents of Kentucky, Arkansas, and West Virginia were current smokers compared with 1 in 10 in Utah and California.80 Table 10. Incidence Rates for Selected Cancers by State, United States, 2012 to 2016 STATE ALL SITES BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PROSTATE UTERINE CERVIX MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE Alabama 520.6 402.7 122.1 50.9 38.3 87.3 50.5 19.5 13.6 119.5 9.3 Alaska 426.1 406.0 121.9 43.4 40.4 64.1 48.8 21.0 13.3 81.1 7.2 Arizona 407.7 373.4 114.5 38.0 28.7 53.1 44.0 18.2 13.1 77.2 6.6 Arkansas 532.9 419.3 117.5 50.8 37.8 97.8 62.6 21.8 15.0 111.4 9.8 California 435.0 386.4 121.0 40.4 31.3 47.4 38.1 22.4 15.2 93.9 7.3 Colorado 425.1 387.7 125.3 37.1 30.2 45.6 40.4 20.8 14.1 94.9 6.1 Connecticut 506.6 452.1 140.1 41.7 32.3 65.6 55.8 26.1 17.3 108.4 6.5 Delaware 552.3 460.6 136.1 43.1 32.9 78.9 62.6 24.9 17.6 128.7 8.1 Dist. of Columbiaa, b 505.2 437.0 140.9 49.0 38.3 62.7 49.6 23.1 12.7 137.8 8.9 Florida 495.8 418.9 117.5 42.0 32.0 68.3 51.3 26.9 19.2 94.7 8.8 Georgia 533.1 420.2 125.8 49.2 35.9 81.2 51.3 22.4 14.9 122.3 7.8 Hawaii 434.5 405.3 137.5 48.1 35.5 57.2 36.4 20.2 13.5 84.9 7.3 Idaho 469.7 419.5 124.2 39.3 32.2 55.6 46.3 22.7 16.2 105.7 6.3 Illinois 506.8 441.4 131.9 50.4 37.2 75.3 57.0 23.5 16.3 109.5 7.7 Indiana 500.5 429.5 121.9 48.5 37.9 88.2 61.3 22.8 15.7 91.8 8.0 Iowa 521.0 444.9 124.2 50.2 39.3 75.0 54.0 26.0 17.6 104.7 7.3 Kansasa 499.1 429.8 126.4 45.5 34.9 61.0 57.0 23.9 17.0 108.2 7.6 Kentucky 578.4 482.4 126.3 57.6 42.4 111.3 77.8 25.1 16.7 104.9 9.2 Louisiana 559.6 422.8 124.2 54.3 39.2 84.8 54.2 23.6 16.1 131.8 8.8 Maine 504.4 458.7 125.7 41.8 33.6 83.3 66.3 24.1 17.2 87.5 5.5 Maryland 490.9 424.4 131.5 40.7 33.0 63.7 51.1 20.8 14.8 122.1 6.4 Massachusetts 470.8 439.5 137.7 39.8 31.6 66.1 59.0 21.8 15.2 99.3 5.2 Michigan 488.9 423.4 123.8 42.4 33.3 73.2 57.2 23.9 16.5 107.9 6.6 Minnesota 500.4 440.0 130.6 42.4 34.3 61.8 51.8 26.2 17.7 106.6 5.5 Mississippi 546.6 411.7 117.8 57.1 40.9 99.5 57.4 20.2 14.4 126.6 9.3 Missouri 492.1 431.0 129.2 47.9 35.5 85.3 63.5 22.7 15.6 92.8 8.4 Montana 486.7 429.0 124.0 43.7 32.9 55.6 54.8 22.0 16.3 113.0 7.1 Nebraska 495.0 422.5 124.6 49.2 37.5 67.5 50.4 23.8 16.2 111.2 7.3 Nevadaa 408.8 382.0 111.1 42.1 32.1 57.6 53.4 17.5 12.9 84.8 8.5 New Hampshire 511.0 466.9 144.6 42.3 33.2 68.3 62.2 25.5 17.6 108.5 4.7 New Jersey 529.1 455.3 134.2 47.2 36.3 62.2 52.0 26.1 18.0 129.6 7.5 New Mexico 390.1 365.7 111.6 37.7 29.0 45.5 34.9 17.4 13.9 80.1 8.0 New York 531.6 452.4 130.7 45.0 34.0 67.0 53.2 26.2 17.9 125.0 7.7 North Carolina 521.3 428.3 132.3 42.8 32.5 84.9 56.7 21.4 14.5 115.9 7.2 North Dakota 495.4 424.9 127.3 52.3 37.6 65.7 51.1 20.6 16.7 115.7 5.2 Ohio 500.7 437.5 127.4 47.6 36.5 81.1 59.1 23.3 15.7 103.0 7.6 Oklahoma 497.8 422.2 121.1 48.8 36.9 83.4 58.0 21.5 15.4 95.2 9.1 Oregon 452.2 416.3 125.2 38.6 30.8 59.7 50.9 22.1 15.7 90.5 6.8 Pennsylvania 527.3 462.4 131.9 48.4 36.4 74.8 56.2 25.4 18.0 105.1 7.4 Rhode Island 500.8 468.5 138.1 38.9 31.5 78.0 65.7 26.1 17.8 97.8 7.3 South Carolina 515.4 415.9 129.2 44.6 33.6 81.8 52.9 20.4 14.1 115.4 7.7 South Dakota 493.2 431.1 131.3 47.1 37.3 67.9 52.9 23.4 15.7 111.7 6.9 Tennessee 519.9 422.1 122.6 46.3 35.6 93.1 61.5 21.7 14.2 110.4 8.5 Texas 450.9 378.2 111.9 44.9 31.6 63.4 43.1 21.0 14.5 92.4 9.2 Utah 440.2 375.5 114.8 33.4 26.5 31.5 23.1 22.4 15.0 113.1 5.0 Vermont 472.1 442.3 131.9 37.3 33.2 68.8 57.2 25.4 17.3 84.3 4.1 Virginia 447.6 401.0 128.3 40.0 32.1 69.0 50.6 20.6 14.1 98.3 6.3 Washington 479.7 433.6 135.1 39.6 32.2 61.3 51.7 24.4 16.2 100.6 6.6 West Virginia 511.9 452.8 117.5 51.9 41.3 95.2 67.0 22.0 16.6 91.3 8.9 Wisconsin 506.6 440.5 130.6 42.3 32.7 67.7 53.9 25.3 17.4 108.1 6.6 Wyoming 423.8 378.0 112.7 37.7 28.6 46.2 42.8 20.3 13.2 100.4 5.8 Puerto Ricoc 409.6 329.8 93.7 51.7 34.7 23.9 12.0 17.1 13.0 143.9 12.6 United States 489.4 421.1 125.2 44.4 33.9 69.3 51.7 23.2 16.0 104.1 7.6 Table 11. Mortality Rates for Selected Cancers by State, United States, 2013 to 2017 STATE ALL SITES BREAST COLORECTUM LUNG & BRONCHUS NON‐HODGKIN LYMPHOMA PANCREAS PROSTATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE Alabama 221.3 143.3 21.5 19.6 13.0 68.5 36.8 6.9 4.1 13.3 9.9 21.2 Alaska 181.5 140.2 19.4 17.0 14.3 45.7 34.2 6.3 4.2 11.2 10.1 18.0 Arizona 165.5 121.9 19.2 15.2 10.6 38.3 28.5 6.2 3.9 11.6 8.8 17.5 Arkansas 224.0 150.4 21.1 19.7 13.6 71.9 42.5 7.0 4.2 12.7 9.5 18.6 California 167.6 124.3 19.5 14.8 10.9 34.9 25.3 6.7 4.1 11.8 9.1 19.7 Colorado 160.8 118.7 18.9 13.9 10.5 31.0 25.7 6.4 3.4 10.7 7.9 21.5 Connecticut 170.0 125.3 17.8 13.0 9.4 39.6 31.0 7.0 4.1 12.2 9.4 17.9 Delaware 198.7 142.3 21.3 16.9 10.7 55.0 37.2 8.5 4.4 14.1 10.3 16.6 Dist. of Columbia 185.8 150.7 26.6 18.3 13.2 40.2 28.9 5.9 3.4 14.8 11.4 28.0 Florida 178.8 127.1 19.1 15.6 10.9 47.4 32.2 6.6 4.0 12.1 8.9 16.7 Georgia 201.3 135.6 22.0 18.9 12.1 56.7 32.1 6.8 4.0 12.3 9.3 22.0 Hawaii 159.9 110.8 16.1 14.8 10.3 39.0 23.5 5.7 3.3 12.4 9.8 14.1 Idaho 181.6 133.8 21.6 15.2 11.1 39.0 29.0 7.7 5.2 13.2 10.0 22.9 Illinois 196.9 143.2 21.3 18.1 12.7 52.3 36.0 7.2 4.3 13.1 9.5 20.1 Indiana 213.8 148.1 20.9 18.1 13.0 64.0 40.8 8.4 4.7 13.6 9.9 19.4 Iowa 198.5 138.2 18.7 17.1 12.5 54.0 34.9 8.3 4.7 13.0 9.6 19.5 Kansas 193.7 138.7 19.4 18.0 12.2 51.9 35.9 7.0 4.7 12.6 10.0 18.6 Kentucky 239.6 162.4 21.2 20.1 13.9 80.8 50.6 8.6 4.5 13.0 9.8 19.6 Louisiana 221.5 149.6 23.1 20.5 14.1 64.5 38.1 7.9 4.3 14.8 11.0 20.8 Maine 206.7 147.1 18.6 14.7 11.3 59.3 40.8 7.7 4.8 12.0 10.4 20.5 Maryland 186.7 137.5 21.7 16.4 11.7 46.2 33.3 6.9 4.0 13.6 9.7 20.0 Massachusetts 183.3 132.5 17.8 13.9 10.5 44.8 34.3 6.7 4.2 13.0 9.9 18.4 Michigan 198.4 145.7 20.7 16.5 12.1 54.3 38.8 7.8 4.8 13.9 10.7 18.7 Minnesota 179.0 131.7 17.9 14.2 10.8 42.6 32.6 7.8 4.6 12.8 9.7 19.9 Mississippi 240.7 154.3 23.5 22.6 15.0 75.6 39.1 7.0 3.9 15.4 11.0 24.7 Missouri 207.5 147.4 21.5 17.7 12.2 62.6 41.8 7.3 4.2 13.2 9.6 17.5 Montana 177.9 135.8 19.5 16.1 10.8 39.5 35.9 7.2 4.1 11.5 9.6 22.7 Nebraska 186.6 135.5 20.1 17.2 12.6 48.3 33.2 7.4 4.5 13.2 9.3 18.3 Nevada 182.6 141.9 21.8 19.3 14.0 45.8 38.2 6.8 3.5 11.7 9.4 19.7 New Hampshire 187.4 138.9 18.9 13.9 11.6 48.3 38.2 7.0 4.5 12.1 8.8 18.9 New Jersey 175.5 134.0 21.2 16.7 11.9 40.8 31.0 7.1 4.1 12.7 10.1 17.7 New Mexico 167.4 122.6 19.3 16.4 11.3 33.5 24.7 5.8 3.8 11.2 8.6 19.6 New York 174.0 129.5 19.2 15.4 11.1 42.4 30.0 7.0 4.1 12.7 9.7 18.0 North Carolina 202.0 137.5 20.9 16.2 11.2 60.0 35.6 6.9 4.0 12.9 9.4 19.9 North Dakota 176.3 127.0 18.0 16.3 11.0 45.6 29.7 6.6 4.7 12.2 8.3 17.8 Ohio 209.7 150.1 22.3 18.4 13.1 60.4 39.4 7.9 4.7 13.3 10.4 19.1 Oklahoma 219.4 152.4 22.4 20.9 13.9 65.0 41.9 7.9 4.7 12.6 9.6 20.4 Oregon 185.9 140.4 20.1 15.2 11.4 43.5 34.8 7.5 4.6 13.3 10.1 20.7 Pennsylvania 199.8 142.7 21.2 17.8 12.6 52.5 34.8 7.7 4.6 14.1 10.2 18.7 Rhode Island 197.1 140.4 18.0 14.8 10.8 53.2 39.9 6.6 4.4 13.9 9.9 18.7 South Carolina 209.2 139.2 21.5 17.5 11.8 58.9 34.0 6.6 4.3 13.2 9.9 21.8 South Dakota 192.7 134.4 19.1 19.8 13.0 49.9 33.9 7.0 4.3 12.2 10.0 19.0 Tennessee 224.1 149.4 21.8 18.5 13.0 70.0 41.1 8.0 4.7 12.9 9.8 19.8 Texas 183.4 127.4 19.8 17.6 11.2 45.2 28.4 6.8 4.1 11.6 9.0 17.8 Utah 146.0 108.9 20.1 12.9 9.7 22.3 15.4 6.8 4.1 10.8 8.3 20.0 Vermont 196.6 141.0 17.7 16.3 13.5 49.6 37.4 7.9 4.5 12.3 9.5 19.1 Virginia 190.5 135.1 21.5 16.6 11.3 50.5 32.6 6.8 4.1 13.1 9.4 19.8 Washington 180.9 134.6 19.9 14.5 10.5 43.0 32.8 7.6 4.4 12.3 9.3 20.2 West Virginia 223.0 160.0 21.8 20.4 15.7 69.5 43.7 7.7 4.8 11.6 9.4 17.4 Wisconsin 191.9 137.1 19.0 15.3 11.2 48.0 34.1 7.7 4.4 13.6 10.0 20.8 Wyoming 163.6 123.1 18.3 14.0 9.7 36.5 29.2 7.0 4.4 11.7 8.6 16.0 Puerto Ricoa 148.0 93.2 17.8 19.5 12.1 18.7 8.7 4.7 2.5 7.9 5.5 25.9 United States 189.3 135.5 20.3 16.6 11.7 49.3 33.2 7.1 4.2 12.7 9.6 19.1 Similarly, cervical cancer incidence and mortality currently vary by 2‐fold to 3‐fold between states, with incidence rates ranging from <5 per 100,000 population in Vermont and New Hampshire to 10 per 100,000 population in Arkansas (Table 10). Ironically, advances in cancer control often exacerbate disparities, and state gaps for cervical and other HPV‐associated cancers may widen in the wake of unequal uptake of the HPV vaccine, which has already shown efficacy in reducing the burden of cervical intraepithelial neoplasia of grade 2 or higher.81 In 2018, up‐to‐date HPV vaccination among adolescents (those aged 13‐17 years) ranged from 38% in Kansas and Mississippi to >70% in North Dakota and Rhode Island among girls and from 27% in Mississippi to >70% in Massachusetts and Rhode Island among boys.75 State/territory differences in other initiatives to improve health, including Medicaid expansion, may also contribute to future geographic disparities.82, 83