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Originally published as JCO Early Release 10.1200/JCO.2008.20.8983 on April 29 2009 © 2009 American Society of Clinical Oncology.
Future of Cancer Incidence in the United States: Burdens Upon an Aging, Changing NationFrom the Radiation Oncology Flight, Wilford Hall Medical Center, Lackland Air Force Base; Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and the Department of Medical Oncology, City of Hope Cancer Center, Duarte, CA. Corresponding author: Benjamin Smith, MD, 2200 Bergquist Dr, Ste #1, Lackland AFB, TX 78236; e-mail: bensmith{at}alumni.rice.edu.
Purpose By 2030, the United States' population will increase to approximately 365 million, including 72 million older adults (age  65 years) and 157 million minority individuals. Although cancer incidence varies by age and race, the impact of demographic changes on cancer incidence has not been fully characterized. We sought to estimate the number of cancer patients diagnosed in the United States through 2030 by age and race. Methods Current demographic-specific cancer incidence rates were calculated using the Surveillance Epidemiology and End Results database. Population projections from the Census Bureau were used to project future cancer incidence through 2030. Results From 2010 to 2030, the total projected cancer incidence will increase by approximately 45%, from 1.6 million in 2010 to 2.3 million in 2030. This increase is driven by cancer diagnosed in older adults and minorities. A 67% increase in cancer incidence is anticipated for older adults, compared with an 11% increase for younger adults. A 99% increase is anticipated for minorities, compared with a 31% increase for whites. From 2010 to 2030, the percentage of all cancers diagnosed in older adults will increase from 61% to 70%, and the percentage of all cancers diagnosed in minorities will increase from 21% to 28%. Conclusion Demographic changes in the United States will result in a marked increase in the number of cancer diagnoses over the next 20 years. Continued efforts are needed to improve cancer care for older adults and minorities.
One of the most defining sociodemographic changes ongoing in the United States is the dramatic increase in the number of older adults and minorities. Specifically, the number of adults age 65 years or older increased from 25 million in 1980 to 35 million in 2000, and is further expected to increase to 72 million by 2030 as the baby boomer generation ages (Figs 1A, 1B).1–3 Similarly, the number of minorities increased from 46 million in 1980 to 83 million in 2000, and is further expected to increase to 157 million in 2030 (Figs 1C, 1D).1–3 As cancer occurs more commonly in older adults, the aging of the United States' population is expected to markedly increase the number of cancer diagnoses.4 The increase in minorities is also likely to impact cancer care, particularly as prior evidence suggests that certain minorities have higher cancer incidence rates and lower cancer survival rates as compared with white people.5 In addition, minorities and older adults represent important populations that may be particularly vulnerable to suboptimal cancer care, because both groups have been under-represented in cancer clinical trials6 and are also subject to disparities in cancer treatment.7,8
These demographic shifts in our society are thus expected to exert a substantial stressor on the health care system, and they highlight the need to address shortcomings in cancer clinical trials and disparities in cancer care. Quantifying the projected number of cancer cases in older and minority patients is fundamental for defining the expected societal burden of cancer, and, accordingly, guiding research and health policy priorities. However, to the best of our knowledge, specific long-term incidence projections for cancer in the United States have not been fully quantified. To address this need, we used data from the Surveillance Epidemiology and End Results (SEER) project and the United States Census bureau to project the anticipated number of cancer cases by age, sex, race, and origin through 2030.
In August 2008, the United States' Census Bureau released updated projections for population growth through 2050,2 which were derived from current data regarding birth rates, death rates, and immigration patterns. The projections reported the estimated number of individuals for each age from 0 through 100 years old stratified by sex, race, and origin. Race categories included white, black, Asian, Pacific Islander, American Indian/Alaska Native, and multiracial. Origin categories included either non-Hispanic or Hispanic. Thus, there are 12 potential combinations of race and origin. Current age-, sex-, race-, and origin-specific cancer incidence rates were calculated for the United States population using the SEER-17 database, which represents approximately 26% of the United States population and includes the following: Connecticut, New Jersey, Atlanta, Rural Georgia, Kentucky, Louisiana, Detroit, Iowa, New Mexico, Utah, Los Angeles, San Francisco-Oakland, San Jose-Monterey, Greater California, Seattle, Alaska Native Tumor Registry, and Hawaii.9 Incidence rates were calculated from 2003 through 2005, which are the three most recent years for which data is available. Cancer sites included all invasive cancers combined (excluding nonmelanoma cutaneous cancer), 23 individual cancer sites, and in situ breast cancer. For incidence calculations, age categories included: 0 years, 1 to 4 years, 5 to 9 years, 10 to 14 years, and so on through 80 to 84 years, with patients age 85 years and older in a single group. Race categories included white, black, Asian/Pacific Islander, and American Indian/Alaska Native. Origin categories included non-Hispanic and Hispanic. Calculated incidence rates were adjusted for delayed reporting according to the method of Clegg et al.10,11 Cancer incidence projections through 2030 were calculated by multiplying the age-, sex-, race-, and origin-specific population projections by the age-, sex-, race-, and origin-specific cancer incidence rates. To account for differences between the census projections and the SEER-based cancer incidence rates, the population projections for Asians and Pacific Islanders were collapsed into a single group. In addition, because SEER does not report cancer incidence rates for multiracial individuals, these individuals were assumed to have a cancer incidence rate equal to that of the total population not adjusted for race. For the purposes of this report, we used the US Census Bureau definition of minority, which was defined as non-white race or Hispanic origin of any race.2 The assumption underlying this method for cancer incidence projection is that the age-, sex-, race-, and origin-specific cancer incidence rates averaged over the years 2003 through 2005 will remain constant through 2030. Recent epidemiologic data suggests that this is a reasonable assumption, as the American Cancer Society reported that the age-adjusted incidence of cancer from all sites combined has remained relatively constant for men since 1995 and for women since 1999.12 In addition, as shown inFigure 2, age-adjusted cancer incidence rates by race and sex have remained stable since 1997 for all population groups except black men, where the incidence of cancer has decreased by 13% since 1997.
Analyses were conducted using SEER*Stat version 6.4.4 (www.seer.cancer.gov/seerstat) and SAS version 9.1 (SAS Institute, Cary, NC). This study was approved by the Wilford Hall Medical Center institutional review board.
All Cancer Sites From 1980 through 2000, the United States population grew by 23% (from 227 million to 279 million), whereas the total yearly cancer incidence increased by 66% (from 807,000 to 1.34 million). From 2010 to 2030, the US population is expected to grow by an additional 19% (from 305 million to 365 million), and the total expected cancer incidence is expected to increase by an additional 45% (from 1.6 million to 2.3 million;Fig 3). This increased incidence is driven disproportionately by instances diagnosed in those patients age 65 years and in minorities. Specifically, between 2010 and 2030, a 67% increase in cancer incidence is anticipated for patients age 65 years or older (1.0 million to 1.6 million instances), compared with only an 11% increase in cancer incidence anticipated for patients younger than the age of 65 years (0.63 million to 0.67 million instances;Figs 4A, 4B). From 2010 to 2030, the percent of all cancers diagnosed in older adults is expected to increase from 61% to 70%.
With respect to race and origin, a 99% increase in cancer incidence is anticipated for minorities (0.33 million to 0.66 million instances), compared with only a 31% increase anticipated for non-Hispanic whites (1.3 million to 1.7 million instances;Fig 5A). The increase in cancer incidence for minorities may be attributed to an increased incidence of 64% for blacks (non-Hispanic), 132% for Asian/Pacific Islanders (non-Hispanic), 76% for American Indian/Alaska Natives (non-Hispanic), 101% for multiracial (non-Hispanic), and 142% for Hispanics of any race (Fig 5B). From 2010 to 2030, the percentage of all cancers diagnosed in minorities is expected to increase from 21% to 28%.
Site-Specific Data Based on absolute case numbers for cancer incidence, the leading cancer sites in the year 2030 are still expected to be prostate (382,000), lung (189,000), and colorectum (, 000) in men; and breast (294,000 invasive and 67,000 in situ), lung (149,000), and colorectum (122,000) in women. Cancer sites with the highest percentage of increase between 2010 through 2030 are expected to be stomach (67%), liver (59%), myeloma (57%), prostate (55%), pancreas (55%), bladder (54%), lung (52%), and colorectum (52%). For patients age 65, a more than 50% increase in incidence by 2030 was projected for every single cancer site examined. In addition, for Asian/Pacific Islanders and Hispanics, a more than 100% increase in incidence by 2030 was projected for the majority of individual cancer sites examined (Table 1 and Appendix Table A1, online only). Projections by individual cancer site are presented in Appendix Figure A1 (online only).
The burden of cancer on our population is expected to rise sharply over the next 20 years. Overall cancer incidence is expected to increase by 45% between 2010 and 2030, with the greatest increase borne by older adults and minorities. By 2030, approximately 70% of all cancers will be diagnosed in older adults, and 28% of all cancers will be diagnosed in minorities. Alarmingly, certain cancer sites with particularly high mortality rates, such as liver, stomach, pancreas, and lung, will be among those with the greatest relative increase in incidence. Therefore, unless substantial improvements in cancer therapy and/or prevention strategies emerge, the number of cancer deaths may also grow dramatically over the next 20 years. Efforts to date to address the rising number of older adults and minorities diagnosed with cancer have met with only modest success. For example, in 1999 the Institute of Medicine released a report entitled The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved13 which included 22 specific recommendations for policy initiatives to improve cancer treatment for minorities and the medically underserved through promotion of National Institutes of Health research efforts, communication of research findings, and enhancement of clinical trial recruitment and retention. Despite these efforts, disparities in cancer treatment and outcomes have persisted. For example, a recent study suggested that cancer treatment disparities did not improve between 1992 and 2002, with minorities still more likely to receive substandard care for breast, lung, prostate, and colorectal cancers.8 Further, blacks have continued to experience a disproportionate burden of both cancer incidence and mortality,5 and clinical trials have failed to accrue sufficient numbers of minorities and older adults.6,14 Looking to the future, several novel programs are seeking to address shortcomings of the past. For example, the Institute of Medicine recently completed a seminal report entitled Retooling for an Aging America: Building the Health Care Workforce15 that provided 13 concrete policy suggestions to prepare the medical system for the coming surge in older adults. With respect to cancer specifically, the American Society of Clinical Oncology, in conjunction with the John A. Hartford Foundation, recently initiated support for 10 fellowship programs in geriatrics and oncology, which has already resulted in the successful training of 28 geriatric oncologists and the formation of the Cancer and Aging Research Group. To address disparities in cancer care experienced by minorities, Congress recently approved the Patient Outreach Navigator and Chronic Disease Prevention Act of 2005, which is being used by the National Cancer Institute's Center to Reduce Cancer Health Disparities to support development of patient navigator programs to narrow race-based disparities by promoting culturally sensitive cancer care.16 Such preparation for the future is critically important, as the striking increase in cancer incidence, and correspondingly an anticipated increase in cancer prevalence, could exceed the capacity of the current health care system. For example, studies from the American Society of Clinical Oncology (ASCO) and the Institute of Medicine project substantial shortages of medical oncologists and geriatricians over the next 20 years.17,18 Ironically, the aging of the American population may also contribute to a reduction in the number of physicians, as more physicians enter retirement themselves.4 In addition to a shortage of physicians, the anticipated increase in cancer incidence will require a major investment in the infrastructure needed to deliver cancer care. Finally, the increasing incidence of cancer, coupled with the rising cost to treat an individual cancer patient,19 could exert a synergistic effect on growth of cancer costs. To address the expected impact of increasing cancer incidence on the health care system, several additional interventions should be considered. For example, professional societies such as the American Association of Medical Colleges and ASCO are already actively exploring strategies to increase the total number of physicians trained and recruitment to oncology-oriented specialties.4,20 Given the marked increase in cancer diagnoses in older adults, coupled with current and projected shortfalls in the number of geriatricians, it may also be worthwhile to routinely integrate geriatrics training into oncology fellowship programs. In addition, in an effort to counter the expected rise in cancer cases, prevention strategies of proven efficacy need to be promoted, such as vaccination for hepatitis B and human papillomavirus21; chemoprevention with tamoxifen and raloxifene; social interventions such as tobacco and alcohol cessation; and removal of premalignant lesions such as colonic polyps.22 Finally, to counter the rising costs of cancer care, oncology-oriented residency and fellowship programs should emphasize training in the cost-effective use of medical resources, and phase III cancer clinical trials should begin to include cost-effectiveness analysis as an important end point. To address the anticipated surge in cancer incidence specifically in older adults, significant research investments are needed. Growing evidence from diverse cancers such as glioblastoma,23 prostate cancer,24 endometrial cancer,25 breast cancer,26 and acute myelogenous leukemia27 suggests that age at diagnosis is a critical factor modifying both cancer biology and response to therapy. Therefore, randomized clinical trials and nonrandomized clinical studies are urgently needed to identify clinically beneficial, cost-effective treatment strategies tailored to older adults. Since chronological age is a poor descriptor of functional age, future studies in geriatric populations should explore factors other than chronological age, such as comorbidity, functional and nutritional status, cognitive functioning, and social support.28 Such studies could ultimately lead to evidence-based clinical guidelines that will help cancer physicians as they adapt their therapies to the unique functional and physiologic limitations of their older patients. The anticipated marked increase in cancer among minorities is also particularly important for several reasons. In addition to race-based disparities in care patterns and outcomes as discussed earlier, the marked increase in cancer among Asian/Pacific Islanders and Hispanics creates the unique challenge of treating difficult malignancies, such as stomach and liver cancer, that are relatively more common in these racial/ethnic groups, in addition to the complexity of providing culturally competent communication to individuals from different backgrounds. Looking to the future, a high priority should be placed not only on addressing disparities in cancer care, but also on increasing recruitment of minorities to cancer clinical trials,14 in order to improve understanding of race-based differences in cancer biology,29 effectiveness of cancer therapy,30 and normal tissue response to cancer therapy.31 The projections in this study are based on the assumption that age-, sex-, race-, and origin-specific cancer incidence rates will remain relatively constant over time. Although this assumption appears reasonable based on historical data as presented inFigure 1, it is likely that continued efforts to promote cancer prevention and risk factor modification, such smoking cessation32 or decreased use of hormone replacement therapy,33 will exert a downward pressure on cancer incidence in the future, though precise quantification of these effects is elusive. Therefore, it is important to underscore that these projections are subject to change as both society and medicine evolve, and will need to be periodically reevaluated. Nevertheless, because physician training and clinical trials often require 10 or more years to complete, the 20-year projections presented in this article are needed, as they will serve to inform current health policy and research priorities. The number of cancer cases, particularly in older and minority individuals, is expected to vastly increase over the next two decades. Consequently, resources needed for cancer prevention, screening, detection, and treatment will need to increase concomitantly. Optimal cancer treatments for older and minority patients remain to be defined, and design of future clinical trials should consider these impending changes. Within a broader perspective, renewed governmental interest in health care reform should include a substantial focus on the elderly, minorities, and the medically underserved in order to address structural causes of unequal cancer care and to promote development of the national health care infrastructure needed to provide skilled and timely cancer care to even the most vulnerable segments of our population.
The author(s) indicated no potential conflicts of interest.
Conception and design: Benjamin D. Smith, Grace L. Smith, Arti Hurria, Gabriel N. Hortobagyi, Thomas A. Buchholz Administrative support: Benjamin D. Smith Provision of study materials or patients: Benjamin D. Smith Collection and assembly of data: Benjamin D. Smith Data analysis and interpretation: Benjamin D. Smith, Grace L. Smith, Thomas A. Buchholz Manuscript writing: Benjamin D. Smith, Grace L. Smith, Arti Hurria, Gabriel N. Hortobagyi, Thomas A. Buchholz Final approval of manuscript: Benjamin D. Smith, Grace L. Smith, Arti Hurria, Gabriel N. Hortobagyi, Thomas A. Buchholz
Presented in part at the 22nd San Antonio Breast Cancer Symposium in December 10-14, 2008. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
