Cancer Facts& Figures2013WA37,290MT5,450OR21,720ND3,510ID7,670WY2,700NV13,830CA171,330WI31,590SD4,570AZ34,010CO23,410NM10,090IL66,090KS14,370OK20,160MO33,950AK3,290AL27,080MA38,250RI6,280CT 21,180NJ 49,440WV11,450DE 5,370VA40,870MD 30,680DC 2,920NC53,200TN36,580AR16,330PA79,560OH66,610KY25,100MS15,830TX112,230IN35,550ME9,190NY108,760MI57,560IA17,480NE9,060UT10,810VT4,200MN28,410NH8,470SC27,620GA49,280LA24,930FL118,320US1,660,290HI6,650PRN/AEstimated numbers of new cancer cases for 2013, excluding basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder.Note: State estimates are offered as a rough guide and should be interpreted with caution. State estimates may not add to US total due to rounding.Special Section:Pancreatic Cancersee page 25ContentsBasic Cancer Facts Age-adjusted Cancer Death Rates, Males by Site, US, 1930-2009* Age-adjusted Cancer Death Rates, Females by Site, US, 1930-2009* Estimated Number of New Cancer Cases and Deaths by Sex, US, 2013* Estimated Numbers of New Cases for Selected Cancers by State, US, 2013* Estimated Number of Deaths for Selected Cancers by State, US, 2013* Incidence Rates for Selected Cancers by State, US, 2005-2009* Death Rates for Selected Cancers by State, US, 2005-2009* 12345678Selected Cancers Leading New Cancer Cases and Deaths – 2013 Estimates* Probability (%) of Developing Invasive Cancers during Selected Age Intervals by Sex, US, 2007-2009* Five-year Relative Survival Rates (%) by Stage at Diagnosis, 2002-2008* Trends in 5-year Relative Survival Rates (%) by Race, US, 1975-2008* 910141718Special Section: Pancreatic Cancer 25Tobacco Use Annual Number of Cancer Deaths Attributable to Smoking by Sex and Site, US, 2000-2004* 3537Cancer Disparities Cancer Incidence and Death Rates by Site, Race, and Ethnicity, US, 2005-2009* Geographic Patterns in Lung Cancer Death Rates by State, US, 2005-2009* 404344Nutrition and Physical Activity 45Environmental Cancer Risks 47The Global Fight against Cancer 49The American Cancer Society 50Sources of Statistics 58Screening Guidelines for the Early Detection of Cancer in Average-risk Asymptomatic People* 60*Indicates a figure or tableCorporate Center: American Cancer Society Inc.250 Williams Street, NW, Atlanta, GA 30303-1002(404) 320-3333©2013, American Cancer Society, Inc. All rights reserved,including the right to reproduce this publicationor portions thereof in any form.For written permission, address the Legal department ofthe American Cancer Society, 250 Williams Street, NW,Atlanta, GA 30303-1002.This publication attempts to summarize current scientific information about cancer.Except when specified, it does not represent the official policy of the American Cancer Society.Suggested citation: American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer Society; 2013.Basic Cancer FactsWhat Is Cancer?Cancer is a group of diseases characterized by uncontrolledgrowth and spread of abnormal cells. If the spread is not controlled, it can result in death. Cancer is caused by both externalfactors (tobacco, infectious organisms, chemicals, and radiation)and internal factors (inherited mutations, hormones, immuneconditions, and mutations that occur from metabolism). Thesecausal factors may act together or in sequence to initiate or promote the development of cancer. Ten or more years often passbetween exposure to external factors and detectable cancer.Cancer is treated with surgery, radiation, chemotherapy, hormonetherapy, biological therapy, and targeted therapy.Can Cancer Be Prevented?A substantial proportion of cancers could be prevented. All cancers caused by cigarette smoking and heavy use of alcohol couldbe prevented completely. The American Cancer Society estimatesthat in 2013 about 174,100 cancer deaths will be caused by tobaccouse. The World Cancer Research Fund estimates that about onequarter to one-third of the new cancer cases expected to occur inthe US in 2013 will be related to overweight or obesity, physicalinactivity, and poor nutrition, and thus could also be prevented.Certain cancers are related to infectious agents, such as humanpapillomavirus (HPV), hepatitis B virus (HBV), hepatitis C virus(HCV), human immunodeficiency virus (HIV), and Helicobacterpylori (H. pylori); many of these cancers could be prevented throughbehavioral changes, vaccines, or antibiotics. Many of the morethan 2 million skin cancers that are diagnosed annually could beprevented by protecting skin from excessive sun exposure andavoiding indoor tanning.In addition to preventing cancer through the avoidance of riskfactors, regular screening tests that allow the detection andremoval of precancerous growths can prevent cancers of thecervix, colon, and rectum.Early detection of cancer, which usually results in less extensivetreatment and better outcomes, can also be achieved throughscreening for some cancers. Screening is known to reducemortality for cancers of the breast, colon, rectum, and cervix. Aheightened awareness of changes in the breast or skin may alsoresult in detection of these tumors at earlier stages. For completecancer screening guidelines, please see page 60.Who Is at Risk of Developing Cancer?Anyone can develop cancer. Since the risk of being diagnosedwith cancer increases with age, most cases occur in adults whoare middle aged or older. About 77% of all cancers are diagnosedin persons 55 years of age and older. Cancer researchers use theword “risk” in different ways, most commonly expressing risk aslifetime risk or relative risk.Lifetime risk refers to the probability that an individual willdevelop or die from cancer over the course of a lifetime. In theUS, men have slightly less than a 1 in 2 lifetime risk of developingcancer; for women, the risk is a little more than 1 in 3. However,it is important to note that these estimates are based on theaverage experience of the general population and may over- orunderestimate individual risk because of differences in exposure (e.g. smoking), and/or genetic susceptibility.Relative risk is a measure of the strength of the relationshipbetween a risk factor and cancer. It compares the risk of developing cancer in persons with a certain exposure or trait to the riskin persons who do not have this characteristic. For example,male smokers are about 23 times more likely to develop lungcancer than nonsmokers, so their relative risk is 23. Most relativerisks are not this large. For example, women who have a firstdegree relative (mother, sister, or daughter) with a history ofbreast cancer are about two times more likely to develop breastcancer than women who do not have this family history.All cancers involve the malfunction of genes that control cellgrowth and division. About 5% of all cancers are strongly hereditary, in that an inherited genetic alteration confers a very highrisk of developing one or more specific types of cancer. However,most cancers do not result from inherited genes but from damageto genes occurring during one’s lifetime. Genetic damage mayresult from internal factors, such as hormones or the metabolismof nutrients within cells, or external factors, such as tobacco, orexcessive exposure to chemicals, sunlight, or ionizing radiation.How Many People Alive Today Have EverHad Cancer?The National Cancer Institute estimates that approximately 13.7million Americans with a history of cancer were alive on January 1,2012. Some of these individuals were cancer free, while others stillhad evidence of cancer and may have been undergoing treatment.How Many New Cases Are Expected to OccurThis Year?About 1,660,290 new cancer cases are expected to be diagnosedin 2013. This estimate does not include carcinoma in situ (non­invasive cancer) of any site except urinary bladder, and does notinclude basal cell and squamous cell skin cancers, which are notrequired to be reported to cancer registries.How Many People Are Expected to Die ofCancer This Year?In 2013, about 580,350 Americans are expected to die of cancer,almost 1,600 people per day. Cancer is the second most commoncause of death in the US, exceeded only by heart disease,accounting for nearly 1 of every 4 deaths.Cancer Facts & Figures 2013  1What Percentage of People Survive Cancer?The 5-year relative survival rate for all cancers diagnosedbetween 2002 and 2008 is 68%, up from 49% in 1975-1977 (seepage 18). The improvement in survival reflects both progress indiagnosing certain cancers at an earlier stage and improvementsin treatment. Survival statistics vary greatly by cancer type andstage at diagnosis. Relative survival compares survival amongcancer patients to that of people not diagnosed with cancer whoare of the same age, race, and sex. It represents the percentage ofcancer patients who are alive after some designated time period(usually 5 years) relative to persons without cancer. It does notdistinguish between patients who have been cured and thosewho have relapsed or are still in treatment. While 5-year relativesurvival is useful in monitoring progress in the early detectionand treatment of cancer, it does not represent the proportion ofpeople who are cured permanently, since cancer deaths canoccur beyond 5 years after diagnosis.Although relative survival for specific cancer types providessome indication about the average survival experience of cancerpatients in a given population, it may or may not predict individual prognosis and should be interpreted with caution. First,5-year relative survival rates for the most recent time period arebased on patients who were diagnosed from 2002 to 2008 andthus, do not reflect the most recent advances in detection andtreatment. Second, factors that influence survival, such as treatment protocols, other illnesses, and biological and behavioraldifferences of individual cancers or people, cannot be taken intoaccount in the estimation of relative survival rates. For moreinformation about survival rates, see Sources of Statistics onpage 58.How Is Cancer Staged?Staging describes the extent or spread of cancer at the time ofdiagnosis. Proper staging is essential in determining the choiceof therapy and in assessing prognosis. A cancer’s stage is basedon the size or extent of the primary (main) tumor and whether ithas spread to other areas of the body. A number of different staging systems are used to classify tumors. A system of summarystaging (in situ, local, regional, and distant) is used for descriptive and statistical analysis of tumor registry data. If cancer cellsare present only in the layer of cells where they developed andhave not spread, the stage is in situ. If cancer cells have penetrated beyond the original layer of tissue, the cancer is invasiveand categorized as local, regional, or distant stage based on theAge-adjusted Cancer Death Rates*, Males by Site, US, 1930-2009100Lung & bronchusRate per 100,000 male population8060StomachProstateColon & rectum4020LeukemiaPancreasLiver01930193519401945195019551960196519701975198019851990199520002005*Per 100,000, age adjusted to the 2000 US standard population.Note: Due to changes in ICD coding, numerator information has changed over time. Rates for cancer of the liver, lung and bronchus, and colon and rectum are affectedby these coding changes.Source: US Mortality Volumes 1930 to 1959, US Mortality Data 1960 to 2009, National Center for Health Statistics, Centers for Disease Control and Prevention.©2013, American Cancer Society, Inc., Surveillance Research2  Cancer Facts & Figures 2013extent of spread. (For a description of the summary stage categories, see the footnotes in the table on page 17, Five-year RelativeSurvival Rates (%) by Stage at Diagnosis, 2002-2008.) Clinicianstypically use the TNM cancer staging system, which assessestumors in three ways: extent of the primary tumor (T), absenceor presence of regional lymph node involvement (N), and absenceor presence of distant metastases (M). Once the T, N, and M categories are determined, a stage of 0, I, II, III, or IV is assigned,with stage 0 being in situ, stage I being early, and stage IV beingthe most advanced disease. Some cancers have alternative stagingsystems (e.g., leukemia). As the molecular properties of cancerhave become better understood, tumor biological markers andgenetic features have been incorporated into prognostic models,treatment plans, and/or stage for some cancer sites.What Are the Costs of Cancer?The National Institutes of Health (NIH) estimates that the overall costs of cancer in 2008 were $201.5 billion: $77.4 billion fordirect medical costs (total of all health expenditures) and $124.0billion for indirect mortality costs (cost of lost productivity dueto premature death). PLEASE NOTE: These numbers are notcomparable to those published in previous years because as of2011, the NIH is calculating the estimates using a different datasource: the Medical Expenditure Panel Survey (MEPS) of theAgency for Healthcare Research and Quality. The MEPS estimates are based on more current, nationally representative dataand are used extensively in scientific publications. As a result,direct and indirect costs will no longer be projected to the current year, and estimates of indirect morbidity costs have beendiscontinued. For more information, please visit nhlbi.nih.gov/about/factpdf.htm.Lack of health insurance and other barriers prevents manyAmericans from receiving optimal health care. According to theUS Census Bureau, approximately 50 million Americans wereuninsured in 2010; almost one-third of Hispanics (31%) and onein 10 children (17 years of age and younger) had no health insurance coverage. Uninsured patients and those from ethnicminorities are substantially more likely to be diagnosed withcancer at a later stage, when treatment can be more extensiveand more costly. For more information on the relationshipbetween health insurance and cancer, see Cancer Facts & Figures2008, Special Section, available online at cancer.org/statistics.Age-adjusted Cancer Death Rates*, Females by Site, US, 1930-2009100Rate per 100,000 female population8060Lung & bronchusUterus†40Breast20Colon & rectumStomachPancreasOvary01930193519401945195019551960196519701975198019851990199520002005*Per 100,000, age adjusted to the 2000 US standard population. †Uterus refers to uterine cervix and uterine corpus combined.Note: Due to changes in ICD coding, numerator information has changed over time. Rates for cancer of the lung and bronchus, colon and rectum, and ovary areaffected by these coding changes.Source: US Mortality Volumes 1930 to 1959, US Mortality Data 1960 to 2009, National Center for Health Statistics, Centers for Disease Control and Prevention.©2013, American Cancer Society, Inc., Surveillance ResearchCancer Facts & Figures 2013  3Estimated Number* of New Cancer Cases and Deaths by Sex, US, 2013Estimated New CasesEstimated DeathsBoth SexesMaleFemaleBoth SexesMaleFemale1,660,290854,790805,500580,350306,920273,43041,38013,59011,40013,9302,46029,6209,9006,73011,2001,79011,7603,6904,6702,7306707,8902,0701,8002,4001,6405,5001,3801,0801,7901,2602,390690720610380Digestive system Esophagus Stomach  Small intestine Colon†  Rectum  Anus, anal canal, & anorectum  Liver & intrahepatic bile duct  Gallbladder & other biliary Pancreas  Other digestive organs290,20017,99021,6008,810102,48040,3407,06030,64010,31045,2205,750160,75014,44013,2304,67050,09023,5902,63022,7204,74022,7401,900129,450144,57082,7003,55015,21012,2208,37010,9906,7404,1401,17061052,39050,83026,30016,7504,4308803307,92021,67014,8905,5703,2301,26022,48038,46019,4803,8502,13087061,8702,9904,25056024,5305506,7801,97018,9801,260Respiratory system Larynx  Lung & bronchus  Other respiratory organs246,21012,260228,1905,760131,7609,680118,0804,000114,4502,580110,1101,76073,29077072,220300All SitesOral cavity & pharynx Tongue Mouth Pharynx  Other oral cavityBones & joints163,8903,630159,48078090,6002,86087,2604803,0101,6801,3301,440810630Soft tissue (including heart)11,4106,2905,1204,3902,5001,890Skin (excluding basal & squamous) Melanoma-skin  Other nonepithelial skin82,77076,6906,08048,66045,0603,60034,11031,6302,48012,6509,4803,1708,5606,2802,2804,0903,200890Breast234,580 2,240 232,340Genital system Uterine cervix Uterine corpus Ovary Vulva  Vagina & other genital, female Prostate Testis  Penis & other genital, male339,810248,08091,73058,48030,40028,08012,34012,3404,0304,03049,56049,5608,1908,19022,24022,24014,03014,0304,7004,7009909902,8902,890840840238,590238,59029,72029,7207,9207,9203703701,5701,570310310Urinary system  Urinary bladder  Kidney & renal pelvis  Ureter & other urinary organs140,43072,57065,1502,710Eye & orbit96,80054,61040,4301,76043,63017,96024,72095040,03029,79015,21013,68090041039,62020,12010,8208,7805209,6704,3904,9003802,8001,4901,310320120200Brain & other nervous system23,13012,77010,36014,0807,9306,150Endocrine system Thyroid Other endocrine62,71016,21046,5002,7701,2701,50060,22014,91045,3101,8508101,0402,4901,3001,190920460460Lymphoma  Hodgkin lymphoma  Non-Hodgkin lymphoma79,03042,670 36,3609,2905,0704,22069,74037,60032,14020,20011,250 8,9501,18066052019,02010,5908,430Myeloma22,35012,44010,710 6,070 4,640Leukemia  Acute lymphocytic leukemia  Chronic lymphocytic leukemia  Acute myeloid leukemia  Chronic myeloid leukemia  Other leukemia‡48,61027,880 20,73023,72013,66010,0606,0703,3502,7201,43082061015,6809,7205,9604,5802,7501,83014,5907,8206,77010,3705,9304,4405,9203,4202,5006103402706,3503,570 2,7806,7303,8202,910Other & unspecified primary sites‡31,86015,4509,91016,41045,42025,02020,400*Rounded to the nearest 10; estimated new cases exclude basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder. About 64,640 carcinomain situ of the female breast and 61,300 melanoma in situ will be newly diagnosed in 2013.  † Estimated deaths for colon and rectal cancers are combined.  ‡ More deathsthan cases may reflect lack of specificity in recording underlying cause of death on death certificates and/or an undercount in the case estimate.Source: Estimated new cases are based on cancer incidence rates from 49 states and the District of Columbia during 1995-2009 as reported by the North AmericanAssociation of Central Cancer Registries (NAACCR), represesnting about 98% of the US population. Estimated deaths are based on US mortality data during 1995-2009,National Center for Health Statistics, Centers for Disease Control and Prevention.©2013, American Cancer Society, Inc., Surveillance Research4  Cancer Facts & Figures 2013Estimated Number* of New Cases for Selected Cancers by State, US, 2013MelanomaNonFemale Uterine Colon & UterineLung &of the HodgkinUrinaryStateAll SitesBreastCervixRectum Corpus Leukemia BronchusSkin Lymphoma Prostate BladderAlabamaAlaskaArizonaArkansasCalifornia27,080 3,720 200 2,390 610 640 4,5501,300 9903,940 9603,290 510 † 310 90 100 470 90 140 44014034,010 4,660 220 2,630 860 920 4,250 1,400 1,360 4,3401,40016,330 2,280 150 1,540 370 450 2,700 530 6802,370 610171,330 25,3601,480 14,690 5,160 5,210 18,720 8,530 7,28023,740 6,920ColoradoConnecticutDelawareDist. of ColumbiaFlorida23,410 3,300 160 1,880 690 840 2,550 1,3101,050 3,870 99021,180 3,050 110 1,670 740 570 2,780 1,080 890 2,9401,0905,370 770 † 430170 140 760 300 220 8602502,920450†24090703209010050090118,320 15,710 940 10,290 3,110 3,490 17,960 5,330 5,06017,3305,720GeorgiaHawaiiIdahoIllinoisIndiana49,280 7,310 420 3,9701,230 1,290 6,690 2,360 1,810 7,930 1,6106,650 960 50 730240 180 900 380 240 8002007,670 1,010 50 670 220 270 930 420 3601,330 38066,090 9,350 500 6,140 2,150 2,020 9,270 2,4802,840 9,2302,99035,550 4,540 260 3,2501,040 1,000 5,500 1,470 1,460 4,3101,560IowaKansasKentuckyLouisianaMaine17,480 2,31014,370 2,16025,100 3,30024,930 3,6309,190 1,1505904507206602802,350 980 7902,270 8101,930 800 6502,020 6004,560 1,540 1,100 3,1301,0603,740 770 9504,040 9301,380 440 3901,290 530Maryland30,680 4,760 220 2,410 950 780Massachusetts 38,250 5,820 210 2,9101,280 990Michigan57,560 8,140 330 4,730 1,920 1,750Minnesota28,410 4,260 120 2,220 890 950Mississippi15,830 2,080 130 1,580 340 3904,040 1,530 1,180 4,8801,2204,880 1,840 1,590 5,7002,0608,250 2,900 2,530 9,4902,8603,860 1,0201,210 4,0901,1902,630 550 5602,490 540MissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingUnited States90 1,64090 1,250190 2,300220 2,40050 73058044070055031033,950 4,680 250 3,1101,040 980 5,410 1,500 1,480 4,1701,4805,450 740 † 510160 180 700 250 260 8702809,060 1,230 50 910 290 310 1,220 460 4301,290 42013,830 1,760 120 1,350 330 400 1,970 440 5201,900 6608,4701,180506402902401,1504103501,18046049,44010,090108,76053,2003,5106,9601,36014,9507,43045046080850360†4,6408609,2104,2603701,7402703,8501,4301001,4303303,2701,4701205,9601,05013,4808,0404602,5204604,2002,6201502,1904004,7402,0801507,1901,61016,7208,1505502,4503805,5102,07017066,610 9,060 440 5,8902,230 1,770 10,230 2,9602,840 8,5303,02020,160 2,690 170 1,780 500 610 3,370 770 8402,500 79021,720 3,310 120 1,610 670 620 2,860 1,410 950 3,3801,03079,560 10,490 480 7,3902,720 2,240 10,980 3,8903,440 9,4503,9806,280900†53021018087027025082034027,6203,5802202,3407107604,3901,3201,0404,1601,0704,570600†43014015062020020073022036,580 5,070 280 3,180 900 990 6,200 1,900 1,450 4,9901,440112,230 14,980 1,110 9,750 2,870 3,740 15,000 3,930 4,83015,7304,03010,810 1,550 70 740 320 380 800 720 4901,960 4204,200 550 † 320130 110 590 220 170 56021040,8706,2803003,2701,240 9905,3802,3801,5906,8401,59037,290 5,610 230 2,730 1,140 1,160 4,700 2,350 1,650 5,6901,69011,4501,460801,1803503302,1005404701,47053031,590 4,490 190 2,6101,080 1,050 4,310 1,250 1,400 4,3701,5302,700 380 † 240 80 80 320 130 120 4301301,660,290232,34012,340142,82049,56048,610228,19076,69069,740238,59072,570*Rounded to the nearest 10. Excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder.  † Estimate is fewer than 50 cases.Note: These estimates are offered as a rough guide and should be interpreted with caution. State estimates may not sum to US total due to rounding and exclusion of stateestimates fewer than 50 cases.©2013, American Cancer Society, Inc., Surveillance ResearchCancer Facts & Figures 2013  5Estimated Number* of Deaths for Selected Cancers by State, US, 2013Brain/Non-Nervous FemaleColon &Lung &HodgkinStateAll Sites SystemBreastRectum LeukemiaLiverBronchus Lymphoma Ovary Pancreas ProstateAlabamaAlaskaArizonaArkansasCalifornia10,430 250 690 970 400 3303,290 320 270 630550980†7080††270††605011,210 310 790 990 480 4602,850 400 310 7406306,650 150 420 610 270 200 2,170 200 150 39032057,290 1,590 4,220 5,150 2,460 2,980 12,700 2,000 1,540 4,0103,390ColoradoConnecticutDelawareDist. of ColumbiaFlorida7,350 230 510 680 320 290 1,710 2506,890 170 460 470 290 230 1,740 2301,940 50 120 170 70 80 580 601,030†80100†50240†42,370 880 2,660 3,640 1,770 1,550 12,070 1,400GeorgiaHawaiiIdahoIllinoisIndiana16,010 360 1,200 1,450 600 530 4,670 460 4101,010 7902,400 † 1402308012058080502101102,660 90 180 220 120 80 670 100 60 20018024,000 530 1,610 2,230 1,010 750 6,560 780 550 1,6201,23013,250 320 850 1,120 550 370 4,110 440 300 820590IowaKansasKentuckyLouisianaMaine6,4201904005,430 150 3609,970 200 5909,040 210 6503,240 90 190230 500440170 53040050 120100†8080930 2,7702,200580280 2001,780230170390350490 250 1701,590 210 140 350240880 340 270 3,510 300 200 540390860 330 3802,670 260 190 580420250 130 90 950 110 60 200160Maryland10,480 230 800 930 410 380 2,810 310 250 730560Massachusetts12,840310 8101,020500 5003,530400340910650Michigan20,570 540 1,360 1,700 910 670 5,940 730 4901,460 890Minnesota9,610 250 610 770 440 3302,500 340 240 630520Mississippi6,300 140 420 630 250 210 2,010 170 110 380330MissouriMontanaNebraskaNevadaNew Hampshire12,730 310 890 1,100 540 4203,940 380 240 8205602,0005012018090 5055070501301403,440100 210 340 140 90 900 130 80 2302104,760 140 360 450 180 2101,480 140 100 3502902,68070170200100807508060200140New JerseyNew MexicoNew YorkNorth CarolinaNorth Dakota16,4103,54034,24018,6201,280OhioOklahomaOregonPennsylvaniaRhode Island25,130 590 1,720 2,170 9807,850 190 490 720 3007,820 230 490 660 32028,680 600 1,950 2,540 1,1902,14050130170100South CarolinaSouth DakotaTennesseeTexasUtah9,8002206608203603402,9902802106005001,5905011015060†44050†1109014,080 360 910 1,220 520 4604,600 440 280 80063037,180 940 2,650 3,390 1,490 1,950 9,670 1,210 850 2,3401,6502,790 110 260 240 150 90 450 120 80 220210VermontVirginiaWashingtonWest VirginiaWisconsinWyoming1,300†8010014,720 320 1,110 1,27012,390 350 800 9804,66010028044011,220 310 700 880950†6080United States580,35034090780390†14,0801,3302402,3901,2609039,6201,5603503,0201,51013050,8306301401,450710605701701,410620†50580520170520†23,7204,0607708,7905,6603105301101,090550†44090900420†750 7,350 8002702,440 260310 2,110 280930 7,640 1,020806006050380480 4,1305303,2601201,4803702,980†24021,670159,480†460440160400†19,0201,1802402,5001,150907502301,77091080560 1,6201,240170 440380220 520460730 1,9501,43050130100†90603701,020 740360 850730100230190300 770630†705014,03038,46029,720*Rounded to nearest 10.  † Estimate is fewer than 50 deaths.Note: These estimates are offered as a rough guide and should be interpreted with caution. State estimates may not sum to US total due to rounding and exclusion ofstate estimates fewer than 50 deaths.©2013, American Cancer Society, Inc., Surveillance Research6  Cancer Facts & Figures 2013Incidence Rates* for Selected Cancers by State, US, 2005-2009All SitesBreastStateColon & RectumLung & BronchusNon-HodgkinLymphomaProstateUrinaryBladderMaleFemale Female MaleFemale MaleFemale MaleFemaleMaleMaleFemaleAlabama AlaskaArizonaArkansas‡California582.4395.4523.7435.7439.6361.0551.6381.6510.5398.9119.4 59.7 41.3 104.8 54.6 19.5 13.4130.0 55.4 44.2 83.8 63.0 22.0 18.3106.7 41.9 31.8 62.5 48.2 17.6 13.3109.2 54.7 39.8 107.4 59.6 21.9 15.0123.3 50.7 38.1 62.4 45.2 23.0 15.6162.1139.9118.1153.4143.033.238.231.532.533.97.49.58.37.98.0ColoradoConnecticutDelawareDist. of Columbia‡Florida493.9396.4594.1462.5613.1448.2562.6399.0528.3403.1125.4137.3127.9128.3114.98.312.511.38.08.8GeorgiaHawaiiIdahoIllinoisIndiana569.8397.2504.3401.6528.7411.6573.5437.8539.3421.5119.7 53.4 38.8125.1 59.6 38.7119.1 45.8 36.5125.4 61.3 44.8116.9 57.5 43.3IowaKansasKentuckyLouisiana†Maine568.2436.5 123.5 59.6 45.9 87.6 56.3 26.5 18.5563.8422.2 124.6 57.6 40.4 85.0 55.0 23.6 17.2615.4459.7 121.2 65.7 46.9 128.2 80.1 25.1 17.3614.5410.9 118.9 64.6 43.7 101.9 58.2 24.2 16.8600.1467.3128.555.843.995.567.625.618.4142.2 43.0 8.7157.3 38.2 9.3139.0 40.3 9.9173.7 34.4 8.2153.648.113.5MarylandMassachusettsMichiganMinnesotaMississippi†532.8411.8581.1459.2578.0433.3566.5424.4612.1395.5158.4157.5166.5179.0174.2MissouriMontanaNebraskaNevadaNew Hampshire548.3423.4 121.9 58.3 42.0 100.0 64.7 22.3 15.9 132.9 36.3 8.4531.6417.9 123.0 52.7 38.5 73.0 58.5 23.0 15.3 164.1 37.6 9.7547.1426.6 124.7 62.8 46.2 78.2 51.7 24.2 17.7 150.9 35.8 8.9514.4405.1114.352.139.376.865.520.915.4 138.438.411.0584.8 452.4132.551.939.581.462.223.917.4155.148.113.3New JerseyNew MexicoNew York North Carolina North Dakota593.0480.8583.3579.2555.6OhioOklahomaOregonPennsylvaniaRhode Island546.5421.5567.8426.7521.7432.3583.8453.7590.8 466.7South CarolinaSouth DakotaTennesseeTexas† Utah559.9 397.7121.452.238.796.753.720.613.6494.3 389.8118.454.241.072.247.120.516.0565.6413.7 119.6 56.2 41.3 106.1 61.5 23.0 16.2533.7 394.6116.153.037.081.849.922.615.9469.7345.2108.039.331.333.822.823.015.5159.030.48.0149.134.28.0145.6 34.9 8.4142.730.16.9169.828.85.6VermontVirginia‡WashingtonWest VirginiaWisconsin‡Wyoming554.3455.5537.0396.9552.6438.4576.5 441.6513.8404.6513.8388.8129.4 45.8 40.4 82.0124.0 49.8 37.9 85.2131.8 48.6 37.2 73.3112.261.845.4112.7118.8 48.2 37.4 70.6113.2 49.5 38.7 59.764.654.557.773.651.247.924.021.426.624.022.520.917.714.317.516.816.515.5150.9157.7155.3138.4144.4162.643.633.839.539.336.442.6United States550.7122.355.923.316.2151.437.5†454.1370.5442.7418.1421.0419.3124.8132.8120.3128.5114.346.055.356.453.049.649.953.352.951.262.735.141.141.442.237.937.940.340.940.144.757.278.590.677.282.844.661.068.845.958.122.225.924.021.321.715.817.917.113.515.2152.3165.2182.8185.1137.731.847.944.224.635.695.6 54.768.7 40.464.6 48.188.9 60.699.5 64.021.620.922.123.823.114.213.017.316.317.0167.8128.4160.1157.9129.233.0 7.826.2 6.436.7 8.940.2 10.336.3 8.977.3 56.681.0 64.087.3 61.366.7 49.8116.4 56.3130.0111.4125.8125.0126.458.246.454.654.562.943.034.641.538.744.176.155.777.1100.171.5119.6123.9130.7125.8133.256.356.147.959.455.242.342.138.344.543.093.2 60.0101.9 64.774.2 59.287.5 58.288.264.754.040.382.756.839.355.158.246.221.125.124.826.921.814.216.317.818.114.433.5 9.345.0 12.342.5 10.940.0 9.631.4 7.225.519.125.923.022.017.614.517.815.617.8172.4141.6167.2158.3169.445.126.942.537.540.911.86.410.99.110.123.022.623.325.423.916.017.616.117.817.6144.1153.2145.1154.1152.639.0 9.735.5 8.737.6 10.044.5 11.052.413.812.68.19.511.49.310.49.3*Per 100,000, age adjusted to the 2000 US standard population.  † Data for 2005 are limited to cases diagnosed from January-June due to the effect of large migrationsof populations on this state as a result of Hurricane Katrina in September 2005.  ‡ This state’s data are not included in the US rates because cancer registry data submittedfor 2009 did not meet high-quality standards according to the North American Association of Central Cancer Registries (NAACCR).Source: NAACCR, 2012. Data are collected by cancer registries participating in the National Cancer Institute’s SEER program and the Centers for Disease Control andPrevention’s National Program of Cancer Registries.American Cancer Society, Surveillance Research, 2013Cancer Facts & Figures 2013  7Death Rates* for Selected Cancers by State, US, 2005-2009All SitesBreastColon & RectumLung & BronchusNon-HodgkinLymphomaPancreasProstateStateMale Female Female Male Female MaleFemale MaleFemale Male Female MaleAlabamaAlaskaArizonaArkansasCalifornia259.0157.4209.5159.6182.1130.0253.7161.2194.9141.724.023.520.523.622.315.114.111.615.212.989.4 41.162.9 45.550.2 33.292.5 46.349.2 33.18.37.97.58.88.15.35.84.85.25.013.3 9.512.3 10.010.9 7.913.6 9.411.8 9.428.722.119.725.323.2ColoradoConnecticutDelawareDist. of ColumbiaFlorida185.0134.4212.0149.6229.6162.8256.3 160.4206.0141.919.9 17.4 13.022.5 17.3 13.023.0 20.3 14.328.023.117.721.5 18.3 13.045.1 31.955.9 38.869.2 48.564.734.863.5 39.38.08.18.49.47.84.45.25.03.54.910.914.712.316.312.08.910.29.710.78.723.824.824.941.319.6GeorgiaHawaiiIdahoIllinoisIndiana230.8146.8184.6119.6195.9143.5229.4160.1244.9163.223.017.821.324.223.920.218.715.922.522.513.810.813.415.615.075.8 38.751.2 27.051.3 35.667.8 41.982.0 47.27.77.58.18.89.74.64.25.45.55.612.412.911.513.113.18.99.49.810.19.427.516.226.725.523.8IowaKansasKentuckyLouisianaMaine220.1151.0221.5149.9267.2173.6260.8165.8240.0161.621.822.923.426.321.420.6 15.221.2 14.024.3 16.625.1 15.720.5 14.467.539.470.6 41.099.7 55.584.4 44.173.1 46.49.29.69.29.09.25.55.25.95.25.512.012.512.513.812.28.89.49.411.09.823.921.424.627.124.4MarylandMassachusettsMichiganMinnesotaMississippi226.5157.3222.6154.0228.1160.9206.8146.0274.2158.824.921.924.021.324.922.019.620.218.024.914.613.814.712.616.265.6 41.862.6 42.570.3 43.955.2 37.297.3 42.37.98.39.29.68.34.95.16.15.24.812.913.113.911.813.810.410.310.19.59.926.723.422.624.331.0MissouriMontanaNebraskaNevadaNew Hampshire237.6160.4203.4150.5215.2145.7213.3158.4218.2 154.724.920.521.223.321.421.617.822.520.719.314.614.715.115.313.279.8 46.057.1 41.362.4 36.062.5 48.862.043.08.48.19.06.77.75.35.45.74.85.013.112.412.212.313.49.78.79.49.810.622.727.224.723.423.2New JerseyNew MexicoNew YorkNorth CarolinaNorth Dakota213.8190.1201.3236.9210.226.121.122.523.522.022.018.719.419.821.615.513.514.013.614.857.944.455.279.356.58.16.78.07.67.45.54.44.95.05.513.311.612.612.112.810.08.99.79.78.722.424.322.225.925.2OhioOklahomaOregonPennsylvaniaRhode Island243.4163.4243.0161.2214.4155.5232.4158.5228.8151.325.223.821.524.121.922.522.918.522.319.615.514.813.915.213.377.4 44.582.7 46.961.2 43.668.5 40.066.343.09.48.98.69.28.85.65.95.75.64.613.112.012.213.412.49.98.710.010.08.425.423.625.723.722.5South CarolinaSouth DakotaTennesseeTexasUtah241.3151.0206.0141.5257.9162.0212.5142.8154.1109.624.020.924.022.221.520.520.122.420.214.314.114.215.113.110.479.640.062.235.591.5 47.263.4 35.928.1 16.18.07.89.38.17.54.85.15.55.04.612.511.113.011.79.59.79.19.38.78.026.922.925.321.424.5VermontVirginiaWashingtonWest VirginiaWisconsinWyoming211.9152.8228.5153.9209.6153.9254.8173.2218.8152.0199.5148.320.7 18.8 14.224.8 19.9 14.221.9 17.7 12.723.624.216.821.6 18.7 13.121.4 18.9 14.261.6 44.370.6 40.758.1 42.887.551.959.9 38.752.8 38.58.1 5.08.3 5.08.8 5.59.16.49.4 5.78.1 5.912.5 9.613.0 9.912.4 9.811.27.712.9 9.813.2 9.722.026.024.921.725.620.9United States219.423.065.78.412.523.6157.7134.3145.2152.7144.1151.122.920.016.822.518.120.214.138.329.135.841.634.339.65.29.5*Per 100,000, age adjusted to the 2000 US standard population.Source: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention.American Cancer Society, Surveillance Research, 20138  Cancer Facts & Figures 2013Selected CancersBreastNew cases: An estimated 232,340 new cases of invasive breastcancer are expected to be diagnosed among women in the USduring 2013; about 2,240 new cases are expected in men. Excluding cancers of the skin, breast cancer is the most frequentlydiagnosed cancer in women. The dramatic decrease in thebreast cancer incidence rate of almost 7% from 2002 to 2003 hasbeen attributed to reductions in the use of menopausal hormonetherapy (MHT), previously known as hormone replacementtherapy, following the publication of results from the Women’sHealth Initiative in 2002; this study found that the use of combined estrogen plus progestin MHT was associated with anincreased risk of breast cancer, as well as coronary heart disease.From 2005 to 2009, the most recent five years for which data areavailable, breast cancer incidence rates were stable.In addition to invasive breast cancer, 64,640 new cases of in situbreast cancer are expected to occur among women in 2013. Ofthese, approximately 85% will be ductal carcinoma in situ(DCIS). In situ breast cancer incidence rates increased 2.8% peryear from 2005 to 2009.Deaths: An estimated 40,030 breast cancer deaths (39,620women, 410 men) are expected in 2013. Breast cancer rankssecond as a cause of cancer death in women (after lung cancer).Death rates for breast cancer have steadily decreased in womensince 1989, with larger decreases in younger women; from 2005to 2009, rates decreased 3.0% per year in women younger than 50and 2.0% per year in women 50 and older. The decrease in breastcancer death rates represents progress in earlier detection,improved treatment, and possibly decreased incidence as aresult of declining use of MHT.Signs and symptoms: Breast cancer typically produces nosymptoms when the tumor is small and most treatable. Therefore, it is important for women to follow recommended screeningguidelines to detect breast cancer at an early stage. Largertumors may become evident as a breast mass, which is oftenpainless. Less common symptoms include persistent changes tothe breast, such as thickening, swelling, distortion, tenderness,skin irritation, redness, scaliness, or nipple abnormalities, suchas ulceration, retraction, or spontaneous discharge. Breast painis more likely to be caused by benign conditions and is not acommon early symptom of breast cancer.Risk factors: Besides being female, increasing age is the mostimportant risk factor for breast cancer. Potentially modifiablerisk factors include weight gain after age 18, being overweight orobese (for postmenopausal breast cancer), use of menopausalhormone therapy (combined estrogen and progestin), physicalinactivity, and alcohol consumption. Medical findings thatpredict higher risk include high breast tissue density (a mammographic measure of the amount of glandular tissue relative tofatty tissue), high bone mineral density (women with low densityare at increased risk for osteoporosis), and biopsy-confirmedhyperplasia (overgrowth of cells), especially atypical hyperplasia(overgrowth of abnormal cells). High-dose radiation to the chestfor cancer treatment also increases risk. Reproductive factorsthat increase risk include a long menstrual history (menstrualperiods that start early and/or end later in life), recent use of oralcontraceptives, never having children, and having one’s firstchild after age 30.Risk is also increased by a family history of breast cancer, particularly having one or more first-degree relatives with breastcancer (though most women with breast cancer do not have afamily history of the disease). Inherited mutations (alterations)in breast cancer susceptibility genes account for approximately5%-10% of all female breast cancers and an estimated 4%-40% ofall male breast cancers, but are very rare in the general population (much less than 1%). Most of these mutations are located inBRCA1 and BRCA2 genes, although mutations in other knowngenes have also been identified. Individuals with a strong familyhistory of breast and certain other cancers, such as ovarian andcolon cancer, should consider counseling to determine if genetictesting is appropriate. Prevention measures may be possible forindividuals with breast cancer susceptibility mutations. InBRCA1 and BRCA2 mutation carriers, studies suggest that prophylactic removal of the ovaries and/or breasts decreases therisk of breast cancer considerably, though not all women whochoose this surgery would have developed breast cancer. Womenwho consider prophylactic surgery should undergo counselingbefore reaching a decision.There is limited, but accumulating evidence that long-term,heavy smoking increases the risk of breast cancer, particularlyamong women who began smoking at an early age. The International Agency for Research on Cancer has concluded that thereis limited evidence that shift work, particularly at night, is alsoassociated with an increased risk of breast cancer.Modifiable factors that are associated with a lower risk of breastcancer include breastfeeding, moderate or vigorous physicalactivity, and maintaining a healthy body weight. Two medications, tamoxifen and raloxifene, have been approved to reducebreast cancer risk in women at high risk. Raloxifene appears tohave a lower risk of certain side effects, such as uterine cancerand blood clots; however, it is only approved for use in postmenopausal women.Early detection: Breast cancer screening for women at averagerisk includes clinical breast exam and mammography. Mammography can often detect breast cancer at an early stage, whentreatment is more effective and a cure is more likely. Numerousstudies have shown that early detection with mammographyCancer Facts & Figures 2013  9Leading New Cancer Cases and Deaths – 2013 EstimatesEstimated DeathsEstimated New Cases*MaleProstate238,590 (28%)Lung & bronchus118,080 (14%)Colon & rectum73,680 (9%)Urinary bladder54,610 (6%)Melanoma of the skin45,060 (5%)Kidney & renal pelvis40,430 (5%)Non-Hodgkin lymphoma37,600 (4%)Oral cavity & pharynx29,620 (3%)Leukemia27,880 (3%)Pancreas22,740 (3%)All sites854,790 (100%)FemaleBreast232,340 (29%)Lung & bronchus110,110 (14%)Colon & rectum69,140 (9%)Uterine corpus49,560 (6%)Thyroid45,310 (6%)Non-Hodgkin lymphoma32,140 (4%)Melanoma of the skin31,630 (4%)Kidney & renal pelvis24,720 (3%)Pancreas22,480 (3%)Ovary22,240 (3%)All sites805,500 (100%)FemaleMaleLung & bronchusLung & bronchus72,220 (26%)87,260 (28%)BreastProstate39,620 (14%)29,720 (10%)Colon & rectumColon & rectum24,530 (9%)26,300 (9%)PancreasPancreas18,980 (7%)19,480 (6%)OvaryLiver & intrahepatic bile duct14,030 (5%)14,890 (5%)LeukemiaLeukemia10,060 (4%)13,660 (4%)Non-Hodgkin lymphomaEsophagus8,430 (3%)12,220 (4%)Uterine corpusUrinary bladder8,190 (3%)10,820 (4%)Liver & intrahepatic bile ductNon-Hodgkin lymphoma6,780 (2%)10,590 (3%)Brain & other nervous systemKidney & renal pelvis6,150 (2%)8,780 (3%)All sitesAll sites273,430 (100%)306,920 (100%)*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.©2013, American Cancer Society, Inc., Surveillance Researchsaves lives and increases treatment options. Steady declines inbreast cancer mortality among women since 1989 have beenattributed to a combination of early detection and improvements in treatment. Mammography is a very accurate screeningtool for women at both average and increased risk; however, likeany medical test, it is not perfect. Mammography will detectmost, but not all, breast cancers in women without symptoms,and the sensitivity of the test is lower for women with densebreasts. However, newer technologies have shown promisingdevelopments for women with dense breast tissue. Digitalmammography has improved sensitivity for women with densebreasts. In addition, the Food and Drug Administration recentlyapproved the use of several ultrasound technologies that couldbe used in addition to standard mammography for women withdense breast tissue. Although the majority of women with anabnormal mammogram do not have cancer, all suspiciouslesions that cannot be resolved with additional imaging shouldbe biopsied for a definitive diagnosis. Annual screening usingmagnetic resonance imaging (MRI) in addition to mammographyis recommended for women at high lifetime risk of breast cancerstarting at age 30. (For more information, see Breast Cancer Facts& Figures at cancer.org/statistics.) Concerted efforts should bemade to improve access to health care and to encourage allwomen 40 and older to receive regular mammograms. For moreinformation on the American Cancer Society’s recommendations for breast cancer screening, see page 60.10  Cancer Facts & Figures 2013Treatment: Taking into account tumor size, extent of spread,and other characteristics, as well as patient preference, treatmentusually involves breast-conserving surgery (surgical removal ofthe tumor and surrounding tissue) or mastectomy (surgicalremoval of the breast). Numerous studies have shown that forearly breast cancer (cancer that has not spread to the skin, chestwall, or distant organs), long-term survival for women treatedwith breast-conserving surgery plus radiation therapy is similarto that for those treated with mastectomy. For women undergoingmastectomy, significant advances in reconstruction techniquesprovide several options for breast reconstruction, including thetiming of the procedure.Removal and evaluation of some of the underarm lymph nodesduring surgery is usually recommended to determine whetherthe tumor has spread beyond the breast. In women with earlystage disease, sentinel lymph node biopsy, a procedure in whichonly the first lymph nodes to which cancer is likely to spread areremoved, has a lower chance of long-term side effects and is aseffective as a full axillary node dissection, in which many nodesare removed.Treatment may also involve radiation therapy, chemotherapy(before or after surgery), hormone therapy (e.g., selective estrogen response modifiers, aromatase inhibitors, ovarian ablation),or/or targeted therapy. Postmenopausal women with early stagebreast cancer that tests positive for hormone receptors benefitfrom treatment with an aromatase inhibitor (e.g., letrozole,anastrozole, or exemestane) in addition to, or instead of, tamoxifen. For women whose cancer tests positive for HER2/neu,approved targeted therapies include trastuzumab (Herceptin)and, for advanced disease, lapatinib (Tykerb) and pertuzumab(Perjetal). The US Food and Drug Administration (FDA) revokedapproval of bevacizumab (Avastin) for the treatment of metastatic breast cancer in 2011 because of evidence showingminimal benefit and some potentially dangerous side effects.It is recommended that all patients with ductal carcinoma insitu (DCIS) be treated to avoid potential progression to invasivecancer. Treatment options for DCIS include breast-conservingsurgery with radiation therapy or mastectomy; either of theseoptions may be followed by treatment with tamoxifen if thetumor is hormone receptor-positive. Removal of axillary lymphnodes is not generally needed, but a sentinel lymph node procedure may be performed. A report by a panel of experts convenedby the National Institutes of Health concluded that in light of thenoninvasive nature and favorable prognosis of DCIS, the primary goal for future research is to accurately define patient riskcategories in order to administer the minimum treatmentrequired for a successful outcome.Survival: The 5-year relative survival rate for female invasivebreast cancer patients has improved from 75% in the mid-1970sto 90% today. The 5-year relative survival for women diagnosedwith localized breast cancer (cancer that has not spread tolymph nodes or other locations outside the breast) is 98%; if thecancer has spread to nearby lymph nodes (regional stage) or distant lymph nodes or organs (distant stage), the survival rate fallsto 84% or 24%, respectively. For all stages combined, relative survival rates at 10 and 15 years after diagnosis are 83% and 77%,respectively. Caution should be used when interpreting longterm survival rates because they represent patients who werediagnosed many years ago and do not reflect recent advances indetection and treatment. For example, 15-year relative survivalis based on patients diagnosed as early as 1991.Many studies have shown that being overweight adverselyaffects survival for postmenopausal women with breast cancer.In addition, women who are more physically active are less likelyto die from the disease than those who are inactive.For more information about breast cancer, see the AmericanCancer Society’s Breast Cancer Facts & Figures, available onlineat cancer.org/statistics.Childhood Cancer (Ages 0-14 years)New cases: An estimated 11,630 new cases are expected tooccur among children 0 to 14 years of age in 2013. Childhoodcancers are rare, representing less than 1% of all new cancerdiagnoses. Overall, childhood cancer incidence rates increasedslightly by 0.6% per year from 2005 to 2009, the most recent 5years of available data.Deaths: An estimated 1,310 cancer deaths are expected to occuramong children 0 to 14 years of age in 2013, about one-third ofthese from leukemia. Although uncommon, cancer is the secondleading cause of death in children, exceeded only by accidents.Mortality rates for childhood cancer have declined by 68% overthe past four decades, from 6.5 (per 100,000) in 1969 to 2.1 in2009. The substantial progress in reducing childhood cancermortality is largely attributable to improvements in treatmentand high rates of participation in clinical trials.Signs and symptoms: Early symptoms are usually nonspecific. Parents should ensure that children have regular medicalcheckups and be alert to any unusual, persistent symptoms.Signs of childhood cancer include an unusual mass or swelling;unexplained paleness or loss of energy; a sudden increase in thetendency to bruise or bleed; a persistent, localized pain; a prolonged, unexplained fever or illness; frequent headaches, oftenwith vomiting; sudden eye or vision changes; and excessive,rapid weight loss. Major categories of pediatric cancer and morespecific symptoms include:•  Leukemia (31% of all childhood cancers, including benignbrain tumors), which may be recognized by bone and jointpain, weakness, pale skin, bleeding or bruising, and feveror infection•  Brain and other central nervous system tumors (25%), whichmay cause headaches, nausea, vomiting, blurred or doublevision, dizziness, and difficulty walking or handling objects•  Neuroblastoma (6%), a cancer of the nervous system that ismost common in children younger than 5 years of age andusually appears as a swelling in the abdomen•  Wilms tumor (5%), a kidney cancer that may be recognizedby a swelling or lump in the abdomen•  Non-Hodgkin lymphoma (4%) and Hodgkin lymphoma (4%),which affect lymph nodes but may involve the bone marrowand other organs, and may cause swelling of lymph nodes inthe neck, armpit, or groin, as well as weakness and fever•  Rhabdomyosarcoma (3%), a soft tissue sarcoma that canoccur in the head and neck, genitourinary area, trunk, andextremities, and may cause pain and/or a mass or swelling•  Osteosarcoma (3%), a bone cancer that most often occurs inadolescents and commonly appears as sporadic pain in theaffected bone that may worsen at night or with activity, witheventual progression to local swelling•  Retinoblastoma (2%), an eye cancer that usually occurs in children younger than 5 years of age and is typically recognizedbecause of discoloration behind the pupil•  Ewing sarcoma (1%), another type of cancer that usuallyarises in bone, is most common in adolescents, and typicallyappears as pain at the tumor site.Cancer Facts & Figures 2013  11(Proportions are based on International Classification of Childhood Cancer groupings, including benign brain/central nervoussystem tumors, and are for all races combined and may varyaccording to race/ethnicity.)Treatment: Childhood cancers can be treated by a combinationof therapies (surgery, radiation, and chemotherapy) chosenbased on the type and stage of cancer. Treatment is coordinatedby a team of experts, including pediatric oncologists and nurses,social workers, psychologists, and others who assist childrenand their families. Because these cancers are uncommon, outcomes are more successful when treatment is managed byspecialists at a children’s cancer center. If the child is eligible,placement in a clinical trial, which compares a new treatment tothe best current treatment, should also be considered.Survival: Survival for all invasive childhood cancers combinedhas improved markedly over the past 30 years due to new andimproved treatments. The 5-year relative survival rate increasedfrom 58% for diagnoses in the mid-1970s to 83% in the mostrecent time period (2002-2008). However, rates vary considerablydepending on cancer type, patient age, and other characteristics.For the most recent time period (2002-2008), the 5-year survivalamong children 0-14 years of age with retinoblastoma is 98%;Hodgkin lymphoma, 96%; Wilms tumor, 89%; non-Hodgkin lymphoma, 86%; leukemia, 84%; neuroblastoma, 75%; Ewing tumors,75%; brain and other central nervous system tumors, 71%; osteosarcoma, 71%; and rhabdomyosarcoma, 68%.Pediatric cancer patients may experience treatment-related sideeffects long after active treatment. Late treatment effects includeimpairment in the function of specific organs, secondary cancers, and cognitive deficits. The Children’s Oncology Group(COG) has developed long-term follow-up guidelines for screening and management of late effects in survivors of childhoodcancer. For more information on childhood cancer management,see the COG Web site at survivorshipguidelines.org. The Childhood Cancer Survivor Study, which has followed more than14,000 long-term childhood cancer survivors, has also providedimportant and valuable information about the late effects ofcancer treatment; for more information, visit ccss.stjude.org.Colon and RectumNew cases: An estimated 102,480 cases of colon and 40,340cases of rectal cancer are expected to occur in 2013. Colorectalcancer is the third most common cancer in both men andwomen. Colorectal cancer incidence rates have been decreasingfor most of the past two decades, which has largely been attributed to increases in the use of colorectal cancer screening teststhat allow for the detection and removal of colorectal polypsbefore they progress to cancer. From 2005 to 2009, incidencerates declined by 4.1% per year among adults 50 years of age andolder, for whom screening is recommended, and increased by1.1% per year among those younger than age 50.12  Cancer Facts & Figures 2013Deaths: An estimated 50,830 deaths from colorectal cancer areexpected to occur in 2013, accounting for 9% of all cancer deaths.Mortality rates for colorectal cancer have declined in both menand women over the past two decades; from 2005 to 2009, therate declined by 2.4% per year in men and by 3.1% per year inwomen. These decreases reflect declining incidence rates andimprovements in early detection and treatment.Signs and symptoms: Early stage colorectal cancer does nottypically have symptoms; therefore, screening is usually necessary to detect this cancer in its early stages. Symptoms ofadvanced disease may include rectal bleeding, blood in the stool,a change in bowel habits, cramping pain in the lower abdomen,decreased appetite, or weight loss. In some cases, blood lossfrom the cancer leads to anemia (low red blood cells), causingsymptoms such as weakness and excessive fatigue. Timely evaluation of symptoms consistent with colorectal cancer in adultsyounger than age 50 is especially important due to the increasein colorectal cancer incidence in this age group in recent years.Risk factors: The risk of colorectal cancer increases with age;90% of cases are diagnosed in individuals 50 years of age andolder. Modifiable factors associated with increased risk includeobesity, physical inactivity, a diet high in red or processed meat,alcohol consumption, long-term smoking, and possibly very lowintake of fruits and vegetables. Hereditary and medical factorsthat increase risk include a personal or family history of colo­rectal cancer and/or polyps, a personal history of chronicinflammatory bowel disease, and certain inherited geneticconditions (e.g., Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer, and familial adenomatous polyposis[FAP]). Studies have also found that individuals with type 2diabetes are at higher risk of colorectal cancer.Consumption of milk and calcium and higher blood levels ofvitamin D appear to decrease colorectal cancer risk. Regular useof nonsteroidal anti-inflammatory drugs, such as aspirin, alsoreduces risk. However, these drugs are not recommended for theprevention of colorectal cancer among individuals at averagerisk because they can have serious adverse health effects. Studyresults are mixed about the association between menopausalhormone therapy and colorectal cancer.Early detection: Beginning at age 50, men and women who areat average risk for developing colorectal cancer should beginscreening. Screening can detect and allow for the removal ofcolorectal polyps that might have become cancerous, as well asdetect cancer at an early stage, when treatment may be lessextensive and more successful. In 2008, the American CancerSociety collaborated with several other organizations to releaseupdated colorectal cancer screening guidelines. These jointguidelines emphasize cancer prevention and draw a distinctionbetween colorectal screening tests that primarily detect cancerand those that can detect both cancer and precancerous polyps.There are a number of recommended screening options thatvary by the extent of bowel preparation, as well as test performance, limitations, time interval, and cost. For detailedinformation on colorectal cancer screening options, see Colorectal Cancer Facts & Figures at cancer.org/statistics, and for theAmerican Cancer Society’s screening guidelines for colorectalcancer, see page 60.Treatment: Surgery is the most common treatment for colorectalcancer. For cancers that have not spread, surgical removal may becurative. A permanent colostomy (creation of an abdominal opening for elimination of body waste) is rarely needed for colon cancerand is infrequently required for rectal cancer. Chemotherapyalone, or in combination with radiation, is given before or after surgery to most patients whose cancer has penetrated the bowel walldeeply or spread to lymph nodes. Adjuvant chemotherapy (anticancer drugs in addition to surgery or radiation) for colon cancerin otherwise healthy patients 70 years of age and older is equallyeffective as in younger patients; toxicity in older patients can belimited if certain drugs (e.g., oxaliplatin) are avoided. Severaltargeted therapies are approved by the FDA to treat metastaticcolorectal cancer: bevacizumab (Avastin) and ziv-aflibercept(Zaltrap) block the growth of blood vessels to the tumor, andcetuximab (Erbitux) and panitumumab (Vectibix) block theeffects of hormone-like factors that promote cancer growth.Survival: The 1- and 5-year relative survival rates for personswith colorectal cancer are 84% and 64%, respectively. Survivalcontinues to decline to 58% at 10 years after diagnosis. Whencolorectal cancers are detected at an early, localized stage, the5-year survival is 90%; however, only 39% of colorectal cancersare diagnosed at this stage, in part due to the underuse of screening. If the cancer has spread regionally to involve nearby organsor lymph nodes at the time of diagnosis, the 5-year survivaldrops to 70%. If the disease has spread to distant organs, the5-year survival is 12%.KidneyNew cases: An estimated 65,150 new cases of kidney (renal) cancer are expected to be diagnosed in 2013. This estimate includescancers of the renal pelvis (6%) and Wilms tumor (1%), a childhood cancer that usually develops before age 5 (see ChildhoodCancer, page 11). From 2005 to 2009, kidney cancer incidencerates increased by 3.1% per year, primarily due to an increase inearly stage disease. Some of the increase in kidney cancer rates,paticularly for early stage disease, may be due to incidental diagnosis during abdominal imaging performed for unrelated issues.Based on the most recent years of data, it appears as though therate may be reaching a plateau after several decades of increase.Deaths: An estimated 13,680 deaths from kidney cancer areexpected to occur in 2013. Death rates for kidney cancerdecreased by 0.5% per year from 2005 to 2009.Signs and symptoms: Early stage kidney cancer usually has nosymptoms. Symptoms that may develop as the tumor progressesinclude a pain or lump in the lower back or abdomen, fatigue,weight loss, fever, or swelling in the legs and ankles.Risk factors: Tobacco use is a strong risk factor for kidney cancer, with the largest increased risk for cancer of the renal pelvis,particularly among heavy smokers. Additional risk factors forrenal cell carcinoma include obesity, to which an estimated 30%of cases can be attributed; hypertension (high blood pressure);chronic renal failure; and occupational exposure to certainchemicals, such as trichloroethylene, an industrial agent used asa metal degreaser and chemical additive. Radiation exposure(e.g., in medical procedures) slightly increases risk. A small proportion of renal cell cancers are the result of rare hereditaryconditions (e.g., von Hippel-Lindau disease and hereditary papillary renal cell carcinoma).Early detection: There are no recommended screening tests forpeople at average risk.Treatment: Active surveillance (observation) may be offered tosome patients with small tumors. Surgery (traditional or laparoscopic, i.e., minimally invasive, performed through very smallincisions) is the primary treatment for most kidney cancers.Patients who are not surgical candidates may be offered ablation therapy, a procedure that uses heat or cold to destroy thetumor. Kidney cancer tends to be resistant to both traditionalchemotherapy and radiation therapy. Improved understandingof the biology of kidney cancer has led to the development of several targeted therapies that control cancer growth by blockingthe tumor’s blood supply or through other mechanisms and areused to treat metastatic disease.Survival: The 1- and 5-year relative survival rates for cancers ofthe kidney are 85% and 71%, respectively. More than half (62%) ofcases are diagnosed at the local stage, for which the 5-year relative survival rate is 91%. Five-year survival is lower for renalpelvis (50%) than for renal cell (72%) carcinoma.LeukemiaNew cases: An estimated 48,610 new cases of leukemia areexpected in 2013. Leukemia is a cancer of the bone marrow andblood and is classified into four main groups according to celltype and rate of growth: acute lymphocytic (ALL), chronic lymphocytic (CLL), acute myeloid (AML), and chronic myeloid (CML).Almost 90% of leukemia cases are diagnosed in adults 20 yearsof age and older, among whom the most common types are CLL(38%) and AML (30%). Among children and teens, ALL is mostcommon, accounting for 75% of leukemia cases (see ChildhoodCancer, page 11). From 2005 to 2009, overall leukemia incidencerates increased slightly by 0.4% per year.Cancer Facts & Figures 2013  13Probability (%) of Developing Invasive Cancers during Selected Age Intervals by Sex, US, 2007-2009*Birth to 39 40 to 59 60 to 69 70 and Older Birth to DeathAll sites MaleFemale1.46 (1 in 69)2.20 (1 in 46)8.79 (1 in 11)9.19 (1 in 11)16.03 (1 in 6)10.39 (1 in 10)38.07 (1 in 3)26.69 (1 in 4)44.81 (1 in 2)38.17 (1 in 3)Urinarybladder‡MaleFemale0.02 (1 in 4,924)0.01 (1 in 12,663)0.37 (1 in 272)0.12 (1 in 864)0.92 (1 in 109)0.24 (1 in 410)3.69 (1 in 27)0.98 (1 in 106)3.81 (1 in 26)1.15 (1 in 87)BreastFemale0.50 (1 in 202)3.78 (1 in 26)3.56 (1 in 28)6.65 (1 in 15)12.38 (1 in 8)Colon &rectumMaleFemale0.08 (1 in 1,212)0.08 (1 in 1,236)0.94 (1 in 106)0.75 (1 in 134)1.40 (1 in 71)0.98 (1 in 102)4.19 (1 in 24)3.80 (1 in 26)5.17 (1 in 19)4.78 (1 in 21)LeukemiaMaleFemale0.16 (1 in 612)0.13 (1 in 746)0.23 (1 in 440)0.15 (1 in 655)0.35 (1 in 288)0.21 (1 in 481)1.26 (1 in 80)0.81 (1 in 123)1.59 (1 in 63)1.14 (1 in 88)Lung &bronchusMaleFemale0.03 (1 in 3,552)0.03 (1 in 3,287)0.92 (1 in 109)0.76 (1 in 131)2.27 (1 in 44)1.72 (1 in 58)6.82 (1 in 15)4.93 (1 in 20)7.77 (1 in 13)6.35 (1 in 16)Melanomaof the skin§MaleFemale0.15 (1 in 691)0.26 (1 in 391)0.63 (1 in 160)0.55 (1 in 181)0.77 (1 in 130)0.40 (1 in 248)2.02 (1 in 50)0.84 (1 in 120)2.87 (1 in 35)1.85 (1 in 54)Non-HodgkinlymphomaMaleFemale0.13 (1 in 753)0.09 (1 in 1,147)0.44 (1 in 225)0.31 (1 in 322)0.60 (1 in 167)0.44 (1 in 229)1.77 (1 in 57)1.40 (1 in 72)2.34 (1 in 43)1.93 (1 in 52)ProstateMale0.01 (1 in 7,964)2.68 (1 in 37)6.78 (1 in 15)12.06 (1 in 8)16.15 (1 in 6)Uterine cervixFemale0.16 (1 in 641)0.27 (1 in 374)0.13 (1 in 795)0.18 (1 in 551)0.68 (1 in 147)Uterine corpusFemale0.07 (1 in 1,348)0.77 (1 in 129)0.89 (1 in 112)1.25 (1 in 80)2.64 (1 in 38)†*For those who are cancer-free at the beginning of each age interval.  †All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder. ‡Includes invasive and in situ cancers.  §Statistic is for whites only.Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.6.1. Statistical Research and Applications Branch, National Cancer Institute, 2012.www.srab.cancer.gov/devcan.American Cancer Society, Surveillance Research, 2013Deaths: An estimated 23,720 deaths are expected to occur in2013. Death rates for leukemia have been declining for the pastseveral decades; from 2005 to 2009, rates decreased by 0.8% peryear among males and by 1.4% per year among females.Signs and symptoms: Symptoms may include fatigue, paleness,weight loss, repeated infections, fever, bruising easily, and nosebleeds or other hemorrhages. In acute leukemia, these signs canappear suddenly. Chronic leukemia typically progresses slowlywith few symptoms and is often diagnosed during routine bloodtests. Patients with CLL may experience swollen lymph nodes orpain in the upper left abdomen due to an enlarged spleen.Risk factors: Exposure to ionizing radiation increases risk ofseveral types of leukemia (excluding CLL). Medical radiation,such as that used in cancer treatment, is a substantial source ofradiation exposure. Leukemia may also occur as a side effect ofchemotherapy. Children with Down syndrome and certain othergenetic abnormalities are at increased risk of leukemia. Workers inthe rubber-manufacturing industry also have an increased risk.Recent studies suggest that obesity increases risk of leukemia.Some factors are most closely associated with specific types ofleukemia. Family history is one of the strongest risk factors forCLL. Cigarette smoking is a risk factor for AML, and there is limited evidence that parental smoking and maternal exposure topaint increases the risk of childhood leukemia. Exposure to certain chemicals, such as formaldehyde and benzene (a component14  Cancer Facts & Figures 2013in cigarette smoke and gasoline that has become more regulateddue to its carcinogenicity), also increases risk of AML. Infectionwith human T-cell leukemia virus type I (HTLV-I) can cause arare type of leukemia called adult T-cell leukemia/lymphoma.The prevalence of HTLV-I infection is geographically localizedand is most common in southern Japan and the Caribbean;infected individuals in the US tend to be descendants or immigrants from endemic regions.Early detection: Leukemia can be difficult to diagnose earlybecause symptoms often resemble those of other, less seriousconditions. When a physician does suspect leukemia, diagnosiscan be made using blood tests and a bone marrow biopsy.Treatment: Chemotherapy is the most effective method oftreating leukemia. Various anticancer drugs are used, either incombination or as single agents. Imatinib (Gleevec), nilotinib(Tasigna), and dasatinib (Sprycel) are very effective drugs that aretargeted at the genetic abnormality that is the hallmark of CML.Imatinib and dasatinib are also FDA-approved to treat a type ofALL with the same genetic defect. People diagnosed with CLL thatis not progressing or causing symptoms may not require treatment. Recent clinical trials have shown that adults with AML whoare treated with twice the conventional dose of daunorubicinexperience higher and more rapid rates of remission. Antibioticsand transfusions of blood components are used as supportivetreatments. Under appropriate conditions, stem cell transplantation may be useful in treating certain types of leukemia.Survival: Survival rates vary substantially by leukemia type,ranging from a 5-year relative survival of 25% for patients diagnosed with AML to 82% for those with CLL. Advances intreatment have resulted in a dramatic improvement in survivalover the past three decades for most types of leukemia. Forexample, from 1975-1977 to 2002-2008, the 5-year relative survival rate for ALL increased from 41% to 68% overall, and from58% to 91% among children. In large part due to the discovery oftargeted cancer drugs like imatinib, the 5-year survival rate forCML increased from 31% for cases diagnosed during 1990-1992to 56% for those diagnosed during 2002-2008.LiverNew Cases: An estimated 30,640 new cases of liver cancer(including intrahepatic bile duct cancers) are expected to occurin the US during 2013. More than 80% of these cases are hepatocellular carcinoma (HCC), originating from hepatocytes, thepredominant liver cell type. Liver cancer incidence rates arethree times higher in men than in women. From 2005 to 2009,rates increased by 3.7% per year in men and by 3.0% per year inwomen.Deaths: An estimated 21,670 liver cancer deaths (6,780 women,14,890 men) are expected in 2013. From 2005 to 2009, death ratesfor liver cancer increased by 2.3% per year in men and 1.3% peryear in women.Signs and symptoms: Common symptoms include abdominalpain and/or swelling, weight loss, weakness, loss of appetite,jaundice (a yellowish discoloration of the skin and eyes), andfever. Enlargement of the liver is the most common physical sign.Risk factors: In the US and other western countries, alcoholrelated cirrhosis, and possibly nonalcoholic fatty liver diseaseassociated with obesity, account for the majority of liver cancercases. Chronic infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) are associated with less than half of livercancer cases in the US, although they are the major risk factorsfor the disease worldwide. In the US, rates of HCC are higher inimmigrants from areas where HBV is endemic, such as China,Southeast Asia, and sub-Saharan Africa. A vaccine that protectsagainst HBV has been available since 1982. The HBV vaccinationis recommended for all infants at birth; for all children under 18years of age who were not vaccinated at birth; for adults in highrisk groups (e.g., health care workers and those younger than 60years who have been diagnosed with diabetes). It is also recommended that all pregnant women be tested for HBV.There is no vaccine available against HCV, but there are treatments that can clear infection and halt liver disease progression.It is estimated that persons who were born between 1945 and1965 account for about three-fourths of HCV-infected individuals and HCV-related deaths in the US. Therefore, the Centers forDisease Control and Prevention (CDC) now recommends one-time HCV testing for all persons born from 1945 to 1965 inaddition to routine testing for individuals at high risk (e.g., injection drug users). Infected individuals can receive treatment thatmay reduce their risk of liver cancer and counseling to reduce therisk of HCV transmission to others. Other preventive measuresfor HCV infection include screening of donated blood, organs,and tissues; adherence to infection control practices duringmedical, surgical, and dental procedures; and needle-exchangeprograms for injecting drug users. For more information onhepatitis infections, including who is at risk, visit the CDC Website at cdc.gov/hepatitis/.Other risk factors for liver cancer, particularly in economicallydeveloping countries, include parasitic infections (schistosomiasis and liver flukes) and consumption of food contaminatedwith aflatoxin, a toxin produced by mold during the storage ofagricultural products in a warm, humid environment.Early detection: Screening for liver cancer has not been provento improve survival. Nonetheless, many doctors in the US screenhigh-risk persons (e.g., HCV-infected persons with cirrhosis)with ultrasound or blood tests.Treatment: Early stage liver cancer can sometimes be successfully treated with surgery in patients with sufficient healthy livertissue; liver transplantation may also be an option. Surgical treatment of early stage liver cancer is often limited by pre-existingliver disease that has damaged the portion of the liver not affectedby cancer. Patients whose tumors cannot be surgically removedmay choose ablation (tumor destruction) or embolization, a procedure that cuts off blood flow to the tumor. Fewer treatmentoptions exist for patients diagnosed at an advanced stage of thedisease. Sorafenib (Nexavar) is a targeted drug approved for thetreatment of HCC in patients who are not candidates for surgery.Survival: The overall 5-year relative survival rate for patientswith liver cancer is 15%. Forty percent of patients are diagnosedat an early stage, for which 5-year survival is 28%. Survivaldecreases to 10% and 3% for patients who are diagnosed atregional and distant stages of disease, respectively.Lung and BronchusNew cases: An estimated 228,190 new cases of lung cancer areexpected in 2013, accounting for about 14% of cancer diagnoses.The incidence rate has been declining in men over the past twodecades, but has just recently begun to decrease in women.From 2005 to 2009, lung cancer incidence rates decreased by1.9% per year in men and by 0.3% per year in women.Deaths: Lung cancer accounts for more deaths than any othercancer in both men and women. An estimated 159,480 deaths,accounting for about 27% of all cancer deaths, are expected tooccur in 2013. Death rates began declining in men in 1991; from2005 to 2009, rates decreased 2.8% per year. Lung cancer deathrates did not begin declining in women until 2003; from 2005 toCancer Facts & Figures 2013  152009, rates decreased by 1.0% per year. Gender differences in lungcancer mortality patterns reflect historical differences in theuptake and reduction of cigarette smoking over the past 50 years.Signs and symptoms: Symptoms may include persistent cough,sputum streaked with blood, chest pain, voice change, andrecurrent pneumonia or bronchitis.Risk factors: Cigarette smoking is by far the most importantrisk factor for lung cancer; risk increases with both quantity andduration of smoking. Cigar and pipe smoking also increase risk.Exposure to radon gas released from soil and building materialsis estimated to be the second leading cause of lung cancer inEurope and North America. Other risk factors include occupational or environmental exposure to secondhand smoke, asbestos(particularly among smokers), certain metals (chromium, cadmium, arsenic), some organic chemicals, radiation, air pollution,diesel exhaust, and paint. Additional occupational exposuresthat increase lung cancer risk include rubber manufacturing,paving, roofing, and chimney sweeping. Risk is also probablyincreased among people with a medical history of tuberculosis.Genetic susceptibility plays a contributing role in the development of lung cancer, especially in those who develop the diseaseat a young age.Early detection: Annual screening with chest x-ray has not beenshown to reduce lung cancer mortality. Results from the NationalLung Screening Trial (NLST), a clinical trial designed to determine the effectiveness of lung cancer screening in high-riskindividuals, showed 20% fewer lung cancer deaths among current and former heavy smokers who were screened with spiral CTcompared to standard chest x-ray. However, these study participants had a history of smoking that was the equivalent of at leasta pack of cigarettes per day for 30 years, so it is unknown whetherthese results are relevant for individuals who have smoked less.In addition, the potential risks associated with screening, including the high rate of false positive results, cumulative radiationexposure from multiple CT scans, and unnecessary lung biopsyand surgery, are important considerations. The American CancerSociety (ACS), the National Comprehensive Cancer Network(NCCN), the American College of Chest Physicians (ACCP), andthe American Society of Clinical Oncology (ASCO) have all issuedinitial lung cancer screening guidelines. The ACS, ACCP, andASCO have endorsed shared decision making with a clinician foradults who meet the eligibility criteria for participation in theNLST, i.e., current and former smokers (quit within previous 15years) ages 55-74 in good health with at least a 30-year packhistory of smoking. The NCCN expands eligibility for adults withadditional risk factors for lung cancer. For more information,visit cancer.org/healthy/findcancerearly.Treatment: Lung cancer is classified as small cell (15%) or nonsmall cell (84%) for the purposes of treatment. Based on type andstage of cancer, treatments include surgery, radiation therapy,chemotherapy, and targeted therapies such as bevacizumab16  Cancer Facts & Figures 2013(Avastin), erlotinib (Tarceva), and crizotinib (Xalkori). For localized non-small cell lung cancers, surgery is usually the treatmentof choice; for most of these patients, survival is improved whenchemotherapy is given after surgery. Because the disease hasusually spread by the time it is discovered, radiation therapy andchemotherapy are often used, sometimes in combination withsurgery. Advanced-stage non-small cell lung cancer patients areusually treated with chemotherapy, targeted drugs, or somecombination of the two. Chemotherapy alone or combined withradiation is the usual treatment of choice for small cell lungcancer; on this regimen, a large percentage of patients experienceremission, though the cancer often returns.Survival: The 1-year relative survival for lung cancer increasedfrom 37% in 1975-1979 to 44% in 2005-2008, largely due to improvements in surgical techniques and combined therapies. However,the 5-year survival rate for all stages combined is only 16%. Only15% of lung cancers are diagnosed at a localized stage, for whichthe 5-year survival rate is 52%. The 5-year survival for small celllung cancer (6%) is lower than that for non-small cell (18%).LymphomaNew cases: An estimated 79,030 new cases of lymphoma willoccur in 2013. Lymphoma is cancer of the lymphocytes, a type ofwhite blood cell, and is classified as Hodgkin (9,290 cases in2013) or non-Hodgkin (69,740 cases in 2013). From 2005 to 2009,incidence rates were stable among men and women for bothHodgkin and non-Hodgkin lymphoma (NHL). (NHL encompasses a wide variety of disease subtypes for which incidencepatterns may vary.)Deaths: An estimated 20,200 deaths from lymphoma will occurin 2013 (Hodgkin lymphoma, 1,180; NHL, 19,020). Death rates forHodgkin lymphoma have been decreasing for the past fourdecades; from 2005 to 2009, rates decreased by 2.7% per year.Death rates for NHL began decreasing in the late 1990s; from2005 to 2009, rates decreased 3.0% per year. Declines in lymphomadeath rates reflect improvements in treatment over time.Signs and symptoms: Symptoms may include swollen lymphnodes, itching, night sweats, fatigue, unexplained weight loss,and intermittent fever.Risk factors: Like most cancers, the risk of developing NHLincreases with age. In contrast, the risk of Hodgkin lymphoma ishighest during adolescence and early adulthood. For most casesof lymphoma, the cause is unknown, though various risk factorsassociated with altered immune function have been identified.Non-Hodgkin lymphoma risk is elevated in persons who receiveimmune suppressants to prevent organ transplant rejection, inpeople with severe autoimmune conditions, and in peopleinfected with human immunodeficiency virus (HIV) and humanT-cell leukemia virus type I. Epstein Barr virus causes Burkittlymphoma (an aggressive type of NHL that occurs most often inFive-year Relative Survival Rates* (%) by Stage at Diagnosis, 2002-2008Breast (female)Colon & rectumEsophagusKidney†LarynxLiver‡Lung & bronchusMelanoma of the skinOral cavity & pharynxAll StagesLocal896417716115169162RegionalDistant9884907038 2091 6476 4228 10522598628257All StagesLocalRegionalDistant24Ovary4492722712Pancreas623923Prostate99 100 100 2812Stomach27 62 28435Testis95 99 96 733Thyroid98 100 97 544Urinary bladder§787033615Uterine cervix6891571635Uterine corpus82956716*Rates are adjusted for normal life expectancy and are based on cases diagnosed in the SEER 18 areas from 2002-2008, followed through 2009.†Includes renal pelvis.  ‡Includes intrahepatic bile duct.  § Rate for in situ cases is 96%.Local: an invasive malignant cancer confined entirely to the organ of origin. Regional: a malignant cancer that 1) has extended beyond the limits of the organ of origindirectly into surrounding organs or tissues; 2) involves regional lymph nodes by way of lymphatic system; or 3) has both regional extension and involvement o­ f regionallymph nodes. Distant: a malignant cancer that has spread to parts of the body remote from the primary tumor either by direct extension or by discontinuous metastasisto distant organs, tissues, or via the lymphatic system to distant lymph nodes.Source: Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2009, National Cancer Institute, Bethesda, MD,www.seer.cancer.gov/csr/1975_2009/, 2012.American Cancer Society, Surveillance Research 2013children and young adults) and is associated with a number ofautoimmune-related NHLs and some types of Hodgkin lymphoma. H. pylori infection increases the risk of gastric lymphoma.A family history of lymphoma and a growing number of common genetic variations are associated with modestly increasedrisk. Workers in the rubber manufacturing industry are atincreased risk of lymphoma, and occupational and environmental exposures to certain chemicals (e.g., solvents such asdichloromethane) may also increase risk.Treatment: Non-Hodgkin lymphoma patients are usuallytreated with chemotherapy; radiation, alone or in combinationwith chemotherapy, is used less often. Highly specific monoclonal antibodies directed at lymphoma cells, such as rituximab(Rituxan) and alemtuzumab (Campath), are used for initialtreatment and the recurrence of some types of NHL, as are antibodies linked to a radioactive atom, such as ibritumomab tiuxetan(Zevalin) and tositumomab (Bexxar). If NHL persists or recursafter standard treatment, stem cell transplantation (with highdose or nonmyeloablative chemotherapy) may be an option.Hodgkin lymphoma is usually treated with chemotherapy, radiation therapy, or a combination of the two, depending on diseasestage and cell type. Stem cell transplantation may be an optionif these are not effective. The targeted drug brentuximab vedotin (Adcetris) is used to treat Hodgkin lymphoma (as well as arare form of NHL) in patients whose disease has failed to respondto other treatment.Survival: Survival varies widely by cell type and stage of disease. For NHL, the overall 1- and 5-year relative survival is 81%and 68%, respectively; survival declines to 57% at 10 years afterdiagnosis. For Hodgkin lymphoma, the 1-, 5-, and 10-year relativesurvival rates are 92%, 85%, and 80%, respectively.Oral Cavity and PharynxNew cases: An estimated 41,380 new cases of cancer of the oralcavity and pharynx (throat) are expected in 2013. Incidencerates are more than twice as high in men as in women. From2005 to 2009, incidence rates were stable in men and decreasingby 0.9% annually in women. However, recent studies have shownthat incidence is increasing for cancers of the oropharynx thatare associated with human papillomavirus (HPV) infectionamong white men and women.Deaths: An estimated 7,890 deaths from oral cavity and pharynxcancer are expected in 2013. Death rates have been decreasingover the past three decades; from 2005 to 2009, rates decreasedby 1.3% per year in men and by 2.2% per year in women.Signs and symptoms: Symptoms may include a sore in thethroat or mouth that bleeds easily and does not heal, a persistentred or white patch or a lump or thickening in the throat ormouth, ear pain, a neck mass, or coughing up blood. Difficultiesin chewing, swallowing, or moving the tongue or jaws are oftenlate symptoms.Risk factors: Known risk factors include all forms of smokedand smokeless tobacco products and excessive consumption ofalcohol. Many studies have reported a synergism between smoking and alcohol use, resulting in a more than 30-fold increasedrisk for individuals who both smoke and drink heavily. HPVinfection is associated with cancers of the tonsil, base of tongue,and some other sites within the oropharynx and is believed to betransmitted through sexual contact.Early detection: Cancer can affect any part of the oral cavity,including the lip, tongue, mouth, and throat. Through visualinspection, dentists and primary care physicians can oftenCancer Facts & Figures 2013  17Trends in 5-year Relative Survival Rates* (%) by Race, US, 1975-2008All racesWhiteAfrican American1975-771987-89 2002-2008 1975-77 1987-89 2002-2008 1975-77 1987-89 2002-2008All sites495668† 5057 69† 3943 60†Brain & other nervous systemBreast (female)ColonEsophagusHodgkin lymphoma222935† 2228758490† 76855161 65† 5161510 19† 611727987† 728034† 2532 41†92† 6271 78†66† 4553 55†21† 3714†88† 7072 83†Kidney & renal pelvisLarynxLeukemiaLiver & intrahepatic bile ductLung & bronchus505772† 50576666 63† 67673443 58† 35443516† 36121317† 121372† 4955 70†65 59 56 5159† 3335 51†16† 23 11†17† 1111 14†Melanoma of the skinMyelomaNon-Hodgkin lymphomaOral cavity & pharynxOvary828893† 8288 93†57‡79‡70‡2528 43† 2527 43† 3030 43†475171† 4752 72† 4846 63†535465† 5456 67† 3634 45†3638 43† 3538 43† 4234 36PancreasProstateRectumStomachTestis24 6† 33 6† 26 5†6883 100† 6985 100† 6172 98†4858 68† 4859 69† 4552 61†1520 28† 1419 27† 1619 28†8395 96† 8396 97†73‡#88‡89ThyroidUrinary bladderUterine cervixUterine corpus9295 98† 9294737980† 74806970697073878383† 888498†81†7085†909250636557605796†62†6163*Survival rates are adjusted for normal life expectancy and are based on cases diagnosed in the SEER 9 areas from 1975-77, 1987-89, and 2002 to 2008, all followedthrough 2009.  †The difference in rates between 1975-1977 and 2002-2008 is statistically significant (p <0.05).  ‡The standard error is between 5 and 10 percentagepoints.  #Survival rate is for cases diagnosed in 1978-1980.Source: Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2009, National Cancer Institute, Bethesda, MD.seer.cancer.gov/csr/1975_2009/, 2012.American Cancer Society, Surveillance Research, 2013detect premalignant abnormalities and cancer at an early stage,when treatment is both less extensive and more successful.Treatment: Radiation therapy and surgery, separately or incombination, are standard treatments; chemotherapy is addedfor advanced disease. Targeted therapy with cetuximab (Erbitux)may be combined with radiation in initial treatment or used totreat recurrent cancer.Survival: For all stages combined, about 84% of persons withoral cavity and pharynx cancer survive 1 year after diagnosis.The 5-year and 10-year relative survival rates are 62% and 51%,respectively.OvaryNew cases: An estimated 22,240 new cases of ovarian cancer areexpected in the US in 2013. Ovarian cancer accounts for about3% of all cancers among women. From 2005 to 2009, incidencerates decreased by 0.9% per year.18  Cancer Facts & Figures 2013Deaths: An estimated 14,030 deaths are expected in 2013. Ovarian cancer accounts for 5% of cancer deaths among women andcauses more deaths than any other cancer of the female reproductive system. The death rate for ovarian cancer decreased by2.0% per year from 2005 to 2009.Signs and symptoms: Early ovarian cancer usually has no obvious symptoms. However, studies have indicated that somewomen may experience persistent, nonspecific symptoms, suchas bloating, pelvic or abdominal pain, difficulty eating or feelingfull quickly, or urinary urgency or frequency. Women who experience such symptoms daily for more than a few weeks shouldseek prompt medical evaluation. The most common sign ofovarian cancer is swelling of the abdomen, which is caused bythe accumulation of fluid. Abnormal vaginal bleeding is rarely asymptom of ovarian cancer, though it is a symptom of cervicaland uterine cancers.Risk factors: The most important risk factor is a strong familyhistory of breast or ovarian cancer. Women who have had breastcancer or who have tested positive for inherited mutations inBRCA1 or BRCA2 genes are at increased risk. Studies indicatethat preventive surgery to remove the ovaries and fallopiantubes in these women can decrease the risk of ovarian cancer.Other medical conditions associated with increased risk includepelvic inflammatory disease and a genetic condition calledhereditary nonpolyposis colorectal cancer (also called Lynchsyndrome). The use of estrogen alone as menopausal hormonetherapy has been shown to increase risk in several large studies.Tobacco smoking increases risk of mucinous ovarian cancer.Heavier body weight may be associated with increased risk ofovarian cancer. Pregnancy, long-term use of oral contraceptives,and tubal ligation reduce the risk of developing ovarian cancer;hysterectomy (with retention of the ovaries) also appears todecrease risk.Survival: Relative survival varies by age; women younger than65 are twice as likely to survive 5 years (56%) following diagnosisas women 65 and older (27%). Overall, the 1-, 5-, and 10-year relative survival of ovarian cancer patients is 75%, 44%, and 34%,respectively. If diagnosed at the localized stage, the 5-year survival rate is 92%; however, only 15% of all cases are detected atthis stage, usually incidentally during another medical procedure. The majority of cases (61%) are diagnosed at distant stage.For women with regional and distant disease, 5-year survivalrates are 72% and 27%, respectively.Early detection: There is currently no sufficiently accuratescreening test for the early detection of ovarian cancer. Pelvicexamination only occasionally detects ovarian cancer, generallywhen the disease is advanced. However, for women who are athigh risk of ovarian cancer, the combination of a thorough pelvicexam, transvaginal ultrasound, and a blood test for the tumormarker CA125 may be offered, though this strategy has not yetproven effective in screening even high-risk groups of women. Apelvic exam, sometimes in combination with a transvaginalultrasound, may be used to evaluate women with symptoms.Although a clinical trial in the US showed that these tests had noeffect on ovarian cancer mortality when used as a screening toolin average risk women, results are expected in 2015 from anotherlarge screening trial under way in the United Kingdom.ProstateTreatment: Treatment includes surgery and usually chemotherapy. Surgery usually involves removal of one or both ovariesand fallopian tubes (salpingo-oophorectomy), the uterus (hysterectomy), and the omentum (fatty tissue attached to some ofthe organs in the belly), along with biopsies of the peritoneum(lining of the abdominal cavity). In younger women with veryearly stage tumors who wish to have children, only the involvedovary and fallopian tube may be removed. Among patients withearly ovarian cancer, complete surgical staging has been associated with better outcomes. For women with advanced disease,surgically removing all abdominal metastases larger than onecentimeter (debulking) enhances the effect of chemotherapyand helps improve survival. For women with stage III ovariancancer that has been optimally debulked, studies have shownthat chemotherapy administered both intravenously and directlyinto the abdomen (intraperitoneally) improves survival. Studieshave also found that ovarian cancer patients whose surgery isperformed by a gynecologic oncologist have more successfuloutcomes. Clinical trials are currently under way to test targeteddrugs such as bevacizumab and cediranib in the treatment ofovarian cancer.PancreasPlease see page 25 for the special section on pancreatic cancer.New cases: An estimated 238,590 new cases of prostate cancerwill occur in the US during 2013. Prostate cancer is the most frequently diagnosed cancer in men aside from skin cancer. Forreasons that remain unclear, incidence rates are 70% higher inAfrican Americans than in whites. Incidence rates for prostatecancer changed substantially between the mid-1980s and mid1990s and have since fluctuated widely from year to year, inlarge part reflecting changes in prostate cancer screening withthe prostate-specific antigen (PSA) blood test. From 2005 to 2009,incidence rates decreased by 1.9% per year.Deaths: With an estimated 29,720 deaths in 2013, prostate cancer is the second-leading cause of cancer death in men. Prostatecancer death rates have been decreasing since the early 1990s inboth African Americans and whites, though they remain morethan twice as high in African Americans as in whites. The higherdeath rate among African Americans is mostly due to higherincidence rates, but also because African American men aremore likely to die from prostate cancer than are white men.Prostate cancer death rates decreased 3.4% per year in white menand 3.5% per year in African American men from 2005 to 2009.Signs and symptoms: Early prostate cancer usually has nosymptoms. With more advanced disease, men may experienceweak or interrupted urine flow; the inability to urinate or difficulty starting or stopping the urine flow; the need to urinatefrequently, especially at night; blood in the urine; or pain orburning with urination. Advanced prostate cancer commonlyspreads to the bones, which can cause pain in the hips, spine,ribs, or other areas.Risk factors: The only well-established risk factors for prostatecancer are increasing age, African ancestry, and a family historyof the disease. About 60% of all prostate cancer cases are diagnosed in men 65 years of age and older, and 97% occur in men 50and older. African American men and Jamaican men of Africandescent have the highest documented prostate cancer incidenceCancer Facts & Figures 2013  19rates in the world. The disease is common in North America andnorthwestern Europe, but less common in Asia and South America. Genetic studies suggest that strong familial predispositionmay be responsible for 5%-10% of prostate cancers. Recent studies suggest that a diet high in processed meat or dairy foods maybe a risk factor, and obesity appears to increase risk of aggressive prostate cancer. There is some evidence that occupationalexposures of firefighters (e.g., toxic combustion products) moderately increase risk.Prevention: The chemoprevention of prostate cancer is anactive area of research. Two drugs of interest, finasteride anddutasteride, reduce the amount of certain male hormones in thebody and are already used to treat the symptoms of benign prostate enlargement. Both drugs have been found to lower the riskof prostate cancer by about 25% in large clinical trials with similar potential side effects, including reduced libido and risk oferectile dysfunction. However, it is not entirely clear which menare most likely to gain benefit from prophylactic treatment withthese agents and an advisory committee to the FDA has recommended against approval for both finasteride and dutasteride forthe prevention of prostate cancer based on risk-benefit analyses.Early detection: At this time, there are insufficient data to recommend for or against routine testing for early prostate cancerdetection with the PSA test. The American Cancer Society recommends that beginning at age 50, men who are at average riskof prostate cancer and have a life expectancy of at least 10 yearsreceive information about the potential benefits and known limitations associated with testing for early prostate cancerdetection and have an opportunity to make an informed decision about testing. Men at high risk of developing prostatecancer (African Americans or men with a close relative diagnosed with prostate cancer before age 65) should have thisdiscussion with their health care provider beginning at age 45.Men at even higher risk (because they have several close relatives diagnosed with prostate cancer at an early age) shouldhave this discussion with their provider at age 40. All men shouldbe given sufficient information about the benefits and limitations of testing and early detection to allow them to make adecision based on their personal values and preferences.Results from clinical trials designed to determine the efficacy ofPSA testing for reducing prostate cancer deaths have beenmixed; two European studies found a lower risk of death fromprostate cancer among men receiving PSA screening while astudy in the US found no reduction. Current research is exploringnew biologic markers for prostate cancer, as well as alternativeages of screening initiation and timing of testing, with the goalof identifying and treating men at highest risk for aggressive disease while minimizing unnecessary testing and treatment ofmen at low risk for prostate cancer death. See page 62 for theAmerican Cancer Society’s screening guidelines for the earlydetection of prostate cancer.20  Cancer Facts & Figures 2013Treatment: Treatment options vary depending on age, stage,and grade of cancer, as well as other medical conditions. Thegrade assigned to the tumor, typically called the Gleason score,indicates the likely aggressiveness of the cancer. Although scoresas low as 2 are theoretically possible, in practice most cancersare assigned scores ranging from 6 (low grade, less aggressive) to10 (high grade, very aggressive). Surgery (open, laparoscopic, orrobotic-assisted), external beam radiation, or radioactive seedimplants (brachytherapy) may be used to treat early stage disease. Data show similar survival rates for patients with earlystage disease treated with any of these methods, and there is nocurrent evidence supporting a “best” treatment for prostate cancer. Hormonal therapy before or after surgery may be indicatedin some cases. All of these treatments may impact a man’s qualityof life through side effects or complications that include urinaryand erectile difficulties. Accumulating evidence indicates thatcareful observation (“active surveillance”), rather than immediate treatment, can be an appropriate option for men with lessaggressive tumors and for older men.Hormonal therapy, chemotherapy, radiation, or a combination ofthese treatments is used to treat more advanced disease. Hormonetreatment may control advanced prostate cancer for long periodsby shrinking the size or limiting the growth of the cancer, thushelping to relieve pain and other symptoms. An option for somemen with advanced prostate cancer that is no longer respondingto hormones is a cancer vaccine known as sipuleucel-T (Provenge).For this treatment, special immune cells are removed from a man’sbody, exposed to prostate proteins in a lab, and then re-infusedback into the body, where they attack prostate cancer cells. Newer,more effective forms of hormone therapy, such as abiraterone(Zytiga) and enzalutamide (Xtandi), have been shown to be beneficial for the treatment of metastatic disease that is resistant toinitial hormone therapy and chemotherapy.Survival: The majority (93%) of prostate cancers are discoveredin the local or regional stages, for which the 5-year relative survival rate approaches 100%. Over the past 25 years, the 5-yearrelative survival rate for all stages combined has increased from68% to almost 100%. According to the most recent data, 10- and15-year relative survival rates are 98% and 93%, respectively.Obesity and smoking are associated with an increased risk ofdying from prostate cancer.SkinNew cases: The number of basal cell and squamous cell skin cancers (i.e., nonmelanoma skin cancers, or NMSC) is difficult toestimate because these cases are not required to be reported tocancer registries. One report on NMSC occurrence in the US estimated that 3.5 million cases were diagnosed and 2.2 millionpeople were treated for the disease in 2006, with some patientshaving multiple diagnoses. Most cases of these forms of skin cancer are highly curable. Melanoma is expected to be diagnosed inabout 76,690 persons in 2013, accounting for less than 5% of allskin cancer cases but the vast majority of skin cancer deaths.Melanoma is rare among African Americans; the lifetime risk ofdeveloping melanoma is 23 times higher among whites thanamong African Americans. Although before age 40, the incidencerate in women is twice that in men, after 40, the rate is higher inmen; among those 80 and older, the rate in men is three timesthat in women. Melanoma incidence rates have been increasingfor at least 30 years. From 2005 to 2009, incidence rates amongwhites increased by 2.8% per year.Deaths: An estimated 12,650 deaths (9,480 from melanoma and3,170 from other nonepithelial skin cancers) will occur in 2013.The death rate for melanoma has been declining rapidly inwhites younger than 50 years of age; from 2005 to 2009, ratesdecreased by 2.8% per year in men and by 2.0% per year inwomen. In contrast, among whites 50 years of age and older,death rates increased by 1.1% per year in men and were stable inwomen during this same time period.Signs and symptoms: Important warning signs of melanomainclude changes in size, shape, or color of a mole or other skinlesion or the appearance of a new growth on the skin. Changesthat progress over a month or more should be evaluated by adoctor. Basal cell carcinomas may appear as growths that areflat, or as small, raised, pink or red, translucent, shiny areas thatmay bleed following minor injury. Squamous cell carcinomamay appear as growing lumps, often with a rough surface, or asflat, reddish patches that grow slowly. Another sign of skin cancers is a sore that doesn’t heal.Risk factors: Risk factors vary for different types of skin cancer.For melanoma, major risk factors include a personal or familyhistory of melanoma and the presence of atypical or numerousmoles (more than 50). Other risk factors for all types of skin cancer include sun sensitivity (sunburning easily, difficulty tanning,natural blond or red hair color); a history of excessive sun exposure, including sunburns; use of tanning booths; diseases thatsuppress the immune system; and a past history of skin cancer.Prevention: Skin should be protected from intense sun exposure by covering with tightly woven clothing and a wide-brimmedhat, applying sunscreen that has a sun protection factor (SPF) of30 or higher to unprotected skin, seeking shade (especially atmidday, when the sun’s rays are strongest), and avoiding sunbathing and indoor tanning. Sunglasses should be worn toprotect the skin around the eyes. Children in particular shouldbe protected from the sun because severe sunburns in childhood may greatly increase risk of melanoma in later life. Tanningbeds and sun lamps, which provide an additional source of UVradiation, are associated with cancer risk and should be avoided.In 2009, the International Agency for Research on Cancerupgraded their classification of indoor tanning devices from“probably carcinogenic” to “carcinogenic to humans” after areassessment of the scientific evidence.Early detection: At this time, the best way to detect skin cancerearly is to recognize changes in skin growths, including theappearance of new growths. Adults should periodically examinetheir skin and be aware of any changes. New or unusual lesionsor a progressive change in a lesion’s appearance (size, shape, orcolor, etc.) should be evaluated promptly by a physician. Melanomas often start as small, mole-like growths that increase in sizeand may change color. A simple ABCD rule outlines the warningsignals of the most common type of melanoma: A is for asymmetry (one half of the mole does not match the other half); B isfor border irregularity (the edges are ragged, notched, orblurred); C is for color (the pigmentation is not uniform, withvariable degrees of tan, brown, or black); D is for diametergreater than 6 millimeters (about the size of a pencil eraser).Other types of melanoma may not have these signs, so be alertfor any new or changing skin growths.Treatment: Removal and microscopic examination of all suspicious skin lesions are essential. Early stage basal cell andsquamous cell cancers can be removed in most cases by one ofseveral methods: surgical excision, electrodesiccation andcurettage (tissue destruction by electric current and removal byscraping with a curette), or cryosurgery (tissue destruction byfreezing). Radiation therapy and certain topical medications maybe used in some cases. For malignant melanoma, the primarygrowth and surrounding normal tissue are removed and sometimes a sentinel lymph node is biopsied to determine stage. Moreextensive lymph node surgery may be needed if the sentinellymph nodes contain cancer. Melanomas with deep invasion orthat have spread to lymph nodes may be treated with surgery,immunotherapy, chemotherapy, and/or radiation therapy.Advanced cases of melanoma are treated with palliative surgery,immunotherapy, and/or chemotherapy, and sometimes radiation therapy. The targeted drug vemurafenib (Zelboraf) and theimmunotherapy drug ipilimumab (Yervoy) have recently beenapproved by the FDA based on improved survival in people withadvanced melanoma.Survival: Most basal cell and squamous cell cancers can be cured,especially if the cancer is detected and treated early. Melanomais also highly curable if detected in its earliest stages and treatedproperly. However, melanoma is more likely than other skintumors to spread to other parts of the body. The 5- and 10-yearrelative survival rates for persons with melanoma are 91% and89%, respectively. For localized melanoma (84% of cases), the5-year survival rate is 98%; survival declines to 62% and 15% forregional and distant stage disease, respectively.ThyroidNew cases: An estimated 60,220 new cases of thyroid cancer areexpected to be diagnosed in 2013 in the US, with 3 in 4 casesoccurring in women. The incidence rate of thyroid cancer hasbeen increasing sharply since the mid-1990s, and it is the fastest-Cancer Facts & Figures 2013  21increasing cancer in both men and women. From 2005 to 2009,incidence rates increased by 5.6% per year in men and 7.0% peryear in women.Deaths: An estimated 1,850 deaths from thyroid cancer areexpected in 2013 in the US. From 2005 to 2009, the death rate forthyroid cancer was stable at 0.5 per 100,000 in both men andwomen.Signs and symptoms: The most common symptom of thyroidcancer is a lump in the neck that is noticed by a patient or felt bya health care provider during a clinical exam. Other symptomsinclude a tight or full feeling in the neck, difficulty breathing orswallowing, hoarseness or swollen lymph nodes, and pain in thethroat or neck that does not go away. Although most lumps inthe thyroid gland are not cancerous, individuals who notice anabnormality should seek timely medical attention.Risk factors: Risk factors for thyroid cancer include beingfemale, having a history of goiter (enlarged thyroid) or thyroidnodules, a family history of thyroid cancer, and radiation exposure related to medical treatment during childhood. Radiationexposure as a result of radioactive fallout from atomic weaponstesting and nuclear power plant accidents, such as Chernobyl,has also been linked to increased risk of thyroid cancer, especially in children. Certain rare genetic syndromes also increaserisk. People who test positive for an abnormal gene that causes ahereditary form of thyroid cancer can decrease the risk of developing the disease with surgical removal of the thyroid gland.Unlike most other adult cancers, for which older age increasesrisk, 80% of newly diagnosed thyroid cancer patients are under65 years of age.Early detection: At present, there is no screening test recommended for the early detection of thyroid cancer in peoplewithout symptoms. However, because symptoms usually developearly, most thyroid cancers (68%) are diagnosed at an early stage.Tests used in the evaluation of thyroid nodules include: bloodtests to determine levels of hormones related to normal functions of the thyroid gland; medical imaging techniques todetermine the size and characteristics of the nodule and nearbylymph nodes; and biopsy to determine if the cells in the noduleare benign or malignant.Treatment: Most thyroid cancers are highly curable, thoughabout 5% of cases (medullary and anaplastic) are more aggressiveand more likely to spread to other organs. Treatment depends onthe cell type, tumor size, and extent of the disease. The firstchoice of treatment is surgery in nearly all cases. Total or partialremoval of the thyroid gland (thyroidectomy), with or withoutlymph node removal, is recommended for most patients. Treatment with radioactive iodine (I-131) after surgery to destroy anyremaining thyroid tissue may be recommended for moreadvanced disease. Hormone therapy is given after thyroidectomyto replace hormones normally produced by the thyroid gland22  Cancer Facts & Figures 2013and to prevent the body from making thyroid-stimulating hormone, decreasing the likelihood of recurrence.Survival: The 5-year relative survival rate for all thyroid cancerpatients is 98%. However, survival varies by stage, age at diagnosis, and disease subtype. The 5-year survival rate approaches100% for localized disease, is 97% for regional stage disease, and54% for distant stage disease. For all stages combined, survival ishighest for patients younger than 45 years of age (almost 100%),and progressively decreases to 83% for those 75 or older.Urinary BladderNew cases: An estimated 72,570 new cases of bladder cancer areexpected to occur in 2013. From 2005 to 2009, bladder cancerincidence rates were stable in men and decreased by 1.3% peryear in women. Bladder cancer incidence is about four timeshigher in men than in women and almost two times higher inwhite men than in African American men.Deaths: An estimated 15,210 deaths will occur in 2013. From2005 to 2009, death rates were stable in men and decreasing by0.6% per year in women.Signs and symptoms: The most common symptom is blood inthe urine. Other symptoms may include increased frequency orurgency of urination and irritation during urination.Risk factors: Smoking is the most well-established risk factor forbladder cancer. Smokers’ risk of bladder cancer is approximatelyfour-fold that of nonsmokers’, and smoking is estimated to causeabout half of all bladder cancer cases in both men and women.Workers in the dye, rubber, leather, and aluminum industries,painters, and people who live in communities with high levels ofarsenic in the drinking water also have an increased risk.Early detection: There is currently no screening method recommended for people at average risk. Bladder cancer is diagnosedby microscopic examination of cells from urine or bladder tissueand examination of the bladder wall with a cystoscope, a slendertube fitted with a lens and light that can be inserted through theurethra. These and other tests may be used to screen people atincreased risk, due to occupational exposure or certain bladderbirth defects, and during follow up after bladder cancer treatmentto detect recurrent or new tumors.Treatment: Surgery, alone or in combination with other treatments, is used in more than 90% of cases. Early stage cancers maybe treated by administering immunotherapy or chemotherapydrugs directly into the bladder after surgery. More advancedcancers may require removal of the entire bladder (cystectomy).Patient outcomes are improved with the use of chemotherapy,alone or with radiation, before cystectomy. Timely follow-upcare is extremely important because of the high rate of bladdercancer recurrence.Survival: For all stages combined, the 5-year relative survivalrate is 78%. Survival declines to 71% at 10 years and 65% at 15years after diagnosis. Half of all bladder cancer patients arediagnosed while the tumor is in situ (noninvasive, present onlyin the layer of cells in which the cancer developed), for which the5-year survival is 96%. Patients with invasive tumors diagnosedat a localized stage have a 5-year survival rate of 70%; 35% ofcancers are detected at this early stage. For patients diagnosedwith regional and distant staged disease, 5-year survival is 33%and 6%, respectively.Uterine CervixNew cases: An estimated 12,340 cases of invasive cervicalcancer are expected to be diagnosed in 2013. Large declines inincidence rates over most of the past several decades have begunto taper off, particularly among younger women; from 2005 to2009, rates were stable in women younger than 50 years anddecreased by 3.0% per year in women 50 and older.Deaths: An estimated 4,030 deaths from cervical cancer areexpected in 2013. Mortality rates declined rapidly in pastdecades due to prevention and early detection as a result ofscreening with the Pap test, but have begun to level off in recentyears. From 2005 to 2009, rates were stable among both womenyounger than 50, and among those 50 years and older.Signs and symptoms: Symptoms usually do not appear untilabnormal cervical cells become cancerous and invade nearbytissue. When this happens, the most common symptom is abnormal vaginal bleeding. Bleeding may start and stop betweenregular menstrual periods, or it may occur after sexual intercourse, douching, or a pelvic exam. Menstrual bleeding may lastlonger and be heavier than usual. Bleeding after menopause orincreased vaginal discharge may also be symptoms.Risk factors: The cause of cervical cancer is persistent infectionwith certain types of human papillomavirus (HPV). Whilewomen who begin having sex at an early age or who have hadmany sexual partners are at increased risk for HPV infectionand cervical cancer, a woman may be infected with HPV even ifshe has had only one sexual partner. In fact, HPV infections arecommon in healthy women and are typically cleared successfully by the immune system; only rarely does the infection persistand result in cervical cancer. Persistence of HPV infection andprogression to cancer may be influenced by many factors,including a suppressed immune system, high parity (number ofchildbirths), and cigarette smoking. Long-term use of oral contraceptives (birth control pills) is also associated with increasedrisk of cervical cancer.Prevention: There are two vaccines (Gardasil and Cervarix)approved for use in females 9 to 26 years of age for the preventionof the most common types of HPV infection that cause cervicalcancer. Gardasil is also approved for the prevention of anal, vaginal, and vulvar cancers (and precancers) in women and for theprevention of anal and penile cancers in males 9 to 26 years ofage; approximately 90% of anal cancers have been linked to HPVinfection. These vaccines may also protect against HPV-relatedhead and neck cancers, which have been increasing in recentyears. HPV vaccines cannot protect against established infections, nor do they protect against all types of HPV.Screening can prevent cervical cancer by detecting precancerouslesions. As screening has become more common, precancerouslesions of the cervix are detected far more frequently than invasive cancer. The Pap test is the most widely used cervical cancerscreening method. It is a simple procedure in which a small sample of cells is collected from the cervix and examined under amicroscope. Pap tests are effective, but not perfect. Sometimesresults are reported as normal when abnormal cells are present(false negative), and likewise, sometimes test results are positivewhen no abnormal cells are present (false positive). HPV tests,which detect types of HPV associated with cervical cancer, canforecast cervical cancer risk many years in the future and areused in conjunction with the Pap test, either as an additionalscreening test or when Pap test results are uncertain. Fortunately, most cervical precancers develop slowly, so most cancerscan be prevented if a woman is screened regularly. It is important for all women, even those who have received the HPVvaccine, to follow cervical cancer screening guidelines.Early detection: In addition to preventing cancer, cervical cancer screening can detect cancer early, when treatment is mostsuccessful. It is important that all eligible women be screenedaccording to guidelines; most cervical cancers are detected inwomen who have never or not recently been screened. TheAmerican Cancer Society, in collaboration with the AmericanSociety for Colposcopy and Cervical Pathology and the AmericanSociety for Clinical Pathology, issued new screening guidelinesfor the prevention and early detection of cervical cancer in 2012.The most important changes to the guidelines are the age rangefor which screening is appropriate and the emphasis on theincorporation of HPV testing in addition to the Pap test. Amongwomen at average risk, screening is now recommended for ages21 years through 65 years and the preferred screening methodfor women 30 to 65 years is now HPV and Pap “co-testing” everyfive years. For more detailed information on the AmericanCancer Society’s screening guidelines for the early detection ofcervical cancer, see page 60.Treatment: Preinvasive lesions may be treated by electrocoagulation (the destruction of tissue through intense heat by electriccurrent), cryotherapy (the destruction of cells by extreme cold),laser ablation, or local surgery. Invasive cervical cancers aregenerally treated with surgery, radiation, or both, and withchemotherapy in selected cases.Cancer Facts & Figures 2013  23Survival: One- and 5-year relative survival rates for cervicalcancer patients are 87% and 68%, respectively. The 5-year survival rate for patients diagnosed with localized disease is 91%.Cervical cancer is diagnosed at an early stage more often inwhites (49%) than in African Americans (40%) and more often inwomen younger than 50 years of age (59%) than in women 50and older (33%).Uterine Corpus (Endometrium)New cases: An estimated 49,560 cases of cancer of the uterinecorpus (body of the uterus) are expected to be diagnosed in 2013.These usually occur in the endometrium (lining of the uterus).From 2005 to 2009, incidence rates of endometrial cancer werestable in white women, but increasing in African Americanwomen by 2.2% per year.Deaths: An estimated 8,190 deaths are expected in 2013. Deathrates for cancer of the uterine corpus were stable in whitewomen, but increasing slightly (by 0.4% per year) in AfricanAmerican women from 2005 to 2009.Signs and symptoms: Abnormal uterine bleeding or spotting(especially in postmenopausal women) is a frequent early sign.Pain during urination, intercourse, or in the pelvic area is also asymptom.Risk factors: Obesity and greater abdominal fatness increasethe risk of endometrial cancer, most likely by increasing theamount of estrogen in the body. Estrogen exposure is a strongrisk factor for endometrial cancer. Other factors that increase24  Cancer Facts & Figures 2013estrogen exposure include menopausal estrogen therapy (without use of progestin), late menopause, never having children,and a history of polycystic ovary syndrome. (Estrogen plus progestin menopausal hormone therapy does not appear to increaserisk.) Tamoxifen, a drug used to reduce breast cancer risk,increases risk slightly because it has estrogen-like effects on theuterus. Medical conditions that increase risk include Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer(HNPCC), and diabetes. Pregnancy, use of oral contraceptives orintrauterine devices, and physical activity provide protectionagainst endometrial cancer.Early detection: There is no standard or routine screeningtest for endometrial cancer. Most endometrial cancer (68%) isdiagnosed at an early stage because of postmenopausal bleeding. Women are encouraged to report any unexpected bleedingor spotting to their physicians. The American Cancer Societyrecommends that women with known or suspected Lynchsyndrome be offered annual screening with endometrial biopsyand/or transvaginal ultrasound beginning at 35 years of age.Treatment: Uterine corpus cancers are usually treated withsurgery, radiation, hormones, and/or chemotherapy, dependingon the stage of disease.Survival: The 1- and 5-year relative survival rates for uterinecorpus cancer are 92% and 82%, respectively. The 5-year survivalrate is 95%, 67%, or 16%, if the cancer is diagnosed at a local,regional, or distant stage, respectively. Relative survival in whitesexceeds that for African Americans by more than 8 percentagepoints at every stage of diagnosis.Special Section:Pancreatic CancerCancer of the pancreas is one of the deadliest cancer types. Mostpancreatic cancer patients will die within the first year of diagnosis, and just 6% will survive five years. Over the past decade,pancreatic cancer death rates have been slowly increasingamong US men and women, in contrast to the downward trendin rates for most other major cancer sites, such as lung, colorectum, female breast, and prostate. The lack of progress in primaryprevention, early diagnosis, and treatment underscores the needfor additional efforts in pancreatic cancer research and hasmotivated us to address this disease in the current edition ofCancer Facts & Figures. Specifically, this special section providesupdated information on occurrence, prevention, early detection,diagnosis, and treatment of pancreatic cancer. This informationis intended to inform anyone interested in learning more aboutpancreatic cancer, including policy makers, researchers, clinicians, cancer control advocates, patients, and caregivers.The pancreas contains two types of glands that each performvery different functions. The exocrine glands produce enzymesthat help digest food; the endocrine glands produce importanthormones such as insulin, which regulates blood sugar levels.Exocrine and endocrine cells form completely different types oftumors with distinct risk factors, symptoms, diagnostic tests,treatment, and survival rates. Exocrine tumors are the focus ofthis special section because they are by far the most commontype of pancreatic cancer, representing about 95% of cases.How Many Cases and Deaths Are Estimatedto Occur in 2013?Pancreatic cancer is the 10th most common cancer diagnosisamong men and the 9th most common among women in the US.In 2013, an estimated 45,220 new cases of pancreatic cancer willbe diagnosed nationwide.Pancreatic cancer accounts for about 7% of all cancer deathsand ranks fourth as a cause of cancer death among both menand women in the US. In 2013, approximately 38,460 people areexpected to die from pancreatic cancer nationwide.Who Gets Pancreatic Cancer?Sex•  Pancreatic cancer is about 30% more common in men thanin women. During 2005-2009, the age-adjusted incidence rate(per 100,000 persons) of pancreatic cancer was 13.6 for menand 10.5 for women.•  The lifetime risk of developing pancreatic cancer is about1.5% for both men and women (Table 1).•  Men are more likely than women to develop pancreaticcancer at every age after 35 years (Figure 1a, page 26).•  During 2005-2009, the age-adjusted death rate (per 100,000 persons) for pancreatic cancer was 12.5 for men and 9.5 for women.Age•  Pancreatic cancer incidence and death rates increase withadvancing age, with a steep increase after about age 50.•  During 2005-2009, the incidence rate (per 100,000) in menwas 1.2 among those 35 to 39 years of age compared to 100.5among those 85 years and older; in women the rate was 1.0among those 35 to 39 years of age compared to 87.7 amongthose 85 years and older (Figure 1a, page 26).•  During 2005-2009, the median age at diagnosis of pancreaticcancer was 71 years of age. This means that about half of allpatients developed this disease when they were older thanage 71.•  The likelihood of developing pancreatic cancer in the next 10years is about four times higher at age 70 than at age 50 (Table 1).Race/Ethnicity•  Pancreatic cancer incidence and mortality rates vary acrossdifferent racial/ethnic groups, with the highest rates inAfrican Americans and the lowest rates in Asian Americans/Pacific Islanders (Figure 2, page 27).•  Incidence rates are higher in African Americans than inwhites at every age (Figure 1b, page 26).•  During 2005-2009, the incidence rate (per 100,000 persons)was 15.3 for African Americans, 11.6 for whites, and 8.8 forAsian Americans/Pacific Islanders.Table 1. Probability (%) of Developing PancreaticCancer over Selected Age Intervals by Sex, US,2007-2009*Age0 to 3940-4950-5960-6970-79Lifetime riskMaleFemale0.01 (1 in 9,746)0.01 (1 in 9,479)0.05 (1 in 2,063)0.04 (1 in 2,674)0.18 (1 in 563)0.12 (1 in 843)0.41 (1 in 241)0.30 (1 in 335)0.65 (1 in 155)0.56 (1 in 179)1.48 (1 in 67)1.45 (1 in 69)*For people free of cancer at beginning of age interval. Percentages and “1in” numbers may not be equivalent due to rounding.Source: DevCan: Probability of Developing or Dying of Cancer Software,Version 6.6.1. Statistical Research and Applications Branch, National CancerInstitute, 2012.srab.cancer.gov/devcan.Cancer Facts & Figures 2013  25Figure 1. Pancreatic Cancer Incidence Rates* by Age and Sex (a) and Age and Race (b), US, 2005-2009.a.b.125100100African AmericanMale7550+-8485-69-64-59-74706560-49-545550-44Age45-34-29-24-394035302520+-84-79-74-69-64-59858075706560-49-44-5455504540353020-390-340-2925-2425-79WhiteFemale8050757525Incidence rate (per 100,000)125Age*Age adjusted to the 2000 US standard population.Source: North American Association of Central Cancer Registries (NAACCR). Data are collected by cancer registries participating in NCI’s SEER program and CDC’sNational Program of Cancer Registries.American Cancer Society, Surveillance Research, 2013•  Mortality rates (per 100,000 persons) during the correspondingtime interval were 13.8, 10.7, and 7.5 for African Americans,whites, and Asian American/Pacific Islanders, respectively.•  Racial differences in pancreatic cancer rates are largelyexplained by established risk factors, such as cigarettesmoking, obesity, and diabetes.1Socioeconomic statusNumber of years of education is one measure of socioeconomicstatus used by researchers to study health disparities.•  Pancreatic cancer death rates are higher among those withfewer years of education.•  One study found that in 2007, the pancreatic cancer deathrate among non-­Hispanic white men 25 to 64 years of age wasabout 80% higher for those with 12 or fewer years of educationthan for those with 16 or more years of education; among nonHispanic white women, the death rate for the less-educatedgroup was double that of the most educated.2•  This study also found that from 1993 to 2007, pancreaticcancer death rates among non-Hispanic white men andwomen 25 to 64 years of age increased among those with theleast education, but remained stable among those with themost education.2•  Another study found that low income was associated withan 80% increased risk of pancreatic cancer in white menand a 170% increased risk in African American men afteraccounting for differences in smoking, dietary factors, andheavy alcohol drinking.126  Cancer Facts & Figures 2013Are There Geographic Differences inPancreatic Cancer in the US?•  Despite substantial international variation, within the US,pancreatic cancer incidence and mortality rates vary onlyslightly between states.•  Among whites, pancreatic cancer death rates are highest inthe Northeast, and range from 8.4 (per 100,000) in the Districtof Columbia to 12.1 in Connecticut (Figure 3, page 28).•  Among African Americans, death rates are highest in theMidwest, and range from 7.8 (per 100,000) in West Virginia to18.9 in Iowa (Figure 3, page 28).How Has the Occurrence of Pancreatic CancerChanged over Time?Incidence trendsDuring the past 10 years of data (2000-2009), for which we havecoverage for almost the entire US, pancreatic cancer incidencerates increased by 0.9% per year among white men, whitewomen, and African American men, while rates remained stablefor African American women and men and women of all othermajor racial and ethnic groups.3Mortality trendsAlthough the pancreatic cancer death rate increased for theoverall US over the past 10 years of data (2000-2009), this increasewas confined to white men and women (by 0.5% per year) andAsian American and Pacific Islander men (by 1.0% per year). 3Figure 2. Pancreatic Cancer Incidence and MortalityRates* by Race and Ethnicity†, US, 2005-2009.20Rate per 100,00016IncidenceMortality15.213.811.71210.910.69.98.388.88.87.540with an even greater risk of pancreatic cancer and a younger ageof disease onset.16 Abdominal obesity may increase risk independent of general obesity, especially in women.15,17Results regarding the association between physical activity andpancreatic cancer risk are mixed.14,18-21 A slightly decreased risk ofpancreatic cancer was linked to total and occupational physicalactivity in a recent literature review 22 but not in a previous one.23There is currently limited evidence to support a protective effectof recreational physical activity on risk of pancreatic cancer.22Alcohol useAfricanAmericanNon-HispanicWhiteHispanic/LatinoAmerican Indian/ Asian American/Alaska NativePacific Islander*Per 100,000, age adjusted to the 2000 US standard population. †Persons ofHispanic/Latino origin may be of any race.Sources: Incidence: North American Association of Central Cancer Registries(NAACCR) data; Mortality: US mortality data, National Center for HealthStatistics, Centers for Disease Control and Prevention. Data for AmericanIndians/Alaska Natives are based on Contract Health Service Delivery Area(CHSDA) counties.American Cancer Society, Surveillance Research, 2013Can Pancreatic Cancer Be Prevented?The causes of pancreatic cancer are not well understood, thoughthere are several factors known to increase risk. Known modifiable risk factors include obesity, cigarette smoking, and otherforms of tobacco use. Risk factors that are not modifiable includea family history of pancreatic cancer and certain inheritedsyndromes. Strategies for preventing pancreatic cancer includenot smoking and maintaining normal body weight. Consumingadequate quantities of fruits and vegetables may also have apreventive effect, although strong evidence for this associationis lacking.Modifiable Risk FactorsTobacco useTobacco use is the most important known risk factor for pancreaticcancer; approximately 20% of pancreatic cancers are attributableto cigarette smoking.4 The risk of developing pancreatic canceris about twice as high among smokers as among never smokers;5risk increases with greater tobacco use and longer duration ofsmoking.6,7 Cigar and pipe smoking also increase risk.8,9 Quittingsmoking rapidly reduces the risk of pancreatic cancer; after 5-10years of cessation, the risk among former smokers returns tothat of never smokers.4,10 Use of smokeless tobacco products alsoincreases the risk of pancreatic cancer.11 Evidence on secondhandsmoke exposure and pancreatic cancer is inconsistent.12Obesity and physical activityObesity has also been fairly consistently linked to increased riskof pancreatic cancer. Obese individuals have a 20% higher riskof developing pancreatic cancer than those who are normalweight.13-15 Being obese during early adulthood may be associatedWhether alcohol use causes pancreatic cancer remains to bedetermined. A positive association between alcohol use andpancreatic cancer was found in several but not all studies.24Accumulating evidence suggests that a moderate increased riskis limited to heavy alcohol users.25 A recent meta-analysis showedthat consumption of three or more drinks of alcohol per day isassociated with a 20% to 30% increased risk of pancreatic cancer.25 However, due to the strong relationship between alcoholconsumption and tobacco use, it is difficult to eliminate theeffect of smoking when studying the association between alcohol drinking and pancreatic cancer risk.Dietary factorsA number of dietary factors have been assessed regarding theirassociation with pancreatic cancer risk. There is some evidencethat the consumption of red and processed meat may slightlyincrease risk.26 Investigators have also found some evidence forincreased risk among those who consume meat that has beencooked at very high temperatures.27 A protective effect of folateintake on pancreatic cancer risk has been reported in severalstudies;28 however, a recent large analysis found no association.29At present, there is limited evidence supporting a protectiveeffect of fruit and vegetable consumption on the risk of pancreatic cancer.30-33 No association between coffee consumption andpancreatic cancer was found in a recent analysis that combinedmany studies.34Sunlight and vitamin DStudies are conflicting about the relationship between sunlight,vitamin D, and pancreatic cancer. Several studies have found thatsun exposure is associated with lower pancreatic cancer deathrates, suggesting that vitamin D, acquired primarily through sunexposure to the skin, may be protective against pancreatic cancer.35-37 However, results from epidemiological studies thatassessed individual-level vitamin D intake and pancreatic cancerrisk have been inconsistent. Two large studies found that bothdietary vitamin D and vitamin D derived from both diet and sunlight exposure are protective.38,39 Conversely, a recently publishedanalysis found that while there was no association between lowlevels of vitamin D and pancreatic cancer, high vitamin D levelswere associated with an increased risk of pancreatic cancer.40Cancer Facts & Figures 2013  27Figure 3. Geographic Patterns in Pancreatic Cancer Death Rates* by State and Race, US, 2005-2009.WhitesWAMTNHNDMEVTORMNMAIDWISDWYMIRIILUTDEWVMOSCMSTXAKNCARNMMDDCVAKYTNOKAZNJOHINCOKSCTPAIANENVCANYGAALRate per 100,000LA8.4-10.210.3-10.7FL10.8-11.111.2-12.1HIAfrican AmericansWAMTNHNDMEVTORMNMAIDWISDWYMIRIILUTDEWVMOOKAZNMTXVAKYMDDCNCTNARSCMSAKNJOHINCOKSCTPAIANENVCANYALGARate per 100,000LA7.8-13.513.6-14.5FL14.6-15.615.7-18.9HIInsufficient data*Age adjusted to the 2000 US standard population. Insufficient data indicates states with fewer than 20 deaths.Source: US mortality data, National Center for Health Statistics, Centers for Disease Control and Prevention.American Cancer Society, Surveillance Research, 201328  Cancer Facts & Figures 2013Non-modifiable Factors and Medical ConditionsFamily historyA number of studies have linked family history to an increasedrisk of pancreatic cancer. Generally, individuals with a familyhistory of pancreatic cancer have a nearly 2-fold increased risk fordeveloping pancreatic cancer, compared to those without such ahistory.41 The risk increases to 7- to 9-fold for individuals with atleast 1 first-degree relative (a parent or sibling) with pancreaticcancer and 17- to 32-fold for individuals with 3 or more firstdegree relatives with pancreatic cancer.42,43 Risk is also increasedif a first-degree relative was diagnosed with pancreatic cancerbefore age 50.43Genetic factorsGenetic factors (factors related to gene variations or alterations)account for approximately 5% to 10% of all pancreatic cancercases.44,45 There are several gene mutations that are associatedwith an increased risk of pancreatic cancer, though these areextremely rare in the general population.46,47 Mutations in theBRCA2 gene are associated with a 3- to 10-fold increased risk ofpancreatic cancer and account for the highest proportion (5% to17%) of known causes of inherited pancreatic cancer.48-50 Mutations in the CDKN2A gene, which are linked to the familialatypical multiple mole-melanoma (FAMMM) syndrome, areassociated with an approximately 13- to 22-fold increased risk ofpancreatic cancer.51 Patients with Peutz-Jeghers Syndrome (PJS),which is usually caused by STK11 mutations, have an 11% to 36%chance of developing pancreatic cancer during their lifetime.52,53The risk among people with hereditary pancreatitis (inflammation of the pancreas) linked to PRSS1 mutations is approximately70 times greater than that expected in the normal population,with lifetime risk of developing pancreatic cancer approximately40% to 55%.54 Patients with hereditary non-polyposis colorectalcancer (HNPCC or Lynch syndrome), which is most often causedby MLH1 or MSH2 mutations, have about a 9-fold increased riskof developing pancreatic cancer.45,55 Recent studies have foundthat people with non-O blood groups (i.e., blood groups A, AB,and B) have a slightly increased risk of pancreatic cancer, thoughthe mechanisms of this association are still unclear.56-58Chronic pancreatitis (inflammation of the pancreas)Accumulating evidence suggests that long-standing chronicpancreatitis is a strong risk factor for pancreatic cancer, thoughpancreatitis may also be an early indicator of pancreatic cancer.54,59,60 After excluding the pancreatic cancer cases diagnosedwithin 2 years from chronic pancreatitis diagnosis, a review studyreported a 6-fold increased risk of pancreatic cancer amongpatients with chronic pancreatitis.54 The risk is especially strongin patients with rare types of pancreatitis, such as hereditarypancreatitis and tropical pancreatitis. The lag period betweenpancreatitis diagnosis and pancreatic cancer onset is usuallyabout 10 to 20 years. Despite the strong association betweenchronic pancreatitis and pancreatic cancer, chronic pancreatitisis uncommon; moreover, only about 4% of these patients willdevelop pancreatic cancer within 20 years of diagnosis.59DiabetesAbout 25% of patients with pancreatic cancer have diabetes mellitus at diagnosis, and roughly another 40% have pre-diabetes(higher than normal blood glucose levels).61,62 Compared withnon-diabetic individuals, patients with long-term (≥ 5 years)type-II diabetes have a 50% increased risk of pancreatic cancer.63Pancreatic cancer can cause diabetes, and sometimes diabetes isan early sign of the tumor.62 Elevated pancreatic cancer risk hasalso been reported among individuals with type-I diabetes.64Recent reports also suggest that hyperglycemia (high blood glucose), abnormal glucose metabolism, and insulin resistance areassociated with increased risk of pancreatic cancer.65-69Infection and other medical conditionsSeveral studies have detected an increased risk of pancreaticcancer among people with chronic infections with hepatitis Bvirus, hepatitis C virus,70,71 and Helicobacter pylori.72 Individualswith a history of cholecystectomy (surgical removal of the gallbladder)73 or partial gastrectomy (partial surgical removal of thestomach)74 have also been found to be at increased risk of developing pancreatic cancer. Other medical conditions that mayincrease risk include cystic fibrosis75 and periodontal disease.76Can Pancreatic Cancer Be Detected Early?Early stage pancreatic cancer usually has no symptoms. Whensymptoms do occur, the tumor has usually spread to surroundingtissues or distant organs. Common symptoms of pancreatic cancer include mild abdominal discomfort, mid-back pain, jaundice(yellowing of the skin or whites of the eyes), and weight loss. Nausea and vomiting may occur among patients with more advanceddisease. In the US, only about 15% to 20% of pancreatic cancercases are diagnosed early enough to be eligible for surgery.To date, there is no single, reliable test for the early detection ofpancreatic cancer; therefore, screening the general population isnot recommended by any health agency.77 Existing screeningprograms have been limited to research settings with a focus ondetecting precancerous lesions among high-risk individuals.78The most frequently tested techniques for pancreatic cancerscreening include endoscopic ultrasound (EUS), helical computedtomography (CT), magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography (ERCP). Single useof EUS or various combinations of these imaging techniques arecapable of detecting early pancreatic cancer or precancer inhigh-risk patients, such as those with chronic, hereditary, ortropical pancreatitis; Peutz-Jeghers syndrome; cystic fibrosis; orfamilial atypical multiple mole-melanoma.79-81 However, it remainsunclear whether screening high-risk populations is effective inCancer Facts & Figures 2013  29Table 2. Median Pancreatic Cancer Survival byStage at DiagnosisStageMedian Survival*IA24.1 MonthsIB20.6 MonthsIIA15.4 MonthsIIB12.7 MonthsIII10.6 MonthsIV4.5 Months*Data from Bilimoria et al.84reducing pancreatic cancer mortality. Therefore, pancreatic cancer screening should currently be limited to high-risk populationswithin a research setting.78 Recent advances in understandingthe molecular basis of cancer offer promise for the discovery ofnew methods for detecting pancreatic cancer early.How Is Pancreatic Cancer Diagnosed?When pancreatic cancer is suspected, patients will be asked toprovide a full medical history and be given a physical exammainly focused on the abdomen, but also of the skin and eyes forindications of jaundice (yellow coloring). Pancreatic cancer istypically diagnosed with the use of an imaging test, usually a CTscan, often with a contrast dye, given by mouth or through injection, to better outline abnormal areas.46,82 This procedure is alsooften used to stage the tumor, with 70% to 85% accuracy for predicting whether or not the tumor can be surgically removed. Ifpancreatic cancer is highly suspected but a CT scan appearsnormal, additional diagnostic tests, such as endoscopic ultrasound or ERCP, may be performed. The ERCP technique isespecially useful in patients with bile duct tumors83 and endoscopic ultrasound can often detect small tumors missed by CTscan. A cancer diagnosis is typically confirmed with a biopsy – aprocedure in which a small sample of the tumor is removed andviewed under a microscope. The most common type of biopsy toconfirm pancreatic cancer is called a fine needle aspirationbiopsy. The needle is inserted into the pancreas guided by anendoscopic ultrasound or CT scan images to obtain tissues forevaluation. However, a tissue diagnosis is not needed for patientswho are scheduled for surgery. Due to the deep location of thepancreas and the medical complications of biopsy, pancreaticcancer is the least likely of all major cancers to be microscopically confirmed.30  Cancer Facts & Figures 2013What Factors Influence Pancreatic CancerSurvival?The prognosis (disease course and expected outcome) of pancreatic cancer is largely determined by the stage of disease atdiagnosis, which is based on the tumor’s size, whether there islymph node involvement, and the extent of spread locally and todistant organs. Table 2 presents the characteristics and mediansurvival time for each stage of invasive pancreatic cancer. Themedian survival ranges from 4.5 months for the most advancedstage to 24.1 months for the earliest stage.84At present, surgery provides the only chance of prolonged survival for pancreatic cancer patients. Even for patients with atumor that has been surgically removed (generally Stages I or II),the 5-year survival is only about 20% to 25%. Indications of a poorsurvival outcome include positive resection margins (cancercells at the outer edge of the removed tissue), poor tumor differentiation (the tumor does not resemble pancreatic tissue), alarge tumor size, lymph node involvement, high levels of preoperative carbohydrate (or cancer) antigen 19-9 (CA19-9), andpersistently elevated levels of postoperative CA 19-9.46,85-89 Inaddition, several molecular markers have been associated withpoor outcome after surgery.90,91 As these molecular markers weremainly evaluated in small studies, their value requires furthervalidation in larger studies, and thus none have been routinelyused in clinical practice.How Is Pancreatic Cancer Treated?TreatmentPatients with pancreatic cancer are best managed by a multi­disciplinary team, including surgeons, medical and radiationoncologists, radiologists, gastroenterologists, pain managementexperts, nutritionists, social workers, and others. The treatmentchoice is largely determined by whether the tumor can be surgically removed. Surgery remains the only treatment that offers achance of cure for pancreatic cancer patients.92For those patients who are candidates for surgery (approximately 20% of all pancreatic cancer patients), the operativeapproaches include cephalic pancreatoduodenectomy (theWhipple procedure), distal pancreatectomy, or total pancreatectomy, depending on the location of the tumor (see sidebar onpage 31). Postoperative (adjuvant) chemotherapy either alone orin combination with radiation has been proven to improve progression-free and overall survival in both randomized controlledtrials and observational studies.93,94 The role of radiation therapyby itself in the adjuvant setting remains unclear.95 Treatmentwith chemotherapy or chemoradiotherapy prior to surgery (neoadjuvant) is an emerging strategy. The goal of neoadjuvanttreatment is to increase the ability to successfully remove all ofthe tumor.96 However, there is no evidence that neoadjuvanttherapy is superior to adjuvant therapy, especially among thosepatients who clearly have resectable disease.97 For this reason,Pancreatic Cancer Treatment OptionsSurgery•  Cephalic pancreatoduodenectomy (Whipple procedure) is the removal of the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct, retaining enough of the pancreas to produce digestive juices and insulin.•  Distal pancreatectomy is the removal of the body and the tail of the pancreas as well as the spleen.•  Total pancreatectomy is the removal of the whole pancreas, part of the stomach, part of the small intestine, the common bile duct,the gallbladder, the spleen, and nearby lymph nodes.Chemotherapy is the use of drugs to kill cancer cells by preventing them from growing and dividing. Gemcitabine is usually the recommended first-line drug for pancreatic cancer patients. It can be given alone or in combination with other drugs.Radiation therapy is the use of high-energy radiation to control or kill cancer cells. Radiation can be delivered by a machine outsidethe body (external beam radiation) or can come from a radioactive substance implanted in or near the cancer (internal radiation orbrachytherapy). Brachytherapy is rarely used in treating pancreatic cancer.Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both. The side effects of this combination therapy are more severe than either therapy alone.Targeted therapy is the use of drugs or other substances to inhibit the growth of cancer cells by interfering with specific moleculesinvolved in tumor progression. Erlotinib, which targets the epidermal growth factor receptor (EGER), may be used with gemcitabineamong pancreatic cancer patients with advanced disease.neoadjuvant treatment is considered more relevant for patientswith locally advanced or borderline resectable disease.97-99The treatment for patients with advanced disease focuses onmanaging symptoms and relieving pain and suffering (palliative care). Treatment options include chemotherapy alone or incombination with radiation. The combination of 5-FU, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) can help prolonglife in patients with advanced disease, though many patients aretoo ill to tolerate this regimen. Other treatment options includegemcitabine alone or in combination with a platinum agent,erlotinib (Tarceva), or fluoropyrimidine.82Supportive careGiven the poor survival and persistent symptoms experiencedby many pancreatic cancer patients who do not respond to treatment, care focusing on relieving and preventing sufferingrepresents an important aspect of managing this disease. Palliative care should be offered at the initiation of any treatmentregimen in order to relieve symptoms and side effects, whichinclude pain, bile duct or gastric outlet obstruction, and loss ofappetite. Palliative efforts may also include psychological support to relieve patients’ stresses associated with pancreaticcancer diagnosis and treatment.Opioid analgesics (morphine and similar drugs) are often neededto help reduce pain. Radiation may be given to help relieve painfrom locally advanced disease. Another pain managementapproach is nerve block, whereby a pain specialist injects eitheran anesthetic or a medication to block or destroy the nerves. Forexample, abdominal pain can sometimes be treated effectivelyby endoscopic ultrasound or CT guided celiac plexus block.If the tumor is blocking the bile duct, a stent (a thin tube) can beplaced to relieve the blockage using nonsurgical approaches,such as ERCP and percutaneous transhepatic cholangiogram(PTC). If a patient develops gastric-outlet obstruction, treatmentmay include duodenal wall stents or PEG (percutaneous endoscopic gastrostomy) placement for decompression. Sometimes,a patient may need surgery to create a bypass (biliary bypass orgastric bypass) to manage obstructive jaundice and gastric outlet obstruction.If the pancreas is not working well or has been partially orentirely removed, a special diet and specially prescribed enzymesmay help the patient’s digestion. Meeting with a nutritionist isalso often very helpful for patients who are losing weight and havea poor appetite because of their disease.What Is the American Cancer Society Doingabout Pancreatic Cancer?ResearchThe American Cancer Society, through its Extramural Grantsprogram, funds individual investigators in medical schools,universities, research institutes, and hospitals throughout theUnited States. Currently, this program is funding $8,077,500 inpancreatic cancer research through 32 research grants. Ongoingresearch includes:•  Identifying new avenues of early detection and treatmentthrough better understanding of the biological mechanisms ofpancreatic cancer development, progression, and metastasis•  Determining the optimal sequencing strategy for pancreaticcancer treatment through mathematical decision analysisCancer Facts & Figures 2013  31•  Examining new biomarkers for drug response to optimizethe effectiveness of common chemotherapeutic agents, suchas gemcitabineResources outside the American Cancer Society•  Testing new therapeutic agents for targeted therapy, such asPARP inhibitors and glutaminase inhibitors•  Pancreatic Cancer Action Network: pancan.org/•  Exploring targeted delivery of pro-apoptotic therapeuticsinto pancreatic cancer cells•  Integrating immunotherapy into pancreatic cancertreatment regimens•  The Lustgarten Foundation: lustgarten.org/•  Hirshberg Foundation for Pancreatic Cancer Research:pancreatic.org/•  National Pancreas Foundation: pancreasfoundation.org/The Society’s intramural research program also conducts a widerange of research on pancreatic cancer. For example, researchersfrom the surveillance research program monitor trends in pancreatic cancer incidence and mortality, and recently published astudy showing that socioeconomic disparities in pancreaticcancer death rates widened among working-age US populationsduring 1993-2007. Using data collected in the Society’s CancerPrevention Study II (CPS-II), Society epidemiologists have alsoexamined the relationship between pancreatic cancer death andvarious factors, including alcohol consumption, carbohydrateintake, aspirin use, and reproductive patterns. In addition, theCPS-II Nutrition Cohort is part of a large international Pancreatic Cancer Cohort Consortium (PanScan), which aims to identifygenetic factors, environmental exposures, and gene-environmentinteractions that contribute to the development of pancreaticcancer. To date, PanScan researchers have discovered four novelregions in the genome associated with risk for pancreatic cancer.In addition, many other epidemiological studies on environmentalrisk factors (including lifestyle factors) have been published.AdvocacyThe American Cancer Society Cancer Action Network (ACSCAN), the nonprofit nonpartisan advocacy affiliate of the American Cancer Society, recognizes that cancer research is theengine behind our ongoing progress in the fight against cancer.Research offers hope to the millions of people who face cancer –for better treatments, for more opportunities to prevent anddetect the disease early, and for improved quality of life for thosealready diagnosed. The National Cancer Institute (NCI) – one ofthe 27 institutes and centers that comprise the National Institutes of Health (NIH) – is the foundation of the nation’s cancerresearch efforts. As a federal agency, NCI-funded research hasplayed a role in every major advance in the fight against cancerover the past 70 years. That’s why it is so important that the NCIcontinues to receive the government investment that it needs tosupport lifesaving research projects. Funding for pancreaticcancer research at NCI has increased from $73 million in 2007 to$100 million in 2011. Billions of dollars exist in the federal budgetfor medical research purposes, and ACS CAN is leading theeffort to lobby our government for the crucial funds necessaryfor the clinical research that could lead to the prevention, earlydetection, and effective treatment of pancreatic cancer.SM32  Cancer Facts & Figures 2013•  National Cancer Institute:cancer.gov/cancertopics/types/pancreatic/•  Pancreatica Initiative: pancreatica.org/References1. Silverman DT, Hoover RN, Brown LM, et al. Why do Black Americanshave a higher risk of pancreatic cancer than White Americans? Epidemiology 2003;14(1): 45-54.2. Jemal A, Simard EP, Xu J, Ma J, Anderson RN. Selected cancers withincreasing mortality rates by educational attainment in 26 states in theUnited States, 1993-2007. Cancer Causes Control 2012.3. Jemal A, Simard EP, Dorell C, et al. Annual Report to the Nation onthe Status of Cancer, 1975-2009, Featuring the Burden and Trends inHPV-Associated Cancers and HPV Vaccination Coverage Levels. JNCI(in press).4. Iodice S, Gandini S, Maisonneuve P, Lowenfels AB. Tobacco and therisk of pancreatic cancer: a review and meta-analysis. Langenbecks ArchSurg 2008;393(4): 535-45.5. Anderson K, Potter JD, Mack TM. Pancreatic cancer. In: SchottenfeldD, Fraumeni JF, editors. Cancer Epidemiology and Prevention. New York:Oxford University Press, 2006:721-62.6. Lynch SM, Vrieling A, Lubin JH, et al. Cigarette smoking and pancreatic cancer: a pooled analysis from the pancreatic cancer cohort consortium. Am J Epidemiol 2009;170(4): 403-13.7. Bosetti C, Lucenteforte E, Silverman DT, et al. Cigarette smoking andpancreatic cancer: an analysis from the International Pancreatic Cancer Case-Control Consortium (Panc4). Ann Oncol 2012;23(7):1880-8.8. Henley SJ, Thun MJ, Chao A, Calle EE. Association between exclusivepipe smoking and mortality from cancer and other diseases. J Natl Cancer Inst 2004;96(11): 853-61.9. Bertuccio P, La Vecchia C, Silverman DT, et al. Cigar and pipe smoking, smokeless tobacco use and pancreatic cancer: an analysis from theInternational Pancreatic Cancer Case-Control Consortium (PanC4).Ann Oncol 2011;22(6): 1420-6.10. Vrieling A, Bueno-de-Mesquita HB, Boshuizen HC, et al. Cigarettesmoking, environmental tobacco smoke exposure and pancreatic cancer risk in the European Prospective Investigation into Cancer andNutrition. Int J Cancer 2010;126(10): 2394-403.11. IARC Working Group on the Evaluation of Carcinogenic Risks toHumans. Smokeless Tobacco and some Tobacco-specific N-Nitrosamines.Lyon, France: IARC, 2007.12. IARC Working Group on the Evaluation of Carcinogenic Risks toHumans. A review of human carcinogens. Part E: Personal habits andindoor combustions. Lyon, France: IARC, 2009.13. Berrington de Gonzalez A, Sweetland S, Spencer E. A meta-analysis ofobesity and the risk of pancreatic cancer. Br J Cancer 2003;89(3): 519-23.14. Michaud DS, Giovannucci E, Willett WC, Colditz GA, Stampfer MJ,Fuchs CS. Physical activity, obesity, height, and the risk of pancreaticcancer. JAMA 2001;286(8): 921-9.15. Arslan AA, Helzlsouer KJ, Kooperberg C, et al. Anthropometric measures, body mass index, and pancreatic cancer: a pooled analysis fromthe Pancreatic Cancer Cohort Consortium (PanScan). Arch Intern Med2010;170(9): 791-802.16. Li D, Morris JS, Liu J, et al. Body mass index and risk, age of onset, andsurvival in patients with pancreatic cancer. JAMA 2009;301(24): 2553-62.17. Larsson SC, Permert J, Hakansson N, Naslund I, Bergkvist L, WolkA. Overall obesity, abdominal adiposity, diabetes and cigarette smokingin relation to the risk of pancreatic cancer in two Swedish populationbased cohorts. Br J Cancer 2005;93(11): 1310-5.18. Heinen MM, Verhage BA, Goldbohm RA, Lumey LH, van den BrandtPA. Physical activity, energy restriction, and the risk of pancreatic cancer: a prospective study in the Netherlands. Am J Clin Nutr 2011;94(5):1314-23.19. Nothlings U, Wilkens LR, Murphy SP, Hankin JH, Henderson BE,Kolonel LN. Body mass index and physical activity as risk factors forpancreatic cancer: the Multiethnic Cohort Study. Cancer Causes Control2007;18(2): 165-75.20. Patel AV, Rodriguez C, Bernstein L, Chao A, Thun MJ, Calle EE. Obesity, recreational physical activity, and risk of pancreatic cancer in alarge U.S. Cohort. Cancer Epidemiol Biomarkers Prev 2005;14(2): 459-66.21. Hanley AJ, Johnson KC, Villeneuve PJ, Mao Y. Physical activity,anthropometric factors and risk of pancreatic cancer: results from theCanadian enhanced cancer surveillance system. Int J Cancer 2001;94(1):140-7.22. O’Rorke MA, Cantwell MM, Cardwell CR, Mulholland HG, MurrayLJ. Can physical activity modulate pancreatic cancer risk? a systematicreview and meta-analysis. Int J Cancer 2010;126(12): 2957-68.23. Bao Y, Michaud DS. Physical activity and pancreatic cancer risk: a systematic review. Cancer Epidemiol Biomarkers Prev 2008;17(10): 2671-82.24. Genkinger JM, Spiegelman D, Anderson KE, et al. Alcohol intake andpancreatic cancer risk: a pooled analysis of fourteen cohort studies.Cancer Epidemiol Biomarkers Prev 2009;18(3): 765-76.25. Tramacere I, Scotti L, Jenab M, et al. Alcohol drinking and pancreatic cancer risk: a meta-analysis of the dose-risk relation. Int J Cancer2010;126(6): 1474-86.26. Larsson SC, Wolk A. Red and processed meat consumption and riskof pancreatic cancer: meta-analysis of prospective studies. Br J Cancer2012;106(3): 603-7.27. Anderson KE, Mongin SJ, Sinha R, et al. Pancreatic cancer risk: associations with meat-derived carcinogen intake in the Prostate, Lung,Colorectal, and Ovarian Cancer Screening Trial (PLCO) cohort. Mol Carcinog 2012;51(1):128-37.28. Larsson SC, Giovannucci E, Wolk A. Folate intake, MTHFR polymorphisms, and risk of esophageal, gastric, and pancreatic cancer: a metaanalysis. Gastroenterology 2006;131(4): 1271-83.29. Bao Y, Michaud DS, Spiegelman D, et al. Folate intake and risk ofpancreatic cancer: pooled analysis of prospective cohort studies. J NatlCancer Inst 2011;103(24): 1840-50.30. Jansen RJ, Robinson DP, Stolzenberg-Solomon RZ, et al. Fruit andvegetable consumption is inversely associated with having pancreaticcancer. Cancer Causes Control 2011;22(12): 1613-25.31. Vrieling A, Verhage BA, van Duijnhoven FJ, et al. Fruit and vegetableconsumption and pancreatic cancer risk in the European ProspectiveInvestigation into Cancer and Nutrition. Int J Cancer 2009;124(8): 1926-34.32. Larsson SC, Hakansson N, Naslund I, Bergkvist L, Wolk A. Fruit andvegetable consumption in relation to pancreatic cancer risk: a prospective study. Cancer Epidemiol Biomarkers Prev 2006;15(2): 301-5.33. Chan JM, Wang F, Holly EA. Vegetable and fruit intake and pancreatic cancer in a population-based case-control study in the San Francisco bay area. Cancer Epidemiol Biomarkers Prev 2005;14(9): 2093-7.34. Turati F, Galeone C, Edefonti V, et al. A meta-analysis of coffee consumption and pancreatic cancer. Ann Oncol 2012;23(2): 311-8.35. Grant WB. An ecologic study of cancer mortality rates in Spain withrespect to indices of solar UVB irradiance and smoking. Int J Cancer2007;120(5): 1123-8.36. Mohr SB, Garland CF, Gorham ED, Grant WB, Garland FC. UltravioletB irradiance and vitamin D status are inversely associated with incidencerates of pancreatic cancer worldwide. Pancreas 2010;39(5): 669-74.37. Boscoe FP, Schymura MJ. Solar ultraviolet-B exposure and cancerincidence and mortality in the United States, 1993-2002. BMC Cancer2006;6: 264.38. Bao Y, Ng K, Wolpin BM, Michaud DS, Giovannucci E, Fuchs CS. Predicted vitamin D status and pancreatic cancer risk in two prospectivecohort studies. Br J Cancer 2010;102(9): 1422-7.39. Giovannucci E. Vitamin D and cancer incidence in the Harvardcohorts. Ann Epidemiol 2009;19(2): 84-8.40. Stolzenberg-Solomon RZ, Jacobs EJ, Arslan AA, et al. Circulating25-hydroxyvitamin D and risk of pancreatic cancer: Cohort ConsortiumVitamin D Pooling Project of Rarer Cancers. Am J Epidemiol 2010;172(1):81-93.41. Permuth-Wey J, Egan KM. Family history is a significant risk factorfor pancreatic cancer: results from a systematic review and meta-analysis. Fam Cancer 2009;8(2): 109-17.42. Klein AP, Brune KA, Petersen GM, et al. Prospective risk of pancreaticcancer in familial pancreatic cancer kindreds. Cancer Res 2004;64(7):2634-8.43. Brune KA, Lau B, Palmisano E, et al. Importance of age of onset inpancreatic cancer kindreds. J Natl Cancer Inst 2010;102(2): 119-26.44. Petersen GM, de Andrade M, Goggins M, et al. Pancreatic cancergenetic epidemiology consortium. Cancer Epidemiol Biomarkers Prev2006;15(4): 704-10.45. Shi C, Hruban RH, Klein AP. Familial pancreatic cancer. Arch PatholLab Med 2009;133(3): 365-74.46. Vincent A, Herman J, Schulick R, Hruban RH, Goggins M. Pancreaticcancer. Lancet 2011;378(9791): 607-20.47. Landi S. Genetic predisposition and environmental risk factors topancreatic cancer: A review of the literature. Mutat Res 2009;681(2-3):299-307.48. Couch FJ, Johnson MR, Rabe KG, et al. The prevalence of BRCA2mutations in familial pancreatic cancer. Cancer Epidemiol BiomarkersPrev 2007;16(2): 342-6.49. Hahn SA, Greenhalf B, Ellis I, et al. BRCA2 germline mutations infamilial pancreatic carcinoma. J Natl Cancer Inst 2003;95(3): 214-21.50. Murphy KM, Brune KA, Griffin C, et al. Evaluation of candidate genesMAP2K4, MADH4, ACVR1B, and BRCA2 in familial pancreatic cancer:deleterious BRCA2 mutations in 17%. Cancer Res 2002;62(13): 3789-93.51. Lynch HT, Fusaro RM, Lynch JF, Brand R. Pancreatic cancer and theFAMMM syndrome. Fam Cancer 2008;7(1): 103-12.52. Giardiello FM, Brensinger JD, Tersmette AC, et al. Very high risk ofcancer in familial Peutz-Jeghers syndrome. Gastroenterology 2000;119(6):1447-53.53. van Lier MG, Wagner A, Mathus-Vliegen EM, Kuipers EJ, SteyerbergEW, van Leerdam ME. High cancer risk in Peutz-Jeghers syndrome: asystematic review and surveillance recommendations. Am J Gastroenterol 2010;105(6): 1258-64; author reply 65.Cancer Facts & Figures 2013  3354. Raimondi S, Lowenfels AB, Morselli-Labate AM, Maisonneuve P, Pezzilli R. Pancreatic cancer in chronic pancreatitis; aetiology, incidence,and early detection. Best Pract Res Clin Gastroenterol 2010;24(3): 349-58.55. Kastrinos F, Mukherjee B, Tayob N, et al. Risk of pancreatic cancer infamilies with Lynch syndrome. JAMA 2009;302(16): 1790-5.56. Amundadottir L, Kraft P, Stolzenberg-Solomon RZ, et al. Genomewide association study identifies variants in the ABO locus associatedwith susceptibility to pancreatic cancer. Nat Genet 2009;41(9): 986-90.57. Wolpin BM, Chan AT, Hartge P, et al. ABO blood group and the risk ofpancreatic cancer. J Natl Cancer Inst 2009;101(6): 424-31.58. Wolpin BM, Kraft P, Gross M, et al. Pancreatic cancer risk and ABOblood group alleles: results from the pancreatic cancer cohort consortium. Cancer Res 2010;70(3): 1015-23.59. Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancreatitis and therisk of pancreatic cancer. International Pancreatitis Study Group. N EnglJ Med 1993;328(20): 1433-7.60. Malka D, Hammel P, Maire F, et al. Risk of pancreatic adenocarcinoma in chronic pancreatitis. Gut 2002;51(6): 849-52.61. Pannala R, Leirness JB, Bamlet WR, Basu A, Petersen GM, Chari ST.Prevalence and clinical profile of pancreatic cancer-associated diabetesmellitus. Gastroenterology 2008;134(4): 981-7.62. Chari ST, Leibson CL, Rabe KG, et al. Pancreatic cancer-associateddiabetes mellitus: prevalence and temporal association with diagnosisof cancer. Gastroenterology 2008;134(1): 95-101.63. Huxley R, Ansary-Moghaddam A, Berrington de Gonzalez A, Barzi F,Woodward M. Type-II diabetes and pancreatic cancer: a meta-analysisof 36 studies. Br J Cancer 2005;92(11): 2076-83.64. Stevens RJ, Roddam AW, Beral V. Pancreatic cancer in type 1 andyoung-onset diabetes: systematic review and meta-analysis. Br J Cancer2007;96(3): 507-9.65. Gapstur SM, Gann PH, Lowe W, Liu K, Colangelo L, Dyer A. Abnormal glucose metabolism and pancreatic cancer mortality. JAMA2000;283(19): 2552-8.66. Jee SH, Ohrr H, Sull JW, Yun JE, Ji M, Samet JM. Fasting serum glucose level and cancer risk in Korean men and women. JAMA 2005;293(2):194-202.67. Stolzenberg-Solomon RZ, Graubard BI, Chari S, et al. Insulin, glucose, insulin resistance, and pancreatic cancer in male smokers. JAMA2005;294(22): 2872-8.75. Maisonneuve P, Marshall BC, Lowenfels AB. Risk of pancreatic cancer in patients with cystic fibrosis. Gut 2007;56(9): 1327-8.76. Fitzpatrick SG, Katz J. The association between periodontal diseaseand cancer: a review of the literature. J Dent 2010;38(2): 83-95.77. Greenhalf W, Grocock C, Harcus M, Neoptolemos J. Screening ofhigh-risk families for pancreatic cancer. Pancreatology 2009;9(3): 215-22.78. Shin EJ, Canto MI. Pancreatic cancer screening. Gastroenterol ClinNorth Am 2012;41(1): 143-57.79. Canto MI, Goggins M, Yeo CJ, et al. Screening for pancreatic neoplasia in high-risk individuals: an EUS-based approach. Clin GastroenterolHepatol 2004;2(7): 606-21.80. Canto MI, Goggins M, Hruban RH, et al. Screening for early pancreatic neoplasia in high-risk individuals: a prospective controlled study.Clin Gastroenterol Hepatol 2006;4(6): 766-81; quiz 665.81. Gemmel C, Eickhoff A, Helmstadter L, Riemann JF. Pancreatic cancerscreening: state of the art. Expert Rev Gastroenterol Hepatol 2009;3(1):89-96.82. Hidalgo M. Pancreatic cancer. N Engl J Med 2010;362(17): 1605-17.83. Dumonceau JM, Vonlaufen A. Pancreatic endoscopic retrogradecholangiopancreatography (ERCP). Endoscopy 2007;39(2): 124-30.84. Bilimoria KY, Bentrem DJ, Ko CY, et al. Validation of the 6th editionAJCC Pancreatic Cancer Staging System: report from the National Cancer Database. Cancer 2007;110(4): 738-44.85. Berger AC, Garcia M, Jr., Hoffman JP, et al. Postresection CA 19-9 predicts overall survival in patients with pancreatic cancer treated withadjuvant chemoradiation: a prospective validation by RTOG 9704. J ClinOncol 2008;26(36): 5918-22.86. Ferrone CR, Finkelstein DM, Thayer SP, Muzikansky A, FernandezdelCastillo C, Warshaw AL. Perioperative CA19-9 levels can predictstage and survival in patients with resectable pancreatic adenocarcinoma. J Clin Oncol 2006;24(18): 2897-902.87. Hernandez JM, Cowgill SM, Al-Saadi S, et al. CA 19-9 velocity predictsdisease-free survival and overall survival after pancreatectomy of curative intent. J Gastrointest Surg 2009;13(2): 349-53.88. Slidell MB, Chang DC, Cameron JL, et al. Impact of total lymph nodecount and lymph node ratio on staging and survival after pancreatectomy for pancreatic adenocarcinoma: a large, population-based analysis. Ann Surg Oncol 2008;15(1): 165-74.68. Stattin P, Bjor O, Ferrari P, et al. Prospective study of hyperglycemiaand cancer risk. Diabetes Care 2007;30(3): 561-7.89. Maithel SK, Maloney S, Winston C, et al. Preoperative CA 19-9 and theyield of staging laparoscopy in patients with radiographically resectable pancreatic adenocarcinoma. Ann Surg Oncol 2008;15(12): 3512-20.69. Stocks T, Rapp K, Bjorge T, et al. Blood glucose and risk of incidentand fatal cancer in the metabolic syndrome and cancer project (mecan): analysis of six prospective cohorts. PLoS Med 2009;6(12): e1000201.90. Blackford A, Serrano OK, Wolfgang CL, et al. SMAD4 gene mutationsare associated with poor prognosis in pancreatic cancer. Clin Cancer Res2009;15(14): 4674-9.70. El-Serag HB, Engels EA, Landgren O, et al. Risk of hepatobiliary andpancreatic cancers after hepatitis C virus infection: A population-basedstudy of U.S. veterans. Hepatology 2009;49(1): 116-23.91. Infante JR, Matsubayashi H, Sato N, et al. Peritumoral fibroblastSPARC expression and patient outcome with resectable pancreatic adenocarcinoma. J Clin Oncol 2007;25(3): 319-25.71. Hassan MM, Li D, El-Deeb AS, et al. Association between hepatitis Bvirus and pancreatic cancer. J Clin Oncol 2008;26(28): 4557-62.92. Shaib Y, Davila J, Naumann C, El-Serag H. The impact of curativeintent surgery on the survival of pancreatic cancer patients: a U.S. Population-based study. Am J Gastroenterol 2007;102(7): 1377-82.72. Risch HA, Yu H, Lu L, Kidd MS. ABO blood group, Helicobacter pyloriseropositivity, and risk of pancreatic cancer: a case-control study. J NatlCancer Inst 2010;102(7): 502-5.73. Lin G, Zeng Z, Wang X, et al. Cholecystectomy and risk of pancreaticcancer: a meta-analysis of observational studies. Cancer Causes Control2012;23(1): 59-67.74. Gong Y, Zhou Q, Zhou Y, et al. Gastrectomy and risk of pancreaticcancer: systematic review and meta-analysis of observational studies.Cancer Causes Control 2012;23(8): 1279-88.34  Cancer Facts & Figures 201293. O’Reilly EM. Refinement of adjuvant therapy for pancreatic cancer.JAMA 2010;304(10): 1124-5.94. Neoptolemos JP. Adjuvant treatment of pancreatic cancer. Eur J Cancer 2011;47 Suppl 3: S378-80.95. Abrams RA. Radiotherapy in the adjuvant management of pancreatic adenocarcinoma: is it helpful? Expert Rev Gastroenterol Hepatol2012;6(2): 149-61.96. Evans DB, Varadhachary GR, Crane CH, et al. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008;26(21): 3496-502.98. Katz MH, Pisters PW, Evans DB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am CollSurg 2008;206(5): 833-46; discussion 46-8.97. Gillen S, Schuster T, Meyer Zum Buschenfelde C, Friess H, Kleeff J.Preoperative/neoadjuvant therapy in pancreatic cancer: a systematicreview and meta-analysis of response and resection percentages. PLoSMed 2010;7(4): e1000267.99. Callery MP, Chang KJ, Fishman EK, Talamonti MS, William TraversoL, Linehan DC. Pretreatment assessment of resectable and borderlineresectable pancreatic cancer: expert consensus statement. Ann SurgOncol 2009;16(7): 1727-33.Tobacco UseSmoking-related diseases remain the world’s most preventablecause of death. Since the first US Surgeon General’s report onsmoking and health in 1964, there have been more than 15 million premature deaths attributable to smoking in the US.1,2 TheWorld Health Organization estimates that there are 6 millionsmoking-related premature deaths worldwide each year.3Health Consequences of SmokingHalf of all those who continue to smoke will die from smokingrelated diseases.4 In the US, tobacco use is responsible for nearly1 in 5 deaths; this equaled an estimated 443,000 prematuredeaths each year between 2000 and 2004.5,6 In addition, an estimated 8.6 million people suffer from chronic conditions relatedto smoking, such as chronic bronchitis, emphysema, and cardiovascular diseases.7•  Smoking accounts for at least 30% of all cancer deaths and87% of lung cancer deaths.1,8•  The risk of developing lung cancer is about 23 times higherin male smokers and 13 times higher in female smokers,compared to lifelong nonsmokers.1•  Smoking increases the risk of the following types of cancer:nasopharynx, nasal cavity and paranasal sinuses, lip, oralcavity, pharynx, larynx, lung, esophagus, pancreas, uterinecervix, ovary (mucinous), kidney, bladder, stomach, colorectum,and acute myeloid leukemia.1,9•  The International Agency for Research on Cancer (IARC)recently concluded that there is limited evidence that tobaccosmoking causes female breast cancer.9•  Smoking is a major cause of heart disease, cerebrovasculardisease, chronic bronchitis, and emphysema, and is associatedwith gastric ulcers.1,10•  The risk of lung cancer is just as high in smokers of “light” or“low-tar” yield cigarettes as in those who smoke “regular” or“full-flavored” products.11Reducing Tobacco Use and ExposureThe US Surgeon General in 2000 outlined the goals and components of comprehensive statewide tobacco control programs.12These programs seek to prevent the initiation of tobacco useamong youth; promote quitting at all ages; eliminate nonsmokers’ exposure to secondhand smoke; and identify and eliminatethe disparities related to tobacco use and its effects amongdifferent population groups.13The Centers for Disease Control and Prevention (CDC) recommends funding levels for comprehensive tobacco use preventionand cessation programs for all 50 states and the District ofColumbia. In fiscal year 2012, 6 states allocated 50% or moreof CDC-recommended funding levels for tobacco control programs.14 States that have invested in comprehensive tobaccocontrol programs, such as California, Massachusetts, and Florida,have reduced smoking rates and saved millions of dollars intobacco-related health care costs.12,15 Recent federal initiativesin tobacco control, including national legislation ensuringcoverage of clinical cessation services, regulation of tobaccoproducts, tax increases, and increased tobacco control fundinghold promise for reducing tobacco use. Provisions in the Affordable Care Act signed into law on March 23, 2010, ensure at leastminimum coverage of evidence-based cessation treatments,including pharmacotherapy and cessation counseling to previously uninsured tobacco users, pregnant Medicaid recipients,and eligible Medicare recipients. The Centers for Medicare andMedicaid subsequently issued a decision memo changing theeligibility requirement for Medicare recipients, so that they nolonger have to be diagnosed with a smoking-related disease inorder to access cessation treatments. Starting in 2014, stateMedicaid programs can no longer exempt cessation pharmacotherapy from prescription drug coverage. Several provisions ofthe Family Smoking Prevention and Tobacco Control Act, whichfor the first time grants the US Food and Drug Administrationthe authority to regulate the manufacturing, selling, and marketing of tobacco products, have already gone into effect. Formore information about tobacco control, see Cancer Prevention& Early Detection Facts & Figures, available online at cancer.org/statistics.Cancer Facts & Figures 2013  35Trends in Smoking•  Between 1965 and 2004, cigarette smoking among adults18 years of age and older declined by half from 42% to 21%.16Between 2005 and 2011, there was a modest, but statisticallysignificant, decline in smoking prevalence from 21% to 19%.17,18However, declines were not consistent from year-to-year andwere not observed in all population subgroups.•  In 2011, approximately 43.8 million adults were currentsmokers, about 2 million fewer than in 2005.•  The proportion of daily smokers reporting light or intermittentsmoking (less than 10 cigarettes/day) increased significantlybetween 2005 (16%) and 2011 (22%), whereas heavy smokingdeclined from 13% to 9%.17,18•  Although cigarette smoking became prevalent among menbefore women, the gender gap narrowed in the mid-1980sand has since remained constant.19 As of 2011, there was a 4%absolute difference in smoking prevalence between white men(23%) and women (19%), an 8% difference between AfricanAmerican men (24%) and women (16%), an 8% differencebetween Hispanic men (17%) and women (9%) and a 9%difference between Asian men (15%) and women (6%).18•  Smoking is most common among the least educated. Whilethe percentage of smokers has decreased at every level ofeducational attainment since 1983, college graduates hadthe greatest decline, from 21% to 9%, in 2011.18,20 By contrast,among those with a high school diploma, prevalence decreasedmodestly from 34% to 24% during the same time period.Adults with a GED certificate (high school equivalencydiploma) had the highest smoking rate (45%) in 2011.18 Groupswith a high school degree or less quit smoking at lower ratesthan higher educated groups between 1998 and 2008.21•  The decrease in smoking prevalence among high schoolstudents between the late 1970s and early 1990s was morerapid among African Americans than whites; consequently,lung cancer rates among adults younger than 40 years ofage, which historically were substantially higher in AfricanAmericans, have converged in these two groups.22•  Although cigarette smoking among US high school studentsincreased significantly from 28% in 1991 to 36% in 1997, therate declined to 21% (male: 22%, female: 22%) by 2003.23,24Between 2003 and 2011, there has been no significant changein the smoking rate among high school males (20%) andfemales (16%).25Smokeless Tobacco ProductsSmokeless tobacco products include moist snuff, chewingtobacco, snus (a “spitless,” moist powder tobacco pouch), dissolvable nicotine products (Orbs, Strips and Sticks), and a varietyof other tobacco-containing products that are not smoked.Recently, the smokeless market in high-income countries,36  Cancer Facts & Figures 2013including the US, has been consolidated from smaller tobaccocompanies into the control of the tobacco multinationals.26 Inthe US, the sales of smokeless tobacco products are growing at amore rapid pace than cigarettes. As part of their marketingstrategy, the industry is actively promoting these products bothfor use in settings where smoking is prohibited and as a way toquit smoking; however, there is no evidence to date that theseproducts are as effective as proven cessation therapies. Whensmokeless tobacco was aggressively marketed in the US in the1970s and 1980s, use of these products increased among adolescent males, but not among older smokers trying to quit.27,28 Useof any smokeless tobacco product is not considered a safe substitute for quitting. These products cause oral, esophageal, andpancreatic cancers, precancerous lesions of the mouth, gumrecession, bone loss around the teeth, and tooth staining; theycan also lead to nicotine addiction.29,30•  Smokers who use smokeless products as a supplementalsource of nicotine to postpone or avoid quitting will increaserather than decrease their risk of lung cancer.31•  Long-term use of snuff substantially increases the risk ofcancers of the oral cavity, particularly cancers of the cheekand gum.30•  According to the US Department of Agriculture, manufacturedoutput of moist snuff has increased more than 80% in less thantwo decades, from 48 million pounds in 1991 to an estimated88 million pounds in 2007. 32,33•  According to the 2010 National Health Interview Survey, 3%of adults 18 years of age and older (5% of men and 0.2% ofwomen) were current users of smokeless products.34•  According to the 2010 National Survey on Drug Use and Health(NSDUH), whites were more likely to use smokeless tobaccothan African Americans, Hispanics/Latinos, or Asians.35•  Adult smokeless tobacco use (including snus use) varied from1% to 10% across states in 2011, with higher rates observed inthe South and North-Central states.36•  Among high school students nationwide, the prevalence ofcurrent smokeless tobacco use (chewing tobacco, snuff, or dip)decreased from 1995 to 2003 (from 11% to 7%), but remainedstable from 2003 to 2011 (7% to 8%). Current (2011) use washigher in males (13%) than females (2%) and higher in whites(9%) than African Americans (3%) and Hispanics (6%).25CigarsCigar smoking has health consequences similar to those of cigarette smoking and smokeless tobacco.37•  Regular cigar smoking is associated with an increased riskof cancers of the lung, oral cavity, larynx, esophagus, andprobably pancreas. Cigar smokers have 4 to 10 times the riskof dying from laryngeal, oral, or esophageal cancer comparedto nonsmokers.37Annual Number of Cancer Deaths Attributable to Smoking by Sex and Site, US, 2000-2004MaleFemaleLarynxLarynxPancreasLungStomachCancer siteCancer siteStomachPancreasLungBladderBladderKidneyKidneyMyeloid leukemiaMyeloid leukemia20Other causesEsophagusEsophagus0Attributable tocigarette smokingOropharynxOropharynx406080Number of deaths (in thousands)Cervix100020406080Number of deaths (in thousands)100Source: Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses – United States, 2000-2004.MMWR Morb Mortal Wkly Rep. 2008;57(45):1226-1228.American Cancer Society, Surveillance Research, 2013•  In 2010, 3% of adults 18 years of age and older (5% of menand 0.5% of women) were current users of cigars (smoked atleast 50 cigars in their lifetime and now smoked some daysor every day).34•  According to the 2010 NSDUH, African Americans andAmerican Indians/Alaska Natives had the highest prevalenceof past month cigar use, followed by, whites, Hispanics, andAsians.35•  Among states, cigar smoking prevalence among adultsranges from 2% to 5%.38•  In 2011, 13% of US high school students had smoked cigars,cigarillos, or little cigars at least once in the past 30 days.25•  Between 1997 and 2007, while sales of little cigars had increasedby 240%, large cigar sales decreased by 6%.39 Small cigars aresimilar in shape and size to cigarettes, but are not regulated ortaxed like cigarettes, making them more affordable to youth.Smoking CessationA US Surgeon General’s Report outlined the benefits of smokingcessation: 40•  People who quit, regardless of age, live longer and are healthierthan people who continue to smoke.•  Smokers who quit before age 50 cut their risk of dying in thenext 15 years in half.•  Quitting smoking substantially decreases the risk of lung,laryngeal, esophageal, oral, pancreatic, bladder, and cervicalcancers.•  Quitting lowers the risk for other major diseases, includingheart disease, chronic lung disease, and stroke.While the majority of ever-smokers in the US have quit smoking,rates of adult smoking cessation remained stable between 1998and 2008.41•  In 2011, an estimated 49.5 million adults were former smokers, representing 53% of living persons who ever smoked.34•  Smokers with an undergraduate or graduate degree are morelikely to quit than less educated smokers.41 Among those whosmoked in 2010, an estimated 20.6 million (or 47%) had stoppedsmoking at least one day during the preceding 12 monthsbecause they were trying to quit.34•  In 47 states and the District of Columbia, the majority ofadults (50% or more) who ever smoked have quit smoking.42•  In 2011, among high school students who were currentcigarette smokers, national data showed that one-half (50%)had tried to quit smoking cigarettes during the 12 monthspreceding the survey; female students (54%) were more likelyto have made a quit attempt than male students (47%).25Tobacco dependence is a chronic disease; effective cessationtreatments can double or triple smokers’ chances of long-termabstinence.43 Certain racial and ethnic groups (Hispanics andnon-Hispanic African Americans) and those with low socioeconomic status are significantly less likely to receive cessationservices.38 Improving access by promoting available coveragefor these treatments through government health programs,including Medicaid and Medicare, and private health insurancemandates can help reduce these disparities.Cancer Facts & Figures 2013  37Secondhand SmokeCosts of TobaccoIn 2006, the US Surgeon General published a comprehensivereport titled The Health Consequences of Involuntary Exposure toTobacco Smoke.44 This report determined that secondhand smoke(SHS), or environmental tobacco smoke, contains numeroushuman carcinogens for which there is no safe level of exposure.It is estimated that more than 88 million nonsmoking Americans 3 years of age and older were exposed to SHS in 2007-2008.45Numerous other scientific consensus groups have also revieweddata on the health effects of SHS.44-50 Public policies to protectpeople from SHS are based on the following detrimental effects:The number of people who die prematurely or suffer illness fromtobacco use impose substantial health-related economic costson society. It is estimated that in the US, between 2000 and 2004,smoking accounted for 3.1 million years of potential life lost in menand 2.0 million years of potential life lost in women. Smoking, onaverage, reduces life expectancy by approximately 14 years.6•  SHS contains more than 7,000 chemicals, at least 69 of whichcause cancer.2In addition:•  Between 2000 and 2004, smoking resulted in more than $193billion in average annual health-related costs, including $96billion in smoking-attributable medical costs and $96.8 billionin productivity losses.6•  SHS causes an estimated 46,000 deaths annually from heartdisease in people who are not current smokers.6•  Annual smoking-attributable health care expenditureswere estimated to increase $24 billion annually between1997-2001 and 2000-2004.6 Over the same time period,smoking-attributable productivity losses were estimated toincrease $4.3 billion annually.6,57•  SHS may cause coughing, wheezing, chest tightness, andreduced lung function in adult nonsmokers.45Conclusion•  Each year, about 3,400 nonsmoking adults die of lung canceras a result of breathing SHS.6•  Some studies have reported an association between SHSexposure and breast cancer. The US Surgeon General has designated this evidence suggestive rather than conclusive.45 Inany case, women should be aware that there are many healthreasons to avoid exposure to tobacco smoke.Laws that prohibit smoking in public places and create smokefree environments are an extremely effective approach to preventexposure to and harm from SHS.51 In addition, there is strongevidence that smoke-free policies decrease the prevalence ofboth adult and youth smoking.52 Momentum to regulate publicsmoking began to increase in 1990, and smoke-free laws havebecome increasingly common and comprehensive over time.53•  In the past decade, the largest decline in SHS exposure amongnonsmokers occurred from 1999-2000 (53%) to 2001-2002(42%), with estimates since remaining relatively unchanged(2007-2008: 40%).44•  In the US, as of July 2012, 3,501 municipalities have passedsmoke-free legislation and 36 states, the District of Columbia, the Northern Mariana islands, Puerto Rico, AmericanSamoa and the US Virgin Islands have either implementedor enacted statewide smoking bans that prohibit smoking inworkplaces and/or restaurants and/or bars.54•  In the US, as of July 2012, there were 774 100% smoke-freecollege campuses; of these, 562 are 100% tobacco-free (i.e., noforms of tobacco allowed).55•  Currently, 48% of the US population is covered by a 100%smoke-free policy in workplaces, restaurants and bars.54Workplace smoking restrictions vary by geographic area; 72% ofSouthern residents reported working under a smoke-free policy,compared to 81% of workers in the Northeast.5638  Cancer Facts & Figures 2013Substantial progress has been made in reducing the disease burden from tobacco over the nearly 50 years since the 1964 SurgeonGeneral’s Report; smoking prevalence rates have been reducedby more than half and millions of premature deaths have beenaverted. Nevertheless, more needs to be done to further reducethe health and economic burden of tobacco on our society.Numerous studies confirm that a comprehensive approach totobacco control, including higher taxes, 100% smoke-free environments, coverage for tobacco dependence treatment, fullimplementation of the FDA Family Smoking Prevention andTobacco Control Act, and vigorous tobacco counter-advertising,can be successful in reducing the death, disease, and economicdisruption from tobacco use.References1. US Department of Health and Human Services. The Health Consequences of Smoking – A Report of the Surgeon General. Rockville, MD:U.S. Department of Health and Human Services, Public Health Service,Centers for Disease Control and Prevention, Center for Chronic DiseasePrevention and Health Promotion, Office on Smoking and Health; 2004.2. US Department of Health and Human Services. How Tobacco SmokeCauses Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease. Rockville, MD: U.S. Department of Health and HumanServices, Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health; 2010.3. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011: Warning about the Dangers of Tobacco. Geneva, Switzerland2011.4. Peto R, Lopez A, Boreham J, Thun M, Heath CJ. Mortality from Smokingin Developed Countries, 1950-2000: Oxford University Press, New York,NY; 1994.5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes ofdeath in the United States, 2000. JAMA. 2004;291(10):1238-1245.6. Centers for Disease Control and Prevention. Smoking-attributable mortality, years of potential life lost, and productivity losses – United States,2000-2004. MMWR Morb Mortal Wkly Rep. Nov 14 2008;57(45):1226-1228.23. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2007 MMWR Morb Mortal Wkly Rep.2008;57(SS-4):1-131.7. Centers for Disease Control and Prevention. Cigarette SmokingAttributable Morbidity – United States, 2000. MMWR Morb Mortal WklyRep. 2003;52(35):842-844.24. Centers for Disease Control and Prevention. Cigarette Use AmongHigh School Students-United States, 1991-2005. MMWR Morb Mortal WklyRep. July 7 2006;55(26):724-726.8. Doll R, Peto R. The Causes of Cancer. New York, NY: Oxford Press; 1981.25. Centers for Disease Control and Prevention. Youth risk behaviorsurveillance – United States, 2011. MMWR Morb Mortal Wkly Rep. June 82012;61(4):1-168.9. Secretan B, Straif K, Baan R, et al. A review of human carcinogens –Part E: tobacco, areca nut, alcohol, coal smoke, and salted fish. LancetOncol. Nov 2009;10(11):1033-1034.10. US Department of Health and Human Services. Reducing the HealthConsequences of Smoking: 25 Years of Progress. A Report of the SurgeonGeneral. Rockville, MD: U.S. Department of Health and Human Services,Public Health Service, Centers for Disease Control and Prevention,Center for Chronic Disease Prevention and Health Promotion, Office onSmoking and Health; 1989.11. Harris JE, Thun MJ, Mondul AM, Calle EE. Cigarette tar yields inrelation to mortality from lung cancer in the Cancer Prevention Study IIprospective cohort, 1982-8. BMJ. 2004;328(7431):72-76.12. US Department of Health and Human Services. Reducing Tobacco Use:A Report of the Surgeon General. Atlanta, Georgia: U.S. Department ofHealth and Human Services, Centers for Disease Control and Prevention,National center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health; 2000.13. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs. Atlanta, GA: U.S. Department ofHealth and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office of Smoking and Health; 2007.14. Campaign for Tobacco-Free Kids, et al. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Thirteen Years Later. Washington,DC: National Center for Tobacco-Free Kids; 2011.15. American Cancer Society. Cancer Prevention & Early DetectionFacts & Figures, 2008. 2008; http://www.cancer.org/downloads/STT/CPED_2008.pdf. Accessed August 7, 2008.16. National Center for Health Statistics. Health, United States, 2011 withChartbook on Trends in the Health of Americans. Hyattsville, MD: PublicHealth Service; 2011.17. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults Aged ≥18 Years – United States, 2005-2010. MMWRMorb Mortal Wkly Rep. 2011;60(35):1207-1212.18. Centers for Disease Control and Prevention. Current CigaretteSmoking Among Adults Aged ≥18 Years – United States, 2011. MMWRMorb Mortal Wkly Rep. 2012;61(44):889-894.19. US Department of Health and Human Services. Women and Smoking:A Report of the Surgeon General. Atlanta, Georgia: U.S. Department ofHealth and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health; 2001.20. National Center for Health Statistics. Health, United States, 2007 withChartbook on Trends in the Health of Americans. Hyattsville, MD: PublicHealth Service; 2008.21. Centers for Disease Control and Prevention. Quitting Smoking AmongAdults – United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 201160(44):1513-1519.22. Jemal A, Center MM, Ward E. The convergence of lung cancer ratesbetween blacks and whites under the age of 40, United States. CancerEpidemiol Biomarkers Prev. Dec 2009;18(12):3349-3352.26. Eriksen M, Ross H, Mackay J. The Tobacco Atlas, Fourth Edition:American Cancer Society & World Lung Foundation; 2012.27. Connolly GN. The marketing of nicotine addiction by one oral snuffmanufacturer. Tobacco control. 1995;4:73-79.28. US Department of Health and Human Services. Preventing TobaccoUse Among Young People: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National center forChronic Disease Prevention and Health Promotion, Office on Smokingand Health; 1994.29. Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco andcancer. Lancet Oncol. 2008;9(7):667-675.30. US Department of Health and Human Services. The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee tothe Surgeon General. Atlanta, GA: U.S. Department of Health and HumanServices,National Institutes of Health, National Cancer Institute;1986.31. Henley SJ, Thun MJ, Connell C, Calle EE. Two large prospective studies of mortality among men who use snuff or chewing tobacco (UnitedStates). Cancer Causes Control. 2005;16(4):347-358.32. US Department of Agriculture. Tobacco Situation and Outlook Report.Pub. No. TBS-256. Washington, DC: US Department of Agriculture, Marketand Trade Economics Division, Economics Research Service; April 2004.33. US Department of Agriculture. Tobacco Outlook, TBS-263. Washington, DC: US Department of Agriculture, Market and Trade EconomicsDivision, Economics Research Service;2007.34. National Center for Health Statistics. National Health Interview Survey Public Use Data File 2010: Centers for Disease Control and Prevention; 2011.35. Substance Abuse and Mental Health Services Administration, Officeof Applied Studies, National Survey on Drug Use and Health. Resultsfrom the 2010 National Survey on Drug Use and Health. Tobacco andAlchohol Use Tables. 2011; http://oas.samhsa.gov/NSDUH/2k10NSDUH/tabs/LOTSect2pe.htm#TopOfPage. Accessed September 22, 2011.36. American Cancer Society. Cancer Prevention & Early Detection Facts& Figures, 2013 (In Press). Atlanta, GA: American Cancer Society; 2013.37. National Cancer Institute. Disease consequences of cigar smoking.Smoking and Tobacco Control, Monograph 9: Cigars – Health Effects andTrends. Vol NIH Publication No. 98-4302,. Washington, DC: NationalInstitutes of Health; 1998:105-160.38. American Cancer Society. Cancer Prevention & Early Detection Facts& Figures, 2012. Atlanta, GA: American Cancer Society; 2012.39. American Legacy Foundation. Cigars, Cigarillos & Little Cigars FactSheet. 2009. Available at: http://www.legacyforhealth.org/PDF/CigarsCigarillos-and-Little-Cigars_FactSheet.pdf. Accessed December 21, 2010.40. US Department of Health and Human Services. The Health Benefitsof Smoking Cessation: A Report of the Surgeon General. Rockville, MD:U.S. Department of Health and Human Services, Public Health Service,Cancer Facts & Figures 2013  39Centers for Disease Control and Prevention, Center for Chronic DiseasePrevention and Health Promotion, Office on Smoking and Health; 1990.41. Centers for Disease Control and Prevention. Cigarette SmokingAmong Adults and Trends in Smoking Cessation – United States, 2008.MMWR Morb Mortal Wkly Rep. 2009;58(44):1227-1232.42. Centers for Disease Control and Prevention. Behavioral Risk FactorSurveillance System Survey Data. Atlanta, GA: U.S. Department of Healthand Human Services, Centers for Disease Control and Prevention;2011.43. Clinical Practice Guideline Treating Tobacco Use and Dependence2008 Update Panel L, and Staff. A clinical practice guideline for treatingtobacco use and dependence: 2008 update. A U.S. Public Health Servicereport. Am J Prev Med. 2008;35(2):158-176. Review.44. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and HumanServices, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.45. Centers for Disease Control and Prevention. Vital Signs: Nonsmokers’ Exposure to Secondhand Smoke – United States, 1999-2008. MMWRMorb Mortal Wkly Rep. 2010;59(35):1141-1146.46. IARC Tobacco Smoke and Involuntary Smoking. IARC Monographs onthe Evaluation of the Carcinogenic Risk of Chemicals to Humans: Volume83. Lyon: International Agency for Research on Cancer; 2004.47. US Environmental Protection Agency. Respiratory Health Effects ofPassive Smoking: Lung Cancer and Other Disorders. Washington, DC: U.S.Environmental Protection Agency;1992. EPA/600/6-90/006F.48. California Environmental Protection Agency. Health Effects of Exposure to Environmental Tobacco Smoke: Final Report. Sacramento, CA:California Environmental Protection Agency, Office of EnvironmentalHealth Hazard Assesment; 1997.49. California Environmental Protection Agency, Air Resource Board,Office of Environmental Health Hazard Assessment. Proposed Identi-fication of Environmental Tobacco Smoke as a Toxic Air Contaminant,SRP Version. 2005; http://www.arb.ca.gov/toxics/ets/dreport/dreport.htm. Accessed August 8, 2005.50. National Institute of Environmental Sciences. 11th Report on Carcinogens. Research Triangle Institute, NC: National Institute of Environmental Sciences, National Toxicology Program; 2005.51. International Agency for Research on Cancer. IARC Handbooks ofCancer Prevention. Volume 13: Evaluating the Effectiveness of Smoke-FreePolicies. Lyon, France: IARC Press; 2009.52. International Agency for Research on Cancer. IARC Handbooks ofCancer Prevention. Volume 13: Evaluating the Effectiveness of Smoke-freePolicies. Lyon, France: IARC Press; 2009.53. National Cancer Institute. State and Local Legislative Action toReduce Tobacco Use. Smoking and Tobacco Control Monograph No. 11.Bethesda, Maryland: U.S. Department of Health and Human Services,National Institutes of Health, National Cancer Institute NIH Pub. No.00-4804; 2000.54. American Nonsmokers’ Rights Foundation. Overview List - How ManySmokefree Laws? 2012; http://www.no-smoke.org/pdf/mediaordlist.pdf.Accessed September 7, 2012.55. American Nonsmokers’ Rights Foundation. U.S. Colleges and Universities with Smokefree and Tobacco-Free Policies. 2012; http://www.nosmoke.org/pdf/smokefreecollegesuniversities.pdf. Accessed September8, 2012.56. US Department of Commerce, Census Bureau. National CancerInstitute and Centers for Disease Control and Prevention Co-sponsoredTobacco Use Supplement to the Current Population Survey (2006-07).Home and Work Environments in Which Smoking is Not Allowed - Percentage Estimates. 2008; http://riskfactor.cancer.gov/studies/tus-cps/results/data0607/table2.html. Accessed September 9, 2011.57. Centers for Disease Control and Prevention. Annual Smoking – Attributable Mortality, Years of Potential Life Lost, and Productivity Losses – UnitedStates, 1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54(25):625-628.Cancer DisparitiesAn overarching objective of the American Cancer Society’s 2015challenge goals is to eliminate disparities in the cancer burdenamong different segments of the US population, defined in termsof socioeconomic status (income, education, insurance status,etc.), race/ethnicity, residence, sex, and sexual orientation. Thecauses of health disparities within each of these groups are complex and include interrelated social, economic, cultural, andhealth system factors. However, disparities predominantly arisefrom inequities in work, wealth, income, education, housing,and overall standard of living, as well as social barriers to highquality cancer prevention, early detection, and treatmentservices.Socioeconomic StatusPersons with lower socioeconomic status (SES) have disproportionately higher cancer death rates than those with higher SES,regardless of demographic factors such as race/ethnicity. For40  Cancer Facts & Figures 2013example, cancer mortality rates among both African Americanand non-Hispanic white men with 12 or fewer years of educationare almost 3 times higher than those of college graduates for allcancers combined, and are 4-5 times higher for lung cancer. Furthermore, progress in reducing cancer death rates has beenslower in persons with lower SES. These disparities occur largelybecause persons with lower SES are at higher risk for cancer andhave less favorable outcomes after diagnosis. People with lowerSES are more likely to engage in behaviors that increase cancerrisk, such as tobacco use, physical inactivity, and poor diet. Thisis in part because of marketing strategies that target these populations, but also because of environmental or communityfactors that provide fewer opportunities for physical activityand less access to fresh fruits and vegetables. Lower SES is alsoassociated with financial, structural, and personal barriers tohealth care, including inadequate health insurance, reducedaccess to recommended preventive care and treatment services,and lower literacy rates. Individuals with no health insuranceare more likely to be diagnosed with advanced cancer and lesslikely to receive standard treatment and survive their disease.For more information about the relationship between SES andcancer, see Cancer Facts & Figures 2011, Special Section, andCancer Facts & Figures 2008, Special Section, available online atcancer.org.Racial and Ethnic MinoritiesDisparities in the cancer burden among racial and ethnic minorities largely reflect obstacles to receiving health care servicesrelated to cancer prevention, early detection, and high-qualitytreatment, with poverty (low SES) as the overriding factor.According to the US Census Bureau, in 2010, more than 1 in 4African Americans and Hispanics/Latinos lived below the poverty line, compared to 1 in 10 non-Hispanic whites. Moreover, 1in 5 African Americans and 1 in 3 Hispanics/Latinos were uninsured, while only 1 in 10 non-Hispanic whites lacked healthinsurance.Discrimination is another factor that contributes to racial/ethnic disparities in cancer mortality. Racial and ethnic minoritiestend to receive lower-quality health care than whites even wheninsurance status, age, severity of disease, and health status arecomparable. Social inequalities, including communication barriers and provider assumptions, can affect interactions betweenpatient and physician and contribute to miscommunication ordelivery of substandard care.In addition to poverty and social discrimination, cancer occurrence in a population may also be influenced by cultural and/orinherited factors that decrease or increase risk. For example,Hispanic women have a lower risk of breast cancer in partbecause they tend to begin having children at a younger age,which decreases breast cancer risk. Individuals who maintaina primarily plant-based diet or do not use tobacco because ofcultural or religious beliefs have a lower risk of many cancers.Populations that include large numbers of recent immigrants,such as Hispanics and Asians, have higher rates of cancersrelated to infectious agents (e.g., stomach, liver, uterine cervix),reflecting a higher prevalence of infection in immigrant countries of origin. Genetic factors may also explain some differencesin cancer incidence. For example, women from population groupswith an increased frequency of mutations in the breast cancersusceptibility genes (BRCA1 and BRCA2), such as women ofAshkenazi Jewish descent, have an increased risk of breast andovarian cancer. Genetic factors may also play a role in theelevated risk of prostate cancer among African American menand the incidence of more aggressive forms of breast cancer inAfrican American women. However, genetic differences associated with race or ethnicity make a minor contribution to thedisparate cancer burden between populations. Following is abrief overview of the cancer burden for each of the four majornonwhite racial/ethnic groups.African Americans: African Americans are more likely todevelop and die from cancer than any other racial or ethnicgroup. The death rate for cancer among African American malesis 33% higher than among white males; for African Americanfemales, it is 16% higher than among white females. AfricanAmerican men have higher incidence and mortality rates thanwhites for each of the cancer sites listed in the table on page 43.For more information on cancer in African Americans, see Cancer Facts & Figures for African Americans, available online atcancer.org/statistics.Hispanics: Hispanics have lower incidence rates for all cancerscombined and for most common types of cancer compared towhites, but have higher rates of cancers associated with infection, such as liver, stomach, and uterine cervix. For example,Hispanic women have the highest incidence rate for cervicalcancer, and rates of liver cancer are about twice as high in Hispanics as in whites. For more information on cancer in Hispanics,see Cancer Facts & Figures for Hispanics/Latinos, available onlineat cancer.org/statistics.Asian Americans and Pacific Islanders: Compared to otherracial/ethnic groups, Asian Americans and Pacific Islandershave the lowest overall cancer incidence rates, as well as thelowest rates for most common cancer types. However, similar toHispanics, this population has higher rates for many of the cancers related to infection. As shown in the table on page 43, theyhave the highest liver cancer incidence and death rates of allracial and ethnic groups in both men and women. Liver cancerincidence and death rates among Asian American and PacificIslander men and women are about 2.5-fold higher than thoseamong whites and 20% higher than those among Hispanics, whohave the second-highest rates. (For more information on cancersrelated to infection, see Cancer Facts & Figures 2005, Special Section, available online at cancer.org.)American Indians and Alaska Natives: Kidney cancer incidence and mortality rates are higher in American Indian andAlaska Native men and women than in any other racial or ethnicpopulation – three times higher than those among Asian Americans/Pacific Islanders, who have the lowest rates. High prevalenceof smoking and obesity likely contribute to this disparity.Cancer information for American Indians and Alaska Natives isknown to be incomplete because the racial/ethnic status ofmany of these individuals is not correctly identified in medicaland death records. Although efforts have been made to collectmore accurate information through linkage with the IndianHealth Service records, available statistics probably do not represent the true cancer burden in this population.Note: It is important to recognize that although cancer data inthe US are primarily reported for broad racial and ethnic minority groups, these populations are not homogenous. There aresignificant variations in the cancer burden within each racial/Cancer Facts & Figures 2013  41ethnic group. For example, among Asian Americans, incidencerates for cervical cancer are almost three times higher in Vietnamese women than in Chinese and Japanese women, partlybecause the Vietnamese, in general, immigrated more recently,are poorer, and have less access to cervical cancer screening.Geographic VariabilityCancer rates in the US vary by geographic area, with larger differences for some cancer sites than others. Lung cancer, for example,shows the most striking variation by state (figure, page 44).Among both men and women, lung cancer death rates are morethan 3-fold higher in Kentucky (100 and 56 per 100,000 in men andwomen, respectively) – the state with the highest rates – than inUtah (28 and 16 per 100,000 in men and women, respectively),which has the lowest rates. These differences reflect the substantial historic and continuing variation in smoking prevalenceamong states, which is influenced to some extent by statetobacco control policies. Geographic variations also reflect differences in environmental exposures, socioeconomic factors inpopulation demographics, and screening behaviors. For moreinformation about cancer disparities, see Cancer Facts & Figures2011, Special Section, available online at cancer.org.Public PolicyThe American Cancer Society and the American Cancer SocietyCancer Action Network SM (ACS CAN), the Society’s nonprofit,nonpartisan advocacy affiliate, are dedicated to reducing cancerincidence and mortality rates among minority and medicallyunderserved populations. This goal can be achieved by institutingeffective policies and public health programs that promote overallwellness and help save lives. Listed below are some of the effortsat both the state and federal levels that the Society and ACS CANhave been involved with in the past few years:•  Patient Protection and Affordable Care Act. The Societyand ACS CAN are working to ensure that key provisions ofthe Affordable Care Act (ACA) that benefit cancer patientsand survivors are implemented as strongly as possible andare adequately funded. Some of the law’s provisions that willdirectly help address disparities include:·· Improving the affordability of coverage by increasinginsurance subsidies and eliminating arbitrary annualand lifetime caps on coverage for all insurance plans sothat families affected by cancer will face fewer financialbarriers to care·· Focusing on prevention and early detection by requiringall new insurance plans to provide coverage for essential,evidence-based preventive measures with no additionalcopays42  Cancer Facts & Figures 2013·· Eliminating discrimination based on health status andpreexisting conditions, which has been so detrimental tocancer patients over the years·· Requiring qualified health plans to provide materials inappropriate languagesACS CAN will continue to look for ways to strengthen the legislation throughout the implementation process both at the federaland state level.•  National Breast and Cervical Cancer Early DetectionProgram. A high priority for the Society and ACS CAN atboth the state and federal level is fighting to increase fundingfor the National Breast and Cervical Cancer Early DetectionProgram (NBCCEDP). This successful program, which began in1991, provides community-based breast and cervical cancerscreening to low-income, uninsured, and underinsuredwomen, more than 50% of whom are from racial/ethnicminority groups. Due to a large cut in funding, screeningrates within the program greatly declined in 2007; rates havebeen increasing slowly since, but still have not fully recovered.ACS CAN is asking Congress to increase funding to $275million for fiscal year 2013 to support continued growthand to give women access to lifesaving screening services.While the Affordable Care Act will greatly improve access toscreening, the NBCCEDP will remain an essential programfor improving breast and cervical cancer screening andtreatment in our nation’s most vulnerable populations. It willbe critical to use the program’s infrastructure and communityoutreach specialists to help women receive the lifesavingservices they need.•  Colorectal Cancer Prevention, Early Detection, andTreatment Act. The Society and ACS CAN are advocatingfor the Colorectal Cancer Prevention, Early Detection, andTreatment Act, a national screening, treatment, and outreachprogram focused on increasing colorectal cancer screeningrates in low-income, medically underserved populations.•  Patient Navigation. Patient navigation demonstrationprograms have shown navigation to be an important aspectof improving satisfaction and care among cancer patients,especially those in medically underserved and minoritypopulations. In order to increase patient navigation services,ACS CAN is looking to expand the reach of patient navigatorsthrough federal funding support.The Society and ACS CAN also are leading efforts to increasefederal investment in cutting-edge biomedical and cancerresearch and treatments, as well as ways to expand access tothem. To learn more, to get involved, and to make a difference inthe fight against cancer, visit cancer.org/involved/advocate.Cancer Incidence and Death Rates* by Site, Race, and Ethnicity†, US, 2005-2009Incidence WhiteAfricanAmericanAsian Americanor Pacific IslanderAmerican IndianHispanic/or Alaska Native‡LatinoAll sites Male Female543.1424.0619.7396.8327.5286.2423.2360.3418.7333.2Breast (female)123.3118.085.989.193.0Colon & rectum Male Female52.839.265.148.041.432.150.741.146.933.3Kidney & renal pelvis Male Female21.211.223.312.110.15.129.016.619.811.49.13.115.04.221.68.116.47.617.56.682.357.599.351.349.428.167.449.545.426.677.298.816.19.313.06.413.58.110.111.8Liver & intrahepatic bile duct Male FemaleLung & bronchus Male FemaleProstate141.0228.7Stomach Male Female8.44.016.38.2Uterine cervix7.810.47.2124.9Mortality All sites Male Female216.7150.8288.3174.6132.693.2184.9135.9146.4100.6Breast (female)22.431.611.916.614.9Colon & rectum Male Female19.513.629.819.813.19.618.814.615.310.2Kidney & renal pelvis Male Female5.92.76.02.62.91.38.84.15.02.3Liver & intrahepatic bile duct Male Female7.43.111.94.014.56.111.95.911.85.3Lung & bronchus Male Female65.340.882.638.035.918.548.333.230.814.1Prostate21.753.1 10.019.717.8Stomach Male Female4.32.2Uterine cervix2.210.34.84.39.05.38.33.87.44.32.03.53.0*Per 100,000, age adjusted to the 2000 US standard population.†Race and ethnicity categories are not mutually exclusive; persons of Hispanic/Latino origin may be of any race.‡Data based on Contract Health Service Delivery Area counties.Source: Jemal A, et al. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancersand HPV vaccination levels. J Natl Cancer Inst.2012. In press.American Cancer Society, Surveillance Research, 2013Cancer Facts & Figures 2013  43Geographic Patterns in Lung Cancer Death Rates* by State, US, 2005-2009MalesWAMTNDMEMNORIDVTNHSDWINYWYMIIANENVILAZMOVA28.1 - 45.145.2 - 58.158.2 - 70.6SCMSTXRate per 100,000DCNCARNMMDKYTNOKAKDEWVKSNJOHINCOCARICTPAUTMAAL70.7 - 84.484.5 - 99.7GALAFLHIFemalesWAMTNDMEMNORIDVTNHSDWINYWYMIIANENVPAUTILINOHCOCAAZMOOKNMAKTXVAKYNCTNSCALNJMDDCRate per 100,00016.1 - 36.036.1 - 40.740.8 - 45.5ARMSRICTDEWVKSMA45.6 - 48.848.9 - 55.5GALAFLHI*Age adjusted to the 2000 US standard population.Source: US Mortality Data, National Center for Health Statistics, Centers for Disease Control and Prevention.American Cancer Society, Surveillance Research, 201344  Cancer Facts & Figures 2013Nutrition and PhysicalActivityIt has been estimated by the World Cancer Research Fund thatone-quarter to one-third of the cancers that occur in high-incomecountries like the US are due to poor nutrition, physical inactivity, and excess weight, and thus could be prevented. Maintaininga healthy body weight, being physically active on a regular basis,and eating a healthy diet are as important as not using tobaccoproducts in reducing cancer risk. The American Cancer Society’snutrition and physical activity guidelines emphasize the importance of weight control, physical activity, dietary patterns, andlimited, if any, alcohol consumption in reducing cancer risk andhelping people stay well; unfortunately, the majority of Americansare not meeting these recommendations. Increasing trends inunhealthy eating and physical inactivity – and resultant increasesin overweight and obesity – have largely been influenced by theenvironments in which people live, learn, work, and play. As aresult, the guidelines include explicit Recommendations forCommunity Action to facilitate the availability of healthy,affordable food choices and opportunities for physical activityin communities, schools, and workplaces.The following recommendations reflect the best nutrition andphysical activity evidence available to help Americans reducetheir risk of cancer, as well as lower their risk of heart diseaseand diabetes.Recommendations for Individual Choices1. Achieve and maintain a healthy weightthroughout life.•  Be as lean as possible throughout life without beingunderweight.•  Avoid excess weight gain at all ages. For those who arecurrently overweight or obese, losing even a small amountof weight has health benefits and is a good place to start.•  Engage in regular physical activity and limit consumptionof high-calorie foods and beverages as key strategies formaintaining a healthy weight.In the United States, it has been estimated that overweight andobesity contribute to 14% to 20% of all cancer-related mortality.Overweight and obesity are clearly associated with increasedrisk for developing many cancers, including cancers of the breastin postmenopausal women, colon and rectum, endometrium,adenocarcinoma of the esophagus, kidney, and pancreas. Overweight and obesity may also be associated with increased risk ofcancers of the liver, non-Hodgkin lymphoma, multiple myeloma,cervix, ovary, and aggressive prostate cancer, and obesity alsolikely increases the risk of cancer of the gallbladder. In addition,abdominal fatness is convincingly associated with colorectalcancer, and probably related to higher risk of pancreatic, endometrial, and postmenopausal breast cancers.Increasing evidence also suggests that being overweightincreases the risk for cancer recurrence and decreases the likelihood of survival for several cancers. Some studies have shownthat surgery to treat morbid obesity reduces mortality frommajor chronic diseases, including cancer. Although knowledgeabout the relationship between weight loss and cancer risk isincomplete, individuals who are overweight should be encouraged and supported in their efforts to reduce weight.At the same time that evidence connecting excess weight toincreased cancer risk has been accumulating, trends in overweight and obesity have been increasing dramatically. Theprevalence of obesity in the US more than doubled between1976-1980 and 2003-2006. Although overall prevalence has stabilized in recent years, more than one-third of adults – 36% ofboth men and women – are currently obese. More than likely,these trends are already impacting cancer trends: in the midpoint assessment of its 2015 Challenge Goals, American CancerSociety researchers reported that while the incidence of bothcolorectal cancer and postmenopausal breast cancer had beendeclining, it is likely that the declines in both would have startedearlier and would have been steeper had it not been for theincreasing prevalence of obesity. Indeed, some researchers havespeculated that the longstanding, historic increases in lifeexpectancy in the US may level off or even decline within thefirst half of this century as a result of the obesity epidemic.Similar to adults, obesity among children and adolescents hastripled over the past several decades across race, ethnicity, andgender. In 2009-2010, 17% of American children ages 2 to 19 yearswere obese; obesity prevalence was 24% in African Americans,21% in Hispanics, and 14% in non-Hispanic whites. Becauseoverweight in youth tends to continue throughout life, efforts toestablish healthy body weight patterns should begin in childhood. The high prevalence of overweight and obesity in childrenand adolescents may increase incidence of cancer in the future.2. Adopt a physically active lifestyle.•  Adults should engage in at least 150 minutes of moderateintensity or 75 minutes of vigorous-intensity activity eachweek, or an equivalent combination, preferably spreadthroughout the week.•  Children and adolescents should engage in at least 1 hourof moderate- or vigorous-intensity activity each day, withvigorous-intensity activity at least three days each week.•  Limit sedentary behavior such as sitting, lying down,and watching television and other forms of screen-basedentertainment.Cancer Facts & Figures 2013  45•  Doing any intentional physical activity above usual activities,even if currently inactive, can have many health benefits.Living a physically active lifestyle is important to reduce therisk of a variety of types of cancer, as well as heart disease anddiabetes. Scientific evidence indicates that physical activity mayreduce the risk of several types of cancer, including cancers ofthe breast, colon, and endometrium, as well as advanced prostate cancer. Physical activity also indirectly reduces the risk ofdeveloping the many types of obesity-related cancers because ofits role in helping to maintain a healthy weight. Being active isthought to reduce cancer risk largely by improving energymetabolism and reducing circulating concentrations of estrogen, insulin, and insulin-like growth factors. Physical activityalso improves the quality of life of cancer patients and is associated with a reduction in the risk of cancer recurrences andimproved overall mortality in multiple cancer survivor groups,including breast, colorectal, prostate, and ovarian cancer.Despite the wide variety of health benefits from being active,25% of adults report no leisure-time activity, and only 49% meetminimum recommendations for moderate activity. Similarly,only 37% of youth meet recommendations. However, recent datareleased by the Centers for Disease Control and Prevention (CDC)indicate that trends may be improving. Walking prevalence(defined as walking for transportation or leisure in at least onebout of 10 minutes or more in the preceding 7 days) among adultsincreased significantly from 56% in 2005 to 62% in 2010.3. Consume a healthy diet, with an emphasis onplant foods.•  Choose foods and beverages in amounts that help achieveand maintain a healthy weight.•  Limit consumption of processed meat and red meat.•  Eat at least 2½ cups of vegetables and fruits each day.•  Choose whole grains instead of refined-grain products.There is strong scientific evidence that healthy dietary patterns,in combination with regular physical activity, are needed tomaintain a healthy body weight and to reduce cancer risk. Studies have shown that individuals who eat more processed and redmeat, potatoes, refined grains, and sugar-sweetened beveragesand foods are at a higher risk of developing or dying from a variety of cancers. Alternatively, adhering to a diet that contains avariety of fruits and vegetables, whole grains, and fish or poultryand fewer red and processed meats is associated with lower risk.A recent study found that dietary and lifestyle behaviors consistent with the American Cancer Society nutrition and physicalactivity guidelines are associated with lower mortality rates forall causes of death combined, and for cancer and cardiovasculardiseases, specifically. Despite the known benefits of a healthydiet, Americans are not following recommendations; accordingto the US Department of Agriculture, the majority of Americans46  Cancer Facts & Figures 2013would need to substantially lower their intake of added sugars,added fats, refined grains, and sodium, and increase their consumption of fruits, vegetables, whole grains, and low-fat dairyproducts in order to meet the 2010 Dietary Guidelines forAmericans.Currrently, the overall evidence related to dietary supplementsdoes not support their use in cancer prevention. The results ofrecently completed randomized clinical trials of antioxidantsupplements and selenium showed no reduction in risk for cancer, at least in generally well-nourished populations.The scientific study of nutrition and cancer is highly complex,and many important questions remain unanswered. It is notpresently clear how single nutrients, combinations of nutrients,over-nutrition, and energy imbalance, or the amount and distribution of body fat at particular stages of life affect a person’s riskof specific cancers. Until more is known about the specific components of diet that influence cancer risk, the best advice is toconsume a mostly plant-based diet that limits red and processedmeats and emphasizes a variety of vegetables, fruits, and wholegrains. A special emphasis should be placed on controlling totalcaloric intake to help achieve and maintain a healthy weight.4. If you drink alcoholic beverages, limitconsumption.People who drink alcohol should limit their intake to no morethan two drinks per day for men and one drink per day forwomen. Alcohol consumption is a risk factor for cancers of themouth, pharynx, larynx, esophagus, liver, colorectum, andbreast. For each of these cancers, risk increases substantiallywith the intake of more than two drinks per day. Even a fewdrinks per week may be associated with a slightly increased riskof breast cancer in women. The mechanism for how alcohol canaffect breast cancer is not known with certainty, but it may bedue to alcohol-induced increases in circulating estrogen or otherhormones in the blood, reduction of folic acid levels, or a directeffect of alcohol or its metabolites on breast tissue. Alcohol consumption combined with tobacco use increases the risk ofcancers of the mouth, larynx, and esophagus far more thaneither drinking or smoking alone.The American Cancer SocietyRecommendations for Community ActionWhile many Americans would like to adopt a healthy lifestyle,many encounter substantial barriers to consuming healthy foodand engaging in physical activity. Increased portion sizes, especially of restaurant meals; marketing and advertising of foodsand beverages high in calories, fat, and added sugar, particularlyto kids; schools and worksites that are not conducive to goodhealth; community design that hinders physical activity; economic and time constraints, as well as other influences, havecollectively contributed to increasing trends in obesity.The Society’s nutrition and physical activity guidelines includeRecommendations for Community Action because of the tremendous influence that the surrounding environment has onindividual food and activity choices. Acknowledging that turning obesity trends around will require extensive policy andenvironmental changes, the Society calls for public, private, andcommunity organizations to create social and physical environments that support the adoption and maintenance of healthynutrition and physical activity behaviors to help people stay well.Achieving these Recommendations for Community Action willrequire multiple strategies and bold action, ranging from theimplementation of community and workplace health promotionprograms to policies that affect community planning, transportation, school-based physical education, and food services.The Centers for Disease Control and Prevention (CDC), the Institute of Medicine, the World Health Organization (WHO), andothers have outlined a variety of evidenced-based approachesin communities, worksites, and schools to halt and ultimatelyturn around the obesity trends. Following are some specificapproaches that are currently under way:•  Limit the availability, advertising, and marketing of foods andbeverages of low nutritional value, particularly in schools.•  Strengthen nutrition standards in schools for foods andbeverages served as part of school meal programs andfor competitive foods and beverages served outside of theprograms.•  Increase the quality and quantity of physical education andthe amount of time students are physically active in K-12schools.•  Ensure that worksites have healthy food and beverage optionsand that physical environments are designed or adapted andmaintained to facilitate physical activity and weight control.•  Provide calorie information on chain restaurant menus.•  Invest in community design that supports development ofsidewalks, bike lanes, and access to parks and green space.The tobacco control experience has shown that policy and environmental changes at the national, state, and local levels arecritical to achieving changes in individual behavior. Measuressuch as clean indoor air laws and increases in cigarette excisetaxes are highly effective in deterring tobacco use. To avert anepidemic of obesity-related disease, similar purposeful changesin public policy and in the community environment will berequired to help individuals maintain a healthy body weight andremain physically active.Environmental Cancer RisksTwo major classes of factors influence the incidence of cancer:hereditary factors and acquired (environmental) factors. Hereditary factors come from our parents and cannot be modified.Environmental factors, which include behavioral choices, arepotentially modifiable. These include tobacco use, poor nutrition, physical inactivity, obesity, certain infectious agents,certain medical treatments, excessive sun exposure, and exposures to carcinogens (cancer-causing agents) that exist aspollutants in our air, food, water, and soil. Some carcinogensoccur naturally, and some are created or concentrated by humanactivity. For example, radon is a naturally occurring carcinogenpresent in soil and rock; however, occupational radon exposureoccurs in underground mines, and substantial exposures alsooccur in poorly ventilated basements in regions where radon soilemissions are high.Environmental factors (as opposed to hereditary factors)account for an estimated 75%-80% of cancer cases and deaths inthe US. Exposure to carcinogenic agents in occupational, community, and other settings is thought to account for a relativelysmall percentage of cancer deaths – about 4% from occupationalexposures and 2% from environmental pollutants (man-madeand naturally occurring). Although the estimated percentage ofcancers related to occupational and environmental carcinogensis small compared to the cancer burden from tobacco smoking(30%) and the combination of poor nutrition, physical inactivity,and obesity (35%), the relationship between such agents andcancer is important for several reasons. First, even a small percentage of cancers can represent many deaths: 6% of cancerdeaths in the US in 2011 correspond to approximately 34,320deaths. Second, the burden of exposure to occupational andenvironmental carcinogens is borne disproportionately bylower-income workers and communities, contributing to disparities in the cancer burden across the US population. Third,although much is known about the relationship between occupational and environmental exposure and cancer, someimportant research questions remain. These include the role ofexposures to certain classes of chemicals (such as hormonallyactive agents) during critical periods of human developmentand the potential for pollutants to interact with each other, aswell as with genetic and acquired factors.How Environmental Carcinogens AreIdentifiedThe term carcinogen refers to exposures that can increase theincidence of malignant tumors (cancer). The term can apply to asingle chemical such as benzene; fibrous minerals such as asbestos; metals and physical agents such as x-rays or ultraviolet light;or exposures linked to specific occupations or industries (e.g.,Cancer Facts & Figures 2013  47nickel refining). Carcinogens are usually identified on the basisof epidemiological studies or by testing in animals. Studies ofoccupational groups (cohorts) have played an important role inunderstanding many chemical carcinogens – as well as radiation – because exposures are often higher among workers, whocan be followed for long periods of time. Some information hasalso come from studies of persons exposed to carcinogens during medical treatments (such as radiation and estrogen), as wellas from studies conducted among individuals who experiencedhigh levels of short-term exposure to a chemical or physicalagent due to an accidental or intentional release (such as survivors of the atomic bomb explosions of Hiroshima and Nagasaki).It is more difficult to study the relationship between exposure topotentially carcinogenic substances and cancer risk in the general population because of uncertainties about exposure andthe challenge of long-term follow up. Moreover, relying upon epidemiological information to determine cancer risk does notfulfill the public health goal of prevention since by the time theincreased risk is detected, a large number of people may havebeen exposed.Thus, for the past 40 years, the US and many other countrieshave developed methods for identifying carcinogens throughanimal testing using the “gold standard” of a 2-year or lifetimebioassay in rodents. This test is expensive and time-consuming,but it can provide information about potential carcinogens sothat human exposure can be reduced or eliminated. Many substances that are carcinogenic in rodent bioassays have not beenadequately studied in humans, usually because an acceptablestudy population has not been identified. Among the substancesthat have proven carcinogenic in humans, all have shown positive results in animals when tested in well-conducted 2-yearbioassays.1 Between 25%-30% of established human carcinogenswere first identified through animal bioassays. Since animaltests necessarily use high-dose exposures, human risk assessment usually requires extrapolation of the exposure-responserelationship observed in rodent bioassays to predict effects inhumans at lower doses. Typically, regulatory agencies in the USand abroad have adopted the default assumption that no threshold level (level below which there is no increase in risk) ofexposure exists for carcinogenesis.Evaluation of CarcinogensThe National Toxicology Program (NTP) plays an important rolein the identification and evaluation of carcinogens in the US, andthe International Agency for Research on Cancer (IARC) playsa similar role internationally. The NTP was established in 1978to coordinate toxicology testing programs within the federalgovernment, including tests for carcinogenicity. The NTP is alsoresponsible for producing the Report on Carcinogens, an informational scientific and public health document that identifies48  Cancer Facts & Figures 2013agents, substances, mixtures, or exposure circumstances thatmay increase the risk of developing cancer.2 There are currently107 agents classified by IARC as Group 1 (i.e., carcinogenic tohumans). For a list of substances included in the 11th Report onCarcinogens that are known or reasonably anticipated to behuman carcinogens, see ntp.niehs.nih.gov/ntp/roc/toc11.html.The IARC is a branch of the World Health Organization that regularly convenes scientific consensus groups to evaluate potentialcarcinogens. After reviewing published data from laboratory,animal, and human research, these committees reach consensus about whether the evidence should be designated “sufficient,”“limited,” or “inadequate” to conclude that the substance is acarcinogen. For a list of substances that have been reviewed bythe IARC monograph program, visit monographs.iarc.fr/ENG/Classification/index.pdf. The American Cancer Society does nothave a formal program to systematically review and evaluatecarcinogens. However, information on selected topics can befound at cancer.org.Although the relatively small risks associated with low-levelexposure to carcinogens in air, food, or water are difficult todetect in epidemiological studies, scientific and regulatory bodies worldwide have accepted the principle that it is reasonableand prudent to reduce human exposure to substances shown tobe carcinogenic at higher levels of exposure. Although muchpublic concern about the influence of manmade pesticides andindustrial chemicals has focused on cancer, pollution mayadversely affect the health of humans and ecosystems in manyother ways. Research to understand the short- and long-termimpact of environmental pollutants on a broad range of outcomes, as well as regulatory actions to reduce exposure torecognized hazards, has contributed to the protection of thepublic and the preservation of the environment for future generations. It is important that this progress be recognized andsustained. For more information on environmental cancer risks,see the article published by Fontham et al. in CA: A Cancer Journal for Clinicians.3References1. Tomatis L, Melnick RL, Haseman J, et al. Alleged “misconceptions” distort perceptions of environmental cancer risks. FASEBJ. 2001; 15:195203.2. National Toxicology Program 11th Report on Carcinogens. ResearchTriangle Park; 2005.3. Fontham ET, Thun MJ, Ward E, et al. American Cancer Society perspectives on environmental factors and cancer. CA Cancer J Clin. 2009;59:343351.The Global Fightagainst CancerThe ultimate mission of the American Cancer Society is to eliminate cancer as a major health problem. Because cancer knowsno boundaries, this mission extends around the world. Cancer isan enormous global health burden, touching every region andsocioeconomic level. Today, cancer accounts for one in everyeight deaths worldwide – more than HIV/AIDS, tuberculosis,and malaria combined. In 2008, there were an estimated 12.7million cases of cancer diagnosed and 7.6 million deaths fromcancer around the world. More than 60 percent of all cancerdeaths occur in low- and middle-income countries, many ofwhich lack the medical resources and health systems to supportthe disease burden. Moreover, the global cancer burden is growing at an alarming pace; in 2030 alone, about 21.3 million newcancer cases and 13.1 million cancer deaths are expected tooccur, simply due to the growth and aging of the population. Thefuture burden may be further increased by the adoption ofbehaviors and lifestyles associated with economic developmentand urbanization (e.g., smoking, poor diet, physical inactivity,and reproductive patterns) in low- and middle-income countries. Tobacco use is a major cause of the increasing globalburden of cancer as the number of smokers worldwide continuesto grow.Worldwide Tobacco UseTobacco use is the most preventable cause of death worldwide,and is responsible for the deaths of approximately half of longterm users. Tobacco use killed 100 million people in the 20thcentury and will kill 1 billion people in the 21st century if current trends continue. Each year, tobacco use is responsible foralmost 6 million premature deaths, and by 2030 this numberis expected to increase to 8 million, 80% of whom will reside inlow- and middle-income countries.•  Between 2002 and 2030, tobacco-attributable deaths areprojected to decline by 9% in high-income countries, but areexpected to double from 3.4 million to 6.8 million in lowand middle-income countries. For example, tobacco use iscurrently the number one killer in China, responsible for 1.2million deaths annually. This number is expected to rise to3.5 million deaths annually by the year 2030.•  Approximately 18% of the world’s population – more than 1billion men and 250 million women – smoke. In 32 countries,male smoking prevalence is greater than or equal to 45%: allbut 5 of these are low- and middle-income countries.•  Data from the Global Youth Tobacco Survey conducted during 1999-2008 found that among youth 13 to 15 years of age,12% of boys and 7% of girls reported smoking cigarettes, and12% of boys and 8% of girls reported using other tobaccoproducts. Data from 1999-2005 showed that in every region ofthe world, the ratio of male-to-female smoking among youthwas smaller than the ratio reported among adults, reflectinga global trend of increased smoking among female youth.•  It has been estimated that in 2004, more than 600,000nonsmokers worldwide died as a result of exposure tosecondhand smoke and 40% of children were exposed tosecondhand smoke.•  The use of smokeless tobacco accounts for a significantand growing portion of tobacco use throughout the world.The majority of smokeless tobacco is consumed in SouthAsia. However, consistent with trends in the US, the sales ofsmokeless tobacco products are growing at a rapid pace inhigh-income countries, even as smoking rates decline.•  As emerging and developing economies come to prominenceand their health systems develop further, the medical costs oftobacco-related disease will continue to grow. In China, forexample, the direct costs of smoking were $6.2 billion in 2008(an increase of 154% compared to 2000), while the indirectcosts of smoking were $22.7 billion in 2008 (an increase of376% compared to 2000).•  Spending on tobacco products diverts resources fromessential goods and services. For example, in India tobaccoconsumption impoverishes roughly 15 million people, andin Cambodia, the amount of money spent on one pack ofpremium cigarettes can buy as much as 3,500 food caloriescomprising a typical daily diet in that country.•  About 55% of the world’s population was covered by one ormore evidence-based tobacco control measures in 2010, upfrom less than 10% in 2008. The WHO estimates that 11% ofthe world’s population lives in smoke-free environments.The first global public health treaty, the Framework Conventionon Tobacco Control (FCTC), was unanimously adopted by theWorld Health Assembly on May 21, 2003, and subsequentlyentered into force as a legally binding accord for all ratifyingstates on February 27, 2005.65 The FCTC features specific provisions to control both the global supply and demand for tobacco,including regulation of tobacco product contents, packaging,labeling, advertising, promotion, sponsorship, taxation, illicittrade, youth access, exposure to secondhand tobacco smoke,and environmental and agricultural impacts. Parties to thetreaty are expected to strengthen national legislation, enacteffective tobacco control policies, and cooperate internationallyto reduce global tobacco consumption. As of August 2012, out of195 eligible countries, 176 have ratified or acceded to the treatyrepresenting approximately 88% of the world’s population. Anumber of major tobacco-producing nations, including Argentina, Indonesia, Malawi, the US, and Zimbabwe, have either notsigned or have signed but not ratified the treaty.Cancer Facts & Figures 2013  49The Role of the American Cancer SocietyWith a century of experience in cancer control, the AmericanCancer Society is uniquely positioned to help in leading theglobal fight against cancer and tobacco by assisting and empowering the world’s cancer societies and anti-tobacco advocates.The Society’s Global Health and Intramural Research departmentsare raising awareness about the growing global cancer burden andpromoting evidence-based cancer and tobacco control programs.The American Cancer Society has established three integratedgoals to reduce the global burden of cancer:•  Make cancer control a political and public healthpriority. According to the World Health Organization,noncommunicable diseases (NCDs) – such as cancer, heartdisease and diabetes – claim more lives each year and accountfor about 60% of the world’s deaths. About 28 million (80%)of these deaths occur in low- and middle-income countries,yet less than 3% of private and public funding for health isallocated to prevent and control cancer and other NCDs inthese areas. The Society has become actively involved inworking with global partners, including the Union for International Cancer Control (UICC), the International DiabetesFederation, the World Heart Federation, Lance ArmstrongFoundation, and others to prioritize cancer and NCDs on theglobal health agenda.•  Reduce tobacco use, with a particular focus on subSaharan Africa. Through an $8 million (US) grant receivedfrom the Bill & Melinda Gates Foundation in 2010, the Society and its partners, including the Africa Tobacco ControlRegional Initiative, the Africa Tobacco Control Alliance, theFramework Convention Alliance, the Campaign for TobaccoFree Kids, and the International Union Against Tuberculosisand Lung Disease, support and assist national governmentsand civil societies in Africa to implement tobacco controlpolicies such as advertising bans, tobacco tax increases,graphic warning labels, and the promotion of smoke-freeenvironments. The partners on this project actively advocatefor further tobacco control resources in sub-Saharan Africaand help establish mechanisms to protect existing laws fromtobacco industry efforts to overturn them. In addition, theSociety supports the development of research and technicalcapacity for tobacco control through partnerships with theUniversity of Cape Town and the University of Pretoria. Theseprojects focus on the advancement of taxation as a tobaccocontrol tool, the economics of tobacco control, and the training of future public health practitioners.•  Increase awareness about the burden of cancer and itsleading risk factor, tobacco use. The Society continues towork with global partners to increase awareness about thegrowing global cancer and tobacco burdens and their impacton low- and middle-income countries. In addition to printpublications, the American Cancer Society provides cancerinformation to millions of individuals throughout the worldon its Web site, cancer.org. More than 20% of the visitors tothe Web site come from outside the US. Information is currently available in English, Spanish, Mandarin, and severalother Asian languages, with plans to include more languagesin the near future. For more information on the global cancerburden, visit the Society’s Global Health program Web siteat cancer.org/international and see the following intramuralresearch program publications available on cancer.org andtobaccoatlas.org:·· Global Cancer Facts & Figures 2nd Edition·· The Tobacco Atlas, Fourth Edition·· The Cancer AtlasThe American Cancer SocietyIn 1913, 10 physicians and five laypeople founded the AmericanSociety for the Control of Cancer. Its purpose was to raise awareness about cancer symptoms, treatment, and prevention; toinvestigate what causes cancer; and to compile cancer statistics.Later renamed the American Cancer Society, Inc., the organization now works with its more than 3 million volunteers to savelives and create a world with less cancer and more birthdays byhelping people stay well, helping people get well, by working tofind cures, and by fighting back against the disease. By workingrelentlessly to bring cancer under control, the Society is makingremarkable progress in cancer prevention, early detection, treatment, and patient quality of life. The overall cancer death ratehas steadily declined since the early 1990s, and the 5-year survival rate is now 68%, up from 49% in the 1970s. Thanks to this50  Cancer Facts & Figures 2013progress, nearly 14 million cancer survivors in the US will celebrate another birthday this year.How the American Cancer Society IsOrganizedThe American Cancer Society, Inc., is a 501(c)(3) nonprofit corporation governed by a Board of Directors that sets policy, developsand approves an enterprise-wide strategic plan and relatedresource allocation, and is responsible for the performance of theorganization as a whole, with the advice and support of regionallybased volunteer boards.The Society’s structure includes a central corporate office inAtlanta, Georgia, regional offices supporting 12 geographicDivisions, and more than 900 local offices in those regions. Thecorporate office is responsible for overall strategic planning;corporate support services such as human resources, financialmanagement, IT, etc.; development and implementation of globaland nationwide endeavors such as our groundbreaking researchprogram, our international program, and 24-hour call center;and provides technical support and materials to regional andlocal offices for local delivery.With a presence in more than 5,100 communities, the AmericanCancer Society fights for every life threatened by every cancer inevery community. Our regional and local offices are organizedto engage communities in the cancer fight, delivering lifesavingprograms and services and raising money at the local level.Offices are strategically placed around the country in an effortto maximize the impact of our efforts, and to be as efficient aspossible with the money donated to the Society to fight cancerand save lives.VolunteersAs a global grassroots force, the Society relies on the strength ofmore than three million dedicated volunteers. From leadershipvolunteers who set strategy and policy to members of the community who organize special events, patient support, and educationprograms, Society volunteers, supported by professional staff,drive every part of our mission. The Society’s vast array of volunteer opportunities empowers people from every community toplay a role in saving lives, while they fulfill their own.How the American Cancer Society Saves LivesThe American Cancer Society is working relentlessly to saveslives from cancer by helping people stay well and get well, byfinding cures, and by fighting back against the disease.Helping People Stay WellThe American Cancer Society provides information that empowers people to take steps that help them prevent cancer or find itearly, when it is most treatable.PreventionThe Society helps people quit using tobacco through the AmericanCancer Society Quit For Life® Program, managed and operated byAlere Wellbeing. These two organizations have more than 35years of combined experience in tobacco cessation coaching andhave helped more than 1 million tobacco users quit. Together,they will help millions more make a plan to quit, realizing theAmerican Cancer Society’s mission to save lives and create aworld with less cancer and more birthdays.The Society offers many programs to companies to help theiremployees stay well and reduce their cancer risk, too. Theseinclude:•  FreshStart®, a group-based tobacco cessation counselingprogram designed to help employees plan a successful quitattempt by providing essential information, skills for copingwith cravings, and group support•  Content subscription service, a free electronic tool kitsubscription offered by the Society to employers that supportthe health and wellness needs of employees with informationabout cancer prevention and early detection, and support services and resources for those facing cancer•  HealthyLiving, a monthly electronic newsletter produced bythe American Cancer Society that teaches the importance ofmaking healthy lifestyle choices•  American Cancer Society Workplace Solutions Assessment,which surveys a company’s health and wellness policies andpractices and recommends evidence-based strategies thathelp improve employee health behaviors, control health carecosts, and increase productivity•  Active For LifeSM , a 10-week online program that usesindividual and group strategies to help employees becomemore physically activeAcross the nation, the Society’s nonprofit, nonpartisan advocacyaffiliate, the American Cancer Society Cancer Action Network SM(ACS CAN), works to create healthier communities by protecting people from the dangers of secondhand smoke. As of July 1,2012, 48% of the US population was covered by comprehensivesmoke-free workplace, restaurant, and bar laws. In 2009, theFamily Smoking Prevention and Tobacco Control Act was signedinto law. A decade in the making, the law, grants the US Foodand Drug Administration the authority to regulate the manufacturing, selling, and marketing of tobacco products. Strongimplementation of the law is vital to reducing death and diseasefrom tobacco products.For the majority of Americans who do not smoke, the mostimportant ways to reduce cancer risk are to maintain a healthyweight, be physically active on a regular basis, and eat a mostlyplant-based diet, consisting of a variety of vegetables and fruit,whole grains, and limited amounts of red and processed meats.The Society publishes guidelines on nutrition and physical activity for cancer prevention in order to review the accumulatingscientific evidence on diet and cancer; to synthesize this evidence into clear, informative recommendations for the generalpublic; to promote healthy individual behaviors, as well as environments that support healthy eating and physical activityhabits; and, ultimately, to reduce cancer risk. These guidelinesform the foundation for the Society’s communication, worksite,school, and community strategies designed to encourage andsupport people in making healthy lifestyle behavior changes.Cancer Facts & Figures 2013  51Early DetectionFinding cancer at its earliest, most treatable stage gives patientsthe greatest chance of survival. To help the public and healthcare providers make informed decisions about cancer screening, the American Cancer Society publishes a variety of earlydetection guidelines. These guidelines are assessed regularly toensure that recommendations are based on the most currentscientific evidence.The Society currently provides screening guidelines for cancersof the breast, cervix, colorectum, prostate, and endometrium,and general recommendations for a cancer-related componentof a periodic checkup to examine the thyroid, mouth, skin,lymph nodes, testicles, and ovaries.Throughout its history, the American Cancer Society has implemented a number of aggressive awareness campaigns targetingthe public and health care professionals. Campaigns to increaseusage of Pap testing and mammography have contributed to a70% decrease in cervical cancer incidence rates since the introduction of the Pap test in the 1950s and a 33% decline in breastcancer mortality rates since 1989. More recently, the Societylaunched ambitious multimedia campaigns to encourage adults50 years of age and older to get tested for colorectal cancer. TheSociety also continues to encourage the early detection of breastcancer through public awareness and other efforts targetingpoor and underserved communities.Helping People Get WellFor the nearly 1.7 million cancer patients diagnosed this yearand appoximately 14 million US cancer survivors, the AmericanCancer Society is available anytime, day and night, to offer freeinformation, programs, services, and community referrals topatients, survivors, and caregivers to help them make decisionsthrough every step of a cancer experience. These resources aredesigned to help people facing cancer on their journey to gettingwell.Information, 24 Hours a Day, Seven Days a WeekThe American Cancer Society is available 24 hours a day, sevendays a week online at cancer.org and by calling 1-800-227-2345.Callers are connected with a Cancer Information Specialist whocan help them locate a hospital, understand cancer and treatment options, learn what to expect and how to plan, help addressinsurance concerns, find financial resources, find a local support group, and more. The Society can also help people whospeak languages other than English or Spanish find the assistance they need, offering services in 170 languages in total.Information on every aspect of the cancer experience, from prevention to survivorship, is also available through the Society’sWeb site, cancer.org. The site includes an interactive cancerresource center containing in-depth information on every majorcancer type.52  Cancer Facts & Figures 2013The Society also publishes a wide variety of pamphlets and booksthat cover a multitude of topics, from patient education, qualityof life, and caregiving issues to healthy living. A complete list ofSociety books is available for order at cancer.org/bookstore.The Society publishes a variety of information sources for healthcare providers, including three clinical journals: Cancer, CancerCytopathology, and CA: A Cancer Journal for Clinicians. Moreinformation about free subscriptions and online access to CAand Cancer Cytopathology articles is available at cancer.org/journals. The American Cancer Society also collaborates withnumerous community groups, nationwide health organizations,and large employers to deliver health information and encourage Americans to adopt healthy lifestyle habits through theSociety’s science-based worksite programs.Day-to-day Help and Emotional SupportThe American Cancer Society can help cancer patients and theirfamilies find the resources they need to make decisions aboutthe day-to-day challenges that can come from a cancer diagnosis, such as transportation to and from treatment, financial andinsurance needs, and lodging when having to travel away fromhome for treatment. The Society also connects people with others who have been through similar experiences to offer emotionalsupport.Help navigating the health care system: Learning how to navigate the cancer journey and the health care system can beoverwhelming for anyone, but it is particularly difficult for thosewho are medically underserved, those who experience languageor health literacy barriers, or those with limited resources. TheAmerican Cancer Society Patient Navigator Program was designedto reach those most in need. The largest oncology-focusedpatient navigator program in the country, it has specially trainedpatient navigators at 119 cancer treatment facilities across thenation. Patient navigators work in cooperation with patients,family members, caregivers, and facility staff to connect patientswith information, resources, and support to decrease barriers andultimately to improve health outcomes. In 2011, approximately89,000 people relied on the Patient Navigator Program to helpthem through their diagnosis and treatment. The Society collaborates with a variety of organizations, including the NationalCancer Institute’s Center to Reduce Cancer Health Disparities,the Center for Medicare and Medicaid Services, numerous cancer treatment centers, and others to implement and evaluatethis program.Transportation to treatment: Cancer patients cite transportation to and from treatment as a critical need, second only todirect financial assistance. The American Cancer Society RoadTo Recovery® program matches these patients with speciallytrained volunteer drivers. This program offers patients an additional key benefit of companionship and moral support duringthe drive to medical appointments. In some areas, primarilywhere transportation assistance programs are difficult to sustain, the Society helps patients or their drivers via prepaid gascards to help defray costs associated with transportation totreatment. In 2011, the American Cancer Society provided morethan 1.4 million transportation services to more than 77,000constituents. Our service requests for transportation assistanceincreased by 15% in 2011 over the previous year, and the numberof rides that we provided in 2011 was up by 18%.Lodging during treatment: When someone diagnosed withcancer must travel away from home for the best treatment,where to stay and how to afford accommodations are immediateconcerns and can sometimes affect treatment decisions. American Cancer Society Hope Lodge® facilities provide free, homelike,temporary lodging for patients and their caregivers close totreatment centers, thereby easing the emotional and financialburden of finding affordable lodging. In 2011, the 31 Hope Lodgelocations provided approximately 250,000 nights of free lodgingto nearly 38,000 patients and caregivers – saving them $23 million in lodging expenses.Breast cancer support: Through the American Cancer SocietyReach To Recovery® program, trained breast cancer survivor volunteers provide one-on-one support, information, and resourcereferrals to people facing breast cancer. Patients are matched witha volunteer who has had a similar breast cancer experience as wellas other similar characteristics. These volunteers will meet oneon-one, either in person, by telephone, or via email, with womenanytime throughout their breast cancer experience.Prostate cancer support: Men facing prostate cancer can findone-on-one or group support through the American CancerSociety Man To Man® program. The program also offers men theopportunity to educate their communities about prostate cancer and to advocate with lawmakers for stronger research andtreatment policies.Cancer education classes: People with cancer and their caregivers need help coping with the challenges of living with thedisease. Doctors, nurses, social workers, and other health careprofessionals provide them with that help by conducting theAmerican Cancer Society I Can Cope® educational classes toguide patients and their families through their cancer journey.Hair-loss and mastectomy products: Some women wear wigs,hats, breast forms, and bras to help cope with the effects of mastectomy and hair loss. The American Cancer Society’s “tlc”Tender Loving Care® is a magazine and catalog in one that offersinformative articles and a line of products to help women whoare battling cancer restore their appearance and self-esteem. Allproceeds from product sales go back into the Society’s programsand services for patients and survivors.Help with appearance-related side effects of treatment:Look Good Feel Better® is a collaboration of the American Cancer Society, the Personal Care Products Council Foundation, andthe Professional Beauty Association that helps women learnbeauty techniques to restore their self-image and cope withappearance-related side effects of cancer treatment. This freeprogram engages certified, licensed beauty professionals trainedas Look Good Feel Better volunteers to provide tips on makeup,skin care, nail care, and head coverings. Information and materials are also available for men and teens.Finding hope and inspiration: People with cancer and theirloved ones do not have to face their cancer experience alone.They can connect with others who have “been there” throughthe American Cancer Society Cancer Survivors Network®. Theonline community is a welcoming and safe place that was created by and for cancer survivors and their families.WhatNextTM is another free online support network developed inpart by the American Cancer Society that helps cancer patients,survivors, and caregivers gain firsthand insight into living withcancer and connect with others facing a similar diagnosis.Finding CuresResearch is at the heart of the American Cancer Society’s mission.For more than 65 years, the Society has been finding answers thatsave lives – from changes in lifestyle to new approaches in therapies to improving cancer patients’ quality of life. No singlenongovernmental, not-for-profit organization in the US hasinvested more to find the causes and cures of cancer than theAmerican Cancer Society. We relentlessly pursue the answersthat help us understand how to prevent, detect, and treat all cancer types. We combine the world’s best and brightest researcherswith the world’s largest, oldest, and most effective communitybased anti-cancer organization to put answers into action.The Society’s comprehensive research program consists of extramural grants, as well as intramural programs in epidemiology,surveillance and health policy research, behavioral research,international tobacco control research, and statistics and evaluation. Intramural research programs are led by the Society’s ownstaff scientists.Extramural GrantsThe American Cancer Society’s extramural grants program supports research in a wide range of cancer-related disciplines atmore than 230 institutions. The Society is currently funding 937research and training grants totaling more than $468 million asof August 28, 2012. Grant applications are solicited through anationwide competition and are subjected to a rigorous externalpeer-review process, ensuring that only the most promisingresearch is funded. The Society primarily funds investigatorsearly in their research careers at, a time when they are less likelyto receive funding from the federal government, thus giving thebest and the brightest a chance to explore cutting-edge ideas ata time when they might not find funding elsewhere. In additionto funding across the continuum of cancer research, from basicCancer Facts & Figures 2013  53science to clinical and quality-of-life research, the Society alsofocuses on needs that are unmet by other funding organizations.For instance, for 10 years, the Society supported a targetedresearch program to address the causes of higher cancer mortality in the poor and medically underserved; this has recentlybecome a priority area for funding.To date, 46 Nobel Prize winners have received grant supportfrom the Society early in their careers, a number unmatched inthe nonprofit sector, and proof that the organization’s approachto funding young researchers truly helps launch high-qualityscientific careers.Intramural ResearchFor more than 65 years, the Society’s intramural research program has conducted and published high-quality epidemiologicresearch to advance understanding of the causes and prevention of cancer and monitored and disseminated surveillanceinformation on cancer occurrence, risk factors, and screening.EpidemiologyAs a leader in cancer research, the Society’s EpidemiologyResearch program has been conducting studies to identify factors that cause or prevent cancer since 1951. The first of these,the Hammond-Horn Study, helped to establish cigarette smoking as a cause of death from lung cancer and coronary heartdisease, and also demonstrated the Society’s ability to conductvery large prospective cohort studies. The Cancer PreventionStudy I (CPS-I) was launched in 1959 and included more than 1million men and women recruited by 68,000 volunteers. Resultsfrom CPS-I clearly demonstrated that the sharp increase in lungcancer death rates among US men and women between 19591972 occurred only in smokers. Epidemiologic study of thiscohort was also among the first to show a relationship betweenobesity and all-cause and cancer mortality.In 1982, Cancer Prevention Study II (CPS-II) was establishedthrough the recruitment of 1.2 million men and women by 77,000volunteers. The more than 480,000 lifelong nonsmokers in CPSII provide the most stable estimates of lung cancer risk in theabsence of active smoking. CPS-II data are used extensively bythe Centers for Disease Control and Prevention (CDC) to estimate deaths attributable to smoking. The CPS-II study alsomade important contributions in establishing the link betweenobesity and cancer. A subgroup of CPS-II participants, the CPSII Nutrition Cohort has been particularly valuable for clarifyingassociations of obesity, physical activity, diet, aspirin use, andhormone use with cancer risk. Blood samples from this groupallow Society investigators and their collaborators at other institutions to study how genetic, hormonal, nutritional, and otherblood markers are related to cancer risk and/or progression.The Cancer Prevention Studies have resulted in more than 500scientific publications and have provided unique contributions54  Cancer Facts & Figures 2013both within the Society and the global scientific community. Inaddition to key contributions to the effects of the tobacco epidemic over the past half-century, other important findings fromthese studies include:•  The association of obesity with increased death rates for atleast 10 cancer sites, including colon and postmenopausalbreast cancer•  The link between aspirin use and lower risk of colon cancer,opening the door to research on chronic inflammation andcancer•  The relationship between cancer and certain potentiallymodifiable factors, such as physical inactivity, prolongedhormone use, and certain dietary factors•  The association between air pollution, especially small particulates and ozone, with increased death rates from heartand lung conditions, which helped to motivate the Environmental Protection Agency to propose more stringent limitson air pollutionWhile landmark findings from the CPS-II Nutrition Cohort haveinformed multiple areas of public health policy and clinicalpractice, the cohort is aging. A new cohort is needed to explorethe effects of changing exposures and to provide greater opportunity to integrate biological measurements into studies ofgenetic and environmental risk factors. In 2006, Society epidemiologists began the enrollment of a new cohort, CPS-3, withthe goal of recruiting and following approximately 300,000 menand women. All participants are providing blood samples at thetime of enrollment. Following on the long history of partneringwith Society volunteers and supporters for establishing a cohort,the Society’s community-based Relay For Life® events are one ofthe primary venues for recruiting and enrolling participants.Although similar large cohorts are being established in Canadaand some European and Asian countries, there are currently nonationwide studies of this magnitude; therefore, the data collected from CPS-3 participants will provide unique opportunitiesfor research in the US.Surveillance & Health Services ResearchThrough the Surveillance Research program, the Society disseminates the most current cancer statistics in CA: A Cancer Journalfor Clinicians (caonline.amcancersoc.org), as well as eight CancerFacts & Figures publications. These publications are the mostwidely cited sources for cancer statistics and are available inhard copy from Society Division offices and online through theSociety’s Web site at cancer.org/statistics. Society scientists alsomonitor trends in cancer risk factors and screening and publishthese results annually – along with Society recommendations,policy initiatives, and evidence-based programs – in Cancer Prevention & Early Detection Facts & Figures. Surveillance Researchalso collaborates with the International Agency for Research onCancer (IARC) to publish Global Cancer Facts & Figures, an international companion to Cancer Facts & Figures.Since 1998, the Society has collaborated with the National Cancer Institute, the Centers for Disease Control and Prevention, theNational Center for Health Statistics, and the North AmericanAssociation of Central Cancer Registries to produce the AnnualReport to the Nation on the Status of Cancer, a peer-reviewedjournal article that reports current information related to cancer rates and trends in the US.Epidemiologists in Surveillance Research also conduct and publish high-quality epidemiologic research in order to advance theunderstanding of cancer. Research topics include exploring differences in the burden of cancer by socioeconomic status in theUS, describing global cancer trends, and demonstrating theassociation between public health interventions, such as tobaccocontrol, and cancer incidence and mortality. Recent studieshave focused on state differences in colorectal cancer mortality,temporal trends in breast cancer incidence rates, and use of sunless tanning products by adolescents in the US.Interest in developing a Health Services Research (HSR) program within the American Cancer Society’s intramural researchprogram began in the late 1990s, motivated by increasing disparities in the quality and outcomes of cancer care. The primaryobjective of the HSR program is to perform high-quality, highimpact research to evaluate disparities in cancer treatment andoutcomes and support the Society’s mission and program initiatives. Additional, related objectives include identifying criticalgaps in quality patient care and taking leadership in policy andtechnical initiatives to address these gaps. The HSR program isuniquely positioned to respond rapidly to critical informationneeds by Society personnel, as well as national and internationalpolicy makers.To accomplish its objectives, the HSR program’s work has primarily involved the use of secondary data sources. The NationalCancer Data Base (NCDB), jointly sponsored by the AmericanCancer Society and the American College of Surgeons, has beenkey to the HSR program’s research on the impact of insurance oncancer status, treatments, and outcomes, as well as for broadersurveillance of cancer incidence/prevalence and treatment patterns. Other databases used to support the HSR program’sobjectives include linked SEER-Medicare data, linked state registry and Medicaid enrollment data, and Medical Expenditure PanelSurvey Data linked with National Health Interview Survey Data.International Tobacco Control ResearchThe predecessor of the International Tobacco Control ResearchProgram (ITCRP), the International Tobacco Surveillance unit,was created in 1998 to support collaborative international tobaccosurveillance efforts involving the Society, the WHO Tobacco FreeInitiative, the World Bank, and the Centers for Disease Controland Prevention’s (CDC) Office of Smoking and Health. Its specialpublications, the Tobacco Control Country Profiles, 1st and 2ndeditions, were distributed during the 11th and 12th World Conference on Tobacco or Health in 2000 and in 2003, respectively.Since 2006, the ITCRP has begun to focus on economic researchin tobacco control, taking advantage of established partnerships with numerous academic and nonprofit organizations. Inaddition to original research, the program helps build capacityfor the collection and analysis of economic data to provide theevidence base for tobacco control in low- and middle- incomecountries. To that end, the ITCRP received funding from theBloomberg Global Initiative to Reduce Tobacco Use, the Bill &Melinda Gates Foundation, and grants from the National Institutes of Health Fogarty International Center.The most important service publication of the ITCRP is TheTobacco Atlas, which is produced in collaboration with the Society’s Global Health department, Georgia State University, andthe World Lung Foundation. The Tobacco Atlas, Fourth Edition(tobaccoatlas.org) was released at the 15th World Conference onTobacco or Health in 2012 in Singapore.Behavioral Research CenterThe American Cancer Society was one of the first organizationsto recognize the importance of behavioral and psychosocialfactors in the prevention and control of cancer and to fundextramural research in this area. In 1995, the Society established the Behavioral Research Center (BRC) as an intramuraldepartment. The BRC’s work currently focuses on cancer survivorship, quality of life, and tobacco research. It also addressesthe issues of special populations, including minorities, the poor,rural populations, and other underserved groups. The BRC’songoing projects include:•  Studies of the quality of life of cancer survivors, which includea nationwide longitudinal study and a cross-sectional study,that explore the physical and psychosocial adjustment tocancer and identify factors affecting quality of life•  Studies to identify and prioritize gaps in information andresources for cancer survivors as they transition from activetreatment back to the community care setting•  Contributions to the development of a National Cancer Survivorship Resource Center meant to advance survivorship asa distinct phase of cancer care, promote healthy behaviors toreduce late and long-term effects of cancer and its treatment,and improve surveillance and screening practices to detectthe return of cancer•  Studies of family caregivers that explore the impact of thefamily’s involvement in cancer care on the quality of life of thecancer survivor and the caregiverCancer Facts & Figures 2013  55•  Efforts to establish and implement a process to measure theeffective control of pain, other symptoms, and side effects forthose who have been affected by cancer•  Studies of racial disparities and the role of sociocultural andneighborhood factors in cancer-related behaviors (smoking,poor diet, lack of exercise, and cancer screening) among astatewide sample of more than 1,000 African Americans inGeorgia•  Studies investigating how social, psychological, and otherfactors impact smokers’ motivation and ability to quit forthe purposes of improving existing Society programs forsmoking cessation (e.g., FreshStart, the Great AmericanSmokeout®) and to develop new technology-based cessationinterventions.Statistics and Evaluation CenterThe Statistics & Evaluation Center (SEC) provides expert statistical, survey, study design, evaluation, sampling and researchconsultation services to the American Cancer Society. Theirmission is to improve Society programs, processes, and servicesbased on good science. They strive to capture, analyze, andreport data that are objective, valid, reliable, accurate, andtimely – to provide a solid evidence base for decision making.High-quality evaluation produces the greatest benefit to cancerpatients, their caregivers, and their families.The SEC has two areas of focus – Statistics and Survey Research –that work independently or in tandem, depending on the natureof the project. SEC staff regularly interact with multiple stakeholders in addition to Society staff, including patients, caregivers,volunteers, and staff from partnering health care systems. TheSEC is engaged in evaluations of many of the priority missionoutcomes around survivorship, quality-of-life, prevention, earlydetection, and tobacco control, collaborating regularly with theSociety’s Health Promotions, Extramural Grants, Cancer ControlSciences, and Global Health departments. The SEC uses multiplemethods, including a variety of quantitative and qualitative app­roaches, all of which help produce robust and effective findings.The SEC, working within the Integrated Evaluation Team, developed a Strategic Leader Discussion Series which has fosteredcommunication, integration, and collaboration, facilitating thesystematic inclusion of evaluation into the planning cycle ofmany of the Society’s transformation efforts (see below). TheCenter continues to provide leadership on evaluation effortsrelated to cancer prevention projects that utilize communityhealth advisors on a large program funded by Walmart. They arealso leading evaluations of the Dietitian-on-Call and the PatientNavigation Center of Excellence programs, as well as some focusedstudies around Hope Lodge facilities – including an innovativereturn-on-investment project. Finally, the SEC completed thethird year of its pilot project around geo-mapping to supportprogram decision making.56  Cancer Facts & Figures 2013In the past year, a large fraction of SEC staff time has beenengaged in support of the strategic and operational planningneeded to transform the Society into an outcomes-focused organization. SEC staff actively participated on multiple nationaltransformation workgroups, as well as provided many of theseteams with data analysis and geo-maps.Fighting BackConquering cancer is as much a matter of public policy as scientific discovery. Whether it’s advocating for quality, affordablehealth care for all Americans, increasing funding for cancerresearch and programs, or enacting laws and policies that helpdecrease tobacco use, lawmakers play a critical role in determining how much progress we make as a country to defeatcancer. The American Cancer Society Cancer Action Network(ACS CAN), the Society’s nonprofit nonpartisan advocacy affiliate, uses applied policy analysis, direct lobbying, grassrootsaction, and media advocacy to ensure elected officials nationwide pass laws that help save lives from cancer.Created in 2001, ACS CAN is the force behind a powerful grassroots movement uniting and empowering cancer patients,survivors, caregivers, and their families to fight back againstcancer. The nation’s leading voice advocating for public policiesthat are helping to defeat cancer, ACS CAN works to encourageelected officials and candidates to make cancer a top nationalpriority. In recent years, ACS CAN has worked to pass a numberof laws at the federal, state, and local levels focused on preventing cancer and detecting it early, increasing research on ways toprevent and treat cancer, improving access to lifesaving screenings and treatment, and improving quality of life for cancerpatients. Some recent advocacy accomplishments impactingcancer patients include:•  Passage and implementation of the Affordable Care Act(ACA) of 2010, comprehensive legislation that:·· Prohibits insurance companies from denying insurancecoverage based on a preexisting conditions (childrenstarting in 2010, adults in 2014)·· Prohibits insurance coverage from being rescinded whena patient gets sick·· Removes lifetime limits from all insurance plans·· Allows children and young adults to be covered under theirparents’ insurance plans until they turn 26·· Makes coverage for routine care costs available to patientswho take part in clinical trials·· Establishes a National Institutes of Health Interagency PainResearch Advisory Committee to coordinate pain management research initiatives and an Institute of MedicinePain Conference series that will be important to relievingcancer-related pain and other chronic pain conditions·· Establishes a National Prevention and Health PromotionStrategy; a National Prevention, Health Promotion andPublic Health Council; and a Prevention and Public HealthFund with mandatory funding to prioritize, coordinate,oversee, and fund prevention-related activities nationwide·· Requires all new health insurance plans and Medicare tocover preventive services rated “A” or “B” by the US Preventive Services Task Force (USPTF) at no cost to patients(including breast, cervical, and colorectal cancer screeningand smoking cessation treatment)·· Requires state Medicaid programs to provide pregnantwomen with tobacco cessation treatment at no cost·· Protects children and families against states rules thatlimit program eligibility or increase premiums or enrollment fees in Medicaid·· Provides funding to states to expand Medicaid coverage tolow-income adults (below 133% of the federal poverty level)·· Saves states money in uncompensated care by replacinglocal dollars with new federal subsidies·· Prioritizes health disparities at the National Institutes ofHealth, establishes a network of federal offices of minorityhealth, and creates an Office of Women’s Health·· Enhances data collection and reporting to ensure racialand ethnic minorities are receiving appropriate, timely,and quality health care·· Authorizes grants to help states and local jurisdictionsaddress health workforce needs·· Secures coverage for a new annual wellness visit witha personalized prevention plan and gradually reducesout-of-pocket costs for prescription drugs for Medicarebeneficiaries·· Creates incentives for health care providers to deliver morecoordinated and integrated care to beneficiaries enrolledin Medicare and Medicaid·· Requires chain restaurants to provide calorie informationon menus and have other nutrition information available toconsumers upon request; requires chain vending machineowners or operators to display calorie information for allproducts available for salePlease refer to The Affordable Care Act: How It Helps People withCancer and their Families for more information (http://action.acscan.org/site/DocServer/Affordable_Care_Act_Through_the_Cancer_Lens_Final.pdf?docID=18421).•  Supporting legislation that focuses on preventing cancer byreducing tobacco use, obesity prevalence, and sun exposure;improving nutrition; and increasing physical activity. By successfully working with partners, ACS CAN has:·· Helped empower the FDA with authority over tobaccoproducts·· Helped pass comprehensive smoke-free laws in 23 statesand the District of Columbia, Puerto Rico, and the USVirgin Islands that require all workplaces, restaurants,and bars to be smoke-free, covering nearly half of the USpopulation, and defended these laws in court·· Helped increase taxes on tobacco products to an averagestate cigarette tax of $1.49 per pack and defended againsttax rollbacks·· Continued its role as intervener in the US government’slawsuit against the tobacco industry, in which manufacturers have been convicted as racketeers for decades offraud associated with marketing of tobacco products·· Begun implementing the Healthy, Hunger-Free Kids Actof 2010, strong legislation to reauthorize the federal childnutrition programs and strengthen school nutrition. Thelaw improves nutrition standards and increases fundingfor school meals, establishes nutrition standards for foodssold in schools outside of meal programs, and strengthenslocal wellness policies by providing resources and technicalassistance for their implementation and requiring them tobe publicly available and periodically reviewed.·· Advocated for state requirements for increased, qualityphysical education in all schools·· Supported the federal government’s development of voluntary nutrition standards for foods marketed to children·· Worked with state governments to implement laws prohibiting tanning bed use for everyone under the age of 18•  Worked to improve access to essential cancer screeningservices, especially among low-income, uninsured, andunderinsured populations•  Advocated for full funding for the National Breast and CervicalCancer Early Detection Program (NBCCEDP), which providesfree breast and cervical cancer screenings and treatment tolow-income, uninsured, and medically underserved women•  Advocated for legislation to create a new nationwide colorectalscreening and treatment program modeled after NBCCEDP•  Improved quality of life for cancer patients by advocating forpatients and survivors to receive the best cancer care thatmatches treatments to patient and family goals across theirlife course. ACS CAN has:·· Advocated for balanced pain policies in multiple states andat the federal level to ensure patients and survivors havecontinued access to the treatments that promote betterpain management and improved quality of lifeCancer Facts & Figures 2013  57·· Advanced a new quality-of-life legislative platform thataddresses the need for better patient access to palliativecare services that address patient symptoms such as painand fatigue that begins at point of diagnosis and is providedalongside curative treatment, as well as expand researchfunding in this area and build the health professions workforce needed to provide patients with serious illnessesbetter patient-centered, coordinated care. Increased publicawareness of the increasingly urgent cancer drug shortageproblem and advocated for solutions to the complex,multiple causes of cancer drug shortagesSome efforts in the fight against cancer are more visible thanothers, but each successful battle is an important contributionto what will ultimately be victory over the disease. ACS CAN ismaking sure the voice of the cancer community is heard in thehalls of government and is empowering communities everywhere to fight back.The Society is also rallying people to fight back against the disease through our Relay For Life and Making Strides AgainstBreast Cancer® programs. The American Cancer Society RelayFor Life is a life-changing event that gives everyone in communities across the globe a chance to celebrate the lives of people whohave battled cancer, remember loved ones lost, and fight backagainst the disease, making it the world’s largest movement toend cancer. At Relay events, teams of people camp out at a localhigh school, park, or fairground and take turns walking or running around track or path for up to 24 hours. Making StridesAgainst Breast Cancer events unite communities to walktogether, one million strong, as the most powerful force to endbreast cancer. Dollars raised fund groundbreaking research,provide free resources and support to help people throughouttheir cancer journey, and ensures access to mammograms forwomen who need them.Sources of StatisticsEstimated new cancer cases in 2013. The numbers of new UScancer cases in 2013 are projected using a two-step process.First, the total number of cases in each state is estimated usinga spatiotemporal model based on incidence data from 49 statesand the District of Columbia for the years 1995-2009 that met theNorth American Association of Central Cancer Registries’(NAACCR) high-quality data standard for incidence, which covers about 98% of the US population. This method considersgeographic variations in sociodemographic and lifestyle factors,medical settings, and cancer screening behaviors as predictorsof incidence, as well as accounting for expected delays in casereporting. Then, the number of new cases nationally and in eachstate is projected four years ahead using a temporal projectionmethod. (For more information on the estimation of new cases,see “A” in Additional information on page 59.)Incidence rates. Incidence rates are defined as the number ofpeople per 100,000 who are diagnosed with cancer during agiven time period. Incidence rates in this publication are ageadjusted to the 2000 US standard population to allow comparisons across populations with different age distributions. Stateincidence rates were published in NAACCR’s publication CancerIncidence in North America, 2005-2009. (See “B” in Additionalinformation, page 59, for full reference.) Trends in cancer incidence provided for selected cancer sites are based on incidencerates that have been adjusted for delays in reporting and wereoriginally published in the Surveillance, Epidemiology, and EndResults (SEER) Cancer Statistics Review (CSR) 1975-2009. (See “C”in Additional information, page 59, for full reference). Incidencerates that are not adjusted for delays in reporting may underes-58  Cancer Facts & Figures 2013timate the number of cancer cases in the most recent timeperiod. Cancer rates most affected by reporting delays are melanoma of the skin, leukemia, and prostate because these cancersare frequently diagnosed in nonhospital settings. Cancer incidence rates by race/ethnicity were obtained from NAACCR.Estimated cancer deaths in 2013. The estimated numbers ofUS cancer deaths are calculated by fitting the numbers of cancerdeaths for 1995-2009 to a statistical model that forecasts thenumbers of deaths expected to occur in 2013. The estimatednumbers of cancer deaths for each state are calculated similarly,using state-level data. For both US and state estimates, data onthe numbers of deaths are obtained from the National Center forHealth Statistics (NCHS) at the Centers for Disease Control andPrevention. (For more information on this method, see “D” inAdditional information on page 59.)Mortality rates. Mortality rates, or death rates, are defined asthe number of people per 100,000 dying of a disease during agiven year. In this publication, mortality rates are based oncounts of cancer deaths compiled by NCHS and population datafrom the US Census Bureau. Death rates in this publication areage adjusted to the 2000 US standard population to allow comparisons across populations with different age distributions.These rates should be compared only to other statistics that areage adjusted to the US 2000 standard population. Trends in cancer mortality rates provided for selected cancer sites are basedon mortality data from 1992 to 2009 and were first published inthe CSR 1975-2009. (See “C” in Additional information, page 59,for full reference.)Important note about estimated cancer cases and deathsfor the current year. The estimated numbers of new cancercases and deaths in the current year are model-based and mayproduce numbers that vary considerably from year to year forreasons other than changes in cancer occurrence. For this reason,the use of our estimates to track year-to-year changes in canceroccurrence or deaths is strongly discouraged. Age-adjusted incidence and mortality rates reported by the SEER program andNCHS, respectively, are the suggested statistics to use whentracking cancer trends for the US. Rates from state cancer registries are useful for tracking local trends.Survival. This report presents relative survival rates to describecancer survival. Relative survival adjusts for normal life expectancy by comparing survival among cancer patients to that ofpeople not diagnosed with cancer who are of the same age, race,and sex. Five-year survival statistics presented in this publication were originally published in CSR 1975-2009 and are fordiagnosis years 2002 to 2008, with all patients followed through2009. In addition to 5-year relative survival rates, 1-, 10-, and15-year survival rates are presented for selected cancer sites.These survival statistics are generated using the National Cancer Institute’s SEER 18 database and SEER*Stat software version7.1.0. (See “E” in Additional information, for full references.) Oneyear survival rates are based on cancer patients diagnosed from2005 and 2008, 10-year survival rates are based on diagnosesfrom 1996 and 2008, and 15-year survival rates are based ondiagnoses from 1991 and 2008; all patients were followedthrough 2009.Additional information. More information on the methodsused to generate the statistics for this report can be found in thefollowing publications:A. Zhu L, Pickle LW, Naishadham D, et al. Predicting US and state-levelcancer counts for the current calendar year: part II – evaluation ofspatio-temporal projection methods for incidence. Cancer 2012;118(4):1100-9.B. Copeland G, Lake A, Firth R, et al. (eds). Cancer in North America:2005-2009. Volume Two: Registry-specific Cancer Incidence in the UnitedStates and Canada. Springfield, IL: North American Association of Central Cancer Registries, Inc. May 2012. Available at naaccr.org/DataandPublications/CINAPubs.aspx.C. Howlader N, Krapcho M, Neyman N, et al. (eds). SEER Cancer StatisticsReview, 1975-2009. National Cancer Institute. Bethesda, MD, 2012. Available at seer.cancer.gov.D. Chen HS, Portier K, Ghosh K, et al. Predicting US and State-levelcounts for the current calendar year: part I – evaluation of temporalprojection methods for mortality. Cancer 2012;118(4):1091-9.E. SEER 18 database: Surveillance, Epidemiology, and End Results(SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence- SEER 18 Regs Research Data + Hurricane Katrina Impacted LouisianaCases, Nov 2011 Sub (1973-2009 varying) - Linked To County Attributes- Total U.S., 1969-2009 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April2012, based on the November 2011 submission. SEER*Stat software:Surveillance Research Program, National Cancer Institute SEER*Statsoftware (www.seer.cancer.gov/seerstat) version 7.1.0.F. DevCan: Probability of Developing or Dying of Cancer Software, Version 6.6.1; Statistical Research and Applications Branch, National Cancer Institute, April 2012. http://srab.cancer.gov/devcanProbability of developing cancer. Probabilities of developingcancer are calculated using DevCan (Probability of DevelopingCancer) software version 6.6.1, developed by the National CancerInstitute. (See “F” in Additional information, for full reference.)These probabilities reflect the average experience of people inthe US and do not take into account individual behaviors andrisk factors. For example, the estimate of 1 man in 13 developinglung cancer in a lifetime underestimates the risk for smokersand overestimates the risk for nonsmokers.Cancer Facts & Figures 2013  59Screening Guidelines for the Early Detection of Cancer in Average-riskAsymptomatic PeopleCancer SitePopulationTest or ProcedureFrequencyBreastWomen,age 20+Breast self-examination(BSE)It is acceptable for women to choose not to do BSE or to do BSE regularly (monthly) orirregularly. Beginning in their early 20s, women should be told about the benefits andlimitations of BSE. Whether or not a woman ever performs BSE, the importance of promptreporting of any new breast symptoms to a health professional should be emphasized.Women who choose to do BSE should receive instruction and have their technique reviewedon the occasion of a periodic health examination.Clinical breast examination(CBE)For women in their 20s and 30s, it is recommended that CBE be part of a periodic healthexamination, preferably at least every three years. Asymptomatic women aged 40 andover should continue to receive a CBE as part of a periodic health examination, preferablyannually.MammographyBegin annual mammography at age 40.*Cervix†Women,ages 21-65Pap test &HPV DNA testCervical cancer screening should begin at age 21. For women ages 21-29, screening shouldbe done every 3 years with conventional or liquid-based Pap tests. For women ages 30-65,screening should be done every 5 years with both the HPV test and the Pap test (preferred),or every 3 years with the Pap test alone (acceptable). Women aged 65+ who have had ≥3consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last10 years, with the most recent test occurring within 5 years, and women who have had atotal hysterectomy should stop cervical cancer screening. Women should not be screenedannually by any method at any age.ColorectalMen andwomen,ages 50+Fecal occult blood test(FOBT) with at least 50%test sensitivity for cancer, orfecal immunochemical test(FIT) with at least 50% testsensitivity for cancer, orAnnual, starting at age 50. Testing at home with adherence to manufacturer’s recommendationfor collection techniques and number of samples is recommended. FOBT with the singlestool sample collected on the clinician’s fingertip during a digital rectal examination is notrecommended. Guaiac based toilet bowl FOBT tests also are not recommended. In comparisonwith guaiac-based tests for the detection of occult blood, immunochemical tests are morepatient-friendly, and are likely to be equal or better in sensitivity and specificity. There is nojustification for repeating FOBT in response to an initial positive finding.Stool DNA test**, orInterval uncertain, starting at age 50Flexible sigmoidoscopy(FSIG), orEvery 5 years, starting at age 50. FSIG can be performed alone, or consideration can begiven to combining FSIG performed every 5 years with a highly sensitive gFOBT or FITperformed annually.Double contrast bariumenema (DCBE), orEvery 5 years, starting at age 50ColonoscopyEvery 10 years, starting at age 50CT ColonographyEvery 5 years, starting at age 50EndometrialWomen, atmenopauseLungLow dose helical CTCurrent orformer smokers (LDCT)ages 55-74 ingood healthwith at least a30 pack-yearhistoryClinicians with access to high-volume, high quality lung cancer screening and treatmentcenters should initiate a discussion about lung cancer screening with apparently healthypatients ages 55-74 who have at least a 30 pack-year smoking history, and who currentlysmoke or have quit within the past 15 years. A process of informed and shared decisionmaking with a clinician related to the potential benefits, limitations, and harms associated withscreening for lung cancer with LDCT should occur before any decision is made to initiatelung cancer screening. Smoking cessation counseling remains a high priority for clinicalattention in discussions with current smokers, who should be informed of their continuingrisk of lung cancer. Screening should not be viewed as an alternative to smoking cessationProstateMen,ages 50+Digital rectal examination(DRE) and prostate-specificantigen test (PSA)Men who have at least a ten-year life expectancy should have an opportunity to make aninformed decision with their health care provider about whether to be screened for prostatecancer, after receiving information about the potential benefits, risks, and uncertaintiesassociated with prostate cancer screening. Prostate cancer screening should not occurwithout an informed decision making process.CancerrelatedcheckupMen andwomen,ages 20+On the occasion of a periodic health examination, the cancer-related checkup should include examination for cancers ofthe thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure,diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures.At the time of menopause, women at average risk should be informed about risks and symptoms of endometrial cancerand strongly encouraged to report any unexpected bleeding or spotting to their physicians.*Beginning at age 40, annual clinical breast examination should be performed prior to mammography.  **The stool DNA test approved for colorectal cancer screeningin 2008 is no longer commercially available. New stool DNA tests are presently undergoing evaluation and may become available at some future time.60  Cancer Facts & Figures 2013Chartered Divisions of the American Cancer Society, Inc.California Division, Inc.1710 Webster StreetOakland, CA 94612(510) 893-7900 (O)(510) 835-8656 (F)East Central Division, Inc.Route 422 and Sipe AvenueHershey, PA 17033-0897(717) 533-6144 (O)(717) 534-1075 (F)Eastern Division, Inc.(NJ, NY)6725 Lyons StreetEast Syracuse, NY 13057(315) 437-7025 (O)(315) 437-0540 (F)Florida Division, Inc.(including Puerto Ricooperations)3709 West Jetton AvenueTampa, FL 33629-5146(813) 253-0541 (O)(813) 254-5857 (F)Puerto RicoCalle Alverio #577Esquina Sargento MedinaHato Rey, PR 00918(787) 764-2295 (O)(787) 764-0553 (F)Great Lakes Division, Inc.(IN, MI)1755 Abbey RoadEast Lansing, MI 48823-1907(517) 332-2222 (O)(517) 664-1498 (F)Great West Division, Inc.(AK, AZ, CO, ID, MT, ND, NM,NV, OR, UT, WA, WY)2120 First Avenue NorthSeattle, WA 98109-1140(206) 283-1152 (O)(206) 285-3469 (F)High Plains Division, Inc.(including Hawaii operations,KS, MO, NE, OK, TX)2433 Ridgepoint DriveAustin, TX 78754(512) 919-1800 (O)(512) 919-1844 (F)Hawaii Pacific Division, Inc.2370 Nuuana AvenueHonolulu, HI(808) 595-7500 (O)(808) 595-7502 (F)Illinois Division, Inc.225 N. Michigan AvenueSuite 1200Chicago, IL 60601(312) 641-6150 (O)(312) 641-3533 (F)Mid-South Division, Inc.(AL, AR, KY, LA, MS, TN)1100 Ireland WaySuite 300Birmingham, AL 35205-7014(205) 930-8860 (O)(205) 930-8877 (F)Midwest Division, Inc.(IA, MN, SD, WI)8364 Hickman RoadSuite DDes Moines, IA 50325(515) 253-0147 (O)(515) 253-0806 (F)New England Division, Inc.(CT, ME, MA, NH, RI, VT)30 Speen StreetFramingham, MA 01701-9376(508) 270-4600 (O)(508) 270-4699 (F)South Atlantic Division, Inc.(DE, GA, MD, NC, SC, VA,Washington, D.C., WV)250 Williams StreetAtlanta, GA 30303(404) 816-7800 (O)(404) 816-9443 (F)AcknowledgmentsThe production of this report would not have been possible without the efforts of: Rick Alteri, MD; KristinAnderson, PhD; Cammie Barnes; Evan Blecher, PhD; Keysha Brooks-Coley, PhD; Vilma Cokkinides, PhD,MSPH; Colleen Doyle, MS, RD; Ted Gansler, MD, MBA; Kerri Gober; Tom Glynn, PhD; Keona Graves; GreggHaifley; Trista Hargrove; Lindsey Haeger, MPH; Angela Jones; Joan Kramer, MD; Marj McCullough, ScD, RD;Jiemin Ma, PhD; Melissa Maitin-Shepard, MPP; Deepa Naishadham, MS; Ken Portier, PhD; Hana Ross, PhD;Debbie Saslow, PhD; Mona Shah, MPH; Scott Simpson; Robert Smith, PhD; Kristen Sullivan, MS, MPH; DanaWagner; Sophia Wang, PhD; Elizabeth Ward, PhD; and Joe Zou.Cancer Facts & Figures is an annual publication of the American Cancer Society, Atlanta, Georgia.For more information, contact:Rebecca Siegel, MPH; Ahmedin Jemal, DVM, PhDSurveillance and Health Services Research?2013, American Cancer Society, Inc.No. 500813 Amer canCancel;Societ We save lives and create more birthdaysby helping you stay well, helping you get well,by finding cures, and by fighting back.cancer.org 1.800.227.2345 ACCREDITEDCHARITY . . Natlonal Health COll1?lC1lThe American Cancer Society, Inc.. Standards of Excellenceadheres to the Better Business Bureau 5 . . . . . Certl?catlon Programstrong standards for charitable giving.