American Cancer Society's report on the status of cancer disparities in the United States, 2021

Introduction

The American Cancer Society (ACS) first reported on cancer disparities by race and socioeconomic status (SES) in the United States in 1986.1-3 The report included multiple recommendations to mitigate these disparities, including increasing awareness of cancer prevention and increasing access to care.2, 3 Despite these recommendations, however, disparities in mortality for all cancers combined and for major cancers by race (Black vs White people), SES, and rurality/urbanicity have increased since the publication of the report,4-7 although the racial disparities for all cancers combined and for some major cancers are narrowing during the most recent period after decades of widening.8

These disparities have largely been attributed to differences in exposure to risk factors, early detection, and access to preventive care and treatment,9-11 which themselves are influenced by social determinants of health (Fig. 1).12, 13 The World Health Organization defines social determinants as conditions in which individuals are born, grow, work, live, and age along with the broader set of forces and systems that shape the conditions of daily life; these include social norms, social policies, political systems, economic policies and systems, and development agendas.14 Social determinants of health could positively or negatively impact cancer occurrence through their effects on educational and job opportunities, income, housing, transportation, public safety, food security, social inclusion and nondiscrimination, and access to affordable health services of high quality.12-14

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Social Determinants of Health and Cancer Disparities.

Racism and discrimination are a deeply rooted social determinant of health that have downstream effects resulting in social inequities and discriminatory policies, which are significant root causes of health disparities.12, 15, 16 Effects of structural racism have generally accumulated across generations,15 eg, through mortgage lending bias such as redlining, which resulted in residential segregation, inequities in wealth, and underinvestment in some communities.17, 18

In this report, we provide comprehensive and up-to-date data on racial/ethnic and SES disparities in cancer occurrence (including incidence, stage at diagnosis, survival, and mortality), major risk factors, and access to and utilization of preventive care and cancer screening in the United States. We also review a variety of programs and resources targeting cancer disparities and provide policy recommendations to mitigate them.

Materials and Methods Data Sources Cancer occurrence

Data on incident cancer cases diagnosed from 2014 through 2018 for all cancers combined and for cancers of the lung and bronchus (lung), female breast, prostate, colorectum, liver and intrahepatic bile duct, kidney and renal pelvis (kidney), stomach, and uterine cervix and for myeloma were obtained by sex and race/ethnicity from the Centers for Disease Control and Prevention's (CDC's) National Program of Cancer Registries (NPCR) and the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) program.19 Sex-specific and race/ethnicity-specific data on cancer mortality nationally (1990-2019) and by state and county (2015-2019) were obtained from the CDC's National Center for Health Statistics (NCHS)20 and by congressional district (2014-2018) from the CDC's US Cancer Statistics Data Visualizations Tool.21 Cancer mortality and population data (2015-2019) by age group, sex, race/ethnicity, and educational attainment were obtained from the NCHS22 and the US Census Bureau,23 respectively. Data on cancer stage at diagnosis (2014-2018) and survival (cancer cases diagnosed in 2011-2017 and followed through 2018) were obtained from the SEER 18 cancer registries,24 stratified by sex, race/ethnicity, county-level median annual household income (<$35,000, $35,000-$54,999, $55,000-$74,999, and ≥$75,000), and rurality of the county of residence; the latter was defined as county of residence in a metropolitan area with ≥250,000 population, a metropolitan area with <250,000 population, a nonmetropolitan area adjacent to a metropolitan area, or a nonmetropolitan area not adjacent to a metropolitan area.

Throughout this report, race/ethnicity categories for cancer occurrence data include non-Hispanic White (White), non-Hispanic Black (Black), non-Hispanic American Indian/Alaska Native (AI/AN), non-Hispanic Asian/Pacific Islander (API), and Hispanic-Latino (Hispanic) populations. Cancer occurrence data for AI/AN people are further confined to individuals residing in Purchased/Referred Care Delivery Area (PRCDA) counties, covering 65% of the AI/AN population from 2014 through 2018, to minimize racial misclassification. These counties contain or are adjacent to tribal lands, and their linkages with the Indian Health Service provide more accurate correction for racial misclassification than non-PRCDA counties, making their cancer rates less prone to underestimation.25

Socioeconomic status

Data on insurance coverage and socioeconomic indicators, including limited educational attainment (defined as high school diploma or less), family income below federal poverty level (FPL), not using a computer or the internet, and measures of food insecurity (often being worried about food running out) or food assistance (receipt of free or reduced school lunch by children and receipt of food stamps) by race/ethnicity were obtained from self-reported measures in the National Health Interview Survey (NHIS), 2019.26

Risk factors

Some surveys do not collect data on the same items every survey cycle; therefore, we included data from the most recent years available. The prevalence of ever cigarette smoking (100 cigarettes in the lifetime) and current smoking by race/ethnicity and SES in individuals aged ≥18 years were obtained from self-reported measures in the NHIS, 2019.26 The prevalence of heavy alcohol drinking (>14 drinks per week in the past year for men or >7 drinks per week in the past year for women) and physical inactivity (defined as no leisure-time physical activity) in individuals aged ≥18 years by race/ethnicity and SES were obtained from self-reported measures in the NHIS, 2018.26 Data on the prevalence of obesity, defined as a body mass index (BMI) ≥30 kg/m2, by race/ethnicity and SES in individuals aged ≥20 years were measured on physical examination and obtained from the National Health and Nutrition Examination Survey (2017-2018 cycle).27

Preventive care and cancer screening

Data on being up to date with vaccination for human papillomavirus (HPV) (≥2 doses) and hepatitis B virus (HBV) (≥3 doses) were based on data from the TeenVaxView survey of teens aged 13 to 17 years in 2019.28 Data on the receipt of hepatitis C virus (HCV) testing (at least once in individuals aged 52-72 years, for whom HCV testing was recommended in 2017, before the recommendation was expanded in 2020 to all adults aged 18-79 years)29 and counseling or medication for smoking cessation (among adults aged ≥18 years who smoked) were from the NHIS, 2017. Data on being up to date with the receipt of screening for cancers of the female breast (aged ≥45 years), colorectum (aged ≥50 years), cervix (aged 21-65 years), and prostate (aged ≥50 years) were obtained from the NHIS, 2018.26 We relied on a previous report and method to estimate lung cancer screening rates in 2018 because the NHIS has not collected detailed smoking history or receipt of lung cancer screening data since 2015.30

Statistical Methods

Incidence and death rates per 100,000 population and 5-year relative survival—all age-adjusted to the 2000 US standard population—were calculated using SEER*Stat software, version 8.3.9. Incidence and death rate ratios based on age-adjusted rates were calculated by race/ethnicity using SEER*Stat software and Stata, version 15.1. Weighted prevalence estimates for measures of SES, exposure to risk factors, and receipt of preventive care and cancer screening by corresponding stratifications were calculated using SAS-callable SUDAAN, release 11.0.1, and accounted for the complex survey designs. Prevalence estimates for insurance coverage, exposure to risk factors, and receipt of preventive care and cancer screening were stratified by race/ethnicity, educational attainment (in individuals aged ≥25 years only: some high school or less, high school diploma, some college, and college graduate or higher), household income level (<100%, 100% to <200%, and ≥200% of FPL), and region (Northeast, Midwest, South, and West). Estimates for exposure to risk factors and receipt of preventive care and cancer screening were further stratified by insurance coverage (uninsured, Medicaid or other public only, and private in individuals aged <65 years; and Medicare [including Medicare Advantage] only, Medicare plus public [Medicare dually eligible] only, and Medicare plus private [Medicare supplemental] in individuals aged ≥65 years).

Disparities in Cancer Occurrence Cancer Incidence

Overall cancer incidence rates from 2014 through 2018 were higher among males than females in all racial/ethnic groups except the API population, among whom rates were comparable (Fig. 2). The overall incidence rate per 100,000 persons per year ranged from 294.8 in API people to 529.0 in Black people among males; among females, it ranged from 297.9 in API people to 443.1 in White people.

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Incidence Rates (2014-2018) and Death Rates (2015-5019) for All Cancers Combined by Sex and Race/Ethnicity, United States. Rates are per 100,000 population and age-adjusted to the 2000 US standard population. Data for the American Indian/Alaska Native (AI/AN) group are based on Purchased/Referred Care Delivery Area counties. API indicates Asian/Pacific Islander. Source: National Program of Cancer Registries/Surveillance, Epidemiology, and End Results (incidence) and National Center for Health Statistics (mortality) data.

Incidence rates of all cancer types evaluated in Table 1 were higher among Black people than among White people, except for all cancers combined and lung and breast cancers among females. Incidence rates of cancer types associated with carcinogenic infections, including cancers of the liver and intrahepatic bile duct, stomach, and cervix, were higher among people of color than among White people (except cervical cancer among API women).

TABLE 1. Incidence and Death Rate Ratios (95% Confidence Intervals) for Select Cancers by Sex and Race/Ethnicity, United States, 2014-2019 CANCER SITE BY SEX NH WHITE RATE RATIO (95% CI) NH BLACK NH AI/AN NH API HISPANIC-LATINO Incidence rate: 2014-2018 All cancers combined Males 1 1.06 (1.05-1.06) 0.81 (0.79-0.82) 0.59 (0.58-0.59) 0.73 (0.72-0.73) Females 1 0.92 (0.91-0.92) 0.86 (0.85-0.87) 0.67 (0.67-0.68) 0.76 (0.75-0.76) Lung and bronchus Males 1 1.12 (1.11-1.13) 0.87 (0.84-0.90) 0.62 (0.61-0.63) 0.52 (0.49-0.53) Females 1 0.84 (0.84-0.85) 0.90 (0.87-0.93) 0.50 (0.49-0.51) 0.43 (0.40-0.44) Breast, female 1 0.96 (0.95-0.97) 0.76 (0.74-0.78) 0.75 (0.74-0.75) 0.72 (0.70-0.72) Prostate 1 1.73 (1.72-1.74) 0.71 (0.68-0.73) 0.55 (0.54-0.56) 0.84 (0.82-0.85) Colorectum Males 1 1.19 (1.18-1.21) 1.06 (1.02-1.10) 0.81 (0.80-0.83) 0.92 (0.88-0.93) Females 1 1.15 (1.14-1.16) 1.10 (1.05-1.15) 0.76 (0.75-0.77) 0.86 (0.81-0.87) Liver and IHBD Males 1 1.63 (1.60-1.65) 1.96 (1.86-2.07) 1.74 (1.70-1.78) 1.85 (1.75-1.89) Females 1 1.40 (1.36-1.44) 2.23 (2.03-2.43) 1.79 (1.73-1.86) 2.08 (1.88-2.13) Kidney and renal pelvis Males 1 1.11 (1.09-1.13) 1.27 (1.21-1.33) 0.48 (0.47-0.50) 0.94 (0.88-0.96) Females 1 1.14 (1.12-1.16) 1.44 (1.36-1.52) 0.46 (0.45-0.48) 1.07 (0.98-1.08) Myeloma Males 1 2.14 (2.10-2.18) 1.03 (0.93-1.13) 0.62 (0.59-0.65) 1.01 (0.91-1.04) Females 1 2.60 (2.54-2.65) 1.23 (1.11-1.35) 0.64 (0.61-0.68) 1.19 (1.07-1.23) Stomach Males 1 1.80 (1.76-1.84) 1.34 (1.21-1.47) 1.71 (1.66-1.76) 1.61 (1.48-1.63) Females 1 2.14 (2.09-2.20) 1.71 (1.55-1.88) 2.13 (2.05-2.20) 2.17 (2.00-2.23) Uterine cervix 1 1.22 (1.19-1.25) 1.26 (1.15-1.37) 0.84 (0.81-0.87) 1.30 (1.19-1.33) Death rate: 2015-2019 All cancers combined Males 1 1.19 (1.18-1.20) 1.04 (0.20-1.88) 0.61 (0.60-0.61) 0.71 (0.68-0.71) Females 1 1.12 (1.12-1.13) 1.02 (0.30-1.74) 0.62 (0.62-0.63) 0.69 (0.67-0.70) Lung and bronchus Males 1 1.15 (1.14-1.16) 0.90 (0.40-1.40) 0.57 (0.56-0.58) 0.47 (0.42-0.48) Females 1 0.85 (0.84-0.86) 0.91 (0.44-1.38) 0.47 (0.46-0.48) 0.35 (0.29-0.35) Breast, female 1 1.41 (1.39-1.43) 0.90 (0.50-1.29) 0.59 (0.58-0.60) 0.69 (0.62-0.70) Prostate 1 2.13 (2.10-2.16) 1.18 (0.66-1.70) 0.48 (0.47-0.50) 0.88 (0.77-0.89) Colorectum Males 1 1.44 (1.42-1.47) 1.35 (0.76-1.94) 0.70 (0.68-0.73) 0.87 (0.76-0.89) Females 1 1.31 (1.29-1.33) 1.27 (0.77-1.77) 0.70 (0.68-0.72) 0.75 (0.65-0.77) Liver and IHBD Males 1 1.57 (1.54-1.60) 2.02 (1.23-2.81) 1.52 (1.48-1.56) 1.57 (1.39-1.60) Females 1 1.35 (1.31-1.39) 2.29 (1.66-2.93) 1.46 (1.41-1.52) 1.67 (1.42-1.72) Kidney and renal pelvis Males 1 0.98 (0.94-1.01) 1.75 (1.16-2.34) 0.45 (0.42-0.48) 0.90 (0.69-0.93) Females 1 0.95 (0.91-1.00) 1.64 (1.18-2.09) 0.44 (0.41-0.49) 0.95 (0.68-1.00) Myeloma Males 1 1.96 (1.90-2.02) 1.14 (0.82-1.45) 0.51 (0.47-0.55) 0.86 (0.65-0.90) Females 1 2.24 (2.18-2.31) 1.23 (0.89-1.57) 0.57 (0.53-0.62) 0.96 (0.73-1.01) Stomach Males 1 2.51 (2.44-2.59) 2.42 (1.75-3.09) 2.07 (1.98-2.16) 2.03 (1.70-2.10) Females 1 2.31 (2.23-2.40) 2.59 (2.08-3.09) 2.55 (2.43-2.68) 2.58 (2.16-2.66) Uterine cervix 1 1.65 (1.59-1.72) 1.53 (1.11-1.96) 0.82 (0.77-0.88) 1.24 (0.98-1.30) Abbreviations: AI/AN, American Indian/Alaska Native; API, Asian/Pacific Islander; CI, confidence interval; IHBD, intrahepatic bile duct; NH, non-Hispanic. a Rate ratios are based on rates age-adjusted to the 2000 US standard population, with the NH White population as the reference group. Data for the AI/AN group are based on Purchased/Referred Care Delivery Area counties.

Source: National Program of Cancer Registries/Surveillance, Epidemiology, and End Results (incidence) and National Center for Health Statistics (mortality) data.

Cancer Stage at Diagnosis

Among people diagnosed with cancers of the lung, colorectum, female breast, cervix, and prostate, for which screening is recommended, Black people generally had the lowest proportion of localized-stage cancer and the highest proportion of distant-stage cancer compared with other racial/ethnic groups from 2014 through 2018, except for prostate cancer, for which AI/AN men had the highest proportion of distant-stage disease (Fig. 3). For example, localized-stage disease was diagnosed in 58% of Black women versus 69% of White women with breast cancer and in 37% of Black women versus 46% of White women with cervical cancer.

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Stage at Diagnosis for Screenable Cancers by Race/Ethnicity, County-Level Median Household Income, and Rurality of the County of Residence: Surveillance, Epidemiology, and End Results (SEER) 18 Registries, 2014 to 2018. Diagnoses exclude tumors with insufficient stage information. Data for the American Indian/Alaska Native group are based on Purchased/Referred Care Delivery Area counties. Metro indicates metropolitan; NH, non-Hispanic. Source: SEER 18 cancer registries.

For the cancers of the lung, colorectum, female breast, and cervix, people residing in counties with the highest median household income and in counties located in more populated metropolitan areas generally had the highest proportions of localized-stage cancers and the lowest proportions of distant-stage cancers compared with people residing in other counties; the differences were greater by county-level median household income (Fig. 3). For example, among people diagnosed with lung cancer from 2014 through 2018, the percentage of localized-stage diagnosis was 27% in more affluent counties (median household income, ≥$75,000 annually) but 20% in counties with the lowest median incomes (<$35,000 annually).

Black people were also more likely than other groups to be diagnosed with advanced disease for most other cancer types. For example, the percentages of distant-stage cancers from 2010 through 2016 were substantially higher in Black people than in White people diagnosed with cancers of the oral cavity and pharynx (29% vs 18%) and the uterus (17% vs 8%).31

Cancer Survival

Cancer survival generally is less favorable in people of lower SES (Fig. 4). For example, the 5-year relative survival rate for people who were diagnosed with cancer from 2011 to 2017 and followed through 2018 in counties with a median household income ≥$75,000 and <$35,000 per year was 71% and 57%, respectively. Similarly, 5-year relative survival rates for people with cancer residing in counties in more populated metropolitan areas were greater than the rates for people living in counties that were not in or adjacent to a metropolitan area (69% vs 62%). A similar pattern was observed in all racial/ethnic groups. However, in all groups of counties defined by rurality and in more affluent counties, White people on average had a greater 5-year survival rate compared with other racial/ethnic groups, likely reflecting White people's higher average income compared with others within the same group of counties. For example, 5-year survival rates in counties with a median household income ≥$75,000 were 72% for White people and 67% for Black people.

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Five-Year Relative Cancer Survival by Race/Ethnicity, County-Level Median Household Income, and Rurality of the County of Residence: Surveillance, Epidemiology, and End Results (SEER) 18 Registries, 2011 to 2017. Five-year survival is illustrated for cancer cases diagnosed in 2011 to 2017 and followed through 2018. Data for the American Indian/Alaska Native (AI/AN) group are based on Purchased/Referred Care Delivery Area counties. API indicates Asian/Pacific Islander; Metro, metropolitan. Source: SEER 18 cancer registries.

The 5-year relative survival rate for many specific cancer types from 2011 through 2017 was higher for White people and lower for Black people compared with other racial/ethnic groups, although AI/AN people had the lowest 5-year survival for certain cancers, including kidney, prostate, and bladder cancer (Fig. 5). Among cancer types with the greatest Black-White difference in 5-year relative survival were uterine corpus cancer (63% vs 84%) and oral cavity/pharynx cancer (51% vs 69%). Later stage at diagnosis is one of the major contributing factors to disparities in cancer survival.32 Disparities in cancer care comprise another major factor because Black people have lower stage-specific survival than White people for many cancer types.31 For certain cancer types, however, higher frequency of subtypes with a poorer prognosis among Black people may also contribute to Black-White differences in survival. These subtypes include triple-negative breast cancer,33 nonendometrioid subtypes of uterine cancer,34, 35 and HPV-negative oral cavity and pharyngeal cancer.36

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Five-Year Relative Survival for Select Cancers by Race/Ethnicity: Surveillance, Epidemiology, and End Results (SEER) 18 Registries, 2011 to 2017. Five-year survival is illustrated for cancer cases diagnosed in 2011 to 2017 and followed through 2018. Data for the American Indian/Alaska Native (AI/AN) group are based on Purchased/Referred Care Delivery Area counties. API indicates Asian/Pacific Islander; IHBD, intrahepatic bile duct; NH, non-Hispanic. Source: SEER 18 cancer registries.

Cancer Mortality

In recent years, overall cancer death rates have decreased among both sexes in every racial/ethnic group (Fig. 6). Steeper declines in cancer death rates among Black people have resulted in the narrowing of the Black-White mortality gap, notably among males. However, overall cancer death rates from 2015 through 2019 in both sexes still remained highest among Black people (221.4 and 152.1 per 100,000 population among males and females, respectively), whereas they were lowest among API people (113.2 and 84.2 per 100,000 among males and females, respectively) (Fig. 2). The overall cancer death rate was 19% higher among Black males than among White males (Table 1). Black females had a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. Similarly, although the overall cancer incidence rate was 14% lower among AI/AN females than among White females, cancer death rates were similar in these 2 groups.

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Trends in Mortality for All Cancers Combined and Select Cancers by Race/Ethnicity: United States, 1990 to 2019. Rates are per 100,000 population and age-adjusted to the 2000 US standard population. Data for the American Indian/Alaska Native (AI/AN) group are based on Purchased/Referred Care Delivery Area counties. API indicates Asian/Pacific Islander; IHBD, intrahepatic bile d

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