1. Cancer Incidence and Mortality among Children and Adolescents in the United States, 2001-2003
Jun Li, MD MPH
Epidemic Intelligence Service Officer
Centers for Disease Control and Prevention
Division of Cancer Prevention and Control
Epidemiology and Applied Research Branch
Good morning, today I will be presenting a study of cancer incidence and mortality among children and adolescents in the United State,
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention

2. Background
Childhood (0-19 years) cancer accounts for 1% of the total cancer cases in U.S.
Most common disease-related cause of death among youth aged 1-19 years
2007 estimates 1
10,400 new cases
1,500 deaths
childhood cancer accounts for about 1% of the total cancer cases in the United States, however, it is the most common disease-related cause of death among youth aged 1-19 years.
According to American Cancer Society, about 10,400 new cases and 1,500 deaths were estimated for children in 2007.
1 Cancer Facts & Figure 2007

3. Background
More meaningfully grouped by morphology using International Classification of Childhood Cancer (ICCC)
ICCC based on International Classification of Diseases for Oncology (ICD-O)
ICD-O-3, issued in 2000, became effective in 2001.
Unlike adulthood cancer, childhood cancers are more meaningfully grouped by morphology using International Classification of Childhood Cancer (ICCC).
ICCC is based on the International Classification of Diseases for Oncology (ICD-O).
The third edition of ICD-O was issued in 2000 and became effective in 2001.

4. Background SEER: Surveillance, Epidemiology, and End Results
This figure was generated from data of Surveillance, Epidemiology, and End Results (SEER) Program.
It illustrates the trend of childhood cancer incidence and mortality from 1975 to While there was a diseasing in cancer mortality, the overall tendency for cancer incidence was upward. There was a slight increase from late 1970s to early 1990s indicated by the red arrow.
SEER: Surveillance, Epidemiology, and End Results

5. Background Incidence rates not well described after using ICD-O-3
Recent cancer death rates not well characterized
Geographic differences in cancer incidence and mortality not well elucidated
Although there was a slight increase in childhood cancer incidence, recent incidence rate has not been well described, especially after utilizing ICD-O-3.
Recent cancer death has not been well characterized, either.
In addition, geographic differences in cancer incidence and mortality have not been well elucidated.

6. Objectives Describe recent cancer incidence and mortality rates
Identify demographic and geographic variations in cancer incidence and mortality
So the objectives of this study is to
Describe recent cancer incidence and mortality rates
And, identify demographic and geographic variation in cancer incidence and mortality

7. Methods---Incidence
Cancer incidence data from National Program of Cancer Registry (NPCR) and SEER
Cover 43 states and the District of Columbia, representing 90% of U.S. population
Cases definition:
Children (0-14 years) and adolescents (15-19 years) diagnosed with a primary malignant neoplasm
Cancer incidence data were from two federally-funded population-based cancer registries: NPCR and SEER
Data covered 43 states and the District of Columbia, representing over 90% of U.S. population.
Cases were restricted to children (0-14 years) and adolescents (15-19 years) diagnosed with a primary malignant neoplasm in the U.S. from 2001 to 2003.

8. Methods---Incidence
Cancers stratified by sex, age, race, ethnicity, and U.S. Census region
Age-adjusted incidence rates (per million), rate ratios, and 95% CI estimated by SEER-Stat
p-values < 0.05 for significance except for racial and regional analyses
In the analysis, patients were stratified by sex, age, race, ethnicity, and U.S. Census region.
Age-adjusted incidence rates (per million), rate ratios, and 95% CI were estimated by SEER*Stat software.
p-values < 0.05 were used to determine significance, except for racial and regional analyses.

9. Methods---Incidence In racial and regional analyses
White and the Northeast as reference groups
Bonferroni correction was applied
Cut-point of p-value was
Multivariate analyses
Negative binomial modeling
Adjust for sex, age, race, ethnicity, region, and year
In racial and regional analysis, we used White and the Northeast as reference groups.
Because of multiple comparisons, the Bonferroni correction was applied and significance was determined by p-values <
Negative binomial modeling was also used to evaluate these demographic and geographic variations with adjusting sex, age, race, ethnicity, U.S. Census region, and year simultaneously.

10. Methods---Mortality Mortality data from NCHS
Cover 50 states and the District of Columbia, representing 100% of U.S. population
Stratified analyses for cancer mortality same as incidence
Mortality data were from National Center for Health Statistics.
Data were reported from 50 states and the District of Columbia, representing 100% of U.S. population.
Stratified analyses for cancer mortality were as same as that for cancer incidence

11. Results I Cancer Incidence Stratify analysis Multivariate modeling
II Cancer Mortality
Now I will be presenting the results

12. Distribution of Childhood Cancer Incidence by ICCC-3 Groups, U. S
This pie chart illustrated the distribution of childhood cancer incidence by 12 ICCC groups.
About 36,000 childhood cancer cases were diagnosed in the United States during the study years. Among them, leukemias were the most common cancer (accounting for 26.3%), followed by CNS neoplasms (17.6%) and lymphomas (14.6%). These 3 diseases accounted for nearly 60% of all childhood cancer cases.
CNS: Central Nervous System

13. Incidence Rate of All Cancers Combined by Sex and Age, 2001-2003** **
This figure showed that for all cancer combined, male had significantly higher incidence rate than female; and adolescents had significantly higher incidence rate than children.
**P<0.05

14. Incidence Rate of All Cancers Combined by Race, Ethnicity, and Region, 2001-2003
Category  
Cases
Rate (95% CI)
White (ref)
29,934
( )
Black
4,004
( ) **
API
1,328
( ) **
AIAN
273
( ) **
Hispanic
6,729
( )
Non-Hispanic
29,717
( )
Northeast (ref)
7,676
( )
Midwest
9,011
( ) **
South
1,1082
( ) **
West
8,677
( ) **
This table showed incidence rate of all cancers combined stratified by Race, Ethnicity, and Census Region.
For all cancers combined, whites had significantly higher rate of cancer than blacks, Asian Pacific Islanders, and American Indians/Alaska Natives, respectively.
Incidence rate for the Northeast was significantly higher than the Midwest, South, and West, respectively.
There was no significant difference for the incidence rate between Hispanics and non-Hispanics.
**Rate is significantly different from the rate of reference groups: white or the Northeast. P<0.0167
ref: reference group

15. Multivariate Modeling* for All ICCC-3 Groups Combined, 2001-2003
Characteristic χ2 P RR
95% CI
Sex
34.88
<.0001
Male vs. Female
1.11
Age
148.65
15-19 vs. 0-14
1.35
Race
288.74
Black vs. White
0.66
API vs. White
0.73
AI/AN vs. White
0.55
Negative binomial regression showed incidence rate of all childhood cancers combined varied significantly by sex, age, and race. These findings were consistent with the stratified analyses.
*Adjusting for sex, age, race, ethnicity, region and year
Underlining denotes reference group

16. Multivariate Modeling* for All ICCC-3 Groups Combined, 2001-2003
Characteristic χ2 P RR
95% CI
Ethnicity
27.6
<.0001
Hispanic vs. Non-Hispanic
0.9
Region
8.36
0.0391
Midwest vs. Northeast
0.93
South vs. Northeast
0.95
West vs. Northeast
0.96
Multivariate modeling also showed that incidence rate varied significantly by ethnicity and U.S. Census region.
Interestingly, we found after adjusting for all the independent variables simultaneously, variation by ethnicity became statistically significant, which was insignificant in the stratified analyses.
(After adjusting all these independent variables the relative ranking of incidence rates of childhood cancers across regions changed, as shown by the magnitude of rate ratio.)
*Adjusting for sex, age, race, ethnicity, region and year
Underlining denotes reference group

17. Distribution of Childhood Cancer Deaths, U.S., 2001-2003
This pie chart illustrated the distribution of childhood cancer death by primary cancer site.
About 6,700 childhood cancer deaths were identified in the United States during the study year. Among them, leukemias were the most common cause of death (accounted for 26.7%), followed by CNS neoplasms (24.8%). These two cancers accounted for more than 50% of all childhood cancer deaths.
CNS: Central Nervous System 17

18. Death Rate of All Cancers Combined by Sex and Age, 2001-2003** **
This figured showed that for all cancer combined, male had significantly higher death rate than female; and adolescents had significantly higher death rate than children.
**P<0.05

19. Death Rate of All Cancers Combined by Race, Ethnicity, and Region, 2001-2003
Category  
Cases
Rate (95% CI)
White (ref)
5,353
( )
Black
1,047
( )
API
259
( ) **
AIAN 71
( ) **
Hispanic (ref)
1,291
( )
Non-Hispanic
5,421
( ) **
West (ref)
1,772
( )
Northeast
1,099
( ) **
Midwest
1,453
( ) **
South
2,406
( ) **
This table showed death rate of all cancers combined stratified by Race, Ethnicity, and Census Region.
For all cancers combined, white had significantly higher rate than API and AIAN, respectively.
The rate for the West was significantly higher than the Northeast, Midwest, and South, respectively.
Hispanic had significantly higher death rate than non-Hispanics.
**Rate is significantly different from the rate of reference groups. P<0.0167
ref: reference group

20. Conclusions
Incidence and death rates varied by sex, age, race, and ethnicity.
Incidence rates significantly higher for
Boys
Adolescents (15-19 years)
Whites
Non-Hispanics
Northeast Census region
In conclusion, consistent with past studies, the childhood cancer incidence and death rates varied by sex, age, race, and ethnicity.
For all cancers combined, incidence rates were significantly higher for
boys
adolescents (15-19 years)
Whites
Non-Hispanics
The youth living in the Northeast

21. Conclusions Death rates significantly higher for Boys
Adolescents (15-19 years)
Hispanics
West Census region
Compared with Non-Hispanics, Hispanics had significantly lower incidence rate, but higher death rate.
For all cancers combined, death rates were significantly higher for
boys
adolescents (15-19 years)
Hispanics
the youth living in the West
Compared with Non-Hispanics, Hispanics had significantly lower incidence rate, but significantly higher death rate

22. Conclusions Northeast: highest incidence rate, lowest death rate
West: highest death rate, second lowest incidence rate
Compared with rates between 1995 and
Incidence rate slightly increased
Death rate slightly decreased
We also found, the youth living in the Northeast had the highest incidence rate, but the lowest death rate.
The youth living in the West had the highest death rate, but the second lowest incidence rate.
Compared with rates between 1995 and
We found that Incidence rate slightly increased
Death rate slightly decreased
1 Cancer May 15;94(10):

23. Strengths
First study to describe cancer incidence using data representing 90% of U.S. population
Describe cancer incidence rate with new ICCC
Addressed geographic variation in childhood cancer incidence and mortality
To our knowledge, this is the first study to describe the childhood cancer incidence using data covering over 90% of U.S. population.
Describe cancer incidence rate with new ICCC coding scheme.
It also identified geographic variation in childhood cancer incidence and mortality by U.S. Census region

24. Limitations
Small cancer case number limits ability to study the geographic variation at state and county level
Underestimation of API, AI/AN, and Hispanics
The study findings are subject to several limitations:
First, small case number limits ability to study the geographic variation at state and local county levels
Second, Asian Pacific Islanders, American Indian/Alaska Natives and Hispanics may be underestimated.

25. Recommendations
Maintain surveillance systems to track and understand changes in incidence and mortality
Need survival study to address the geographic and ethnic discordance between incidence and mortality
Last, recommendations:
Continued surveillance systems should be well maintained to better track and understand changes in childhood cancer incidence and mortality
Survival studies are needed to better understand the geographic and ethnic discordance between cancer incidence and mortality.

26. Acknowledgements Centers for disease control and prevention:
Sherri L. Stewart, PhD
Lori A. Pollack, MD/MPH
Trevor D. Thompson, BS
Jacqueline W. Miller, MD
Christie R. Eheman, PhD
Mary C. White, ScD
I would like to acknowledge the following people for their assistance in this study.