Cancer mortality rates have declined by more than 20% in the United States between 1980 and 2014, but substantial differences in trends and patterns exist among certain US regions, with some counties exhibiting especially high cancer mortality rates, according to a new analysis by Ali H. Mokdad, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, and colleagues.1
Using death records from the National Center for Health Statistics and population counts from the Census Bureau, Dr Mokdad and colleagues found that 19,511,910 cancer-related deaths were recorded between 1980 and 2014, ranging from 5,656,423 deaths attributed to tracheal, bronchus, and lung cancers to 13,927 deaths attributed to pancreatic cancer. During that period, the cancer mortality rate decreased by 20.1%, from 240.2 deaths per 100,000 population to 192 deaths per 100,000 population.
Unlike previous reports, which focused primarily on variation in cancer mortality rates by state, this analysis focused on cancer mortality across US counties.
“There is a value for data at the county level because public health programs and policies are mainly designed and implemented at the local level. Moreover, local information can also be useful for health care clinicians to understand community needs for care and aid in identifying hot spots that need more investigation to understand the root causes,” the researchers stated.1
US Counties with High Cancer Deaths
Despite an overall decrease in US cancer mortality rates, there were clusters of counties with strikingly high mortality rates, and the location of these clusters varied by the cancer type.
Between 1980 and 2014, breast cancer mortality declined by 32.7% in the United States overall, with the largest reductions seen in the Northeast, the northern Midwest, and in Florida. Summit County, CO, and Nassau County, NY, saw the highest decreases (55.3% and 54.9%, respectively) during that period. However, the Southern Belt and counties along the Mississippi River had particularly high breast cancer mortality rates (ie, 51.8 per 100,000 in Madison County, MS).
Similarly, the West and Northeast and Florida saw reductions in tracheal, bronchus, and lung cancer mortality rates, whereas the South, Appalachian region, and the Midwest had increases in these mortality rates, with the largest increases (between 1980 and 2014) reported in Owsley County, KY (99.7%).
The majority of US counties had a decline in colon and rectum cancer deaths, with the largest reductions seen in Howard County, MD, and Nassau County, NY.
Clusters of high mortality rates from colon and rectum cancers were reported in 2014 along the Mississippi River in Missouri; in Mississippi, Arkansas, Louisiana, Southern Alabama, and Alaska; and along the border between West Virginia and Kentucky.
Overall, deaths from prostate cancer declined by 21.7%, with the highest reductions seen in Aleutians East Borough and Aleutians West Census, AK. High prostate cancer mortality rates were found in the South, along the Mississippi River, and in Alabama, Georgia, South Carolina, and Virginia.
Liver Cancer Remains the Exception
Liver cancer and mesothelioma were the main exceptions to these trends, and were associated with increased mortality. Liver cancer had an 87.6% increase in mortality rates, especially in counties along the West Coast, in New Mexico, and in West Texas.
Recommendations for Cancer Prevention
The new analysis provides an excellent opportunity for clinicians, health officials, and policymakers to inform the debate on prevention, access to care, and appropriate treatment, and to implement interventions at a local level.
“Monitoring cancer mortality at the county level can help identify worsening incidence, inadequate access to quality treatment, or potentially other etiological factors involved,” noted Dr Mokdad and colleagues.1 For example, they attributed increases in lung cancer mortality in the South to high smoking rates in those regions, advising that “Local efforts to reduce smoking in poor and rural areas are needed to reduce the burden of smoking-related cancer and other diseases.”1
Dr Mokdad and colleagues recommend renewing efforts to reduce overweight and obesity, emphasizing that weight maintenance should be the first step. Obesity is a major risk factor for cancer and is especially prevalent in the South, which may explain the differences in cancer mortality rates across US counties.
Dietary intake was identified as a risk factor for cancer mortality, and Americans should be doing more to improve their diets, suggest Dr Mokdad and colleagues. “Improving and monitoring dietary intake in the United States should be a priority for local, state, and federal agencies.”1
In an accompanying editorial, Stephanie B. Wheeler, PhD, MPH, Health Policy and Management, University of North Carolina at Chapel Hill, and Ethan Basch, MS, MSc, Cancer Outcomes Research Program, University of North Carolina, agreed that this analysis can be instrumental for improving the prevention and treatment of cancer on a local level.2
However, Dr Wheeler and Mr Basch underline that before any intervention can be implemented, region-specific variables that determine cancer outcomes should be thoroughly understood, such as poor health literacy, suboptimal access to care, language barriers, social isolations, lack of health insurance, lack of motivation to seek care, and inconvenience of screening or treatment.
“The reality is that barriers to cancer prevention and control are not one size fits all in communities with higher cancer mortality; therefore, policies and interventions targeting those regions cannot be one size fits all. Effective strategies in these regions must be tailored to address specific barriers to care, respond to local community needs and expectations, and attend to local community resource capacity constraints, cultural norms, and leadership, governance, and social network structures,”2 Dr Wheeler and Mr Basch noted.
- Mokdad AH, Dwyer-Lindgren L, Fitzmaurice C, et al. Trends and patterns of disparities in cancer mortality among US counties, 1980-2014. JAMA. 2017;317:388-406.
- Wheeler SB, Basch E. Translating cancer surveillance data into effective public health interventions. JAMA. 2017;317:365-367.