Document rpJdBqOL1O57q3ojVv9mXYzYJ

CHEMICAL MANUFACTURERS ASSOCIATION July 5, 1994 5 Dear Vinyl Chloride Research Coordinators: The following items are enclosed: 1) the agenda for the August 2, 1994 VCRC meeting; 2) the June 13, 1994 Record of Conference Call; 3) the July 5, 1994 letter to EPA requesting a meeting with the Agency to discuss Richard Reitz's pharmacokinetic risk assessment model for vinyl chloride; 4) a list of ATSDR chemicals added to EPA's Master Testing List under TSCA Section 4. Please note that EPA has invited manufacturers of the listed chemicals to submit testing plans and enter into consent agreements for testing. For vinyl chloride, the proposed testing includes undertaking a two-generation reproductive effects study and a developmental effects study. Both studies are proposed to be conducted by the inhalation route. EPA intends to issue a final test rule for any listed chemicals which are not covered by a consent order or a voluntary testing agreement. Jonathan Ramlow has agreed to expedite his review of the available reproductive and developmental effects data on vinyl chloride to develop an industry position on the need for any additional data; 5) a draft letter to the American Cancer Society commenting on the TIME Magazine article. Please call me with your comments on the letter by July 19; 6) Cancer Facts and Figures, 1994. This report is the source of the TIME Magazine article; 7) draft Green Seal Standard on Anti-Corrosive Paints. A ban on vinyl chloride in the manufacture of final anti-corrosive paint products is proposed on page 6 of the draft under item 4.2.4; 8) draft EPA Recommended Inhalation Testing for Hazardous Air Pollutants to be Considered for TSCA Section 4 Test Rule Process (First Rule). The draft recommends the following tests for ethylene dichloride by the inhalation route: SL 107278 acute/subchronic systemic; acute/subchronic respiratory; acute/subchronic neurotoxicity; * * species development toxicity; and, 2-generation reproductive test. 2501 M Street, NW, Washington, DC 20037 Telephone 202-887-1100 Fax 202-887-1237 Responsible Care* 1W APublicCommitment VCRC July 5, 1994 Page 2 EPA is seeking industry comments on its draft testing proposal. The proposed testing for EDC is very expensive, probably in excess of $500,000. Mr. Joe Ledvina of Vista Chemical has suggested to me that it would be cost-effective for the Vinyl Chloride Research Coordinators to initially work with EPA on the proposed testing for EDC as all vinyl chloride manufacturers will be impacted by the proposed testing. For many companies, the same representatives will be addressing both the vinyl chloride and ethylene dichloride testing issues. Therefore, a consolidation of efforts for both chemicals under the Vinyl Chloride Panel Research Coordinators would increase the efficient use of economic and man-power resources. Please complete the enclosed ballot to indicate your approval/disapproval of Mr. Ledvina's recommendation; and, 9) a commitment form for vinyl chloride research and advocacy activities. Please complete the form and send it to me as soon as possible. I have used the nameplate capacity data from Chemical Data Inc. to determine your company's pro-rata share of the estimated $300,000 budget for the 1994 and 1995 vinyl chloride related research and advocacy activities. Lastly, I want to confirm that our next VCRC meeting is scheduled for August 2, 1994, starting at 10:00 a.m. The meeting will be held at the CMA offices in Washington, D.C. As many important issues are on the agenda for discussion, please make every effort to attend the meeting. If you have any questions or need additional information, please call me at (202) 887-1192. Sincerely, Enclosures Hasmukh C. Shah, Ph.D. Manager, Vinyl Chloride Panel SL 107279 BENEFITS OF UPDATING INTER-INDUSTRY STUDY OF VINYL CHLORIDE WORKERS Product Stewardship - Demonstrates to workers, community residents, customers, and other audiences our collective commitment to characterize cancer risks associated with employment in VCM/PVC processes. Scientific Knowledge - Refines the estimate of the number of cases of human angiosarcoma of the liver (ASL) associated with operating VCM/PVC plants in the pre-1972 era in North America. - Provides basis for refining human cancer risk assessments which are used by government agencies for permitting facilities, etc. - Contributes ASL cases to the international registry. - Helps to resolve unanswered questions about alleged links to cancers of the brain, lung, and hematopoeitic system as well as address non cancer causes of death such as emphysema. Litigation Defense - VCM/PVC manufacturers continue to face toxic tort litigation alleging that numerous other types (non-ASL) of cancer are related to VCM/PVC employment. This type of research is useful in defending such litigation. GGB 3/15/94 SL 107276 BENEFITS OF UPDATING INTER-INDUSTRY STUDY OF VINYL CHLORIDE WORKERS (cont.) Chlorine Issue - VCM/PVC continue to be a part of the general debate on health and environmental impacts of chlorinated organics. This type of research serves a valuable role in helping to debate the issues on the basis of good science. GGB 3/15/94 SL 107277 CHEMICAL MANUFACTURERS ASSOCIATION Vinyl Chloride Panel Vinyl Chloride Research Coordinators Tentative Agenda DATE: TIME: PLACE: August 2, 1994 10:00 a.m. - 3:00 p.m., EDT CMA Offices 2501 M Street, NW Washington, D.C. 1.0 Approval of June 13, 1994 Record of Conference Call 2.0 Status of Company Commitments to Update the Vinyl Chloride Epidemiology Study 3.0 Discussion of Vinyl Chloride Epidemiology Study Update Proposals from Contractors 4.0 Approval of Line Item Budgets for the VCRC Activities 5.0 Discussion of Short-term Vinyl Chloride Exposure Effects Studies with James Swinberg of the University of North Carolina at Chapel Hill (Tentative) 6.0 Status of Meeting With EPA to Discuss Vinyl Chloride Risk Assessment 7.0 Status of Dow Chemical's Review of Vinyl Chloride Teratology and Reproductive Effects Studies 8.0 Discussion- of VCRC Negotiating with EPA on Testing of Ethylene Dichloride Under TSCA Section 4 9.0 Discussion of Course of Action with EPA on VC and EDC Testing Program Under TSCA Section 4 10.0 Finalization of Response to TIME Magazine's Article on Vinyl Chloride Exposure and Development of Lymphoma 11.0 Set Date for Next Conference Call or Meeting Subject to Approval Hasmukh C. Shah, Ph.D. Manager, Vinyl Chloride Panel 107280 SL In * ANTITRUST CHECKLIST FOR CMA MEETINGS This antitrust checklist is for use by CMA staff and member representatives in the conduct of CMA-sponsored meetings. Muted discussion topics apply equally to soda! gatherings incidental to CMA-sponsored meetings. The Checklist is not hausuve and does not address antitrust issues relating to activities other dun CMA meetings. Participants in CMA meetings should be thoroughly familiar with: (1) "Antitrust Guide for CMA Committee Members;" and, (2) "General ftincipies Applica ble to the Structure and Operations of Committees." Both of these documents may be found in the CMA Directory. DO Ensure stria performance in areas of: OVEaStGHI/SUPEKVISIONi Haves CMA staff representative at each CMA-sponsored meet ing (unless an exception has been authorised by the appro priate CMA vice-president); consufr h an attorney ofiheOIA Office ofGenoa/Coined on all anoeust questions relating to CMA-sponsored meettogs; tout meeting discussions to agenda topics (unless additional topics have been approved by the appropnate CMA naff rep resentative). and provide each member company representative and Q4A staff representative attending a CMA-sponsored meeting wfch a copy of this checklist, and have a copy available for refetence at all CMA-sponsored meetings. RECORDKEEPING: Have an agenda and minutes which accurately retoa the mat ters which occur. provide agendas and minutes to the CMA Office of General Counsel for review and approval in advance of dmrfoudon. and. fuDv describe the purposes and authorities of all task groups, work groups, ad hoc or other standing committee subgroups in the minutes of the appropriate parent commmee. VIGILANCE: Protest against any discussion or meeting activities which ap pear to violate this checklist, disassociate yourself from any such discussion or activities and leave any meeting m which they continue Revised 3'80 (single page version) Reformned l /S9 MDB DONT Do not. fan faa or appearance, discuss or exchange tnibrmstaQoa: maes, maxmNG> Individual company price, price changes, price differentials, mariagu, dacounea. allowances, credit terras, etc.: Individual company data on corns, production, capacity. mvaaorics. sates, ma and. toduny pricing policies, price tods, price changes, differen dak, me. PRODUCTION, TMOUMNG: Hans ofindividual companies concerning die design, produc tion, datribution or msrkeung of particular products, mdudfog propoed icwiiones or customers and, changes in induxry production, capacity or inventories. TRANSPORTATION BATES: Kates or tare policies for individual shipments, including bas ing point systems, me prices, height equalisation, etc. MARKET PROCEDURES. DiOXJDDfGt Company bids on contracts for particular products; company procedures for responding so bid mvttaoons. and, matters relating to actual or potential individual suppliers or cunomets ihsr might have the effect of excluding them hum arty matter or influencing the business conduct of firms to ward them. CONSENT DECREE SUBSTANCE: Any matter relating to triaodium phosphate (a restriction re quired by a 1962 consent decree to which CMA is a party) SL 107281 CHEMICAL MANUFACTURERS ASSOCIATION Vinyl Chloride Panel Research Coordinators Record of Conference Call DATE: TIME: June 13, 1994 10:00 a.m. List of Participants: Ed Beeler Frank Borrelli Mark Gruenwald Jim Knaak Dave Penney Jonathan Ramlow GEON Georgia Gulf Borden Oxy Vista Dow Chemical Bob Ondocsin Has Shah CMA CMA 1.0 The May 19, 1994 Record of Meeting was approved with one change. On page 3, line 1, the proper name is changed from the American Chemical Society to the American Cancer Society. 2.0 There appears to be overall support from member companies to proceed with the update of the epidemiology study. Each company representative, however, will inform Has Shah of his company's final decision by June 24. 3.0 Jonathan Ramlow briefly reviewed the revised scope of work for the epidemiology study update. All comments on the draft scope of work should be sent to Dr. Ramlow with a copy to Dr. Shah by June 24, 1994. 4.0 Dr. Ramlow estimated Dow Chemical's cost to design the update, evaluate bids, monitor the study, provide technical guidance to the selected contractor, and evaluate the interim and draft reports at $30,000. 5.0 Dr. Shah will invite Jim Swinberg of the University of North Carolina at Chapel Hill to the next VCRC meeting to discuss the vinyl chloride short-term exposure effects evaluation program. 6.0 Dr. Shah reported that EPA's Carcinogen Review Assessment Verification Endeavor (CRAVE) currently is updating its IRIS risk assessment for vinyl chloride. Dr. Shah will contact Jim Cogliano, William Farland, and Hugh McKinnon of the Agency to request a meeting to discuss Richard Reitz's physiologically-based pharmacokinetic risk assessment model for vinyl chloride. SL 107282 ROCC VCRC June 13, 1994 Page 2 7.0 Dr. Ramlow informed the VCRC members that he did not find any new references in his literature search on reproductive and teratogenic effects of vinyl chloride other than Dow's own studies. Dr. Ramlow will review these studies and prepare a position paper on the adequacy of these studies or on the need for any additional studies. 8.0 David Penney will send a draft response to TIME Magazine's article on vinyl chloride exposure and development of lymphoma to Dr. Shah within the next two weeks. 9.0 The next VCRC meeting is scheduled for August 2, 1994 at 10:00 a.m. 10.0 The conference call ended at approximately 11:30 a.m. Subject to Approval 3^/-- Hasmukh C. Shah, Ph.D. Manager, Vinyl Chloride Panel SL 107283 CMIZ& CHEMICAL MANUFACTURERS ASSOCIATION July 5, 1994 James Cogliano Chairman, Carcinogen Review Assessment Verification Endeavor U.S. EPA (8602) 401 M Street, S.E. Washington, D.C. 20460 Dear Mr. Cogliano: It has come to my attention that EPA's Carcinogen Review Assessment Verification Endeavor currently is reassessing human health risk for vinyl chloride. The Chemical Manufacturers Association Vinyl Chloride Panel applauds EPA's efforts to review the latest health effects information to determine risks posed by specific chemicals. Dr. Richard Reitz, formerly of Dow Chemical, has developed a physiologically-based pharmacokinetic model for vinyl chloride risk assessment. Dr. Reitz recently presented his model to the Vinyl Chloride Panel and has agreed to present his model to EPA prior to its publication, if the Agency provides an opportunity for the presentation. Therefore, the Vinyl Chloride Panel requests a meeting with appropriate EPA and/or contractor staff to discuss the new vinyl chloride risk assessment model. Dr. Reitz's abstract of the model is enclosed with this letter. Also, the Panel conducted an epidemiologic study of vinyl chloride workers covering a period of time from 1942-1982. The final report on the study was submitted to the EPA Administrator in 1986. A copy of the report is enclosed with this letter just in case the report did not reach CRAVE or CAG personnel. The following articles related to the CMA-sponsored vinyl chloride epidemiology study also are enclosed: 1991 An Industry-Wide Epidemiologic Study of Vinyl Chloride Workers, 1942-1982; 1993 Letter to the Editor, Diagnostic Bias in Occupational Epidemiologic Studies (H. Shah); and, 1993 Response to Letter to the Editor, Diagnostic Bias in Occupational Epidemiologic Studies: An Example Based on the Vinyl Chloride Literature (0. Wong). SL 107284 2501 M Street, NW, Washington, DC 20037 Telephone 202-887-1100 Fax 202-887-1237 Responsible Can* APubUeCDmnMmant James Cogliano July 5, 1994 Page 2 I will call you in the next few weeks to discuss the possibility of meeting to examine scientific issues related to the vinyl chloride risk assessment. Meanwhile, if you have any questions or need additional information, please contact me at (202) 887-1192. Sincerely, Mo-o ___ Hasmukh C. Shah, Ph.D. Manager, Vinyl Chloride Panel Enclosures cc: William Farland, Director, Office of Health and Environmental Assessment, EPA Hugh McKinnon, M.D., Director, Human Health Assessment Group, EPA SL JUN 24 '94 09:44 FR GEON-ENU-SAFE-HEALTH 216 447 6459 TO 93023238105 I Existing Chemicals P.04/25 ATSDR Chemicals Added to MTL FWX 5>e*~S- F.PA is adding 32 chemicals to the Master Testing List in response to a request for testing by the Agency Tor Toxic Substances and Disease Registry (ATSDR). The chemicals are: benzene. Ixtryllium, chloroethane, chromium, cyanide, di (2erhylhcxyl) phtliaiate, mercury, methylene chloride, tetrachloroethylene, toluene, trichloroethyl ene. and vinyl chloride. ATSDR is required to identify the hazardous substances most commonly found at Superfund sites, prepare toxicological pro files, and identify priority data needs for those substances. ATSDR is also required to initiate a research program to meet the priority data needs it identifies. October 1992, ATSDR requested EPA to use its authorities under TSCA and EIFRA to fill some of the data needs it identified on 37 chemicals. In its response to ATSDR, EPA agreed to develop a test rule under section 4 of TSCA to obtain data on 12 of the chemi cals, but noted that a TSCA test rule would not be an appropriate mechanism for obtaining data on the other 25 chemicals. Before initiating rulemaking, EPA is inviting manufacturers of the 12 chemicals listed in the following table to submit testing plans and enter into consent agreements for tesung. EPA intends to issue a test rule in late 1994 for any of the 12 substances which are not covered by a consent order or a voluntary testing agreement. Chemical Mercury Vinyl chloride Benzene Tichloroethylene Chromium .............. Tetrachloroethyiene Cyanide Beryllium Toluene Methylene chloride Chloroethane Testing to be Proposed Immunotoxicity oral Chronic oral Reproductive oral Acute oral Reproductive inhalation Developmental inhalation Subchronic oral Neurotoxicity oral Subchronic oral Neurotoxicity oral Acute oral Reproductive oral Immunotoxicity oral Reproductive inhalation Neurotoxicity inhalation Immunotoxicity inhalation Developmental inhalation Acute inhalation Subchronic inhalation Developmental inhalation Fate in soil Acute inhalation Subchronic inhalation with reproductive and pulmonary pathology Developmental inhalation Immuotoxicity inhalation Bioavailabiiity Fate in air | Comparative Pharmacokinetics Immunotoxicity oral i ' Subchronic oral j immunotoxicity oral Developmental oral Neurotoxicity oral Comparative Pharmacokinetics Immunotoxicity oral SL 107286 12 CHEMICALS IN PROGRESS CANCER FACTS & FIGU 994 MD 23,500 DE 3,800 PUERTO RICO 9,400 SL 107287 AMERICAN CANCER * SOCIETY* Estimated number of new cancer cases in 1994 by state, total: 1,208,000 (excluding Puerto Rico).* Excluding basal and squamous cell skin cancer and carcinoma in situ. Contents CANCER: BASIC FACTS................................................................................. 1 RESEARCH, PREVENTION, DIAGNOSIS AND TREATMENT......... Cancer Death Rates by Site, Males, US, 1930-1990......................... Cancer Death Rates by Site, Females, US, 1930-1990..................... 30-Year Trends in Cancer Death Rates per 100,000 Population, 1958-60 to 1988-90 ........................................................... Estimated Neve Cancer Cases and Deaths, US, 1994 ......................... Estimated New Cancer Cases, by State--1994 ..................................... Cancer Mortality, by State--1994 .............................................................. 2 4 4 5 6 7 8 SELECTED CANCERS..................................................................................... 9 Lung Cancer.......................... 9 Colon and Rectum Cancer.............................................................................. 9 Breast Cancer........................................................................................................ 10 Prostate Cancer.....................................................................................................10 Leading Sites of Cancer Incidence and Death--1994 Estimates..............................................................................................................11 How to Estimate Cancer Statistics Locally............................................... 12 Pancreas Cancer................................................................................................... 12 Uterus (Cervix) Cancer.......................................................................................12 Percentage of Population (Probability) Developing Invasive Cancers at Certain Ages................................................................13 Uterus (Endometrial) Cancer........................................................................... 13 Cancer in Children................................................ 13 Leukemia.................................................................................................................14 Lymphoma.............................................................................................................. 14 Skin Cancer.................................................................... ,................................... 15 Tables are indicated in bold print Ovary Cancer....................................................................................................... 15 Five-Year Relative Survival Rates by Stage at Diagnosis................... 16 Bladder Cancer................................................................................................... 16 Oral Cancer............................................................................................................ 16 Trends In Cancer Survival, by Race.............................................................17 CANCER IN MINORITIES............................................................................. 18 Number of Cancer Deaths for Black, American Indian, Chinese, Japanese, and Hispanic Persons, US, 1990 . ........... 18 PREVENTION................................. ..................... ............... 19 Environmental Cancer Risks.................................................... ............... 20 EARLY DETECTION.................................................................... ............... 21 TOBACCO USE............................................................................ ............... 22 THE AMERICAN CANCER SOCIETY................................... Research................... ....................................................................... Public Education.......................................................................... Professional Education............................................................... Patient Services............................................................................. Public Issues.................................................................................. COSTS OF CANCER.................................................................... THE DISADVANTAGED............................................................. Allocation of ACS Foods, 1992.............................................. Summary of Research Grants and Fellowships................ Cancer Around the World......................................................... Cancer Centers.............................................................................. Chartered Divisions of the ACS............................................... ............... 24 ............... 24 ............... 24 ............... 25 ............... 25 ............... 25 ............... 26 ............... 26 ............... 26 ................ 27 ............... 2t ............... 29 Back Cover Sources of Statistics Incident*. Since there is no nationwide cancer registry, there is no way of knowing exactly how many new cases of cancer are diagnosed each year. The American Cancer Society (ACS) estimates cancer incidence for the upcoming year using the best available data sources at the time. Estimates of cancer incidence in Fads and Figures editions prior to 1974 were based on rates from two state cancer registries, the Connecticut Tumor Registry and the New York State TUmor Registry. The issues from 1974 to 1978 used information from the National Cancer Institute's Third National Cancer Survey (1969-1971) of nine major areas of the United States. In 1973, the NCI began the Surveillance, Epidemiology and End Results (SEER) program to collect ongoing data on cancer incidence and patient survival. The SEER program includes data from nine population-based cancer registries, covering about 10% of the US population. Beginning with the 1979 edition of Fads and Figures, estimates of cancer incidence have been based on incidence rates obtained through the SEER program, applied to the US Census estimates of the population for the current year. Estimates of new cancer cases include invasive cancers only, excluding in situ tumors except for cancers of the urinary bladder. Basal and squamous cell skin cancers are also excluded. It is not appropriate or accurate to evaluate cancer incidence and mortality trends using only ACS estimates of cases and deaths, since these numbers are projected before the year begins, using data that are several years old. The numbers are presented to give the best available measure of the scope of the disease in the US at the time of publication. Comparable incidence rates are available for 1973 through 1990 from the National Cancer Institute's SEER program to evaluate cancer trends. The estimates of total US cancer cases diagnosed in 1994 are based on age-specific incidence rates from the SEER program for 1988-1990 applied to the 1994 Census population projections. Some adjustment is made for sites with recently increasing or decreasing rates. Estimated new cases by state are calculated according to the distribution of estimated 1994 cancer deaths by state for each primary cancer site. Mortality, Mortality statistics are derived from underlying cause of death data reported by the Division of Vital Statistics, National Center for Health Statistics, Department of Health and Human Services. The 1994 estimates of cancer deaths are based an cancer mortality data from 1984 through 1990. Beginning with the 1981 edition of Finds and Figures, age-adjusted mortality rates per 100,000 are standardized to the 1970 census population distribution. Age-adjustment or age-standardization is a method used to malm valid statistical comparisons among rates by assuming the same age distribution occurs among the different groups being compared. Death rates by state: Since 1990, actual age-adjusted mortality rates, based on reported deaths in a recent 5-year period, have been presented. State mortality rate estimates from earlier Fads and Figures are not comparable. Cancer Around the World; International mortality rates were calculated from data made available by the World Health Organization,* and are adjusted to the old world population standard. Probability ofDeveloping Cancer, The probabilities of developing cancer are based on incidence rates for first primary cancers for that site, as reported to the NCI SEER program for 1988 through 1990. SEER area mortality rates for 1988-1990 were used to calculate survival into each age interval. Detailed methodology is available from the Applied Research Brandi, National Cancer Institute. SunioaL Cancersurvival statistics are usually reported as 5-yearrelative survival rates. In this edition, we present survival statistics for cases diagnosed in the period 1983-1989, as reported from the SEER program and followed through 1990. The relative survival rate is the ratio of the observed survival rate for the patient group to the expected survival rate for persons in the general population similar to the patient group with respect to age, sex, race and calendar year of observation. Because there is a certain lag time required in measuring survival, these rates may not reflect the most recent treatment advances. SEER Report. The NCt SEER program is the source of specific data components for Cancer Fads & Figures 1994, including incidence rates and survival rates. These and other data are available in the SEER Cancer Statistics Review; 19731990, National Cancer Institute. NIH Pub. No. 93-2789,1993. c199*. Atnmcan Omar Society, Inc All riyhtj nerved including the rigid to teprodixe this pobldOdet oe portions thereatm any brm For imtttn prnrusOon, eddmi the American Coko- Society. 159$ QiAon Rood. N.tL. Alton. CA 3Q32&42SI. SL 107288 Cancer: Basic Facts What is cancer? Cancer is a group of diseases characterized by uncon trolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. What causes cancer? Cancer is caused by both external (chemicals, radiation, and viruses) and internal (hormones, immune conditions, and inherited mutations) factors. Causal factors may act together or in sequence to initiate or promote carcino genesis. Ten or more years often pass between exposures or mutations and detectable cancer. Can cancer be prevented? Yes, about 90% of the 700,000 skin cancers that will be diagnosed in 1994 could have been prevented by protection from the sun's rays. All cancers caused by cigarette smoking and heavy use of alcohol could be prevented completely. The ACS estimates that in 1994, about 165,000 lives will be lost to cancer because of tobacco use. About 17,000 cancer deaths will be related to excessive alcohol use, frequently in combination with cigarette smoking. Regular screening and self-exams can detect cancers of the breast, tongue, mouth, colon, rectum, cervix, prostate, testis, and melanoma at an early stage, when treatment is more likely to be successful. These sites include nearly half of all new cases. Of these cases, about two-thirds of all patients currently survive five years. With early detection, about 90% would survive. This means that of those persons diagnosed with these cancers in 1994, about 100,000 more would survive if their cancers had been detected in a localized stage and treated promptly. How is cancer treated? By surgery, radiation, radioactive substances, chemicals, hormones, and immunotherapy. Who gets cancer? Anyone. Since incidence rises with age, most cases affect adults in mid-life or older. Among children ages 1-14, cancer causes more deaths in the US than any other disease. In the 1980s there were over 4.5 million cancer deaths, almost 9 million new cancer cases, and some 12 million people under medical care for cancer. How many people alive today have ever had cancer? Over 8 million Americans alive today have a history of cancer, 5 million diagnosed five or more years ago. Most of these 5 million can be considered cured, while others still have evidence of cancer. "Cured" means that a patient has no evidence of disease and has the same life expectancy as a person who never had cancer. How many new cases will there be this year? About 1,208,000 new cancer cases will be diagnosed. This estimate does not include carcinoma in situ and basal and squamous cell skin cancers. The incidence of these skin cancers is estimated to be over 700,000 cases annually. How many people will die? This year about 538,000 will die of cancer--over 1,400 people a day. One out of every five deaths in the US is from cancer. What is the national cancer death rate? There has been a steady rise in the cancer mortality rate in the US in the last half-century. The age-adjusted rate in 1930 was 143 per 100,000 population. It rose to 157 in 1950, to 163 in 1970, and was 174 in 1990. The major cause of this increase has been lung cancer. Death rates for many major cancer sites have leveled off or declined over the past 50 years (see page 5). If lung cancer deaths were excluded, cancer mortality would have declined 14% between 1950 and 1990. How many people are surviving cancer? In the early 1900s, few cancer patients had any hope of long-term survival. In the 1930s, less than one in five was alive five years after treatment. In the 1940s, it was one in four, and in the 1960s, it was one in three. About 483.000 Americans, or 4 of 10 patients who get cancer this year, will be alive 5 years after diagnosis. The gain from 1 in 3 in the 1960s to 4 in 10 now represents over 85.000 persons each year. This 4 in 10, or about 40% is called the "observed" survival rate. When adjusted for normal life expectancy (factors such as dying of heart disease, accidents, and diseases of old age), a "relative" 5-year survival rate of 53% is seen for all cancers. The relative survival rate is commonly used to measure progress in the early detection and treatment of cancer. SL 107289 1 CANCER FACTS & FIGURES 1994 Research, Prevention, Diagnosis, & Treatment The vocabulary of cancer is ever increasing, as knowledge about the disease mounts. In the past decade, words such as oncogenes, retinoids, and growth factors have become standard. Indeed, our knowledge of the genetics of cancer has soared, and it is now possible to envision the day when the genetic basis of individual cancers will be known, along with mechanisms to correct the problem. In addition to looking to the future, we can enjoy some successes now. Some cancers that only a few decades ago had a very poor outlook are often cured today: acute lymphocytic leukemia in children, Hodgkin's disease, Burkitt's lymphoma, Ewing's sarcoma (a form of bone cancer), Wilms' tumor (a kidney cancer in children), rhabdomyosarcoma (a cancer in certain muscle tissue), testicular cancer, and osteogenic (bone) sarcoma. This section highlights some developments in cancer research, prevention, diagnosis, and therapy, and indicates the directions of current and future research. Oncogenes, which play a role in normal cell growth and differentiation, can mutate and cause the runaway cell growth associated with cancer. The ras oncogene is mutated in 50% of colon cancers and 90% of pancreatic cancers. The presence of certain oncogenes is being used to predict which tumors are likely to recur after surgery and/or to identify family members at risk. Suppressor genes, which exist in normal cells to control cell growth, also play a role in cancer. Some cancers are caused when mutations occur in these genes, allowing uncontrolled cell growth. For example, the p53 suppressor gene frequently is altered in many types of cancer, including breast and lung. In one familial syndrome, where family members have high rates of cancer, about 90% of those who inherit the abnormal p53 gene get cancer by the age of 50. Family members can now be screened for this genetic abnormality before cancer develops. Through genetic engineering, researchers may be able to correct or modify hereditary susceptibility by transplanting normal copies of genes into cells that have mutated copies of those genes. Growth factors can be used to stimulate normal bone marrow cells to withstand very high doses of chemother apeutic drugs. A genetic fusing of cancer cells with normal cells can produce disease-fighting monoclonal antibodies (specific antibodies tailored to seek out chosen targets on cancer cells). Their potential in the diagnosis and treatment of cancer is under study, and they are showing promise for carrying cancer-killing radiation and drugs to a precise location. Researchers are understanding how cancer cells spread to healthy tissues, a process called metastasis. Cell mutations can cause increased production of destructive enzymes that allow them to invade surrounding tissues and penetrate blood vessels to travel to other parts of the body. A powerful enzyme inhibitor, TIMP-2 is showing promise for abolishing the metastatic potential of tumor cells. A metastasis suppressor gene, NM23, has also been identified. New ways have been found to treat early breast and colon cancers postoperatively with drugs. This "adjuvant" treatment may eradicate cancer cells remaining after surgery and increase cure rates. Neoadjuvant chemotherapy (giving chemotherapy to shrink the cancer and then removing it surgically) has been tried against various types of cancers. This is a prom ising new treatment approach. Understanding the causes of pain in cancer patients has increased the options for controlling pain. Regular use of orally administered pain medicines, infusions or injections of analgesics, and procedures to interrupt pain pathways are among the effective approaches available for the majority of patients with pain from cancer. Researchers are examining synthetic retinoids (cousins of vitamin A) and other substances to see if recurrences of certain cancers can be prevented and if these agents can reduce cancer in high-risk groups. The cancer prevention capabilities of many other compounds are also being researched. In clinical trials, taxol, an agent obtained currently from the bark of Pacific yew trees, has been effective in treating ovarian cancer. Research efforts are underway to synthesize this scarce drug in the laboratory and the synthesized taxol will be tested for efficacy in all types of cancer. New approaches to drug therapy use combinations of chemotherapeutic drugs, or chemotherapy plus surgery or radiation. New classes of agents are being tested for their effectiveness in treating patients whose disease is resistant to drug therapies now in use. Understanding the basis of drug resistance and developing counterattacks are major areas of research today. Many patients with primary bone cancer now are treated successfully by removing and replacing a section of bone rather than by amputating the leg or arm. Drugs and radiation therapy are being used effectively after bone cancer surgery, resulting in dramatic improvement in survival. 2 CANCER FACTS & FIGURES 1994 SL 107290  New high-technology diagnostic imaging techniques have replaced exploratory surgery for some cancer patients. Magnetic resonance imaging (MRI) is one example of such technology. In MRI, a huge electromagnet is used to detect idden tumors by mapping the vibrations of the various atoms in the body on a computer screen. Computerized tomography (CT) scanning uses x-rays to examine parts of the body. In both of these painless, noninvasive pro cedures, cross-section pictures can show a tumor's shape and location more accurately than is possible with conventional x-ray techniques. For patients undergoing radiation therapy, CT scanning may enable the therapist to pinpoint the tumor more precisely, and thus provide more accurate radiation dosage while sparing normal tissue. Positron emission tomography (PET) is another imaging technique. One of the advances in the area of imaging combines two or three different types of images (e.g., MRI and PET) in a computer to create a threedimensional picture that can be rotated on the screen. This technology is currently used in some medical centers to help plan for surgery and radiation therapy in areas such as the brain. Immunotherapy holds the hope of enhancing the body's own disease-fighting systems to help control cancer. Interferon (a naturally occurring body protein capable of killing cancer cells or stopping their growth), interleukin2 (a growth factor that stimulates cells of the immune system to fight cancer), and other biologic response %lodifiers are under study. Recently, interferon was made ivailable to all doctors as the treatment for hairy cell leukemia, a rare blood cancer of older Americans. Interleukin-2 is under active research in the treatment of kidney cancer and melanoma. Gene therapy is the newest approach to stimulating immune cells to fight cancer. Vaccines against several types of cancer are also being developed. Many cancers develop in a two-stage process through exposure to substances known as initiators and promoters. Research scientists are exploring ways to interrupt this process. Ongoing research into new drug development will result in compounds that are less toxic to normal cells and more potent against tumor cells. New drugs will also allow physicians to circumvent the problem of drug resistance that many cancer cells develop. Along that same line of research, genes responsible for cancer cell resistance to chemotherapy have recently been discovered. New technologies have made it possible to use bone marrow transplantation as an important treatment option in select patients with leukemia and lymphoma. Bone marrow transplantation for breast cancers and other malignant tumors is under study. Because disruption of bone marrow function is a side effect of some cancer treatments, researchers are evaluating autologous bone marrow transplants, in which a portion of the patient's own marrow is removed before treatment, saved, and later restored. This procedure eliminates the problems of matching a donor with the recipient patient, and may make it possible for the patient to tolerate larger doses of anticancer drugs or radiation therapy. Improvements in cancer treatment have made possible more conservative management of some early cancers. In early cancer of the larynx, many patients are now able to retain the larynx and voice; in colorectal cancer, fewer permanent colostomies are needed; in many cases, the surgery for breast cancer is often more limited; and special nerve-sparing surgery now commonly used for prostate cancer could enable men to maintain normal penile function. Prostatic ultrasound (a rectal probe using ultrasonic waves to produce an image of the prostate) is currently being investigated as a potential means to increase the early detection of occult (not clinically suspected) prostate cancer. Recently, prostatic ultrasound has been combined with a blood test for prostate-specific antigen to aid in early detection of prostate cancer. A large clinical trial is underway to evaluate the usefulness of an estrogen-blocking drug called tamoxifen. Commonly used to treat women when they have breast cancer, this large study hopes to see if tamoxifen can also be used to prevent breast cancer in women who are at high risk. With medical progress producing longer survival periods for many cancer patients, clinical concerns are expanding to include not only patients' physical well-being, but also their psychosocial needs. The response of both patient and family to the disease, the patient's sexual concerns, employment and insurance needs, and ways to provide psychosocial support have emerged as important areas of research and clinical care. Psychosocial and behavioral research is showing much promise as evidence mounts that lifestyle (tobacco, diet) and environmental factors influence a person's general health and chances of developing cancer, as well as the mental ability to cope with cancer if it occurs. Research on behavioral modification is having a significant impact on symptoms of cancer and its treatment, such as pain, nausea, and vomiting. Other research deals with stress during treatment and during recovery after surgery or radiation treatment. A number of investigations concentrate on breast cancer, specifically on how women can be motivated to make use of mammography screening, and how to adjust to surgery, if such intervention becomes necessary. 107291 SI* 3 CANCER FACTS l FIGURES 1994 Cancer Death Rates by Site, Males, United States, 1930-90 Rates are per 100,000 and are age-adjusted to the 1970 US census population. Cancer Death Rates by Site, Females, United States, 1930-90 Available on reproduction sheet (5005.94) Rates are per 100,000 and are age-adjusted to the 1970 US census population. 4 CANCER FACTS & FIGURES 1994 Available on reproduction sheet (5005.94) SL 107292 30-Year Trends in Cancer Death Rates* per 100,000 Population, 1958-60 to 1988-90 Sites Percent Number of Sex 1958-1960 1988-1990 Changes Deaths 1960 All Sites Oral Esophagus Stomach Male Female Male Female Male Female Male Female 180.9 136.8 6.0 1.6 4.8 1.2 17.5 9.0 218.0 140.8 4.6 1.7 5.9 1.5 6.9 3.1 21% f -22% 9% 23% 25% -61% -65% 143,498 124,084 4,668 1,507 3,832 1,083 13,085 7,774 Colon & rectum . Colon. Male Female Male Female 25.2 22.8 17.0 17.4 ` 23.5 16.1 20.0 14.1 - 7% -30% 17% -19% 19,127 20,265 13,010 15,527 Rectum Male Female 8.2 5.4 3.5 -58% 2.0 -63% 6,117 4,738 Liver* Male Female 5.7 5.9 5.2 - 8% 3.2 -45% 4,566 5,828 Pancreas Male 10.1 9.9 t 7,982 Female 6.2 7.1 14% 5,693 Larynx Male Female 2.7 0.3 2.5 - 6% 0.5 87% 2,201 225 Lung Male 36.4 74.2 104% Female 5.5 30.6 452% 31,257 5,163 Melanoma of skin Male Female 1.4 1.0 3.0 120% 1.5 48% 1,194 989 Other skin Male Female 1.7 . 0.8 1.3 -25% 0.4 -56% 1,156 670 Breast Male 0.3 0.2 -33% Female 25.7 27.4 7% 215 23,755 Cervix uteri Female 9.4 3.0 -68% 8,487 Other uterus Female 6.6 3.5 -47% 5,929 Ovary Female 8.8 7.9 -10% 8,046 Prostate Male 20.5 25.3 23% 14,452 Bladder Male Female 7.2 2.7 5.6 -22% 1.7 -38% 5,440 2,425 Kidney Male Female 3.8 2.0 5.1 2.4 35% 16% 3,145 1,794 Brain Male Female 4.0 2.7 5.1 3.4 26% 27% 3,700 2,484 Non-Hodgkin's Male 4.8 7.7 62% lymphoma Female 3.2 5.0 58% 4,015 2,839 Hodgkin's disease Multiple myeloma Male Female Male Female 2.2 1.3 2.0 1.4 0.7 -67% 0.4 -68% 3.6 85% 2.5 76% 1,877 1,198 1,687 1,342 Leukemia Male 8.9 8.2 - 7% Female 5.7 4.8 -16% 7,371 5,354 Number of Deaths 1990 268,283 237,039 5,636 2,769 7,213 2,506 8,336 5,737 28,635 28,895 24,385 25,325 4,250 3,570 6,557 5,811 12,199 12,883 2,977 733 91,091 50,194 3,844 2,576 1,556 614 272 43,391 4,627 6,052 12,762 32,378 6,910 3,431 6,271 4,042 6,339 5,291 9,795 8,806 956 676 4,561 4,373 10,192 8,382 'Adjusted to the age distribution of the 1970 US Census population. tPercent changes not listed because they ore not meaningful. ^Primary and non-specified. Notes Even though death rates declined or remained stable, the number of deaths increased because the papulation has became larger and older. The US papulation increased 38% from I960 to 1990. SL 107293 5 CANCER FACTS & FIGURES 1994 Estimated New Cancer Cases and Deaths, United States--1994* All sites Buccal cavity 5, pharynx Ltp Tongue Mouth Pharynx (Oral) Digestive organs Esophagus Stomach Small intestine Large intestine 1 Rectum i ,, , _ _ , (Colan-Rectum) Liver and biliary passages Pancreas Other and unspecified digestive Estimated New Cases Bath Sexes Male Female 1,208,000 632,000 576,000 29,600 3,300 6,000 11,100 9,200 19,800 2,800 3,800 6,600 6,600 9,800 500 2,200 4,500 2,600 233,300 11,000 24.000 3.600 107.000 -42,000 16,100 27.000 2.600 123,100 8,000 15.000 2.000 52.000 23.000 8,800 13.000 1,300 110,200 3.000 9.000 1,600 55.000 19.000 7.300 14.000 1.300 Estimated Deaths Both Sexes Male 538,000 283,000 7,925 75 1,750 2,100 4,000 5,150 50 1,100 1,200 2,800 121,450 10,400 14.000 950 49.000 7,000 13,200 25,900 64,550 7.800 8.400 500 24,000 3.800 7,200 12.400 450 Female 255,000 2,775 25 650 900 1,200 56,900 2,600 5,600 450 25.000 3,200 6.000 13,500 ' Respiratory system Larynx Lung Other L unipecined respiratory 189,000 12,500 ' 112,800 9,800 100,000 3,000 76,200 2,700 72,000 1,500 158,200 3,800 153,000 1,400 97,900 3,000 94,000 900 60,300 800 59,000 500 Bone i(000 1,100 900 1,075 600 475 Connective tissue 6,000 3,300 2,700 3,300 1,600 1700 Melanoma of skin Breast 32,000 183,000 17,000 1,000 15,000 182,000 6,900 46,300 4,300 300 2,600 46,000 Genital organs Cervix uteri 3 Corpus & unspecified i ' *rul' Ovary Other & unspecified genital, female Prostate Testis Other & unspecified genital, male 283,400 ' 15,000 31,000 24,000 5,300 200,000 6,800 1,300 208,100 ___ -- -- -- 200,000 6,800 1,300 75,300 15,000 31,000 24,000 5,300 -- ____ -- 63,725 4,600 5,900 13,600 1,100 38,000 325 200 38,525 __ 38,000 325 200 25,200 4,600 5,900 13,600 1,100 -- Urinary organs Bladder Kidney & other urinary 78,800 51,200 27,600 55,000 38,000 17,000 23,800 13,200 10,600 21,900 10,600 11,300 13,800 7,000 6,800 8,100 3,600 4,500 Eye 1750 950 800 250 125 125 Brain & central nervous system 17,500 9,600 7,900 12,600 6,800 5,800 Endocrine glands Thyroid Other endocrine 14,450 13,000 1,450 4,150 3,400 750 10,300 9,600 700 1,725 1,025 700 750 400 350 975 625 350 Leukemia Lymphocytic leukemia Granulocytic leukemia Other & unspecified leukemia 28,600 12,500 11,400 4700 16,200 7,300 6,200 2700 12,400 5,200 5,200 2,000 19,100 5,700 7,500 5,900 10400 3400 4,100 3,100 8,600 2,400 3,400 2,800 Other blood & lymph tissues Hodgkin's disease Non-Hodgkin's lymphoma Multiple myeloma 65,600 7,900 45,000 12700 35,900 4,400 25,000 6,500 29700 3400 20,000 6,200 32,550 1,550 21,200 9,800 17,100 900 11,200 5,000 15,450 650 10,000 4,800 All other & unspecified sites 43,000 24,000 19,000 41,000 21,000 20,000 'Excludes basal and squamous cell concert and in situ carcinomas except bladder. Carcinoma in situ of the uterine cervix accounts for about 55,000 new cases annually, carcinoma in situ of the female breast accounts for about 25,000 new eases annuolly, ond melanoma carcinoma in situ accounts for about 8,000 new cases annually. Overall, about 100,000 new coses of carcinoma in situ of all sites of cancer are diagnosed eoch year. Basal cell ond squamous cell skin coneen account for more than 700,000 new coses annually. About 2,300 nonmelanoma skin cancer deaths will occur in 1994. Incidence estimates are based on rates from NCI SEER program 1988-90. SL 107294 6 CANCER FACTS 4 FIGURES 1994 Estimated New Cancer Cases, by State--1994 State All Sites Female Breast Colon & Rectum Lung Oral Uterus Prostate Skin Melanoma Pancreas Leukemia Alabama 21,000 Alaska 1,300 Arizona 17,500 Arkansas 14,000 California 124,000 Colorado 12,000 Connecticut 16,200 Delaware 3,800 Dist. of Columbia 4,000 Florida 82,000 Georgia 28,000 Hawaii 4,100 Idoho 4,200 Illinois 57,000 Indiana 27,000 lowo 14,200 Kansas 12,300 Kentucky 20,000 Louisiana 20,500 Maine 6,900 Maryland 23,500 Massachusetts 31,000 Michigan 43,500 Minnesota 19,300 Mississippi 13,200 Missouri 27,500 Montana 3,900 Nebraska 7700 Nevada 5,900 New Hampshire 5700 New Jersey 42,000 New Mexico 5,800 New York 88,000 North Carolina 33,000 North Dakota 3,300 Ohio 55,000 Oklahoma Oregon 15700 14,500 Pennsylvania 69,000 Rhode Island 5700 South Carolina 16,500 South Dakota 3700 Tennessee 25,500 Texas 66,000 Utah 4700 Vermont 2700 Virginia 28,000 Washington 22,000 West Virginia 10,600 Wisconsin 24,000 Wyoming 2,000 United States 1708,000 Puerto Rk 9,400 2,800 150 2,500 1,900 19,000 1,900 2,500 600 600 11,500 4,200 475 600 8,800 4,200 2,200 1,900 2,600 2,900 900 3700 4,900 6,800 3,100 1700 4,100 550 1700 800 900 6,800 850 15,000 4,800 425 8,800 2,100 1,900 11,000 900 2700 475 3700 9700 750 425 4,400 3700 1,400 3700 300 182,000 1700 2,200 150 2,000 1,700 14,000 1,500 2,300 500 500 10,200 3,000 550 500 7,600 3,300 2,100 1,700 2,400 2,200 850 2,900 4,400 5,400 2,600 1,400 3,200 500 900 600 650 5,600 650 12,500 4,000 425 7,000 1700 1,600 9,400 800 1,800 450 3,200 7700 500 275 3,100 2700 1,200 3,000 200 149,000 1,100 3,100 250 2,500 2,300 17,000 1,500 2,100 550 450 13,000 4,200 500 550 7,600 4,100 1,900 1,700 3,500 3,300 1,000 3,400 3,900 6,000 2,300 2,100 4,200 500 1,000 1,000 700 5,400 700 11,500 5,000 350 8,000 2700 2700 9700 750 2700 425 4,200 10,000 375 350 4,200 3,200 1,800 2,800 250 172,000 650 550 50 350 250 3,300 275 400 125 150 2,500 900 100 100 1,400 500 300 300 375 500 150 600 950 950 350 350 450 125 175 100 150 1,000 150 2700 900 70 1,200 350 350 1,400 125 600 60 500 1700 60 60 650 500 275 550 25 29700 425 850 60 550 600 5,000 450 500' 125 225 3,000 900 125 150 2,200 1,000 450 475 800 750 175 800 950 1700 650 500 1,000 100 300 225 200 1700 225 3,600 1,400 100 2700 650 500 2,800 200 700 100 950 2700 275 75 1,100 650 375 900 90 46,000 425 3,200 150 3,100 2,600 18,000 2,600 2,500 600 800 16,000 4700 650 1,000 9,400 4,000 2,600 2,100 2,800 3,100 1,200 3700 4700 7,100 4,000 2700 4700 850 1,400 800 850 6,800 1,000 13,000 6700 950 8,600 2,600 2700 11,400 850 3,000 650 4,000 10,000 1700 600 4,800 3,800 1700 4700 350 200,000 1,800 500 40 550 325 4,000 475 400 125 40 2,500 750 60 125 1,300 600 450 400 500 400 200 550 950 850 500 275 650 100 250 150 150 1,100 150 2,200 1,000 70 1700 425 400 1,800 150 400 90 700 1,600 175 70 750 550 325 550 30 32,000 75 450 25 400 325 2,900 300 375 60 100 1,800 600 100 100 1,200 600 300 250 400 500 150 500 700 950 450 300 550 90 175 125 100 900 125 2,100 750 60 1,100 300 325 1700 125 400 75 600 1,600 100 60 650 500 225 600 30 27,000 225 425 30 450 325 3,100 275 400 75 75 1,900 650 80 125 1,400 600 375 325 400 450 125 475 650 1,100 550 275 650 80 150 125 100 850 175 2,000 800 100 1,400 400 400 1700 100 350 80 600 1,800 125 70 600 550 250 650 60 28,600 225 'Does not include carcinoma in situ or basal and squamous cell skin cancers. These estimates are offered as a rough guide and should not be regarded as definitive. They are calculated according to the distribution of estimated 1994 cancer deaths by state. SL 107295 7 CANCER FACTS 4 FIGURES 1994 Cancer M rtality by State--1994 _ Estimated Number of Deaths Reported ___________________________________________________________________ Death Rate Female Colon & State per 100,000' All Sites Breast Rectum Lung Oral Uterus Prostate Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Moine Maryland Massachusetts 179 175 157 176 166 146 170 195 230 166 176 138 150 180 178 158 157 188 190 184 193 179 9,400 500 7,800 6,200 52,000 5,400 7,200 1,600 1,700 37,700 12,300 1,800 1,900 25,400 12,100 6,300 5,500 9,100 9,100 3,100 10,500 13,800 700 50 600 475 4,600 475 600 150 150 3,000 1,000 125 175 2,200 1,100 600 500 650 750 225 850 1,200 850 50 750 650 5,100 550 800 200 200 3,800 1,100 200 175 2,900 1,200 800 600 900 850 325 1,100 1,700 2,800 175 2,200 2,100 14,500 1,200 1,900 500 400 11,500 3,800 425 475 6,800 3,700 1,700 1,500 3.100 2,900 900 3,100 3,600 150 20 100 70 900 80 100 40 40 650 200 30 30 400 125 75 75 100 150 40 175 225 200 10 125 150 1,100 100 100 30 50 700 200 30 30 500 225 100 100 175 150 40 175 200 600 25 600 500 3,600 450 450 100 150 3,000 850 125 175 1,800 750 500 375 500 600 225 700 850 Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Nodh Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania 176 156 178 174 160 159 184 179 185 146 176 173 155 181 169 167 180 19,500 8,600 5,900 12,300 1700 3,400 2,600 2,300 18700 2,600 39,000 15,200 1,400 24,700 7,000 6,500 31,000 1,700 800 425 i,obo 150 325 200 225 1700 225 3,900 1,200 125 2,200 550 500 2,800 2,100 1,000 550 1400 175 325 250 225 2,100 250 4,500 1,500 150 2,600 650 600 3400 5,400 2,100 1,800 3,800 450 900 850 600 4,900 600 10,200 4,600 325 7,200 2,200 2,000 8400 250 90 90 125 25 40 25 40 275 40 600 250 20 325 90 90 375 400 1,400 150 750 125 450 250 800 30 175 80 275 50 150 50 175 400 1400 50 175 850 2400 300 1,200 25 175 500 1400 125 475 100 475 650 2400 Rhode Island 181 2400 225 300 700 30 50 150 South Carolina 175 7,400 600 700 2400 150 175 550 South Dakota 152 1400 125 175 350 20 30 125 Tennessee 178 11400 900 1,200 3700 125 225 750 Texas. Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 164 124 175 180 164 180 165 154 31,000 2,000 1,100 12400 9400 4700 10,800 800 2400 200 125 1,100 850 350 950 75 2,900 200 100 1400 900 475 1,200 75 9,000 325 300 3,600 2,900 1400 2400 225 475 20 20 175 150 75 150 10 600 1,900 50 225 20 125 250 900 175 700 80 300 200 900 20 75 United States Puerto Rico 172 538,000 46,000 56,000 153,000 7,925 10400 38,000 129 4,500 325 425 600 175 150 450 Skin Melanoma 100 10 125 70 900 100 80 30 10 500 150 20 30 275 125 90 80 100 80 40 125 225 175 125 60 150 25 50 30 30 225 40 475 225 15 275 100 80 375 30 90 20 150 350 40 20 150 125 70 125 10 6,900 25 Pancreas 425 25 375 300 2,800 275 350 60 100 1,800 550 100 100 1,200 550 300 250 375 500 150 475 650 900 450 300 500 90 175 125 100 850 125 2,000 700 60 1,100 300 325 1,400 125 375 75 600 1400 100 60 600 475 200 550 30 25,900 200 Leukemia 300 20 300 225 2,000 200 250 50 50 1400 425 60 90 900 400 250 225 300 300 90 325 425 750 375 200 450 50 125 80 60 550 125 1400 550 70 900 275 275 1,000 75 225 50 400 1,200 90 50 400 350 175 425 40 19,100 150 1 `Average annual modality rate for 1984-1790, adjusted to the age distribution of the 1970 US Census Population, SL 107296 8 CANCER FACTS & FIGURES 1994 Selected Cancers Lung Cancer Incidence: An estimated 172,000 new cases in 1994. The incidence rate, which had been increasing steadily in men and women for several decades, has declined in men, from a high of 87 per 100,000 in 1984 to 80 in 1990. The incidence rate in women continues to increase to 41 per 100,000 in 1990. Mortality: An estimated 153,000 deaths in 1994. Since 1987, more women have died of lung cancer than breast cancer, which, for over 40 years, was the major cause of cancer death in women. Signs and Symptoms: Persistent cough, sputum streaked with blood, chest pain, recurring pneumonia or bronchitis. Risk Factors: Cigarette smoking; exposure to certain industrial substances, such as arsenic, certain organic chemicals and asbestos, particularly for persons who smoke; radiation exposure from occupational, medical, and envi ronmental sources. Radon exposure may increase risk, especially in cigarette smokers. Exposure to sidestream cigarette smoke increases the risk for nonsmokers. Early Detection: Because symptoms often don't appear until the disease is in advanced stages, early detection is very difficult. In smokers who stop smoking at the time of early precancerous cellular changes, damaged bronchial lining tissues often return to normal. Smokers who persist in smoking may form abnormal cell growth patterns that lead to cancer. Chest x-ray, analysis of the types of cells contained in sputum, and fiberoptic examination of the bronchial passages assist diagnosis. lYeatment: Determined by the type and stage of the cancer. Options include surgery, radiation therapy, and chemotherapy. For many localized cancers, surgery is usually the treatment of choice. Because the disease has usually spread by the time it is discovered, radiation therapy and chemotherapy are often needed in combination with surgery. In small cell cancer, chemotherapy alone or combined with radiation has replaced surgery as the treatment of choice; on this regimen, a large percentage of patients experience remission, which in some cases is long-lasting. Survival: The 5-year relative survival rate is only 13% in all patients, regardless of stage at diagnosis. The rate is 46% for cases detected when the disease is still localized, but only 16% of lung cancers are discovered that early. Colon and Rectum Cancer Incidence: An estimated 149,000 new cases in 1994, including 107,000 of colon cancer and 42,000 of rectum cancer. Mortality: An estimated 56,000 deaths (49,000 from colon cancer, 7,000 from rectum cancer) in 1994. Mortality from colorectal cancer has fallen 30% for women and 7% for men over the last 30 years. Signs and Symptoms: Rectal bleeding, blood in the stool, change in bowel habits. Risk Factors: Personal or family history of cancer or polyps of the colon or rectum; inflammatory bowel disease. High-fat and/or low-fiber diet may be associated with increased risk. Early Detection: Digital rectal examination, stool blood test, and proctosigmoidoscopy are recommended by the American Cancer Society to detect colon or rectum cancer in asymptomatic patients. Digital rectal examination is performed by a physician during an office visit. The American Cancer Society recommends that this examination be performed annually after age 40. The stool blood test is a simple method to test feces for hidden blood. The specimen is obtained by the patient at home and returned to the physician's office, a hospital, or a clinic for analysis. The Society recommends annual testing after age 50, In proctosigmoidoscopy, the physician uses a hollow lighted tube or a fiberoptic sigmoidoscope to inspect the rectum and lower colon. To detect cancers higher in the colon, longer, flexible instruments are being used. The American Cancer Society recommends sigmoidoscopy, preferably flexible, every 3 to 5 years after age 50. If any of these tests reveal possible problems, more extensive studies, such as colonoscopy (examination of the entire colon) and barium enema (an x-ray procedure in which the intestines are viewed), may be needed. Treatment: Surgery, at times combined with radiation, is the most effective method of treating colorectal cancer. The role of chemotherapy in treating advanced cases is under study. Combinations of chemotherapy and immu nologic agents have recently been described as beneficial in postoperative patients with cancerous lymph nodes. Colostomy (creation of an abdominal opening for elim ination of body wastes) is seldom needed for colon cancer and is infrequently required for rectal cancer. The American Cancer Society has a patient assistance program for those who do have permanent colostomies (see p. 25). SL 107297 9 CANCER FACTS 4 FIGURES 1994 Survival: When colorectal cancer is detected in an early, localized stage, the 5-year survival rates are 92% for colon cancer and 85% for rectal cancer. After the cancer has spread regionally, to involve adjacent organs or lymph nodes, the survival rates drop to 61%,and 51%, respectively. Survival rates for persons with distant metastases are less than 7%. Breast Cancer Incidence: An estimated 182,000 new cases among women in the United States during 1994. About 1,000 new cases of breast cancer will be diagnosed in men in 1994. Breast cancer incidence rates for women increased about 2% a year since 1980, but recently have leveled off at about 108 per 100,000. Most of the recent rise in rates is believed to be due to marked increases in mammography utilization, allowing the detection of early stage breast cancers, frequently before they would become clinically apparent. Other reasons for a longer-term increase in breast cancer are not yet understood. Mortality: An estimated 46,300 deaths (46,000 women, 300 men) in 1994; in women, the second major cause of cancer death. Although incidence rates are increasing, early detection and improved treatment have kept mortality rates fairly stable over the past 50 years. Signs and Symptoms: Breast changes that persist, such as a lump, thickening, swelling, dimpling, skin irritation, distortion, retraction, scaliness, pain, tenderness of the nipple, or nipple discharge. Risk Factors: Over age 40, increases with age; personal or family history of breast cancer; early age at menarche, late age at menopause, never had children or late age at first live birth, and higher education and socioeconomic status. International variability in cancer incidence rates correlate with variations in diet, especially fat intake, although a causal role for dietary factors has not been firmly established. Breast cancer risk factors appear to be more useful in providing clues to the development of cancer than in identifying prevention strategies. Since adult women may not be able to alter their personal risk factors in any practical sense, the best opportunity for reducing mortality is through early detection. Many women will have one or more risk factors for breast cancer. How ever, most risks are at such a low level that they only partly explain the high frequency of the disease in the population. Early Detection: The Society recommends that women have a screening mammogram by age 40; women 40 to 49 should have a mammogram every 1-2 years; asymp tomatic women age 50 and over should have a mammogram every year. In addition, a clinical physical examination of the breast is recommended every three years for women 20 to 40, and every year for those over 40. The Society also recommends monthly breast self-examination as a routine good health habit for women 20 years or older. Most breast lumps are not cancer, but only a physician can make a diagnosis. M Besides its effectiveness in screening asymptomatH women, mammography is recognized as a valuable diag nostic technique for women who have findings suggestive of breast cancer. Once a breast lump is found, mammog raphy can help determine if there are other lesions too small to be felt in the same or opposite breast. Since a small percentage of breast cancers may not be seen on a mammogram, all suspicious lumps should be biopsied for a definitive diagnosis, even when current or recent mammography findings are described as normal. IVeatment: 'faking into account the medical situation and the patient's preferences, treatment may require lumpectomy (local removal of the tumor), mastectomy (surgical removal of the breast), radiation therapy, chemo therapy, or hormone manipulation therapy. Often, two or more methods are used in combination. Patients should discuss with their physicians possible options for the best management of their breast cancer. New techniques in recent years have made breast reconstruction possible after mastectomy, and the cosmetic results usually are good. Reconstruction has become an important part of treatment and rehabilitation. Survival: The 5-year survival rate (which includes all women living five years after diagnosis, whether the patient is in remission, disease-free, or under treatment) for localized breast cancer has risen from 78% in the 1940s to 93% today. If the cancer has spread regionally at the time of diagnosis, however, the 5-year survival rate is 72%, for persons with distant metastases at the time of diagnosis, the 5-year survival rate is 18%. From current data, based on women diagnosed in the early 1970s, the long-term breast cancer survival rate is about 50%. Prostate Cancer Incidence: An estimated 200,000 new cases in the United States during 1994. Prostate cancer incidence rates are 30% higher for black men than white men. Between 1980 and 1990, prostate cancer incidence rates increased 50%, largely due to improved detection. Further increased incidence is expected with widespread use of serum screening tests. Mortality: An estimated 38,000 deaths in 1994, the second leading cause of cancer death in men. Signs and Symptoms: Weak or interrupted urine flow; inability to urinate, or difficulty starting or stopping the urine flow; the need to urinate frequently, especially at night; blood in the urine; pain or burning on urination; continuing pain in lower back, pelvis, or upper thighs. 10 CANCER FACTS X FIGURES 1994 SL 107298 Leading Sites of Cancer Incidence and Death--1994 Estimates Cancer Incidence by Site and Sex* Mole Female Cancer Deaths by Site and Sex Male Female All Sites 632,000 All Sites 576,000 *Excluding basal and squamous cell skin cancer and carcinoma in situ. Available on reproduction sheet (5005.94) Most of these symptoms are nonspecific and may be similar to those caused by benign conditions such as infection or prostate enlargement. Risk Factors: Incidence increases with age; over 80% of all prostate cancers are diagnosed in men over age 65. The disease is more common in northwestern Europe and North America. It is rare in the Near East, Africa, Central America, and South America. For reasons not currently known, black Americans have the highest incidence rate in the world. There is some familial association, but it is unclear whether this is due to genetic or environmental factors. International studies suggest that dietary fat may be a factor. Early Detection: Every man 40 and over should have a digital rectal examination as part of his regular annual physical checkup. In addition the American Cancer Society recommends that men 50 and over have an annual prostate-specific antigen blood test If either result is suspicious, further evaluation in the form of transrectal ultrasound should be performed. Treatment: Surgery, radiation, and/or hormones and anticancer drugs, are treatment options. Hormone treat ment and anticancer drugs may control prostate cancer for long periods by shrinking the size of the tumor, thus relieving pain. Survival: Fifty-eight percent of all prostate cancers are discovered while still localized; the 5-year relative survival rate for patients whose tumors are diagnosed at this stage is 92%. Survival rates for all stages combined have steadily improved, and in the past 30 years have increased from 50% to 78%. SL 107299 11 CANCER FACTS & FIGURES 1994 How t Estimate Cancer Statistics Locally Estimated number of... Number per Multiply community 100,000 population by Special Notes New concer cases, 1994 Cancer deaths, 1994 400 200 Cancer survivors, 1994 2,000 Cancer cases under care, 1994 People who will eventually develop concer People who will eventually die of cancer People who will be saved from cancer in 1994 40,000 20,000 200 0.004 0.002 0.020 0.016 0.400 0.200 0.002 Estimated cases and deaths will not reflect the age and ethnic characteristics of the population, access to detection and treatment, and varying risk factors. Actual data from a population-based tumor registry will allow more accurate estimates. Represents the number of people who were diagnosed over 5 years ago and are still living today. Represents the number of people diagnosed in 1994 and within the previous 5 years. All are assumed to be under treatment or follow-up care. If current incidence and mortality rates remain the same, about 40% will develop cancer before they die. If current mortality rates remain the same, about 1 in 5 people living today will die of concer. Based on 5-year relative survival rate of 53%. Note: The figures ore only a rough approximation of actual data far a community and should be used with caution. Numbers may vary according to the age distribution of the tocol population. Pancreas Cancer Incidence: at. estimated 27,000 new cases in the United States in 1994. The disease is more common in men, and occurs more frequently in black Americans than in white Americans. Mortality: An estimated 25,900 deaths in 1994. Pan creatic cancer incidence and mortality rates have been fairly stable since the early 1970s, except among black women, whose rates have increased slightly. Signs and Symptoms: Cancer of the pancreas is a "silent" disease, one that occurs without symptoms until it is in advanced stages. Risk Factors: Very little is known about what causes the disease or how to prevent it Risk increases after age 50, with the most cases occurring between ages 65 and 79. Smoking is a risk factor; incidence is more than twice as high for smokers as nonsmokers. Some studies have suggested associations with chronic pancreatitis, diabetes, or cirrhosis. In countries where the diet is high in fat, pancreatic cancer rates are higher. Early Detection: At present, only a biopsy yields a certain diagnosis, and because of the "silent" course of the disease, the need for biopsy is likely to be obvious only after the disease has advanced. Researchers are focusing on ways to diagnose pancreatic cancer before symptoms occur. Ultrasound imaging and computerized tomography scans are being tried. IVeatment: Surgery, radiation therapy, and anticancer drugs are treatment options, but have had little influence on the outcome. Diagnosis is usually so late that none of these is used. Survival: Only 3% of patients live more than 5 years after diagnosis. Uterus (Cervix) Cancer Incidence: An estimated 15,000 invasive and 55,000 carcinoma in situ cases will be diagnosed in 1994. The rate of invasive cervical cancer has decreased steadily over the last several decades, but has increased in recent years in women under 50. Cervical carcinoma in situ, a precancerous condition, is now more frequent than invasive cancer, especially in women under 50. Mortality: An estimated 4,600 deaths from cervical cancer in 1994. The mortality rate is more than twice as high for black women as for white women. Signs and Symptoms: Abnormal uterine bleeding or spotting; abnormal vaginal discharge. Pain and systemic symptoms are late manifestations of the disease. Risk factors: Early age at first intercourse, multiple sex partners, cigarette smoking, and infection with certain types of human papillomavirus. Early Detection: The Pap test is a simple procedure that can be performed at appropriate intervals by health care professionals as part of a pelvic examination. A small sample of cells is swabbed from the cervix, transferred to a slide, and examined under a microscope. This test should be performed annually with a pelvic examination in women who are, or have been, sexually active or who have reached age 18 years. After three or more consecutive annual examinations with normal findings, the Pap test 12 CANCER FACTS A FIGURES 1994 SL 107300 Percentage f P pulati n (Probability) Developing Invasive Cancers at Certain Ages 1 Birth to 39 40 to 59 60 to 79 All sites Male Female 1.68 (1 in 60) 1.91 (1 in 52) 7.51 (1 in 13) 9.29 (1 in 11) 32.27 (1 in 3) 23.06 (1 in 4) Breast Female 0.45 (1 in 222) 3.78 (1 in 26) 6.78 (1 in 15) Colon & rectum Male Female 0.06 (1 in 1,667) 0.05 (1 in 2,000) 0.91 (1 in 110) 0.73 (1 in 137) 4.45 (1 in 22) 3.34 (1 in 30) Prostote Male Less than 1 in 10,000 0.78 (1 in 128) 10.71 (1 in 9) lung Male Female 0.04 (1 m 2,500) 0.03 (1 in 3,333) 1.60 (1 in 63) 1.07 (1 in 93) 6.69 (1 in 15) 3.49 (1 in 29) Ever (Birth to Death) 42.52 (1 in 2) 38.88 (1 in 3) 12.20 (1 in 8) 6.12 (1 in 16) 5.96 (1 in 17) 13.05 (1 in 8) 8.43 (1 in 12) 5.02 (1 in 20) Note: This chart shows the risks of being diagnosed with the most common cancers over certain age intervals. These risks are calculated for persons free of the specified cancer ot the beginning of the age interval. Risk estimates do not assume all persons live to the end of the age interval or to any fixed age. Risk estimates are presented to give an approximate measure of the burden of cancer to society. Measures are based on population level rates and do not take into account individual behaviors and risk factors. For example, lung cancer is rare among nonsmokers or persons not heavily exposed to environmental tobacco smoke, so the risk for a nonsmoking man getting lung cancer in his lifetime is much lower than 8.4%, and it is much higher for a smoker. It is clear that the risk of developing cancer increases with oge. For prostate cancer, the risk before age 60 is very low, but between age 60 and 80,1 in 9 men will be diognosed with prostate cancer. Source of data: Applied Research Branch, National Cancer Institute Available on reproduction sheet (5005.94) may be performed less frequently at the discretion of the physician. Treatment: Cervix cancers generally are treated by surgery or radiation, or by a combination of the two. In precancerous (in situ) stages, changes in the cervix may be treated by cryotherapy (the destruction of cells by extreme cold), by electrocoagulation (the destruction of tissue through intense heat by electric current), or by local surgery. Survival: The 5-year survival rate for cervical cancer patients is 67%. For women diagnosed with localized disease the survival rate is 90%. Uterus (Endometrial) Cancer Incidence: An estimated 31,000 cases of cancer of the corpus (body) of the uterus, usually of the endometrium (lining). Endometrial cancer is most frequently diagnosed in women over age 50. Mortality: An estimated 5,900 deaths in 1994. Signs and Symptoms: Abnormal uterine staining or bleeding, especially postmenopausal. Pain and weight loss occur late in the disease. Risk Factors: Early menarche, late menopause, history of infertility, failure to ovulate, tamoxifen or unopposed estrogen therapy, obesity. During menopause, the level of hormones (estrogens) normally produced by the ovaries declines. This causes symptoms such as "hot flashes" or painful sexual inter course due to thinning of the vaginal lining. To control these symptoms, estrogen replacement therapy may be given to women during and after menopause. This therapy may increase the risk of endometrial cancer, therefore, the benefits and risks ofsuch treatment should be discussed by the woman and her physician. Early Detection: The Pap test, highly effective in detecting early cancer of the uterine cervix, is only partially effective in detecting endometrial cancer. Women 40 and over should have an annual pelvic exam by a health professional. Women at high risk of developing endometrial cancer should have an endometrial tissue sample evaluated at menopause. Treatment: Uterine cancers are usually treated with surgery, radiation, hormones, and/or chemotherapy depending on the stage of disease. Survival: The 5-year survival rate for endometrial cancer is 83% overall, 94% if discovered at an early stage, and 69% if diagnosed in a regional stage. Cancer in Children Incidence: An estimated 8,200 new cases in 1994; as a childhood disease, cancer is rare. Common sites include the blood and bone marrow, bone, lymph nodes, brain, nervous system, kidneys, and soft tissues. Mortality: An estimated 1,600 deaths in 1994, about onethird of them from leukemia. Despite its rarity, cancer is the chief cause of death by disease in children between the ages of 1 and 14. Mortality rates have declined 60% since 1950. Early Detection: Cancers in children often are difficult to recognize. Parents should see that their children have regular medical checkups and should be alert to any unusual symptoms that persist. These include: an unusual mass or swelling; unexplained paleness and loss of energy; sudden tendency to bruise; a persistent, localized pain or limping; prolonged, unexplained fever or illness; frequent headaches, often with vomiting; sudden eye or vision SL 107301 13 CANCER FACTS & FIGURES 1994 changes; and excessive, rapid weight loss. Some of the main childhood cancers are: Leukemia, below. Osteogenic sarcoma and Ewing's sarcoma are bone cancers. These may cause no pain at first, and swelling in the area of the tumor is often the first sign. Neuroblastoma can appear anywhere but usually in the abdomen, where a swelling occurs. Rhabdomyosarcoma, the most common soft tissue sarcoma, can occur in the head and neck area, genito urinary area, trunk, and extremities. Brain cancers in early stages may cause headaches, blurred or double vision, dizziness, difficulty in walking or handling objects, and nausea. Lymphomas and Hodgkin's disease are cancers that involve the lymph nodes, but also may invade bone marrow and other organs. They may cause swelling of lymph nodes in the neck, armpit, or groin. Other symptoms may include general weakness and fever. Retinoblastoma, an eye cancer, usually occurs in children under age four. When detected early, cure is possible with appropriate treatment. Wilms' tumor, a kidney cancer, may be recognized by a swelling or lump in the abdomen. Treatment: Childhood cancers can be treated by a combination of therapies. Treatment is coordinated by a team of experts including oncologic physicians, pediatric nurses, social workers, psychologists, and others who assist children and their families. Survival: Five-year survival rates vary considerably, depending on the site: all sites, 68%; bone cancer, 58%; neuroblastoma, 57%; brain and central nervous system, 60%; Wilms' tumor (kidney), 88%; Hodgkin's disease, 88%; and acute lymphocytic leukemia, 72%. Leukemia Incidence: An estimated 28,600 new cases in 1994, approximately evenly divided into acute leukemia and chronic leukemia. Although often thought of as primar ily a childhood disease, leukemia will strike many more adults (26,000 this year) than children (2,600 this year). Acute lymphocytic leukemia accounts for approximately 2,000 of the cases of leukemia among children. In adults, the most common types are acute granulocytic (approxi mately 7,000 cases) and chronic lymphocytic (approxi mately 8,500 cases). Mortality: An estimated 19,100 deaths in 1994. Signs and Symptoms: Fatigue, paleness, weight loss, repeated infections, bruising easily, and nosebleeds or other hemorrhages. In children, these signs can appear suddenly. Chronic leukemia can progress slowly and with few symptoms. Risk Factors: Leukemia strikes both sexes and all ages. Causes of most cases are unknown. Persons with Down syndrome and certain other genetic abnormalities have higher than normal incidence of leukemia. It has also been linked to excessive exposure to ionizing radiation and ta^fc certain chemicals such as benzene, a commercially usea^r toxic liquid that is also present in lead-free gasoline. Certain forms of leukemia and lymphoma are caused by a retrovirus, HTLV-I (human T-cell leukemia/lymphoma virus-I). Early Detection: Because symptoms often resemble those of other, less serious conditions, leukemia can be difficult to diagnose early. When a physician does suspect leukemia, diagnosis can be made using blood tests and biopsy of the bone marrow. Treatment: Chemotherapy is the most effective method of treating leukemia. Various anticancer drugs are used, either in combinations or as single agents. Transfusions of blood components and antibiotics are used as supportive treatments. To illuminate hidden cells, therapy of the central nervous system has become standard treatment, especially in acute lymphocytic leukemia. Under appro priate conditions, bone marrow transplantation may be useful in the treatment of certain leukemias. Survival: The 5-year survival rate for patients with leukemia is 38%, due partly to very poor survival of patients with some types of leukemia such as acute granulocytic. Over the last 30 years, however, there has been a dramatic improvement in survival of patients with acute lymphocytic leukemia; from a 5-year survival rate of 4% for people diagnosed in the early 1960s to 28% in the early 1970s to 52% in the mid-1980s. In children, the improvement has been from 4% to 72%. Lymphoma Incidence: An estimated 52,900 new cases in 1994, including 7,900 cases of Hodgkin's disease and 45,000 non-Hodgkin's lymphoma. Since the early 1970s, incidence rates for non-Hodgkin's lymphoma have increased over 65%. Incidence of Hodgkin's disease has declined over the same time period, especially among the elderly. Mortality: An estimated 22,750 deaths in 1994 (nonHodgkin's lymphoma, 21,200; Hodgkin's disease, 1,550). Signs and Symptoms: Hodgkin's disease: enlarged lymph nodes, itching, fever, night sweats, and weight loss. Fever can come and go in periods of several days or weeks. Non-Hodgkin's lymphoma: enlarged lymph nodes, anemia, weight loss, and fever. Risk Factors: Risk factors are largely unknown but in part involve reduced immune function and exposure to certain infectious agents. Persons with organ transplants are at higher risk due to altered immune function. Human immunodeficiency virus (HIV) and human T-cell leukemia/ lymphoma virus-I (HTLV-I) are associated with increased risk of non-Hodgkin's lymphoma. Burkitt's lymphoma in SL 107302 14 CANCER FACTS & FIGURES 1994 Africa is partly caused by the Epstein-Barr herpes virus. Other possible risk factors include exposures to herbicides, industrial solvents, and vinyl chloride. Treatment: Hodgkin's disease: chemotherapy and radio therapy are useful for most patients. Non-Hodgkin's lymphoma: early stage, localized lymph node disease can be treated with radiotherapy. Patients with later stage disease often benefit from the addition of chemotherapy. New programs using highly specific monoclonal antibodies directed at lymphoma cells, and improved techniques in bone marrow preservation, are under investigation in selected patients who relapse after standard treatment. Survival: Survival rates vary widely by cell type and stage of disease. The overall 5-year survival rate for Hodgkin's disease is 78%. The overall 5-year survival for nonHodgkin's lymphoma has steadily improved, and in the past 30 years has increased from 31% to 52%. Skin Cancer Incidence: Over 700,000 cases a year of highly curable basal cell or squamous cell cancers. They are more common among individuals with lightly pigmented skin. The most serious skin cancer is melanoma, which will be diagnosed in about 32,000 persons in 1994. Since 1973, the incidence rate ofmelanoma has increased about 4% per year. Incidence rates are over ten times higher among whites than blacks. An additional 10,000 invasive nonmelanoma skin cancers will occur in 1994, mostly sarcomas, including Kaposi's sarcoma. Mortality: An estimated 9,200 deaths this year, 6,900 from malignant melanoma and 2,300 due to other skin cancers. Signs and Symptoms: Any unusual skin condition, especially a change in the size or color of a mole or other darkly pigmented growth or spot. Scaliness, oozing, bleeding, or change in the appearance of a bump or nodule, the spread of pigmentation beyond its border, a change in sensation, itchiness, tenderness, or pain. Risk Factors: Excessive exposure to ultraviolet radiation; fair complexion; occupational exposure to coal tar, pitch, creosote, arsenic compounds, or radium. Prevention: The sun's ultraviolet rays are strongest between 10 a.m. and 3 p.m. Exposure at these times should be avoided, and protective clothing should be worn. Sunscreens should be used. These come in various strengths, ranging from those facilitating gradual tanning to those that allow practically no tanning. Because of the possible link between severe sunburns in childhood and greatly increased risk of melanoma in later life, children, in particular, should be protected from the sun. Early Detection: Early detection is critical. Recognition of changes in skin growths or the appearance of new growths is the best way to find early skin cancer. Adults should practice skin self-examination once a month, and suspicious lesions should be evaluated promptly by a physician. Basal and squamous cell skin cancers often take the form of a pale, waxlike, pearly nodule, or a red, scaly, sharply outlined patch. A sudden or progressive change in a mole's appearance should be checked by a physician. Melanomas often start as small, mole-like growths that increase in size, change color, become ulcerated, and bleed easily from a slight injury. A simple ABCD rule outlines the warning signals of melanoma: A is for asymmetry. One half of the mole does not match the other half. B is for border irregularity. The edges are ragged, notched, or blurred. C is for color. The pigmentation is not uni form. D is for diameter greater than 6 millimeters. Any sudden or progressive increase in size should be of special concern. Treatment: There are four methods of treatment: surgery (used in 90% of cases), radiation therapy, electrodessication (tissue destruction by heat), or cryosurgery (tissue destruction by freezing) for early skin cancer. For malignant melanoma, the primary growth must be adequately excised, and it may be necessary to remove nearby lymph nodes. Removal and microscopic examination of all suspicious moles is essential. Advanced cases of melanoma are treated according to the characteristics of the case. Survival: For basal cell or squamous cell cancers, cure is highly likely if detected and treated early. Malignant melanoma can spread to other parts of the body quickly; however, when detected in its earliest stages, and with proper treatment, it is highly curable. The overall 5-yearsurvival rate for patients with malignant melanoma is 84%. The 5-year survival rate for localized malignant melanoma is 92%; survival rates for regional and distant disease are 55% and 14%, respectively. About 82% of melanomas are diagnosed in a local stage. Ovary Cancer Incidence: An estimated 24,000 new cases in the United States in 1994. It accounts for 4% of all cancers among women. Mortality: An estimated 13,600 deaths in 1994. Although ovarian cancer ranks second in incidence among gyne cological cancers, it causes more deaths than any other cancer of the female reproductive system. Signs and Symptoms: Ovarian cancer is often "silent," showing no obvious signs or symptoms until late in its development. The most common sign is enlargement of the abdomen, which is caused by the accumulation of fluid. Rarely will there be abnormal vaginal bleeding. In women over 40, vague digestive disturbances (stomach discomfort, gas, distention) that persist and cannot be explained by any other cause may indicate the need for a thorough evaluation for ovarian cancer. SL 107303 15 CANCER FACTS & FIGURES 1994 Five-Year Relative Survival Rates by Stage at Diagnosis* Site Ail Stages % locals Oral Colon-rectum Pancreas Lung Melanoma Female breast Cervix uteri Corpus uteri Ovary Prostate Bladder Kidney 53 78 58 89 38 13 46 84 92 79 93 67 90 83 94 39 88 77 92 79 91 55 86 'Adjusted for normal life expectancy. This chart based on cases diagnosed in 1983-87, followed through 1990. Source: Concer Statistics Branch, Notional Cancer Institute Regional % 42 58 4 13 55 72 52 69 36 82 46 57 Distant % 19 6 2 1 14 18 13 27 17 28 9 10 j i Available an reproduction sheet (5005.94) Risk Factors: Risk for ovarian cancer increases with age. Women who have never had children are more likely to develop ovarian cancer than those who have. Increased number of pregnancies and the use of oral contraceptives, appear to be protective against ovarian cancer. Women who have had breast cancer or have a family history of ovarian cancer are at increased risk. Gertain rare genetic disorders are associated with increased risk. With the exception of Japan, the highest incidence rates are reported from the more industrialized countries. Early Detection: Periodic, thorough pelvic examinations are important The Pap test, useful in detecting cervical cancer, does not reveal ovarian cancer. Women over the age of 40 should have a cancer-related checkup every year. Treatment: Surgery, radiation therapy, and drug therapy are treatment options. Surgery usually includes the removal of one or both ovaries (oophorectomy), the uterus (hys terectomy), and the fallopian tubes (salpingectomy). In some very early tumors, only the involved ovary will be removed, especially in young women. In advanced disease, an attempt is made to remove all intraabdominal disease, to enhance the effect of chemotherapy. Survival: Overall, the 5-year survival rate for ovarian cancer is 41%. If diagnosed and treated early, the relative survival rate is 88%; however, only about 23% of all cases are detected at the localized stage. Survival rates for women with regional and distant disease are 36% and 17%, respectively. Bladder Cancer Incidence: An estimated 51,200 new cases in 1994; 38,000 in men, 13,200 in women. Overall, the incidence rate of bladder cancer is four times greater among men than among women, and is higher in whites than in blacks. Mortality: An estimated 10,600 deaths in 1994. Signs and Symptoms: Blood in the urine. Usually associated with increased frequency of urination. Risk Factors: Smoking is the greatest risk factor in bladder cancer, with smokers experiencing twice the risk of nonsmokers. Smoking is estimated to be responsible for approximately 47% of the bladder cancer deaths amongj men and 37% among women. People living in urban area? and workers exposed to dye, rubber, or leather also are at higher risk. Early Detection: Bladder cancer is diagnosed by exam ination of the bladder wall with a cystoscope, a slender tube fitted with a lens and light that can be inserted into the tract through the urethra. Treatment: Surgery, alone or in combination with other treatments is used in over 90% of cases. Preoperative chemotherapy alone or with radiation before cystectomy (bladder removal) has improved some treatment results. Survival: When detected at an early stage, the 5-year survival rate for bladder cancer is 91%. For regional and distant disease, the survival rates are 46% and 9%, respectively. Oral Cancer Incidence: An estimated 29,600 new cases in 1994. Incidence is more than twice as high in men as in women, and is most frequent in men over age 40. Mortality: An estimated 7,925 deaths in 1994. Signs and Symptoms: A sore that bleeds easily and doesn't heal; a lump or thickening; a red or white patch that per sists. Difficulty in chewing, swallowing, or moving tongue or jaws are often late changes. 16 CANCER FACTS & FIGURES 1994 10134 Trends in Cancer Survival, by Race Cases Diagnosed in 1960-63,1970-73,1974-76,1977-79,1983-89 White Black Relative 5-Year Survival % Relative 5-Year Survival % Site 1960-63' 1970-73' 1974-76' 1977-79' 1983-89' 1960-63' 1970-73' 1974-76' 1977-79' 1983-89' All sites 39 43 50 51 55* 27 31 39 39 39 Oral cavity & pharynx 45 43 55 54 54 --wv 36 36 33 Esophagus 4 4 5 6 10* 1 44 3 7* Stomach 11 13 14 16 17* 8 13 16 15 18 Colon 43 49 50 53 60* 34 37 46 48 49* Rectum 38 45 49 50 58* 27 30 42 38 45 Liver 2 3 4 3 6* -- 165 Pancreas 1 2 3 2 3* 1 2 2 4 5* Larynx 53 62 66 68 68 -- 59------ 55 54 Lung & bronchus 8 10 12 14 13* 5 7 11 11 11 Melanoma of skin 60 68 80 82 84* 69f 52* 72f Female breast 63 68 75 75 81* 46 51 63 63 64 Cervix uteri 58 64 69 69 69 47 61 63 62 57* Corpus uteri 73 81 89 86 85* 31 44 60 58 56 Ovary 32 36 36 38 40* 32 32 41 40 40 Prostate 50 63 68 72 79* 35 55 58 62 64* Testis 63 72 79 88 93* -- -- 76f ___ 84f Urinary bladder 53 61 74 76 80* 24 36 48 55 61* Kidney & renal pelvis 37 46 52 51 56* 38 44 49 52 51 Brain & nervous system 18 20 22 24 26* 19 19 27 28 31 Thyroid gland 83 86 92 92 94* __ 87 92 92 Hodgkin's disease 40 67 72 73 79* Non-Hodgkin's 69 73 74 lymphoma 31 41 48 48 52* Multiple 48 50 44 myeloma 12 19 24 25 27* 27 34 29 Leukemia 14 22 35 37 39* -- -- 31 30 30 Source: Cancer Statistics Branch, National Cancer Institute 'Rates are based on End Results Group data from a senes of hospital registries and one population-based registry. 'Rates are from the SEER Program. They are based on data from population-based registries in Connecticut, New Mexico, Utah, Iowa, Hawaii, Atlanta, Detroit, Seattle-Puget Sound, and San Francisco-Oaldand. Rotes are based on follow-up of patients through 1990. The difference in rates between 1974-76 and 1983-89 is statistically significant (p < 0.05). fThe standard error of the survival rote is between 5 and 10 percentage points. tThe standard error of the survival rate is greater than 10 percentage points. --Valid survival rote could not be calculated. Risk Factors: Cigarette, cigar, or pipe smoking; use of smokeless tobacco; excess use of alcohol. Early Detection: Cancer can affect any part of the oral cavity, including the lip, tongue, mouth, and throat. Dentists and primary care physicians have the opportunity, during regular checkups, to see abnormal tissue changes and to detect cancer at an early, curable stage. TVeatment: Principal methods are radiation therapy and surgery. Chemotherapy is being studied as an adjunct to surgery in advanced disease. Survival: Five-year survival rates vary substantially, depending on the site. Rates range from 2596 for cancer of the hypopharynx to 90% for lip cancer. Overall, 5-year survival for oral cancer patients is about 52%, SL 107305 17 CANCER FACTS & FIGURES 1994 * Cancer in Minorities In 1994, about 1,208,000 cancers will be diagnosed in the United States. About 120,000 of these cancers will be among black Americans and 35,000 among other minority Americans. Cancer incidence and mortality rates are generally higher for black Americans than for whites. In 1990, the incidence rates were 423 per 100,000 for blacks and 393 for whites, about a 6% difference. In 1990, the mortality rates were 230 for blacks and 170 for whites. Cancer sites for which blacks have significantly higher incidence and mortality rates include esophagus, uterine cervix, stomach, liver, prostate, larynx, and multiple myeloma. Rates for esophageal cancer are over three times higher among blacks than whites. The 5-year survival rate for cancer in blacks diagnosed from 1983 through 1989 was about 39% compared with 55% for whites. A considerable part of this difference in survival can be attributed to late diagnosis. Many cancers are more frequently diagnosed in a localized stage among whites than among blacks. Most of these sites represent cancers for which screening tests are available or which present symptoms early in the disease process. Early detection and timely treatment can increase survival. Incidence and mortality rates for other minority groups such as Hispanics are often lower than those for white or black Americans. Because cancer risk is strongly associated with lifestyle and behavior, differences in ethnic and cultural groups can provide clues to factors involved in the development of cancer such as dietary patterns, alcohol use, and sexual and reproductive behaviors involved in the development of cancer. Cultural values and belief systems can affect attitudes about seeking medical care or following screening guidelines (see p. 21). Socioeco nomic factors such as lack of health insurance or transportation can impede access to care, and lead to late diagnosis and poor survival. Number of Cancer Deaths for Black, American Indian, Chinese, Japanese, and Hispanic Persons, United States, 1990 Cancer She Black Males Black Females American Indian Chinese Japanese Hispanic* All sites Oral cavity Esophagus Stomach Colon & rectum Liver & other biliary Pancreas Lung (male) Lung (female) Melanoma of skin Breast (female) Cervix uteri Other uterus Ovary Prostate Bladder Kidney Brain & CNSf Lymphoma Leukemia Multiple myeloma 31,995 1,000 1,433 1,341 2,898 757 1,442 10,632 -- 51 -- -- -- -- 5,181 466 563 372 747 854 745 25,082 311 541 917 3,169 615 1,581 -- 4,512 55 4,659 972 899 975 -- 381 382 319 573 737 708 1,275 23 19 67 117 68 52 205 117 9 89 47 12 34 59 9 39 21 50 52 39 1,527 60 45 117 166 168 65 238 145 2 88 22 15 29 42 21 12 35 47 47 15 1,122 23 32 132 168 66 77 148 75 3 79 12 14 22 56 12 14 14 42 27 6 14,003 232 233 811 1,414 769 795 1,824 787 89 1,246 296 168 385 728 210 355 376 688 735 273 `Persons classified as of Hispanic origin on death certificates may be of any race. Hispanic origin reporting, however, may be incomplete on death certificates in some states. These numbers are believed to include over 90% of cancer deaths in Hispanics in 1990. fCNS = Central nervous system. Available on reproduction sheet (5005.94) 18 f A N C F R FACTS A FIGURES 1994 SL 107306 Prevention Smoking Cigarette smoking is responsible for 90% of lung cancer among men and 79% among women--about 87% overall. Smoking accounts for about 30% of all cancer deaths. Those who smoke two or more packs of cigarettes a day have lung cancer mortality rates 12 to 25 times greater than nonsmokers. (See Tobacco Use.) Nutrition and Diet Research is showing the important role nutrition plays in preventing cancer. Evidence indicates that people may reduce their cancer risk by observing these nutrition guidelines: 1. Maintain a desirable weight. Individuals 40% or more overweight increase their risk of colon, breast, prostate, gallbladder, ovary, and uterus cancers. Physicians can recommend a suitable diet and exercise regimen to help maintain appropriate weight and body fitness. 2. Eat a varied diet A varied diet eaten in moderation offers the best hope for lowering the risk of cancer. 3. Include a variety of vegetables and fruits in the daily diet. Studies have shown that daily consumption of vegetables and fresh fruits is associated with a decreased risk of lung, prostate, bladder, esophagus, colorectal, and stomach cancers. 4. Eat more high-fiber foods such as whole grain cereals, breads, and pasta; and vegetables and fruits. High-fiber diets are a healthy substitute for fatty foods and may reduce the risk of colon cancer. 5. Cut down on total hit intake. A diet high in fat may be a factor in the development of certain cancers, particularly breast, colon, and prostate. 6. Limit consumption of alcohol, if you drink at all. Heavy drinking, especially when accompanied by cigarette smoking or smokeless tobacco use, increases risk of cancers of the mouth, larynx, throat, esophagus, and liver. 7. limit consumption of salt-cured, smoked, and nitritecured foods. In areas of the world where salt-cured and smoked foods are eaten frequently, there is higher incidence of cancer of the esophagus and stomach. Modern methods of food processing and preserving appear to avoid the cancer-causing byproducts associated with older methods of food treatment Sunlight Almost all of the more than 700,000 cases of basal and squamous cell skin cancer diagnosed each year in the US are sun-related (ultraviolet radiation). Epidemiologic evidence shows that sun exposure is a major factor in the development of melanoma and that incidence increases for those living near the equator. (See Selected Cancers: Skin Cancer.) Alcohol Oral cancer and cancers of the larynx, throat, esophagus, and liver occur more frequently among heavy drinkers of alcohol especially when accompanied by smoking cigarettes or chewing tobacco. (See Selected Cancers: Oral Cancer.) Smokeless Tobacco Use of chewing tobacco or snuff increases risk of cancer of the mouth, larynx, throat, and esophagus and is a highly addictive habit. (See Selected Cancers: Oral Cancer.) Estrogen Estrogen treatment to control menopausal symptoms can increase risk of endometrial cancer. However, including progesterone in estrogen replacement therapy helps to minimize this risk. Consultation with a physician will help each woman to assess personal risks and benefits. Continued research is needed in the area of estrogen use and breast cancer. (See Selected Cancers: Uterus and Cervix Cancer). Occupational Hazards Exposure to several different industrial agents (nickel, chromate, asbestos, vinyl chloride, etc.) increases risk of various cancers. Risk of lung cancer from asbestos is greatly increased when combined with cigarette smoking. (See Environmental Cancer Risks.) Ionizing Radiation Excessive exposure to ionizing radiation can increase cancer risk. Most medical and dental x-rays are adjusted to deliver the lowest dose possible without sacrificing image quality. Excessive radon exposure in homes may increase risk of lung cancer, especially in cigarette smokers. If levels are found to be too high, remedial actions should be taken. SL 107307 19 CANCER FACTS 8. FIGURES 1994 Environmental Cancer Risks The environmental causes of cancer include exposures in the community or workplace settings, as well as exposures determined by individual lifestyle choices (smoking, diet, medications, etc.). The degree of cancer hazard posed by such risks depends on the concentration or intensity of the carcinogen in the environment and the exposure dose a person receives. These factors in combination create a range of risk. For example, in situations where high levels of carcinogen are present and where exposures are extensive, significant hazards may exist, but where concentrations are low and exposures limited, hazards are often negligible. Risk Assessment To protect people against unsafe exposures, risks should be assessed so that appropriate environmental standards can be set. Risk assessment is a two-step process: identifying the toxic properties of potential oncogenic hazards and measuring the extent of human exposure. The first step, hazard identification, evaluates the chemical or physical nature of hazards and their onco genicity in observed clinical and epidemiologic studies and in laboratory tests using animals or cell systems. Special attention is given to any evidence suggesting that cancer risk may increase with dose (dose-response relationships). The second step, exposure measurement, determines the levels of hazards in the environment (air, water, food, etc.) and the extent to which people are actually exposed (how much they eat of a particular food, use a particular water source, etc.). Knowledge of how the body absorbs, metab olizes, and excretes chemicals or is exposed to radiation sources is essential to determine accurately the actual carcinogenic dose delivered to humans. Unfortunately, evidence of risk for most potential car cinogens usually rests on the results of high-dose animal experiments or on human observations where high-dose exposures have occurred. To use such information in setting human safety standards, scientists must extrapolate from animals to humans and from high-dose to low-dose conditions. Both extrapolations involve much uncertainty; therefore conservative assumptions are used so that risk assessment will err on the side of safety. For cancer safety standards, only increased risks ofone case or less per million persons over a lifetime are usually accepted. Safety standards developed in this way for chemical or radiation exposures are the basis for federal regulatory activities at the Food and Drug Administration, the Environmental Protection Agency, and the Occupational Safety and Health Administration. The application of laws and procedures by which standards are implemented and risks are controlled is called risk management Chemicals and Radiation Not all chemicals or all forms of radiation cause cancer. Only a limited number of chemicals (for example, benzene, asbestos, vinyl chloride, arsenic, aflatoxins) show definite^ evidence of human carcinogenicity or are probable human! carcinogens based on animal experiments (for example, chloroform, dichlorodiphenyltrichloroethane [DDT], for maldehyde, polychlorinated biphenyls [PCBs], polycyclic aromatic hydrocarbons). The only forms of radiation proven to cause human cancer are ionizing radiation (for example, x-rays, radon, cosmic rays) and ultraviolet radiation (principally UV-B radiation). Unproven Risks Public concern about environmental cancer risks often focuses on risks for which no carcinogenicity has been proven or on situations where known carcinogen exposures are at such low levels that risks are negligible. For example: 1. Non-ionizing radiation. Electromagnetic radiation at frequencies below ionizing and ultraviolet levels has not been shown to cause cancer. While some epidemiologic studies suggest associations with cancer, others do not, and experimental studies have not yielded reproducible evidence of carcinogenic mechanisms. Low frequency radiation includes radiowaves, microwaves, and radar, as well as power frequency radiation arising from the electric and magnetic Helds associated with electric currents (often called ELF or extremely low frequency radiation). 2. Pesticides. Many kinds of pesticides (insecticides, herbicides, etc.) are widely used in producing and marketing our food supply. While some of these chemicals cause cancer at high doses in experimental animals, the very low concentrations found in some foods are generally within established safety levels. Environmental pollution by slowly degraded pesticides such as DDT, a result of past agricultural practices, can lead to food chain bioaccumulation and to persistent residues in body fat. Such residues have been suggested as a possible risk factor for breast cancer, concentrations in tissue are low, however, and the evidence is not conclusive. Continued research regarding pesticide use is essential for maximum food safety, improved food production through alternative pest control methods, and reduced pollution of the environment. At the same time, banning any man-made chemicals with carcinogenic potential (as required for processed foods under the 1958 Delaney Amendment of the Food and Drug Act) is unrealistic, given the very low concentrations involved and the value of pesticides in sustaining our food supply. Scientists and consumer groups stress the important health benefits of a diet which includes many fruits and vegetables in contrast to the minimal risks associated with pesticide residues. 3. Toxic wastes. Toxic wastes in dump sites can threaten 20 CANCER FACTS & FIGURES 1994 l0738 SI* human health through air, water, and soil pollution. Although many toxic chemicals contained in such wastes can be carcinogenic at high doses, most community exposures appear to involve very low or negligible dose levels. Clean-up of existing dump sites and close control of toxic materials in the future is essential to ensure healthy living conditions in our industrialized society. 4. Nuclear power plants. Ionizing radiation emissions from nuclear facilities are closely controlled and involve negligible levels of exposure for communities near such plants. Although reports about cancer case clusters in such communities have raised public concern, studies show that clusters do not occur more often near nuclear plants than they do by chance elsewhere in the population. Early Detection Each person should be aware of the cancer early detection guidelines that pertain to them. To understand the role of the cancer-related checkup, the ACS adopted the following definitions. Screening is the search for disease in persons without symptoms. Once a person has had a positive screening test, or once signs or symptoms have been identified, further tests are considered diagnostic. Detection is the discovery of an abnormality in a person with or without symptoms. Diagnostic evaluation is the evaluation of a patient who has signs or symptoms suggestive of disease to determine the actual existence and nature of the disease. The following recommendations are for the early detection of cancer in asymptomatic persons on an individual basis. The recommendations are intended to help individual providers and their patients determine the most appropriate early cancer detection tests to meet their individual needs. Guidelines for the early detection of cancer in people without symptoms are recommended by the American Cancer Society as follows: A cancer-related checkup by a physician every three years for persons aged 20-39 and annually for those aged 40 and over. Some persons at particular risk for certain cancers may need tests more often and should discuss this with their doctor. The checkup should always include health counseling (how to quit smoking, etc.) and exams for cancer of the breast, uterus, cervix, colon, rectum, prostate, mouth, skin, testes, thyroid, and lymph nodes. In 1989 and 1990, Congress passed legislation mandating Medicare coverage for cervical and breast cancer screening, respectively. For women over age 65, Medicare currently covers a Pap smear once every three years and a mam mogram every two years. Although this policy does not strictly conform to ACS screening recommendations, it does begin to address the benefits of early detection. SL 107309 Breast The American Cancer Society recommends that screening mammography begin by age 40. Women aged 4049 should have a mammogram every 1-2 years, depending on physical and mammographic findings. Women aged 50 and older should have mammograms yearly. The ACS recommends the monthly practice of breast self-exam (BSE) by women 20 years and older as a routine good health habit. Examination of the breast by a health care professional should be done every three years from ages 2040 and then every year. Colon and Rectum The American Cancer Society recommends three tests for the early detection of colon and rectum cancer in people without symptoms. A digital rectal examination by a physician during an office visit should be performed every year after the age of 40; the stool blood test is recommended every year after age 50; and sigmoidoscopy, preferably flex ible, should be performed every 3 to 5 years. Uterus For cervical cancer, women who are or have been sexually active, or have reached age 18, should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of her physician. Women at high-risk for endometrial cancer (those who have a history of infertility, obesity, failure to ovulate, abnormal uterine bleeding, or unopposed estrogen or tamoxifen therapy) should have an endometrial tissue sample taken at menopause and thereafter at the discretion of the physician. Prostate Men who have reached 50 years of age and older should have a digital rectal examination (DRE) annually. Annual prostate-specific antigen blood testing should be performed on men age 50 and older. 21 CANCER FACTS & FIGURES 1994 ft Tobacco Use Smoking is the most preventable cause of death in our society. Tobacco use is responsible for nearly one in five deaths in the United States, Based upon data from the American Cancer Society's Cancer Prevention Study II, it is estimated that smoking is related to about 419,000 US deaths each year. Although the number of cardiovas cular deaths are declining, smoking-related cancer deaths continue to rise. According to the World Health Orga nization approximately 3 million people die worldwide each year as a result of smoking. Smokers lose an average of 15 years of life. The risks of dying of lung cancer are 22 times higher for male smokers and 12 times higher for female smokers than for people who have never smoked. In addition to being responsible for 87% of lung cancers, smoking is also associated with cancers of the mouth, pharynx, larynx, esophagus, pancreas, uterine cervix, kidney, and bladder. Smoking accounts for 30% of all cancer deaths, is a major cause of heart disease, and is associated with conditions ranging from colds and gastric ulcers to chronic bronchitis, emphysema, and cerebrovascular disease. Trends in Smoking The National Health Interview Survey (NHIS) reports that cigarette smoking among adults aged 18 and over declined from 42% in 1965 to 25% in 1991. The NHIS data from 1974 to 1991 show: * Smoking among women decreased from 33% to 24%. Smoking among men dropped from 43% to 28%. Rates for college graduates declined from 28% to 14%. * Rates for persons without a high school education decreased slightly from 44% to 37%. Data from the 1991 NHIS indicate that the decline in cigarette smoking among adults has begun to level off. Between 1990 and 1991, smoking rates rose for the first time in nearly 20 years due to increased smoking among blacks and women. Contributing to this rise may be the grovyth in discount cigarette products and the recent surge in the tobacco industry's domestic advertising and pro motion expenditures. According to the 1989 Surgeon General's Report, decisions to quit or not to start through 1985 will postpone or prevent an additional 2 million smoking-related deaths between 1986 and the year 2000. Per capita cigarette consumption dropped 37% from 1973 to 1992 (4,148 to 2,640). This is the lowest per capita cigarette consumption since 1942. Profile ofSmokers In 1991, the number of current smokers in the US: 46 million. The prevalence of smoking is highest among people who live below poverty level: men 39%; women 29%. Smoking rates are highest in the age group 25-44. Approximately 50% of smokers start smoking regularh before age 18. More than 3,000 teenagers become regular smokers each day in the United States. According to the Centers for Disease Control and Prevention's 1991 Youth Risk Behavior Survey: 70% of all students in grades 9-12 reported ever trying cigarettes. About 13% of high school students reported frequent cigarette use. Cost of Tobacco The 1992 Surgeon General's Report estimates that the total lifetime excess medical care costs for smokers exceed those for nonsmokers by $501 billion. The US Congress Office of Technology Assessme^ estimates that cigarettes cost Americans $68 billiol annually in tobacco-related health care costs and lost productivity. The cost of treating smoking-related diseases and lost productivity amounts to $2.59 for each pack of cigarettes sold in the US. For every 10% increase in the price of tobacco products, it is estimated that tobacco consumption would decline 4%. Cigarette Exports US cigarette exports have increased due to aggressive marketing by tobacco companies and expanding foreign markets. A September 1993 tobacco report of the US Department of Agriculture estimates: US cigarette exports have increased about 275% since 1985. US cigarette exports to Japan have increased almost 800%, from 6.5 billion in 1985 to 56 billion in 1993. Exports to South Korea have grown from 1.3 billion in 1987 to 4 billion in 1993. Exports to the countries that formerly comprised the Soviet Union have increased from 4.6 billion in 1991 to 13.6 billion in 1993. US cigarette output from July 1992 to June 1993 was 702 billion. Even though domestic consumption has dropped, this recent increase in output is the result of 22 CANCER FACTS l FIGIIPFC iqo< SL 107310 foreign demand of US tobacco leaf and US manufacturers offering discounted cigarettes and lower prices on premium brands. Nicotine Addiction Tobacco smoke contains over 4,000 chemical compounds including at least 43 different carcinogenic substances. The 1988 Surgeon General's Report on Nicotine Addiction concluded: Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Nicotine is found in substantial amounts in tobacco. It is absorbed readily from tobacco smoke in the lungs and from smokeless tobacco in the mouth or nose and is rapidly distributed throughout the body. Smoking Cessation By 1991, almost 44 million Americans had quit smoking cigarettes, nearly half of all living adults who ever smoked. In September 1990, the Surgeon General outlined the benefits of smoking cessation: People who quit smoking, regardless of age, live longer than people who continue to smoke. Smokers who quit before age 50 have half the risk of dying in the next 15 years compared with those who continue to smoke. Quitting smoking substantially decreases the risk of lung, laryngeal, esophageal, oral, pancreatic, bladder, and cervical cancers. Benefits of cessation include risk reduction for other major diseases including coronary heart disease and cardiovascular disease. A 1989 Gallup Survey reported that the following people want to quit smoking: 57% of smokers 50 and older 67% of smokers aged 30-49 68% of smokers aged 18-29. Environmental Tobacco Smoke In December 1992, the Environmental Protection Agency concluded that widespread exposure to environmental tobacco smoke (ETS) presents "a serious and substantial" public health problem in the United States. Each year about 3,000 nonsmoking adults die of lung cancer as a result of breathing the smoke of other's cigarettes. The risk of dying of lung cancer is 30% higher for a nonsmoker living with a smoker compared with a nonsmoker living with a nonsmoker. It is estimated that ETS causes 35,000 to 40,000 excess heart disease deaths among people who are not current okers. ETS contains essentially all of the same carcinogens and toxic agents that are inhaled by the smoker. ETS can result in aggravated asthmatic conditions, impaired blood circulation, bronchitis, and pneumonia. ETS poses additional health hazards for unborn and young children. According to the 1988 NHIS, about 10 million children under the age of six are exposed to ETS by a household member. Children exposed to secondhand smoke have increased risks of respiratory illnesses and infections, impaired development of lung function, and middle ear infections. Infants born to women who smoked during pregnancy are more likely to die of Sudden Infant Death syndrome. Smokeless Tobacco There has been a resurgence in the use of all forms of smokeless tobacco--plug, leaf, and snuff--but the greatest cause for concern centers on the increased use of "dipping snuff." In this practice, tobacco that has been processed into a coarse, moist powder is placed between the cheek and gum, and nicotine, along with a number of carcinogens, is absorbed through the oral tissue. Dipping snuff is highly addictive, and exposes the body to levels of nicotine equal to those of cigarettes. In 1986, the US Surgeon General concluded that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence." Oral cancer occurs several times more frequently among snuff dippers compared with non-tobacco users. The excess risk of cancer of the cheek and gum may reach nearly fiftyfold among long-term snuff users. The use of smokeless tobacco is increasing among male adolescents and young male adults. According to the US Department of Agriculture, US output of moist snuff has risen 83% from about 30 million pounds in 1981 to an estimated 55 million pounds in 1993. About 5 million US adults use smokeless tobacco. The Centers for Disease Control and Prevention's 1991 Youth Risk Behavior Survey reported that 19% of male high school students used smokeless tobacco. Industrial Hazards Industrial workers are especially susceptible to lung diseases due to the combined effects of cigarette smoke and exposure to certain toxic industrial substances, such as fumes from rubber and chlorine, and dust from cotton and coal. Exposure to asbestos in combination with cigarette smoking increases an individual's lung cancer risk nearly 60 times. Smoking also enhances lung cancer risk in underground miners exposed to radon. 23 CANCER FACTS & FIGURES 1994 * The American Cancer Society In 1913, 10 physicians and five laymen founded the American Society for the Control of Cancer. Its stated purpose was to "disseminate knowledge concerning the symptoms, treatment, and prevention of cancer; to inves tigate conditions under which cancer is found; and to compile statistics in regard thereto." Later renamed the American Cancer Society, Inc., the organization now con sists ofover 2 million Americans working to conquer cancer. Organization: The American Cancer Society, Inc., consists of a National Society, 57 Divisions, and over 3,400 Units. The National Society: A 285-member Board of Directors provides representation from the 57 Divisions. The National Society is responsible for overall planning and coordination, providing technical help and materials to Divisions and Units, administering programs of research, medical grants and clinical fellowships, and performing public and professional education at the national level. The 57 Divisions: Located in all states plus five metropolitan areas, the District of Columbia, and Puerto Rico, the Divisions are governed by members of Divisional boards of directors. The Units: These are organized to cover the counties in the United States. There are thousands of community leaders who direct the Society's programs at this level. Descriptions of some of the Society's major programs follow. Research The American Cancer Society is the largest private source of cancer research funds in the United States, second only to the federal government's National Cancer Institute in total dollars spent. In fiscal year 1993, the Society invested approximately $100 million in research--slightly over 26% of its budget To date, the Society has invested more than $1.5 billion in cancer research. The research program consists of two components: extramural grants and awards, and intramural epidemiology research. The extramural program supports investigatorinitiated projects taking place in leading centers across the country. Applications for grants are subjected to a rigorous external peer review which ensures that only the highest quality applications receive funding. The success of the Society's research program is exemplified by the fact that 26 Nobel Prize winners received grant support from the Society early in their careers. Epidemiology The Society supports an active program of epidemiologic research at its National office. This program analyzes trends in cancer occurrence and has conducted three large pro spective studies of cancer risk in Americans over the past 40 years. The Hammond-Horn study demonstrated the effects of smoking on mortality and cancer risk in 188,000 men observed from 1952-1955. Cancer Prevention Study I, conducted from 1959 through 1972, encompassed 1 million men and women in 25 states and examined potential cancer risk factors related to the environment and to individual lifestyles. Cancer Prevention Study II (CPS II), was launched in 1982 and is still in progress, examining the habits and exposures of more than 1 million Americans. Causes of death among these people over subsequent years are being studied to learn how lifestyles and environmental factors affect the development of cancer. Over 77,000 volunteers enrolled the men and women in CPS II. These volunteer researchers distributed ques tionnaires to participants who were asked about their lifestyles. . Another questionnaire was sent in October 1992, tq 160,000 households participating in CPS II. This ques tionnaire seeks additional dietary information to gain more specific knowledge about how diet impacts disease. Public Education The Society's Public Education programs focus on tobacco control, the relationship between diet and cancer, comprehensive school health education and early detection. The programs are divided into two audiences: adult and youth. Adults are reached through the worksites, healthsites, and the community. Volunteers are recruited and trained both to promote and to deliver programs. Examples of adult education include Taking Control, which identifies 10 steps to a healthier lifestyle; Smart Move, a single-session stop-smoking program; SelfDefense, which explains how a person can work with a health care provider to become familiar with cancer tests and examinations; and Special Touch, which explains breast cancer and early detection techniques. The Society has joined with other health, education, and social service agencies to promote comprehensive school health education. The best way to ensure good cancer education in the schools, comprehensive school health 24 CANCER FACTS & FIGURES 1994 SL 1073H education is the means of delivering a planned health edu cation curricula from pre-school to grade 12. The Society's education programs emphasize the impor tance of developing good health habits. Beginning in pre school, students learn about the dangers of tobacco use with Starting Free: Good Air for Me. Other tobacco pre vention programs include: An Early Start to Good Health (grades K-3), and Health Myself (grades 7-9). Changing the Course curricula help elementary and secondary stu dents make good dietary choices that will reduce their risk of developing a number of diseases, including cancer. High school students can also learn in-depth about cancer through Right Choices. Professional Education The Society's Professional Education Department pro vides health care professionals with the latest information on developments in cancer prevention, early detection, and treatment through: National conferences and workshops (The Society is accredited by the Accreditation Council for Continuing Medical Education) Materials (videotapes, slide programs, audiotapes, textbooks, proceedings of conferences and workshops, and booklets on key issues are examples, in addition to two national journals for health care professionals) Clinical awards, professorships, and scholarships (Clinical Oncology Fellowships, Clinical Oncology Career Development Awards, Oncology Social Work Awards, Cancer Control Career Development Awards). Over the past 40 years, Clinical Fellowships and Junior Faculty Clinical Fellowships have supported the education of more than 9,600 individuals. Nursing programs (a newsletter, scholarships, and professorships) Information on questionable methods of cancer management. Patient Services In 1993, approximately 745,141 cancer patients were reached through the service and rehabilitation programs of the American Cancer Society. Service Programs Community Connection: Resources, Information, and Guidance: provides information about Society services and other resources in the community to meet the practical, social, psychological, and other support needs of cancer patients and their families. Transportation: Trained volunteer drivers provide trans portation that enables patients to get to and from treatment. Home Care Items: offers supplies and equipment to care for the patient at home. Rehabilitation Programs Reach to Recovery: This one-on-one visitation program provides information and support to women with experience with breast cancer; additional information for husbands, children, and friends of breast cancer patients is available. Laryngectomy Rehabilitation: Spearheaded by the International Association of Laryngectomees, this program provides pre- and/or postoperative support for patients by laryngectomee visitors. Look Good...Feel Better: In partnership with the Cosmetic, Toiletry and Fragrance Association and National Cosmetology Association, this program is an opportunity for people undergoing cancer treatment to develop skills to cope with appearance changes. CanSurmount: A short-term program for cancer patients and their families. Trained volunteers who have experienced the same type of cancer offer support through one-to-one visits. Ostomy Rehabilitation: In cooperation with the United Ostomy Association and enterostomal therapists, trained volunteers who have experienced the same type of surgery as the patient offer help on a one-to-one basis. Children's Camps: Many Divisions offer camps for chil dren who have or have had cancer. These camps can cope with the special needs of children undergoing treatment. Patient and Family Education Programs Group and individual programs designed to help patients of all ages and their families understand the complexities of cancer. I Can Cope: offers information on cancer treatments, nutrition, resources, and other issues to patients and families. Group Support Programs Offered to patients, families and friends, these programs vary according to each Division's needs and resources. Public Issues Cancer has become a political, as well as a medical, social, psychological, and economic issue. Policy makers at all levels of government make decisions which impact the lives of more than 8 million Americans with a history of cancer, their families, and millions of potential cancer patients. Therefore, the Society's Public Issues program educates policy makers about cancer and how it affects the indi viduals and families they represent. The Society is orga nized to advocate for public policy initiatives which relate to and affect: 25 CANCER FACTS & FIGURES 1994 SL 107312  the welfare of the cancer patient and his/her family risks to and protection of the potential cancer patient cancer research The Society supports increased federal funding and pro vides direction for the federal government's cancer research program run by the National Cancer Institute. The Public Issues program also supports the work of the Society's cancer education and service programs by influencing public policy on tobacco control, access to health care, employment discrimination against cancer patients, environmental cancer issues, and other issues affecting cancer survivors and their families. Among the major public policy changes that the Society has advocated are: smoking ban on airlines. - restricted tobacco advertising. expanded access to screening mammography and Pap tests. Costs of Cancer reduces suffering and saves lives if cancer is detected at an earlier, treatable stage. The current debate on health care reform highlights these figures in a new way. An estimated $900 billion will be spent on health care this year in the United States, yet 34 million Americans do not have any health insurance. The number of uninsured, moreover, does not take into account the tens of millions of Americans now living with disease or disability who daily encounter problems with our health care system, including 8 million Americans who have had cancer. The American Cancer Society's Statement of Principles on Health Care System Reform calls for high quality cancer care for all Americans; expanded support for basic and clinical cancer research; comprehensive school health education as a key cost saving primary prevention strategy; and, an increase of at least $2.00 in the federal cigarette excise tax and a comparable increase for other tobacco products to prevent death and disease from smoking. The financial costs of cancer are great both for the individual and for society as a whole. Cancer accounts for about 10% of the total cost of disease in the US and its share of the total cost of premature deaths was about 18% of all causes of death in 1985. The National Cancer Institute estimates overall costs for cancer at $104 billion; $35 billion for direct medical costs, $12 billion for morbidity costs (cost oflost productivity), and $57 billion for mortality costs. Over half of the direct medical costs are due to treatment of breast ($6 billion), lung ($5 billion), and prostate ($5 billion) cancers. The cost of cancer screenings, including mammograms, Pap smears, and colorectal exams adds another $3 to $4 billion to overall cancer costs, but The Disadvantaged Since 1988, the Society has funded over 100 community demonstration projects to provide cancer education mes sages and programs (cancer screening and education, trans portation, and patient service support) to the poor and underserved of our country. Overall, approximately 10 to 12 million adults in socioeconomically disadvantaged pop ulations are reached annually with public education programs. In addition, the Society currently has over $2 million in research grants in effect in this area. Allocation of American Cancer Society Funds Based on Total 1992*1993 Budget--$376,381 Fundraising $64, 17.1% Professional Education* $35,791 9.5% Management & General $26600 71% Patient Services $52,479 Community Services $27405 7.3% Public Education $69,531 18.5% *The Society's cancer prevention, detection, and treatment programs are carried out through these areas, figures taken (ram 1992 Annua! Report (in thousands). Research $100,243 26.6% 26 CANCER FACTS 4 FIGURES 1994 SL 107313 CANCER FACTS & FIGURES 1994 K> N t/3 H O <1 U> H Summary of Research Grants & Fellowships Awarded by the American Cancer Society (National and Division) During the Fiscal Year Ending August 31,1993 (Subject to Audit) AlbanyMedicol College, Albany, NY Albert Einstein College of Medicine, iron*. NY American Assn, for Cancer Research, Philadelphia, PA Americon Health Foundation, New York, NY Baylor College of Medicine, Houston, TX Belh Israel Hospital, Boston, MA Boston Gty Hospital, Boston, MA Boston College, Chestnut Hill, MA Boston Univ., Boston, MA Bowman Gray Sch. of Medicine, Winston-Salem, NC Brandets Univ., WaSlhom, MA Brighorn l Womens Hospital, Boston, MA Brigham Young Unh., Provo, lit Brcwm Univ., Providence, Rl Cofifomio fnsl. of Biologkol Res., to Jofta California Inst, of Technology, Pasadena Cade Foundation Hospital, Urbana, ft Camegie Institution of Washington, Baltimore, MD Cose Western Reserve Univ., Cleveland, OH Oiicogo Medico! School, North Chicago, K Childrens Hospital, Boston, MA Children's Hospital of Los Angeles, los Angeles, CA City of Hope National Medical Ctr., Duarte, CA Cold Spring Horbor lab.. Cold Spring Harbor, NY Colorado State Univ., Fort Collins Columbia Univ., New York, NY Cornell Univ., New York, NY DonaFarber Cancer Institute, Boston, MA Dartmouth College, Hanover, NH Dartmouth-Hitehcodt Medicol Center, Lebanon, NH Drexel Unhr., Philodefphfa, PA Duke Univ., Durham, NC Eleanor Roosevelt Inst, for Cancer Res., Denver, CO Eastern Virginia Medical School, Norfolk Emory Univ., Atlanta, GA European Mcf. Biol, laboratory, Heidelberg, Germany foundation for Biomedical Research, Washington, DC Fox Chose Concer Center, Phitodefphia, PA Fred Hutchinson Cancer Ret. Center, Seattle, WA Georgetown Univ., Washington, DC Georgio Inst, of Technology, Atlanta, GA Hahnemann Unhtnity, Pfildelpfifa, PA Horringtan Cancer Center, Amarillo, TX Harvaro Univ. Medical School, Boston, MA Harvard Univ., Cambridge, MA Henry Ford Hospital, Detroit, Ml Hunter College CUNY, New York, NY Imperial Concer Reieorch Fund, London, England Indiana Univ., tndwnopoTrs Indiana Univ., Bloomington Inti. Union Against Concer, Geneva, Switzerland Iowa State Univ., Ames jocbon Laboratory, Bar Harbor, ME Johns Hopkins Unh., Baltimore, MD Kaiser Permonente Health Research, Portland, OR Kansas State Univ., Manhattan lo Jolla Concer Research Foundation, to Joffo, CA lo Jolla Inst. Allergy and tmrnunology, La Jofto, CA Louisiana Slate Unn. Med. Ctr., Shreveport, LA lonkenou Medical Research Center, Wymewood, PA Loyola Univ. of Oiicogo, Maywood, IL Massachusetts General Kosptlol, Charlestown Massochuselli Inst, of Technology, Cambridge Mayo C&nit Foundation, Rochester, MN McLaughlin Research VistM Great Foils, MT Medicdl Biology Institute, Lo Jofia, CA Medical College of Ohio, Toledo (3) (8) 111 (3) in 13) I 1) 11) (3) ID 13) |5) (1) 131 (1) (?) M) M) (4) 1 3) 1 3) PI 1 3) (51 11) (13) 13) m i ii (it m (1!) 11) (31 (5) M) I 1) (8) 1 8) P) (1| (1| (1) 113} (51 PI 111 ID M) (31 1 3) (1) 1*11 P8| dl (!) (4) (11 (31 (1) (1) (81 (fl dl tD (!) (1) Note; Numberi m parentheses *ndicole numbers of granls per institution. $ 333,000 797,000 140,000 341,000 1,000,000 371,1SO 90,100 90,100 411,000 410,000 373000 701,000 131,000 310,000 114,000 633400 11,000 314,190 404,000 311,000 373,100 390,000 344,000 430,071 10,190 1,911,400 311,000 131,000 71,000 310,000 110,000 1,937,000 101,000 194,000 474,000 79,100 10,000 931,000 747,970 431,000 110,000 1,313 100,000 1,310,110 491,100 40,000 131,000 79,000 103,100 371,300 701,000 101,000 491,000 3,131,000 90,000 114,000 131,000 310,000 370,000 300,100 91,000 711,000 171,010 71,000 101,000 134,194 10,004 Medicat College of Virginia, Richmond Medical College of Wisconsin, Milwaukee Medical Foundation of Buffalo, Buffalo, NY Medical Univ. of South Carolina, Charleston Memorial Sloan-Kettering Concer Ctr., New York, NY Michigan State Univ., East Lansing Montano State Untv., Bozeman Monlefiore Medical Center, Bronx, NY MRC tab. of Mol. Biology, Cambridge, England Mt. Sinai Medico! Center, New York, NY Nat). Jewish Hospital & Research Ctr., Denver, CO New England Medkaf Center Hospitals, Boston, MA New Jersey Medicol School, Newark New York Medical College, Valhalla New York Univ, NYC National Institutes of Health, Bethesda, MD North Carolino State Univ., Raleigh North Dakota State Univ., Fargo Northwestern Univ., Chicogo, It Oak Ridge Assoc., Univ. of Tennessee, Oak Ridge Oberlin University, Oberiin, OH Ohio State Univ., Columbus Oklahoma Medicol Res. fdn., Oklahoma Gty Oregon HeoFlh Science Univ., Portland Oregon Slate Univ., Corvallis Pennsylvania State Univ., Herehey Pennsyfvania Stole Univ., University Pork Philodelphio Coll. PSarm. & Science, Philodelphio, PA Picower Institute Med. Research, Monhasset, NY Pittsburgh Concer Research Institute, PA Princeton Univ., Princeton, NJ Public Health Res. Inst, of New York, NYC Purdue Univ., West Lafayette, IN Reed College, Portland, OR Rockefeller Univ, New York, NY Roger Williams General Hospital. Providence, Rl Roswell fork Memorial Institute, Buffalo, NY Rush Presbyierkm-Sl Luke's Med. Ctr., Chicago, IL Rutgers, State Univ. of New Jersey, Piscolowoy State Univ. of New York {SUNY) at Stony Brook Stale Univ. of New York {SUNY} at Syracuse Salk Institute, Lo Jolla, CA Scripps Cfcnic l Research foundation, Lo Jolla, CA Southwest foundation Biomed. Res., Son Antonio, TX St. Jude's Children* Research Hospital, Memphis, TN St. John'i Univ., Jamoico,NY St. Louis Univ., St. Louis, MO Stanford Univ., Stanford, CA Texas ABM Univ., College Station, TX Thomas Jefferson Univ., Philodelphio, PA Tufts Unhr., Boston, MA University Hospital* of Cleveland, Cleveland, OK UMDNJ-Roberi Wood Johnson Medical School, NJ Univ. of Alabama, Birmingham Univ. of Arizona, Tucson Univ. of Arkansas for Med. Science, Little Rock Univ. of Californio ot Berkeley Univ. of Californio at Davis Univ. of Colifornio at Irvine Univ. of California ot Los Angeles Univ. of California ot Riverside Univ. of Californio at Santa Barbara Univ. of California at Son Francisco Unhr. of Colifomio al Son Diego Unhr. of Cctifomia ot Santa Cruz Univ. of Chicogo, IL Univ. of Cincinnati, OH (3) $ 113,000 Univ, of Colorado Hlfh. Set. Center, Denver ini M) 43,000 Univ. of Coforodo, Boulder pi ID 140,000 Untv. of Connecticut, Farmington (!) ( !| 79,000 Univ, of Delaware, Nework 1 3) (1?) *3,310,100 Univ, of Florida, Gainesville <D ID 130,000 Univ. of Georgia, Athens (D 1 3) 134,000 Univ, of Hawaii, Honolulu (D (D 13,000 Univ, of Houston, TX 11| (D 40,000 Univ, of Iowa, Iowa City 1D (4| 349,300 Univ. of Kansas, Lawrence ID (D 100,000 Univ. of Kentucky, Lexington ID (!) 304,000 Univ. of Illinois, Chicogo PI (D 100,000 Univ. of Illinois, Urbana PI (31 341,000 Univ, of Maryland, Baltimore PI PI 1,109,000 Univ. of Morykmd, College Pork (D ID 134,000 Univ. of Massachusetts Med. Center, Worcester ID (D 33,000 Univ. of Miami, FL 1 5) ID 331,100 Univ. of Michigan, Ann Arbor (14) ID 940,100 Univ. of Minnesota, Minneapolis (10) ID 114,000 Univ. of Nebraska Med. Center, Omaha P) (D 74,000 Unh. of Nebraska, Lincoln 1D PI 1,001,000 Univ. of NeW Mexico, Albuquerque PI (D 44,000 Univ, of New Orleans, LA 1D PI 144,000 Unw. of North Carolina, Chopet Hill 115) PI 91,000 Univ. of Oklahoma, Oklahoma City PI PI 410,000 Univ. of Oregon, Eugene PI P) 147,300 Univ. of Oxford, Oxford, England 1D (D 71,000 Univ. of Pennsylvania, Philadelphia PI Pt 140,000 Univ, of Pittsburgh, PA 1 B) PI 143,000 Unhr. of Rochester, NY I 8) ID 1,079,000 Unh. of South Carolina, Columbia 1D f 3) 314,000 Unh. of South Florida, Tempo 1D PI 133000 Unh. of Southern California, to* Angeles PI ID 93,000 Univ. of Tennessee, Knoxville 1 !} (D 140,004 Univ. of Tennessee, Memphis PI (D 111,444 Unh. of Texas MD Anderson Ca. Ctr., Houston (11) ( 4) 444,000 Univ. of Texas, Austin 1D (3) 131,000 Univ. of Texas Med. 8r., Galveston (D PI 401,000 Unhr. of Texas Southwestern Med. Ctr. ot Dallas PI (1!) 1,334000 Unh. of Texas Hllh. Sci. Ctr. at Houston 1D ID 90,040 Unh. of Texas Hlth, Sci. Ctr. at Son Antonio 13) Pi 131,100 Unh. of Texas Health Ctr., Tyler 1D PI 104,410 Univ. of Utah, Sob Lake City 1 5) (D 44,000 Univ, of Vermont, Burlington PI 1 3) 314,000 Unh. of Virginia, Charlottesville (10) <3| 194,000 Unh. of Washington, Seattle PI PI 344,000 Unh. of Wisconsin, Madison (13) PD 3,311,411 Unh, of Wisconsin, Milwaukee 1 1) (31 111,000 Unh, of Wyoming, Laramie 1 1) in 931,444 Utah State Univ., Logon 1D ( 5) 444O04 Vanderbilt Univ., Nashville, TN ID 11) 390,004 Virginia Polytechnic Inst,, Blacksburg 1D 11) 390,004 W. Alton Janes Cell Sci. Clr., Lake Placid, NY 1 3] PI 411,100 Washington State Unh., Pullman PI t 4) 134,000 Washington Unh., St Louis, MO (5| ID 410,000 Wayne State Unh., Detroit, Ml 1 5] PI 400,000 Wesleyan Univ, Middletown, CT f 3) (51 341,100 West Virginia Unh., Morgantown ID (ID 943,100 Whifebeod Institute, Cambridge, MA PI (151 1,131,100 Wichita Stale Unhtrvty, Wichita, KS dl ID * 110,000 William Patterson Coflege, Wayne, NJ (D (4) 374,000 Wislor Institute, Philadelphia, PA P) (33) 3,144,000 Yale Univ., New Haven, CT (3D (H) 1,334,400 Subtotal (847) (D 313,000 Dhisfan Research Grants (3) 730,100 ID $ 41,000 Grand Totof 1,441,100 191,900 131,000 373,000 300,000 14,000 300,000 304,000 391,000 141,000 90,000 334,000 344,500 334,000 15,500 834,473 441,000 3000,100 t,047,000 441,000 19,000 49,131 73,000 1,193,000 413,000 1,011,000 71,000 1,091,850 193,000 703,313 191,000 135,000 1,190,000 43,000 341,000 1,116,000 10,000 10,000 1,449,000 90,100 193,000 140,000 486,000 749,000 1,433,000 1,117,670 3357,000 99,000 164,000 90,000 991,000 137,000 400,000 191,000 491,670 443,000 379,100 306,000 343100 19,000 101,000 407,100 3,915,374 *91,131,117 * 3,911,011 *99,716,903 Cancer Around the World, 1988-1991, Death Rates per 100,000 Population for 46 Countries I~> 5>* ~z. m TO -n o -H co to Eto OO **n o cr m cn -- o cn tr1 H* o -o u> H* ui COUNTRY United Stales Argentina} Austroliol Austria Bulgaria Conada} Chile} China*} Ccsto Rica} Cubaf Cz<chastovottkrf Denmark Ecuador) Engtend L Woles Finland Francef Germany, fed.R Greece} Hong Kong} Hungary Iceland Ireland} Israel} Holy} Japan Luxembourg Mafta Mauritius Mexico} Netherlands} New Zealand} North Ireland Norway} Poland Portugal Puerto Pico) Romonia Scotland Singapore! Spain} Sweden} Switzerland IMiguavi USSR} Venezuela} Yugoslavia! AU SITU Mol* female M.4P4) ISIS (19) 144.0(15) 171J (18) 139.0(37) 170.8(11) 140.8(36) 154.1(17) 166.6(H) H9.B(39| 23?0( 1) 179.5(11) 83.6(45) 179.1(11) 1S4.1 (IS) 300.7( S) 177.9(13| 1443(34) 1711(14) 1441 (1) 1471(31) 174.9(17) 115.5(41) 1913(10) 1503(30) 1971(4 144.0P5) 85.0(44] 83.5(46) 19S.3( 9) 171.9(19| 174.6(14) 148.1(31) 103.5| 4) 145.9(33) 115.5(41) 1353(38) 198.5( 6) 175.3(15) 1663(13) 119.4(40) 171.1 (M) 1043(3) 1983(7) 927(43) 158.4(16) 110.6(11) 971(16) 101.2(H) 106.9(19) 84.2(38) 110.6(11] 109.4(14) 873(35) 1081(16) 9S.6(1S| 12l.0| 8} 139.8 ( 1) 85.1(37) 1257 ( 6) 90.6(32) 88.1(34) 108.3(17) 77.5)43) 91.0(31) 13t.5| 3) 1141(10) 127.5} 4) 987(34) 993(13) 767(44) 109.4(15) 911 pO) 623(46) 797(41) 1091(13) 116.8( 5) 1113( 7) 101.1(11) K7.B|18) 86.6(36) 75.1(45) 83.8(39) 137.1 (1) M3.9(M) 80.8(41) 98.1(151 97.2(17) 1161( 9) 94.5(19) 837(40) 903(33) ORAL Malt Female 37(29) 4.0(16) 47(20) 5.9(16) 31(28) 4.4(H) 2.3(39) 1.5(36) 31(31) 5.6(19) 9.0(6) 4.0(27) 07(46) 2.9(33) 2.3(40) 13.6( 3) 63(13) 1.6(44) 14.5| D )4.7()) 2.1(41) 4.4(24) 1.0(45) 63)11) 13(41) 10.1(5) 3.6(30) 4.6(21) 2.0(43) 2.8(35) 4.3(25) 21(34) 3.1(32) 63(14) 57(18) 391 7) 57(17) 4.4(23| 12.9 ( 4) 6.3(12) 34(38) 6.6(10) 6.0(15) 7.4(8) 24(37) 6.9(9) 13(11) 0.9(35) 13(13) 0.9(33) 0.6(45) 13(14) 0.6(44) 13(17) 1.0(15) 1.0|3| 1.0(16) l.4(9| 07(40) 13(18) 0.8(39| t.3(15| 1.0(21) 0.6146) 4.4(1) >7(5) >0(17) 1.0(18) 07(41) 1.0(13] 0.6(43) 1.4(10) 1.6(6) U| 4) 07(41) 1.0(31) 1-4 ( 8| 1.0(31) 1.1(10) 1.0(14) 0.8(37) 1.4(7} 1.0(29) 1.3(11) 4.4( l| 0.8(38) 0.8(36] 1.1(16) 0.9(34) 10(3(8 1.1)19) 1.0(21) COLON A RECTUM Male female 167(20) 137(31) 31-519) 32.4)6) 111(15) 17.8(17) 7.0(40| 7.9(39) 6.8)41) 101(36) 307( 1) 22.0} 5) 1.7(46) 203(11) 11.2(35) 17.3(19) 11.1(10) 60(41) 14.8(29) 190(1) 14.9(17) 23.1(4) 14.4(30) 15.6(11) 111(14) 310(7) 13.5(33) 50(44) 3J(45) 17.9(16) 257(3) 11-5 ( 8) 10.0(13] 14.9(16) 153(H) 9.6(38) 97(37) 10.6(11) t'.,'<4) 14.9(18) 183(15) 177(18) l'?[?3) - I'l) 13.4(33) 11.4(19) 93(33) 147(9) 143(11) 107(26) 11.0(17) 6.0(41) 6.5(40) 6.7(39) 1M(20) Ml 4) 13.5} 3) 4.1(45) 137(14) B.6|36) 10.3(27) 15-3 (6) 5.5(41) 107(1S| 18.1(1) 10.8(14) 15.1(7) 11.9(18) 103(18) 97(33) 124 (U) 100(31) 4.1|44| 3.1(46) 133(15) 205( 1) 140 ( 8) 14.2(10] 103(19) 10.1(30) 74(37) 7.2(38} 153) 5) 14.0(13) 9.2 (35) 11.1(11) 109(23) 14.1(11) 109(23) 5-3(43) 93(34) PROSTATE Male 166(17) 13.1(19) 172(151 167(18) 70(39) 16.9|16) 13.1(28) 19.6( 5) 10.71 7} 13.6126) 1B.1|10) 11.1(321 16.6)10) 17.5(11) 17.3(13| 15.9(21) 8.1(38} 26(45) 157)13) 19-41 i| 176(11) 8.6)37) 110(31} 30(44) 160(19) 9.1(35) 50(41) 106(33) 163( 9) 187 (8) 15.4(13) 217} ?| 90(34) 14.5|25) 173(14) 71)40) 14.9(14) 4.1(43) 11.9)30) 10.4(3| 33-5( 1) 19.9 ( 4) 63(41) 133(37) 8.9(36) UINO Male Female 57.1(10) 39.1(30) 45.1(25) 411(34) 403(39) 57.31 9) 21.1(40) 34.0(33) 175(43) 39.0(33) 74.4} 2| 51.9(15) 6.9(46) 57.0(11| 47.8(11) 460(32) 487(19) 490(17) 54.2114} 76.4( !| 300(34) 47.9(30) 24.5(38) 58.9[ 8) 301(36) 63.9(7) 43.2(38) 18.9(43) 16.5(45] 71.11 *1 44-4(37) 55.4117) 303(35) 70 4 ( 5) 16.0(37) 19.5(41) 39.1(31) 71313} 50.6(16) 45.2(33) 23.4(39) 44.9(26) 550113| 63.6(6) 16.5)44) 4S.9|1S| 247(1) 5.8(38} 120(15) 9.0(30) 6.3(36) 206( 6) 5.8(39) 14.5(13) 6.4(34) 14.3(14) 83(22) 23.9 ( 3) 20146) 10.51 7| 66(33) 5.0(41) 7.8(16) 4.9(32) 133(5) 14.9)12) 13.81 4) 19.21 8) 7.9(24) 73(28) 8.0(13) 80(21) 3.7(44) 5.1 M 5.9(37) 10.1(17) 17.3(11) 170f 9) I03(14| 9.7119} 4.4(43) 7.0(31) 0.4 (35) 28.3( 1) 175110) 3.4(45) 9.9(18) 7.3|19) 4.6(42) 7.1(30) 7.9(15) 73(27) NOTE: Figures in parentheses on order of rank willun tile and sex group. Rates or* oge-adjusttd lo the WHO work) rtondard population. 'Oral cancer rale Include nasopharynx only- f1988-1990 only. }1983-1989 only. 11988 only. 11989-1990 only. IREAST Female 22.4(10} 10.9)19) 107(11) 22.0(17) 15.6(31) 23.9(12) 11.5(39) 4.6(44) 12.9(38) 14.8(33) 19.8(221 27.7 ( 4) 5.6(45) 287( 1) 17.0(28) 197(23) 21.9(18) 15.2(31) 8.6(41) 22.4(15) 237(13) 27.8| 3) 230(14) 20.8(10) 4.3(44) 254(10) 18.1(2) <7(4^ 8.1(42) 16.8( 7) 27.0) 6) 26.5 ( S| 19.1(24) 15.7(30} 178(26) 14.2(35) 140|34) 37.1(51 13.9(37) 171(17) 18.1(15) 143(11) 14.4(9) 13.6(36) 9.6(40} 15.9(29) UTERUS Cervix Other 2.4(33) 4.6(16) 3.1(29) 2.9(30) 4.1(H) 13(37) 12.51 1; 4.2(31, 10.4 ( 3] 6.3(9) 5.6(11) 53(12) 50(10) 4.4(18) 1.7)43) 1.8(40) 3.6(25) 1.3(45) 3.9(23) 6.8(7) 26(34) 3.2(27) 1.4(44) 0.9(46} 10(41) 3.2(26) 1.9(39) 3.4(34) 159( 1) 1.5P5) 4.5(17) 25(16) 43(19) 7.9 ( 6) I.3(36| 2.6(31) 103( <1 40(15) 6.4(81 17(43) 2.1(38| 1.4(33) 47(14) 5.1(13) 97(5} 4.1(20) 10(33) 65(5) 1.7(44| 51(9) 6.0|7) 7 5(35) 1.4(38| 35(H) 73(4) 571 8) 3 5(23) 13.7) 1) 2.5(34) 26)31) 4.0(17) 3.3|25) 3.0(16| 1.4(45) 5.0(11) 10(41) 2.9(17) 2.2(39) 51 HP) 14(37) 45(14) 30(10] 7.4(3) 2.4(21) 15(36) 1.8 [28| 1.0(41) 3.8(19) 4 0(16) 4.9(11) 3.5(21) 3.9(181 2.1(40) 1.8(43) 30(19) 2.7(30) 23(34) 0-41 6) 4.4(15) 7.9)2] 4.6(13) STOMACH Malt Female , 5.2(46) 12.8(16) 8.4(41) 167(19) 19.8(11) 8.0(41) 35.21 3) 33.6(5} 54 7( 1) 73(45) 19.7(12) 78(43) 26.9) 6) 125)29) 120(25) 9.1(38) 14,9(21) 9.6(36| 115(31) 24.0| B| 18.1(15) 11.0(30) 77(44) 18.1(14} 34.9( 4) 11.3(32) 14.9(H) 127(37) 105(35} 13.1(13) 80(40] 11.6(18) 11.0(34) 13.1(9) 34.9 ( 7) 11.0(33] 18.2(I3| 13.1(14) 10.3(10) 15.0(10) 8.9(39) 9,6(37) 17.0(18) 36.8(1) 17.1(17) 18.0(16) 2.3(46) 5.6(19) 26(44) 8.2|1S| 10.7| 9) 3 4(45) 13.6| 6) 157( 4} H.B( 1) 38(42) 8.9(121 4 2(41) 19,2 ( 2| 51(31) 70(23) 3 6|-43} 77(17) 4 9(34) 53(30) 10.1(10) 77(18) 5.9(17) 4.1(40) 8.6(13) 155| S| 4.3|38) 6.1(16) 77(21) 7.6(19) 5,0(33) 4,7(35) 67(25) 5 0(32) 82(14) )2.0| 7) 45(36] 71(72) 5 9(78) 10B( 8) 4 9124) 45137) 4.2)39) 73(101 16.0 ( 3) 9.5|11) 70(14) LEUKEMIA Male female 63(8) 4 6(33| 61(11) 5.4(21] 4 5(36) 6.2(10) 3.9(42) 41)40) 6 2(9] 4 6(3?) 67( 4) 6 8(3) 37(45) 5 3(24) 52(25) 6.1 (13) 5.9(14) 5.7(16) 3.8(43) 7.2( 1) 4.9(29) 6.1(12) 6.4(7) 67| 5) 4.3(38) <-7| 6) 5.4(22) 35(44) 3.8(44) 5.6(18) 72 ( 2) 4 5(34) 4 9(78) 58(15) 50(77) 4 8(30] 4.5(35) *4(37) 4 2(39) 5 3(23) 5.1(26] 5.6|17) 55(20) 55(19) 40(41) 4.7|31| 3.81 9) 3.3(28) 3.8(10) 3 5(24) 2.9 (43) 3-91 8) 3.3(32) 33(77) 4-9 ( 1] 3 6 16) 4-3 ( 4] 4 1(5) 3 2(33| 3 3(31) 3.0(38) 3 7(15] 3.7(13} 34(25) 77(45) 4.6(2) 31(37) 3.7(12) 4.5(3) 4-0|7) 7.8(44} 36(71) 3.4(17) 2.3(44) 3.0(40) 3.5(23) 4.1(6) 3.7134) 33(30] 34(18) 3.7114) 3.5(72] 3.0(39) 31(35] 3.0(41) 3.4(26] 3.3(29) 3.6(20) 3.8(11) 36(19} 3 1 (36) 3.0(42) i Cancer Centers The institutions listed have been recognized as Cancer Centers by the National Cancer Institute. These centers have been rigorously reviewed by the National Cancer Advisory Board. They receive financial support from the National Cancer Institute, the American Cancer Society and many other sources. ALABAMA University of Alabama at Birmingham* Comprehensive Cancer Center (205) 934-5077 ARIZONA University of Arizona* Arizona Cancer Center (602) 626-6372 CALIFORNIA The Kenneth Norris, Jr. Comprehensive Cancer Center* University of Southern California (213) 226-2370 Jonsson Comprehensive Cancer Center* University of California at Los Angeles 1-800-825-2631 La Jolla Cancer Research Foundation (619) 455-6480 University of California at San Diego Cancer Center (619) 543-6178 City of Hope Beckman Research Institute (818) 359-8111 Armand Hammer Center for Cancer Biology Salk Institute (619) 453-4100 COLORADO University of Colorado Cancer Center University of Colorado Health Sciences Center (303) 270-3007 CONNECTICUT Yale University* Comprehensive Cancer Center 1-800-4-CANCER DISTRICT OF COLUMBIA Lombardi Cancer Research Center* Georgetown University Medical Center (202) 687-2192 FLORIDA Sylvester Comprehensive Cancer Center* University of Miami Medical School (305) 545-1000 ILLINOIS University of Chicago Cancer Research Center (312) 702-6180 Lurie Cancer Center Northwestern University (312) 908-5250 INDLANA Purdue University Cancer Center (317) 494-9129 MAINE The Jackson Laboratory (207) 288-3371 MARYLAND The Johns Hopkins Oncology Center* (410) 955-8800 Indicates Comprehensive Cancer Center. MASSACHUSETTS Dana-Farber Cancer Institute* (617) 632-3000 Worcester Foundation for Experimental Biology (508) 842-8921 Massachusetts Institute of Technology Center for Cancer Research (617) 253-6421 MICHIGAN Meyer L. Prentis Comprehensive Cancer Center of Metropolitan Detroit 1313) 7454329 University of Michigan Comprehensive Cancer Center* (313) 936-9583 MINNESOTA Mayo Comprehensive Cancer Center* (507) 284-3413 NEBRASKA Eppley Institute University of Nebraska Medical Center 1-800-999-5465 NEW HAMPSHIRE Norris Cotton Cancer Center* Dartmouth-Hitchcock Medical Center (603)650-5000 NEW YORK Cold Spring Harbor Laboratory (516) 367-8397 Memorial Sloan-Kettering Cancer Center* 1-800-525-2225 Roswell Park Cancer Institute* 1-800-ROSWELL Albert Einstein College of Medicine Cancer Research Center (71819204826 Columbia University Comprehensive Cancer Center (212) 30S-6921 Kaplan Comprehensive Cancer Center* New York University Medical Center (212) 2638485 University of Rochester Cancer Center (716) 2754911 Nelson Institute for Environmental Medicine New York University Medical Center (212) 263-5280 American Health Foundation (212) 953-1900 NORTH CAROLINA Duke University Comprehensive Cancer Center* (919) 684-2748 Lineberger Cancer Research Center* University of North Carolina (919)966-3036 Wake Forest University* Comprehensive Cancer Center Bowman Gray School of Medidne (919) 7164464 OHIO Ohio State University* Comprehensive Cancer Center Arthur C. James Cancer Hospital 16006388996 Case Western Reserve University Ireland Cancer Center (216) 844-5432 PENNSYLVANIA Pox Chase Cancer Center* (215) 728-2570 University of Pennsylvania Cancer Center* (215)6626364 Wistar Institute Cancer Center (215) 898-3926 Feis Research Institute Temple University School of Medicine (215)2214000 Pittsburgh Cancer Institute* University of Pittsburgh 16005374063 RHODE ISLAND Brown University Roger Williams Cancer Center (401) 456-2071 TENNESSEE Drew-Meharry-Morehouse Consortium Cancer Center (615) 3276927 SL Jude Children's Research Hospital (901) 5228306 TEXAS M.D. Anderson Cancer Center* University of Thus (713) 7928245 San Antonio Cancer Institute (210)6778850 UTAH Utah Cancer Center University of Utah School of Medicine (801) 5814048 VERMONT Vermont Cancer Center* University of Vermont (802) 6564414 VIRGINIA Massey Cancer Center Medical College of Virginia/VCU (804) 371-5116 University of Virginia Cancer Center (804) 924-5811 WASHINGTON Fred Hutchinson Cancer Research Center* (206) 667-5000 WISCONSIN Comprehensive Cancer Center* University of Wisconsin (608)2636600 McArdle Laboratory for Cancer Research University of Wisconsin Medical School (608) 262-2177 Chartered Divisions of the American Cancer Society, Inc* Alabama Dhrisioa, lac. 504 Brookwood Boulevard Homewood. Alabama 35209 (205) 879-2242 Alula Division, lac. 406 West Fireweed Lane Anchorage, Alaska 99503 (907) 277-8696 Arizona D(vision, Inc, 2929 East Thomas Road Phoeniz, Arizona 85016 (602) 224-0524 Arkansas Division, Inc. 901 North University Little Rock, Arkansas 72203 (501) 664-3480 California Division, Inc. 1710 Webster Street Oakland, California 94612 (510) 893-7900 Colorado Division, Inc. 2255 South Oneida Denver, Colorado 80224 (303) 758-2030 Connecticut Division, Inc. Barnes Park South 14 Village Lane Wallingford. Connecticut 06492 (203) 265-7161 Delaware Division, Inc. 92 Read's Way New Castle, Delaware 19720 (302) 324-4227 District of Columbia Division, Inc. 187S Connecticut Avenue, N.W. Washington, DC 20009 (202) 483-2600 Florida Division, Inc. 3709 West Jetton Avenue Tampa, Florida 33629-5146 (813) 2534)541 Georgia Division, Inc. 2200 Lake Blvd. Atlanta, Ceorgia 30319 (404) 816-7800 Hawaii Padfte Division. Inc. 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Unit 501 Bedford, New Hampshire 03110-5032 (603) 472-8899 New Jersey Division, Inc. 2600 US Highway 1 North Brunswick, New Jersey 089020803 (908) 297-8000 New Mexico Dhrisioo, Inc. 5800 Lomas Blvd., NE Albuquerque, New Mexico 87110 (505)260-2105 New York State Division, Inc. 6725 Lyons Street East Syracuse, New York 13057 (315) 437-7025 Long Island Division, Inc. 75 Davids Drive Hauppauge, New York 11788 (516)436-7070 O New York City DWsioo, Inc. 19 West 56th Street New York, New York 10019 (212) 586-8700 a Queens Dhrisioa, Inc. 112-25 Queens Boulevard Forest Hills, New Yotk 11375 (718) 263-2224 d Westchester Division, Inc. 30 Glenn Street White Plains, New York 10603 (914) 9494800 North Carolina Division, Ine. 11 South Boylait Avenue Raleigh, North Carolina 27603 (919)8344463 North Dakota Division, Inc. 123 Roberts Street Fargo, North Dakota 58102 (701) 232-1385 Ohio Division, Inc. 5555 Frants Road Dublin, Ohio 43017 (614)889-9565 Oklahoma Dhrisioo, Inc. 4323 63d, Suite 110 Oklahoma City, Oklahoma 73116 (405)843-9888 Oregon Division, Inc. 0330 SW Cutty Portland, Oregon 97201 (503) 2954422 Pennsylvania Dhrisioa, Inc. 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Box 6359 Clen Allen, Virginia 23058-6359 (804) 527-3700 Washington Dhrisioo, Inn 2120 First Avenue North Seattle, Washington 98109-1140 (206) 283-1152 West Virginia Dhrisioa, Inn 2428 Kanawha Boulevard East Charleston, West Virginia 25311 (304) 344-3611 Wisconsin Dhrisioa, Inn P.O. Box 902 Pewaukee, Wisconsin 53072-0902 (414) 523-5500 Wyoming Dhrisioa, Inn 2222 House Avenue Cheyenne, Wyoming 82001 (307) 638-3331 THERE'S HOTHIMC MIGHTIER TMAH THE SWORD AMERICAN VCANCER ? SOCIETY* SL 107317 FOR MORE INFORMATION CALL THE AMERICAN CANCER SOCIETY TOLL FREE: 1-800-ACS-2345 The American Cancer Society is the nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives from cancer, and diminishing suffering from cancer through research, education, and service. National Headquarters: American Cancer Society, Inc., 1599 Clifton Road N.E., Atlanta, CA 30329-4251 1994. American Cancer Society, Ine. 94-375M-No, 5008.94 CANCER FACTS & FlGURES-1994 AMERICAN V CANCER * SOCIETY' 107287 Estimated number of new cancer cases in 1994 by state, total: 1,208,000 (excluding Puerto Rico).* `Excluding basal and squamous cell skin cancer and carcinoma in situ. Contents CANCER: BASIC FACTS................................................................................. 1 RESEARCH, PREVENTION, DIAGNOSIS AND TREATMENT......... Cancer Death Rates by Site, Males, US, 1930-1990......................... Cancer Death Rates by Site, Females, US, 1930-1990..................... 30-Year Trends in Cancer Death Rates per 100,000 Population, 1958-60 to 1988-90 ........................................................... Estimated New Cancer Cases and Deaths, US, 1994 ......................... Estimated New Cancer Cases, by State--1994 ..................................... Cancer Mortality, by State--1994 .............................................................. 2 4 4 5 6 7 8 SELECTED CANCERS..................................................................................... 9 Lung Cancer........................................................................................................ 9 Colon and Rectum Cancer.............................................................................. 9 Breast Cancer........................................................................................................ 10 Prostate Cancer.....................................................................................................10 Leading Sites of Cancer Incidence and Death--1994 Estimates..............................................................................................................11 How to Estimate Cancer Statistics Locally............................................... 12 Pancreas Cancer................................................................................................... 12 Uterus (Cervix) Cancer.......................................................................................12 Percentage of Population (Probability) Developing Invasive Cancers at Certain Ages............................................................... 13 Uterus (Endometrial) Cancer........................................................................... 13 Cancer in Children............................................. 13 Leukemia................................................................................................................ 14 Lymphoma.............................................................................................................. 14 Skin Cancer.................................................................... ,.................................. 15 'tables are indicated in bold print Ovary Cancer...................................................................................................... {5 Five-Year Relative Survival Rates by Stage at Diagnosis..................... 16 Bladder Cancer..................................................................................................... 15 Oral Cancer............................................................................................................16 Trends in Cancer Survival, by Race.......................................................... 17 CANCER IN MINORITIES............................................................................... 18 Number of Cancer Deaths for Black, American Indian, Chinese, Japanese, and Hispanic Persons, US, 1990.........................18 PREVENTION....................................................................................................... 19 Environmental Cancer Risks...........................................................................20 EARLY DETECTION...........................................................................................21 TOBACCO USE....................................................................................................22 THE AMERICAN CANCER SOCIETY..........................................................24 Research................................................................................................................. 24 Public Education................................................................................................. 24 Professional Education......................................................................................25 Patient Services................................................................................................... 25 Public Issues.........................................................................................................25 COSTS OF CANCER.......................................................................................... 26 THE DISADVANTAGED....................................................................................26 Allocation of ACS Funds, 1992.................................................................... 26 Summary of Research Grants and Fellowships............................... .27 Cancer Around the World................................................................................28 Cancer Centers..................................................................................................... 29 Chartered Divisions of the ACS................................................... Back Cover Sources of Statistics Incidence. Since there is no nationwide cancer registry, there is no way of knowing exactly how many new cases of cancer are diagnosed each year. The American Cancer Society (ACS) estimates cancer incidence for the upcoming year using the best available data sources at the time. Estimates of cancer incidence in Pacts and Figures editions prior to 1974 were based on rates from two state cancer registries, the Connecticut Tumor Registry and the New York State Tumor Registry. The issues from 1974 to 1978 used information from the National Cancer Institute's Third National Cancer Survey (1969-1971) of nine major areas of the United States. In 1973, the NCI began the Surveillance, Epidemiology and End Results (SEER) program to collect ongoing data on cancer incidence and patient survival. The SEER program includes data from nine population-based cancer registries, covering about 10% of the US population. Beginning with the 1979 edition of Facts and Figures, estimates of cancer incidence have been based on incidence rates obtained through the SEER program, applied to the US Census estimates of the population for the current year. Estimates of new cancer cases include invasive cancers only, excluding in situ tumors except for cancers of the urinary bladder. Basal and squamous cell skin cancers are also excluded. It is not appropriate or accurate to evaluate cancer incidence and mortality trends using only ACS estimates of cases and deaths, since these numbers are projected before the year begins, using data that are several years old. The numbers are presented to give the best available measure of the scope of the disease in the US at the time of publication. Comparable incidence rates are available for 1973 through 1990 from the National Cancer Institute's SEER program to evaluate cancer trends. The estimates of total US cancer cases diagnosed in 1994 are based on age-specific incidence rates from the SEER program for 1988-1990 applied to the 1994 Census population projections. Some adjustment is made for sites with recently increasing or decreasing rates. Estimated new cases by state are calculated according to the distribution of estimated 1994 cancer deaths by state for each primary cancer site. Mortality. Mortality statistics are derived from underlying cause of death data reported by the Division of Vital Statistics, National Center for Health Statistics, Department of Health and Human Services. The 1994 estimates of cancer deaths are based on cancer mortality data from 1984 through 1990. Beginning with the 1981 edition of Facts and Figures, age-adjusted mortality rates per 100,000 are standardized to the 1970 census population distribution. Age-adjustment or age-standardization is a method used to make valid statistical comparisons among rates by assuming the same age distribution occurs among the different groups being compared. Death rates by state: Since 1990, actual age-adjusted mortality rates, based on reported deaths in a recent 5-year period, have been presented. State mortality rate estimates from earlier Facts and Figures are not comparable. Cancer Around the World: International mortality rates were calculated from data made available by the World Health Organization,' and are adjusted to the old world population standard. Probability of Developing Cancer, The probabilities of developing cancer are based on incidence rates for first primary cancers for that site, as reported to the NCI SEER program for 1988 through 1990. SEER area mortality rates for 1988-1990 were used to calculate survival into each age interval. Detailed methodology is available from the Applied Research Branch, National Cancer Institute. SureioaL Cancersurvival statistics are usually reported as 5-year relative survival rates. In this edition, we present survival statistics for cases diagnosed in the period 1983-1989, as reported from the SEER program and followed through 1990. The relative survival rate is the ratio of the observed survival rate for the patient group to the expected survival rate for persons in the general population similar to the patient group with respect to age, sex, race and calendar year of observation. Because there is a certain lag time required in measuring survival, these rates may not reflect the most recent treatment advances. SEER Report The NCI SEER program is the source of specific data components for Cancer Facts & Figures 1994, including incidence rates and survival rates. These and other data are available in the SEER Cancer Statistics Review: 19731990, National Cancer Institute. N1H Pub. No. 93-2789,1993. WH American Corner Society. Inc. All rights served, including the rigid to ivpnxiuct this pubHcatim orportions thereatin any farm Fbr written permusion, eddtecs the American Cancer Society. IS99 CtiDon Rood. N.E.. Atlanta. C4.10.1294251 SL 107288 Cancer: Basic Facts What is cancer? Cancer is a group of diseases characterized by uncon trolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. What causes cancer? Cancer is caused by both external (chemicals, radiation, and viruses) and internal (hormones, immune conditions, and inherited mutations) factors. Causal factors may act together or in sequence to initiate or promote carcino genesis. Ten or more years often pass between exposures or mutations and detectable cancer. Can cancer be pretented? Yes, about 90% of the 700,000 skin cancers that will be diagnosed in 1994 could have been prevented by protection from the sun's rays. All cancers caused by cigarette smoking and heavy use of alcohol could be prevented completely. The ACS estimates that in 1994, about 165,000 lives will be lost to cancer because oftobacco use. About 17,000 cancer deaths will be related to excessive alcohol use, frequently in combination with cigarette smoking. Regular screening and self-exams can detect cancers of the breast, tongue, mouth, colon, rectum, cervix, prostate, testis, and melanoma at an early stage, when treatment is more likely to be successful. These sites include nearly half of all new cases. Of these cases, about two-thirds of all patients currently survive five years. With early detection, about 90% would survive. This means that of those persons diagnosed with these cancers in 1994, about 100,000 more would survive if their cancers had been detected in a localized stage and treated promptly. How is cancer treated? By surgery, radiation, radioactive substances, chemicals, hormones, and immunotherapy. Who gets cancer? Anyone. Since incidence rises with age, most cases affect adults in mid-life or older. Among children ages 1-14, cancer causes more deaths in the US than any other disease. In the 1980s there were over 4.5 million cancer deaths, almost 9 million new cancer cases, and some 12 million people under medical care for cancer. How many people alive today have ever had cancer? Over 8 million Americans alive today have a history of cancer, 5 million diagnosed five or more years ago. Most of these 5 million can be considered cured, while others still have evidence of cancer. "Cured" means that a patient has no evidence of disease and has the same life expectancy as a person who never had cancer. How many new cases will there be this year? About 1,208,000 new cancer cases will be diagnosed. This estimate does not include carcinoma in situ and basal and squamous cell skin cancers. The incidence of these skin cancers is estimated to be over 700,000 cases annually. How many people will die? This year about 538,000 will die of cancer--over 1,400 people a day. One out of every five deaths in the US is from cancer. What is the national cancer death rate? There has been a steady rise in the cancer mortality rate in the US in the last half-century. The age-adjusted rate in 1930 was 143 per 100,000 population. It rose to 157 in 1950, to 163 in 1970, and was 174 in 1990. The major cause of this increase has been lung cancer. Death rates for many major cancer sites have leveled off or declined over the past 50 years (see page 5). If lung cancer deaths were excluded, cancer mortality would have declined 14% between 1950 and 1990. How many people are surviving cancer? In the early 1900s, few cancer patients had any hope of long-term survival. In the 1930s, less than one in five was alive five years after treatment. In the 1940s, it was one in four, and in the 1960s, it was one in three. About 483.000 Americans, or 4 of 10 patients who get cancer this year, will be alive 5 years after diagnosis. The gain from 1 in 3 in the 1960s to 4 in 10 now represents over 85.000 persons each year. This 4 in 10, or about 40% is called the "observed" survival rate. When adjusted for normal life expectancy (factors such as dying of heart disease, accidents, and diseases of old age), a "relative" 5-year survival rate of 53% is seen for all cancers. The relative survival rate is commonly used to measure progress in the early detection and treatment of cancer. SL 107289 1 CANCER FACTS & FIGURES 1994 Research, Prevention, Diagnosis, & Treatment The vocabulary of cancer is ever increasing, as knowledge about the disease mounts. In the past decade, words such as oncogenes, retinoids, and growth factors have become standard. Indeed, our knowledge of the genetics of cancer has soared, and it is now possible to envision the day when the genetic basis of individual cancers will be known, along with mechanisms to correct the problem. In addition to looking to the future, we can enjoy some successes now. Some cancers that only a few decades ago had a very poor outlook are often cured today: acute lymphocytic leukemia in children, Hodgkin's disease, Burkitt's lymphoma, Ewing's sarcoma (a form of bone cancer), Wilms' tumor (a kidney cancer in children), rhabdomyosarcoma (a cancer in certain muscle tissue), testicular cancer, and osteogenic (bone) sarcoma. This section highlights some developments in cancer research, prevention, diagnosis, and therapy, and indicates the directions of current and future research. Oncogenes, which play a role in normal cell growth and differentiation, can mutate and cause the runaway cell growth associated with cancer. The ras oncogene is mutated in 50% of colon cancers and 90% of pancreatic cancers. The presence of certain oncogenes is being used to predict which tumors are likely to recur after surgery and/or to identify family members at risk. Suppressor genes, which exist in normal cells to control cell growth, also play a role in cancer. Some cancers are caused when mutations occur in these genes, allowing uncontrolled cell growth. For example, the p53 suppressor gene frequently is altered in many types of cancer, including breast and lung. In one familial syndrome, where family members have high rates of cancer, about 90% of those who inherit the abnormal p53 gene get cancer by the age of 50. Family members can now be screened for this genetic abnormality before cancer develops. Through genetic engineering, researchers may be able to correct or modify hereditary susceptibility by transplanting normal copies of genes into cells that have mutated copies of those genes. Growth factors can be used to stimulate normal bone marrow cells to withstand very high doses of chemother apeutic drugs. A genetic fusing of cancer cells with normal cells can produce disease-fighting monoclonal antibodies (specific antibodies tailored to seek out chosen targets on cancer cells). Their potential in the diagnosis and treatment of cancer is under study, and they are showing promise for carrying cancer-killing radiation and drugs to a precise location. Researchers are understanding how cancer cells spre^^ to healthy tissues, a process called metastasis. Cell mutations can cause increased production of destructive enzymes that allow them to invade surrounding tissues and penetrate blood vessels to travel to other parts of the body. A powerful enzyme inhibitor, TIMP-2 is showing promise for abolishing the metastatic potential of tumor cells. A metastasis suppressor gene, NM23, has also been identified. New ways have been found to treat early breast and colon cancers postoperatively with drugs. This "adjuvant" treatment may eradicate cancer cells remaining after surgery and increase cure rates. Neoadjuvant chemotherapy (giving chemotherapy to shrink the cancer and then removing it surgically) has been tried against various types of cancers. This is a prom ising new treatment approach. Understanding the causes of pain in cancer patients has increased the options for controlling pain. Regular use of orally administered pain medicines, infusions or injections of analgesics, and procedures to interrupt pain pathways are among the effective approaches available for the majority of patients with pain from cancer. Researchers are examining synthetic retinoids (cousimy^ of vitamin A) and other substances to see if recurrences^^ of certain cancers can be prevented and if these agents can reduce cancer in high-risk groups. The cancer prevention capabilities of many other compounds are also being researched. In clinical trials, taxol, an agent obtained currently from the bark of Pacific yew trees, has been effective in treating ovarian cancer. Research efforts are underway to synthesize this scarce drug in the laboratory and the synthesized taxol will be tested for efficacy in all types of cancer. New approaches to drug therapy use combinations of chemotherapeutic drugs, or chemotherapy plus surgery or radiation. New classes of agents are being tested for their effectiveness in treating patients whose disease is resistant to drug therapies now in use. Understanding the basis of drug resistance and developing counterattacks are major areas of research today. Many patients with primary bone cancer now are treated successfully by removing and replacing a section of bone rather than by amputating the leg or arm. Drugs and radiation therapy are being used effectively after bone cancer surgery, resulting in dramatic improvement in survival. 2 CANCER FACTS 4 FIGURES 1994 SL 107290  New high-technology diagnostic imaging techniques have replaced exploratory surgery for some cancer patients. Magnetic resonance imaging (MRI) is one example of such technology. In MRI, a huge electromagnet is used to detect hidden tumors by mapping the vibrations of the various atoms in the body on a computer screen. Computerized tomography (CT) scanning uses x-rays to examine parts of the body. In both of these painless, noninvasive pro cedures, cross-section pictures can show a tumor's shape and location more accurately than is possible with conventional x-ray techniques. For patients undergoing radiation therapy, CT scanning may enable the therapist to pinpoint the tumor more precisely, and thus provide more accurate radiation dosage while sparing normal tissue. Positron emission tomography (PET) is another imaging technique. One of the advances in the area of imaging combines two or three different types of images (e.g., MRI and PET) in a computer to create a threedimensional picture that can be rotated on the screen. This technology is currently used in some medical centers to help plan for surgery and radiation therapy in areas such as the brain. Immunotherapy holds the hope of enhancing the body's own disease-fighting systems to help control cancer. Interferon (a naturally occurring body protein capable of killing cancer cells or stopping their growth), interleukin2 (a growth factor that stimulates cells of the immune system to fight cancer), and other biologic response modifiers are under study. Recently, interferon was made available to all doctors as the treatment for hairy cell leukemia, a rare blood cancer of older Americans. Interleukin-2 is under active research in the treatment of kidney cancer and melanoma. Gene therapy is the newest approach to stimulating immune cells to fight cancer. Vaccines against several types of cancer are also being developed. Many cancers develop in a two-stage process through exposure to substances known as initiators and promoters. Research scientists are exploring ways to interrupt this process. Ongoing research into new drug development will result in compounds that are less toxic to normal cells and more potent against tumor cells. New drugs will also allow physicians to circumvent the problem of drug resistance that many cancer cells develop. Along that same line of research, genes responsible for cancer cell resistance to chemotherapy have recently been discovered. New technologies have made it possible to use bone marrow transplantation as an important treatment option in select patients with leukemia and lymphoma. Bone marrow transplantation for breast cancers and other malignant tumors is under study. Because disruption of bone marrow function is a side effect of some cancer treatments, researchers are evaluating autologous bone marrow transplants, in which a portion of the patient's own marrow is removed before treatment, saved, and later restored. This procedure eliminates the problems of matching a donor with the recipient patient, and may make it possible for the patient to tolerate larger doses of anticancer drugs or radiation therapy. Improvements in cancer treatment have made possible more conservative management of some early cancers. In early cancer of the larynx, many patients are now able to retain the larynx and voice; in colorectal cancer, fewer permanent colostomies are needed; in many cases, the surgery for breast cancer is often more limited; and special nerve-sparing surgery now commonly used for prostate cancer could enable men to maintain normal penile function. Prostatic ultrasound (a rectal probe using ultrasonic waves to produce an image of the prostate) is currently being investigated as a potential means to increase the early detection of occult (not clinically suspected) prostate cancer. Recently, prostatic ultrasound has been combined with a blood test for prostate-specific antigen to aid in early detection of prostate cancer. A large clinical trial is underway to evaluate the usefulness of an estrogen-blocking drug called tamoxifen. Commonly used to treat women when they have breast cancer, this large study hopes to see if tamoxifen can also be used to prevent breast cancer in women who are at high risk. With medical progress producing longer survival periods for many cancer patients, clinical concerns are expanding to include not only patients' physical well-being, but also their psychosocial needs. The response of both patient and family to the disease, the patient's sexual concerns, employment and insurance needs, and ways to provide psychosocial support have emerged as important areas of research and clinical care. Psychosocial and behavioral research is showing much promise as evidence mounts that lifestyle (tobacco, diet) and environmental factors influence a person's general health and chances of developing cancer, as well as the mental ability to cope with cancer if it occurs. Research on behavioral modification is having a significant impact on symptoms of cancer and its treatment, such as pain, nausea, and vomiting. Other research deals with stress during treatment and during recovery after surgery or radiation treatment. A number of investigations concentrate on breast cancer, specifically on how women can be motivated to make use of mammography screening, and how to adjust to surgery, if such intervention becomes necessary. SL 3 CANCER FACTS & FIGURES 1994 Cancer Death Rates by Site, Males, United States, 1930-90 Rates are per 100,000 and are age-adjusted to the 1970 US census population. Cancer Death Rates by Site, Females, United States, 1930-90 Available on reproduction sheet (5005.94) Rates are per 100,000 and are age-adjusted to the 1970 US census population. 4 CANCER FACTS 4 FIGURES 1994 Available on reproduction sheet (5005.94) SL 107292 30-Year Trends in Cancer Death Rates* per 100,000 P pulation, 1958-601 1988-90 Sites All Sites Oral Esophagus Stomach Colon & rectum Colon. Rectum Liver Pancreas Larynx Lung Melanoma f skin Other skin Breast Cervix uteri Other uterus Ovary Prostate Bladder Kidney Brain Non-Hodgkin's lymphoma Hodgkin's disease Multiple myeloma Leukemia Sex Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Female Female Female Male Male Female Male Female Male Female Male Female Male Female Male Female Male Female 1958-1960 180.9 136.8 6.0 1.6 4.8 1.2 17.5 9.0 25.2 22.8 17.0 17.4 ` 8.2 5.4 5.7 5.9 10.1 6.2 2.7 0.3 36.4 5.5 1.4 1.0 1.7 . 0.8 0.3 25.7 9.4 6.6 8.8 20.5 7.2 2.7 3.8 2.0 4.0 2.7 4.8 3.2 2.2 1.3 2.0 1.4 8.9 5.7 1988-1990 218.0 140.8 4.6 1.7 5.9 1.5 6.9 3.1 23.5 16.1 20.0 14.1 3.5 2.0 5.2 3.2 9.9 7.1 2.5 0.5 74.2 30.6 3.0 1.5 1.3 0.4 0.2 27.4 3.0 3.5 7.9 25.3 5.6 1.7 5.1 2.4 5.1 3.4 7.7 5.0 0.7 0.4 3.6 2.5 8.2 4.8 Percent Changes 21% f -22% 9% 23% 25% -61% -65% - 7% -30% 17% -19% -58% -63% - 8% -45% f 14% - 6% 87% 104% 452% 120% 48% -25% -56% -33% 7% -68% -47% -10% 23% -22% -38% 35% 16% 26% 27% 62% 58% -67% -68% 85% 76% - 7% -16% Number of Deaths 1960 143,498 124,084 4,668 1,507 3,832 1,083 13,085 7,774 19,127 20,265 13,010 15,527 6,117 4,738 4,566 5,828 7,982 5,693 2,201 225 31,257 5,163 1,194 989 1,156 670 215 23,755 8,487 5,929 8,046 14,452 5,440 2,425 3,145 1,794 3,700 2,484 4,015 2,839 1,877 1,198 1,687 1,342 7,371 5,354 Number of Deaths 1990 268,283 237,039 5,636 2,769 7,213 2,506 8,336 5,737 28,635 28,895 24,385 25,325 4,250 3,570 6,557 5,811 _ 12,199 12,883 2,977 733 91,091 50,194 3,844 2,576 1,556 614 272 43,391 4,627 6,052 12,762 32,378 6,910 3,431 6,271 4,042 6,339 5,291 9,795 8,806 956 676 4,561 4,373 10,192 8,382 'Adjusted to the age distribution of the 1970 US Census population, fFeccent changes not listed because they are not meaningful. ^Primary ond non-specifted. Note: Even though death rotes declined or remained stable, the number of deaths increased because the population has become larger and older. The US population increased 38% from 1960 to 1990. SL 107293 5 CANCER FACTS & FIGURES 1994 Estimated New Cancer Cases and Deaths, United States--1994* All sites Buccal cavity & pharynx Lip Tongue Mouth Pharynx (Oral) Digestive organs Esophagus Stomach Small intestine Large intestine 1 Rectum J ,_ . (Colon-Rectum) Liver and biliary passages Pancreas Other and unspecified digestive Respiratory system Larynx Lung Other & unspecified respiratory Bone Connective tissue Melanoma of skin Breast Genital organs Cervix uteri 1 Corpus & unspecified J (Uterui> Ovary Other & unspecified genital, female Prostate Testis Other & unspecified genital, male estimated New Cases Both Sexes Male Female 1,208,000 632,000 576,000 29,600 3,300 6,000 11,100 9,200 . 19,800 2,800 3,800 6,600 6,600 9,800 500 2,200 4,500 2,600 233,300 11,000 24,000 3,600 107,000 -42,000 16,100 27,000 2,600 123,100 8,000 15.000 2,000 52.000 23.000 8,800 13,000 1,300 110,200 3,000 9,000 1,600 55.000 19.000 7,300 14,000 1,300 189,000 12,500 00 . 112,800 9,800 100,000 3,000 76,200 2,700 72,000 1,500 2,000 1,100 900 6,000 3,300 2,700 32,000 17,000 15,000 183,000 1,000 182,000 283,400 ` 15,000 31,000 24,000 5,300 200,000 6,800 1,300 208,100 -- -- -- -- 200,000 6,800 1,300 75,300 15,000 31,000 24,000 5,300 -- -- EsmmiTea yearns Both Sexes Male 538,000 283,000 7,925 75 1,750 2,100 4,000 5,150 50 1,100 1,200 2,800 121,450 10,400 14,000 950 49,000 7,000 13,200 25,900 1,000 64,550 7,800 8,400 500 24,000 3,800 7,200 12,400 450 158,200 3,800 153,000 1,400 97,900 3,000 94,000 900 1,075 600 3,300 1,600 6,900 4,300 46,300 300 63,725 4,600 5,900 13,600 1,100 38,000 325 200 38,525 ____ _ 38,000 325 200 Female 255,000 2775 25 650 900 1,200 56,900 2,600 5,600 450 25,000 3,200 6,000 13,500 550 60,300 800 59,000 500 475 1700 2,600 46,000 25,200 4,600 5>00 13,600 1,100 _ Urinary organs Bladder Kidney & other urinary 78,800 51,200 27,600 55,000 38,000 17,000 23,800 13,200 10,600 21,900 10,600 11,300 13,800 7,000 6,800 8,100 3,600 4,500 Eye 1,750 950 800 250 125 125 Brain & central nervous system 17,500 9,600 7,900 12,600 6,800 5,800 Endocrine glands Thyroid Other endocrine 14,450 13,000 1,450 4,150 3,400 750 10,300 9,600 700 1,725 1,025 700 750 400 350 975 625 350 Leukemia Lymphocytic leukemia Granulocytic leukemia Other & unspecified leukemia 28,600 12,500 11,400 4700 16,200 7,300 6,200 2,700 12,400 5,200 5,200 2,000 19,100 5,700 7,500 5,900 10,500 3,300 4,100 3,100 8,600 2,400 3,400 2,800 Other blood & lymph tissues Hodgkin's disease Non-Hodgkin's lymphoma Multiple myeloma 65,600 7,900 45,000 12700 35,900 4,400 25,000 6,500 29700 3,500 20,000 6,200 32,550 1,550 21,200 9,800 17,100 900 11,200 5,000 15,450 650 10,000 4,800 All other & unspecified sites 43,000 24,000 19,000 41,000 21,000 20,000 'Excludes basal and squamous cell cancers and in situ corcinomas except blodder. Carcinoma in situ of the uterine cervix accounts lor about 55,000 new coses annually, carcinoma in situ of the female breast accounts for about 25,000 new cases annually, and melanoma carcinoma in situ accounts for about 8,000 new cases annually. Overall, about 100,000 new cases of carcinoma in situ of all sites of cancer are diagnosed each year. Basal cell and squamous cell skin cancers account for more than 700,000 new coses annually. About 2,300 nonmelanoma skin cancer deaths will occur in 1994. Incidence estimates are based on rates from NCI SEER program 1988*90. SL 107294 6 CANCER FACTS & FIGURES 1994 Estimated New Cancer Cases, by State--1994 State AH Sites Female Breast Colon & Rectum Lung Oral Uterus Prostate Skin Melanoma Pancreas Leukemia Alabama Alasko Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming United States Puerto Rko 21,000 1,300 17,500 14,000 124,000 12,000 16,200 3,800 4,000 82,000 28,000 4,100 4,200 57,000 27,000 14,200 12,300 20,000 20,500 6,900 23,500 31,000 43,500 19,300 13,200 27,500 3,900 7700 5,900 5700 42,000 5,800 88,000 33,000 3700 55,000 15700 14,500 69,000 5700 16,500 3700 25700 66,000 4700 2700 28,000 22,000 10,600 24,000 2,000 1^08,000 9,400 2,800 150 2,500 1,900 19,000 1,900 2,500 600 600 11,500 4,200 475 600 8,800 4,200 2,200 1,900 2,600 2,900 900 3700 4,900 6,800 3,100 1700 4,100 550 1700 800 900 6,800 850 15,000 4,800 425 8,800 2,100 1,900 11,000 900 2700 475 3700 9700 750 425 4,400 3700 1,400 3700 300 182,000 1700 2,200 150 2,000 1,700 14,000 1,500 2,300 500 500 10,200 3,000 550 500 7,600 3,300 2,100 1,700 2,400 2,200 850 2,900 4,400 5,400 2,600 1,400 3,200 500 900 600 650 5,600 650 12,500 4,000 425 7,000 1700 1,600 9,400 800 1700 450 3,200 7700 500 275 3,100 2700 1,200 3,000 200 149,000 1,100 3,100 250 2,500 2,300 17,000 1,500 2,100 550 450 13,000 4,200 500 550 7,600 4,100 1,900 1,700 3,500 3,300 1,000 3,400 3,900 6,000 2,300 2,100 4,200 500 1,000 1,000 700 5,400 700 11,500 5,000 350 8,000 2700 2,200 9700 750 2700 425 4,200 10,000 375 350 4,200 3,200 1,800 2,800 250 172,000 650 550 50 350 250 3,300 275 400 125 150 2,500 900 100 100 1,400 500 300 300 375 500 150 600 950 950 350 350 450 125 175 100 150 1,000 150 2700 900 70 1,200 350 350 1,400 125 600 60 500 1700 60 60 650 500 275 550 25 29700 425 850 60 550 600 5,000 450 500 125 225 3,000 900 125 150 2,200 1,000 450 475 800 750 175 800 950 1,700 650 500 1,000 100 300 225 200 1700 225 3,600 1,400 100 2700 650 500 2,800 200 700 100 950 2700 275 75 1,100 650 375 900 90 46,000 425 3,200 150 3,100 2,600 18,000 2,600 2,500 600 800 16,000 4700 650 1,000 9,400 4,000 2,600 2,100 2,800 3,100 1,200 3,800 4,600 7,100 4,000 2,500 4,300 850 1,400 800 850 6,800 1,000 13,000 6700 950 8700 2700 2700 11,400 850 3,000 650 4,000 10,000 1700 600 4,800 3,800 1,500 4700 350 200,000 1,800 500 40 550 325 4,000 475 400 125 40 2,500 750 60 125 1,300 600 450 400 500 400 200 550 950 850 500 275 650 100 250 150 150 1,100 150 2,200 1,000 70 1700 425 400 1,800 150 400 90 700 1700 175 70 750 550 325 550 30 32,000 75 450 25 400 325 2,900 300 375 60 100 1,800 600 100 100 1,200 600 300 250 400 500 150 500 700 950 450 300 550 90 175 125 100 900 125 2,100 750 60 1,100 300 325 1,500 125 400 75 600 1,600 100 60 650 500 225 600 30 27,000 225 . 425 30 450 325 3,100 275 400 75 75 1,900 650 80 125 1,400 600 375 325 400 450 125 475 650 1,100 550 275 650 80 150 125 100 850 175 2,000 800 100 1,400 400 400 1700 100 350 80 600 1,800 125 70 600 550 250 650 60 28,600 225 Does not include carcinoma in situ or basal and squamous cell slcin cancers. These estimates are offered as a rough guide and should not be regarded as definitive. They ore calculated according to the distribution of estimated 1994 cancer deaths by state. SL 107295 7 CANCER FACTS & FIGURES 1994 Cancer M rtality by State--1994 Estimated Number of Deaths Reported ------------------------------------------------------------------------------------------------------- Death Rate Female Colon & State per 100,000' All Sites Breast Rectum Lung Oral Uterus Prostate Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Konsas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming United States Puerto Rico 179 175 157 176 166 146 170 195 230 166 176 138 150 180 178 158 157 188 190 184 193 179 176 156 178 174 160 159 184 179 185 146 176 173 155 181 169 167 180 181 175 152 178 164 124 175 180 164 180 165 154 172 129 9,400 500 7,800 6,200 52,000 5,400 7,200 1,600 1,700 37,700 12,300 1,800 1,900 25,400 12,100 6,300 5,500 9,100 9,100 3,100 10,500 13,800 19,500 8,600 5,900 12,300 1700 3,400 2,600 2,300 18700 2,600 39,000 15,200 1,400 24,700 7,000 6,500 31,000 2,500 7,400 1,500 11700 31,000 2,000 1,100 12,500 9/00 4700 10,800 800 538,000 4,500 700 50 600 475 4,600 475 600 150 150 3,000 1,000 125 175 2,200 1,100 600 500 650 750 225 850 1,200 1,700 800 425 1,060 150 325 200 225 1700 225 3,900 1,200 125 2,200 550 500 2,800 225 600 125 900 2700 200 125 1,100 850 350 950 75 46,000 325 850 50 750 650 5,100 550 800 200 200 3,800 1,100 200 175 2,900 1,200 800 600 900 850 325 1,100 1,700 2,100 1,000 550 1,300 175 325 250 225 2,100 250 4,500 1,500 150 2,600 650 600 3,500 300 700 175 1,200 2,900 200 100 1,200 900 475 1,200 75 56,000 425 2,800 175 2,200 2,100 14,500 1,200 1,900 500 400 11,500 3,800 425 475 6,800 3,700 1,700 1,500 3,100 2,900 900 3,100 3,600 5,400 2,100 1,800 3,800 450 900 850 600 4,900 600 10,200 4,600 325 7700 2,200 2,000 8700 700 2700 350 3700 9,000 325 300 3,600 2,900 1700 2,600 225 153,000 600 150 20 100 70 900 80 100 40 40 650 200 30 30 400 125 75 75 100 150 40 175 225 250 90 90 125 25 40 25 40 275 40 600 250 20 325 90 90 375 30 150 20 125 475 20 20 175 150 75 150 10 7,925 175 200 10 125 150 1,100 100 100 30 50 700 200 30 30 500 225 100 100 175 150 40 175 200 400 150 125 250 30 80 50 50 400 50 850 300 25 500 125 100 650 50 175 30 225 600 50 20 250 175 80 200 20 10700 150 600 25 600 500 3,600 450 450 100 150 3,000 850 125 175 1,800 750 500 375 500 600 225 700 850 1,400 750 450 800 175 275 150 175 1,300 175 2,600 1,200 175 1700 475 475 2,200 150 550 125 750 1,900 225 125 900 700 300 900 75 38,000 450 Skin Melanoma Pancreas 100 425 10 25 125 375 70 300 900 2,800 100 275 80 350 30 60 10 100 500 1,800 150 550 20 100 30 100 275 1,200 125 550 90 300 80 250 100 375 80 500 40 150 125 475 225 650 175 900 125 450 60 300 150 500 25 90 50 175 30 125 30 100 225 850 40 125 475 2,000 225 700 15 60 275 1,100 100 300 80 325 375 1,400 30 125 90 375 20 75 150 600 350 1,500 40 100 20 60 150 600 125 475 70 200 125 550 10 30 6,900 25 25,900 200 Leukemia 300 20 300 225 2,000 200 250 50 50 1,300 425 60 90 900 400 250 225 300 300 90 325 425 750 375 200 450 50 125 80 60 550 125 1,300 550 70 900 275 275 1,000 75 225 50 400 1,200 90 50 400 350 175 425 40 M M 19,100 150 'Average annual mortality rate for 1986-1990, adjusted to the age distribution of the 1970 US Census Population. SL 107296 8 CANCER FACTS 4 FIGURES 1994 Selected Cancers Lung Cancer Incidence; An estimated 172,000 new cases in 1994. The incidence rate, which had been increasing steadily in men and women for several decades, has declined in men, from a high of 87 per 100,000 in 1984 to 80 in 1990. The incidence rate in women continues to increase to 41 per 100,000 in 1990. Mortality: An estimated 153,000 deaths in 1994. Since 1987, more women have died of lung cancer than breast cancer, which, for over 40 years, was the major cause of cancer death in women. Signs and Symptoms: Persistent cough, sputum streaked with blood, chest pain, recurring pneumonia or bronchitis. Risk Factors: Cigarette smoking; exposure to certain industrial substances, such as arsenic, certain organic chemicals and asbestos, particularly for persons who smoke; radiation exposure from occupational, medical, and envi ronmental sources. Radon exposure may increase risk, especially in cigarette smokers. Exposure to sidestream cigarette smoke increases the risk for nonsmokers. Early Detection; Because symptoms often don't appear until the disease is in advanced stages, early detection is very difficult. In smokers who stop smoking at the time of early precancerous cellular changes, damaged bronchial lining tissues often return to normal. Smokers who persist in smoking may form abnormal cell growth patterns that lead to cancer. Chest x-ray, analysis of the types of cells contained in sputum, and fiberoptic examination of the bronchial passages assist diagnosis. Treatment: Determined by the type and stage of the cancer. Options include surgery, radiation therapy, and chemotherapy. For many localized cancers, surgery is usually the treatment of choice. Because the disease has usually spread by the time it is discovered, radiation therapy and chemotherapy are often needed in combination with surgery. In small cell cancer, chemotherapy alone or combined with radiation has replaced surgery as the treatment of choice; on this regimen, a large percentage of patients experience remission, which in some cases is long-lasting. Survival: The 5-year relative survival rate is only 13% in all patients, regardless of stage at diagnosis. The rate is 46% for cases detected when the disease is still localized, but only 16% of lung cancers are discovered that early. Colon and Rectum Cancer Incidence: An estimated 149,000 new cases in 1994, including 107,000 of colon cancer and 42,000 of rectum cancer. Mortality: An estimated 56,000 deaths (49,000 from colon cancer, 7,000 from rectum cancer) in 1994. Mortality from colorectal cancer has fallen 30% for women and 7% for men over the last 30 years. Signs and Symptoms: Rectal bleeding, blood in the stool, change in bowel habits. Risk Factors: Personal or family history of cancer or polyps of the colon or rectum; inflammatory bowel disease. High-fat and/or low-fiber diet may be associated with increased risk. Early Detection: Digital rectal examination, stool blood test, and proctosigmoidoscopy are recommended by the American Cancer Society to detect colon or rectum cancer in asymptomatic patients. Digital rectal examination is performed by a physician during an office visit. The American Cancer Society recommends that this examination be performed annually after age 40. The stool blood test is a simple method to test feces for hidden blood. The specimen is obtained by the patient at home and returned to the physician's office, a hospital, or a clinic for analysis. The Society recommends annual testing after age 50, In proctosigmoidoscopy, the physician uses a hollow lighted tube or a fiberoptic sigmoidoscope to inspect the rectum and lower colon. To detect cancers higher in the colon, longer, flexible instruments are being used. The American Cancer Society recommends sigmoidoscopy, preferably flexible, every 3 to 5 years after age 50. If any of these tests reveal possible problems, more extensive studies, such as colonoscopy (examination of the entire colon) and barium enema (an x-ray procedure in which the intestines are viewed), may be needed. TYeatment: Surgery, at times combined with radiation, is the most effective method of treating colorectal cancer. The role of chemotherapy in treating advanced cases is under study. Combinations of chemotherapy and immu nologic agents have recently been described as beneficial in postoperative patients with cancerous lymph nodes. Colostomy (creation of an abdominal opening for elim ination of body wastes) is seldom needed for colon cancer and is infrequently required for rectal cancer. The American Cancer Society has a patient assistance program for those who do have permanent colostomies (see p. 25). SL 107297 9 CANCER FACTS i FIGURES 1994 Survival: When colorectal cancer is detected in an early, localized stage, the 5-year survival rates are 92% for colon cancer and 85% for rectal cancer. After the cancer has spread regionally, to involve adjacent organs or lymph nodes, the survival rates drop to 61%,and 51%, respectively. Survival rates for persons with distant metastases are less than 7%. Breast Cancer Incidence: An estimated 182,000 new cases among women in the United States during 1994. About 1,000 new cases of breast cancer will be diagnosed in men in 1994. Breast cancer incidence rates for women increased about 2% a year since 1980, but recently have leveled off at about 108 per 100,000. Most of the recent rise in rates is believed to be due to marked increases in mammography utilization, allowing the detection of early stage breast cancers, frequently before they would become clinically apparent. Other reasons for a longer-term increase in breast cancer are not yet understood. Mortality: An estimated 46,300 deaths (46,000 women, 300 men) in 1994; in women, the second major cause of cancer death. Although incidence rates are increasing, early detection and improved treatment have kept mortality rates fairly stable over the past 50 years. Signs and Symptoms: Breast changes that persist, such as a lump, thickening, swelling, dimpling, skin irritation, distortion, retraction, scaliness, pain, tenderness of the nipple, or nipple discharge. Risk Factors: Over age 40, increases with age; personal or family history of breast cancer; early age at menarche, late age at menopause, never had children or late age at first live birth, and higher education and socioeconomic status. International variability in cancer incidence rates correlate with variations in diet, especially fat intake, although a causal role for dietary factors has not been firmly established. Breast cancer risk factors appear to be more useful in providing clues to the development of cancer than in identifying prevention strategies. Since adult women may not be able to alter their personal risk factors in any practical sense, the best opportunity for reducing mortality is through early detection. Many women will have one or more risk factors for breast cancer. How ever, most risks are at such a low level that they only partly explain the high frequency of the disease in the population. Early Detection: The Society recommends that women have a screening mammogram by age 40; women 40 to 49 should have a mammogram every 1-2 years; asymp tomatic women age 50 and over should have a mammogram every year. In addition, a clinical physical examination of the breast is recommended every three years for women 20 to 40, and every year for those over 40. The Society also recommends monthly breast self-examination as a routine good health habit for women 20 years or older. Most breast lumps are not cancer, but only a physician can make a diagnosis. Besides its effectiveness in screening asymptom women, mammography is recognized as a valuable diaiF nostic technique for women who have findings suggestive of breast cancer. Once a breast lump is found, mammog raphy can help determine if there are other lesions too small to be felt in the same or opposite breast. Since a small percentage of breast cancers may not be seen on a mammogram, all suspicious lumps should be biopsied for a definitive diagnosis, even when current or recent mammography findings are described as normal. TVeatment: Taking into account the medical situation and the patient's preferences, treatment may require lumpectomy (local removal of the tumor), mastectomy (surgical removal of the breast), radiation therapy, chemo therapy, or hormone manipulation therapy. Often, two or more methods are used in combination. Patients should discuss with their physicians possible options for the best management of their breast cancer. New techniques in recent years have made breast reconstruction possible after mastectomy, and the cosmetic results usually are good. Reconstruction has become an important part of treatment and rehabilitation. Survival: The 5-year survival rate (which includes all women living five years after diagnosis, whether the patient is in remission, disease-free, or under treatment) fo| localized breast cancer has risen from 78% in the 1940* to 93% today. If the cancer has spread regionally at the time of diagnosis, however, the 5-year survival rate is 72%, for persons with distant metastases at the time ofdiagnosis, the 5-year survival rate is 18%. From current data, based on women diagnosed in the early 1970s, the long-term breast cancer survival rate is about 50%. Prostate Cancer Incidence: An estimated 200,000 new cases in the United States during 1994. Prostate cancer incidence rates are 30% higher for black men than white men. Between 1980 and 1990, prostate cancer incidence rates increased 50%, largely due to improved detection. Further increased incidence is expected with widespread use of serum screening tests. Mortality: An estimated 38,000 deaths in 1994, the second leading cause of cancer death in men. Signs and Symptoms: Weak or interrupted urine flow; inability to urinate, or difficulty starting or stopping the urine flow; the need to urinate frequently, especially at night; blood in the urine; pain or burning on urination; continuing pain in lower back, pelvis, or upper thighs. 10 CANCER FACTS A FIGURES 1994 SL 107298 Leading Sites of Cancer Incidence and Death--1994 Estimates Cancer Incidence fay Site and Sex* Male Female Cancer Deaths fay Site and Sex Male Female All Sites 632,000 All Sites 576,000 'Excluding basal and squamous cell skin cancer and carcinoma in situ. All Sites 283,000 All Sites 255,000 Available on reproduction sheet (5005-94) Most of these symptoms are nonspecific and may be similar to those caused by benign conditions such as infection or prostate enlargement. Risk Factors: Incidence increases with age; over 8096 of all prostate cancers are diagnosed in men over age 65. The disease is more common in northwestern Europe and North America. It is rare in the Near East, Africa, Central America, and South America. For reasons not currently known, black Americans have the highest incidence rate in the world. There is some familial association, but it is unclear whether this is due to genetic or environmental factors. International studies suggest that dietary fat may be a factor. Early Detection: Every man 40 and over should have a digital rectal examination as part of his regular annual physical checkup. In addition the American Cancer Society recommends that men 50 and over have an annual prostate-specific antigen blood test If either result is suspicious, further evaluation in the form of transrectal ultrasound should be performed. Treatment: Surgery, radiation, and/or hormones and anticancer drugs, are treatment options. Hormone treat ment and anticancer drugs may control prostate cancer for long periods by shrinking the size of the tumor, thus relieving pain. Survival: Fifty-eight percent of all prostate cancers are discovered while still localized; the 5-year relative survival rate for patients whose tumors are diagnosed at this stage is 92%. Survival rates for all stages combined have steadily improved, and in the past 30 years have increased from 50% to 78%. SL 107299 11 CANCER FACTS 4 FIGURES 1994 How t Estimate Cancer Statistics Locally Estimated number of... Number per Multiply community 100,000 population by Special Notes J New cancer cases, 1994 Cancer deaths, 1994 400 200 Cancer survivors, 1994 2,000 Cancer cases under care, 1994 1,60C People who will eventually develop cancer People who will eventually die of cancer People who will be saved from cancer in 1994 40,000 20,000 200 0.004 0.002 0.020 0.016 0.400 0.200 0.002 Estimated cases and deaths will not reflect the age and ethnic characteristics ^ of the population, access to detection and treatment, and varying risk factors. Actual data from a population-based tumor registry will allow more accurate estimates. Represents the number of people who were diagnosed over 5 years ago and are still living today. Represents the number of people diagnosed in 1994 and within the previous 5 years. All are assumed to be under treatment or follow-up care. If current incidence and mortality rates remain the same, about 40% will develop cancer before they die. If current mortality rates remain the same, about 1 in 5 people living today will die of cancer. Based on 5-year relative survival rate of 53%. Note; The figures ate only a rough approximation of actual data for a community and should be used with caution. Numbers may vary according to the age distribution of the local population. Pancreas Cancer Incidence: An estimated 27,000 new cases in the United States in 1994. The disease is more common in men, and occurs more frequently in black Amerioans than in white Americans. Mortality: An estimated 25,900 deaths in 1994. Pan creatic cancer incidence and mortality rates have been fairly stable since the early 1970s, except among black women, whose rates have increased slightly. Signs and Symptoms: Cancer of the pancreas is a "silent" disease, one that occurs without symptoms until it is in advanced stages. Risk Factors: Very little is known about what causes the disease or how to prevent it Risk increases after age 50, with the most cases occurring between ages 65 and 79. Smoking is a risk factor; incidence is more than twice as high for smokers as nonsmokers. Some studies have suggested associations with chronic pancreatitis, diabetes, or cirrhosis. In countries where the diet is high in fat, pancreatic cancer rates are higher. Early Detection: At present, only a biopsy yields a certain diagnosis, and because ofthe "silent" course ofthe disease, the need for biopsy is likely to be obvious only after the disease has advanced. Researchers are focusing on ways to diagnose pancreatic cancer before symptoms occur. Ultrasound imaging and computerized tomography scans are being tried. IVeatment: Surgery, radiation therapy, and anticancer drugs are treatment options, but have had little influence on the outcome. Diagnosis is usually so late that none of these is used. Survival: Only 3% of patients live more than 5 years after diagnosis. Uterus (Cervix) Cancer Incidence: An estimated 15,000 invasive and 55,00(4 carcinoma in situ cases will be diagnosed in 1994. The rate of invasive cervical cancer has decreased steadily over the last several decades, but has increased in recent years in women under 50. Cervical carcinoma in situ, a precancerous condition, is now more frequent than invasive cancer, especially in women under 50. Mortality: An estimated 4,600 deaths from cervical cancer in 1994. The mortality rate is more than twice as high for black women as for white women. Signs and Symptoms: Abnormal uterine bleeding or spotting; abnormal vaginal discharge. Pain and systemic symptoms are late manifestations of the disease. Risk factors: Early age at first intercourse, multiple sex partners, cigarette smoking, and infection with certain types of human papillomavirus. Early Detection: The Pap test is a simple procedure that can be performed at appropriate intervals by health care professionals as part of a pelvic examination. A small sample of cells is swabbed from the cervix, transferred to a slide, and examined under a microscope. This test should be performed annually with a pelvic examination in women who are, or have been, sexually active or who have reached age 18 years. After three or more consecutive annual examinations with normal findings, the Pap test 12 CANCER FACTS 4 FIGURES 1994 SL 107300 Percentage of Population (Probability) Developing Invasive Cancers at Certain Ages Birth to 39 40 to 59 60 to 79 Ever (Birth to Death) All sites Breast Colon & rectum Prostate lung Male Female Female Male Female Male Male Female 1.68 (1 in 60) 1.91 (1 in 52) 0.45 (1 in 222) 0.06 (1 in 1,667) 0.05 (lin 2,000) Less than 1 in 10,000 0.04 (lin2,500) 0.03 (lin3,333) 7.51 (1 in 13) 9.29 (1 in 11) 3.78 (1 in 26) 0.91 (lin 110) 0.73 (1 in 137) 0.78 (1 in 128) 1.60 (1 in 63) 1.07 (1 in 93) 32.27 (1 in 3) 23.06 (1 in 4) 6.78 (1 in 15) 4.45 (1 in 22) 3.34 (lin30) 10.71 (lin 9) 6.69 (1 in 15) 3.49 (1 in 29) 42.52 (lin2) 38.88 (lin3) 12.20 (1 in 8) 6.12 (1 in 16) 5.96 (lin 17) 13.05 (lin8) 8.43 (1 in 12) 5.02 (lin20) Note: This chart shows the risks of being diagnosed with the most common cancers over certain age intervals. These risks are calculated for persons free of the specified cancer at the beginning of the age interval. Risk estimates do not assume all persons live to the end of the age interval or to any fixed age. Risk estimates are presented to give on approximate measure of the burden of cancer to society. Measures ore based on population level rates and do not take into account individual behaviors and risk factors. For example, lung cancer is rare among nonsmokers or persons not heavily exposed to environmental tobacco smoke, so the risk for a nonsmoking man getting lung cancer in his lifetime is much lower than 8.4%, and it is much higher for a smoker. It is clear that the risk of developing cancer increases with age. For prostate cancer, the risk before age 60 is very low, but between oge 60 and 80,1 in 9 men will be diagnosed with prostate cancer. Source of data: Applied Research Branch, National Cancer Institute Available on reproduction sheet (5005.94) may be performed less frequently at the discretion of the physician. IVeatment: Cervix cancers generally are treated by surgery or radiation, or by a combination of the two. In precancerous (in situ) stages, changes in the cervix may be treated by cryotherapy (the destruction of cells by extreme cold), by electrocoagulation (the destruction of tissue through intense heat by electric current), or by local surgery. Survival: The 5-year survival rate for cervical cancer patients is 67%. For women diagnosed with localized disease the survival rate is 90%. Uterus (Endometrial) Cancer Incidence: An estimated 31,000 cases of cancer of the corpus (body) of the uterus, usually of the endometrium (lining). Endometrial cancer is most frequently diagnosed in women over age 50. Mortality: An estimated 5,900 deaths in 1994. Signs and Symptoms: Abnormal uterine staining or bleeding, especially postmenopausal. Pain and weight loss occur late in the disease. Risk Factors: Early menarche, late menopause, history of infertility, failure to ovulate, tamoxifen or unopposed estrogen therapy, obesity. During menopause, the level of hormones (estrogens) normally produced by the ovaries declines. This causes symptoms such as "hot flashes" or painful sexual inter course due to thinning of the vaginal lining. To control these symptoms, estrogen replacement therapy may be given to women during and after menopause. This therapy may increase the risk of endometrial cancer, therefore, the benefits and risks ofsuch treatment should be discussed by the woman and her physician. Early Detection: The Pap test, highly effective in detecting early cancer of the uterine cervix, is only partially effective in detecting endometrial cancer. Women 40 and over should have an annual pelvic exam by a health professional. Women at high risk of developing endometrial cancer should have an endometrial tissue sample evaluated at menopause. Treatment: Uterine cancers are usually treated with surgery, radiation, hormones, and/or chemotherapy depending on the stage of disease. Survival: The 5-year survival rate for endometrial cancer is 83% overall, 94% if discovered at an early stage, and 69% if diagnosed in a regional stage. Cancer in Children Incidence: An estimated 8,200 new cases in 1994; as a childhood disease, cancer is rare. Common sites include the blood and bone marrow, bone, lymph nodes, brain, nervous system, kidneys, and soft tissues. Mortality: An estimated 1,600 deaths in 1994, about onethird of them from leukemia. Despite its rarity, cancer is the chief cause of death by disease in children between the ages of 1 and 14. Mortality rates have declined 60% since 1950. Early Detection: Cancers in children often are difficult to recognize. Parents should see that their children have regular medical checkups and should be alert to any unusual symptoms that persist. These include: an unusual mass or swelling; unexplained paleness and loss of energy; sudden tendency to bruise; a persistent, localized pain or limping; prolonged, unexplained fever or illness; frequent headaches, often with vomiting; sudden eye or vision SL 107301 13 CANCER FACTS & FIGURES 1994 changes; and excessive, rapid weight loss. Some of the main childhood cancers are: Leukemia, below. Osteogenic sarcoma and Ewing's sarcoma are bone cancers. These may cause no pain at first, and swelling in the area of the tumor is often the first sign. Neuroblastoma can appear anywhere but usually in the abdomen, where a swelling occurs. Rhabdomyosarcoma, the most common soft tissue sarcoma, can occur in the head and neck area, genito urinary area, trunk, and extremities. Brain cancers in early stages may cause headaches, blurred or double vision, dizziness, difficulty in walking or handling objects, and nausea. Lymphomas and Hodgkin's disease are cancers that involve the lymph nodes, but also may invade bone marrow and other organs. They may cause swelling of lymph nodes in the neck, armpit, or groin. Other symptoms may include general weakness and fever. Retinoblastoma, an eye cancer, usually occurs in children under age four. When detected early, cure is possible with appropriate treatment. Wilms' tumor, a kidney cancer, may be recognized by a swelling or lump in the abdomen. Treatment: Childhood cancers can be treated by a combination of therapies. TYeatment is coordinated by a team of experts including oncologic physicians, pediatric nurses, social workers, psychologists, and others who assist children and their families. Survival: Five-year survival rates vary considerably, depending on the site: all sites, 68%; bone cancer, 58%; neuroblastoma, 57%; brain and central nervous system, 60%; Wilms' tumor (kidney), 88%; Hodgkin's disease, 88%; and acute lymphocytic leukemia, 72%. Leukemia Incidence: An estimated 28,600 new cases in 1994, approximately evenly divided into acute leukemia and chronic leukemia. Although often thought of as primar ily a childhood disease, leukemia will strike many more adults (26,000 this year) than children (2,600 this year). Acute lymphocytic leukemia accounts for approximately 2,000 of the cases of leukemia among children. In adults, the most common types are acute granulocytic (approxi mately 7,000 cases) and chronic lymphocytic (approxi mately 8,500 cases). Mortality: An estimated 19,100 deaths in 1994. Signs and Symptoms: Fatigue, paleness, weight loss, repeated infections, bruising easily, and nosebleeds or other hemorrhages. In children, these signs can appear suddenly. Chronic leukemia can progress slowly and with few symptoms. Risk Factors: Leukemia strikes both sexes and all ages. Causes of most cases are unknown. Persons with Down syndrome and certain other genetic abnormalities have higher than normal incidence of leukemia. It has also been linked to excessive exposure to ionizing radiation and certain chemicals such as benzene, a commercially usAV toxic liquid that is also present in lead-free gasoline. Certain forms of leukemia and lymphoma are caused by a retrovirus, HTLV-I (human T-cell leukemia/lymphoma virus-I). Early Detection: Because symptoms often resemble those of other, less serious conditions, leukemia can be difficult to diagnose early. When a physician does suspect leukemia, diagnosis can be made using blood tests and biopsy of the bone marrow. Treatment: Chemotherapy is the most effective method of treating leukemia. Various anticancer drugs are used, either in combinations or as single agents. Transfusions of blood components and antibiotics are used as supportive treatments. To illuminate hidden cells, therapy of the central nervous system has become standard treatment, especially in acute lymphocytic leukemia. Under appro priate conditions, bone marrow transplantation may be useful in the treatment of certain leukemias. Survival: The 5-year survival rate for patients with leukemia is 38%, due partly to very poor survival of patients with some types of leukemia such as acute granulocytic. Over the last 30 years, however, there has been a dramatic improvement in survival of patients with acute lymphocytic leukemia; from a 5-year survival rate of 4% for people diagnosed in the early 1960s to 28% in the early 197fiflfc to 52% in the mid-1980s. In children, the improvement^ has been from 4% to 72%. Lymphoma Incidence: An estimated 52,900 new cases in 1994, including 7,900 cases of Hodgkin's disease and 45,000 non-Hodgkin's lymphoma. Since the early 1970s, incidence rates for non-Hodgldn's lymphoma have increased over 65%. Incidence of Hodgkin's disease has declined over the same time period, especially among the elderly. Mortality: An estimated 22,750 deaths in 1994 (nonHodgkin's lymphoma, 21,200; Hodgkin's disease, 1,550). Signs and Symptoms: Hodgkin's disease: enlarged lymph nodes, itching, fever, night sweats, and weight loss. Fever can come and go in periods of several days or weeks. Non-Hodgkin's lymphoma: enlarged lymph nodes, anemia, weight loss, and fever. Risk Factors: Risk factors are largely unknown but in part involve reduced immune function and exposure to certain infectious agents. Persons with organ transplants are at higher risk due to altered immune function. Human immunodeficiency virus (HIV) and human T-cell leukemia/ lymphoma virus-I (HTLV-I) are associated with increasetfk risk of non-Hodgkin's lymphoma. Burkitt's lymphoma ir^^ SL 107302 14 CANCER FACTS 4 FIGURES 1994 Africa is partly caused by the Epstein-Barr herpes virus. Other possible risk factors include exposures to herbicides, industrial solvents, and vinyl chloride. Treatment: Hodgkin's disease: chemotherapy and radio therapy are useful for most patients. Non-Hodgkin's lymphoma: early stage, localized lymph node disease can be treated with radiotherapy. Patients with later stage disease often benefit from the addition of chemotherapy. New programs using highly specific monoclonal antibodies directed at lymphoma cells, and improved techniques in bone marrow preservation, are under investigation in selected patients who relapse after standard treatment. Survival: Survival rates vary widely by cell type and stage of disease. The overall 5-year survival rate for Hodgkin's disease is 78%. The overall 5-year survival for nonHodgkin's lymphoma has steadily improved, and in the past 30 years has increased from 31% to 52%. Skin Cancer Incidence: Over 700,000 cases a year of highly curable basal cell or squamous cell cancers. They are more common among individuals with lightly pigmented skin. The most serious skin cancer is melanoma, which will be diagnosed in about 32,000 persons in 1994. Since 1973, the incidence rate ofmelanoma has increased about 4% per year. Incidence rates are over ten times higher among whites than blacks. An additional 10,000 invasive nonmelanoma skin cancers will occur in 1994, mostly sarcomas, including Kaposi's sarcoma. Mortality: An estimated 9,200 deaths this year, 6,900 from malignant melanoma and 2,300 due to other skin cancers. Signs and Symptoms: Any unusual skin condition, especially a change in the size or color of a mole or other darkly pigmented growth or spot. Scaliness, oozing, bleeding, or change in the appearance of a bump or nodule, the spread of pigmentation beyond its border, a change in sensation, itchiness, tenderness, or pain. Risk Factors: Excessive exposure to ultraviolet radiation; fair complexion; occupational exposure to coal tar, pitch, creosote, arsenic compounds, or radium. Prevention: The sun's ultraviolet rays are strongest between 10 a.m. and 3 p.m. Exposure at these times should be avoided, and protective clothing should be worn. Sunscreens should be used. These come in various strengths, ranging from those facilitating gradual tanning to those that allow practically no tanning. Because of the possible link between severe sunburns in childhood and greatly increased risk of melanoma in later life, children, in particular, should be protected from the sun. Early Detection: Early detection is critical. Recognition of changes in skin growths or the appearance of new growths is the best way to find early skin cancer. Adults should practice skin self-examination once a month, and suspicious lesions should be evaluated promptly by a physician. Basal and squamous cell skin cancers often take the form of a pale, waxlike, pearly nodule, or a red, scaly, sharply outlined patch. A sudden or progressive change in a mole's appearance should be checked by a physician. Melanomas often start as small, mole-like growths that increase in size, change color, become ulcerated, and bleed easily from a slight injury. A simple ABCD rule outlines the warning signals of melanoma: A is for asymmetry. One half of the mole does not match the other half. B is for border irregularity. The edges are ragged, notched, or blurred. C is for color. The pigmentation is not uni form. D is for diameter greater than 6 millimeters. Any sudden or progressive increase in size should be of special concern. Treatment: There are four methods of treatment: surgery (used in 90% of cases), radiation therapy, electrodessication (tissue destruction by heat), or cryosurgery (tissue destruction by freezing) for early skin cancer. For malignant melanoma, the primary growth must be adequately excised, and it may be necessary to remove nearby lymph nodes. Removal and microscopic examination of all suspicious moles is essential. Advanced cases of melanoma are treated according to the characteristics of the case. Survival: For basal cell or squamous cell cancers, cure is highly likely if detected and treated early. Malignant melanoma can spread to other parts of the body quickly; however, when detected in its earliest stages, and with proper treatment, it is highly curable. The overall 5-yearsurvival rate for patients with malignant melanoma is 84%. The 5-year survival rate for localized malignant melanoma is 92%; survival rates for regional and distant disease are 55% and 14%, respectively. About 82% of melanomas are diagnosed in a local stage. Ovary Cancer Incidence: An estimated 24,000 new cases in the United States in 1994. It accounts for 4% of all cancers among women. Mortality: An estimated 13,600 deaths in 1994. Although ovarian cancer ranks second in incidence among gyne cological cancers, it causes more deaths than any other cancer of the female reproductive system. Signs and Symptoms: Ovarian cancer is often "silent," showing no obvious signs or symptoms until late in its development. The most common sign is enlargement of the abdomen, which is caused by the accumulation of fluid. Rarely will there be abnormal vaginal bleeding. In women over 40, vague digestive disturbances (stomach discomfort, gas, distention) that persist and cannot be explained by any other cause may indicate the need for a thorough evaluation for ovarian cancer. SL 107303 15 CANCER FACTS & FIGURES 1994 Five-Year Relative Survival Rates by Stage at Diagnosis* Site All Stages % Local % Oral Colon-rectum Pancreas Lung Melanoma Female breast Cervix uteri Corpus uteri Ovary Prostate Bladder Kidney 53 78 58 89 38 13 46 84 92 79 93 67 90 83 94 39 88 77 92 79 91 55 86 'Adjusted for normal life expectancy. This chart based on cases diagnosed in 1983-87, followed through 1990, Source: Cancer Statistics Branch, National Cancer Institute Regional % 42 58 4 13 55 72 52 69 36 82 46 57 Distant % 19 6 2 1 14 18 13 27 17 28 9 10 Available an reproduction sheet (5005.94) Risk Factors: Risk for ovarian cancer increases with age. Women who have never had children are more likely to develop ovarian cancer than those who have. Increased number of pregnancies and the use of oral contraceptives, appear to be protective against ovarian cancer. Women who have had breast cancer or have a family history of ovarian cancer are at increased risk. Certain rare genetic disorders are associated with increased risk. With the exception of Japan, the highest incidence rates are reported from the more industrialized countries. Early Detection: Periodic, thorough pelvic examinations are important The Pap test, useful in detecting cervical cancer, does not reveal ovarian cancer. Women over the age of 40 should have a cancer-related checkup every year. IVeatment: Surgery, radiation therapy, and drug therapy are treatment options. Surgery usually includes the removal of one or both ovaries (oophorectomy), the uterus (hys terectomy), and the fallopian tubes (salpingectomy). In some very early tumors, only the involved ovary will be removed, especially in young women. In advanced disease, an attempt is made to remove all intraabdominal disease, to enhance the effect of chemotherapy. Survival: Overall, the 5-year survival rate for ovarian cancer is 41%. If diagnosed and treated early, the relative survival rate is 88%; however, only about 23% of all cases are detected at the localized stage. Survival rates for women with regional and distant disease are 36% and 17%, respectively. Bladder Cancer Incidence: An estimated 51,200 new cases in 1994; 38,000 in men, 13,200 in women. Overall, the incidence rate of bladder cancer is four times greater among men than among women, and is higher in whites than in blacks. Mortality: An estimated 10,600 deaths in 1994. Signs and Symptoms: Blood in the urine. Usually associated with increased frequency of urination. Risk Factors: Smoking is the greatest risk factor in bladder cancer, with smokers experiencing twice the risk of nonsmokers. Smoking is estimated to be responsible for approximately 47% of the bladder cancer deaths amor^^ men and 37% among women. People living in urban arelj^P and workers exposed to dye, rubber, or leather also are at higher risk. Early Detection: Bladder cancer is diagnosed by exam ination of the bladder wall with a cystoscope, a slender tube fitted with a lens and light that can be inserted into the tract through the urethra. Treatment: Surgery, alone or in combination with other treatments is used in over 90% of cases. Preoperative chemotherapy alone or with radiation before cystectomy (bladder removal) has improved some treatment results. Survival: When detected at an early stage, the 5-year survival rate for bladder cancer is 91%. For regional and distant disease, the survival rates are 46% and 9%, respectively. Oral Cancer Incidence: An estimated 29,600 new cases in 1994. Incidence is more than twice as high in men as in women, and is most frequent in men over age 40. Mortality: An estimated 7,925 deaths in 1994. Signs and Symptoms: A sore that bleeds easily and doesn't heal; a lump or thickening; a red or white patch that pet sists. Difficulty in chewing, swallowing, or moving tong^A or jaws are often late changes. 16 CANCER FACTS & FIGURES 1994 10^04 Trends in Cancer Survival, by Race Cases Diagnosed in 1960-63,1970-73,1974-76,1977-79,1983-89 White Black Relative 5-Year Survival % Relative 5-Year Survival % Site 1960-63' 1970-73' 1974-76' 1977-79' 1983-89' 1960-63' 1970-73' 1974-76' 1977-79' 1983-89' All sites Oral cavity & pharynx Esophagus Stomach Colon Rectum Liver Pancreas Larynx Lung & bronchus Melanoma of skin Female breast Cervix uteri Corpus uteri Ovary Prostate Testis Urinary bladder Kidney ft renal pelvis Brain & nervous system Thyroid gland Hodgkin's disease Non-Hodgkin's lymphoma Multiple myeloma Leukemia 39 45 4 11 43 38 2 1 53 8 60 63 58 73 32 50 63 53 37 18 83 40 31 12 14 43 50 43 55 45 13 14 49 50 45 49 34 2 '3 62 '66 10 12 68 80 68 75 64 69 81 89 36 36 63 68 72 79 61 74 46 52 20 22 86 92 67 72 41 48 19 24 22 35 51 55* 27 54 54 -- 6 10* 1 16 17* 8 53 60* 34 50 58* 27 3 6* -- 2 3* 1 68 68 -- 14 13* 5 82 84* -- 75 81* 46 69 69 47 86 85* 31 38 40* 32 72 79* 35 88 93* -- 76 80* 24 51 56* 38 24 26* 19 92 94* -- 73 79* -- 48 52* -- 25 27* -- 37 39* -- 31 39 39 39 -- 36 36 33 4 4 3 7* 13 16 15 18 37 46 48 49* 30 42 38 45 --1 6 5 2 2 4 5* 59----- . 55 54 7 11 11 11 -- 69f 52* 72f 51 63 63 64 61 63 62 57* 44 60 58 56 32 41 40 40 55 58 62 64* -- 76f ___ 84f 36 48 55 61* 44 49 52 51 19 27 28 31 --V 87 92 92 -- 69 73 74 -- 48 50 44 -- 27 34 29 -- 31 30 30 Source: Cancer Statistics Branch, National Cancer Institute 'Rates are based on End Results Group data from a series of hospital registries and one population-based registry. 'Rates are from the SEER Program. They are bosed on data from population-bosed registries in Connecticut, New Mexico, Utah, Iowa, Hawaii, Atlanta, Detroit, Seattle-Puget Sound, and San Franciseo-Oakland, Rates are based on follow-up of patients through 1990. *The difference in rates between 1974-76 and 1983-89 is statistically significant (p <0.05). fThe standard error of the survival rate is between 5 and 10 percentage points. +The standard error of the survival rote is greater thon 10 percentage points. --Valid survival rate could not be calculated. Risk Factors: Cigarette, cigar, or pipe smoking; use of smokeless tobacco; excess use of alcohol. Early Detection: Cancer can affect any part of the oral cavity, including the lip, tongue, mouth, and throat. Dentists and primary care physicians have the opportunity, during regular checkups, to see abnormal tissue changes and to detect cancer at an early, curable stage. Treatment: Principal methods are radiation therapy and surgery. Chemotherapy is being studied as an acljunct to surgery in advanced disease. Survival: Five-year survival rates vary substantially, depending on the site. Rates range from 25% for cancer of the hypopharynx to 90% for lip cancer. Overall, 5-year survival for oral cancer patients is about 52%. SL 107305 17 CANCER FACTS ft FIGURES 1994 Cancer in Minorities In 1994, about 1,208,000 cancers will be diagnosed in the United States. About 120,000 of these cancers will be among black Americans and 35,000 among other minority Americans. Cancer incidence and mortality rates are generally higher for black Americans than for whites. In 1990, the incidence rates were 423 per 100,000 for blacks and 393 for whites, about a 6% difference. In 1990, the mortality rates were 230 for blacks and 170 for whites. Cancer sites for which blacks have significantly higher incidence and mortality rates include esophagus, uterine cervix, stomach, liver, prostate, larynx, and multiple myeloma. Rates for esophageal cancer are over three times higher among blacks than whites. The 5-year survival rate for cancer in blacks diagnosed from 1983 through 1989 was about 39% compared with 55% for whites. A considerable part of this difference in survival can be attributed to late diagnosis. Many cancers are more frequently diagnosed in a localized stage among whites than among blacks. Most of these sites represent cancers for which screening tests are available or which present symptoms early in the disease process. Early detection and timely treatment can increase survival. Incidence and mortality rates for other minority groups such as Hispanics are often lower than those for white or black Americans. Because cancer risk is strongly associated with lifestyle and behavior, differences in ethnic and cultural groups can provide clues to factors involved in the development of cancer such as dietary patterns, alcohol use, and sexual and reproductive behaviors involved in the development of cancer. Cultural values and belief systems can affect attitudes about seeking medical care or following screening guidelines (see p. 21). Socioeco nomic factors such as lack of health insurance or transportation can impede access to care, and lead to late diagnosis and poor survival. Number of Cancer Deaths for Black, American Indian, Chinese, Japanese, and Hispanic Persons, United States, 1990 Cancer She Black Males Black Females American Indian Chinese Japanese Hispanic* All sites Oral cavity Esophagus Stomach Colon & rectum Liver & other biliary Pancreas Lung (male) Lung (female) Melanoma of skin Breast (female) Cervix uteri Other uterus Ovary Prostate Bladder Kidney Brain & CNSf Lymphoma Leukemia Multiple myeloma 31,995 1,000 1,433 1,341 2,898 757 1,442 10,632 -- 51 -- -- -- -- 5,181 466 563 372 747 854 745 25,082 311 541 917 3,169 615 1,581 -- 4,512 55 4,659 972 899 975 -- 381 382 319 573 737 708 1,275 23 19 67 117 68 52 205 117 9 89 47 12 34 59 9 39 21 50 52 39 1,527 60 45 117 166 168 65 238 145 2 88 22 15 29 42 21 12 35 47 47 15 1,122 23 32 132 168 66 77 148 75 3 79 12 14 22 56 12 14 14 42 27 6 14,003 232 233 811 1,414 769 795 1,824 787 89 1,246 296 168 385 728 210 355 376 688 735 273 'Persons classified os of Hispanic origin on death certificates may be of ony race. Hispanic origin reporting, however, may be incomplete on death certificates in some states. These numbers are believed to include over 90% of cancer deaths in Hispanics in 1990. fCNS = Central nervous system. Available on reproduction sheet (5005.94) 18 CANCFR FACTS it FIGURES 1994 * SL 107306 Prevention Smoking Cigarette smoking is responsible for 90% of lung cancer among men and 79% among women--about 87% overall. Smoking accounts for about 30% of all cancer deaths. Those who smoke two or more packs of cigarettes a day have lung cancer mortality rates 12 to 25 times greater than nonsmokers. (See Tobacco Use.) Nutrition and Diet Research is showing the important role nutrition plays in preventing cancer. Evidence indicates that people may reduce their cancer risk by observing these nutrition guidelines: 1. Maintain a desirable weight Individuals 40% or more overweight increase their risk of colon, breast, prostate, gallbladder, ovary, and uterus cancers. Physicians can recommend a suitable diet and exercise regimen to help maintain appropriate weight and body fitness. 2. Eat a varied diet. A varied diet eaten in moderation offers the best hope for lowering the risk of cancer. 3. Include a variety of vegetables and fruits in the daily diet. Studies have shown that daily consumption of vegetables and fresh fruits is associated with a decreased risk of lung, prostate, bladder, esophagus, colorectal, and stomach cancers. 4. Eat more high-fiber foods such as whole grain cereals, breads, and pasta; and vegetables and fruits. High-fiber diets are a healthy substitute for fatty foods and may reduce the risk of colon cancer. 5. Cut down on total fat intake. A diet high in fat may be a factor in the development of certain cancers, particularly breast, colon, and prostate. 6. Limit consumption of alcohol, if you drink at all. Heavy drinking, especially when accompanied by cigarette smoking or smokeless tobacco use, increases risk ofcancers of the mouth, larynx, throat, esophagus, and liver. 7. Limit consumption ofsalt-cured, smoked, and nitritecured foods. In areas of the world where salt-cured and smoked foods are eaten frequently, there is higher incidence of cancer of the esophagus and stomach. Modern methods of food processing and preserving appear to avoid the cancer-causing byproducts associated with older methods of food treatment. Sunlight Almost all of the more than 700,000 cases of basal and squamous cell skin cancer diagnosed each year in the US are sun-related (ultraviolet radiation). Epidemiologic evidence shows that sun exposure is a major factor in the development of melanoma and that incidence increases for those living near the equator. (See Selected Cancers: Skin Cancer.) Alcohol Oral cancer and cancers of the larynx, throat, esophagus, and liver occur more frequently among heavy drinkers of alcohol especially when accompanied by smoking cigarettes or chewing tobacco. (See Selected Cancers: Oral Cancer.) Smokeless Tobacco Use of chewing tobacco or snuff increases risk of cancer of the mouth, larynx, throat, and esophagus and is a highly addictive habit. (See Selected Cancers: Oral Cancer.) Estrogen Estrogen treatment to control menopausal symptoms can increase risk of endometrial cancer. However, including progesterone in estrogen replacement therapy helps to minimize this risk. Consultation with a physician will help each woman to assess personal risks and benefits. Continued research is needed in the area of estrogen use and breast cancer. (See Selected Cancers: Uterus and Cervix Cancer). Occupational Hazards Exposure to several different industrial agents (nickel, chromate, asbestos, vinyl chloride, etc.) increases risk of various cancers. Risk oflung cancer from asbestos is greatly increased when combined with cigarette smoking. (See Environmental Cancer Risks.) Ionizing Radiation Excessive exposure to ionizing radiation can increase cancer risk. Most medical and dental x-rays are adjusted to deliver the lowest dose possible without sacrificing image quality. Excessive radon exposure in homes may increase risk of lung cancer, especially in cigarette smokers. If levels are found to be too high, remedial actions should be taken. SL 107307 19 CANCER FACTS & FIGURES 1994 Environmental Cancer Risks The environmental causes of cancer include exposures in the community or workplace settings, as well as exposures determined by individual lifestyle choices (smoking, diet, medications, etc.). The degree of cancer hazard posed by such risks depends on the concentration or intensity of the carcinogen in the environment and the exposure dose a person receives. These factors in combination create a range of risk. For example, in situations where high levels of carcinogen are present and where exposures are extensive, significant hazards may exist, but where concentrations are low and exposures limited, hazards are often negligible. Risk Assessment To protect people against unsafe exposures, risks should be assessed so that appropriate environmental standards can be set. Risk assessment is a two-step process: identifying the toxic properties of potential oncogenic hazards and measuring the extent of human exposure. The first step, hazard identification, evaluates the chemical or physical nature of hazards and their onco genicity in observed clinical and epidemiologic studies and in laboratory tests using animals or cell systems. Special attention is given to any evidence suggesting that cancer risk may increase with dose (dose-response relationships). The second step, exposure measurement, determines the levels of hazards in the environment (air, water, food, etc.) and the extent to which people are actually exposed (how much they eat of a particular food, use a particular water source, etc.). Knowledge of how the body absorbs, metab olizes, and excretes chemicals or is exposed to radiation sources is essential to determine accurately the actual carcinogenic dose delivered to humans. Unfortunately, evidence of risk for most potential car cinogens usually rests on the results of high-dose animal experiments or on human observations where high-dose exposures have occurred. To use such information in setting human safety standards, scientists must extrapolate from animals to humans and from high-dose to low-dose conditions. Both extrapolations involve much uncertainty; therefore conservative assumptions are used so that risk assessment will err on the side of safety. Fbr cancer safety standards, only increased risks ofone case or less per million persons over a lifetime are usually accepted. Safety standards developed in this way for chemical or radiation exposures are the basis for federal regulatory activities at the Food and Drug Administration, the Environmental Protection Agency, and the Occupational Safety and Health Administration. The application of laws and procedures by which standards are implemented and risks are controlled is called risk management Chemicals and Radiation Not all chemicals or all forms of radiation cause cancer. Only a limited number of chemicals (for example, benzene, asbestos, vinyl chloride, arsenic, aflatoxins) show definibw evidence of human carcinogenicity or are probable hunuj^p carcinogens based on animal experiments (for example^ chloroform, dichlorodiphenyltrichloroethane [DDT], for maldehyde, polychlorinated biphenyls [PCBs], polycyclic aromatic hydrocarbons). The only forms of radiation proven to cause human cancer are ionizing radiation (for example, x-rays, radon, cosmic rays) and ultraviolet radiation (principally UV-B radiation). Unproven Risks Public concern about environmental cancer risks often focuses on risks for which no carcinogenicity has been proven or on situations where known carcinogen exposures are at such low levels that risks are negligible. For example: 1. Non-ionizing radiation. Electromagnetic radiation at frequencies below ionizing and ultraviolet levels has not been shown to cause cancer. While some epidemiologic studies suggest associations with cancer, others do not, and experimental studies have not yielded reproducible evidence of carcinogenic mechanisms. Low frequency radiation includes radiowaves, microwaves, and radar, as well as power frequency radiation arising from the electric and magnetic fields associated with electric currents (often called ELF or extremely low frequency radiation). 2. Pesticides. Many kinds of pesticides (insecticide^^ herbicides, etc.) are widely used in producing anc^ marketing our food supply. While some of these chemicals cause cancer at high doses in experimental animals, the very low concentrations found in some foods are generally within established safety levels. Environmental pollution by slowly degraded pesticides such as DDT, a result of past agricultural practices, can lead to food chain bioaccumulation and to persistent residues in body fat. Such residues have been suggested as a possible risk factor for breast cancer; concentrations in tissue are low, however, and the evidence is not conclusive. Continued research regarding pesticide use is essential for maximum food safety, improved food production through alternative pest control methods, and reduced pollution of the environment. At the same time, banning any man-made chemicals with carcinogenic potential (as required for processed foods under the 1958 Delaney Amendment of the Food and Drug Act) is unrealistic, given the very low concentrations involved and the value of pesticides in sustaining our food supply. Scientists and consumer groups stress the important health benefits of a diet which includes many fruits and vegetables in contrast to the minimal risks associated with pesticide residues. 3. Toxic wastes. Toxic wastes in dump sites can threat^J^ 20 CANCER FACTS & FIGURES 1994 l07308 human health through air, water, and soil pollution. Although many toxic chemicals contained in such wastes can be carcinogenic at high doses, most community exposures appear to involve very low or negligible dose levels. Clean-up of existing dump sites and close control of toxic materials in the future is essential to ensure healthy living conditions in our industrialized society. 4. Nuclear power plants. Ionizing radiation emissions from nuclear facilities are closely controlled and involve negligible levels of exposure for communities near such plants. Although reports about cancer case clusters in such communities have raised public concern, studies show that clusters do not occur more often near nuclear plants than they do by chance elsewhere in the population. Early Detection Each person should be aware of the cancer early detection guidelines that pertain to them. Tb understand the role of the cancer-related checkup, the ACS adopted the following definitions. Screening is the search for disease in persons without symptoms. Once a person has had a positive screening test, or once signs or symptoms have been identified, further tests are considered diagnostic. Detection is the discovery of an abnormality in a person with or without symptoms. Diagnostic evaluation is the evaluation of a patient who has signs or symptoms suggestive of disease to determine the actual existence and nature of the disease. The following recommendations are for the early detection of cancer in asymptomatic persons on an individual basis. The recommendations are intended to help individual providers and their patients determine the most appropriate early cancer detection tests to meet their individual needs. Guidelines for the early detection of cancer in people without symptoms are recommended by the American Cancer Society as follows: A cancer-related checkup by a physician every three years for persons aged 20-39 and annually for those aged 40 and over. Some persons at particular risk for certain cancers may need tests more often and should discuss this with their doctor. The checkup should always include health counseling (how to quit smoking, etc.) and exams for cancer of the breast, uterus, cervix, colon, rectum, prostate, mouth, skin, testes, thyroid, and lymph nodes. In 1989 and 1990, Congress passed legislation mandating Medicare coverage for cervical and breast cancer screening, respectively. For women over age 65, Medicare currently covers a Pap smear once every three years and a mam mogram every two years. Although this policy does not strictly conform to ACS screening recommendations, it does begin to address the benefits of early detection. Breast The American Cancer Society recommends that screening mammography begin by age 40. Women aged 4049 should have a mammogram every 1-2 years, depending on physical and mammographic findings. Women aged 50 and older should have mammograms yearly. The ACS recommends the monthly practice of breast self-exam (BSE) by women 20 years and older as a routine good health habit. Examination of the breast by a health care professional should be done every three years from ages 2040 and then every year. Coton and Rectum The American Cancer Society recommends three tests for the early detection of colon and rectum cancer in people without symptoms. A digital rectal examination by a physician during an office visit should be performed every year afterthe age of40; the stool blood test is recommended every year after age 50; and sigmoidoscopy, preferably flex ible, should be performed every 3 to 5 years. Uterus For cervical cancer, women who are or have been sexually active, or have reached age 18, should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of her physician. Women at high-risk for endometrial cancer (those who have a history of infertility, obesity, failure to ovulate, abnormal uterine bleeding, or unopposed estrogen or tamoxifen therapy) should have an endometrial tissue sample taken at menopause and thereafter at the discretion of the physician. Prostate Men who have reached 50 years of age and older should have a digital rectal examination (DRE) annually. Annual prostate-specific antigen blood testing should be performed on men age 50 and older. SL 107309 21 CANCER FACTS 4 FIGURES 1994 Tobacco Use V Smoking is the most preventable cause of death in our society. Tobacco use is responsible for nearly one in five deaths in the United States. Based upon data from the American Cancer Society's Cancer Prevention Study II, it is estimated that smoking is related to about 419,000 US deaths each year. Although the number of cardiovas cular deaths are declining, smoking-related cancer deaths continue to rise. According to the World Health Orga nization approximately 3 million people die worldwide each year as a result of smoking. Smokers lose an average of 15 years of life. The risks of dying of lung cancer are 22 times higher for male smokers and 12 times higher for female smokers than for people who have never smoked. In addition to being responsible for 87% of lung cancers, smoking is also associated with cancers of the mouth, pharynx, larynx, esophagus, pancreas, uterine cervix, kidney, and bladder. Smoking accounts for 30% of all cancer deaths, is a major cause of heart disease, and is associated with conditions ranging from colds and gastric ulcers to chronic bronchitis, emphysema, and cerebrovascular disease. Trends in Smoking The National Health Interview Survey (NHIS) reports that cigarette smoking among adults aged 18 and over declined from 42% in 1965 to 25% in 1991. The NHIS data from 1974 to 1991 show: Smoking among women decreased from 33% to 24%. Smoking among men dropped from 43% to 28%. Rates for college graduates declined from 28% to 14%. Rates for persons without a high school education decreased slightly from 44% to 37%. Data from the 1991 NHIS indicate that the decline in cigarette smoking among adults has begun to level off. Between 1990 and 1991, smoking rates rose for the first time in nearly 20 years due to increased smoking among blacks and women. Contributing to this rise may be the growth in discount cigarette products and the recent surge in the tobacco industry's domestic advertising and pro motion expenditures. According to the 1989 Surgeon General's Report, decisions to quit or not to start through 1985 will postpone or prevent an additional 2 million smoking-related deaths between 1986 and the year 2000. Per capita cigarette consumption dropped 37% from 1973 to 1992 (4,148 to 2,640). This is the lowest per capita cigarette consumption since 1942. Profile ofSmokers In 1991, the number of current smokers in the US: 46 million. The prevalence of smoking is highest among people who live below poverty level: men 39%; women 29%. Smoking rates are highest in the age group 25-44. Approximately 50% of smokers start smoking regularly before age 18. More than 3,000 teenagers become regular smokers each day in the United States. According to the Centers for Disease Control and Prevention's 1991 Youth Risk Behavior Survey: 70% of all students in grades 9-12 reported ever trying cigarettes. About 13% of high school students reported frequent cigarette use. Cost of Tobacco The 1992 Surgeon General's Report estimates that the total lifetime excess medical care costs for smokers exceed those for nonsmokers by $501 billion. The US Congress Office of Technology AssessiMrt estimates that cigarettes cost Americans $68 bii|0 annually in tobacco-related health care costs and lost productivity. The cost of treating smoking-related diseases and lost productivity amounts to $2.59 for each pack of cigarettes sold in the US. For every 10% increase in the price of tobacco products, it is estimated that tobacco consumption would decline 4%. Cigarette Exports US cigarette exports have increased due to aggressive marketing by tobacco companies and expanding foreign markets. A September 1993 tobacco report of the US Department of Agriculture estimates: US cigarette exports have increased about 275% since 1985. US cigarette exports to Japan have increased almost 800%, from 6.5 billion in 1985 to 56 billion in 1993. Exports to South Korea have grown from 1.3 billion in 1987 to 4 billion in 1993. Exports to the countries that formerly comprised the Soviet Union have increased from 4.6 billion in 1991 to 13.6 billion in 1993. US cigarette output from July 1992 to June 1993 was 702 billion. Even though domestic consumption has dropped, this recent increase in output is the result m 22 CANCER FACTS & FIGIIRFC SL 107310 foreign demand of US tobacco leaf and US manufacturers offering discounted cigarettes and lower prices on premium brands. Nicotine Addiction Tobacco smoke contains over 4,000 chemical compounds including at least 43 different carcinogenic substances. The 1988 Surgeon General's Report on Nicotine Addiction concluded: Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Nicotine is found in substantial amounts in tobacco. It is absorbed readily from tobacco smoke in the lungs and from smokeless tobacco in the mouth or nose and is rapidly distributed throughout the body. Smoking Cessation By 1991, almost 44 million Americans had quit smoking cigarettes, nearly half of all living adults who ever smoked. In September 1990, the Surgeon General outlined the benefits of smoking cessation: People who quit smoking, regardless of age, live longer than people who continue to smoke, Smokers who quit before age 50 have half the risk of dying in the next 15 years compared with those who continue to smoke. Quitting smoking substantially decreases the risk of lung, laryngeal, esophageal, oral, pancreatic, bladder, and cervical cancers. Benefits of cessation include risk reduction for other major diseases including coronary heart disease and cardiovascular disease. A1989 Gallup Survey reported that the following people want to quit smoking: 57% of smokers 50 and older 67% of smokers aged 3049 68% of smokers aged 18-29. Environmental Tobacco Smoke In December 1992, the Environmental Protection Agency concluded that widespread exposure to environmental tobacco smoke (ETS) presents "a serious and substantial" public health problem in the United States. Each year about 3,000 nonsmoking adults die of lung cancer as a result of breathing the smoke of other's cigarettes. The risk of dying of lung cancer is 30% higher for a nonsmoker living with a smoker compared with a nonsmoker living with a nonsmoker. It is estimated that ETS causes 35,000 to 40,000 excess heart disease deaths among people who are not current smokers. ETS contains essentially all of the same carcinogens and toxic agents that are inhaled by the smoker. ETS can result in aggravated asthmatic conditions, impaired blood circulation, bronchitis, and pneumonia. ETS poses additional health hazards for unborn and young children. According to the 1988 NHIS, about 10 million children under the age of six are exposed to ETS by a household member. Children exposed to secondhand smoke have increased risks of respiratory illnesses and infections, impaired development of lung function, and middle ear infections. Infants born to women who smoked during pregnancy are more likely to die of Sudden Infant Death syndrome. Smokeless Tobacco There has been a resurgence in the use of all forms of smokeless tobacco--plug, leaf, and snuff--but the greatest cause for concern centers on the increased use of "dipping snuff." In this practice, tobacco that has been processed into a coarse, moist powder is placed between the cheek and gum, and nicotine, along with a number ofcarcinogens, is absorbed through the oral tissue. Dipping snuff is highly addictive, and exposes the body to levels of nicotine equal to those of cigarettes. In 1986, the US Surgeon General concluded that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes. It can cause cancer and a number of noncancerous oral conditions and can lead to nicotine addiction and dependence." Oral cancer occurs several times more frequently among snuff dippers compared with non-tobacco users. The excess risk of cancer of the cheek and gum may reach nearly fiftyfold among long-term snuff users. The use of smokeless tobacco is increasing among male adolescents and young male adults. According to the US Department of Agriculture, US output of moist snuff has risen 83% from about 30 million pounds in 1981 to an estimated 55 million pounds in 1993. About 5 million US adults use smokeless tobacco. The Centers for Disease Control and Prevention's 1991 Youth Risk Behavior Survey reported that 19% of male high school students used smokeless tobacco. Industrial Hazards Industrial workers are especially susceptible to lung diseases due to the combined effects of cigarette smoke and exposure to certain toxic industrial substances, such as fumes from rubber and chlorine, and dust from cotton and coal. Exposure to asbestos in combination with cigarette smoking increases an individual's lung cancer risk nearly 60 times. Smoking also enhances lung cancer risk in underground miners exposed to radon. 23 CANCER FACTS & FIGURES 1994 The American Cancer Society In 1913, 10 physicians and five laymen founded the American Society for the Control of Cancer. Its stated purpose was to "disseminate knowledge concerning the symptoms, treatment, and prevention of cancer; to inves tigate conditions under which cancer is found; and to compile statistics in regard thereto." Later renamed the American Cancer Society, Inc., the organization now con sists ofover 2 million Americans working to conquer cancer. Organization: The American Cancer Society, Inc., consists of a National Society, 57 Divisions, and over 3,400 Units. The National Society: A 285-member Board of Directors provides representation from the 57 Divisions. The National Society is responsible for overall planning and coordination, providing technical help and materials to Divisions and Units, administering programs of research, medical grants and clinical fellowships, and performing public and professional education at the national level. The 57 Divisions: Located in all states plus five metropolitan areas, the District of Columbia, and Puerto Rico, the Divisions are governed by members of Divisional boards of directors. The Units: These are organized to cover the counties in the United States. There are thousands of community leaders who direct the Society's programs at this level. Descriptions of some of the Society's major programs follow. Research The American Cancer Society is the largest private source of cancer research funds in the United States, second only to the federal government's National Cancer Institute in total dollars spent. In fiscal year 1993, the Society invested approximately $100 million in research--slightly over 2696 of its budget. To date, the Society has invested more than $1.5 billion in cancer research. The research program consists of two components: extramural grants and awards, and intramural epidemiology research. The extramural program supports investigatorinitiated projects taking place in leading centers across the country. Applications for grants are subjected to a rigorous external peer review which ensures that only the highest quality applications receive funding. The success of the Society's research program is exemplified by the fact that 26 Nobel Prize winners received grant support from the Society early in their careers. Epidemiology The Society supports an active program of epidemiologic research at its National office. This program analyzes trends in cancer occurrence and has conducted three large pro spective studies of cancer risk in Americans over the past 40 years. The Hammond-Horn study demonstrated the effects of smoking on mortality and cancer risk in 188,000 men observed from 1952-1955. Cancer Prevention Study I, conducted from 1959 through 1972, encompassed 1 million men and women in 25 states and examined potential cancer risk factors related to the environment and to individual lifestyles. Cancer Prevention Study II (CPS II), was launched in 1982 and is still in progress, examining the habits and exposures of more than 1 million Americans. Causes of death among these people over subsequent years are being studied to learn how lifestyles and environmental factors affect the development of cancer. Over 77,000 volunteers enrolled the men and women in CPS II. These volunteer researchers distributed ques tionnaires to participants who were asked about their lifestyles. Another questionnaire was sent in October 1992, 160,000 households participating in CPS II. This ques tionnaire seeks additional dietary information to gain more specific knowledge about how diet impacts disease. Public Education The Society's Public Education programs focus on tobacco control, the relationship between diet and cancer, comprehensive school health education and early detection. The programs are divided into two audiences: adult and youth. Adults are reached through the worksites, healthsites, and the community. Volunteers are recruited and trained both to promote and to deliver programs. Examples of adult education include Taking Control, which identifies 10 steps to a healthier lifestyle; Smart Move, a single-session stop-smoking program; SelfDefense, which explains how a person can work with a health care provider to become familiar with cancer tests and examinations; and Special Touch, which explains breast cancer and early detection techniques. The Society has joined with other health, education, and social service agencies to promote comprehensive school health education. The best way to ensure good cancer education in the schools, comprehensive school healt 24 CANCER FACTS 4 FIGURES 1994 SL 107311 education is the means of delivering a planned health edu cation curricula from pre-school to grade 12. The Society's education programs emphasize the impor tance of developing good health habits. Beginning in pre school, students learn about the dangers of tobacco use with Starting Free: Good Air for Me. Other tobacco pre vention programs include: An Early Start to Good Health (grades K-3), and Health Myself (grades 7-9). Changing the Course curricula help elementary and secondary stu dents make good dietary choices that will reduce their risk of developing a number of diseases, including cancer. High school students can also learn in-depth about cancer through Right Choices. Professional Education The Society's Professional Education Department pro vides health care professionals with the latest information on developments in cancer prevention, early detection, and treatment through: National conferences and workshops (The Society is accredited by the Accreditation Council for Continuing Medical Education) Materials (videotapes, slide programs, audiotapes, textbooks, proceedings of conferences and workshops, and booklets on key issues are examples, in addition to two national journals for health care professionals) Clinical awards, professorships, and scholarships (Clinical Oncology Fellowships, Clinical Oncology Career Development Awards, Oncology Social Work Awards, Cancer Control Career Development Awards). Over the past 40 years. Clinical Fellowships and Junior Faculty Clinical Fellowships have supported the education of more than 9,600 individuals. Nursing programs (a newsletter, scholarships, and professorships) Information on questionable methods of cancer management. Patient Services In 1993, approximately 745,141 cancer patients were reached through the service and rehabilitation programs of the American Cancer Society. Service Programs Community Connection: Resources, Information, and Guidance: provides information about Society services and other resources in the community to meet the practical, social, psychological, and other support needs of cancer patients and their families. Transportation: TVained volunteer drivers provide trans portation that enables patients to get to and from treatment. Home Care Items: offers supplies and equipment to care for the patient at home. Rehabilitation Programs Reach to Recovery: This one-on-one visitation program provides information and support to women with experience with breast cancer; additional information for husbands, children, and friends of breast cancer patients is available. Laryngectomy Rehabilitation: Spearheaded by the International Association of Laryngectomees, this program provides pre- and/or postoperative support for patients by laryngectomee visitors. Look Good...Feel Better: In partnership with the Cosmetic, Toiletry and Fragrance Association and National Cosmetology Association, this program is an opportunity for people undergoing cancer treatment to develop skills to cope with appearance changes. CanSurmount: A short-term program for cancer patients and their families. TVained volunteers who have experienced the same type of cancer offer support through one-to-one visits. Ostomy Rehabilitation: In cooperation with the United Ostomy Association and enterostomal therapists, trained volunteers who have experienced the same type of surgery as the patient offer help on a one-to-one basis. Children's Camps: Many Divisions offer camps for chil dren who have or have had cancer. These camps can cope with the special needs of children undergoing treatment. Patient and Family Education Programs Group and individual programs designed to help patients of all ages and their families understand the complexities of cancer. I Can Cope: offers information on cancer treatments, nutrition, resources, and other issues to patients and families. Group Support Programs Offered to patients, families and friends, these programs vary according to each Division's needs and resources. Public Issues Cancer has become a political, as well as a medical, social, psychological, and economic issue. Policy makers at all levels of government make decisions which impact the lives of more than 8 million Americans with a history of cancer, their families, and millions of potential cancer patients. Therefore, the Society's Public Issues program educates policy makers about cancer and how it affects the indi viduals and families they represent. The Society is orga nized to advocate for public policy initiatives which relate to and affect: 25 CANCER FACTS & FIGURES 1994 SL 107312  the welfare of the cancer patient and his/her family risks to and protection of the potential cancer patient cancer research The Society supports increased federal funding and pro vides direction for the federal government's cancer research program run by the National Cancer Institute. The Public Issues program also supports the work of the Society's cancer education and service programs by influencing public policy on tobacco control, access to health care, employment discrimination against cancer patients, environmental cancer issues, and other issues affecting cancer survivors and their families. Among the major public policy changes that the Society has advocated are: smoking ban on airlines. restricted tobacco advertising. expanded access to screening mammography and Pap tests. Costs of Cancer reduces suffering and saves lives if cancer is detected at an earlier, treatable stage. The current debate on health care reform highlights these figures in a new way. An estimated $900 billion will beM spent on health care this year in the United States, yj 34 million Americans do not have any health insurance? The number of uninsured, moreover, does not take into account the tens of millions of Americans now living with disease or disability who daily encounter problems with our health care system, including 8 million Americans who have had cancer. The American Cancer Society's Statement of Principles on Health Care System Reform calls for: high quality cancer care for all Americans; expanded support for basic and clinical cancer research; comprehensive school health education as a key cost saving primary prevention strategy; and, an increase of at least $2.00 in the federal cigarette excise tax and a comparable increase for other tobacco products to prevent death and disease from smoking. The financial costs of cancer are great both for the individual and for society as a whole. Cancer accounts for about 10% of the total cost of disease in the US and its share of the total cost of premature deaths was about 18% of all causes of death in 1985. The National Cancer Institute estimates overall costs for canter at $104 billion; $35 billion for direct medical costs, $12 billion for morbidity costs (cost oflost productivity), and $57 billion for mortality costs. Over half of the direct medical costs are due to treatment of breast ($6 billion), lung ($5 billion), and prostate ($5 billion) cancers. The cost of cancer screenings, including mammograms, Pap smears, and colorectal exams adds another $3 to $4 billion to overall cancer costs, but The Disadvantaged Since 1988, the Society has funded over 100 community demonstration projects to provide cancer education mes sages and programs (cancer screening and education, trans portation, and patient service support) to the poor an^k underserved of our country. Overall, approximately 10 to^P 12 million adults in socioeconomically disadvantaged pop ulations are reached annually with public education programs. In addition, the Society currently has over $2 million in research grants in effect in this area. Allocation of American Cancer Society Funds Based on Total 1992-1993 Budget--$376,381 Fundraising $64, 17.1% Professional Education* $35,791 9.5% Management & General $2^600 71% Patient Services $52,479 Community Services $27405 73% Public Education $69,531 18.5% *The Society's cancer prevention, detection, and treatment programs are carried out through these areas, figures taken from 1992 Annual Report (in thousands). Research $100,243 26.6% 26 CANCER FACTS A FIGURES 1994 SL 107313 SL 107314 > m po > tn K> O TmO Cft o ! Summery of Research Grants & Fellowships Awarded by the American Cancer Society (National and Division) During the Fiscal Year Ending August 31,1993 (Subject to Audit) Albony Medical College, Albany, NY Albert Einstein College of Medicine, Bronx, NY American Assn, for Cancer Research, Philadelphia, PA American Health Foundation, New York, NY Baylor College of Medicine, Houston, TX Beth Israel Hospital, Boston,MA Boston Gty Hospital, Boston, MA Boston College, Chestnut Hill, MA Boston Univ., Boston, MA Bowman Gray Sch. of Medicine, Winston-Salem, NC Brandeis Univ., Waltham, MA Brigham A Women's Hospital, Boston, MA Brigham Young Unhr,, Provo, UT Brwn Univ., Providence, Rl Colifomia Inst, of Biological Res., Is Jolla California fast, af Technology, Pasadena Carle Foundation Hospital, Urbano, ft Carnegie Institution of Washington, Baltimore, MD Cose Western Resene Unrv., uevefond, OH Chicago Medical School, North Chicogo, IL Childrens Hospital, Boston, MA Children's Hospitof of Los Angeles, tos Angeles, CA Gty of Hope Notional Medical Ctr., Duarte, CA Cold Spring Harbor lab.. Cold Spring Harbor, NY Colorado State Univ., Foil Collins Columbia Univ., New fork, NY Cornell Univ., New fork, NY Dana-Farber Concer Institute, Boston, MA Dartmouth College, Honaer, NK Dartmouth-Hitchcoidi Medical Center, Lebanon, NH Drexef Univ., Philadelphia, PA Duke Univ., Durham, NC Eleanor Roosevelt Inst, far Concer Ret., Denver, CO Eostem Virginia Medical School, Norfolk Emory Untv., Atlanta, GA European Mol Biol, laboratory, Heidelberg, Germany Foundation for Biomedical Research, Washington, DC Fox Chase Cancer Center, Philadelphia, PA Fred Hutchinson Cancer Res. Center, Seattle, WA Georgetown Univ., Washington, DC Georgia Inst, of Technology, Atlanta, GA Hahnemann University, Pmdefphio, PA Harrington Concer Center, AmariBo, TX Harvard Univ. Medical School, Boston, MA Harvard Univ., Cambridge, MA Henry Ford Hospital, Detroit, Ml Hunter College CUNY, New Yoti NY Imperial Cancer Research Fund, London, England Indiono Univ., htdkmopolrs Indiana Univ., Bloomington Inll. Union Against Concer, Geneva, Switzerland tawa Stole Univ., Ames Jackson Laboratory, Bor Harbor, ME Johns Hopkins Univ., Baltimore, MD Kaiser Pfermonente Health Research, Portland, OR Konsas State Univ., Manhattan La Jofta Cancer Research Foundation, La Jolla, CA La Jolla Inst. Allergy and Immunology, La Jolla, CA Louisiana State Unrv. Med. Ctr, Shreveport, LA Lonkenou Medical Research Center, Wynnewood, PA Loyola Univ. of Chicogo, Maywood, ft Massachusetts General Hospital, Charlestown Massachusetts Inst, of Technology, Cambridge Mayo Oink Foundation, Rochester, MN McLaughlin Research Inst., Great Falls, MT Medical Biology Institute, La Jolla, CA Medical College of Ohio, Toledo (3i ((311) $ 333,000 797,000 140,000 Medical College of Virginia, Richmond Medical College of Wisconsin, Milwaukee Medical Foundation of Buffalo, Buffalo, NY 2) 341,000( Medical Univ. of South Carolina, Charleston 9) 1,000,000( Memorial Sloan-Kettering Cancer Or., New York, NY 371, 5(0(31 Michigan State Univ., East Lansing -(1) 90,300 Montano State Univ., Bozeman M) 90,500 MonteFiore Medical Center, Bronx, NY 451,000(3) MRC Lob. ofMol Biology, Cambridge, England Ml 410,000 Mt. Sinaf Medical Center, New York, NY 373,0001 3) Noll. Jewish Hospital A Research Ctr., Denver, CO 701,000TO New England Medical Center Hospitals, Boston, MA 133,000HI New Jersey Medical School, Newark 310,000(31 New York Medico! College, VoEhallo (1J 1(0,000 New York Univ., NYC 030,400(7) National Institutes of Health, Bethesda, MD M) 15,000 North Carolina State Univ., Raleigh 350,190(4) North Dakota State Univ., Fargo 400,000HI Northwestern Univ., Chicogo, 11 (31 213,000 Oak Ridge Assoc., Univ. of Tennessee, Oak Ridge 373,500(31 Oberlin University, Oberlin, OH 390,000(3) Ohio State Univ., Columbus 304,000(3) Oklahoma Medical Res. fdn., Oklahoma City 430,075(5) Oregon Health Science Univ., Portland 1) 50,190< Oregon State Unhr., Corvottis 1,913,000(13) Pennsylvania Stole Univ., Hershey 315,000(3) Pennsylvania Stale Univ., University Park 533,000(?) Phiboelphio Coll. Phami. A Science, Philadelphia, PA 1) 75,000( Pkower Institute Med. Research, Manhossel, NY 310,000(3) Pittsburgh Concer Research Institute, PA Ml 110,000 Princeton Unrv., Princeton, NJ 1,927,000(IB) Public Health Res. Inst, of New York, NYC 105,000(It Purdue Untv., West Lofoyette, IN 394,000( 3) Reed CoQege, Portland, OR 474,000TO Rockefeller Univ., New York, NY (11 79,500 Roger Williams General Hospital, Providence, Rl (1) 10,000 Roswell Pork Memorial Institute, Buffalo, NY (3) 931,000 Rush ftesbyterion-St Luke's Med. Ctr., Chicago, IL Ml 747,970 Rutgers, State Univ. of New Jersey, Piscotaway Ml 431,000 State Univ. of New York (SUNY) ol Stony Brook 140,000(i) State Unhr. of New York {SUNY} at Syracuse (11 1,313 Salk Institute, La Joilo, CA 100,000(i) Scripps Clinic A Research Foundation, Lo Jolla, CA 1,320,150(131 Southwest Foundation Btomed. Res., San Antonio, TX 491,300(31 St. Jude's Children's Research Hospital Memphis, TN 40,000(1) Si. John's Univ., Jamaica, NY 133,000(1) St. Lours Univ., St. Louis, MO 79,000(1) Stanford Univ., Stanford, CA 504^500[4) Texas A A M Univ., CoRege Station, TX 373,300(3) Thomas Jefferson Univ., Philadelphia, PA 705,0001 3) Tufts Univ., Boston, MA 105,00011) University Hospitals of Cleveland, Cleveland, OH 491,000TO UMDNJ-Robert Wood Johnson Medico! School, NJ 3,531,000(IB( Univ. ofAlabama, Birmingham Ml 90,000 Univ. ofArizona, Tucson 1(4,000(21 Univ. of Arkansas forMed. Science, Little Rock 531,000(<] Univ. of California at Berkeley 210,000(1) Univ. of Colifomia at Davis 370,000(31 Univ. of California at Irvine 300,500(21 Univ. of California at Los Angeles 9(,000(1) Umv. of Californio at Riverside 731,000( B) LWv. of California at Santa Barbara (71,030(3) Univ. of Californio at San Francisco Ml 7,000 Unrv. ofCalifornia at San Diego 105,000(1) Univ. of California at Santa Cruz 134,194(2) Univ. of Chicogo, IL Ml (0,000 Univ. of Gncinnoti, OH (3) (1) (') Ml TO ((2t|) Ml Ml Ml (M2|l 111 1 2| TO TO TO (i) (?) TO TO Ml ((2l)) (3) (2) (3) Ml M) TO TO Ml TO TO TO MI Ml TO (5) dll M) (3} (35 (1) (3) (3) (3) TO (I) (7) (5) (2) (!) (5) Ml Ml TO TO (U) (15) M) HI (33) TO (1) (7) M) $ 113,000 43,000 1(0,000 79,000 $3,250,500 120,000 125,000 53000 (0,000 349,300 100,000 304,000 100,000 341,000 1,109,000 121,000 32,000 325,500 940,500 111,000 74,000 1,00t,000 4(,000 t((,000 95,000 410,000 347,300 71,000 140,000 543,000 1,079,000 354,000 133,000 93,000 1(0,000 125,000 444,000 135,000 405,000 1,23(,000 90,000 535,500 204,(10 ((,000 354,000 194,000 344,000 3,35MSI 1(1,000 933,500 44(,000 390,000 269(40,,500000 (34,000 430,000 (00,000 311,500 943,100 1,533,500 $ 310,000 374,000 3,544,000 1,334,400 313,000 730,500 $ 4(,000 Univ. of Colorado Hllh. Sci. Center, Denver Univ. of Colorado, Boulder Univ. of Connecticut, Farmington Univ. of Delaware, Newark Unrv. of Florida, Gainesville Univ. of Georgia, Athens Unrv. of Hawaii, Honolulu Univ. of Houston, TX Unk of lowo, Iowa City Univ. of Kansas, Lawrence Univ. of Kentucky, Lexington Univ. of Illinois, Chicogo Unhr. of Illinois, Urbano Unrv. of Maryland, Baltimore Unrv. of Maryland, College Pork Univ. of Massachusetts Med. Center, Worcester Univ. of Miami, FI Univ. of Michigan, Ann Arbor Univ. of Minnesota, Minneapolis Univ. of Nebraska Med. Center, Omaha Univ. of Nebrasko, Lincoln Univ. of NeW Mexico, Albuquerque Univ. of New Orleans, LA Univ. of North Carolina, Chapel Hill Univ, of Oklahomo, Oklahomo CHy Unhr, of Oregon, Eugene Univ. of Oxford, Oxford, England Univ. of Pennsylvania, Philadelphia Univ. of Pittsburgh, PA Unrv. of Rochester, NY Univ. of South Carolina, Columbia Univ. of South Florida, Tampa Unrv. of Southern California, Los Angeles Univ. of Tennessee, Knoxville Univ. of Tennessee, Memphis Univ. of Texas MD Anderson Co. Clr., Houston Univ. of Texas, Austin Univ. of Texas Med. Br., Galveston Univ. of Texas Southwestern Med. Ctr. ol Dallas Univ, of Texos Hllh. Sci. Ctr, at Houston Univ. of Texas Hllh. Sci. Ctr. at Son Antonio Univ, of Texas Health Ctr., Tyler Univ. of Utah, Salt lake Gty Univ. of Vermont, Burlington Univ. of Virginia, Charlottesville Univ. of Washington, Seattle Univ. of Wisconsin, Modison Univ. of Wisconsin, Milwaukee Univ. of Wyoming, Laramie Utah State Univ., Logan Vonderbilt Unhr., Nashville, TN Virginia folytechnic Inst., Blocbburg W, Alton Janes Cell Sci. Or., Lake Placid, NY Washington State Unhr., Pullman Washington Univ., St Louis, MO Wayne State Unhr., Detroit, Ml Wesleyan Univ., Middletown, G West Virginia Univ., Morgantown Whiteheod Institute, Cambridge, MA Wichita State University, Wichita, K$ William Patterson CofJege, Wayne, NJ Wistar Institute, Philadelphia, PA Yale Univ., New Haven, G Subtotal Division Research Grants Grand Total Note Numbers tn parentheses indicate numbers of grants per institution. ini (8) (31 (!) TO [ l| [ l| 11) Ml 1 11 TO (4) TO M) TO (7) ( 5] (16| (101 Ml ( 11 TO 11| TO (2! 1?) TO ((H8)I ( 3) I 1) [ 'I [ 3) 13) TO [HI ( 1] f 1| TO < i) (!) ( 1) Ml TO TO (Ml TO (i) < i| Ml (7} 11) (!) (3) M) (5) TO TO Ml (l) TO (4) (37) 1847} 1.449444,,950000 131,000 373,000 300,000 44,000 330006,,000000 319451,,000000 33940,,000000 346,500 336,000 45,500 436,472 641,000 3000,500 1,047,000 41491,,000000 49,125 73,000 1,593000 14,01131,,000000 1,07944,,010500 492,000 703,343 191,000 135,000 1,190,000 43,000 345,000 1,514,000 50,000 1,45409,,000000 90,500 114903,,000000 444,000 749,000 1,433,000 1,117,470 3,357,000 99,000 144,000 99901,,000000 137,000 400,000 195,000 495,670 443,000 333047493,,505000000 15095,,000000 3941057,,357040 $95,(31,1(7 $ 3,911,015 $99,756,903 CANCER FACTS & FIGURES 1994 Cancer Around the World, 1988-1991, Death Rates per 100,000 Population for 46 Countries COUNTRY AUSITE5 Mol* Ftmale ORAL Mate Female COLON* RECTUM Main Female PROSTATE Male LUNG Main Female United States 164.4(24) 1104(11) 37(29) Argentina! 151.8(29) 97.4(24) 4.0(24) AusfmliaS 144.0(25) 1012(22) 47(20) Austria T72J3(1S) 1069(19) 5.9(14) Bulgaria 139.0(37) 81.2(38| 3.8(28| Canadaf 170.8(21) 1106(13) 4.4(23) Chile! 110.8(34) 109.4(14) 2.3(39) Owio*! 154.1 (2?) 833(35) 25(34) Costa Eica! 1464(33) 1086(14) 3,2(31) Cubaf 119.8(39) 954(38} 54(19) Czechoslovakia! 332.8 ( 3) 1?1.0( 8) 9.0( 4) Denmarit 1395(11) 139.8( 1) 4.0(23) Ecuador! 83.4(15) 85.2(33) 0.7(44| England 4 Wales 179.2 (12) 1257(4) 2.9(33) Finland 151.1(38) 906(32) 33(40) France! 3007(5) 88.1(31} 136(3) Germany, fed.S 137.9(13) 1083(13) 43(13) Greece! 1143(31) 335(43) 1.4(44) Kong Kong! Hungary 135.1(14) 3145(1) 91.0(31) 1315{ 3) 145(2) USi 1) Iceland 117.4(33) 1146(1(9 2.1(43) Ireland! 00 Israel! 171.9(13) 1155(13) 1235) 4) 987(24) 4.4)24) 1.0(45) Holy! 1933(101 993(23) 43(11) Japan 1503(30) 767(44) 23(41) Luxembourg 193.41 8) 109.4(15) 01 (5) Malta 144.0(35) 925(30) 36(30) Mauritius 860(41) 423(44) 46(21) Mexico! Netherlands! 835(44) 195.3(9) 797(42| 109.8(13) 2.0(43| 26(35) New Zealand! 131.9(19) 134.8(5) 43(251 North Ireland 1764(11} 1233(7] 2.8(34) i Norway! 148.3(31) 1023(21) 3.1 p2) Poland 303.5( 4} 1033(18) 4.2(14) i Portugal 145.9(33) 846)34) 57(18) i Puerto Ricof 1365(41) 75.1(45) 7,9(3) 1 Remark} 1353(38) 83.8(39) 57(13) 1 Scotland 1985( 4) 137.1(2) 4.4(23) ' Singapore! Spaing Sweden! 1353(15) 1463(33) 139.4(10) 103.9(30) 805(41) 98.1(25) 1?.9( 4) 4.3(12) 2.4(38) ! Switzerland 131.1(201 973(27) 46(10) , Uruguay! i USSR! 2017(3) 1983(3) 1164 (9) 945(29) 4.0 |15i| 7.4 (8) Venezuela! Yugoslavia! 917(13) 158.4(24) 837(40) 903(33) 2.4(37) 4.9(9) 13(12) 0.9(35) 13(13) 0.9(33) 0.4(45) 13(14) 06(44) 13(17) 1.0(25) 2.0(3) 1.0(24) 1.4(9) 07(40) 53(18) 0.8(39) 13(15) 1.0(22) 06(44) 4.4(2) U<5) 1.0(27) 1.0(28) 07(42) 1.0(28) 06(43) up0) 16(4) UI4) 03(41) 1.0(32) 1.4(8) 1.0(31| 1.1(20) 1.0(24) 0.8(37) 1.4(7) 1.0(29) 13(11) 4.4 ( )) 03(38) 06(34) 13(14) 0.9(34) 1.0(30) 1.1(19} 1.0(21) 163(20) 07(31) 215(9) M.4[i> 161(25) 17.8(17) 7.0(40) 77(39) 68(42) 10.2(34) 30.7( 1) 223(5) 27(44) 203(12) 123(35) 173(19) 21.1(10) 68(41} 14.8(29) 29.0(2) 14.9(27) 233( 4) 14.4(30) 156(21) 15t(24| 213(7) 135(32) 50(44) 33(45) 17.9114) 257(3) 2t.5( 8) 20.0(13) 14.9(24) 153(27) 96(38) 9.7(37) 206(11) 19.1(14) >--m34) 14.9(78) 183(15| 137(18) ;. ;*3) 13.4(33) 11.4(19) 93(33) 147(9) 143(11) 107(24) 12.0(17) 60(41} 45)40) 47(39) 11.4(20) 17.0| 4) 175( 3) 4.1(45) 137(14) 8.4(34) 103(27) 15.2 ( 4) 55(42) 107(25) 18.1(2) 103(24) 15.1(7) 11.9(18) 103(28) 97(32) 134(14) 10.0(31) 4,1(44) 11(44) 133(15) 205( 1) 14.8) 8) 143110) 103(29) 10.1130) 7.4(37} 7.2(38) 1531 5} 14.0(13) 93(35| 11.1(21) 109(23) 14.1(12) 10.9(22) 53(43) 93(34) 368(17) 13.1(29) 173(15) 147(18) 7.8(39) 169(14) 13.1(28) 196 ( 5| 1871 7) 13.4|24) 18.1(10) 11.1(32) 14.4(30) 175(12) 173(13) 159(21) 8.1(38) 26(45) 157(22) 19.4(4) 176(11) 86(37) 115(31) 3.8(44) 164(19) 9.1(35) 53(421 106(33) 183(9) 1B.7( B) 154)23) 21,7(2) 9.8(34) 145(25) 17.3(14) 7.1(40) 14.9(34) 43(43) 12.9(30) 30.4{3| 22,5( 1) 19.9( 4) 4.3(41) 133(27) 8.9(34) 57.1(10) 393(30) 451(25) 45.1(24) 403(29) 573( 9} 21.1(40) 34.0(33| 175(43) 39.0(32) 74-4 ( 2) 51.9(15) 6.9(44'} 57.0(11) 47.8(21) 44.8(22) 487(19) 493(17) 543(14) 764| 1) 30.8(34) 47.9(20) 245(33) 58.9(8) 30.1(36) 62.9(7) 423(28) 18.9(42) 165(45| 713( 4) 44.4(27) 55.4(12) 303(35) 70.4 ( 5) 26.0(37) 195(41) 39.1(31) 71.3(3) 50.6(16) 453(23) 214(39) 44.9(26) 55.0(13} 436( 6) 165(44) 48.9(18) 247( 3) 58(38) 12.8(15) 9.0(20] 63(34} 20.6( 6) 53(39) 14.5(13) 4.4(34) 14.3(14) 6.3(22) 23.9 (3) 2.8(46) 205( 7) 4.6(33) 5.0(41] 7.8(26) 69(32) 213(5) 14.9(12) 218( 4) 193(8) 7.9(24) 7.3(38) 8.0(23) 83(21) 37(44) 51(40) 5.9(37) 103(17) 17.3(11) 173 ( 9) 10.3(16) 9.7(19) 4.4(43) 7.0(31) 6.4 (35) 2B.3( 1) 175110) 14(45] 9.9(18) 7.2(29) 46)43) 7.1(30) 7.9(35) 73(27) NOTE: Oi in pareofaje* ore order of rank within site end se* group. Rate* oreage-odjusledto Ae WHO world standard population, ites include rwsophaf>iwcnly.fl9flB-!Wo(Jy.t1988-19B9 only. fitPSS cnJy*#1989-1990 only. RREAST Female 22.4(16) 20.9(19) 202(21) 22.0(17) 156(31) 219(12) 125(39) 46(44) 12.9(38) 14.8(33) 193(22) 27.7| 4) 5.6(45) 28.7( 1) 17.0(28) 197(23) 21.9(18) 15.3(33) 8.6(41) 226(15) 217(13) 273 ( 3) 23.0(14) 203(20} 43(44) 254(10| 281(2| 47 (43) 81(42) 288( 7) 27.0( 6} 265( 8) 193(24) 157130) 17.8(24) 143(35) 14.8(34) 27.1 ( 5) 12.9(37) 171(27) 182(25) 243(11) 284(9) 116(36) 96(4(8 15.9(29) UTERUS Cervix Other 26(33) 46(16) 3.1(29) 2.9(30) 4.1(22) 2.3(37) 125(2) 43(21) 10.4 (3) 43(9) 56(1!) 53(12) 5.8(10) 4.4(18) 17(43) 1.8(40) 36(25) 13(45) 19(23) 68(7) 26(14) 12(27) 16(44) 0.9(44) 8(41) 12(28) WPS) 36(24) 159( 1) 2.5(35) 45(17| 35(26) 4.3(19) 7.9( 6) 23(34) 2.6(32) 103 ( 4) 46(15) 6.4 ( 8) 17(42) 23(38) 26(33) 47(14) 52(13) W(5) 43(20) 26(33) 65(5) 1.7(44| 51(9) 6.0(7) 25(35) 2.4(38) 3.5(22) 73( 4) 57(8) 15(23) 137 ( 1) 25(34) 26(31) 4.0(17) 12(25) 3.0(26) 1.4(45) 5.0(11) 1.8(42) 2.9(27) 23(39) 51(10) 2.4(37) 4.5(14) 3.8(20) 7.4(3) 26(32) 25(34} 2.8(28) 2.0(41) 2.8(29) 4.0(16) 4.9(12} 15(21) 3.9(13) 2.1(40) 1.8(43) 18(19} 27(30) 3.3(24) 4.4(4) 4.4(15) 7.9(2) 46(13| STOMACH Male female 53(44} 12.8(26) 8.4(41| 167(19) 19.8(11) 8.0(42) 353 ( 3) 3261 5) 547 ( l| 7.3(45) 19.7(12) 78(43) 26.91 6] 125(29) 110(25) 9.1(38) 14.9(21) 96(34) 115(31) 24.0( 8) 18.1(15) 12.0(30} 7,7|44) tB.2(14) 34.9 ( 4) 11.3(32) 14.9(22) 127(27) 105)35) 13.1(23) 8.8(401 12.4(28) 11.0(34] 23.1(9) 24.9{ 7) 11.0(33) 18.2(13) 111(24) 20,3(10) 15.0(20) 8,9(39) 96(37) 170(18) 36.3(2) 17.1(17) 18.0(14) 2.3(44) 56(29) 16(44) 83(15) 107) 9) 3.4(45) 13 6( 6) 15.7| 4) 22.8( 1) 3.8(42) 8.9(12) 4 2(41] 19.2 ( 2) 5.1(31) 70(23) 36(43) 7.7(17) 4.9(34) 5 3(30) 103(10) 77(18) 5.9(27) 4.2(40) B6(13| 155( 5) 4.3(38) 4.1(26) 72(21) 7.6(19) 5.0(33) 4.7(35) 6,7(25) 5.0(32) 8.2(14) 12,0( 7) 4 5(36) 7.1(22) 5.9(28) 10.8 (8) 4.9(24) 45(37) 43(39] 73(20) 16.0 { 3) 95(11) 7.8(16) LEUKEMIA Male Female 6.3 ( 8) 4.6(33) 6.1(11) 5-4(31) 4.5(34) 6.2|10| 3.9(42) 4.1(40) 4.2( 9] 4 4(32) 6 7( 4) 6.8| 3] 3 7(45) 53(24) 5.2(25) 6.1 (13) 5.9(14) 5.7(16) 3.8(43) 7.2 ( 1) 4.9(29) 4.1(12) 6.4(7) 47(5| 4.3(38) 4.7( 6) 5.4(22) 35(46) 3.8(44) 56(18) 73(2) 4 5(34) 4.9(28) 5.8(15) 5.0(27) 4.8(30] 4.5(35) 4.4(37) 4.2(39) 5.3(23) 5.1(26) 56(17) 55(20) 5.5(19) 4.0(41) 4.7(31) 1 3.8(9) 3.3(28) 3.8(10) 35(24) 2.9(43) 3.9 ( 8) 3.3(32) 3.3(27) 4.9( 1) 3.6(16) 4,3( 4) 4.1(5) 32(33) 3.3(31) 3.0(38) 3.7(15) 3.7(13) 3.4(25) 27(45) 46(2) 31(37) 3.7)12) 45(3) 4.0(7) 2.8(44) 36(21) 36(17) 23(46] 3.0(40) 3.5(23) 4.1(6) 3.2(34) 33(30) 34(18) 3.7(14) 35(22) 3.0(39) 3.1(35) 3.0(4l| 3.4(24) 33(29) 3.4(20) 3.8(11) 36(19) 3.1(34) 3.0(42) #- Cancer Centers The institutions listed have been recognized as Cancer Advisory Board. They receive financial support from the Centers by the National Cancer Institute. These centers National Cancer Institute, the American Cancer Society have been rigorously reviewed by the National Cancer and many other sources. ALABAMA University of Alabama at Birmingham* Comprehensive Cancer Center (205) 934-5077 ARIZONA University of Arizona* Arizona Cancer Center (602) 6264372 CALIFORNIA The Kenneth Norris, Jr. Comprehensive Cancer Center* University of Southern California (213)226-2370 Jonsson Comprehensive Cancer Center* University of California at Los Angeles 1-800-825-2631 La Jolla Cancer Research Foundation (619) 455-6480 University of California at San Diego Cancer Center (619) 543-6178 City of Hope Beckman Research Institute (818) 359-8111 Armand Hammer Center for Cancer Biology Salk Institute (619) 453-4100 COLORADO University of Colorado Cancer Center University of Colorado Health Sciences Center (303) 2704007 CONNECTICUT Yale University* Comprehensive Cancer Center 1-800-4-CANCER DISTRICT OF COLUMBIA Lombardi Cancer Research Center* Georgetown University Medical Center (202) 687-2192 FLORIDA Sylvester Comprehensive Cancer Center* University of Miami Medical School (305) 545-1000 ILLINOIS University of Chicago Cancer Research Center (312) 7024180 Lurie Cancer Center Northwestern University (312) 908-5250 INDIANA Purdue University Cancer Center (317)494-9129 MAINE The Jackson Laboratory (207) 288-3371 MARYLAND The Johns Hopkins Oncology Center* (410) 955-8800 Indicates Comprehensive Cancer Center. MASSACHUSETTS Dana-Farber Cancer Institute* (617) 632-3000 Worcester Foundation for Experimental Biology (508) 8424921 Massachusetts Institute of Technology Center for Cancer Research (617) 2534421 MICHIGAN Meyer L Prentis Comprehensive Cancer Center of Metropolitan Detroit (313) 745-4329 University of Michigan Comprehensive Cancer Center* (313) 936-9583 MINNESOTA Mayo Comprehensive Cancer Center* (507) 284-3413 NEBRASKA Eppley Institute University of Nebraska Medical Center 1400-999-5465 NEW HAMPSHIRE Norris Cotton Cancer Center* Dartmouth-Hitchcock Medical Center (603) 650-5000 NEW YORK Cold Spring Harbor Laboratory (516) 3674397 Memorial Sloan-Kettering Cancer Center* 1400425-2225 Roswell Park Cancer Institute* 1400-ROSWELL Albert Einstein College of Medicine Cancer Research Center (718) 9204826 Columbia University Comprehensive Cancer Center (212) 3054921 Kaplan Comprehensive Cancer Center* New York University Medical Center (212) 263-6485 University of Rochester Cancer Center (716) 2754911 Nelson Institute for Environmental Medicine New York University Medical Center (212) 263-5280 American Health Foundation (212) 953-1900 NORTH CAROLINA Duke University Comprehensive Cancer Center* (919)684-2748 Lineberger Cancer Research Center* University of North Carolina (919) 966-3036 Wake Forest University* Comprehensive Cancer Center Bowman Cray School of Medicine (919) 7164464 OHIO Ohio State University* Comprehensive Cancer Center Arthur C. James Cancer Hospital 14004384996 Case Western Reserve University Ireland Cancer Center (216) 844-5432 PENNSYLVANIA Fox Chase Cancer Center* (215) 728-2570 University of Pennsylvania Cancer Center* (215) 6624364 Wistar Institute Cancer Center (215) 898-3926 Fels Research Institute Temple University School of Medicine (215) 2214000 Pittsburgh Cancer Institute* University of Pittsburgh 14004374063 RHODE ISLAND Brown University Roger Williams Cancer Center (401) 456-2071 TENNESSEE Drew-Mehany-Morehouse Consortium Cancer Center (615) 3274927 St, Jude Children's Research Hospital (901) 5224306 TEXAS M.D. Anderson Cancer Center* University of Tfcxas (713) 792-3245 San Antonio Cancer Institute (210) 677-3850 UTAH Utah Cancer Center University of Utah School of Medicine (801) 5814048 VERMONT Vermont Cancer Center* University af Vermont (802)6564414 VIRGINIA Massey Cancer Center Medical College of Vitginia/VCU (804) 371-5116 University of Virginia Cancer Center (804) 924-5811 WASHINGTON Fled Hutchinson Cancer Research Center* (206) 667-5000 WISCONSIN Comprehensive Cancer Center* University of Wisconsin (608)2634600 McArdle Laboratory for Cancer Research University of Wisconsin Medical School (608) 262-2177 sv Chartered Divisions of the American Cancer Society, Inc. Alabama Division, Inc. 504 Brookwood Boulevard Homewood, Alabama 35209 (205) 879-2242 Alaska Division, Inc. 406 West Fireweed Lane Anchorage. Alaska 99503 (907) 277-86% Arizona Division, Inc. 2929 Cast Thomas Road Phoenix, Arizona 85016 (602) 224-0524 Arkansas Division, Inc. 901 North University Little Rock, Arkansas 72203 (501)664-3480 California Division, Inc, 1710 Webster Street Oakland, California 94612 (510) 893-7900 Colorado Division, Inc, 2255 South Oneida Denver, Colorado 80224 (303) 758-2030 Connecticut Division, Inc. Barnes Park South 14 Village Lane Wallingford, Connecticut 06492 (203) 265-7161 Delaware Division, Inc. 92 Read's Way New Castle, Delaware 19720 (302) 324-4227 District of Columbia Division, Inc. 1875 Connecticut Avenue, N.W. Washington, DC 20009 (202) 483-2600 Florida Division, Inc. 3709 West Jetton Avenue Tampa, Florida 33629-5146 (813) 253-0541 Georgia Division, Inc. 2200 Lake Blvd. Atlanta, Ceorgia 30319 (404) 8167800 Hawaii Pacific Division, Inc. Community Services Center Bldg. 200 North Vineyard Boulevard Honolulu, Hawaii 96817 (808) 531-1662 Idaho Division, Inc. 2676 Vista Avenue Boise, Idaho 837060836 (208) 343-4609 Illinois Division, Inc. 77 East Monroe Chicago, Illinois 60603-5795 (312) 641-6150 Indiana Division, Inc. 8730 Commerce Park Place Indianapolis, Indiana 46268 (317) 872-4432 Iowa Division, Inc8364 Hickman Road Des Moines, Iowa 50325 (515) 253-0147 Kansas Division, Inc. 1315 SW Arrowhead Road Topeka, Kansas 66604 (913) 273-4114 Kentucky Division, Inc. 701 West Muhammad All Blvd. Louisville, Kentucky 40203-1909 (502) 584-6782 Louisiana Division, Inc. 2200 Veteran's Memorial Blvd, Suite 214 Kenner, Louisiana 70062 (504) 4690021 Maine Division, Inc. 52 Federal Street Brunswick, Maine 04011 (207) 729-3339 Maryland Division, Inc. 8219 Tbwn Center Drive Baltimore, Maryland 21236-0026 (410) 931-6868 Massachusetts Division, Inc. 247 Commonwealth Avenue Boston, Massachusetts 02116 (617) 267-2650 Michigan Division, Inc. 1205 East Saginaw Street Lansing, Michigan 48906 (517) 371-2920 Minnesota Division, Inc. 3316 West 66th Street Minneapolis, Minnesota 55435 (612) 925-2772 Mississippi Division, Inc. 1380 Livingston Lane Lakeover Office Park Jackson, Mississippi 39213 (601)362-8874 Missouri Division, Inc. 3322 American Avenue Jefferson City, Missouri 65102 (314)893-4800 Montana Division, Inc. 17 North 26th Billings, Montana 59101 (406) 252-7111 Nebraska Division, Inc. 8502 West Center Road Omaha, Nebraska 68124-5255 (402) 393-5800 Nevada Division, Inc. 1325 East Harmon Las Vegas, Nevada 89119 (702) 798-6857 New Hampshire Division, Inc. 360 Route 101, Unit 501 Bedford, New Hampshire 03110-5032 (603) 472-8899 New Jersey Division, Inc. 2600 US Highway 1 North Brunswick, New Jersey 089020803 (908) 297-8000 New Mexico Division, Inc. 5800 Lomas Blvd., NE Albuquerque, New Mexico 87110 (505) 260-2105 New York State Division, Inc. 6725 Lyons Street East Syracuse, New York 13057 (315)437-7025 Long Island Division, Inc, 75 Davids Drive Hauppauge, New York 11788 (516) 436-7070 New York City DMsioa, Inc. 19 West 56th Street New York, New York 10019 (212) 5868700 Queens Division, Inc. 112-25 Queens Boulevard Forest Hills, New York 11375 (718) 263-2224 0 Westchester Division, Inc. 30 Clenn Street White Plains, New York 10603 (914) 9494800 North Carolina Division, Inc. 11 South Boylan Avenue Raleigh, North Carolina 27603 (919) 834-8463 North Dakota Division, Inc. 123 Roberts Street Fargo, North Dakota 58102 (701) 232-1385 Ohio Division, Inc. 5555 Frantz Road Dublin, Ohio 43017 (614) 889-9565 Oklahoma Division, Inc. 4323 63d, Suite 110 Oklahoma City, Oklahoma 73116 (405)843-9888 Oregon Division, Inc. 0330 SW Curry Portland, Oregon 97201 (503) 295-6422 Pennsylvania Division, Inc. Route 422 & Sipe Avenue Hershey, Pennsylvania 170334)897 (717) 533-6144 P Philadelphia Division, Inc. 1422 Chestnut Street Philadelphia, Pennsylvania 19102 (215) 665-2900 Puerto Rico Division, Inc. Calle Alwrio #577 Esquina Sargento Medina Hato Rey, Puerto Rico 00918 (809) 764-2295 Rhode Island Division, Inc. 400 Main Street Pawtucket, Rhode Island 02860 (401) 722-8480 South Carolina Division, Inc. 128 Stonemarit Lane Columbia, South Carolina 29210-38SS (803) 750-1693 South Dakota Division, Inc. 4101 Carnegie Place Sioux Falls, South Dakota 57106-2322 (605) 361-8277 Iknnessee Division, Inc. 1315 Eighth Avenue, South Nashville, Tennessee 37203 (615) 255-1227 Texas Division, lac. 2433 Ridgepoint Drive Austin, Texas 78754 (512) 928-2262 Utah DMsioa, Inc. 941 East 3300 S. Salt Lake City, Utah 84106 (801)483-1500 Vermont DMsioa, Inc. 13 Loomis Street Montpelier, Vermont 05602 (802) 223-2348 Virginia Division, Inc. P.O. Box 6359 Glen Allen, Virginia 23058-6359 (804) 527-3700 Washington Division, Inc. 2120 First Avenue North Seattle, Washington 98109-1140 (206) 283-1152 West Virginia DMsioa, Inc. 2428 Kanawha Boulevard East Charleston. West Virginia 25311 (304) 344-3611 Wisconsin DMsioa, Inc. P.O. Box 902 Pewaukee, Wisconsin 53072-0902 (414) 523-5500 Wyoming DMsioa, Inc. 2222 House Avenue Cheyenne, Wyoming 82001 (307) 638-3331 THERE'S HOTHIHG MIGHTIER THAR THE SWORD AMERICAN VCANCER ? SOCIETY SL 107317 FOR MORE INFORMATION CALL THE AMERICAN CANCER SOCIETY TOLL FREE: 1-800-ACS-2345 The American Cancer Society is the nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives from cancer, and diminishing suffering from cancer through research, education, and service. National Headquarters: American Cancer Society, Inc., 1599 Clifton Road N.E., Atlanta, GA 303294251 1994, American Cancer Society, Inc. 94-375M-NO. 5008.94 National Rxait& , Coatings ------------ -- ^ Hay 24, 1994 TO: PROM: RE: Air Quality Committee Architectural Coatings Committaa Industrial coatings committee Labeling and product Safety committee Manufacturing Management Committee water Quality/Waste Management committee Soonie McDavid, Aasimtant Director Environmental Affairs DRAFT Green Seal Standard on Anti-Corrosive Paints Enclosed is a DRAFT Green Seal Environmental Criteria for AntiCorrosive Paints dated May 20, 1994. Green Seal is seeking comments to this proposed standard vhiah will be used in a product certification program. Please revise and return your oonmentr to me by June 10, 1994. Green Seal was founded in 1990 by Earth Day founder Dennis Hayes to help identify environmentally preferable products in an effort t encourage consumers to purchase products with reduced environmental impacts/burdens. Green Seel hopes to encourage manufacturers to develop products which are significantly less damaging to the environment then their predecessors, NFCA commented on Green Seal's Environmental standard for Paints (primarily focused on architectural coatings), which was focused on a life-cycle analysis approach, in 1992. 1500 Rhode Island Avenue. NW * Washington. DC 20005-5597 202/462-6272 FAX 202/462-8549 SL 107318 0 May 20,1994 Ms. Soony McDavid Director Environmental Affairs NPCA 1500 Rhode Island Avenue, NW Washington, DC 20005 Dear Ms. McDavid: Green Seal is now accepting comments on proposed environmental criteria we are developing for anti-corrosive paints. Green Seal's existing standard for paint, GS-11, covers primarily architectural coatings. A separate standard for antt-conosivt> paints allows Green Seal to establish environmental requirements mare appropriate far this category and to develop performance criteria to evaluate the rust inhibiting properties of products. -- While the proposed standard is still in draft form. Green Seal is soliciting comment on the appropriateness of the criteria we have chosen for evaluating environmentally preferable anti-corroaive paints. We also would appreciate suggestions regarding other performance or environmental requirements you believe Green Seal should indude in this standard. Enclosed is an outline of proposed criteria for evaluating anti-corrosive paints. In lieu of, or in addition to written comments/ I hope to discuss with you directly any comments you have about the proposed standards. Thank you in advance for your time. I will call you next week to discuss the proposed environmental criteria with you. Or feel free to contact me at Green Seal at 202-331-7337. Sincerely, Project Manager MMlM VNUKMMIWKMi VI tMtlVKSDMn --wwtt.w'lidu--VtfMH.aN.Mim Mfimumu ittmm*. SL 107319 May 20, 1994 GC-03 GREEN SEAL environmental CRITERIA FOR ANTI-CORROSIVE PAINTS > > May 20, 1994 COPYRIGHT e 1994 GREEN SEAL, INC. ALL RIGHTS RESERVED. Cram Baal1* EtrriraammUl iMirti an aaayrtflhM M pratarf Craaa Baal's yablMattm rifMa, not to raalrM tbahr urn ia pratad Maiga or amlMBllaa. SL io T& GREEN SEAL Green Seal is a n n-profit organization devoted to environmental standard setting, product certification, and public education. Green Seal helps identify environmentally preferable products in order to encourage and enable consumers to purchase such products with reduced impacts en the earth. Through its standard setting, certification and education programs, Green Seal: identifier products that are designed and manufactured In an environmentally preferable manner, m offers scientific analysis to help consumers make educated purchasing decisions reaardins environmental impacts: ensures consumers that any product bearing the Green Seal Certification Marie has earned the right to use it; and encourages manufacturers to develop new products that axe significantly less damaging to the environment than their predecessors. THE ENVIRONMENTAL STANDARDS The intent of Green Seal's standards is to reduce, to the extent etmoUginaHy and economically feasible, the environmental impacts associated with the manufacture, use, and disposal of products. Set on a category-by-category basis, Environmental Standards focus on opportunities to significantly reduce a product's environmental impact Each Green Seal Environmental Standard is first issued in proposed form. Industry, trade associations, government agencies, environmental and other public interest organizations, users, and other interested parties are encouraged to comment on the proposal. Standards are then established after careful review and consideration of the comments. Green Seal offers the opportunity to achieve certification to all products covered by its sandards. Manufacturers may submit their productsfor evaluation by Green Seal. Those which comply with Green Seal's requirements may be authorized to use the Green Seal Certification Mark on products and in product advertising. Manufacturers authorized to use the Green Seal Certification Mark on their product are subject to an ongoing program of testing, inspection, and enforcement. Underwriters Laboratories Inc., the nation's premier product testing and inspection organization, serves as Green Seal's primary testing and factory inspection contractor. For additional information on Green Seal or any of its programs, contact: Green Seal 1250 23rd Street, NW, Suite 275 Washington, DC 20037-1101 (202) 331-7337 SL 107321 May tO. IW l>rfl Ewytronmtwtal Criteria , TABLE OF CONTENTS j> ** Summary of Comments Requested ...... 4 Draft Environmental Criteria 1 Scope ...........................................:....................... ..................5 2 Definitions .........................................................................3 3 Product-Specific Performance Requirements...........................5 4 Product-Specific Environmental Requirements........................ 5 5 Packaging Requirements ................................. 7 Appendix t Labeling Requirements......................................................... ft " SL 107322 Oran liifwiiinitl CrtfrU SUMMARY OF COMMENTS REQUESTED When reviewing the standard please pay pardcular mention id tbc following areas: 4 Performance Requirements Has Green Seal chosen appropriate testing protocols for adhesion and hiding power? When developing the standard, it came id our attention that a test protocol for corrosion/weathering is currently under development by ASTM subcommittee 27. This test reportedly imitates real world oorrosion characteristics better than the traditional ait fog test for measuring a paint's rust inhibiting properties. The corrosion/weathering test also reportedly produces more consistent results on a product by product basis. What would be the advantages and disadvantages ofGreen Seal using the corrosion/weathering test currently under development instead ofthe salt fog test? What would constitute acceptable performance by a product when using the test protocols of the salt fog test7 Should other performance requirements be specified? Environmental Requirements Has Green Seal chosen appropriate VOC limits to recognize environmentally preferable ami-corrosive paints? If not, what levels should be specified? How widespread is the use of heavy metals in and-corrosive paints? Are there any differences in the use and concentrations of heavy metals in industrial anil-corrosive paints versus consumer anti-corrosive paints? Are the chemical component restrictions appropriate? Should additional compounds be added or should any listed components be deleted? SL 107323 May ao. 1994 Pratt Bnvtramtwitat Crlttrta 5 environmental standard 1 Scope. This Standard establishes environmental requirements for anti-corrosive paints. 2 Definitions. For the purpose of this Standard, the following definitions apply. 2.1 Paints: Liquid, liquefiable or mastic composition that is converted to a solid protean . or functional adherent film after application as a thin layer. These coatings are intended for application to metal surfaces to provide protection horn rusting. 2.2 Volatile Organic Compounds (VOCs): Compounds as defined by U. S. Environmental Protection Agency (EPA) in 40 GFR ( 51.100 (s), (s) (1). 2.3 Aromatic Compounds: Hydrocarbon compounds containing one or more 6-crbon benzene rings in the molecular structure. 3 Product-Specific Performance Requirements. \ 3.1 Adhesion. The product shall demonstrate a minimum of Classification 4B according to ASTM D3359-90 Method B, Standard Test Methodsfor Measuring Adhesion by Tape Test, 3.2 Corrosion/Weathering (Prohesion. QUV) Teat, (protocols to be determined.) OR Salt Spray (fog) Testing according to ASTM designation B117-90. (parameters to be determined) 3.3 Hiding Power (Opacity). The product shall demonstrate a minimum 0.95 contrast ratio at 400 square feet per gallon as determined by ASTM D2805-88, Standard Test Methodfor Hiding Power ofPaints by Reflectometry. 4 Product-Specific Environmental Requirements. 4.1 Chemical Component Limitations. 4.1.1 VOCs. The VOC concentrations of the product shall not exceed those listed below as determined by U. S. Environmental Protection Agency (EPA) Reference Test Method 24 (Determination of Volatile Matter Content. Water Content, Density Volume $olid& and Weight Solids of Surface Coatings), Code of Federal Regulations Title 40, Part 60, Appendix A, The calculation of VOCs shall exclude water and tinting color added at the point of sale. SL 107324 M" 20. W Pr wv>fwiwwiui Crttrt Coatinilyps VQC weight in mnu/lto of product minus wter Clou 250 Semi-Gloss 225 Satin and Flat 200 4.1.2 Aromatic Compounds. The product must contain no more than 1,0% by weight of the turn total of aromatic compounds. Testing for the concentration of these compounds will be performed if they are determined to be present in the product during a materials audit 4.2 Chemical Component Restriction!. The manufacturer shall demonstrate that the following chemical compounds are not used as ingredients in the manufacture of the final product 4.2.1 Halomethanes , methylene chloride 4.2.2 Chlorinated ethanes _ 1,1,1-trichloroethane --- 4.2.3 Aromatic solvents benzene toluene (methylbenzene) ethylbenzene 4.2.4 Chlorinated ethylenes vinyl chloride 4.2.5 Polynuclear aromatics naphthalene 4.2.6 Chlorobenzenes 1,2-dichlorobenzene 4.2.7 Phthalate eaters di (2-echylhexyl) phthalate butyl benzyl phthalate di-n*butyl phthalate di-n-octyl phthalate SL 107325 l*Z_2l--lL diethyl phthalate dimethyl phthalate Dfft En-lronreinui cnwrtji 7 4.2.8 Miscellaneous semi-volatile organics isophorone 472.9 Metals and their compounds antimony cadmium hexavalent chromium lead mercury 4.2.10 Preservatives (antifouling agents) formaldehyde 4.2.11 Ketones methyl ethyl ketone methyl isobutyl ketone _ 4.2.12 Miscellaneous volatile organics acrolein acrylonitrile 5 Packaging Requirements. 5.1Toxics in Packaging. 5.1.1 The manufacturer shall demonstrate that paint cans and their components are not fabricated with lead. SL 107326 My 1WOwn. EnWrwimfWMl Criter|f Annendta lj>heHiir Rem.lrmnN far fVrtlflaiflrei hv fSr--n Rl Unless otherwise approved in writing by Green Seal, the following labeling requirements *hfl|| apply; 1 The Green Seal Certification Marie must ippear on the packaging. 2 Whenever the certification marie appears on a package orproduct, the product or package mustContain a description of die basis for the certification. The description shall be in & location, style, and typeface that are easily readable by the consumer, jhe description shall read as follows: This product has reduced volatile organic compound (VOQ levels: does not contain specified toxic chemicals. 3 Paints which have been formulated without VOCs shall be designated Class A and may contain a special designation to that effect on the label 101^ June 22, 1994 DRAFT RECOMMENDED INHALATION TESTING HAZARDOUS AIR POLLUTANTS TO BE CONSIDERED FOR TSCA SECTION 4 TEST RULE PROCESS (1ST RULE) Biphenyl Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity 2-Generation Reproductive Test Carbonyl Sulfide Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 2-Generation Reproductive Test Cancer test (2 species in both sexes) Ames, in vitro gene mutation mammalian test, bone marrow cytogenetics Chlorine Acute Systemic (in both sexes) Acute Respiratory (in both sexes) Chlorobenzene Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/subchronic Neurotoxicity Chloroorene Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity 2-Generation Reproductive Test Cresols(mixture or isomers) Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute Neurotoxicity SL 107328 Cumene Acute Systemic Acute Respiratory Acute Neurotoxicity 2-Generation Reproductive Test Dibutvl Phthalate Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity Diethanolamine Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 2-Generation Reproductive Test Ethylbenzene Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity 2-Generation Reproductive Test Ethvl Chloride Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity 2-Generation Reproductive Test Ethylene Dichloride Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity 2-Generation Reproductive Test Ethylene Glycol Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity Hydrochloric Acid Acute Respiratory Hydrogen Fluoride Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 2-Generation Reproductive Test Maleic Anhydride Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 1 species Developmental Toxicity ' Cancer Test (2 species in both sexes Methvl Isobutvl Ketone Acute Systemic Acute Respiratory 2-Generation Reproductive Test Methyl Methacrylate Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 2-Generation Reproductive Test Naphthalene Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 2-Generation Reproductive Test phenol Acute Systemic Acute Respiratory Phthalic Anhydride Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 2-Generation Reproductive Test Cancer Test(2 species in both sexes) 1.2.4 Trichlorobenzene Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 1.1.2 Trichloroethane Acute/Subchronic Systemic Acute/Subchronic Respiratory Acute/Subchronic Neurotoxicity 2 species Developmental Toxicity 2-Generation Reproductive Test Cancer Test(modified, i.e. Huff Approach) Bone marrow cy~-genetics Vinvl Acetate Acute Respiratory l species Developmental Toxicity Vinvlidene Chloride Acute Systemic Acute Respiratory Acute/Subchronic Neurotoxicity SL 107331 TOXICITY TESTING OF HAZARDOUS AIR POLLUTANTS On June 22, 1994, EPA held a briefing to provide industry with background information on the Hazardous Air Pollutant (HAP) Test Rule that will be proposed this Fall. EPA also distributed a list of the HAPs and the testing that will be proposed for each of the chemicals. Briefings have already been held with the environmental groups and other interested parties. In order to make multi-chemical risk assessment/risk management decisions, the Office of Air Quality Planning and Standards has requested that 3 TSCA section 4 Test Rules be promulgated for HAPs that are missing inhalation data. The data generated by the test rules would provide EPA with a consistent/even data base and allow them to do residual risk analyses on mixtures. EPA's intent is that this test rule respond to the CAA concern for both cancer and non-cancer health effects and that a dose-response via the inhalation route be established. EPA stated that if the database for a chemical was rich in oral data, they might agree that focused pharmacokinetic will provide enough data for route-to-route extrapolation. In that case, EPA would also require subchronic inhalation studies to evaluate entry portal sensitivity and damage. Only drinking water or feeding studies will be considered when oral data is evaluated. EPA is seeking industry comment in several areas .* There will be a problem testing low vapor pressure chemicals, EPA feels that conducting aerosol testing may mimic human exposure and is seeking comment. - Even though EPA wants all testing by the inhalation route, it is seeking industry input on the most appropriate routes of exposure. EPA is also soliciting feedback on what testing will give the best information to make risk assessments. EPA realized that there may not be an adequate number of inhalation chambers available and is looking for ways to "piggyback" tests. - Test standards will be proposed with the test rule and EPA will be seeking comment on the appropriateness of the methods. EPA is trying to generate good histopathological data on the respiratory system. The proposed rule will require all testing via the inhalation route. The rat will be the species of choice unless otherwise noted. EPA expects the proposed test rule to be published in the early or late Fall of 1994. (over) SL 107332 SELECTION OF CANDIDATE HAPs FOR TEST RULES EPA has identified 189 chemicals as hazardous air pollutants. When deciding on the HAP test rule, this group was divided into those with TRI emissions of 50 tons/year or greater and those with TRI emissions of less than 50 tons/year or no TRI data. EPA determined that there are 66 HAPs in the 1st category. When the existing data was assessed, 16 HAPs had adequate data or were currently undergoing testing. Of the 50 remaining chemicals, 25 were proposed for the 1st test rule. For the 2nd test rule, EPA is evaluating the remaining 25 chemicals and 10 chemicals that have potential concern under the Great Waters and Urban Toxics provisions of the Clean Air Act. Industry has not been apprised which HAPs are being evaluated for this rule. The remaining 113 chemicals with TRI emissions of less than 50 tons/year will be evaluated for the 3rd test rule. EPA has stated that some HAPs will :^mediately be dropped from consideration, i.e. dioxin and asbestos. TENTATIVE HAPs TEST RULE SCHEDULE o 1994 o 1995 o 1996 o 1997 1st test rule proposed (25 HAPs) 1st test rule promulgated 2nd test rule proposed (approx. 25 HAPs) 2nd test rule promulgated 3rd test rule proposed (approx. 25 HAPs) 3rd test rule promulgated SL 107333 QmA. \/c *> 0 / 2*,Wr * V,/</r '<, SL 107336 JUL-13-1994 10:24 CHEMSTAR CHEMICAL MANUFACTURERS ASSOCIATION 202 887 4756 P.001/002 RUNG INSTRUCTIONS: TO: FROK: Vinyl Chloride Panel Research Coordinators Fax July 13, 1994 <6YVVOROS: L.... Janes Barter Ed Beeler Frank Borrelli Ron Gilbert Mark Gruenwald James Knaak Dave Penney David Pun Jonathan Ramlow PPC GEON Georgia Gulf Westlake Borden OxyChem Vista Formosa Dow 412/434-2137 216/447-6459 302/323-8105 713/963-1540 614/431-6611 716/286-3141 512/331-2387 201/716-7283 517/636-1875 Has Shah RE: Vinyl Chloride Panel Research Coordinators Meeting PAGES: 2 (including cover) SENDER: Kim Reed PHONE: (202) 887-1191 SL IO7337 2501 M Street, NW, Washington. DC 20037 Telephone 202-887-1100 Fax 202-887-1237 ft Can* Conmltmei i m \ 202 88? 4756 P.002/002 CHEMICAL MANUFACTURERS ASSOCIATION July 13, 1994 Dear Vinyl Chloride Research Coordinators; I an forced to cancel the next Research Coordinators nesting scheduled for August 2. Instead, we will have a conference call at 10:00 a.m., EOT. We will follow the agenda that was sent to you on July 5. 1 would like to include Westlake Polymers on the call, if possible. Hr. Ron Gilbert should call me if he is available to participate on the call. The main purpose of the meeting was to review the bids for the epidemiology stud update from contractors. However, because commitments are still outstanding from Formosa and PPG, 1 have not sent our requests for proposals for the update. I hope to hear from Formosa and PPG within the next few days. Contractors will need at least a month to prepare their proposals. Therefore, the next Research Coordinators meeting will be scheduled for early September. We will set the date for the next meeting on the conference call. Meanwhile, please send me your comments on the draft letter to the American Cancer Society on the TIME Magazine article, your ballot for undertaking EDC activities, and the completed commitment form for the 1994>1995 budget. All of the above items were included in my July 5 package to you. I am looking forward to talking with you on August 2 at 10:00 a.m. Sincerely 1 --Hasmukh C. Shah, Ph.D. Manager, Vinyl Chloride Panel SL 107338 2501 M Street, NW, Washington, DC 20037 Telephone 202-867-1100 Fax 202-887-1237 TOTAL P.002 July 5, 1994 Explanation of Vinyl Chloride Research Coordinator Budget An initial budget of $300,000 is proposed for the following activities: Contractor cost for the update of vinyl chloride epidemiology study Dow Chemical's expenses for designing, monitoring, consulting with the selected contractor, and reviewing interim, draft and final reports for the epidemiological update Consultant expenses for vinyl chloride risk assessment and short-term exposure effects studies Administrative expenses for update of the epidemiology study; follow-ups with EPA on VC risk assessment; follow-ups with EPA on VC and/or EDC testing under TSCA Section 4; follow-ups with consultants on VC risk assessment and short-term exposure effects studies; meeting planning, attendance, and other routine services; follow-up of action items resulting from meetings and conference calls; and, monitoring of regulatory activities impacting vinyl chloride manufacturing companies The VCRC has proposed to share the estimated $300,000 budget based upon the 1993 VC nameplate capacity. CMA has used the nameplate capacities for VC published in the attached chart from Chemical Data Inc., September 1993, to determine each company's pro-rata share as follows: Total 1993 VC Nameplate Capacity Westlake 1993 VC Nameplate Capacity Total 1993 VC Nameplate Capacity Used in Determining VCRC Member Companies Pro-Rata Share 12.918 M lbs. 1.000 M lbs, 11.918 M lbs. COMPANY NAMEPLATE CAPACITY (Million Lbs.) PRO-RATA SHARE Borden Chemical Dow Chemical Formosa Plastics GEON Georgia Gulf Occidental (w/OxyMar) PPG Industries Vista Chemical 935 2,210 1,793 1,400 1,260 2,600 840 880 23,536 55,630 45,133 35,241 31,717 65,447 21,145 22.151 TOTAL 11,918 300,000 If the above budget is committed by all companies, one-half of the commitment will be due in August, 1994 and the remainder in January, 1995. If Westlake joins the VCRC at a later date, your 1995 amount due will be adjusted accordingly. SL 107334 monthly Petrochemical & Plastics Analysis u.s. VINYL CHLORIDE MONOMER AVERAGE DESIGN CAPACITY (Minions ot Pounds Per Year) PBOPUCER LOCATION EEEPSTQQKS Borden Chemical Getsmar, LA Gelsmar, LA Ethylene Acetylene Dow Chemical Oyster Creek, TX Oyster Creek, TX Plaquemine, LA Ethylene Ethylene Ethylene Formosa Plastics Point Comfort, TX Baton Rouge, LA Baton Rouge, LA Ethylene Ethylene EDO Geon Calvert City, KY (formally Goodrich) La Porte, IX Ethylene Ethylene Georgia Gift Plaquemine. LA Ethylene Occidental Chem Deer Parte TX Ethylene OxyMar Corpus Christl, TX Ethylene PPGIndL Lake Charles, LA Ethylene She* Deer Park, TX Ethylene Vista Chemical Lake Charles, LA Ethylene WesSafce Monomers Calvert City, KY Ethyleno 1966 J28Z 1988 1962 1990 1991 1992 mi 1921 1996 1226 1997 525 525 525 568 610 6t0 610 610 610 610 610 610 325 325 325 325 325 325 325 325 325 325 325 325 750 810 610 833 900 900 900 910 910 910 910 910 ------- -- 563 750 750 750 850 900 1,040 1.200 1,200 1,275 1,300 1.300 1,300 1,300 1,300 1,300 560 580 580 890 838 900 900 900 900 900 900 900 420 420 420 420 420 420 315 53 420 420 420 420 - -- - - - - 537 840 840 840 840 640 1.000 1,000 1.000 1,000 fe6tlake 1,100 1,100 1,250 1,300 1.300 1,400 1,400 1,400 1,400 1,400 1.400 1,400 1,025 1,100 1.220 1,260 1,260 1,260 1,260 1,260 1,260 1.260 1.260 1,260 - 450 925 1,100 1,100 1,100 1,100 1,100 1,100 1,100 1,100 MOO - ~ - - - 1,467 1,500 1,500 1,500 1.500 1,500 1,500 600 750 800 BOO 840 840 640 840 840 840 840 840 900 450 See Occident! Cheml reHl 700 738 750 825 825 825 635 880 910 970 990 990 ..... __ . 1,000 1.000 1.000 1000 1000 1.000 1.060 1.060 Total 6,775 9,148 9,645 10,320 10.618 f 2.322 12,622 12,918 13.878 14,125 14.196 14,196 s iz lo i SEPTEMBER 1993 CHEMICAL MANUFACTURERS ASSOCIATION Vinyl Chloride Panel Vinyl Chloride Research Coordinators Commitment Form / My company commits its pro-rata share of $300,000 research an< advocacy budget as described in the attached July 5, 1994 Explanation of VGRC Budget. The Vinyl Chloride Panel is conducted under the policies and procedures outlined in the CHEMSTAR Panel Guidelines and briefly noted on the reverse of this form. While appreciating the opportunity, my company declines to participate. CMA has estimated that 16% of the total CMA 1994/95 fiscal year "dues and similar income", which includes CHEMSTAR contributions, is allocable to lobbying and political expenditures to which Section 162 (e)(1) of the Internal Revenue Code of 1986, as amended, applies. Consequently, this portion of your commitment is not deductible as an ordinary and necessary business expense for federal income tax purposes. Further, contributions to CMA are not tax deductible as charitable contributions. Panel Representative__________ Management Contact James A. Barter Name (Typed) Manager, Industrial Hygiene, itea-ith &-Toxiculogy PPG Industries, Inc. Company 1 PPG Place, 36 West Address Pgh., PA 15272 412-434-2801 Telephone 412-434-2137 Telecopier Please return signed form to: Name (Signed) Name (Typed) Title Company Address Telephone Telecopier SL 107339 Hasmukh C. Shah, Manager Chemical Manufacturers Association 2501 M Street, NW Washington, D.C. 20037 PPG Industries, Inc. One PPG Place Pittsburgh, PA 15272 USA James A. Barter, Ph.D. Manager, Industrial Hygiene, Health, and Toxicology Chemicals (412) 434-2801 FAX; (412)434-2137 July 27, 1994 Dr. Has Shah CMA 2501 M Street, NW Washington, DC 20037 Dear Dr. Shah, Executed copies of the Vinyl Chloride Panel Commitment Form to conduct research and advocacy activities on vinyl chloride and the vote on the CMA Vinyl Chloride Research Coordinators addressing the ethylene dichloride hazardous air pollutant testing issues with EPA are enclosed. Copies of these documents have been retained for our files: Please contact me if you need any additional information. Sincerely, SL 107341 CHEMICAL MANUFACTURERS ASSOCIATION Vinyl Chloride Research Coordinators July 5, 1994 I agree with Mr. Joe Ledvina's (Vista Chemical) suggestion that the VCRC initially address the ethylene dichloride hazardous air pollutant testing issues with EPA along with vinyl chloride testing issues under TSCA Section 4 This arrangement would consolidate the technical and economic resources of EDC and VC manufacturers. I do not agree with Mr. Ledvina's suggestion but offer the following alternative suggestion to deal with EPA on the EDC testing issues: COMPANY: PPCr SiUu<z7<?/e^ /n c~ PHONE: Please return by fax to: Hasmukh C. Shah, Ph.D. Chemical Manufacturers Association Fax (202) 887-5427