Cancer Statistics,2014
Rebecca Siegel,MPH1;Jiemin Ma,PhD2,*;Zhaohui Zou,MS3;Ahmedin Jemal,DVM,PhD4
Each year,the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence,mortality,and survival.Incidence data were collected by the National Cancer Institute,the Centers for Disease Control and Prevention,and the North American Association
of Central Cancer Registries and mortality data were collected by the National Center for Health Statistics.A total of1,665,540
new cancer cases and585,720cancer deaths are projected to occur in the United States in2014.During the most recent5 years for which there are data(2006-2010),delay-adjusted cancer incidence rates declined slightly in men(by0.6%per year)
and were stable in women,while cancer death rates decreased by1.8%per year in men and by1.4%per year in women.The combined cancer death rate(deaths per100,000population)has been continuously declining for2decades,from a peak of 215.1in1991to171.8in2010.This20%decline translates to the avoidance of approximately1,340,400cancer deaths (952,700among men and387,700among women)during this time period.The magnitude of the decline in cancer death rates
from1991to2010varies substantially by age,race,and sex,ranging from no decline among white women aged80years and older to a55%decline among black men aged40years to49years.Notably,black men experienced the largest drop within every10-year age group.Further progress can be accelerated by applying existing cancer control knowledge across all seg-ments of the population.CA Cancer J Clin2014;00:000-000.V C2014American Cancer Society,Inc.
Keywords:cancer,epidemiology,health disparities,incidence,survival,trends
Introduction
Cancer is a major public health problem in the United States and many other parts of the world.One in4deaths in the United States is due to cancer.In this article,we provide the expected numbers of new cancer cases and deaths in2014in
the United States nationally and for each state,as well as a comprehensive overview of cancer incidence,mortality,and survival rates and trends using the most current population-based data available.In addition,we estimate the total number
of deaths averted since the early1990s as a result of2decades of declining cancer death rates and present the actual number
of deaths reported in2010by age for the10leading causes of death and the5leading causes of cancer death.
Materials and Methods
Incidence and Mortality Data
Mortality data from1930to2010were obtained from the National Center for Health Statistics(NCHS).1Population-based cancer incidence data in the United States are collected both by the National Cancer Institute’s(NCI’s)Surveillance, Epidemiology,and End Results(SEER)Program and the Centers for Disease Control and Prevention’s(CDC’s)National Program of Cancer Registries(NPCR).The SEER program reports long-term(beginning in1973),high-quality incidence,prevalence,and survival data.Long-term incidence and survival trends(1975-2010)were based on data from the
9oldest SEER areas(Connecticut,Iowa,Hawaii,New Mexico,Utah,and the metropolitan areas of Atlanta,Detroit,San Francisco-Oakland,and Seattle-Puget Sound),representing approximately10%of the US population.2As of1992,SEER data have been available for4additional populations(Alaska Natives,Los Angeles County,San Jose-Monterey,and rural Georgia)that increase the coverage of minority groups and allow for strati?cation by race and ethnicity.3Data from these
1Director,Surveillance Information,Surveillance and Health Services Research,American Cancer Society,Atlanta,GA;2Senior Epidemiologist,Surveil-lance and Health Services Research,American Cancer Society,Atlanta,GA;3Information Management Services,Inc,Silver Spring,MD;4Vice President, Surveillance and Health Services Research,American Cancer Society,Atlanta,GA
Corresponding author:Rebecca Siegel,MPH,Surveillance and Health Services Research,American Cancer Society,250Williams St,NW,Atlanta,GA30303-1002;rebecca.siegel@https://www.doczj.com/doc/ce2406518.html,
*Dr.Ma’s current address:Department of Emergency Medicine,Brigham and Women’s Hospital,Boston,MA.
The authors would like to thank Carol DeSantis,MPH,and Jiaquan Xu,MD,for their technical assistance.
DISCLOSURES:Mr.Zou’s contribution was funded under a contract between the American Cancer Society and Information Management Services,Inc.The sta-tistical model and methodologies used in this publication were initially developed by the National Cancer Institute.Mr.Zou has received fees from the National Cancer Institute for work unrelated to this publication.
doi:10.3322/caac.21208.Available online at https://www.doczj.com/doc/ce2406518.html,
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TABLE1.Estimated New Cancer Cases and Deaths by Sex,United States,2014*
ESTIMATED NEW CASES ESTIMATED DEATHS
BOTH SEXES MALE FEMALE BOTH SEXES MALE FEMALE All sites1,665,540855,220810,320585,720310,010275,710 Oral cavity&pharynx42,44030,22012,2208,3905,7302,660 Tongue13,5909,7203,8702,1501,450700 Mouth11,9207,1504,7702,0701,130940 Pharynx14,41011,5502,8602,5401,900640 Other oral cavity2,5201,8007201,6301,250380 Digestive system289,610162,730126,880147,26084,97062,290 Esophagus18,17014,6603,51015,45012,4503,000 Stomach22,22013,7308,49010,9906,7204,270 Small intestine9,1604,8804,2801,210640570 Colon?96,83048,45048,38050,31026,27024,040 Rectum40,00023,38016,620
Anus,anal canal,&anorectum7,2102,6604,550950370580 Liver&intrahepatic bile duct33,19024,6008,59023,00015,8707,130 Gallbladder&other biliary10,6504,9605,6903,6301,6102,020 Pancreas46,42023,53022,89039,59020,17019,420 Other digestive organs5,7601,8803,8802,1308701,260 Respiratory system242,550130,000112,550163,66090,28073,380 Larynx12,63010,0002,6303,6102,870740 Lung&bronchus224,210116,000108,210159,26086,93072,330 Other respiratory organs5,7104,0001,710790480310 Bones&joints3,0201,6801,3401,460830630 Soft tissue(including heart)12,0206,5505,4704,7402,5502,190 Skin(excluding basal&squamous)81,22046,63034,59012,9808,8404,140 Melanoma-skin76,10043,89032,2109,7106,4703,240 Other nonepithelial skin5,1202,7402,3803,2702,370900 Breast235,0302,360232,67040,43043040,000 Genital system338,450243,46094,99058,97030,18028,790 Uterine cervix12,36012,3604,0204,020 Uterine corpus52,63052,6308,5908,590 Ovary21,98021,98014,27014,270 Vulva4,8504,8501,0301,030 Vagina&other genital,female3,1703,170880880 Prostate233,000233,00029,48029,480
Testis8,8208,820380380
Penis&other genital,male1,6401,640320320
Urinary system141,61097,42044,19030,35020,6109,740 Urinary bladder74,69056,39018,30015,58011,1704,410 Kidney&renal pelvis63,92039,14024,78013,8608,9004,960 Ureter&other urinary organs3,0001,8901,110910540370 Eye&orbit2,7301,4401,290310130180 Brain&other nervous system23,38012,82010,56014,3208,0906,230 Endocrine system65,63016,60049,0302,8201,3001,520 Thyroid62,98015,19047,7901,8908301,060 Other endocrine2,6501,4101,240930470460 Lymphoma79,99043,34036,65020,17011,1409,030 Hodgkin lymphoma9,1905,0704,1201,180670510 Non-Hodgkin lymphoma70,80038,27032,53018,99010,4708,520 Myeloma24,05013,50010,55011,0906,1104,980 Leukemia52,38030,10022,28024,09014,04010,050 Acute lymphocytic leukemia6,0203,1402,8801,440810630 Chronic lymphocytic leukemia15,7209,1006,6204,6002,8001,800 Acute myeloid leukemia18,86011,5307,33010,4606,0104,450 Chronic myeloid leukemia5,9803,1302,850810550260 Other leukemia?5,8003,2002,6006,7803,8702,910 Other&unspecified primary sites?31,43016,37015,06044,68024,78019,900 *Rounded to the nearest10;estimated new cases exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.
About62,570carcinoma in situ of the female breast and63,770melanoma in situ will be newly diagnosed in2014.
?Estimated deaths for colon and rectum cancers are combined.
?More deaths than cases may reflect lack of specificity in recording underlying cause of death on death certificates and/or an undercount in the case estimate.
2CA:A Cancer Journal for Clinicians
TABLE2.Incidence Rates for All Cancers Combined(2006-2010)and Estimated New Cases*for Selected Cancers (2014)by State
STATE INCIDENCE
RATE?
ALL
CASES
FEMALE
BREAST
UTERINE
CERVIX
COLON&
RECTUM
UTERINE
CORPUS LEUKEMIA
LUNG&
BRONCHUS
MELANOMA
OF THE SKIN
NON-HODGKIN
LYMPHOMA PROSTATE
URINARY
BLADDER
Alabama469.626,7703,6602102,3506506904,1601,3209903,760990 Alaska469.33,750450?28010010043090140530150 Arizona401.132,8304,5202102,5609109504,2801,4301,3204,3901,490 Arkansas§460.616,5202,0501401,5004004802,6604906602,240640 California442.2171,73026,1301,55013,9305,6505,65018,7808,4407,77023,0107,210 Colorado432.523,8103,7801601,7207508702,5401,4001,0603,6801,040 Connecticut505.722,0703,1601201,6507906102,7301,0909203,1201,170 Delaware511.75,320760?420180150790290220800260
Dist.of Columbia486.92,840430?250100603208010051080 Florida452.0114,56015,48096010,2303,4103,81017,9605,3205,05016,5905,800 Georgia471.347,3907,0104203,9401,3101,3706,5402,1801,8207,6001,710 Hawaii430.16,6401,09060700270220890410300810250
Idaho455.67,9901,100506102302909604503601,320390
Illinois491.266,8409,2304705,5302,2902,1809,1002,4402,8908,8203,090 Indiana464.035,5604,5902603,0201,0701,0605,5401,5501,4804,3901,600
Iowa485.617,6302,3201001,5806106402,3309808002,340830 Kansas476.814,6302,0901001,1204704901,9007806501,980620 Kentucky523.225,7703,3702002,1707207904,6901,5401,0703,2801,100 Louisiana494.124,3003,1602002,2705407203,4707509603,720940
Maine511.19,2701,220507003403101,4004403801,160540 Maryland462.030,6804,5702302,5001,0208003,9901,4001,2105,0001,280 Massachusetts503.337,9405,5602002,8001,3201,1404,9301,8001,6005,6002,030 Michigan492.358,6107,6603404,5702,0101,8308,0902,8302,5008,7402,930 Minnesota??-29,3403,8201302,2409501,0503,0701,0301,2403,8701,220 Mississippi480.915,7402,1301401,5103604102,4205605602,210540 Missouri467.733,8904,6102402,9701,0901,0405,3701,5101,4304,0101,530 Montana466.35,850860?5001802007602902601,010300 Nebraska464.59,5501,360608803203301,2204604401,250430 Nevada§448.714,4501,8801201,2903504402,0404705501,890680
New Hampshire507.28,4501,150?6003002501,1104003501,160460
New Jersey503.751,1307,2903804,2801,8201,5606,1302,5902,2507,3202,510
New Mexico405.910,2101,450808303003701,0604704001,400400
New York504.1107,20015,2308508,5904,0403,46013,7204,2404,72015,4405,330
North Carolina477.252,5507,5803804,2301,5701,5507,8502,5402,1107,5802,170
North Dakota460.03,730510?350110130400160160460180
Ohio§474.767,0008,7104005,4502,2801,8909,7603,1702,8608,6903,110 Oklahoma475.819,8302,7001601,7605306603,3206508502,570830 Oregon462.222,5303,3201301,5407206402,9501,4409603,2001,080 Pennsylvania502.679,92010,6605006,7902,8402,42010,2903,8203,42010,9304,070
Rhode Island506.56,370870?500230180870260250840340
South Carolina463.826,3903,7502102,2007507904,1301,3501,0304,0001,100
South Dakota439.74,490600?410150160540200200590210 Tennessee475.836,5704,8402903,0309301,0405,9801,9101,4704,6701,510
Texas441.5115,73016,0801,1409,7603,1304,19014,8903,4205,03015,9004,190
Utah418.610,7801,440606503503906507704901,780420 Vermont489.84,130560?290140110550220160580210 Virginia449.040,9706,1702903,2801,3001,0805,5802,1301,6406,3301,700 Washington483.038,2305,6202302,6701,1601,2504,6302,4101,7105,3801,730
West Virginia484.611,7001,350901,0603803302,0905404801,450570 Wisconsin466.032,4804,3301902,5201,1401,1504,0201,4401,4104,6301,580 Wyoming435.02,890420?2409090330150120490140
United States469.61,665,540232,67012,360136,83052,63052,380224,21076,10070,800233,00074,690
*Rounded to the nearest10;excludes basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder.
?Rates are per100,000and age adjusted to the2000US standard https://www.doczj.com/doc/ce2406518.html, rate excludes cases from Arkansas,Minnesota,Nevada,Ohio,and Virginia.
?Estimate is fewer than50cases.
§High-quality incidence data were not available for all5years.Arkansas rate is based on cases diagnosed during2006to2008;Nevada and Ohio rates are based on2006to2009.
??Incidence data were not available.
Note:These model-based estimates are offered as a rough guide and should be interpreted with caution.State estimates may not add to US total due to rounding.
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SEER 13registries were the source for the annual percent change in incidence from 1992to 2010.The SEER program added 5additional catchment areas beginning with cases diagnosed in 2000(greater California,greater Georgia,Kentucky,Louisiana,and New Jersey),achieving 28%population coverage.4Data from all 18SEER areas were the source for cancer stage distribution,stage-speci?c survival,and the lifetime probability of developing cancer.Much of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review,1975-2010.5
The North American Association of Central Cancer Registries (NAACCR)compiles and reports incidence data from 1995onward for cancer registries that participate in the SEER program or the NPCR.These data approach 100%coverage of the US population and were the source for incidence rates by state and race/ethnicity,as well as the projection of new cancer cases in 2014.6Some of the data
presented herein were previously published in volumes 1and 2of Cancer in North America:2006-2010.7,8
All cancer cases were classi?ed according to the International Classi?cation of Diseases for Oncology .9The lifetime probability of cancer was calculated using the NCI’s DevCan software (version 6.7.0).10All incidence and death rates were age-standardized to the 2000US standard population and expressed per 100,000population,as calculated by NCI’s SEER*Stat software (version 8.1.2).11Cancer incidence rates in this report were adjusted for delays in reporting whenever possible.This adjustment,which is available only for SEER data,is based on historic patterns of case ascertainment and accounts for anticipated future corrections to registry data primarily due to a lag in case reporting.Delay adjustment has the largest effect on the most recent years of data for cancers that are frequently diagnosed in outpatient settings (eg,melanoma,leukemia,and prostate cancer)and provides a more accurate
portrayal
FIGURE 1.Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex,United States,2014.
*Estimates are rounded to the nearest 10and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.
4
CA:A Cancer Journal for Clinicians
of the cancer burden in the most recent time period.12For example,melanoma incidence rates adjusted for reporting delays are14%higher than unadjusted rates in the most recent data year.Delay-adjusted rates were obtained from the SEER Canques database(https://www.doczj.com/doc/ce2406518.html,/ delay/canques.html[accessed August6,2013]).
TABLE3.Death Rates for All Cancers Combined(2006-2010)and Estimated Deaths*for Selected Cancers (2014)by State
STATE DEATH
RATE?
ALL
SITES
BRAIN&
OTHER
NERVOUS
SYSTEM
FEMALE
BREAST
COLON&
RECTUM LEUKEMIA
LIVER&
INTRAHEPATIC
BILE DUCT
LUNG&
BRONCHUS
NON-HODGKIN
LYMPHOMA OVARY PANCREAS PROSTATE
Alabama196.410,5102706909504103503,310310*********
Alaska182.5990?7090??270??6060 Arizona155.211,4003107809905004702,840390310790640 Arkansas198.06,7301504206202702102,200200140400310 California160.357,9501,5904,2705,1502,5103,14012,5902,0001,5604,1503,380 Colorado152.87,4802405306703303001,720240240510450 Connecticut166.46,8801804704602902501,760220180520390 Delaware187.71,980?1201607090600605013090
Dist.of Columbia199.01,010?80100?60230??8080
Florida168.442,7409202,7703,5601,7601,62012,0501,4309402,8902,170 Georgia179.216,3203801,2201,4806205904,6904604301,040800
Hawaii143.72,450?140230901405808060210120
Idaho162.82,73080180210130806709060210180
Illinois183.924,0205401,6102,1901,0208106,5707805601,6101,190 Indiana192.613,3703108601,0905503804,140440310840580
Iowa174.36,3801903905702801901,780230180410330 Kansas174.75,4601503704802601701,560200140370250 Kentucky209.510,1302105908503702803,570300200570390 Louisiana201.39,0402006408403304002,650260190600400
Maine187.73,3009019025013011097010060200160 Maryland179.010,5002408208903904002,760300270760550 Massachusetts177.612,8103107909905105503,500400********* Michigan185.120,8005501,4001,6809107105,9907204801,480890 Minnesota168.99,7502606207804603602,480340240650540 Mississippi203.56,3501404206402502401,990180120380330 Missouri189.212,8703109101,0905404503,950390250860550 Montana166.32,0005013017090505207060130130 Nebraska170.73,48010021034014010090013080240200 Nevada179.04,7901403804801902201,420140100370280
New Hampshire177.32,67070170200100807508060190130
New Jersey175.016,3503501,2901,5106306003,9705104401,220760
New Mexico155.53,6009026035014017079011090240220
New York166.634,4407902,3902,9701,4401,4708,7901,1109102,5401,760
North Carolina182.818,9804101,3101,5007206605,7005604301,190920
North Dakota164.81,270?9013060?310??8080
Ohio192.425,2606001,7202,1409907907,3708105701,7301,200 Oklahoma193.37,9802005106903202802,440270180470370 Oregon176.37,9402305106603203402,090280220550440 Pennsylvania184.528,6706101,9402,4901,2009807,6001,0107301,9901,370
Rhode Island177.52,1405013016090805806050130100
South Carolina187.69,9502206708403603702,970280230610510
South Dakota168.41,61050110150705044050?11090 Tennessee199.114,2803509101,2205405004,630440*********
Texas169.737,8309502,7003,4301,5302,0809,6001,2309002,4401,660
Utah131.32,87011027025015010046012080240210 Vermont177.91,340?801005060390??9070 Virginia179.314,7503501,0901,2405705204,1104603801,010730 Washington175.012,5503808209705405503,270430360880730
West Virginia201.24,6801002704201701201,480160100230190 Wisconsin175.611,3603107108605503903,000400300800630 Wyoming167.8990?609070?250??8040
United States176.4585,72014,32040,00050,31024,09023,000159,26018,99014,27039,59029,480
*Rounded to the nearest10.
?Rates are per100,000and age adjusted to the2000US standard population.
?Estimate is fewer than50deaths.
Note:State estimates may not add to US total due to rounding and the exclusion of states with fewer than50deaths.
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Projected Cancer Cases and Deaths in2014
The most recent year for which incidence and mortality data are available lags3to4years behind the current year due to the time required for data collection,compilation, quality control,and dissemination.Therefore,we project the numbers of new cancer cases and deaths in the United States in the current year in order to provide an estimate of the contemporary cancer burden.These estimates are not useful for tracking cancer occurrence over time because they are model-based and because the calculation methodology changes every few years in order to take advantage of improvements in modeling techniques,increased cancer registration coverage,and updated risk factor surveillance. A3-step spatio-temporal model was used to project the number of new invasive cancer cases that will be diagnosed in2014based on1995through2010high-quality incidence data from49states and the District of Columbia, representing89%population coverage.(All states did not meet high quality data standards for all years and Minnesota did not submit incidence data to NAACCR during the2012call for data.)This method accounts for expected delays in case reporting and considers geographic variations in sociodemographic and lifestyle factors, medical settings,and cancer screening behaviors as predictors of incidence.13First,complete incidence counts were estimated for each county from1995through2010. Then these counts were adjusted to account for delays in cancer reporting.Finally,a temporal projection method (the vector autoregressive model)was applied to the last15 years of data(1996-2010)to estimate counts for2014,which were then aggregated to obtain state-level estimates. This method cannot estimate numbers of basal cell or squamous cell skin cancers because data on the occurrence of these cancers are not reported to cancer registries.For the complete details of the case projection methodology, please refer to Zhu et al.14
TABLE4.Probability(%)of Developing Invasive Cancers Within Selected Age Intervals by Sex,United States, 2008to2010*
BIRTH TO4950TO5960TO6970AND OLDER BIRTH TO DEATH All sites?Male 3.5(1in29) 6.8(1in15)15.4(1in6)36.9(1in3)43.9(1in2)
Female 5.4(1in19) 6.0(1in17)10.1(1in10)26.7(1in4)38.0(1in3) Kidney&renal pelvis Male0.2(1in480)0.3(1in289)0.6(1in154) 1.3(1in75) 2.1(1in49)
Female0.1(1in753)0.2(1in586)0.3(1in317)0.7(1in134) 1.2(1in83) Breast Female 1.9(1in53) 2.3(1in43) 3.5(1in29) 6.7(1in15)12.3(1in8) Colorectum Male0.3(1in305)0.7(1in144) 1.3(1in76) 4.0(1in25) 5.0(1in20)
Female0.3(1in334)0.5(1in189)0.9(1in109) 3.7(1in27) 4.6(1in22) Leukemia Male0.2(1in421)0.2(1in614)0.4(1in279) 1.3(1in76) 1.7(1in60)
Female0.2(1in526)0.1(1in979)0.2(1in475)0.8(1in120) 1.2(1in86) Lung&bronchus Male0.2(1in548)0.7(1in134) 2.1(1in47) 6.7(1in15)7.6(1in13)
Female0.2(1in522)0.6(1in171) 1.6(1in62) 4.9(1in20) 6.3(1in16) Melanoma of the skin?Male0.4(1in284)0.4(1in134)0.8(1in129) 2.1(1in48) 2.9(1in34)
Female0.5(1in206)0.3(1in313)0.4(1in243)0.9(1in113) 1.9(1in53) Non-Hodgkin lymphoma Male0.3(1in357)0.3(1in338)0.6(1in171) 1.8(1in56) 2.4(1in42)
Female0.2(1in537)0.2(1in475)0.4(1in233) 1.4(1in71) 1.9(1in52) Prostate Male0.3(1in298) 2.3(1in43) 6.4(1in16)11.2(1in9)15.3(1in7) Uterine cervix Female0.3(1in348)0.1(1in812)0.1(1in824)0.2(1in619)0.7(1in154) Uterine corpus Female0.3(1in370)0.6(1in171)0.9(1in111) 1.3(1in78) 2.7(1in37) *For people free of cancer at beginning of age interval.
?All sites excludes basal cell and squamous cell skin cancers and in situ cancers except urinary bladder.
?Probabilities for whites
only.
FIGURE2.Trends in Cancer Incidence and Death Rates by
Sex,United States,1975to2010.
Rates are age adjusted to the2000US standard population.Incidence rates
are adjusted for delays in reporting.
6CA:A Cancer Journal for Clinicians
To estimate the number of in situ female breast and melanoma cases diagnosed in 2014,we ?rst estimated the number of cases occurring annually from 2001through 2010by applying age-speci?c SEER 13incidence rates to the corresponding US population estimates provided in SEER*Stat.11(Delay-adjusted rates were available for in situ breast cancer but not for in situ melanoma.)We then projected the total number of cases in 2014based on the average annual percent change in case counts from 2001through 2010generated by the joinpoint regression model.15
We estimated the number of cancer deaths expected to occur in 2014in the United States overall and in each state using the joinpoint regression model based on the actual numbers of cancer deaths from 1995through 2010at the state and national levels as reported to the NCHS.For the complete details of this methodology,please refer to Chen et al.16
Other Statistics
The estimated number of cancer deaths averted in men and women due to the reduction in overall cancer death rates was calculated by ?rst estimating the number of
cancer deaths that would have occurred if death rates had remained at their peak.The expected number of deaths was estimated by applying the 5-year age-speci?c cancer death rates in the peak year for age-standardized cancer death rates (1990in men and 1991in women)to the corresponding age-speci?c populations in the subsequent years through 2010.Then the difference between the number of expected and recorded cancer deaths in each age group and calendar year was summed for men and women separately.
Selected Findings
Expected Numbers of New Cancer Cases
Table 1presents the estimated numbers of new cases of invasive cancer expected among men and women in the United States in 2014.The overall estimate of 1,665,540new cases is the equivalent of more than 4,500new cancer diagnoses each day.About 62,570cases of breast carcinoma in situ and 63,770cases of melanoma in situ are expected to be newly diagnosed in 2014.The estimated numbers of new cancer cases by state for selected cancer sites are shown in Table
2.
FIGURE 3.Trends in Incidence Rates for Selected Cancers by Sex,United States,1975to 2010.
Rates are age adjusted to the 2000US standard population and adjusted for delays in reporting.*Includes intrahepatic bile duct.
VOLUME 00_NUMBER 00_MONTH 2014
7
Figure1indicates the most common cancers expected to occur in men and women in2014.Among men,cancers of the prostate,lung and bronchus,and colorectum will account for about50%of all newly diagnosed cancers.Prostate cancer alone will account for27%(233,000)of incident cases in men.The3most commonly diagnosed types of cancer among women in2014will be breast,lung and bronchus,and colorectum,accounting for one-half of
TABLE5.Trends in Cancer Incidence(Delay-Adjusted)and Death Rates for Selected Cancers by Sex,United States, 1992to2010
TREND1TREND2TREND3TREND4
2006–2010 YEARS APC YEARS APC YEARS APC YEARS APC AAPC All sites
Incidence
Overall1992-1994-3.2*1994-19980.41998-2010-0.4*-0.4*
Male1992-1994-5.6*1994-2010-0.6*-0.6*
Female1992-1994-0.41994-1998 1.21998-2003-0.8*2003-20100.10.1 Death
Overall1992-2001-1.0*2001-2010-1.5*-1.5*
Male1992-2001-1.4*2001-2010-1.8*-1.8*
Female1992-1995-0.21995-1998-1.2*1998-2001-0.42001-2010-1.4*-1.4* Lung&bronchus
Incidence
Male1992-2010-1.9*-1.9*
Female1992-19980.8*1998-2001-1.32001-20050.72005-2010-1.2*-1.2* Death
Male1992-2005-1.9*2005-2010-2.9*-2.9*
Female1992-1996 1.1*1996-20040.22004-2010-1.4*-1.4* Colorectum
Incidence
Male1992-1995-2.6*1995-1998 1.41998-2008-2.5*2008-2010-4.2*-3.3*
Female1992-1995-1.8*1995-1998 1.81998-2008-1.9*2008-2010-4.1*-3.0* Death
Male1992-2002-2.0*2002-2005-4.0*2005-2010-2.5*-2.5*
Female1992-2001-1.7*2001-2010-3.0*-3.0* Liver&intrahepatic bile duct
Incidence
Male1992-2010 3.7* 3.7*
Female1992-2010 2.9* 2.9* Death
Male1992-2010 2.3* 2.3*
Female1992-2010 1.4* 1.4* Melanoma of skin
Incidence
Male1992-2010 2.4* 2.4*
Female1992-1997 3.9*1997-2010 1.7* 1.7* Death
Male1992-20100.4*0.4*
Female1992-2010-0.5*-0.5* Thyroid
Incidence
Male1992-1996-0.91996-2010 5.4* 5.4*
Female1992-1998 3.9*1998-2010 6.5* 6.5* Death
Male1992-2010 1.6* 1.6*
Female1992-1994-6.41994-20100.9*0.9* Female breast
Incidence1992-1999 1.3*1999-2004-2.2*2004-20100.20.2 Death1992-1995-1.3*1995-1998-3.4*1998-2010-1.9*-1.9* Prostate
Incidence1992-1995-11.2*1995-2000 2.22000-2010-2.0*-2.0* Death1992-1994-1.01994-2004-3.8*2004-2010-3.1*-3.1* APC indicates annual percent change based on incidence(delay-adjusted)and mortality rates age adjusted to the2000US standard population;AAPC,aver-age annual percent change.
*The APC or AAPC is significantly different from zero(P<.05).
Note:Trends analyzed by the Joinpoint Regression Program,version4.0.3,allowing up to3joinpoints.Incidence trends based on Surveillance,Epidemiology, and End Results(SEER)13areas.
8CA:A Cancer Journal for Clinicians
all cases in women.Breast cancer alone is expected to account for29%(232,670)of all new cancers among women.
Expected Numbers of Cancer Deaths
Table1also shows the expected numbers of deaths from cancer projected for2014.It is estimated that about 585,720Americans will die from cancer this year, corresponding to about1,600deaths per day.Cancers of the lung and bronchus,prostate,and colorectum in men and cancers of the lung and bronchus,breast,and colorectum in women continue to be the most common causes of cancer death.These4cancers account for almost half of the total cancer deaths among men and women (Fig.1),with more than one-quarter of all cancer deaths due to lung cancer.Table3provides the estimated numbers of cancer deaths in2014by state for selected cancer sites.
Lifetime Probability of Developing Cancer
The lifetime probability of being diagnosed with an invasive cancer is higher for men(44%)than for women (38%)(Table4).However,because of the earlier median age at diagnosis for breast cancer(61years)compared with prostate(66years)and other major cancers,women have a slightly higher probability of developing cancer than men before age65years.These estimates are based on the average experience of the general population and may over-or underestimate individual risk because of differences in exposure(eg,smoking history),medical history,and/or genetic susceptibility.
Trends in Cancer Incidence
Figures2and3illustrate long-term trends in cancer incidence rates for all cancers combined and for selected cancer sites by sex.Trends since1992are presented in Table5in terms of the annual percent change in rates using joinpoint regression analysis.Joinpoint is a tool used to describe and quantify trends by?tting observed rates to lines connected at“joinpoints”where trends change in direction or magnitude.15,17
The overall cancer incidence rate is23%lower among women compared with men.However,during the past5 years for which there are data(2006-2010),the incidence rate decreased by0.6%per year among males but remained stable in females(Table5).The decrease in men is driven by the rapid declines in colorectal(3.3%per year),prostate (2.0%per year),and lung(1.9%per year)
cancers.
FIGURE4.Total Number of Cancer Deaths Averted From1991to2010in Men and From1992to2010in Women.
The blue line represents the actual number of cancer deaths recorded in each year,and the red line represents the number of cancer deaths that would have
been expected if cancer death rates had remained at their peak.
VOLUME00_NUMBER00_MONTH20149
Among women,although colorectal cancer declines are similar to those in men,the lung cancer rate has been slow to decline and breast cancer incidence rates have remained relatively ?at since 2003(Fig.3).
Declines in incidence rates for the major cancers re?ect improvements in cancer control and prevention.The long-term declines in colorectal cancer incidence rates since the mid-1980s have been attributed to both changes in risk factors and the introduction of screening.18However,the rapid declines in recent years (eg,greater than 4.0%per year from 2008-2010)have been attributed to the increased uptake of colonoscopy,which prevents cancer by allowing for the removal of precancerous lesions.19,20Prostate cancer incidence rates have been generally declining since around 2000,although rates have ?uctuated widely from year to year (Fig.3),likely re?ecting variation in the prevalence of prostate-speci?c antigen testing for the detection of prostate cancer.Lung cancer incidence rates began declining in the mid-1980s in men and in the late 1990s in women as a result of reduced smoking prevalence.5Differences in lung cancer incidence patterns between men and women (Fig.3)re?ect historical differences in tobacco use;cigarette smoking prevalence peaked about 20years later in women than in men.21
In contrast to the stable or declining trends for most cancer types,incidence rates are increasing for melanoma of
the skin;esophageal adenocarcinoma;cancers of the thyroid,liver,kidney,anus,and pancreas;and human papillomavirus-positive oropharyngeal cancers.5,22Among both men and women,the largest annual increases from 2006to 2010were for cancers of the thyroid (5.4%and 6.5%in men and women,respectively)and liver (3.7%and 2.9%in men and women,respectively)(Table 5).
Trends in Cancer Mortality
The overall cancer death rate rose for most of the 20th century,peaking at 215.1deaths per 100,000population in 1991.This increase was largely driven by rapid increases in lung cancer deaths among men as a consequence of the tobacco epidemic.Over the past 2decades,however,there has been a steady decline in the cancer death rate (to 171.8in 2010)as a result of advances in prevention,early detection,and treatment,including the implementation of comprehensive tobacco control.As a result of this 20%decline,an estimated 1,340,400cancer deaths (952,700in men and 387,700in women)that would have occurred had peak rates persisted have been averted (Fig.4).
Overall declines in the cancer death rate from 1991to 2010occurred among white women (16%),black women (20%),white men (24%),and black men (33%).Figure 5illustrates the variation in the magnitude of the declines
by
FIGURE 5.Relative Decline in Cancer Death Rates From 1991to 2010by Age,Race,and Sex.
The relative decline is the difference between the 2010and 1991rate expressed as a percentage of the 1991rate.
10
CA:A Cancer Journal for Clinicians
race,sex,and 10-year age group.Downturns occurred for black and white men and women of all ages with the exception of white women aged 80years and older.Notably,black males experienced the largest drop in death rates in every age group.The sharpest decrease (44%–55%)occurred among black men aged 30years to 59years.In general,middle-aged men and women experienced the largest declines,particularly compared with adults aged 70years and older.The smaller declines among seniors re?ect the lingering effects of the tobacco epidemic on older birth cohorts.Progress is more stunted among women than men in this generation because of the later onset and more protracted decline in smoking prevalence among
women.
FIGURE 6.Trends in Death Rates Overall and for Selected Sites by Sex,United States,1930to 2010.
Rates are age adjusted to the 2000US standard population.Due to changes in International Classification of Diseases (ICD)coding,numerator information has changed over time.Rates for cancers of the lung and bronchus,colorectum,liver,uterus,and ovary are affected by these changes.*Uterus includes uter-ine cervix and uterine corpus.
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Figure6depicts long-term trends in cancer death rates among men and women overall and for selected cancer sites.In contrast to male cancer death rates,which rose continuously prior to1990,female cancer death rates fell from the late1940s to the mid-1970s(Fig.6a).It is also interesting to note that prior to1941,men had a lower risk of dying from cancer than women due to the high death rate for uterine cancer(uterine corpus and uterine cervix combined),which was the leading cause of cancer death among women in the early20th century.Uterine cancer death rates declined by more than80%between1930and 2010,largely due to the widespread uptake of screening for
TABLE6.Ten Leading Causes of Death by Age and Sex,United States,2010
ALL AGES AGES1TO19AGES20TO39AGES40TO59AGES60TO79AGES 80 MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes All Causes 1,232,4321,236,00313,3807,10260,73028,205224,613140,576475,230376,110444,690673,087
1Heart
diseases
307,384
Heart
diseases
290,305
Accidents
(unintentional
injuries)
5,124
Accidents
(unintentional
injuries)
2,450
Accidents
(unintentional
injuries)
21,504
Accidents
(unintentional
injuries)
7,818
Cancer
54,440
Cancer
50,509
Cancer
156,723
Cancer
128,760
Heart
diseases
131,682
Heart
diseases
193,291
2Cancer
301,037
Cancer
273,706
Assault
(homicide)
1,978
Cancer
824
Intentional
self-harm
(suicide)
9,463
Cancer
4,429
Heart
diseases
52,472
Heart
diseases
21,458
Heart
diseases
117,385
Heart
diseases
72,817
Cancer
84,636
Cancer
89,153
3Accidents
(unintentional
injuries)
75,921Cerebro-
vascular
diseases
77,109
Intentional
self-harm
(suicide)
1,510
Congenital
anomalies
501
Assault
(homicide)
7,098
Heart
diseases
2,339
Accidents
(unintentional
injuries)
23,991
Accidents
(unintentional
injuries)
11,469
Chronic
lower
respiratory
diseases
31,964
Chronic
lower
respiratory
diseases
31,397
Chronic
lower
respiratory
diseases
27,899
Cerebro-
vascular
disease
51,984
4Chronic Chronic Cancer Assault Heart Intentional Intentional Chronic Cerebro-Cerebro-Cerebro-Alzheimer lower lower1,039(homicide)diseases self-harm self-harm lower vascular vascular vascular disease
respiratory respiratory5005,202(suicide)(suicide)respiratory disease disease disease50,503
diseases diseases2,29712,253diseases19,70319,26125,130
65,42372,6575,172
5Cerebro-Alzheimer Congenital Intentional Cancer Assault Chronic liver Cerebro-Diabetes Diabetes Alzheimer Chronic vascular disease anomalies self-harm4,163(homicide)disease&vascular mellitus mellitus disease lower
diseases58,130506(suicide)1,342cirrhosis disease16,71813,43119,934respiratory
52,36742310,8995,128diseases
35,719 6Diabetes Accidents Heart Heart HIV Pregnancy,Diabetes Chronic liver Accidents Nephritis,Influenza&Influenza& mellitus(unintentional diseases diseases disease childbirth&mellitus disease&(unintentional nephrotic pneumonia pneumonia
35,490injuries)4272591,016puerperium7,403cirrhosis injuries)syndrome&13,26618,344 44,9386324,74613,459nephrosis
8,266 7Intentional Diabetes Chronic lower Influenza&Chronic liver Diabetes Cerebro-Diabetes Nephritis,Accidents Nephritis,Diabetes self-harm mellitus respiratory pneumonia disease&mellitus vascular mellitus nephrotic(unintentional nephrotic mellitus
(suicide)33,581diseases96cirrhosis587disease4,445syndrome&injuries)syndrome&15,082
30,2771548286,675nephrosis7,937nephrosis
9,58112,217 8Alzheimer Influenza&Cerebro-Cerebro-Diabetes Cerebro-Chronic Intentional Chronic liver Alzheimer Accidents Nephritis, disease pneumonia vascular vascular mellitus vascular lower self-harm disease&disease(unintentional nephrotic
25,36426,482disease disease779disease respiratory(suicide)cirrhosis7,431injuries)syndrome&
13393diseases3,7937,73411,195nephrosis
5765,02714,891 9Nephritis,Nephritis,Influenza&Chronic Cerebro-HIV HIV Septicemia Influenza&Septicemia Diabetes Accidents nephrotic nephrotic pneumonia lower vascular disease disease2,269pneumonia6,715mellitus(unintentional syndrome&syndrome&114respiratory disease5534,0547,36610,548injuries)
nephrosis nephrosis diseases66114,786
24,86525,61190
10Influenza&Septicemia In situ,In situ,Congenital Chronic liver Viral Nephritis,Septicemia Influenza&Parkinson Hypertension pneumonia18,743benign,benign,anomalies disease&hepatitis nephrotic6,768pneumonia disease&hypertensive 23,615&unknown&unknown477cirrhosis3,306syndrome&5,9198,291renal disease* neoplasms neoplasms466nephrosis10,756
97902,087
HIV indicates human immunodeficiency virus.
*Includes primary and secondary hypertension.
Note:Deaths within each age group do not sum to all ages combined due to the inclusion of unknown ages.In accordance with the National Center for Health Statistics’cause-of-death ranking,"Symptoms,signs,and abnormal clinical or laboratory findings"and categories that begin with"Other"and"All other"were not ranked.
Source:US Final Mortality Data,2010,National Center for Health Statistics,Centers for Disease Control and Prevention,2013.
12CA:A Cancer Journal for Clinicians
the prevention and early detection of cervical cancer.A similar dramatic decline occurred for stomach cancer, which accounted for30%and20%of male and female cancer deaths,respectively,in the1930s.By2010,stomach cancer accounted for just2%of cancer deaths.Rates of stomach cancer have declined worldwide due to improved hygiene,resulting in a lower prevalence of Helicobacter pylori,and advances in food preservation techniques(eg,refrigeration),which have led to lower salt intake and higher consumption of fresh fruits and vegetables.
During the most recent5years for which data are available,the average annual decline in cancer death rates was slightly larger among men(1.8%)than women(1.4%) (Fig.6)(Table5).These declines are driven by continued decreases in death rates for the4major cancer sites(Fig.6). Due to the reduction in tobacco use over the past50years, the lung cancer death rate declined34%between1991 and2010among males and9%between2002and 2010among females.5,23Death rates for breast,prostate, and colorectal cancers are down from peak rates by34%,45%,and46%,respectively,as a result of improvements in early detection and treatment.5,18,24,25
In contrast,joinpoint trend analysis for2001to2010 indicates that death rates are rising for cancers of the oropharynx,anus,liver,pancreas,and soft tissue(including the heart),and for melanoma in men.5The rate of death from thyroid cancer is also increasing according to joinpoint analysis(Table5),although the observed rates increased only slightly from0.47(per100,000 population)to0.50among men and from0.48to0.51 among women.
Recorded Number of Deaths in2010
A total of2,468,435deaths were recorded in the United States in2010,of which574,743(23%)were from cancer. Overall,cancer is the second leading cause of death following heart disease.However,within20-year age groups,cancer is the leading cause of death among adults aged40years to79years(Table6).Among females,cancer is the?rst or second leading cause of death in every age group.
TABLE7.Five Leading Types of Cancer Death by Age and Sex,United States,2010
ALL AGES<2020TO3940TO5960TO79 80
MALE
ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES
300,4641,0704,16354,440156,72384,636 Lung&bronchus Leukemia Leukemia Lung&bronchus Lung&bronchus Lung&bronchus 87,69929355014,68752,23320,504
Prostate Brain&ONS Brain&ONS*Colorectum Colorectum Prostate
28,5612725035,64513,27215,188
Colorectum Bones&joints Colorectum Liver&bile duct Prostate Colorectum
27,074924424,45811,9497,708
Pancreas Soft tissue Non-Hodgkin Pancreas Pancreas Urinary bladder
18,699(including heart)lymphoma3,74810,3714,766
83276
Liver&intrahepatic Non-Hodgkin Lung&bronchus Esophagus Liver&intrahepatic Pancreas bile duct lymphoma2662,737bile duct4,466
13,658556,803
FEMALE
ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES ALL SITES
273,7068554,42950,509128,76089,153
Lung&bronchus Leukemia Breast Breast Lung&bronchus Lung&bronchus 70,55023596311,50739,54019,681
Breast Brain&ONS*Uterine cervix Lung&bronchus Breast Breast
40,99622643011,08217,37511,151
Colorectum Bones&joints Leukemia Colorectum Colorectum Colorectum
24,972743954,1859,85510,588
Pancreas Soft tissue Colorectum Ovary Pancreas Pancreas
18,189633383,1138,9116,692
Ovary Liver&intrahepatic Brain&ONS*Pancreas Ovary Non-Hodgkin
14,572bile duct3092,5067,338lymphoma
254,144
ONS indicates other nervous system.
Note:Ranking order excludes category titles that begin with“Other.”
VOLUME00_NUMBER00_MONTH201413
Table7presents the number of deaths from all cancers combined and from the5most common sites for each 20-year age group by sex.For all ages combined,men have a higher number of deaths for shared sites with the exception of pancreatic cancer,for which the burden is similar.Among males,leukemia is the leading cause of cancer death in those
ALL CANCERS BREAST COLORECTUM
LUNG&
BRONCHUS
NON-HODGKIN
LYMPHOMA PROSTATE URINARY BLADDER
STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE MALE FEMALE Alabama573.2395.2118.757.240.3103.254.019.513.6157.733.37.5 Alaska521.0430.3127.753.144.583.860.421.816.1137.338.09.8 Arizona441.4371.2110.241.432.061.847.918.013.4112.732.28.4 Arkansas*?557.7388.1110.355.640.5108.460.421.215.3156.433.98.1 California505.7397.1122.049.437.360.444.422.915.6140.333.58.0 Colorado483.1396.4125.343.633.656.144.222.515.9142.731.28.2 Connecticut576.2456.9136.351.339.275.559.525.217.3160.046.812.6 Delaware601.7443.3126.553.139.687.165.823.716.7177.343.211.3 Dist.of Columbia574.8427.7139.750.944.877.548.121.813.4194.425.19.0 Florida518.8399.9114.347.836.679.456.721.915.2131.235.38.6 Georgia568.7403.1121.552.138.493.355.021.514.8165.733.97.9 Hawaii484.4393.4123.156.938.064.338.720.713.7119.925.8 6.3 Idaho513.3410.1119.543.234.861.547.221.317.5152.936.18.9 Illinois566.6440.3126.459.143.486.760.924.016.4153.939.49.9 Indiana527.4422.0117.454.741.896.463.523.317.0122.435.28.8 Iowa555.7437.1123.456.944.384.754.926.818.9137.241.78.8 Kansas552.2422.0123.255.039.980.254.523.416.8152.437.99.3 Kentucky611.2462.4121.363.946.0125.980.325.317.5134.640.59.7 Louisiana603.4413.6119.762.444.099.657.724.516.5169.334.18.1 Maine581.5460.6126.551.441.291.567.325.417.9144.848.013.2 Maryland529.1415.0128.047.636.774.455.821.315.0157.233.49.2 Massachusetts568.1460.4134.249.938.878.364.125.016.5153.643.911.9 Michigan574.1433.5120.051.039.386.161.624.917.7163.741.310.7 Minnesota?------------Mississippi598.6396.9113.861.344.7112.756.221.614.5166.330.87.2 Missouri530.8423.3121.555.340.895.664.322.316.0126.234.88.4 Montana520.8421.9124.151.139.068.956.322.815.0155.236.49.9 Nebraska526.2420.9122.357.744.474.651.223.517.7143.035.08.6 Nevada*§509.8399.2112.752.038.175.764.720.415.3138.937.310.7 New Hampshire580.3452.1132.046.738.080.162.225.117.1155.449.113.2 New Jersey582.6450.6129.354.741.272.855.325.217.8169.243.611.6 New Mexico461.9362.5108.844.133.652.938.118.213.8134.126.2 6.2 New York585.4449.2127.753.340.976.356.026.318.1167.342.110.6 North Carolina564.9416.0124.950.837.196.757.222.615.7151.937.58.9 North Dakota528.6410.2123.059.241.868.143.322.018.4156.238.69.2 Ohio*§548.1425.4120.555.542.292.660.723.016.1145.238.79.6 Oklahoma552.2422.0121.753.640.896.162.722.417.1148.434.78.6 Oregon508.8429.2129.545.536.870.657.622.815.3139.337.19.5 Pennsylvania573.6454.8126.056.042.884.457.925.217.8149.544.111.0 Rhode Island575.7462.4131.051.341.384.164.522.517.9148.948.713.8 South Carolina551.7401.1122.350.337.994.153.920.513.4152.830.88.4 South Dakota499.4395.9117.955.741.873.848.021.615.9145.533.68.3 Tennessee562.0416.0118.853.440.4103.461.322.616.3144.335.48.2 Texas513.9389.9114.450.935.778.249.022.215.9133.229.5 6.9 Utah494.8357.7110.839.431.234.123.325.216.3175.931.4 5.3 Vermont539.8453.8131.444.838.381.265.624.117.7139.940.512.2 Virginia*521.7397.4124.546.936.782.253.921.714.2150.333.38.3 Washington544.6437.7131.046.136.372.157.326.217.4151.638.99.3 West Virginia557.7434.1110.258.043.8106.470.023.217.5131.838.810.7 Wisconsin530.8419.2122.548.437.573.653.424.317.3142.939.29.7 Wyoming497.1384.2110.847.537.757.346.019.815.0152.238.79.9 United States542.3418.8122.251.739.180.055.123.316.3146.636.99.1 Rates are per100,000and age adjusted to the2000US standard population.
*This state’s data are not included in the US combined rates because it did not meet high-quality standards for one or more years during2006to2010 according to the North American Association of Central Cancer Registries(NAACCR).
?Rates are based on incidence data for2006to2008.
?This state’s registry did not submit cancer incidence data to the NAACCR.
§Rates are based on incidence data for2006to2009.
14CA:A Cancer Journal for Clinicians
aged younger than40years,while lung cancer ranks?rst in men aged40years and older.Among females,leukemia is the leading cause of cancer death in children and adolescents (aged younger than20years),breast cancer ranks?rst in women aged20years to59years,and lung cancer causes the most cancer deaths in those aged60years and older.Regional Variations in Cancer Rates
Tables8and9depict cancer incidence and death rates for selected cancers by state.Lung cancer shows the largest geographic variation in cancer occurrence by far,re?ecting the large historical and continuing differences in smoking prevalence among states.23For example,lung cancer
ALL SITES BREAST COLORECTUM
LUNG&
BRONCHUS
NON-HODGKIN
LYMPHOMA PANCREAS PROSTATE
STATE MALE FEMALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE Alabama255.4156.423.322.515.087.440.88.0 5.313.29.728.9
Alaska210.5161.024.219.615.161.845.87.6 5.512.99.822.5
Arizona186.0131.720.617.111.949.833.27.6 4.811.48.320.5 Arkansas250.6160.923.422.715.690.145.48.6 5.513.29.625.3 California189.8139.821.917.512.747.232.37.8 4.911.79.422.3 Colorado181.4133.219.616.712.444.231.37.8 4.410.89.022.9 Connecticut199.5144.721.616.212.152.738.27.5 4.913.99.922.3 Delaware228.0159.322.820.413.368.247.78.3 4.813.09.523.7
Dist.of Columbia248.5167.629.822.218.961.935.08.0 4.016.912.038.8
Florida204.5140.721.318.112.861.438.87.8 4.912.18.820.1
Georgia228.3147.823.420.213.873.138.77.6 4.512.59.127.1
Hawaii178.4117.116.417.310.948.825.97.2 4.312.39.715.7
Idaho192.9140.221.616.112.449.234.57.2 5.612.09.225.9
Illinois223.3158.523.621.715.465.841.98.5 5.313.010.124.3
Indiana238.8161.523.921.314.579.446.79.3 5.413.09.423.2
Iowa212.6148.421.320.015.264.138.38.9 5.512.28.822.7
Kansas214.4146.522.220.613.166.839.49.1 5.312.69.120.7 Kentucky262.7173.323.123.416.297.155.89.0 5.712.79.623.9 Louisiana254.7164.425.424.015.780.943.68.6 5.214.211.126.6
Maine231.1158.320.920.213.969.946.08.8 5.111.69.822.9 Maryland216.9154.024.520.514.061.740.87.4 4.512.910.325.0 Massachusetts216.6152.521.318.713.460.642.17.8 4.812.710.422.4 Michigan223.0159.524.019.414.268.243.98.9 5.813.910.221.8 Minnesota203.9145.020.917.612.653.337.09.4 5.211.99.323.9 Mississippi270.6159.124.724.816.595.442.08.3 4.714.110.131.2 Missouri231.1160.224.221.214.676.546.28.3 5.413.09.921.8 Montana195.3145.119.816.714.052.139.67.9 4.911.88.426.4 Nebraska208.4143.820.121.415.060.335.58.4 5.712.09.722.9
Nevada211.4153.623.021.014.959.746.57.1 4.612.69.723.9
New Hampshire211.7154.221.317.913.159.043.37.3 4.713.210.422.4
New Jersey207.8154.325.221.014.955.837.27.8 5.213.410.121.6
New Mexico187.4131.620.918.812.743.428.6 6.6 4.510.98.424.4
New York199.7145.422.319.213.854.336.17.9 4.912.89.921.8
North Carolina232.2149.923.119.413.176.640.77.5 5.012.09.625.8
North Dakota203.6137.221.621.213.954.132.2 6.7 5.112.68.323.6
Ohio236.5162.624.821.815.274.844.29.2 5.613.110.123.8 Oklahoma238.8161.023.922.114.579.646.69.0 6.012.28.923.5
Oregon208.5153.421.618.113.358.442.78.5 5.312.39.924.4 Pennsylvania225.6157.023.821.515.065.839.68.9 5.513.410.022.7
Rhode Island221.8149.620.818.613.264.942.68.3 4.412.28.920.6
South Carolina240.1151.723.520.214.277.139.97.8 4.712.79.827.5
South Dakota206.8141.320.319.813.961.934.17.8 5.311.19.323.4 Tennessee256.4160.423.321.815.389.546.69.2 5.413.19.425.2
Texas209.3141.821.820.013.160.735.47.9 4.911.88.821.3
Utah157.1112.321.814.310.727.516.87.7 4.710.08.425.9 Vermont212.0154.320.417.414.862.345.17.8 5.012.49.322.1
Virginia221.1151.424.019.214.067.140.08.2 4.812.79.724.7 Washington207.2152.221.517.112.557.042.18.6 5.412.710.024.2
West Virginia246.9168.622.123.416.184.350.98.7 6.611.37.820.9 Wisconsin213.7149.721.318.012.758.438.49.0 5.512.810.024.5 Wyoming196.0146.821.318.714.749.936.47.6 5.312.99.022.8
United States215.3149.722.619.613.963.539.28.2 5.112.59.623.0
Rates are per100,000and age adjusted to the2000US standard population.
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incidence rates in Kentucky,which has historically had the highest smoking prevalence,are almost4-fold higher than those in Utah,which has the lowest smoking prevalence (126vs34cases per100,000men).There is also a large range for prostate cancer incidence rates,from112.7in Arizona to194.4in the District of Columbia,which likely re?ects state differences in PSA testing prevalence and racial distribution.26In contrast,state variations for other cancer sites are smaller in both absolute and relative terms. For example,the breast cancer incidence rate ranges from 140(per100,000population)in the District of Columbia to109in New Mexico,a difference of28%.State variation in incidence rates re?ects differences in the use of screening tests or detection practices in addition to differences in disease occurrence.
Cancer Occurrence by Race/Ethnicity
Cancer incidence and death rates vary considerably between and within racial and ethnic groups.Of the5broadly
TABLE10.Incidence and Death Rates by Site,Race,and Ethnicity,United States,2006to2010
NON-HISPANIC
WHITE BLACK
ASIAN AMERICAN/
PACIFIC
ISLANDER
AMERICAN
INDIAN/
ALASKA NATIVE*HISPANIC Incidence
All sites
Male548.6601.0326.1441.1426.8 Female436.2395.9282.6372.0330.8 Breast(female)127.3118.484.790.391.1 Colorectum
Male50.962.540.851.747.3 Female38.646.731.042.732.6 Kidney&renal pelvis
Male21.623.010.630.620.5 Female11.212.2 5.117.511.5 Liver&intrahepatic bile duct
Male8.714.921.317.818.8 Female 2.9 4.48.08.0 6.9 Lung&bronchus
Male82.994.748.870.245.9 Female59.950.428.052.126.6 Prostate138.6220.075.0104.1124.2 Stomach
Male7.815.715.613.113.9 Female 3.58.19.0 6.98.2 Uterine cervix7.210.3 6.79.710.9
Mortality
All sites
Male217.3276.6132.4191.0152.2 Female153.6171.292.1139.0101.3 Breast(female)22.730.811.515.514.8 Colorectum
Male19.228.713.118.716.1 Female13.619.09.715.410.2 Kidney&renal pelvis
Male 5.9 5.7 3.09.5 5.1 Female 2.6 2.6 1.2 4.4 2.3 Liver&intrahepatic bile duct
Male7.111.814.413.212.3 Female 2.9 4.1 6.0 6.1 5.4 Lung&bronchus
Male65.778.535.549.631.3 Female42.737.218.433.114.1 Prostate21.350.910.120.719.2 Stomach
Male 3.99.88.78.17.6 Female 1.9 4.7 5.1 3.8 4.4 Uterine cervix 2.1 4.2 1.9 3.5 2.9 Rates are per100,000population and age adjusted to the2000US standard population.Nonwhite race categories are not mutually exclusive of Hispanic origin.
*Data based on Indian Health Service Contract Health Service Delivery Areas.
16CA:A Cancer Journal for Clinicians
de?ned groups in Table10,black men have the highest cancer incidence and death rates–about double those of Asian Americans,who have the lowest rates.Cancer incidence and death rates are higher among black than white men for every site included in Table10except kidney cancer mortality.Factors known to contribute to racial disparities vary by cancer site and include differences in exposure to underlying risk factors(eg,historical smoking prevalence for lung cancer),access to high-quality screening(breast,cervical,and colorectal cancers),and timely diagnosis and treatment.27It is notable that although white women have the highest breast cancer incidence rate,black women have the highest breast cancer mortality rate.The higher incidence rate among white women is thought to re?ect a combination of factors that affect both diagnosis(more prevalent mammography)and underlying disease occurrence(such as later age at?rst birth and greater use of menopausal hormone therapy).28 The high breast cancer mortality rate among black women has been attributed to a higher prevalence of comorbidities, a longer time to follow-up after an abnormal mammogram, less access to high-quality treatment,and a higher prevalence of aggressive tumor characteristics.29–31 Cancer incidence and death rates are lower among Asian Americans/Paci?c Islanders,American Indians/Alaska Natives,and Hispanics than whites for all cancer sites combined and for the4most common cancer sites. However,cancers associated with infectious agents(eg, those of the uterine cervix,stomach,and liver)are generally more common in nonwhite populations.For example, stomach and liver cancer incidence and death rates are twice as high in the Asian American/Paci?c Islander population as in whites,re?ecting a higher prevalence of chronic infection with Helicobacter pylori and hepatitis B virus,respectively.32Kidney cancer incidence and death rates are the highest among American Indians/Alaska Natives,which may be due in part to high rates of obesity and smoking in this population.33
Table11presents trends in cancer incidence and death rates during the most recent10years for which there are data(2001-2010)by race and ethnicity.These trends are based on rates that are not adjusted for reporting delays because the long-term incidence data required for delay adjustment are not available for populations other than whites or blacks.Among men,incidence rates declined between1.6%and2.0%per year for all groups except American Indians/Alaska Natives.Declines in death rates among men were of a similar magnitude,and were highest among blacks(2.5%per year).Among women,incidence rate declines were smaller and were con?ned to non-Hispanic whites(0.5%per year)and Hispanics(0.8%per year),though mortality declines of greater than1.0%per year were experienced by all racial/ethnic groups except American Indians/Alaska Natives.As in men,black women had the largest annual decline in cancer death rates (1.7%).
Cancer Survival
The stage-speci?c5-year relative survival rate is lower for blacks than for whites for nearly every cancer type(Fig.7). Studies suggest that racial disparities in survival are primarily due to differences in treatment,stage at diagnosis,and comorbidities,as opposed to differences in cancer biology.34As shown in Figure8,blacks are less likely than whites to be diagnosed with cancer at a localized stage,when treatment is more successful.This disparity is particularly striking for cancers of the breast,cervix,uterine corpus,and oral cavity and pharynx.Lower socioeconomic status among blacks likely explains much of the stage disparity and is also associated with receipt of less
TABLE11.Average Annual Percent Change in Cancer Incidence and Mortality Rates From2001to2010
by Race/Ethnicity,United States
INCIDENCE MORTALITY
MALE FEMALE MALE FEMALE
All race/ethnicities-1.6*-0.3*-1.8*-1.4*
Non-Hispanic white?-1.6*-0.5*-1.6*-1.3*
Black-1.8*-0.1-2.5*-1.7*
Asian American/Pacific Islander-1.7*0.0-1.6*-1.0* American Indian/Alaska Native?-0.8-0.2-0.10.1 Hispanic?-2.0*-0.8*-1.6*-1.4*
*Average annual percent change is statistically significant(P<.05).
?Excludes deaths from Connecticut,District of Columbia,Maine,Maryland,Minnesota,New Hampshire,New York,North Dakota,Oklahoma,South Carolina,
and Vermont due to unreliable Hispanic origin data for some years.
?Data based on Indian Health Service Contract Health Service Delivery Areas.
Notes:Trends analyzed by the Joinpoint Regression Program,version3.5.0,allowing up to2joinpoints.Incidence trends based on the North American Associa-
tion of Central Cancer Registries(NAACCR)data.Nonwhite race categories are not mutually exclusive of Hispanic origin.
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aggressive treatment.35,36Even among Medicare-insured patients,blacks are less likely than whites to receive standard cancer therapies for lung,breast,colorectal,and prostate cancers.37
There have been notable improvements in survival over the past3decades for most cancers among both whites and blacks(Table12).Between1975and1977and2003and 2009,overall5-year relative survival rates increased19
FIGURE7.Five-Year Relative Survival Rates for Selected Cancers by Race and Stage at Diagnosis,United States,2003to2009.
*The standard error of the survival rate is between5and10percentage points.
?The survival rate for carcinoma in situ of the urinary bladder is96%for All Races,97%for Whites,and91%for blacks.
18CA:A Cancer Journal for Clinicians
percentage points among whites and 22percentage points among blacks.The largest improvements in survival have been for leukemia and non-Hodgkin lymphoma,while lung and pancreatic cancers have shown the least improvement.Relative survival rates cannot be calculated for some minority populations because accurate life tables are not https://www.doczj.com/doc/ce2406518.html,parison of cause-speci?c survival rates for patients diagnosed from 2003to 2009indicates that Asian American/Paci?c Islander women have the
highest
FIGURE 8.Stage Distribution of Selected Cancers by Race,United States,2003to 2009.
*The proportions of carcinoma in situ of the urinary bladder are 51%for All Races,52%for Whites,and 38%for blacks.Stage categories do not sum to 100%because sufficient information is not available to assign a stage to all cancer cases.
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19
probability of surviving5years after a cancer diagnosis (69.5%),while American Indian/Alaska Native men have the lowest probability of surviving(56.8%).5For both sexes combined,whites and Hispanics have the highest5-year cause-speci?c survival(66.7%),while American Indians/Alaska Natives have the lowest(59.0%). Limitations
The projected numbers of new cancer cases and cancer deaths should be interpreted with caution because they are model-based estimates that may vary considerably from year to year for reasons other than changes in cancer occurrence.For instance,estimates are affected by changes in method,which are implemented regularly as modeling techniques improve and surveillance coverage becomes more complete.In addition,the model is sometimes oversensitive or undersensitive to abrupt or large changes in observed data.For these reasons,the projections are not an accurate measure of year-to-year changes in cancer occurrence and death.The data sources used for tracking cancer trends are age-standardized or age-speci?c cancer death rates from the NCHS and cancer incidence rates from SEER and/or the National Program of Cancer Registries.Nevertheless,the American Cancer Society projections of new cancer cases and deaths provide a reasonably accurate estimate of the current cancer burden in the United States.
Errors in reporting race/ethnicity in medical records and on death certi?cates may result in underestimates of cancer incidence and mortality rates in nonwhite and nonblack populations.It is also important to note that cancer data in the United States are primarily reported for broad racial and ethnic groups that are not homogenous,masking important differences in the cancer burden within these groups. Conclusions
Cancer death rates have been continuously declining for the past2decades.Overall,the risk of dying from cancer decreased by20%between1991and2010.Progress has been most rapid for middle-aged black men,among whom death rates have declined by approximately50%.Despite this substantial progress,5-year survival rates among blacks continue to lag behind whites by as much as22percentage points for uterine cancer,21percentage points for cancer of
TABLE12.Trends in5-Year Relative Survival Rates*(%)by Race and Year of Diagnosis,United States,1975to2009
ALL RACES WHITE BLACK
1975TO 19771987TO
1989
2003TO
2009
1975TO
1977
1987TO
1989
2003TO
2009
1975TO
1977
1987TO
1989
2003TO
2009
All sites495568?505769?394361?Brain&other nervous system222935?222833?253241?Breast(female)758490?768592?627179?Colon516065?516167?455256?Esophagus5919?61120?4714?Hodgkin lymphoma727988?728089?707283?Kidney&renal pelvis505773?505773?495572?Larynx666663?676764585652 Leukemia344359?354460?333553?Liver&intrahepatic bile duct3518?3617?2312?Lung&bronchus121318?121318?111114?Melanoma of the skin828893?828893?57?79?77?Myeloma252745?242745?303044?Non-Hodgkin lymphoma475171?475172?484664?Oral cavity535465?545667?363446?Ovary363844?353844?423436 Pancreas246?337?266?Prostate6883100?6984100?617198?Rectum485868?485968?445262?Stomach152029?141828?161929?Testis839597?839697?73?§88?90 Thyroid929498?929498?909297?Urinary bladder727980?738081?506364?Uterine cervix697069707371645763 Uterine corpus878284?888486?605764 *Survival rates are adjusted for normal life expectancy and are based on cases diagnosed in the Surveillance,Epidemiology,and End Results(SEER)9areas from1975to1977,1987to1989,and2003to2009,all followed through2010.
?The difference in rates between1975to1977and2003to2009is statistically significant(P<.05).
?The standard error of the survival rate is between5and10percentage points.
§Survival rate is for1978to1980.
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[GWICC2014]长期口服抗凝治疗合并出血的评估与对策 2014年10月30日11:01来源：https://www.doczj.com/doc/ce2406518.html, 抗凝治疗是一把双刃剑，其最大的挑战是出血，合理评估出血风险与对策显得尤为重要。在第25届长城国际心脏病学会议上，阜外心血管病医院心内科急重症中心的杨艳敏教授讲解了长期口服抗凝治疗合并出血的评估与对策。 一、需要抗凝治疗的人群 √ 80%以上的房颤患者具有抗凝指征，其中30%合并血管病变，20%行PCI治疗，这些患者均需要长期抗凝 √深静脉血栓栓塞症（VTE） √人工瓣膜置入术后等 二、抗凝面临的挑战 自2010年以来抗凝领域发生了显著变化，我们面临以下挑战： （1）新型口服抗凝药物的问世以及对抗凝质控（TTR）关注影响着卒中预防； （2）房颤合并ACS或PCI，使抗凝治疗变得更加复杂； （3）新的介入技术的应用，如TAVI或经皮二尖瓣修复等合并房颤的抗栓治疗； （4）围术期以及围介入操作期抗凝的桥接。 但是抗凝治疗最大的挑战是出血，合理评估出血风险与对策显得尤为重要。 三、抗凝药物所致出血的定义 目前多采用2004年6月18日在威尼斯举办的50届科学和标准委员会抗凝小组的ISTH 标准。 1、非外科手术患者大出血定义为：（1）致命性出血，和/或；（2）重要部位或器官的症状性出血，如颅内、脊髓内、眼内、腹膜后、关节腔内、心包或肌间出血伴骨筋膜室综合征，和/或；（3）出血导致血红蛋白下降超过20g/l，或导致输全血或红细胞2单位以上。 2、其他类型的出血归类为小出血 3、临床相关非大出血（NMCR） 四、抗凝治疗合并出血的评估
影响抗凝治疗合并出血的因素很多，包括抗凝强度、抗凝管理、患者的临床特征（年龄、基因多态性、既往卒中史、出血史、贫血、合并症如高血压、肾损伤及肝病等）以及合并用药和酒精的影响（抗血小板药、NASID、影响抗凝效果的药物以及酒精等）。 房颤患者的出血风险评估主要有以下三种评分系统。 1、HAS-BLED评分 √高血压：SBP＞160mmHg （1分） √肾功能异常：长期透析或肾移植或血清肌酐≥200μmol/l （1分） √肝功能异常：慢性肝病（如肝硬化）或显著肝紊乱（1分） √出血：指既往出血史和（或）出血易感性（1分） √ INRs易变：指INRs不稳定（1分） √药物/酒精应用：指同时应用抗血小板药物、非甾体类抗炎药或酗酒等（药物/酒精应用各占1分） HAS-BLED评分是目前指南普遍推荐的评分方法，≥3分提示出血高风险。 2、HEMORR2HAGES评分 HEMORR2HAGES评分比较复杂，使用较少，常规进行遗传学检测不方便。包含的条目有肝肾疾病、酒精滥用、恶性疾病、高龄、血小板计数或功能异常、反复出血、高血压、贫血、遗传因素、跌倒和卒中。 3、ATRIA评分 条目包括：贫血 3分，严重肾病 3分，年龄≥75岁 2分，出血史 1分，高血压1 分。0-1分为低危，2-3分为中危，4-10分为高危。 在上述3种评分中，HAS-BLED评分更优，预测性更强；它不但能够预测抗凝导致的出血，而且能够预测服用阿司匹林患者的出血。 出血的危险因素中有很多也是栓塞的危险因素，例如高血压、年龄、卒中史等。因此，一个患者出血风险高，其栓塞的风险可能也高，这常常将我们置于两难的境地。研究显示，卒中高风险患者（CHA2DS2-VASC评分≥2分）和出血高风险的患者（HAS-BLED评分≥3分）更能从口服抗凝治疗中获益；除了低卒中风险的患者（CHA2DS2-VASC评分=0分）和极度出血高风险的患者，所有的房颤患者都应该给予抗凝药物治疗。 五、抗凝治疗合并出血的对策
ACS 抗栓治疗合并出血防治多学科专家共识—出血风险评 估与预防 抗栓治疗已成为急性冠状动脉综合征（ACS）药物治疗的 基石，与抗栓治疗相关的各种出血并发症也日渐增加。中国 医师协会心血管内科医师分会及其血栓防治专业委员会联合中华医学会消化内镜学分会及北京神经内科学会等学术团体，组织10 余个学科知名专家共同讨论制定《急性冠状动脉综合征抗栓治疗合并出血防治多学科专家共识》。以下主要为该专家共识中抗栓治疗的出血风险评估与预防部分内容。出血风险评估出血的预测因素抗栓治疗后出血的预测因素包括：（1）患者因素，如高龄、女性、低体重、慢性肾 脏病、贫血、心力衰竭、高血压、糖尿病、原有血管疾病、血小板减少症、既往出血病史、抗血小板药物高反应性等； 2）药物因素，如抗栓药物的种类、剂量、时程、联合用 药的数量以及交叉重叠使用等；（3）介入操作与器械因素， 如血管径路、血管鞘外径、血管鞘置人时间以及是否应用血管缝合器等。由于出血往往是多种因素共同作用的结果，单 因素预测出血的能力有限，因而通常采用综合因素评分的方法进行风险评估。 出血的风险评分出血的风险评分共识推荐所有ACS 患者在 PCI 术前常规采用CRUSADE 评分预测出血风险（表2）。
11.9 ％和 19.5 ％。 出血的预防策略合理选择和使用抗栓药物 1．阿司匹林：所 有无禁忌证的 ACS 患者发病后应立即口服水溶性阿司匹林 或嚼服阿司 匹林肠溶片 300 mg ，继以 100 mg/d 长期维持。 长期服用宜选择肠溶制剂，不宜掰开或咬碎服用，不建议餐 后服用（多 建议临睡前服用） ，以降低胃肠道损伤风险。 2．P2Y12 受体抑制剂： 所有 ACS 患者建议在阿司匹林基础 上联合使用一种 P2Y12受体抑制剂。所有无禁忌证的非 ST 段抬高急性冠状动脉综合征（ NSTE-ACS ）患者，无论接受 体抑制剂治疗至少 12 个月。若出血风险不高（如 CRUSADE 30 分）,建议优先选择替格瑞洛负荷量 维持量 90 mg , 2次/d ;也可选择氯吡格雷负荷量 mg ,维持量75 mg/d 。接受直接 PCI 的STEMI 优先选择负荷量替格瑞洛 180 mg ，其后给予维持量 90 mg ， 2次/d ;或氯吡格雷负荷量 300?600 mg ，维持量75 mg , 1次/d oPCI 术后P2Y12受体抑制剂一般建议维持 12个月。 接受溶栓治疗的 STEMI 患者，如年龄W 7岁，给予300 mg 负荷量氯吡格雷，随后 75 mg/d ，维持至少 14 d ?12 个月; 根据评分将出血风险分为很低危（W 2分）、 低危（ 21 ? 30 分）、 中危（31?40 分） 、高危（ 41 ? 50 分） 和很高危（ >50 分），其相应的院内出血风险分别为 3.1％、 4.5％、 8.6％、 早期侵入策略还是药物保守治疗策略，均应给予 P2Y12 受 180 mg ， 300 ?600
ACS抗栓治疗合并消化道出血多学科专家共识 ACS抗栓治疗合并出血怎么办？ 一般原则对于抗栓治疗合并出血的ACS患者，如何做到迅速控制出血并兼顾缺血风险是临床医生经常面临的两难境地。如前所述，ACS合并大出血本身增加死亡风险，而发生出血后停用抗栓药物可能导致缺血事件，后者亦增加死亡风险。因此，一旦发生出血应进行综合评估并权衡利弊，制定个体化的临床方案。 (一)出血相关评估依据出血程度(BARC出血分型)、部位、原因及止血方法对出血患者进行评估并采取不同的干预措施(表4)。 (二)缺血相关评估与缺血事件相关的因素较多，临床医生需结合临床特征、病变特征、介入操作及器械特征、术中并发症、PCI时间以及血小板功能等综合评估(表5)。 (三)临床决策路径对于ACS抗栓治疗合并出血的患者，应尽快完成出血与缺血双评估，在选择合理止血方案的基础上，决定后续抗栓治疗策略。在出血的评估与处理、缺血风险的评估和抗栓策略调整等过程中，心血管内科医师必须与相关学科密切协作，在整合多学科意见的基础上做出最佳临床决策(图4)。 (四)输血有关问题严重出血可导致循环衰竭乃至死亡，但输
血本身也可导致或加重炎症反应，输血适应证把握不当可能增高病死率。一般建议，血红蛋白低于70 g/L时应考虑输血，但仅建议将血红蛋白升至70～90g/L。有研究显示，通过输血将血红蛋白升至90～110 g/L反而升高病死率。因而，只要患者生命体征平稳，临床上不建议过多输血。上消化道出血成人上消化道出血(UGIB)的病死率为2.5％～10.0％，尽管内镜和抗酸药物已得到广泛应用，再出血率仍高达13％。1.风险评估：主要依据临床症状、实验室检查及内镜检查行风险评估，内容包括：(1)临床评估：结合症状与体征评估血流动力学是否稳定，是否需要给予液体复苏治疗。(2)实验室评估：红细胞压积(3)危险评分：建议对所有急性上消化道出血患者进行Blatchford评分，以便在内镜检查前预判哪些患者需要接受输血、内镜检查或手术等干预措施，其取值范围为0～23分。内镜检查后还可以结合患者年龄、休克状况、伴发病等进行Rockall评分，以评估患者的死亡风险，其取值范围为0～11分，0～2分提示再出血和死亡风险均较低。此外，对消化性溃疡出血患者，还应结合内镜下表现进行Forrest分级，有助于优化止血治疗方案。2.抗栓治疗策略的调整：ACS抗栓治疗过程中一旦发生上消化道出血，应综合评估缺血与出血风险；小出血(如BARC出血分型满足以下条件考虑出血已经得到控制，5 d后可恢复使用抗血小板药物：(1)血流动力学稳定；(2)不输血情况下，血红蛋白稳定；
广元市x x x x医院 关于举办2019年省级继续教育项目“高血压及其合并症的规范治疗”学术活动的通知 各医疗卫生机构： 为提高广元市各医疗机构心血管内科疾病的诊疗技术水平，广元市xxxx医院将于7月x日-x日举办2019年省级继续教育项目“高血压及其合并症的规范治疗”学术活动，项目编号：。。。。。现将有关事项通知如下： 一、会议时间 2019年7月x日-x日 二、会议地点 广元市利州区苴国路广元市xxxx学术报告厅 三、会议内容（理论授课） 1.高血压管理指南（亚洲临床实践精粹） --四川大学华西医院陈xx 主任医师、教授 2.心力衰竭治疗新进展 --四川大学华西医院张x 主任医师、教授 3.爆发性心肌炎救治（中国方案） --广元市第一人民医院王x 主任医师 4.ACS患者抗栓治疗合并出血防治进展
--川北医学院附属医院吕x 主任医师、教授 5.ACS有创诊断策略 --四川省绵阳404医院李xx 主任医师 6.终末期心衰患者心脏移植手术时机的选择 --北京阜外医院黄x 主任医师、教授 7.冠心病合并房颤患者的新选择 --广元市第一人民医院胡xx 副主任医师 四、参会人员 （一）大会特邀知名专家。 （二）广元市内各级医疗机构从事心血管内科的临床医护人员。 （三）广元市医学会心血管内科专委会全体委员及心血管内科质量控制中心全体成员。 （四）谨邀四川成都、遂宁、甘肃陇南、陕西汉中等心血管内科专业人员到会。 五、其他事项 （一）会议报到时间：2019年7月x日14：30-19：00，报到地点：广元国际大酒店 （二）参加学习的医护人员免收会务费、住宿费，中午提供午餐，交通自理，按规定回单位报销。 （二）本次会议授予省级I类学分贰分，请参会人员带上身份证，按规定刷身份证授予学分。 会议组联系人： x姝：
ACS抗栓治疗合并出血防治多学科专家共识—出血风险评 估与预防 抗栓治疗已成为急性冠状动脉综合征(ACS)药物治疗的基石，与抗栓治疗相关的各种出血并发症也日渐增加。中国 医师协会心血管内科医师分会及其血栓防治专业委员会联 合中华医学会消化内镜学分会及北京神经内科学会等学术 团体，组织10余个学科知名专家共同讨论制定《急性冠状 动脉综合征抗栓治疗合并出血防治多学科专家共识》。以下主要为该专家共识中抗栓治疗的出血风险评估与预防部分 内容。出血风险评估出血的预测因素抗栓治疗后出血的预测 因素包括：（1）患者因素，如高龄、女性、低体重、慢性肾 脏病、贫血、心力衰竭、高血压、糖尿病、原有血管疾病、 血小板减少症、既往出血病史、抗血小板药物高反应性等；（2）药物因素，如抗栓药物的种类、剂量、时程、联合用 药的数量以及交叉重叠使用等；（3）介入操作与器械因素，如血管径路、血管鞘外径、血管鞘置人时间以及是否应用血 管缝合器等。由于出血往往是多种因素共同作用的结果，单 一因素预测出血的能力有限，因而通常采用综合因素评分的 方法进行风险评估。 出血的风险评分出血的风险评分共识推荐所有ACS患者在PCI术前常规采用CRUSADE评分预测出血风险（表2）。
根据评分将出血风险分为很低危（≤20分）、低危（21～30分）、中危（31～40分）、高危（41～50分）和很高危（>50分），其相应的院内出血风险分别为 3.1％、4.5％、8.6％、11.9％和19.5％。 出血的预防策略合理选择和使用抗栓药物1．阿司匹林：所 有无禁忌证的ACS患者发病后应立即口服水溶性阿司匹林 或嚼服阿司匹林肠溶片300 mg，继以100 mg/d长期维持。长期服用宜选择肠溶制剂，不宜掰开或咬碎服用，不建议餐 后服用（多建议临睡前服用），以降低胃肠道损伤风险。 2．P2Y12受体抑制剂：所有ACS患者建议在阿司匹林基础 上联合使用一种P2Y12受体抑制剂。所有无禁忌证的非ST 段抬高急性冠状动脉综合征（NSTE-ACS）患者，无论接受 早期侵入策略还是药物保守治疗策略，均应给予P2Y12受体抑制剂治疗至少12个月。若出血风险不高（如 CRUSADE≤30分），建议优先选择替格瑞洛负荷量180 mg，维持量90 mg，2次/d；也可选择氯吡格雷负荷量300～600 mg，维持量75 mg/d。接受直接PCI的STEMI患者，建议优先选择负荷量替格瑞洛180 mg，其后给予维持量90 mg，2次/d；或氯吡格雷负荷量300～600 mg，维持量75 mg，1次/d。PCI术后P2Y12受体抑制剂一般建议维持12个月。接受溶栓治疗的STEMI患者，如年龄≤75岁，给予300 mg 负荷量氯吡格雷，随后75 mg/d，维持至少14 d～12个月；
《急性冠状动脉综合征抗栓治疗合并出血防治多学科专家共识》要点 前言 抗栓治疗已成为急性冠状动脉综合征(ACS)药物治疗的基石，对于ACS及其接受经皮冠状动脉介入治疗(PCI)的患者，双联抗血小板治疗(DAPT，阿司匹林联合P2Y12受体抑制剂）能够显著降低早期和长期不良心血管事件的发生率。同时，ACS急性期和PCI术中应用抗凝药物能进一步减少血栓性事件的发生。然而，与抗栓治疗相关的各种出血并发症也日渐增加。抗栓治疗合并出血既增加死亡等不良事件风险，又因涉及多学科且缺乏明确指南或共识而使临床医生面临艰难抉择，亟需整合多学科意见形成共识，以利指导临床实践。基于以上背景，中国医师协会心血管内科医师分会及其血栓防治专业委员会联合中华医学会消化内镜学分会及北京神经内科学会等学术团体，组织心血管内科、消化内科、神经内科、神经外科、呼吸科、泌尿科、血液科、腹部外科、血管外科、妇产科、眼科、耳鼻喉科等10余个学科知名专家共同讨论制定本共识，旨在通过多学科协作，制定针对此类患者的最佳处理策略，以指导临床实践。 出血的定义与分级 有关出血的定义或分级存在诸多标准，为进一步规范统一和便于数据比较，2011年出血学术研究会(BARC)制定了统一的出血分类标准，即BARC出血定义。多项研究显示，BARC出血定义对PCI术后1年死亡率的预测价值最高。本共识推荐统一采用BARC标准对ACS抗栓治疗后出血进行分型(表1)。
表1 出血学术研究会(BARC)出血分型（出血类型临床指征） 0型无出血 1型无需立即干预的出血，患者无需因此就医或住院，包括出血后未经咨询医生而自行停药等情况 2型任何明显的、有立即干预征象的出血(如出血量多于根据临床情况估算的出血量，包括仅在影像学中发现的出血)，尚达不到以下3～5型标准，但符合以下至少l项者：(1)需要内科、非手术干预；(2)需住院或需要提升治疗级别；(3)需要进行评估 3型 3a型明显出血且血红蛋白下降30～<50g/L；需输血的明显出血3b型明显出血且血红蛋白下降≥50g/L；心脏压塞；需外科手术干预或控制的出血(除外牙齿、鼻部、皮肤和痔疮)；需静脉应用血管活性药物的出血 3c型颅内出血(除外微量脑出血、脑梗死后出血性转化，包括椎管内出血)；经尸检、影像学检查、腰椎穿刺证实的亚型；损害视力的出血 4型冠状动脉旁路移植术(CABG)相关的出血：(1)围术期48h内颅内出血；(2)胸骨切开术关胸后为控制出血而再次手术；(3)48h内输入≥l000ml 全血或浓缩红细胞；(4)24h内胸管引流≥2L