Minnesota Cancer Facts & Figures 2011

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1 Minnesota Cancer Facts & Figures 211

2 Table of Contents Introduction Stay Well. Get Well. Find Cures. Fight Back. 1 American Cancer Society Challenge Goals for Estimated New Cancer Cases and Cancer Deaths in Minnesota, Minnesota Cancer Alliance... 3 Frequently Asked Questions about Cancer. 4 Cancer in Minnesota.. 7 Cancer Disparities in Minnesota.. 1 Lung and Bronchus Cancer in Minnesota. 13 Colon and Rectum Cancer in Minnesota.. 19 Breast Cancer in Minnesota.. 25 Prostate Cancer in Minnesota.. 31 Cervical Cancer in Minnesota.. 35 Melanoma of the Skin in Minnesota.. 39 Mesothelioma in Minnesota.. 41 Childhood Cancer in Minnesota.. 43 Living a Healthy Life.. 45 Survivorship American Cancer Society Resources to Improve Quality of Life. 5 Summary Tables and End Notes Cancer Incidence in Minnesota, Cancer Mortality in Minnesota, Stage at Diagnosis for Screening-Sensitive Cancers.. 53 Average Number of New Cancer Cases by County, Minnesota, Average Number of Cancer Deaths by County, Minnesota, American Cancer Society Screening Guidelines for the Early Detection of Cancer. 58 Glossary Acronyms/Abbreviations Used Frequently in This Report. 6 Data Sources.. 6 Understanding Cancer Rates.. 61 Acknowledgements This report represents the efforts and contributions of many individuals and organizations. It was designed and printed by the American Cancer Society, Midwest Division. We gratefully acknowledge the generous contributions of time and energy of many American Cancer Society staff. The production of this document was also funded in part by the Centers for Disease Control and Prevention through the National Program of Cancer Registries and through the National Comprehensive Cancer Control Program. This report would not have been able to provide information specific to Minnesota without the Minnesota Cancer Surveillance System (MCSS) and the Minnesota Behavioral Risk Factor Surveillance System (BRFSS). We would like to thank the staff of MCSS, cancer registrars, and health care providers throughout the state whose hard work and diligence make cancer surveillance in Minnesota possible. We also thank the thousands of Minnesota residents who took time to participate in the BRFSS, and thereby provide us with an invaluable picture of health behaviors in our state.

3 Stay Well. Get Well. Find Cures. Fight Back. March 211 We are pleased to present the fourth edition of Minnesota Cancer Facts and Figures. The American Cancer Society, the Minnesota Department of Health and the Minnesota Cancer Alliance have collaborated to produce this summary of cancer in our state. Stakeholders in cancer control will use this document to measure progress in meeting the objectives stated in Cancer Plan Minnesota, the state s comprehensive cancer control plan. Cancer patients, health care and public health professionals, policy makers, advocates, news organizations and the public may find it useful when seeking detailed, easy-to-read information about cancer in Minnesota. Stay Well This report shows the risk of developing several common cancers is falling. There is no doubt this progress is due to the concerted efforts of many organizations and individuals to reduce smoking, increase screening and grow public awareness about cancer prevention strategies. One-third of cancer deaths would be prevented if no one smoked cigarettes or used tobacco products. Another third could be prevented if individuals maintained a healthy weight, ate a healthy diet and regularly exercised. We are dedicated to making even more progress in helping Minnesotans stay well. Get Well An estimated 2, Minnesotans are living with a history of cancer. Cancer survival is improving because new treatments are being developed, cancer patients participate in clinical trials to test those treatments, and physicians and other health care providers incorporate improved treatments into their practice. We are committed to making sure every Minnesotan diagnosed with cancer has access to the information and support needed to help them get well. Find Cures Research provides lifesaving information about the causes of cancer, how to prevent it and how to detect it early, as well as how to successfully treat and cure the disease while maintaining a high quality of life. However, the causes of many cancers are still unknown and cures for many remain elusive. We support research to find cures. Fight Back We ask you to join us in our efforts to reduce the burden of cancer for all Minnesotans and to eliminate cancer as a cause of illness and death. Live a healthy life. Volunteer for the American Cancer Society. Join the Minnesota Cancer Alliance. Support cancer research. Be an activist for cancer control. Sincerely, Jari Johnston-Allen Chief Executive Officer American Cancer Society Midwest Division Edward P. Ehlinger, MD, MSPH Commissioner Minnesota Department of Health Cheri Rolnick, PhD, MPH Chair Minnesota Cancer Alliance Minnesota Cancer Facts and Figures 211 1

4 American Cancer Society 215 Challenge Goals The American Cancer Society has set ambitious goals for 215: Reduce the age-adjusted cancer mortality rate by 5 percent. Reduce the age-adjusted cancer incidence rate by 25 percent. Improve the quality of life for all cancer survivors. Estimated New Cancer Cases and Cancer Deaths in Minnesota, 21* New Cases Deaths All Sites 25,8 9,2 Brain and Nervous System Female Breast 3,33 61 Cervix 14 9 Colon and Rectum 2,41 78 Corpus Uteri (Uterus) Leukemia Liver Lung and Bronchus 3,15 2,45 Melanoma of the Skin Non-Hodgkin Lymphoma 1,11 33 Ovary Pancreas 72 6 Prostate 3,87 44 Urinary Bladder 1,16 24 Source: American Cancer Society, Inc. Cancer Facts & Figures 21, including supplemental tables published online * Rounded to the nearest 1. Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Note: Estimated new cases are based on incidence rates from 44 states and the District of Columbia as reported by the North American Association of Central Cancer Registries, representing about 89% of the U.S. population. Estimated deaths are based on data from U.S. Mortality Data, 1969 to 27, National Center for Health Statistics, Centers for Disease Control and Prevention, 21. If there are abbreviations or terms in this report that you do not understand, please see the End Notes section of this report. 2 Minnesota Cancer Facts and Figures 211

5 Minnesota Cancer Alliance The Minnesota Cancer Alliance is a coalition of almost 1 organizations committed to eliminating the burden of cancer in Minnesota. Since 25 Alliance members have worked together to identify, create and act on opportunities to implement strategies in Cancer Plan Minnesota By linking existing initiatives, leveraging resources and forging innovative partnerships, Alliance members have contributed to the promotion of statewide smoke-free policy, and have generated momentum around efforts to increase colon and rectum cancer screening, improve access to information regarding resources for cancer survivors and their families, create a model survivor care plan and develop cancer-related training for community health workers. For a more complete list of Alliance teams and projects, or to become a member, visit mncanceralliance.org. Cancer Plan Minnesota This year, the Minnesota Cancer Alliance released Cancer Plan Minnesota , a framework for action for the next five years. Through a process which involved input from a broad range of stakeholders, objectives and strategies were refined, data indicators were strengthened and updated and several new topic areas were added. The plan s 23 objectives continue to address the spectrum of cancer care, from primary prevention to screening and treatment to quality of life and survivorship. The Alliance is poised to launch several new initiatives in 211 while continuing to build on successful collaborations of the past five years. The plan is available at mncanceralliance.org. A Call to Action There are many ways that you or your organization can support implementation of Cancer Plan Minnesota In addition to joining an Alliance Project, below are a few examples of things that you can do which link to the goals and objectives of Cancer Plan Minnesota If you are a COMMUNITY BASED ORGANIZATION Conduct targeted outreach to increase breast, colon and rectum and cervical cancer screening among groups that have higher mortality rates Become familiar with non-clinical support resources available for cancer patients at If you are a PUBLIC HEALTH AGENCY Implement local policy, system and environmental changes that promote healthy eating and physical activity Refer eligible patients to SAGE Programs for free cancer screening If you are a HEALTH SYSTEM Build existing cancer treatment summary templates into your system of care Incorporate tools for shared decision-making into the electronic health record If you are a HEALTH CARE PROVIDER Implement clinic systems that ensure appropriate follow-up of patients with abnormal screening results Provide your patients with information about cancer clinical trials Discuss and promote the completion of advanced care directives with your patients Use community health workers to extend your reach into the community If you are POLICYMAKER Support pricing strategies that discourage the use of tobacco products Support statewide and local smoke-free policies Ban the use of tanning beds by minors If you are an EMPLOYER Provide comprehensive tobacco cessation benefits to your employees Minnesota Cancer Facts and Figures 211 3

6 Frequently Asked Questions About Cancer What is cancer? Cancer is not a single disease. It is a group of diseases that share in common the uncontrolled growth and spread of abnormal cells. Cancer cells can form a mass, referred to as a tumor, which may compress, invade, and destroy normal tissue. If cells break away from the tumor, they can be carried by the lymph system or by way of the bloodstream to other areas of the body. This spreading, or traveling, of the original tumor is called metastasis. In this new location, the cancerous cells continue to grow. If the spread is not controlled, it can result in death. damage can either directly lead to uncontrolled growth, or more commonly, is part of sequence of events that ultimately prevents cell repair and growth from functioning normally. The cell can be damaged or inhibited from repairing damage by external or internal factors. Some examples of external factors are tobacco, chemicals, sunlight and other forms of radiation, and viruses and bacteria. Internal factors include hormone levels, inherited conditions, immune function, and mutations that occur from metabolism. Causal factors may act together or in sequence to initiate or promote cancer. Ten or more years often pass between exposure or mutations and detectable cancer. Cancer is classified by the part of the body in which it originates, by its appearance under the microscope, and by the results of laboratory tests. Since cancer is not a single disease, each type of cancer will vary in growth and pattern of spread, and will also respond differently to various types of treatment. This makes it very important to treat each cancer and each cancer patient individually. What causes cancer? Although the cause of a cancer in an individual can only rarely be determined, scientists believe that the first step in developing cancer is damage to a cell. This Causes of Cancer Deaths in the U.S. Tobacco Use Diet & Obesity 3 3 Sedentary Lifestyle Family History Infectious Agents Occupational Exposures Prenatal Factors & Growth Reproductive Factors Socioeconomic Status Alcohol Pollution Radiation 2 2 Medicine Food Additives & Contaminants Source: Harvard Report on Cancer Prevention, Percent 4 Minnesota Cancer Facts and Figures 211

7 Who is at risk? Anyone. Even people who do everything right can develop cancer. Based on current statistics for the state, about half of Minnesotans will be diagnosed with a potentially serious cancer during their lifetime, and about 25 percent will die from one of these diseases. Cancer risk increases with age. Approximately 55 percent of cancers in Minnesota are diagnosed among persons age 65 years and older, and nearly 75 percent of cancer deaths are in this age group. Cancer is about 35 percent more common among men than women. Leading Sites of New Cancer Cases and Deaths among Males, Minnesota, 27 Cases Deaths Prostate 33.9% 1.3% Lung and Bronchus 11.5% 27.6% Colon and Rectum 9.1% 9.2% Urinary Bladder 6.4% 3.3% Melanoma of the Skin 5.% ** Non-Hodgkin Lymphoma 4.7% 4.2% Kidney and Renal Pelvis 3.8% 3.2% Leukemia 3.6% 5.3% Oral Cavity and Pharynx 3.2% ** Pancreas 2.% 5.7% Liver and Bile Duct ~ 3.8% Esophagus ~ 3.7% All Others 16.8% 23.7% Leading Sites of New Cancer Cases and Deaths among Females, Minnesota, 27 Cases Deaths Breast 3.9% 14.6% Lung and Bronchus 11.8% 25.% Colon and Rectum 1.2% 9.4% Corpus and Uterus, NOS 6.7% 2.5% Melanoma of the Skin 4.6% ** Non-Hodgkin Lymphoma 4.4% 3.5% Thyroid 3.5% ** Leukemia 2.8% 4.2% Ovary 2.8% 5.% Kidney and Renal Pelvis 2.8% 2.2% Pancreas ~ 6.2% Brain and CNS ~ 2.8% All Others 19.3% 24.6% All Sites 1.% 1.% Source: MCSS and Minnesota Center for Health Statistics. ~ Not one of the ten most commonly diagnosed cancers among males. ** Not one of the ten most common sites of cancer death among males. All Sites 1.% 1.% Source: MCSS and Minnesota Center for Health Statistics. ~ Not one of the ten most commonly diagnosed cancers among females. ** Not one of the ten most common sites of cancer death among females. Minnesota Cancer Facts and Figures 211 5

8 Can cancer be prevented? Tobacco use is responsible for about 3 percent of cancer deaths. If no one used tobacco products, nearly one out of three cancer deaths would be prevented. More and more evidence indicates that poor diet, lack of exercise, and obesity increase risk for cancer. It is estimated that a third of deaths from cancer could be prevented if we maintained a healthy weight, ate a healthy diet, and exercised regularly. Being vaccinated for hepatitis B virus and being tested and treated for HBV may prevent many liver cancers. Being treated for Helicobacter infections of the stomach can prevent some stomach cancers. Avoiding exposure to human papilloma virus (HPV) and human immunodeficiency virus, both of which are sexually transmitted, can also eliminate some cervical and other cancers. A vaccine to prevent infection with HPV was released during 26 but will not prevent infection with all cancer-causing strains of HPV or eliminate current infections. Colon and rectum cancer and cervical cancer can be prevented by early detection and removal of precancerous growths. If everyone had access to and followed screening recommendations, most of these cancers could be prevented. What is meant by stage at diagnosis? Stage at diagnosis describes the extent to which the cancer has spread from the site in which it originated at the time it is discovered. For most cancers, it is one of the best predictors of survival. A number of different staging systems are used to classify tumors. It can be confusing because some systems use numbers (I, II, etc), some use terms (in situ, localized, etc), and some are only used for specific types of cancers. Some cancers, especially those originating in the blood and the immune system, are not typically staged. Definitions of terms related to stage at diagnosis used in this report are provided in the Glossary. Survival rates measure the proportion of people with cancer who are alive a certain length of time, usually five years, after diagnosis. Because of lead time, five-year survival rates can appear to be higher in a group of people who are screened than in a comparable group who haven t been screened, simply because they found out about their cancer earlier. If increases in survival are meaningful, and not biased by lead time, screened cancer patients will live to an older age, and mortality will be lower than in an unscreened group. Since lead time cannot be measured directly, a decrease in the mortality rate, rather than an increase in the survival rate, is considered the best measure of the effectiveness of a screening method. Can cancer be cured? The answer to this question depends very much on the type of cancer and whether or not the cancer is detected early. The five-year relative survival rate for many common cancers (cancers of the breast, prostate, colon and rectum, cervix, uterus, bladder, and testis, and melanoma of the skin) is greater than 9 percent if found before the cancer has metastasized. Following guidelines for cancer screening increases the likelihood of finding cancer early and, therefore, of survival. Based on data from the SEER Program, the five-year relative survival rate for cancers diagnosed between 1999 and 26 was 67 percent. Why is the mortality rate a better measure of the effectiveness of screening than the survival rate? Identifying a cancer through screening before there are any symptoms of disease (that is, during the preclinical stage of tumor development) only benefits a patient if treatment is more effective when begun during the preclinical stage than later on. While it seems, intuitively, that this would always be the case, it hasn t proven to be true for all potential screening methods. In some cases this occurs because certain tumors, if left undiagnosed, would grow so slowly that they would never become life-threatening, and the person would die of another cause. In other cases this occurs because treatment is equally effective, or ineffective, whether the tumor is discovered during the preclinical phase or early in the clinical stage. When either of these situations exists, cancers can be diagnosed at an earlier date without actually extending life a patient would live to the same age with or without screening, but with screening, he or she would simply have known about the cancer for a longer period of time, called lead time. 6 Minnesota Cancer Facts and Figures 211

9 Cancer in Minnesota Cancer is very common. From 23 to 27, an average of 24,42 Minnesotans were diagnosed with a potentially serious cancer each year, and more than 9,6 Minnesotans died of these diseases annually. The overall cancer mortality rate in Minnesota has been declining significantly for two decades and began declining even more rapidly around 2. The overall cancer mortality rate declined gradually by an average of.5 percent each year from 1988 to 2 and then decreased by 1.6 percent a year from 2 to 27. After adjusting for population growth and aging, the overall cancer mortality rate in Minnesota was 15 percent lower in 27 (169.5 deaths per 1, persons) than it was 2 years earlier, in 1988 (199.5); cancer mortality declined 17 percent among men and 15 percent among women. This hard won progress reflects significant declines in mortality for many of the common cancers, such as cancers of the prostate, colon and rectum, stomach, brain, oral cavity, and female breast, as well as leukemia and Hodgkin and non-hodgkin lymphomas. Lung and bronchus cancer mortality has been significantly declining for the last 2 years among men; among women, it finally appears to have peaked around 23 and is no longer increasing. In fact, the only cancer sites for which mortality rates in Minnesota were significantly increasing at the end of the twenty-year period were liver cancer (for males and females) and esophageal cancer (for males only). The overall cancer incidence rate in Minnesota did not increase significantly from 2 to 27 for either men or women, but the long term trends are markedly different for each gender. When data for both sexes are combined, the overall cancer incidence rate increased significantly by.3 percent annually over the twenty-year period. After adjusting for population growth and aging, the overall cancer incidence rate in Minnesota was eight percent higher in 27 (481.4 new cases per 1, persons) than it was in 1988 (445.6); over the twenty-year period, cancer incidence increased by six percent among men and seven percent among women. Incidence rates for thyroid cancer and melanoma of the skin are increasing the most rapidly; the rate for each of these cancers has doubled since However, mortality has not increased for either site. Cancers of the liver and esophagus were the only two cancers to show significant increases in both incidence and mortality. Increasing incidence rates for these and a number of other sites are partially balanced by substantial and significant decreases in incidence for colon and rectal, stomach, laryngeal, cervical, and ovarian cancers, and among males, lung and oral cancers. 6 Overall Cancer Trends in Minnesota, Rate per 1, persons Incidence increased by an average of.3% annually Mortality decreased by an average of.5% annually. Incidence Mortality Mortality decreased by an average of 1.6% annually Year of Diagnosis/Death Source: MCSS (May 21). Rates are age-adjusted to the 2 U.S. population. A hashed bar indicates where the trend significantly changed direction. Interval trends are statistically significant unless stated otherwise. Minnesota Cancer Facts and Figures 211 7

10 Nearly half of all Minnesotans will be diagnosed with a potentially serious cancer. Based on current statistics for the state, 51 percent of men and 41 percent of women in Minnesota will be diagnosed with a potentially serious cancer during their lifetimes. The lifetime risk of developing cancer is somewhat higher in Minnesota than in the 17 geographic areas participating in the SEER Program (44% for males and 38% for females) despite similar cancer rates in Minnesota because life expectancy is higher in Minnesota, and therefore, more people live to develop cancer. Cancer became the leading cause of death in Minnesota in 2. In 28, 27 percent more Minnesotans died from cancer (9,439 deaths) than from the second leading cause of death, heart disease (7,451 deaths). Cancer became the leading cause of death in Minnesota in part because the heart disease mortality rate decreased much more rapidly and began decreasing earlier than cancer mortality. While national trends for heart disease and cancer mortality are similar to those in Minnesota, the crossover between cancer and heart disease mortality occurred earlier in Minnesota than in other states primarily because Minnesota consistently has one of the lowest rates of heart disease mortality in the nation, about 3 percent lower than the national average, while the cancer mortality rate is only slightly lower. The overall cancer incidence rate in Minnesota is similar to what is reported for the nation. Over the five-year period 23-27, the overall cancer incidence rate in Minnesota (471.6 new cases per 1, persons) was about two percent higher than reported by the 17 geographic areas participating in the SEER Program (461.6). However, the incidence rate was somewhat lower in Minnesota than SEER for each race/ethnic group except American Indians. In the SEER Program, American Indians have one of the lowest cancer rates; in Minnesota, they have the highest. The overall cancer mortality rate in Minnesota is somewhat lower than for the nation. Over the five-year period 23-27, the overall cancer mortality rate in Minnesota (173.5 cancer deaths per 1, persons) was six percent lower than for the U.S. as a whole (183.8). The mortality rate was nearly the same or somewhat lower in Minnesota than nationally for each race/ethnic group except American Indians and Asian/ Pacific Islanders. Among American Indians, the cancer mortality rate is more than two times higher in Minnesota than in the U.S. 4 Deaths Due to Heart Disease and Cancer, Minnesota, Rate per 1, persons Heart Disease 2 Cancer Year of Death Source: MCSS. Rates are age-adjusted to the 2 U.S. population. 8 Minnesota Cancer Facts and Figures 211

11 Cancer Incidence by Race/Ethnicity, Minnesota and the U.S., Rate per 1, persons SEER Minnesota African American AI/AN* Statewide AI/AN CHSDA* Asian/Pacific Islander Hispanic (all races) Non-Hispanic White Source: MCSS (May 21) and SEER Cancer Statistics Review, Rates are age-adjusted to the 2 U.S. population. SEER incidence data are from the SEER 17 Areas; rates for Hispanics and non-hispanic whites exclude cases from the Alaska Native Registry. * AI/AN=American Indian/Alaska Native; CHSDA=Contract Health Service Delivery Area. 35 Cancer Mortality by Race/Ethnicity, Minnesota and the U.S., Rate per 1, persons U.S. Minnesota African American AI/AN* Statewide AI/AN CHSDA* Asian/Pacific Islander Hispanic (all races) Non-Hispanic White Source: MCSS and SEER Cancer Statistics Review, Rates are age-adjusted to the 2 U.S. population. Mortality data are for the entire U.S.; rates for Hispanics and non-hispanic whites exclude deaths in the District of Columbia, New Hampshire and North Dakota. * AI/AN=American Indian/Alaska Native; CHSDA=Contract Health Service Delivery Area. Minnesota Cancer Facts and Figures 211 9

12 Cancer Disparities in Minnesota It is clear that the risk of being diagnosed with and dying from cancer varies by race and ethnicity, and that, for some cancers, populations of color experience an excess burden. This is true nationally as well as in Minnesota. Measuring race/ethnic differences in cancer risk in Minnesota is limited by incomplete and potentially inaccurate reporting of race and ethnicity on the medical record and death certificate, uncertain accuracy of population estimates, and the relatively small size of populations of color in our state. This report presents American Indian cancer rates for two geographic areas in Minnesota: statewide, and for residents of the 29 counties which are part of the Indian Health Service s Contract Health Services Delivery Area (CHSDA). About half of the American Indian population in the state lives in a CHSDA county. Cancer rates calculated for the CHSDA counties are thought to provide a more accurate picture of cancer rates among American Indians, but this is difficult to verify. African Americans: Over the five-year period 23-27, African American men had the second highest overall cancer incidence rate in Minnesota, second only to American Indian men living in CHSDA counties, and just somewhat higher than American Indian men statewide. African American and American Indian men also had the highest cancer mortality rates compared to other race/ethnic and gender groups in the state. The cancer incidence rate among African American men in Minnesota was 13 percent higher than for non-hispanic white men, while their mortality rate was 42 percent higher. Higher overall cancer mortality among African American compared to non-hispanic white men reflected higher rates for the three most common cancers: lung (36% higher), prostate (119% higher), and colon and rectum (31% higher). Over the same time period, the overall cancer incidence rate among African American women in Minnesota was seven percent lower than that of non-hispanic white women, but their cancer mortality rate was 21 percent higher. Higher overall cancer mortality among African American compared to non- Hispanic white women reflected higher rates for the three most common cancers: lung (3% higher), colon and rectum cancer (18% higher), and breast cancer (24% higher). The overall cancer incidence rate among African Americans is very similar in Minnesota and the 17 geographic areas participating in the SEER Program. The overall cancer mortality rate among African Americans is similar in Minnesota and the U.S. as a whole. Cancer Incidence by Race/Ethnicity and Gender, Minnesota, Rate per 1, persons African American AI/AN* Statewide AI/AN CHSDA* Asian/Pacific Islander Hispanic (all races) Non-Hispanic White 1 Males Females Source: MCSS (May 21). Rates are age-adjusted to the 2 U.S. population. * AI/AN=American Indian/Alaska Native; CHSDA=Contract Health Service Delivery Area. 1 Minnesota Cancer Facts and Figures 211

13 American Indians: As discussed above, cancer rates for American Indians have been calculated for residents of the CHSDA counties as well as for the entire state. The overall cancer incidence and mortality rates are each approximately 2 percent higher for American Indians in CHSDA counties than when calculated for American Indians statewide. Cancer rates calculated for the CHSDA counties are thought to be more accurate, but this is difficult to verify. Over the five-year period 23-27, American Indian men living the CHSDA counties had the highest overall cancer incidence rate and the highest overall cancer mortality rate in Minnesota; American Indian men statewide had the third highest rates, only marginally lower than for African American men. The cancer incidence rate among American Indian men living in CHSDA counties in Minnesota was 27 percent higher (7% higher statewide) than for non-hispanic white men, while their mortality rate was 5 percent higher (35% higher statewide). Higher cancer mortality among American Indian compared to non-hispanic white men was primarily due to lung cancer (two times higher) and colon and rectum cancer (two times higher). Over the same time period, the overall cancer incidence rate among American Indian women living in CHSDA counties in Minnesota was 27 percent higher (13% higher statewide) than that of non-hispanic white women, but their cancer mortality rate was 86 percent higher (49% higher statewide). Higher cancer mortality among American Indian compared to non-hispanic white women was primarily due to lung cancer (more than two times higher) and colon and rectum cancer (55% higher). Cancer rates among American Indians in Minnesota are roughly two times higher than reported for the nation as a whole. However, there is increasing evidence that an elevated risk for cancer is found in the Northern Plains tribes in general, and is probably not limited to Minnesota. Asian/Pacific Islanders: Over the five-year period 23-27, Asian/Pacific Islanders had the lowest overall cancer incidence rate in Minnesota, and their cancer mortality rate was somewhat higher than among Hispanics, who had the lowest rate. The overall cancer incidence rate among Asian/Pacific Islander men in Minnesota was 49 percent lower than among non-hispanic white men, but their mortality rate was only 29 percent lower. Similarly, the overall cancer incidence rate among Asian/Pacific Islander women in Minnesota was 41 percent lower than among non- Hispanic white women, but their mortality rate was only 29 percent lower. This indicates that although their risk of developing cancer is lower, Asian/Pacific Islanders in Minnesota may have poorer survival than non-hispanic whites, or are more likely to be diagnosed with more lethal cancers. 7 Cancer Mortality by Race/Ethnicity and Gender, Minnesota, Rate per 1, persons 6 5 African American AI/AN* Statewide 4 AI/AN CHSDA* Asian/Pacific Islander Hispanic (all races) Non-Hispanic White Males Females Source: MCSS (May 21). Rates are age-adjusted to the 2 U.S. population. * AI/AN=American Indian/Alaska Native; CHSDA=Contract Health Service Delivery Area. Minnesota Cancer Facts and Figures

14 Although Asian/Pacific Islanders had the lowest rates for most of the cancers included in this report, they had the highest rates of liver and stomach cancer, three or more times higher than among non-hispanic whites. Asian/Pacific Islander women were also at increased risk of cervical cancer compared to non-hispanic white women. Although overall cancer incidence among Asian/Pacific Islanders was 18 percent lower in Minnesota than in the 17 geographic areas covered by the SEER Program, their cancer mortality rate was 12 percent higher than among Asian/Pacific Islanders in the U.S. as a whole. Much remains to be learned about the causes of race/ ethnic differences in cancer incidence and mortality, and the relative importance of cultural, social, economic, and genetic differences is controversial. However, until all Minnesotans have equal access to quality health care, it is likely that disparities will persist. Hispanics (all races): Over the five-year period 23-27, Hispanics had the second lowest overall cancer incidence rate in Minnesota, and the lowest cancer mortality rate. The overall cancer incidence rate among Hispanic men in Minnesota was 36 percent lower than among non-hispanic white men, and their mortality rate was 39 percent lower. The overall cancer incidence rate among Hispanic women in Minnesota was 17 percent lower than among non-hispanic white women, and their mortality rate was 46 percent lower. Although Hispanics had the lowest rates for most of the cancers included in this report, they had the second highest rates of liver and stomach cancer, two or more times higher than among non- Hispanic whites. Hispanic women were also at increased risk of cervical cancer compared to non-hispanic white women. Overall cancer incidence among Hispanics is somewhat lower in Minnesota than in the 17 geographic areas covered by the SEER Program and their cancer mortality rate is somewhat lower than Hispanics in the U.S. as a whole. 12 Minnesota Cancer Facts and Figures 211

15 Lung and Bronchus Cancer in Minnesota Almost as many Minnesotans die from lung and bronchus cancer as from the next four leading causes of cancer death combined: breast, prostate, colon and rectum, and pancreas cancer. What is particularly tragic is that we know how to prevent nearly all lung cancers. Approximately 85-9 percent of lung cancers are caused by cigarette smoking. Tobacco use also increases the risk of developing cancers of the nasal passages, mouth, throat, esophagus, stomach, liver, pancreas, kidney, bladder, and cervix, and some forms of leukemia. When heart disease and other types of lung disease caused by tobacco are considered, CDC estimates that smoking reduces life expectancy by 13.2 years for men and 14.5 years for women. Given that current life expectancy in the U.S. is 77.9 years, this means that smoking can basically eliminate your retirement years. The second leading cause of lung cancer is exposure to radon. Radon is a radioactive gas that is emitted naturally from rocks and soils containing uranium. Radon can enter homes from the surrounding soil through cracks, joints, and gaps in construction and without adequate ventilation, can reach rather high levels. When inhaled, particles called radon progeny can damage the lungs and increase the risk of developing lung cancer. EPA estimated in 23 that of the 16, lung cancer deaths in the U.S. each year, 21, (13%) are associated with exposure to radon. About 2,9 of these radon-related deaths occur among people who have never smoked. The amount of radon in the environment depends in large part on geology and other characteristics of the soil. Radon levels vary widely throughout the U.S. The upper Midwest has geological formations that can yield higher than average radon levels. MDH estimates that one in three Minnesota homes have enough radon to pose a significant risk to the occupants health over many years of exposure. The risk of lung cancer among persons exposed to radon is many times higher for smokers than non-smokers. EPA estimates that a lifetime exposure to 4 pci/l (picocuries per liter) of radon will cause seven lung cancers among 1, non-smokers, but 62 lung cancers among the same number of smokers. test results show radon levels above 4 pci/l. You can obtain more information on radon and options for testing your home from the MDH Indoor Air Unit at radon or by calling (651) (toll free ) to request a radon fact sheet. The third leading cause of lung cancer is secondhand smoke, estimated to cause 3, lung cancer deaths among non-smokers each year in the U.S. Breathing in the tobacco smoke of others is also estimated to be responsible for 46, deaths each year from heart disease, and to increase the risk among children for low birthweight, SIDS and asthma. The Minnesota legislature passed the Freedom to Breathe (FTB) provisions in 27. This expansion of the Minnesota Clean Indoor Air Act went into effect on October 1, 27. It prohibits smoking in virtually all public indoor places and indoor places of employment. Going smoke free in public places is a big step forward in cancer control in our state. You can obtain more information from MDH at Risk Factors for Lung Cancer Tobacco smoking, even low-tar cigarettes Breathing in radon, a radioactive gas produced by uranium and present in some homes, especially among smokers Breathing in secondhand smoke, whether in the home or workplace Exposure to asbestos fibers, especially among smokers Occupational exposures to diesel exhaust, gasoline, some organic chemicals, radioactive ores, and dust from chromium, cadmium and arsenic Chronic inflammation of the lungs due to pneumonia, tuberculosis, silicosis, or berylliosis Air pollution The MDH recommends that all homes and schools in Minnesota be tested for radon every 2-5 years. Testing can be done with a radon test kit available from city and county health departments, many hardware stores, or directly from radon testing laboratories. Most are priced under $2, and some local health agencies have a limited supply at low cost. Remediation is recommended if Minnesota Cancer Facts and Figures

16 The Burden of Lung Cancer in Minnesota Over the five-year period 23-27, an average of 2,93 Minnesotans were diagnosed with lung and bronchus cancer each year. It was the second most commonly diagnosed cancer among men and among women. About 67 percent of Minnesotans diagnosed with lung cancer were 65 years of age or older. The age-adjusted incidence rate for lung cancer in Minnesota in 27 was 67.1 new cases per 1, men and 5.6 new cases per 1, women. These rates may be underestimated because MCSS only collects information on lung cancers that are microscopically confirmed. Nationally, about eight percent of lung cancers are clinically diagnosed without microscopic confirmation. From 23 to 27, an average of 2,34 Minnesotans died of lung cancer each year. It was the leading cause of cancer death for men and for women, and killed as many Minnesotans as prostate, breast, colon and rectum, and pancreas cancers combined. About 72 percent of deaths due to lung cancer occurred among Minnesotans 65 years of age or older. The age-adjusted mortality rate for lung and bronchus cancer in Minnesota in 27 was 57.8 deaths per 1, men and 36.9 deaths per 1, women. These rates are based on the underlying cause of death on the death certificate, whether or not the cancer was microscopically confirmed, and are therefore comparable to mortality rates reported for the U.S. Although about the same number of Minnesotans were diagnosed with lung cancer as with colon and rectum cancer each year, more than two and a half times as many died from lung cancer. Based on data from the SEER Program, the five-year relative survival rate for lung cancer is 15 percent, compared to 65 percent for colon and rectum cancer. Even when diagnosed at the same stage, lung cancer patients have a poorer chance of survival than persons diagnosed with many other of the most common cancers. Five-Year Relative Survival from Lung and Bronchus Cancer in the U.S. Stage Disparities in Lung Cancer Whites Blacks Localized 53.5% 45.1% Regional 24.1% 2.9% Distant 3.5% 3.1% All Stages 16.1% 12.6% Source: SEER Cancer Statistics Review, Based on cases diagnosed in with follow-up into 27. American Indian men and women living in the CHSDA counties have the highest lung cancer rates in Minnesota, and American Indian men and women statewide have the second highest lung cancer rates. Their risk of dying of this disease is two to three times higher than among non-hispanic whites of the same gender. Similarly, African American men and women are 3-4 percent more likely to die of lung cancer than non-hispanic whites of the same gender. Lung and Bronchus Cancer Mortality by Race/Ethnicity and Gender, Minnesota, Rate per 1, persons Males Females African American AI/AN* Statewide AI/AN CHSDA* Asian/Pacific Islander Hispanic (all races) Non-Hispanic White Source: MCSS (May 21). Rates are age-adjusted to the 2 U.S. population. * AI/AN=American Indian/Alaska Native; CHSDA=Contract Health Service Delivery Area. 14 Minnesota Cancer Facts and Figures 211

17 Trends in Lung Cancer Lung cancer trends are very different for men and women, both nationally and in Minnesota. Among men, lung cancer mortality has been declining steadily and significantly since Between 1988 and 27, lung cancer mortality decreased by 17 percent among Minnesota men. In sharp contrast, lung cancer mortality increased by 32 percent among women in Minnesota over the same time period. However, the rate of increase slowed down in 1993, and for the first time in Minnesota, there was no significant increase in lung cancer mortality among women from 22 to 27. Lung Cancer Mortality Trends by Gender in Minnesota and the U.S. 1 9 Rate per 1, persons Males % annually. U.S. Minnesota 3 2 Females % annually No significant trend % annually Year of Death Source: MCSS (May 21) and SEER Cancer Statistics Review, Rates are age-adjusted to the 2 U.S. population. National mortality is for the U.S. white population. The results of Joinpoint trend analyses are only shown for Minnesota. A hashed bar indicates where the trend significantly changed direction. Interval trends are statistically significant unless stated otherwise. Minnesota Cancer Facts and Figures

18 Geographic Differences in Lung Cancer Mortality Among men: During 23-27, the lung cancer mortality rate among men was 18 percent lower in Minnesota than among non-hispanic white men in the U.S. as a whole. Although lung cancer mortality was about the same as or lower in Minnesota than nationally for other race/ethnic and gender groups, mortality among American Indians was two to three times higher in Minnesota than in the U.S. as a whole. The male lung cancer mortality rate was significantly higher than the statewide average in Northeast and Central Minnesota, and was significantly lower in South Central Minnesota. Lung cancer mortality among males was lower than the U.S. average in each Minnesota region and in the six largest counties. Among women: During 23-27, the lung cancer mortality rate among women was 16 percent lower in Minnesota than among non-hispanic white women in the U.S. as a whole. The female lung cancer mortality rate varied by nearly twofold across Minnesota. Anoka and St. Louis Counties and Metro and Northeast Minnesota had rates that were significantly higher than the statewide average. Rates in these areas were similar to U.S. rate. Rates were significantly lower than the state average in Southeast, Southwest, and West Central Minnesota. The average number of lung cancer cases and deaths each year in Minnesota counties is shown in the End Notes section of this report. Lung Cancer Mortality Rates among Males in Minnesota Regions and Six Largest Counties, Lung Cancer Mortality Rates among Females in Minnesota Regions and Six Largest Counties, Minnesota = 58.2 U.S.* = 71.1 Kittson Roseau Lake of the Woods Significantly higher than state average Not significantly different from state average Significantly lower than state average Minnesota = 36.9 U.S.* = 43.8 Kittson Roseau Lake of the Woods Significantly higher than state average Not significantly different from state average Significantly lower than state average Marshall Northwest 57.1 Pennington Polk Red Lake Clear Water Beltrami Koochiching Itasca St. Louis Northeast 67.4 Lake Cook Marshall Northwest 37.6 Pennington Polk Red Lake Clear Water Beltrami Koochiching Itasca St. Louis Northeast 45.3 Lake Cook Norman Mahnomen Mahnomen Norman Clay Becker Hubbard Clay Becker Hubbard Wilkin Traverse Big Stone Lincoln Grant Stevens Ottertail West Central 53.4 Yellow Medicine Lyon Pipestone Murray Douglas Pope Swift Chippewa Lac Qui Parle Redwood Wadena Todd Kandiyohi Renville Cass Stearns Meeker Sibley Crow Wing Central 65.5 Morrison McLeod Nicollet Benton Wright Sherburne Carver Le Sueur Rice Watonwan Steele Cottonwood Waseca Blue Earth Dakota Goodhue Dodge Wabasha Olmsted Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston Mille Lacs Scott Isanti Hennepin Brown Southwest South Central Aitkin Kanabec Anoka Metro 57.6 Carlton Pine Chisago Southeast 55.6 County Rate Anoka 6.4 Dakota 57.4 Hennepin 56.2 Ramsey 62.3 St. Louis 65.1 Washington 53.6 Rates are per 1, persons, age-adjusted to the 2 U.S. population. Statistical significance (p <.5) based on SEER*Stat analysis using Tewari modification. *Non-Hispanic whites in the U.S. excluding the District of Columbia, New Hampshire, and North Dakota, SEER Cancer Statistics Review, Ramsey Washington Wilkin Traverse West Central 3.3 Big Stone Chippewa Lac Qui Parle Yellow Medicine Lincoln Grant Stevens Ottertail Lyon Southwest 25.7 Pipestone Murray Douglas Pope Swift Redwood Wadena Todd Kandiyohi Renville Cottonwood Cass Central 38.4 Stearns Meeker Brown Morrison McLeod Sibley Crow Wing Nicollet Benton Wright Sherburne Carver South Central Watonwan34.7 Lacs Metro Le Sueur Kanabec 39.5 Metro 39.5 Rice Steele Waseca Blue Earth Dakota Goodhue Southeast 31. Dodge Olmsted County Rate Anoka 47.5 Dakota 39.9 Hennepin 38.1 Ramsey 39.9 St. Louis 46.1 Washington 39.6 Wabasha Winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston Mille Aitkin Scott Isanti Hennepin Anoka Chisago Washington Ramsey Rates are per 1, persons, age-adjusted to the 2 U.S. population. Statistical significance (p <.5) based on SEER*Stat analysis using Tewari modification. *Non-Hispanic whites in the U.S. excluding the District of Columbia, New Hampshire, and North Dakota, SEER Cancer Statistics Review, Carlton Pine 16 Minnesota Cancer Facts and Figures 211

19 Lung Cancer Screening Chest x-rays have not been found to reduce lung cancer mortality, even among smokers. In November 21, the National Lung Screening Trial reported a 2 percent reduction in lung cancer mortality among heavy smokers age 55 to 74 who were screened with low-dose spiral CT scanning. Although this is very promising news, the full results have not yet been published. A number of important questions will need to be answered before recommendations for lung cancer screening are updated. Cigarette Smoking Considerably lower lung cancer rates in Minnesota indicate that two or three decades ago, cigarette smoking was much less common in Minnesota than in the U.S. as a whole, but statespecific smoking rates prior to 1984 are not available to confirm this. Data from the BRFSS indicate that smoking rates in our state have been the same or just slightly lower than nationally for the last two decades. The smoking prevalence rate in Minnesota has decreased slowly but steadily for the last nine years, from 22.2 percent in 21 to 16.8 percent in 29 (18.6% among males and 14.9% among females). American Indians are the least represented race/ethnic group in the Minnesota BRFSS; on average, only 34 American Indians participate each year. To obtain more stable estimates of smoking prevalence for American Indians, data were combined for the nine-year period rather than the five-year period for the other race/ethnic groups. American Indians are nearly twice as likely to report that they currently smoke than the other race/ethnic and gender groups in the state. Cigarette smoking is strongly associated with education: among persons who do not have a high school degree, 33 percent currently smoke, compared to 25 percent of high school graduates, 21 percent of those with some post-secondary education, and 9 percent of college graduates. 4 Trends in Adult Smoking, Minnesota and the U.S., Percent Current Smokers 3 2 U.S. Minnesota Source: BRFSS Web site ( Current smokers have smoked at least 1 cigarettes and smoke every day or some days. U.S. is the median of the 5 states and Washington D.C. 7 Adult Smoking by Gender and Race/Ethnicity, Minnesota, 25-29* Percent Current Smokers 6 5 African American 4 39* 42* American Indian Asian/Pacific Islander Hispanic Non-Hispanic White Males Females Source: Minnesota BRFSS. Analyses were conducted by MCSS. Current smokers have smoked at least 1 cigarettes and smoke every day or some days. * Due to the relatively small number of interviews with American Indians, data are for the nine-year period to provide more stable estimates. Minnesota Cancer Facts and Figures

20 Adult Smoking by Education and Residence, Minnesota, Percent Current Smokers Not a HS Graduate HS Graduate Post-HS Education College Grad Rural Urban Source: Minnesota BRFSS. Analyses were conducted by MCSS. Current smokers have smoked at least 1 cigarettes and smoke every day or some days. HS is high school. Urban residents live in one of the 21 counties designated as metropolitan by the Census Bureau in 25. Trends in Student Smoking by Grade, Minnesota, Percent Smoked Cigarettes during the Previous 3 Days Grade 12 Grade 9 Grade 6 Source: Modified from online tables in 21 Minnesota Student Survey Data 21 (11/15/21): Select trends in student behaviors and perceptions between 1992 and 21. Although cigarette smoking is slightly more common among adults residing in rural (19%) than in urban (17%) Minnesota, smoking rates are about the same at each education level. The Minnesota Student Survey reported that cigarette smoking among students has declined each year since 1998, and is now lower in each group than it was in Call it Quits Call it Quits is a collaboration among Minnesota s major health plans and ClearWay Minnesota SM to make it easier for healthcare providers to help their patients who want to stop smoking. The Minnesota Clinic Fax Referral Program began on October 1, 27, the same day Minnesota s statewide smoke-free law took effect. The new program allows clinics across the state to more easily refer a patient to stop-smoking phone coaching support, regardless of the patient s health care coverage. To learn more about Call it Quits, the Minnesota Clinic Fax Referral Program or about how to stop smoking, visit preventionminnesota.com and click on the Call it Quits icon on the home page. 18 Minnesota Cancer Facts and Figures 211

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