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New ACS report outlines social determinants' role in cancer

Latest in American Cancer Society’s Blueprint for Cancer Control series

A new report outlines the critical role social determinants play in shaping population health, highlighting that health disparities are systemic, and cut across multiple population characteristics, including race/ethnicity, age, disability status, sexual orientation or gender identity, or other characteristics historically linked to discrimination or exclusion.

The report is the latest in the American Cancer Society’s Cancer Control Blueprint series, and highlights that many solutions for better health exist outside of the health care system. It appears today in CA: A Cancer Journal for Clinicians, the American Cancer Society’s flagship journal.

The World Health Organization defines social determinants as “the circumstances in which people are born, grow up, live, work, and age and the systems put in place to deal with illness” that are shaped by the “distribution of money, power, and resources at global, national, and local levels.” Social determinants include housing and neighborhood conditions, educational and economic factors, transportation systems, social connections, and other social factors and reflect interconnected social structures and economic systems shaped by the inequitable distribution of power and resources.” The National Academies of Sciences, Engineering, and Medicine acknowledge that structural inequities make poorer health outcomes suffered by disadvantaged groups unfair and unjust.

Although cancer mortality rates declined in the U.S. in recent decades, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many socioeconomic disparities in health persist because disadvantaged communities persistently lack resources that enable them to take advantage of advances that can protect and enhance health. “Addressing social determinants that drive disparities in cancer incidence… because of inequitable risk factor exposure will require policy action beyond the health care system,” write the authors.

Among the actions recommended:

  • Address income and wealth inequality: In recent decades, gains in wealth have been substantially greater for the wealthiest segment of the population compared with other segments. Failure to promote wealth growth in the poorest sectors of society will perpetuate determinants of inequitable health outcomes.
  • Support targeted provisions: Compared with socioeconomically disadvantaged groups, socioeconomically privileged populations are better able to take advantage of new information and access interventions at earlier stages. Therefore, public policies without explicit provisions for disadvantaged groups may unintentionally widen health inequalities.
  • Support models of care that consider social risk: Addressing social determinants must systemically acknowledge and attend to social risk resulting from marginalization, stigmatization, and discrimination. Concerns have been raised that providers may be less willing to care for patients with social risk. Given that disadvantaged patients have more complex needs than other patients, policy strategies that enable providers to be incentivized for the provision of more holistic health care warrant close consideration.

“The cancer control continuum comprises a range of intervention targets, from prevention and screening to survivorship and end-of-life care,” conclude the authors. “Just as current cancer control efforts must target this entire continuum of influence, so must future cancer control efforts target the entire social determinants continuum of influence, including social-structural factors. Failure to embrace this perspective will inevitably contribute to the perpetuation, and potentially widening, of cancer disparities.”

The report was led by Kassandra Alcaraz, PhD, MPH, senior principal scientist in our Behavioral and Epidemiology Research Group of the Intramural Research Department.

Read earlier Blueprint articles here.

  • Welcome Dr. Cance!

    This week marks a new and exciting chapter in the history of the American Cancer Society, as we welcome William G. Cance, MD, as chief medical and scientific officer and leader of our research and cancer control programs.

    "Bill’s road to the American Cancer Society, like many of us, began early in life. I encourage you to take a few minutes to watch this video to learn more about his story, and why he is so excited to join us in our lifesaving work," said ACS CEO Gary Reedy.

    Learn more about Bill here.

  • ACS mourns the passing of Bernard Fisher, MD, a pioneer in the treatment of breast cancer

    ​"He will be long remembered for what he accomplished that benefited so many," said Len Litchenfeld, MD, our deputy chief medical officer, on Twitter.

    It was the work of Bernard Fisher, MD, FACS, born 1918 in Pittsburgh, that showed that early-stage breast cancer could be more effectively treated by lumpectomy, in combination with radiation therapy, chemotherapy, and/or hormonal therapy, than by radical mastectomy.

    The oncology journal and website OncLive described Dr. Fisher's research as "launching the breast cancer community into the modern era" and honored him with a Giants of Cancer Care award for his work that ultimately ended the standard practice of performing the Halsted radical mastectomy, a treatment that had been in place for more than 75 years.

    Dr. Fisher faced constant attacks from within medical ranks as he worked to disprove the efficacy of the old status quo treatment, but he prevailed and was awarded the Albert Lasker Award for Clinical Medical Research in 1985 "for his pioneering studies that have led to a dramatic improvement in survival and in the quality of life for women with breast cancer."

    Dr. Len said: "We at the American Cancer Society join Dr. Fisher’s friends, colleagues, and those with cancer in mourning his passing and celebrating his accomplishments. He was truly a giant in cancer care and research. His efforts formed the foundation of many advances we have relied on for decades in treating breast cancer and other cancers. "

    He added: "His wisdom challenged us as early as the 1960’s to rethink our understanding of breast cancer and led the way to more effective and more focused treatments."

    Dr. Fisher, who turned 101 in August, was a University of Pittsburgh Distinguished Service Professor of Surgery. Read more about him here.

  • The Cancer Atlas, Third Edition, unveiled Oct. 16 at the World Cancer Leaders' Summit in Kazakhstan.

    Highlights patterns and inequities in cancer burden around the world

    The Cancer Atlas aims to open readers' eyes to the facts and figures of cancer: the scale and magnitude globally, the major causes, and the different ways the disease can be prevented and treated. This theme of the current edition is "Access Creates Progress," drawing attention not only to the problem at hand, but also the means of tackling the cancer burden through access to information and services. 

    It is grouped into three sections: Risk Factors, The Burden, and Taking Action:

    RISK FACTORS highlights regional and international variations in many of the major risk factors for cancer, including tobacco use, infections, excess body weight, and ultraviolet radiation. Tobacco smoking continues to be the predominant cause of cancer in most high-income countries, while infections still play a major role in many sub-Saharan African and Asian countries. The importance of excess body weight as a major risk factor for cancer continues to escalate in most parts of the world, including many economically transitioning countries.

    THE BURDEN describes the geographic diversity in cancer occurrence worldwide and, in separate chapters, for each of the major world regions. This burden is also described in terms of the national Human Development Index, the primary measure of a country's societal and economic development used in this book. Profiles of cancer survival and cancer survivorship are expanded in this third edition, and global cancer survival statistics are presented for the first time in print, while pressing issues such as the financial burden of cancer are highlighted. A new chapter on cancer in Indigenous populations describes the specific challenges facing these underserved populations around the world.

    The final section, TAKING ACTION, describes major interventions across the cancer continuum, from the prevention of risk factors to early detection, treatment, and palliative care, highlighting disparities in the availability and implementation of these interventions across the world. It also portrays the multiple organizations working in cancer control and the importance of policies and legislation and building synergies between diseases and health systems for broad implementation of known interventions. In this edition, a new chapter on universal health care and "Access Creates Progress" text boxes in chapters throughout the book highlight successful strategies to address the cancer burden.

    The Cancer Atlas and its accompanying interactive website ( were carefully designed to ensure user-friendly, accessible, and downloadable descriptions and graphics can be easily used by cancer control advocates, government and private public health agencies, and policymakers, as well as patients, survivors, and the general public.  

    The report was produced by ACS, the Union for International Cancer Control (UICC), and International Agency for Research on Cancer (IARC). It was released Oct. 16 at the World Cancer Leaders Summit in Nur-Sultan, Kazakhstan. 

    Two of its four editors are ACS staffers: Ahmedin Jemal, DVM, PhD, scientific VP of our Surveillance & Health Services Research Program, and Lindsey Torre, MSPH, an epidemiologist in the Surveillance and Health Services Research group.

    Highlights of the 3rd Edition: 

    • Cancer is the leading or second-leading cause of premature death (under age 70) in 91 countries worldwide.  Based on expected population growth and aging alone, the number of global cancer cases is expected to increase by 60% in 2040. More widespread distribution of lifestyle factors such as smoking, unhealthy diet, and physical inactivity are likely to make that number considerably larger. 
    • Tobacco causes more preventable cancer deaths than any other risk factor. In 2017 alone, smoking was responsible for an estimated 2.3 million cancer deaths globally, accounting for 24% of all cancer deaths. There are still 1.1 billion smokers worldwide. Progress in tobacco control legislation over the last decade means 1.5 billion people in 55 countries are now protected by smoke-free legislation. 
    • While infectious agents are responsible for an estimated 15% of all new cancer cases worldwide, the proportion ranges from around 4% in many very high-income countries to more than 50% in several sub-Saharan African countries. The four major infectious agents (which together account for more than 90% of all infection-related cancers) are Helicobacter pylori, human papillomavirus (HPV), hepatitis B virus (HBV) , and hepatitis C virus (HCV) . 
    • Excess body weight increases risk of 13 types of cancer, and in 2012 accounted for 3.6% of all new cancer cases among adults worldwide. The prevalence of excess body weight is rising worldwide: in 2016, an estimated 39% of men and 40% of women aged 18 years and older, and 27% of boys and 24% of girls aged 5–18 years, were obese. High amounts of sugar-sweetened beverages and sedentary behaviors, including screen-time, increase risk of excess body weight.  
    • The cancer burden associated with unhealthy diet, excess body weight, and physical inactivity is expected to grow in most parts of the world, particularly in parts of the Middle East and several other low- and middle-income countries in parts of Asia and Oceania because of the obesity epidemic. 
    • Alcohol is responsible for 4.2% of all cancer deaths globally, with marked variation across countries.  
    • Breast cancer is the most common cancer in women in almost all countries worldwide, and accounts for almost one in four new cancer cases among women. Lifetime risk of breast cancer among females in high-income countries can be up to three times that in low-income countries. 
    • Each year, about 270,000 cancer cases are diagnosed in children. Today, 5-year survival from childhood cancer in high-income countries is greater than 80%, but it can be as low as 20% in low-income countries. With interventions to improve early diagnosis and adherence to appropriate treatment, childhood cancer survival can be increased to 60% in low-income countries, saving almost 1 million children's lives over a decade. 
    • Over the next half century, an estimated 44 million cervical cancer cases will occur worldwide if current trends continue. Effective delivery of combined high coverage screening and vaccination could avert over 13 million cervical cancer cases by 2069, and eventually lead to cervical cancer eliminated as a major public health problem. 
    • Approximately 3 to 6% of all cancers worldwide are caused by exposures to carcinogens in the workplace. 
    • Outdoor air pollution causes over half a million lung cancer deaths and millions of deaths from other diseases each year. Outdoor air pollution levels are particularly high in rapidly-growing cities in low- and middle-income countries. Diesel exhaust, classified as a lung carcinogen by IARC, contributes to outdoor air pollution and is also an occupational lung carcinogen. 
    • Radiotherapy is indicated for about 60% of cancer patients to relieve symptoms, shrink tumors before surgery, or kill remaining cancer cells after surgery to avoid recurrence. Radiotherapy coverage is less than optimal in many low- and middle-income countries. In Ethiopia, for example, a population of approximately 100 million is served by a single radiotherapy center. 
    • The growing number of cancer survivors represents a global challenge for survivors and their families, employers, healthcare systems, and governments. In 2018, there were approximately 43.8 million cancer survivors diagnosed within the previous 5 years. Many cancer survivors face late and lasting medical, emotional, and social challenges resulting in 7.8 million years lived with disability globally in 2017.

  • ACS study: difficulty navigating insurance linked to financial hardship

    ​A new American Cancer Society study links health insurance literacy with medical financial hardship as well as non-medical financial sacrifices among adult cancer survivors in the U.S. 

    The authors say the study indicates that health insurance literacy may be an important intervention for addressing financial problems associated with cancer. 

    "Is Health Insurance Literacy Associated with Financial Hardship Among Cancer Survivors? Findings from a National Sample in the United States," appears in JNCI Cancer Spectrum.

    Rising costs of cancer care can result in financial hardship for cancer survivors, even among those with health insurance. Meanwhile, growing evidence indicates that many adults have limited knowledge, ability, and confidence to obtain, evaluate, and use health insurance information that may impact the ability to best use health benefits and lead to unnecessary medical spending.

    Improving health insurance literacy has been proposed as a potential intervention to help minimize financial hardship. To date, however, little is known about the associations between health insurance literacy and medical financial hardship and non-medical financial sacrifices in cancer survivors.

    To learn more, investigators led by Jingxuan Zhao, MPH, of the American Cancer Society, identified 914 adult cancer survivors from the 2016 Medical Expenditure Panel Survey Experiences with Cancer self-administered questionnaire, a nationally representative household survey overseen by the Agency for Healthcare Research and Quality. The survey addresses financial hardship, health insurance coverage, and access to care related to cancer, its treatment, and lasting effects of treatment.

    Health insurance literacy was measured by the question, “Did you ever have a problem understanding health insurance or medical bills related to your cancer, its treatment, or the lasting effects of that treatment?” Medical financial hardship was measured by reports of problems paying medical bills, worry about paying medical bills, and delaying or foregoing care because of cost. Non-medical financial sacrifices were measured by changes in spending, living situation, or use of savings.

    They found that, adult cancer survivors aged 18-64 and ≥65 years with health insurance literacy problems were more likely to report any material hardship (18-64 years: odds ratio: 3.02; ≥65 years: odds ratio: 3.33), and more likely to report psychological hardship (18-64 years: odds ratio: 5.53; ≥65 years: odds ratio: 8.79) than those without the literacy problems. Cancer survivors with health insurance literacy problems were also more likely to report all types of non-medical financial sacrifices and more likely to report any financial sacrifices than those without the problems (18-64 years: odds ratio: 9.90; ≥65 years: odds ratio: 2.12).

    "Growing evidence suggests that health insurance literacy is a nationwide problem in the United States, and is associated with adverse effects,” write the authors, saying future longitudinal studies are warranted to assess if improving health insurance literacy can mitigate financial hardship. “Interventions such as financial and health insurance navigation, decision aids, and more user-friendly and easier-to-read medical bills, which improve patients understanding of health insurance and medical costs, could potentially be applied to improve health insurance literacy and benefit cancer survivors.”

  • ACS creates Center for Cancer Screening

    One goal is to attract funding for research and development focused on cancer screening

    We are proud to announce the establishment of the American Cancer Society Center for Cancer Screening. This new Center (not a physical structure) will build on the organization’s long history of advancing the importance of evidence-based early cancer detection and advocating for high-quality cancer screening. 

    The Center also will enhance collaboration within the organization and with outside experts and organizations engaged in research, practice, and policy related to cancer screening. Although no new staff hiring is planned at this time, the Center will invite some internal staff and external experts who have an interest in cancer screening research, practice, and policy to be affiliated with it.

    Since 1980, ACS has regularly published evidence-based cancer screening guidelines, educated health professionals and the public about the importance of regular cancer screening, influenced health insurance coverage, and supported efforts to improve the quality of cancer screening. ACS has also conducted important research on cancer screening. 

    Now, the ACS Center for Cancer Screening will increase our reach and impact. The Center will be directed by Robert Smith, PhD, senior vice president of cancer screening (pictured here). Bob is a longtime ACS leader with more than 30 years of experience in cancer screening.

    “We believe the Center will strengthen the development and promotion of ACS screening guidelines by fostering more timely updates of established screening recommendations, as well as staying on top of emerging evidence that may lead to new screening recommendations. One of the principal goals of the Center is to strengthen internal and external collaborations on screening research and policy,” said Bob. “The Center will also increase our long-standing emphasis on the quality of cancer screening tests and follow-up, attract funding for research and development focused on cancer screening, and be the home of the National Lung Cancer Roundtable, which was established in 2017 to make an impact on death from lung cancer,” he said.

    Rich Wender, MD, chief cancer control officer added: “The creation of the Center will increase our visibility and allow us to foster relationships with other guideline development organizations and screening experts.”

  • ACS researcher receives impressive honor

    His article published last year in Annals of Epidemiology received the 2019 Award for Overall Best Paper

    Let's hear it for Eric Jacobs, PhD, senior scientific director, Epidemiology Research (pictured here)!

    The American College of Epidemiology (ACE) named an article he was the lead author on as the best overall paper of the year published in the journal Annals of Epidemiology. Co-authors, as he was quick to point out, include ACS epidemiologists Christina Newton, MSPH; Ying Wang, PhD; Peter Campbell, PhD; and Susan Gapstur, PhD; and Dana Flanders, MD, an epidemiologist from Emory University.

    The award is given each year to recognize and support high-quality epidemiologic research published in the Annals of Epidemiology, which carefully reports and addresses questions of substantial public health or methodological significance.

    The article by Eric and others - "Ghost-time bias from imperfect mortality ascertainment in aging cohorts" - describes a potential problem in many research studies that ACS epidemiologists identified while analyzing data from our Cancer Prevention Study II (CPS-II). (CPS-II is a large epidemiologic study of over a million men and women, followed since 1982, that has resulted in hundreds of scientific publications about the causes of cancer.)

    As explained by Eric, "In 2016, a team of ACS researchers was analyzing data from CPS-II to compare the influence of social isolation on death from cancer and other causes in black and white Americans. For the most part, social isolation was linked with higher death rates, as reported in a separate publication. However, the researchers noticed this was not true in a relatively small subgroup of participants, those who were aging into their late 90s or even 100s, a result they found suspicious. The researchers eventually identified the problem. While the vast majority of deaths in epidemiologic studies are correctly identified through computerized linkage with national death certificate data, a few participant deaths are inevitably missed, for example due to misreported Social Security numbers or the use of nicknames. These participants can live forever as “ghosts” in the researcher’s dataset and distort results among the very oldest participants in unexpected ways. The ghost-time bias paper presents simulations that show such distortion can happen under conditions that occur in many ageing study cohorts, and discusses ways for researchers to recognize and avoid it, thereby producing higher quality health research.”

    Each year's award-winning paper is selected by a panel of judges from both the ACE Publications Committee and Annals of Epidemiology, underscoring the close affiliation of the College with the Journal. 

    Congratulations to Eric, Christina, Ying, Peter, and Susan!

  • Two ACS-funded researchers win Nobel Prize!

    This brings to 49 the number of ACS-funded researchers who have won the Nobel Prize!

    Two American Cancer Society-funded researchers - William G. Kaelin, Jr., MD, of Harvard Medical School and Dana-Farber Cancer Institute, and Gregg L. Semenza, MD, PhD, of Johns Hopkins University - are two of three scientists receiving the Nobel Prize in Medicine or Physiology this year. They are the 48th and 49th Society-funded researchers to earn this prestigious award.

    Drs. Semenza, Kaelin, and Peter J. Ratcliffe, MD, (not an ACS grantee)identified the molecular machinery that regulates the activity of genes in response to varying levels of oxygen. They established the basis for our understanding of how oxygen levels affect cellular metabolism and physiological function. Their work has already had a significant impact on our understanding of how cancer cells thrive and helped establish new treatment strategies. Their discoveries have also paved the way for promising new strategies to fight anemia, cancer, and many other diseases.

    Dr. Semenza received his first ACS grant in 2012 to study the role of hypoxia in breast cancer metastasis. He is currently an ACS Research Professor, the most prestigious research grant made by the national program. The title of American Cancer Society Professor can be used throughout the remainder of the scientist's career.

    Dr. Kaelin, who also works at the Howard Hughes Medical Institute in Chevy Chase, MD, received a one-year American Cancer Society Clinical Oncology Fellowship in 1987, while at the Dana-Farber Cancer Institute.

    "This is an incredible accomplishment for our organization and its mission to attack cancer from every angle," said Gary Reedy, our CEO, this morning. "I hope you are as proud as I am of this latest accolade for our groundbreaking research program, which does so much to help save lives from this disease. No other non-profit organization has even come close to funding as many Nobel laureates as your American Cancer Society has – a distinction that should only drive us to push that total even higher."

    J. Leonard Lichtenfeld, MD, MACP, our interim chief medical officer, had this to say: "The American Cancer Society is honored to have identified and supported so many gifted investigators early in their careers. The investigators we fund study everything from nutrition to genetics to environmental and even behavioral factors to identify cancer causes and treatments. These discoveries lead to understanding, grow hope, and support our efforts to attack this disease from all angles. The success of our research program is surely exemplified by the fact that our organization has now supported 49 Nobel laureates."

    Here is a New York Times story on the awardees.

    More on the Nobel Prize winners

    William G. Kaelin, Jr. was born in 1957 in New York. He obtained an MD from Duke University, Durham. He did his specialist training in internal medicine and oncology at Johns Hopkins University, Baltimore, and at the Dana-Farber Cancer Institute, Boston. He established his own research lab at the Dana-Farber Cancer Institute and became a full professor at Harvard Medical School in 2002. He is an Investigator of the Howard Hughes Medical Institute since 1998.

    Gregg L. Semenza was born in 1956 in New York. He obtained his B.A. in Biology from Harvard University, Boston. He received an MD/PhD degree from the University of Pennsylvania, School of Medicine, Philadelphia in 1984 and trained as a specialist in pediatrics at Duke University, Durham. He did postdoctoral training at Johns Hopkins University, Baltimore, where he also established an independent research group. He became a full professor at the Johns Hopkins University in 1999, and since 2003 has been the director of the Vascular Research Program at the Johns Hopkins Institute for Cell Engineering.

    Sir Peter J. Ratcliffe is director of clinical research at the Francis Crick Institute in London, the director of the Target Discovery Institute in Oxford, and a member of the Ludwig Institute for Cancer Research.

  • Decades-long drop in breast cancer death rate continues

    Mortality decline has slowed in recent years; breast cancer now leading cause of cancer death for black women in six states

    A decades-long decline in the breast cancer death rate continues, but has begun to slow in recent years, while breast cancer incidence rates continue to inch up. These trends are outlined in Breast Cancer Statistics, 2019-2020, the latest edition of the American Cancer Society's biennial update of breast cancer statistics in the U.S., published in CA: A Cancer Journal for Clinicians, and the accompanying Breast Cancer Facts & Figures 2019-2020 which will be posted on

    After skin cancers, breast cancer is the most common cancer diagnosed among U.S. women, and the second leading cause of cancer death among women after lung cancer. In 2019, approximately 268,600 new cases of invasive breast cancer will be diagnosed among U.S. women, and 41,760 women will die from the disease.

    The overall breast cancer death rate has decreased consistently since 1989, attributed both to improvements in early detection (through screening as well as increased awareness of symptoms) and treatment, for a total decline of 40% through 2017. As a result of this decline, 375,900 breast cancer deaths have been averted in U.S. women through 2017.

    The latest data shows that the pace of the mortality decline has slowed in recent years—from a drop of 1.9% per year during 1998 through 2011 to 1.3% per year during 2011 through 2017, largely driven by the trend in white women. Consequently, the black-white disparity in breast cancer mortality that widened over the past three decades has remained stable since 2011. Nevertheless, in the most recent period (2013-2017), the breast cancer death rate was 40% higher in black women versus white women, despite slightly lower incidence rates. This disparity is magnified among black women under 50, among whom the death is rate double that of whites.

    In the most recent 5-year period (2013-2017), the breast cancer death rate declined by 2.1% per year in Hispanics/Latinas, 1.5% per year in blacks, 1.0% per year in whites, and 0.8% per year in Asians/Pacific Islanders, and was stable in American Indians/Alaska Natives. However, mortality rates are no longer declining for black women in Colorado and Wisconsin, and for white women in Nebraska, Texas, and Virginia.

    Meanwhile, the breast cancer incidence rate has continued to slowly increase by 0.3% per year since 2004, largely because of rising rates of local stage and hormone receptor-positive (HR+) disease. The increase in rates of HR+ breast cancer is likely driven in part by increasing prevalence of excess body weight and declining fertility rates – risk factors that are more strongly associated with this subtype. In contrast, incidence rates have decreased for hormone receptor-negative breast cancer, which is associated with poorer survival.

    During 2016-2017, breast cancer was the leading cause of cancer deaths (surpassing lung cancer) among black women in six states (Arizona, Colorado, Florida, Georgia, Mississippi, and South Carolina), as well as among white women in Utah. In four other states (Alabama, Massachusetts, New York, and Texas), the numbers of breast and lung cancer deaths among black women were similar.

    "We can't say for sure what the reasons are for the slowing of the decline in breast cancer mortality. It could be due in part to the slight increase in incidence since 2004, as well as a sign that optimal breast cancer treatment has become more widespread, particularly among white women," explained Carol DeSantis, MPH, lead author of the report. "However, more can and should be done to ensure that all women have access to quality care to help eliminate disparities and further reduce breast cancer mortality."

    Other findings from the report:

    • During 2012 through 2016, breast cancer incidence rates increased among Asians/Pacific Islanders (1.5% per year), American Indians/Alaska Natives (0.8% per year), and blacks and whites (both 0.5% per year), but were relatively stable among Hispanic/Latina women.
    • The lifetime risk of a breast cancer diagnosis is now rounded to 13% (12.8%; previously 12.4%), which still equates to about 1 in 8 women diagnosed with breast cancer in her lifetime.
    • The 10-year probability of a breast cancer diagnosis is highest for women in their 70s (4%), whereas the 10-year risk of breast cancer death is highest in women in their 80s (1%).
    • Among women 50 and older, rates of ductal carcinoma in situ (DCIS) increased more than 11-fold between 1980 and 2008 (from 7 cases per 100,000 to 83), but decreased by 2.1% per year in the most recent time period (2012-2016), largely reflecting trends in the use of mammography, which increased from 29% in 1987 to 70% in 2000 and has since declined slightly.
    • As of January 1, 2019, there were more than 3.8 million women with a history of breast cancer living in the United States. This estimate includes more than 150,000 women living with metastatic disease, three-quarters of whom were originally diagnosed with stage I, II, or III breast cancer.
    • Higher breast cancer death rates in black women reflect a combination of factors that are difficult to parse, including later stage at diagnosis, unfavorable tumor characteristics, higher prevalence of obesity and pre-existing medical conditions, and less access to timely and high-quality prevention, early detection, and treatment services. 

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