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C A N C E R F A C T 5 A N D F I G U R E s 1 9 8 9 SELECTED CANCER SITES the use of postmenopausal estrogens in terms of the benefit an.d risk to the individual patient. Treatmiealt: Uterine cancers generally are treated by surgery or radiation, or by a combination of the two. In precancerous (in situ) stages, changes in the cervix may be treated by cryotherapy (the destruction of cells by extrem e cold), by electrocoagulation (the destruction of tissue through intense heat by electric current) or by local surgery. Precancerous endometrial changes may be treated with the hormone progesterone. Survival: The 5-year survival rate for all cervical cancer patients is 66%. For patients diagnosed early, however, the rate is 80-90%. Cancer in situ is virtually 100%. The figures for endometrial cancer are 83% all stages, 91% early and virtually 100% for endometrial precancerous lesions. During a recent 10-year period, there was moderate improvement for both uterine sites. ®VARIAN CANCER Incider ce: An estimated 20,000 new cases in the United Si:ates in 1989. It is estimated that about 1.4% or one out of every 70 newborn girls will develop ovar- ian cancer during her lifetime. It accounts for 4% of all cancers among women and 27% of the cancers of the female reproductive system. Mortality: An estimated 12,000 deaths in 1989. Although ovarian cancer ranks second in incidence among gynecological cancers, it causes more deaths than any other cancer of the female reproductive system. Warning Signals: Ovarian cancer is often "silent," showing no obvious signs or symptoms until late in its development. The most common sign is an enlarged abdomen caused by the collection of fluid. Rarely will there be abnormal vaginal bleeding. In women over 40, vague digestive disturbances (stomach discomfort, gas, distention) which persist and cannot be explained by any oth er cause may indicate the need for a thorough checkup for ovarian cancer. Risk Factors: Risk for ovarian cancer increases with age, with highest rates for women 65-84. Women who have never had children are twice as likely to develop ovarian cancer as those who have. A number of inter- related, reproductive factors,, such as age at first live birth, age at first pregnancy, and number of pregnan- cies are all involved in varying degrees. In addition, years of ovulation, the product of a number of other interrelated factors such as length of pregnancies and oral contraceptive use (which may themselves actually decrease risk), are also tied to an observed increased risk. Breast and endometrial cancer increases a.woman's chances of developing ovarian cancer twofold. Patients with colorectal cancer are at increased risk of ovarian cancer, although risk decreases over time following diagnosis of their colorectal cancer. Some rare genetic disorders are associated with increased risk. Incidence rates are higher in North America and Northern Europe, and lower in Asia and Africa. Rates are significantly higher for nuns, Jewish women, and women who have never been married. Early Detection: Periodic, thorough pelvic examina- tions are important. The Pap test, useful in detecting cervical cancer, does not reveal ovarian cancer. Women over the age of 40 should have a cancer-related checkup every year. Treatment: Surgery, radiation therapy and drug ther- apy are all options in the treatment of ovarian cancer. Surgical treatment usually includes the removal of one or both ovaries, the uterus (hysterectomy) and the fallopian tubes. In some very early tumors, only the involved ovary may be removed, especially in young women. In advanced disease, an attempt is made to remove all intra-abdominal disease to enhance the effect of chemotherapy. Survival: If ovarian cancer is diagnosed and treated early, about 85% of such patients live 5 years or longer. However, when diagnosed in an advanced stage, the survival rate drops to 23%. It has improved with mod- em chemotherapeutic agents. Overall, the survival rate for ovarian cancer is 38%. ORAL CANCER Incidence~~ An estimated 31,000 new cases in 1989. Incidence is more than twice as high in males as in females, and i.; most frequent in men over age 40. Cancer can affect any part of the oral cavity, from lip to tongue to mouth and throat. Mortality: An estimated 8,650 deaths in 1989. Warning Si:gnals: A sore that bleeds easily and doesn't heal; a lump or thickening; a reddish or whitish patch that peisists. Difficulty in chewing, swallowing or moving tongue or jaws are often late changes. Risk Factors: Cigarette, cigar and pipe smoking; use of smokeless tobacco; excess use of alcohol. Early Detection: Dentists and primary care physi- cians have the opportunity, during regular checkups, to see abnormal tissue changes and to detect cancer at an early and curable stage. Treatment: Principal methods are radiation therapy and surgery. Chemotherapy is being studied as an aid to surgery in advanced disease. Survival: Five-year survival rates vary substantially depending on the site. Rates range from 32% for cancer of the pharynx to 91% for lip cancer. Overall, 5-year survival for oral cancer patients is about 51%. 11

C A N C E R F A C T S A N D F 1 G U R E S SELECTED CANCER Sal°ES 1 9 8 9 CANCER INCIDENCE AND DEATH S B Y SITE AND SEX-1989 ESTIMATES CANCIER INCIDENCE BY SITE AND SEXt CANCER DEATHS BY SITE AND SEX SKIN I 3% 3% SKIN SKIN 2yo 1% SKIN ORAL ~ 4% 2% ORAL ORAL ORAL LUNG [20% 28% BREAST LUNG 357% 18% BREAST COLON &~14oJo 11% LUNG RECTUM l. COLON & 11% 21% LUNG RECTUM 15% COLON & PANCREAS [3% RECTUM 13% COLON & PANCREAS 5% RECTUM PROSTATE [t1°Jo 3% PANCREAS PROSTATE j1% rJ°Jo PANCREAS 4% OVARY URINARY C'0°Jo 5% OVARY URINARY nj /0 0 LEUKEMIA & 7 l;°JQ g°Jo UTERUS LYMPHOMAS I_ LEUKEMIA & 9pofO 4°lo UTERUS LYMPHOMAS 4% URINARY ALL OTHER 3°lo URINARY ALL OTHER 20% 7oJO LEUKEMIA & 9oJ0 LEUKEMIA & LYMPHOMAS LYMPHOMAS l4°Jo ALL OTHER 20°lo ALL OTHER fiExcluding non-melanoma skin cancer and carcinoma in situ. ® PROSTATE CANCER Incidence: An estimated 103,000 new cases in the United States durilg 1989. About one out of 11 men will develop prost2 te cancer at some time during his lifetime. The third highest incidence of cancer in men, next to skin cancer and lung cancer. Mortality: An estimated 28,500 deaths in 1989, the third leading cause of cancer deaths in men. Warning Signals: Most signs or symptoms of pros- tate cancer are nonspecific, and do not distinguish from benign conditions such as infection or prostate enlarge- ment. These include weak or interrupted flow of urine; inability to urinate or difficulty in starting urination; need to urinate frequently, especially at night; blood in the urine; urine flow that is not easily stopped; painful or burning urination; continuing pain in lower back, pelvis or upper thighs. Risk Factors: Incidence increases with age through the most advanced ages; about 80% of all prostate cancers are diagnosed in men over the age of 65. The disease is more common in northwest Europe and North America; rare in the Near East, Africa, Central and South America. Black Americans have the highest rate of incidence in the world for reasons not currently known. There is sor.ae familial association, but it is unclear whether thi:> is due to genetic or environmental association. Dietary fat may be a factor, based on studies conducted internatio,nally. Workers who work with cadmium are found ta be at slightly higher risk. Studies of migrating populations have suggested that environ- mental factors, such as diet and lifestyle, may play an important role in the risk of developing cancer of the prostate. Early Detection: Every man over 40 should have a rectal exam as part of his regular annual physical checkup. A new technique, prostate ultrasound is being investigated for the early detection of small non- palpable cancers. This new approach may be of special benefit:to high risk men.,Men over 40 should be alert to changes such as urinary difficulties, continuing pain in lower back, pelvis or upper thighs, and should see their physician immediately should any occur. The key to saving lives from prostate cancer is early detection and treatment. Treatment: Surgery, alone or in combination with radiation and/or hormones, and anticancer drugs are all options available in the treatment of prostate cancer. Surgery or radiation therapy may be the treatment chosen to cure prostate cancer if it is found in an early localized state. Hormone treatment and anticancer drugs also may control prostate cancer for long periods by shrinking the size of the tumor and greatly relieving pain. Survival: Sixty-four percent of all prostate cancers are discovered while still localized within the general region of the prostate; 84% of all patients whose tumors are diagnosed at this stage are alive 5 years after treatment. Survival rates for all stages combined have steadily improved since 1940, and in the last 20 years have increased from 48% to 71%. 12

C A N C E R F A C T S A N D F I G U R E S 1 98 9 SELECTED CANCER SITES BLADDER CANCER Incidence: An estimated 47,000 new cases of bladder cancer in 1989; 34,500 in males, 12,500 in females. Blad- der c:ancers account for 7% of the new cancer cases diagnosed each year in men and 3% in women. Bladder cancer is the 5th most common form of cancer in males and 10th most common form of cancer in females in this country. McM:ality: An estimated"10,200 deaths in 1989 from bladder cancers, the 8th leading cause of cancer deaths in males and 14th in females. Warning Signals: Blood in the urine. Usually asso- ciated with increased frequency of urination. Risk Factors: Smoking is the greatest risk factor in bladder cancer, with smokers experiencing twice the risk of nonsmokers. Smoking is estimated to be respon- sible ;Eor about 49% of the bladder cancers among men and 10% among women. Overall, the incidence rate of bladder cancer is 4 times as great among men as women, and higher in whites than in blacks. People living in urban areas, and dye, rubber and leather workers also are at higher risk. Coffee and artificial sweeteners have been found to increase cancer risk in a few studies but most studies have not found an increased risk. Diagnosis: Diagnosis of bladder cancer is achieved by examination of the bladder wall with a cystoscope, a slender tube fitted with a lens and light that can be inserted into the tract through the urethra. Treatment: Surgery, alone or in combination with other treatments, is used in 92% of cases. Survival: The 5-year survival rate for bladder cancer is 88% when detected in an early stage. For those can- cers more advanced, the survival rate drops to 41%. SKIN CANCER Incidence: Over 500,000 cases a year, the vast major- ity of which are highly curable basal or squamous cell cance!rs. They are more common among individuals with lightly pigmented skin, living at latitudes near the equator. The most serious skin cancer is malignant melanoma, which strikes about 27,000 persons each year. The incidence of melanoma is increasing at the rate of ,3.4% per year. Mortality: An estimated 8,200 deaths this year, 6,000 from malignant melanoma, and 2,200 due to other skin cancers. Warning Signals: Any unusual skin condition, especially a change in the size or color of a mole or other darkly pigmented growth or spot. Scaliness, oozing, bleeding or the appearance of a bump or nodule, the spread of pigment beyond the border, a change in sen sation, itchiness, tenderness -or pain are all warning signs of melanoma. Risk Factors: Excessive exposure to the sun; fair compaexion; occupational exposure to coal tar, pitch, creosote, arsenic compounds or radium. Among blacks, because of heavy skin pigmentation, skin cancer is negligible. One study has found that severe sunburn in childhood carries with it an excessive risk of mel- anoma in later life. Prevention: Avoid the sun between 10 a.m. and 3 p.m. when ultraviolet rays are strongest, and use protective clothing. Use one of a number of sunscreen preparations, especially those containing such ingre- dients as PABA (para-aminobenzoic acid). They come in varying strengths, ranging from those that permit graduzil tanning to those allowing practically no tanning at all. Children, in particular, should be protected from traumatiic sunburns. Early Detection: Early detection is critical. Recog- nition of changes in or the appearance of new skin growths is the best way to find early skin cancer. Basal and squamous cell skin cancers often take the form of a pale, waxlike, pearly nodule, or a red scaly, sharply outlined patch. A sudden or continuous change in a mole's appearance should be checked by a physician. Melanomas often start as small, mole-like growths that increase in size, change color, become ulcerated and bleed easily from a slight injury. There is a simple ABCD rule that will help individuals remember the warning signs of melanoma: A is for asymmetry. One half of the mole does not match the other half. B is for border irregularity. The edges are ragged, notched or blurred. C is for color. The pigmentation is not uniform. D is for diameter greater than 6 millimeters. Any sudden or continuing increase in size should be of special concern. Adults should practice skin self-examination once a month. Treatment: There are four methods of treatment: surgery (used in 90% of cases), radiation therapy, electrodesiccation (tissue destruction by heat), or cryosurgery (tissue destruction by freezing) for early skin cancer. For malignant melanoma, adequate surgical excision of the primary growth is indicated. Nearby lymph nodes may be removed. The microscopic examination of all suspicious moles is essential. Advanced cases of melanoma are treated on an individual basis. Survival: For basal cell and squamous cell cancers, cure is highly likely with early detection and treatment. Malignant melanoma can spread to other parts of the body quickly. However, when detected in its earliest stages, with proper treatment, it is highly curable. The overall 5-year survival rate for white patients with malignant melanoma is 80% compared with 95% for patients with other kinds of skin cancer. The 5-year survival rate for localized malignant melanoma is 89%; however, the survival rate, once melanoma has spread, is 39%. 13 202554591202

C A N C E R F A C T 5 A N D F I G U R E S 1 9 8 9 SELECTED CANCER StT'ES PANCREATIC CANCER Incidence: An estimated 27,000 new cases in the United States in 1989.1'ancreatic cancer is the 5th leading cancer killer. The incidence rate of pancreatic cancer among U.S. blacks is about 1.5 times higher than for whites. li4ortality: An estimated 25,000 deaths in 1989 due to pancreatic cancer. From 1954 to 1984, the death rates for pancreatic caj.lcer in the United States rose 12% to 10.2 deaths per 100,000 men. During the same period, the death rates for women rose 26% to 7.2 deaths per 100,000 women. Warning SignadLs: Cancer of the pancreas is a "silent" disease, one that occurs without symptoms until it is advanced. Itisk Factors: F:isk increases with age after age 30, with the highest frequency of incidence occurring between ages 65 a nd 79. Smoking is a major risk factor, incidence is more than twice as high for smokers versus nonsmokers. The disease is 30% more common in men, and occurs about 50%o more frequently in black, versus white Americans. Some studies, as yet unconfirmed, suggest an association with chronic pancreatitis, dia- betes and cirrhosis. High-fat diets may be a risk factor, countries with higher fat consumption levels have higher pancreatic cancer rates. Coffee has been inves- tigated as a possible risk factor, but no conclusive evi- dence is currently available. Early Detection: Research has focused on ways to diagnose pancreatic cancer before it is advanced enough to cause symptoms. Ultrasound and CT scans are being tried, but to date only a biopsy yields a certain diagnosis. Prevention: Very little is known about what causes the disease, or how to prevent it. Treatment: Surgery, radiation therapy and anti-cancer drugs are used to treat pancreatic cancer, but so far have had little influence on outcome. In 59% of cases, diagnosis is so late that none of these is used. Survival: Only 4% of patients live more than 3 years after diagnosis. The 2% of patients whose cancers occur in the insulin-producing cells, and not the duct cells of the pancreas tend to live longer; about 30% of these patients live more than 3 years after diagnosis. LEUKEMIA Incidence: An estimated 27,300 new cases in 1989, about half of them acute leukemia, and half of them chronic leukemia, Although it is often thought of as primarily a childhood disease, leukemia strikes many more adults (25,000 cases per year compared with 2,300 in children). Acute lymphocytic leukemia accounts for about 1,800 of the cases of leukemia among children, whereas in adults the most common types are acute granulocytic (about 8,000 cases annually), and chronic lymphocytic (9,6(N) cases annually). 1Vlortality: An es,timated 18,100 deaths in 1989. Warning Signals: Symptoms of acute leukemia in children can appear suddenly. Early signs may include fatigue, paleness, weight loss, repeated infections, easy bruising, nose bleeds or other hemorrhages. Chronic leukemia can progress slowly and with few symptoms. Risk Factors: Leukemia, a cancer of the bloodforming tissues, strikes both sexes and all ages. Causes of most cases are unknown. Individuals with Down's syndrome (mongolism) and certain other hereditary abnormalities have higher than normal incidence of leukemia. It has also been linked to excessive exposure to radiation and certain chemicals such as benzene. Early Detection: Leukemia may be difficult to diag- nose early because symptoms often appear to be those of other less serious conditions. When a physician does suspect leukemia, a diagnosis can be made through blood tests and am examination of bone marrow. Treatment: Chemotherapy is the most effective meth- od of treating leuk _mia. Today, continuing research in leading U.S. medird centers is yielding new and better drugs for treating leukemia patients. A variety of anti- cancer drugs are used, either in combinations or as single agents. To prevent persistence of hidden cells, therapy of the central nervous system has become standard treatment, especially in acute lymphocytic leukemia. Under appropriate conditions, bone marrow transplantation may be useful in the treatment of certain leukemias. When leukemia occurs, millions of abnormal, imma- ture white blood cells are released into the circulatory systems. These abnormal cells crowd out normal white cells to fight infection, platelets to control hemorrhaging and red blood cells to prevent anemia. Transfusions of blood components and antibiotics are used as supportive treatments. Survival: The overall, average 5-year survival rate for white patients with leukemia is 33%, due partly to very poor survival of patients with some types of leukemia such as acute granulocytic. The 5-year survival rate for black patients is 28%. Over the last 30 years, however, there has been a dramatic improvement in survival of patients with acute lymphocytic leukemia: From a 5- year survival of 4% for white males diagnosed in the early 1960's to 27% in the early 1970's to 46% around 1980; for white females diagnosed in the same time periods, from 3% to 29%a to 52%. In white children, the improvement has been from 4% to 68%. Moreover, in some medical centers, optimum treatment has raised survival of children with acute lymphocytic leukemia up to 75%. 14

FIVE-YEAR CANCER SURVIVAL RATES* FOR SELECTED SITES ORAL COLON- RECTUM PANCREAS LUNG MELANOMA FEMALE BREAST CERVIX UTERI IJTERI OVARY PROSTATE TESTIS BLADDER LEUKEMIA el% 0 20 60 : .. . . ..... . .. . kl % `'M ALL STAGES ® LOCALRED REG{ONAL 100 QDtSTANT `Adjusted for normal life expectancy. Source: Surveillance and Operations Research Branch, fhis chart is based on cases diagnosed in 1979-1984. National Cancer Institute. HOW TO ESTIMATE CANCER STATISTICS LOCALLY ommunity Population Estimated No. Who Are Alive, Saved from Cancer Estimated No. Cancer Cases Under Medical Care in 1989 Estimated No. Who Will Die of Cancer in 1989 Estimated No. of New Cases in 1989 Estimated No. Who Will Be Saved from Cancer in 1989 Estimated No. Who Will Eventually Develop Cancer Estimated No. Who Will Die of Cancer if Present Rates Continue 1,000 10 5 1 3 1 280 180 2,000 20 11 4 7 3 560 360 3,000 30 16 5 10 4 840 540 4,000 40 21 7 13 5 1,120 720 5,000 50 26 9 16 6 1,400 900 10,000 100 52 18 33 12 2,800 1,800 25,000 250 131 45 79 30 7,000 4,500 50,000 500 262 90 158 59 14,000 9,000 100,000 1,000 525 180 325 122 28,000 18,000 200,000 2,000 1,050 360 650 244. 56,000 36,000 500,000 5,000 2,625 900 1,575 590 140,000 90,000 NOTE: The figures can only be the roughest approximation of actual data for your community and should be used with caution. It is suggested that every effort be made to obtain actual data from a Registry source. 15

l. A N l. G K r A L i J A h U r i l, U K [ J j y b y CANCER BY AG E AN D RACE* BLACK AMERICANS A study of cancer rates over several decades shows that the cancer incidence rate for blacks is higher than for whites, and that the death rate is also higher. Over a 30-year period, black male cancer death rates rose by 77% compared to a 10% increase in black females. Incidence rates inn blacks also have increased in both males and females. The overall cancer incidence rate for blacks went up 27%, while for whites it increased 12%. Cancer mortality has increased in. both races, but the rate for blacks is greater than for whites. The rates were virtually the same 30 years ago. Since then, cancer death rates in whites have increased 10%, while black rates have increased almost 50%. Cancer sites where blacks had significantly higher increases in incidence and mortality rates included the lung, colon-rectum, prostate and esophagus. Esopha- geal cancer, long considered mainly a disease of males, remained about the same in whites and rose rapidly in blacks of both sexes. The incidence of invasive cancer of the uterine cervix dropped in both black and white women, although the incidence in blacks is still double that in whites. However, the rate for endometrial cancer-or cancer of the body of the uterus-for white women is almost double that of black women. Survival rates for patients diagnosed between 1974 and 1982 were compared for whites and blacks. More whites than blacks had cancer diagnosed in an early, localized stage when the chances of cure are best: 39% for whites versus 33% for blacks. In a survey done for the ACS by the Gallup Orga- nization in December 1987, the public's awareness and use of cancer tests was determined. The survey showed that 93% of white women knew of the Pap test and that 88% had had the test at some time, while 92% of black women knew of it and 79% had had it. For proctoscopic exams, 60% of the white population were aware of the procedure and 29% had had it at some time. For blacks, only 49% were aware of it and 22% had had it. THE ECONOMICALLY DISADVANTAGED A 1986 ACS Special Subcommittee report, "Cancer in the Economically Disadvantaged" found that cancer survival, and in some cases incidence, are related to socioeconomic factors such as the availability of health services. The report also found that ethnic differences in cancer are secondary to socioeconomic factors, and that there are higher rates of cancer mortality for patients of low socioeconomic status compared to those in higher brackets. Estimates suggest that at least half of the differences in survival rates are due to late diagnosis among economically disadvantaged patients, pointing up the need for more effective early detection programs and better access to treatment among this segment of the American population. HISPANIC-AMERICANS A recent ACS-sponsored report described Hispanic attitudes toward cancer, cancer risk reduction and early detection. The study, conducted for the Society by the firm of Clark, Mart;ire and Bartolomeo, Inc., underscored an urgent need for extensive cancer education and information programs directed to Hispanic-Americans. Survey findings shcwed that Hispanic-Americans are not adequately aware of most of the warning signals of cancer or of ways to reduce cancer risk, and that they tend not to seek early detection or treatment. The study identified the key psychological, cultural and economic barriers hindering the,fight against cancer in the Hispanic-American community. CHILDREN Incidence: An estimated 6,600 new cases in 1989, making it rare as a childhood disease. Common sites include the blood andd bone marrow, bone, lymph nodes, brain, nervous system, kidneys and soft tissues. Mortality: An estimated 1,800 deaths in 1989, about half of them from leukemia. Despite its rarity, cancer is the chief cause of death by disease in children between the ages of 3 and 14. Mortality has declined from 8.3 per 100,000 i~n 1950 to 3.5 in 1986. Early Detection: Cancers in children often are dif- ficult to recognize. Parents should see that their children have regular medical checkups, and be alert to any unusual symptoms that persist. They include: unusual mass or swelling; unexplained paleness and loss of energy; sudden tendency to bruise; persistent, localized pain or limping; prolonged, unezplained fever or illness; frequent headaches, often with vomiting; sudden eye or vision changes; and excessive, rapid weight loss. Some of the main childhood cancers are: Leukemia: See preceding section. Osteogenic Sarcoma and Ewing's Sarcoma are bone can- cers. There may be no pain at first, but swelling in the area of the tumor is often a first sign. 16

C A N C E R F A C T 5 A N D F 1 G U R E 5 1 9 8 9 CANCER BY AGE AND RACE Neurobtastoma can appear anywhere but usually in the abdomen, where a swell.irtg occurs. Rhabdomiiosarcoma, the most common soft tissue sarcoma, can occur in the head and neck area, genito- urinary area, trunk and extremities. Brain Czncers in early stages may cause headaches, blurred or double vision, dizziness, difficulty in walking or handling objects, and nausea. Lymphomcrs, and Hodgkin's Disease are cancers that involve the lymph nodes, and also may invade bone marrow and other organs. They may cause swelling of lymph nodes in the neck, armpit or groin. Other symptoms nnay include general weakness and possibly fever. RetinoblasEoma, or an eye cancer, usually occurs in' children under the age of four. When detected early, cure is possible with appropriate treatment. Wilms' Tumor, a kidney cancer, may be recognized by a swelling or lump in the abdomen. Treatment: Childhood cancers can be treated by a combination of therapies, coordinated by a team of experts. They include oncologic physicians, pediatric nurses, social workers, psychologists and others who assist children and their families. Survival: Five-year survival rates vary considerably, depending on the site. Among those for white children: bone cancer, 48%; neuroblastoma, 56%; brain and cen- tral nervous system, 56%; Wilms' tumor (kidney), 82%; and Hodgkin's disease, 91%. (Data for black children is insufficient.) 'Figures for carcer incidence are from the National Cancer Institute National Surveys, 1947, and the NCI SEER Program, 1973-1985; those for cancer mortality are from the National Center for Health Statistics, 1953-55 to 1983-85. TRENDS IN SURVIVAL BY SITE OF CANCER, BY RACE Cases Diagnosed in 1960-63, 1970-73, 1974-76, 1977-78, 1979-84 11 _ WHITE BLACK RELATIVE 5-YEAR SURVIVAL RELATIVE 5-YEAR SURVIVAL SITE 1960-631 1970-731 1974-762 1977-782 1979-84= 1960-63' 1970-731 1974-76z 1977-782 1979-842 All Sites 39% 43% 50% 50% 50% 27% 31% 38% 38% 37% Oral Cavity & Pharynx 45 43 54 53 54 - - 35 35 31 Esophagus 4 4 5 6 7 1 4 4 2 5 Stomach 11 13 14 15 16' 8 13 15 16 17 Colon 43 49 50 52 54' 34 37 45 44 49 Rectum 38 45 48 50 52' 27 30 40 40 34 Liver 2 3 4 3 3 - - 1 1 5 Pancreas 1 2 3 2 3 1 2 2 3 5 Larynx 53 62 66 69 66 - - 58 59 55 Lung & Bronchus 8 10 12 13 13' 5 7 11 10 11 Melanoma of Skin 60 68 78 81 80' - - 62## - 61iF Breast (females) 63 68 74 75 75' 46 51 62 62 62 Cervix Uteri 58 64 69 69 67 47 61 61 63 59 Corpus Uteri 73 81 89 87 83• 31 44 61 58 52* Ovary 32 36 36 37 37' 32 32 41 40 36 Prostate Gland 50 63 67 70 73' 35 55 56 64 60' Testis 63 72 78 86 91' - - 77ii - 82a Urinary Bladder 53 61 73 75 77' 24 36 47 53 57' Kidney & Renal Pelvis 37 46 51 50 51 38 44 49 54 53 Brain & Nervous System 18 20 22 23 23 19 19 27 24 31 Thyroid Gland 83 86 92 92 93 - - 88 92 95 Hodgkin's Disease 40 67 71 73 74' - - 67M 79# 69 Non-Hodgkin's iLymphoma 31 41 47 48 49• - - 47 46 49 Multiple Myeloma 12 19 24 24 24 - - 28 30 29 Leukemia 14 22 34 37 32 - - 30 31 27 Source: Surveillance snd Operations Research Branch, National Cancer Institute. ' Rates are based on IEnd Results Group data from a series of hospital registries and one population-based registry. I Rates are from the SEER Program. They are based on data from population-based registries in Connecticut, New Mexico, Utah, Iowa, Hawaii, Atlanta, Detroit, Seattle-Puget Souna' and San Francisco-Oakland. Rates are based on follow-up of patients through 1985. ° The difference in rates between 1974-76 and 1979-84 is statistically significant (p <.05). , fl The standard error of the survival rate is between 5 and 10 percentage points. i» The standard error of the survival rate is greater than 10 percentage points. -Valid survival rate could not be calculated. 17

C A N C E R F A C T S A N D F i G U R E S 1 9 8 9 PREVENTION PRIMARY PREVENTION REFERS TO STEPS THAT MIGHT BE TAKEN TO AVOID THOSE FACTORS THAT MIGHT LEAD TO THE DEVELOPMENT OF CANCER. SMOKING Cigarette smoking is responsible for 85% of lung cancer cases among men and 75% among women-about 83% overall. Smoking accounts for about 30% of all cancer deaths. Those who smoke two or more packs of cigarettes a day have lung cancer mortality rates 15 to 25 times greater than nonsmokers. SUNLIGHT Almost all of the more than 500,000 cases of non-melanoma skin cancer developed each year in the U.S. are considered to be sun-related. Recent epidemiological evidence shows that sun exposure is a major factor in the development of melanoma and that the incidence increases for those living near the equator. (See Selected Cancer Sites: Skin Cancer) ALCOHOL Oral cancer and cancers of the larynx, throat, esophagus, and• liver occur more frequently among heavy drinkers of alcohol. (See Selected Cancer Sites: Oral Cancer) SMOKELESS Increased risk factor for cancers of the mouth, larynx, throat, and esophagus. Highly habit TOBACCO forming. (See Selected Cancer Sites: Lung Cancer and Oral Cancer) ESTROGEN For mature women, certain risks associated with estrogen treatment to control menopausal symptoms, including an increased risk of endometrial cancer. Use of estrogen by menopausal women needs careful discussion by the woman and her physician. (See Selected Cancer Sites: Uterine Cancer) RADIATION Excessive exposure to radiation can increase cancer risk. Most medical X rays are adjusted to deliver the lowest dose possible without sacrificing image quality. The ACS believes there is a potential problem of radon in the home. If levels are found to be too high, remedial actions should be taken. OCCUPATIONAI. Exposure to a number of industrial agents (nickel, chromate, asbestos, vinyl chloride, etc.) I-iAZARDS increases risk. Risk factor greatly increased when combined with smoking. NUTRITION Risk for colon, breast and uterine cancers increases for obese people. High-fat diet may be a factor in the development of certain cancers such as breast, colon and prostate. High- fiber foods may help reduce risk of colon cancer, and can be a wholesome substitute for high-fat diets. Foods rich in vitamins A and C may help lower risk for cancers of larynx, esophagus, stomach and lung. Eating cruciferous vegetables may help protect against certain cancers. Salt-cured, smoked and nitrite-cured foods have been linked to esophageal and stomach cancer. The heavy use of alcohol, especially when accompanied by cigarette smoking or chewing tobacco, increases risk of cancers of the mouth, larynx, throat, esophagus, and liver. (See above) SECONDARY PREVENTION REFERS TO STEPS TO BE TAKEN TO DIAGNOSE A CANCER OR PRECURSOR AS EARLY AS POSSIBLE AFTER IT HAS DEVELOPED. COLORECTAL The ACS recommends three tests for the early detection of colon and rectum cancer in people TESTS without symptoms. The digital rectal examination, performed by a physician during an office visit, should be performed every year after the age of 40; the stool blood test is recommended every year after 50; and the proctosigmoidoscopy examination should be carried out every 3 to 5 years after the age of 50 following two annual exams with negative results. (See Selected Cancer Sites: Colon and Rectum Cancer) PAP TEST For cervical cancer, women who are or have been sexually active, or have reached age 18 years, should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of her physician. BREAST CANCER DETECTION The ACS recommends the monthly practice of breast self-examination (BSE) by women 20 years and older as a routine good health habit. Physical examination of the breast should be done every three years from ages 20-40 and then every year. The ACS recommends a mammogram every year for asymptomatic women age 50 and over, and a baseline mammo- gram between ages 35 and 39. Women 40 to 49 should have mammography every 1-2 years, depending on physical and mammographic findings. 28

C A N C E R F A C T S A N D F I G U R E S 1 9 8 9 PREVENTION CANCER-RELATED CHECKUP GUIDELINES Guidelines for the early detection of cancer in people without symptoms are recommended by the American Cancer So- iety as follows: A cancer-related checkup: • every 3 years for those 20-40 years of age. • every year for those 40 and over. The Society advises that you talk with your doctor. Ask how rhe guidelines apply to you. The checkup should always include health counseling (such as tips on quitting smoking) and examinations for cancer of the thyroid., testes, prostate, mouth, ovaries, skin and lymph nodes. In particular. • Ages 20-40-For breast cancer, an examination by a physician every three years, a self-exam every month, and one baseline breast X ray between the ages of 35 and 39. For i:ervical cancer, women who are or have been sexually active, or have reached age 18, should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be per- formed less frequently at the discretion of her physician. • Ages 40 and over-For breast cancer, a professional exam every year, a self-exam every month and a breast X ray every 1-2 years for those 40-49; every year for those 50 and over. For cervical cancer, women who are or have been sexually active, or have reached age 18 years, should have an annual Pap test and pelvic examination. After a women has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of her physician. For women at risk, an endometrial tissue sample at menopause should be taken. For colon and rectum cancer, a digital rectal exam every year after 40, and a stool blood test every year after 50 as well as a procto exam every 3-5 years after two initial negative tests one year apart. Some people are at higher risk for certain cancers and may need tests more frequently. (See pp. 9-14 for high risk factors.) COLORECTAL CANCER: EARLY DETECTION IS THE KEY When cancer of the colon and rectum is found and treated in an early, localized stage, the 5-year survival rate is 90% for colon cancer and 80% for rectal cancer. However, survival figures drop to 40% and 31%, re- spectively, after the cancer has started to spread to other parts of the body. Because colorectal cancer develops over a period of time, detection of the disease is possible long before symptoms appear. Early detection of small cancers and polyps reduces the likelihood of major surgery and the need for a coi~.ostomy-an abdominal opening created for the elimination of wastes. In fact, permanent colos- tomies are rare in cases of colon cancer, and are neces- sary in only l:i% of rectal cancer cases. Colorectal cancer is second only to lung cancer in terms of incidence. Currently, about 151,000 new cases develop each year; about 61,000 people die from the disease annually. The incidence of colorectal cancer tends to increase with age, starting at 40 years. More than 94% of all cases occur after the age of 50. Colorectal cancer occurs about equally in both sexes. Anyone with a personal or family history of colorectal cancer, polyps in the colon. or inflammatory bowel disease, is at particularly high risk for the disease and should be examined care ~ully. Evidence suggests that bowel cancer may be linked to a diet high in fat and/or low in fiber content. Projected `.i-year survival rates for colorectal cancer show that earl'.y detection saves lives. Currently, the 5-year survival'. rate is estimated at 55%. With the use of early detection techniques, such as the digital rectal exam, the stool blood test and sigmoidoscopy, and with appropriate ma.nagement, the survival rate for patients with colorectal cancer could be increased from 55% to 85%. This means that, over a period of time, 125,000 lives, versus the current 80,000, could be saved each year. It is recommended that the following procedures, all part of a cancer-related checkup, be performed at designated intervals: • A digital rectal examination every year after age 40. • A stool blood test every year after age 50. • A procto every three to five years after the age of 50, following two annual negative examinations. These guidelines apply only to people without symp- toms. Persons with rectal bleeding, cramping abdom- inal pain, or a change in bowel habits should see their physicians immediately. A 1987 study of men and women age 40 and over, conducted for the Society by the Gallup Organization, revealed a number of important findings concerning Americans' attitudes toward detection measures for colorectal cancer. There has been some increase in public awareness of the 3 tests recommended to detect the disease, but there is much room for improvement. The study found, for instance, that the percentage of Americans who ever had a digital rectal examination increased slightly since 1983, from 51% to 56%. Likewise, the percentage of Americans who ever had a stool blood test rose, from 28% in 1983 to 40% in 1987. And while the percentage of men and. women 50 and over .who ever had a proctoscopic examination rose from 31% in 1983 to 42% in 1987, 60% of Americans who should have the examination (according to the ACS guidelines) have not had it. The survey also showed that 24% of those individuals in the 40-plus age group have ever asked their doctor to examine their colon or rectum. And of this group, more than half did so only because something was bothering them. On the promising side, the survey showed that almost 50% of all Americans would be interested in learning more about this form of cancer. 19

C A N C E R F A C T S A N D F I G U R E S 1 9 8 9 PREVENTION BREAST CANCER: A PROGRAM OF ACTION About one cut of every 10 women in the United States will develop breast cancer during her lifetime. And until the disease ca)1 be prevented, the best way women can protect themselves is through early detection and prompt treatment. Today, with modern technologies, breast cancer can be detected at very early stages of development, when the chance of cure is highest. The risk of breast cancer increases as a woman grows older, and genetic and lifestyle variances-a history of breast cancer ir1 a close family relative, giving first birth after age 30, never giving birth, and obesity (body weight 40% above normal)-may increase risk further. The American Cancer Society recommends that women develop a three-part, personal plan of action, in cooperation with their doctors for early detection of breast cancer. (See page 19 for Checkup Guidelines.) A clinical breast exam should be performed by a doctor as part of a regular health checkup. This includes a visual inspection of the breasts, looking for changes in shape or size or skin dimpling, followed by a thor- ough inspection of the breast, chest and armpits. Women should ask their doctors how often they should have a clinical breast exam. A mammogram is a low-dose breast X ray that can identify cancers too small to be felt. Follow the ACS guidelines for recommended frequency, depending on age and health history. Recent improvements have reduced the amount of radiation necessary for high- quality mammograms. The Society recommends that all women over the age of 20 perform breast self-examination once a month. BSE is important because breast cancer symptoms may develop and be found between clinical breast exams or mammography. Through regular self-examination women become familiar with their breasts, making any changes more likely to be noticed. TOBACCO USE The American. Cancer Society estimates that cigarette smoking is respcnsible for 85% of lung cancer cases among men and 75% among women-about 83% overall. The cancer death rate for male cigarette smokers is more than double that of nonsmokers, and the rate for female smokers is 67% higher than for nonsmokers. The American Car cer Society estimates that 40% of male smokers and 28% of female smokers die prematurely, or about 35% overall. The higher ca nc:er rates for men reflect the fact that in the past, more men than women smoked, and smoked more heavily. In recent years, however, the gap between male and female smoking has been narrowing. Smoking also has been implicated in cancers of the mouth, pharynx, larynx, esophagus, pancreas, cervix uteri and bladder. Smoking accounts for about 30% of all cancer deaths, is a major cause of heart disease, and is linked to conditions ranging from colds and gastric ui<cers to chronic bronchitis and emphysema. Smoking is relai:ed to 390,000 deaths each year. A September 1985 study by the U.S. Congress Office of Technology Assessment estimates the cost of smoking to the economy from $38 billion to $95 billion, with a middle estimate of $65 billion. This amounts to $2.17 in lost productivity and the treatment of smoking- related diseases for each pack of cigarettes sold. A Decline in Smoking A September 198;' tobacco report of the U.S. Depart- ment of Agriculture estimates cigarette output in 1987 at 654 billion, down 1.0% from 1986, about the same decrease as the previous year. From 1976 to 198' 7, adult male smokers (20 years and older) dropped from 42% of the population to 33%, while women smokers decreased from 32% to 28%, according to the National Center for Health Statistics. Overall, the percentage of adult smokers in the population had dropped to 30%. A 1987 report from the Office of Smoking and Health says that 26.5% of Americans now smoke. Per capita cigarette consumption among adults has fallen-from 4,141 in 1974 to 3,121 in 1988-reflecting a growing number of ex-smokers. This is the lowest per capita consumption since 1944. From 1965 to 1987, the proportion of adult male ex-smokers (20 years and older) in the total U.S. population increased from 20% to 31%, while female ex-smokers rose from 8% to 19%. A survey supported by the National Institute on Drug Abuse indicated that the percentage of high school seniors (aged 17 and 18) who smoked cigarettes daily decreased from 29% in 1976 to 19% in 1987. It is now estimated-from past national surveys and data from the Cancer Prevention Study 11-that there are about 40 million ex-cigarette smokers in the U.S. today and about 50 million smokers. At the same time, however, the average smoker appears to be smoking more heavily. The U.S. Office on Smoking and Health reports that the proportion of adult male smokers (20 years and older) consuming 25 or more cigarettes per day increased from 30.7% to 32% between 1976 and 1985, and female smokers from 19.0% to 21%. Figures from the U.S. Department of Agriculture show that a total of 567 billion cigarettes were 'con- sumed in 1988, down from 575 billion in 1987. Nicotine Addiction The Surgeon General released a report on nicotine addiction in May 1988. The report points out that all tobacco products contain substantial amounts of nicotine. Nicotine is absorbed readily from tobacco smoke in the lungs and from smokeless tobacco in the mouth or nose, and is rapidly distributed throughout 20