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Figure.
Annual Percent Change (APC) in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years in the United States by Race, 1970-2014
Annual Percent Change (APC) in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years in the United States by Race, 1970-2014

Lines were fitted according to the Joinpoint Regression Program (National Cancer Institute), version 4.4.0.0, which uses permutation analysis to fit a series of straight lines on a logarithmic scale to observed rates, indicated by circles; up to 4 joinpoints (5 line segments) were allowed.

aThe APC is statistically significantly different from 0 (2-sided P < .05), based on the permutation method.

bAge-adjusted to the 2000 US standard population.

Table.  
Trends in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years by Race and Age in the United States, 1970-2014a
Trends in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years by Race and Age in the United States, 1970-2014a
1.
Siegel  RL, Fedewa  SA, Anderson  WF,  et al.  Colorectal cancer incidence patterns in the United States, 1974-2013.  J Natl Cancer Inst. 2017;109(8).PubMedGoogle Scholar
2.
Austin  H, Henley  SJ, King  J, Richardson  LC, Eheman  C.  Changes in colorectal cancer incidence rates in young and older adults in the United States: what does it tell us about screening.  Cancer Causes Control. 2014;25(2):191-201.PubMedGoogle ScholarCrossref
3.
Mokdad  AH, Dwyer-Lindgren  L, Fitzmaurice  C,  et al.  Trends and patterns of disparities in cancer mortality among US counties, 1980-2014.  JAMA. 2017;317(4):388-406.PubMedGoogle ScholarCrossref
4.
Surveillance Epidemiology, and End Results Program.  SEER*Stat database. http://seer.cancer.gov/mortality. Accessed June 29, 2017.
5.
Fedewa  SA, Sauer  AG, Siegel  RL, Jemal  A.  Prevalence of major risk factors and use of screening tests for cancer in the United States.  Cancer Epidemiol Biomarkers Prev. 2015;24(4):637-652.PubMedGoogle ScholarCrossref
6.
Eddy  D.  Cancer of the colon and rectum.  CA Cancer J Clin. 1980;30(4):208-215.Google ScholarCrossref
Research Letter
August 8, 2017

Colorectal Cancer Mortality Rates in Adults Aged 20 to 54 Years in the United States, 1970-2014

Author Affiliations
  • 1Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
JAMA. 2017;318(6):572-574. doi:10.1001/jama.2017.7630

Colorectal cancer (CRC) incidence has been increasing in the United States among adults younger than 55 years since at least the mid-1990s,1 with the increase confined to white men and women and most rapid for metastatic disease.2 Although CRC mortality is declining overall,3 trends for all ages combined mask patterns in young adults, which have not been comprehensively examined. We analyzed CRC mortality among persons aged 20 to 54 years by race from 1970 through 2014.

Methods

This study did not require institutional review board approval based on guidelines from the National Human Research Protections Advisory Committee because it was based on government-issued, deidentified, public use data. CRC mortality rates per 100 000 population (age-adjusted to the 2000 US standard population) from 1970 through 2014 were obtained from SEER*Stat (National Cancer Institute), version 8.3.4, for decedents who were aged 20 to 54 years, as reported by the National Center for Health Statistics (NCHS).4 NCHS mortality data are based on the underlying cause of death reported on death certificates filed in all 50 states and the District of Columbia reflecting more than 99% of deaths. Deaths were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes 153, 154, and 159 during 1970-1998 and ICD-10 codes C18 to C20 and C26 during 1999-2014. Rates were stratified by race (black, white, and other) and age (20-29, 30-39, 40-49, and 50-54 years). Trends were quantified using the Joinpoint Regression Program (National Cancer Institute), version 4.4.0.0, which uses permutation analysis to fit a series of straight lines on a logarithmic scale to observed rates to estimate annual percent change (APC), resulting in trends of variable length. Trends were only described as increasing or decreasing when the APC was significantly different from 0 (P < .05) using a 2-sided test.

Results

During 1970-2014, 242 637 people aged 20 to 54 years died from CRC at a median age of 49 years (interquartile range, 44-52). Decedents were 54% male, 80% white, 17% black, and 3% other race. CRC mortality rates per 100 000 population among individuals aged 20 to 54 years declined from 6.3 in 1970 to 3.9 in 2004, then increased by 1.0% annually (95% CI, 0.7% to 1.4%) to 4.3 in 2014 (Figure). The increase was confined to white individuals, among whom mortality rates increased by 1.4% annually (95% CI, 1.1% to 1.8%), from 3.6 in 2004 to 4.1 in 2014. Among black individuals, mortality rates declined by 0.4% annually (95% CI, −0.6% to −0.3%) to 1.1% annually (95% CI, −1.5% to −0.7%), from 8.1 in 1970 to 6.1 in 2014. Among other races combined, mortality rates declined from 1970-2006 and were stable thereafter.

In age-stratified analyses, mortality trends in white individuals during the most recent period defined by joinpoint were stable for those aged 20 to 29 years from 1988-2014, but increased by 1.6% annually (95% CI, 1.2% to 2.1%) for those aged 30 to 39 years from 1995-2014, by 1.9% annually (95% CI, 1.2% to 2.5%) for those aged 40 to 49 years, and by 0.9% annually (95% CI, 0.1% to 1.6%) for those aged 50 to 54 years from 2005-2014 (Table). In contrast, rates in black individuals decreased over the entire study period among those aged 20 to 49 and since 1993 among those aged 50 to 54 years.

Discussion

CRC mortality rates decreased since 1970 in black individuals aged 20 to 54 years, but increased in white individuals since 1995 among those aged 30 to 39 years and since 2005 among those aged 40 to 54 years following decades of decline. These trends are consistent with CRC incidence from 1998-2009 among those younger than 50 years, which was stable in black individuals, but increased in white individuals by 1.5% annually for local-stage and regional-stage disease and by 3% annually for distant-stage disease.2 Disparate racial patterns conflict with trends in major CRC risk factors like obesity, which are similar in white and black individuals.5

Although 5-year survival in persons aged 15 to 64 years has improved,3 mortality is a function of incidence and survival and can increase if increased CRC occurrence is of sufficient magnitude to outweigh improvements in survival. Increased mortality is particularly unexpected among those aged 50 to 54 years, for whom screening has been recommended since the 1970s.6

This study is limited by its ecologic nature and inaccuracies in about 5% of all death certificates listing CRC as the underlying cause of death. Escalating mortality rates in young and middle-aged adults highlight the need for earlier CRC detection through age-appropriate screening and more timely follow-up of symptoms.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: May 26, 2017.

Correction: This article was corrected to remove an erroneous citation number on August 31, 2017.

Corresponding Author: Rebecca L. Siegel, MPH, 250 Williams St NW, 6D302, Atlanta, GA 30303 (rebecca.siegel@cancer.org).

Author Contributions: Mss Siegel and Miller had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Siegel.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Miller.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Siegel, Miller.

Supervision: Jemal.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was funded by the American Cancer Society.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

References
1.
Siegel  RL, Fedewa  SA, Anderson  WF,  et al.  Colorectal cancer incidence patterns in the United States, 1974-2013.  J Natl Cancer Inst. 2017;109(8).PubMedGoogle Scholar
2.
Austin  H, Henley  SJ, King  J, Richardson  LC, Eheman  C.  Changes in colorectal cancer incidence rates in young and older adults in the United States: what does it tell us about screening.  Cancer Causes Control. 2014;25(2):191-201.PubMedGoogle ScholarCrossref
3.
Mokdad  AH, Dwyer-Lindgren  L, Fitzmaurice  C,  et al.  Trends and patterns of disparities in cancer mortality among US counties, 1980-2014.  JAMA. 2017;317(4):388-406.PubMedGoogle ScholarCrossref
4.
Surveillance Epidemiology, and End Results Program.  SEER*Stat database. http://seer.cancer.gov/mortality. Accessed June 29, 2017.
5.
Fedewa  SA, Sauer  AG, Siegel  RL, Jemal  A.  Prevalence of major risk factors and use of screening tests for cancer in the United States.  Cancer Epidemiol Biomarkers Prev. 2015;24(4):637-652.PubMedGoogle ScholarCrossref
6.
Eddy  D.  Cancer of the colon and rectum.  CA Cancer J Clin. 1980;30(4):208-215.Google ScholarCrossref
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