Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010 | Breast Cancer | JAMA Oncology | JAMA Network
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    1 Comment for this article
    Disparities in the Improvement of Survival for Major Cancers
    Kailin Yang, PhD | Cleveland Clinic Lerner College of Medicine
    The study by Zeng and colleagues (1) systematically analyzed the survival of patients with seven major types of solid tumors, using a dataset from 1990 to 2009 from the Surveillance, Epidemiology, and End Results (SEER) program by National Cancer Institute (NCI). They argued that younger patients and those diagnosed from 2005-2009 benefited the most from recent advances in cancer treatment. However, one major concern with this study is the underestimation of lead-time bias when reaching the above conclusion. During the past two decades, novel diagnostic test and imaging modality have greatly improved the detection of cancer at early stage. Therefore, a higher proportion of latent and slow-growing tumors would be included in recent time periods such as 2005-2009.Taking prostate cancer as an example, the wide application of prostate specific antigen (PSA) testing since the 1990s has resulted in significant downward stage and grade migration (2,3). Lead-time bias caused by PSA testing is estimated to be as high as 12 years (4), according to the European Randomized Study of Screening for Prostate Cancer (ERSPC). Such change would generate a high risk of overdiagnosis and overtreatment, especially in men who would otherwise have no clinical symptoms during their lifetime. Because survival rate by cancer-specific death was used as the major outcome in this study, the presence of a higher percentage of early stage patients and those with low potential to progress clinically in the cohort of recent time period would confound data interpretation. Although the SEER program has crude information for tumor characteristics (for example, tumor grade and histology were used for adjustment in prostate cancer), these factors might not be sensitive enough to correct for lead-time bias, given the wide range of molecular complexity between tumors of low and high risks. Demographic changes among the 9 SEER registries might further confound the analysis in this study. The authors corrected for SEER registry site, race, sex, and marital status when calculating hazard ratios. However, information such as body mass index or other comorbidities were not collected. Since 1990, the prevalence of overweight and obesity has dramatically increased in the United States (5), and higher BMI is known to be associated with higher cancer incidence especially for breast and colon cancers. Similarly, the evolution of clinical management for other comorbidities linked to cancer, such as diabetes or chronic inflammation, might also contribute to the improved cancer survival seen in this study.


    1. Zeng C, Wen W, Morgans AK, Pao W, Shu X-O, ZHeng W. Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010. JAMA Oncology. 2015;1(1):88-96.

    2. Catalona WJ, Smith DS, Ratliff TL, Basler JW. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA. 1993;270(8):948-954.

    3. Moore AL, Dimitropoulou P, Lane A, et al. Population-based prostate-specific antigen testing in the UK leads to a stage migration of prostate cancer. BJU Int. 2009;104(11):1592-1598.

    4. Draisma G, Boer R, Otto SJ, et al. Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst. 2003;95(12):868-878.

    5. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.

    Original Investigation
    April 2015

    Disparities by Race, Age, and Sex in the Improvement of Survival for Major Cancers: Results From the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010

    Author Affiliations
    • 1Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, Tennessee
    • 2Division of Hematology and Oncology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
    JAMA Oncol. 2015;1(1):88-96. doi:10.1001/jamaoncol.2014.161

    Importance  Substantial progress has been made in cancer diagnosis and treatment, resulting in a steady improvement in cancer survival. The degree of improvement by age, race, and sex remains unclear.

    Objective  To quantify the degree of survival improvement over time by age, race, and sex in the United States.

    Design, Setting, and Participants  Longitudinal analyses of cancer follow-up data from 1990 to 2010, from 1.02 million patients who had been diagnosed as having cancer of the colon or rectum, breast, prostate, lung, liver, pancreas, or ovary from 1990 to 2009 and who were included in 1 of 9 population-based registries of the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

    Main Outcomes and Measures  Hazard ratios (HRs) and 95% CIs for cancer-specific death were estimated for patients diagnosed as having any of these cancers during 1995 to 1999, 2000 to 2004, and 2005 to 2009, compared with those diagnosed in 1990 to 1994.

    Results  Significant improvements in survival were found for cancers of the colon or rectum, breast, prostate, lung, and liver. Improvements were more pronounced for younger patients. For patients aged 50 to 64 years and diagnosed from 2005 to 2009, adjusted HRs (95% CIs) were 0.57 (95% CI, 0.55-0.60), 0.48 (95% CI, 0.45-0.51), 0.61 (95% CI, 0.57-0.69), and 0.32 (95% CI, 0.30-0.36), for cancer of the colon or rectum, breast, liver, and prostate, respectively, compared with the same age groups of patients diagnosed during 1990 to 1994. However, the corresponding HRs (95% CIs) for elderly patients (those 75-85 years old) were only 0.88 (95% CI, 0.84-0.92), 0.88 (95% CI, 0.82-0.95), 0.76 (95% CI, 0.69-0.84), and 0.65 (95% CI, 0.61-0.70), for the same 4 cancer sites, respectively. A similar, although weaker, age-related period effect was observed for lung and pancreatic cancers. The adjusted HRs (95% CIs) for lung cancer were 0.75 (95% CI, 0.73-0.77) and 0.84 (95% CI, 0.81-0.86), respectively, for patients aged 50 to 64 years and 75 to 85 years diagnosed between 2005 and 2009, compared with the same age groups of patients diagnosed between 1990 and 1994 (0.73 [95% CI, 0.69-0.77] and 0.90 [95% CI, 0.85-0.95], respectively. Compared with whites or Asians, African Americans experienced greater improvement in prostate cancer survival. From 1990 to 2009, ovarian cancer survival declined among African Americans but improved among whites. No apparent sex difference in the degree of improvement for any non–sex-specific cancer was noted.

    Conclusions and Relevance  Younger patients experienced greater benefit from recent oncology advances than elderly patients. African Americans experienced poorer survival than whites for all cancers, and the racial difference decreased for prostate cancer but increased for ovarian cancer. Identifying factors associated with varied improvement in cancer survival can inform future improvements in cancer care for all.