eTable 1. Hazard Ratios and 95% Confidence Intervals (CI) and Rates per 1 000 000 Person-Years by Study Group for All Children: Results for Singletons and Multiples
eTable 2. Hazard Ratios and 95% Confidence Intervals (CI) and Rates per 1 000 000 Person-Years Among IVF-Conceived Children by IVF Treatment Parameters
eTable 3. Hazard Ratios and 95% Confidence Intervals (CI) and Rates per 1 000 000 Person-Years Among IVF-Conceived Children by Indication for IVF
eTable 4. Descriptive Characteristics of the IVF and Non-IVF Study Populations Matched on Child’s Sex, State of Birth, Maternal Age, Race/Ethnicity, and Education
eTable 5. Hazard Ratios and 95% Confidence Intervals (CI) and Rates per 1 000 000 Person-Years by Study Group for the Matched Sample (eTable 4) of IVF and Non-IVF Children
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Spector LG, Brown MB, Wantman E, et al. Association of In Vitro Fertilization With Childhood Cancer in the United States. JAMA Pediatr. Published online June 01, 2019173(6):e190392. doi:10.1001/jamapediatrics.2019.0392
Is the incidence of childhood cancers among children conceived in vitro different than that among children conceived naturally?
In this population-based cohort study assembled by data linkage, the rate of hepatic tumors was significantly higher among children conceived via IVF than among children conceived naturally (hepatic tumor rate, 18.1 vs 5.7); the rates of other cancers did not differ between the 2 groups.
An association of conception by IVF with childhood cancer is small and limited to rare tumors; however, continued follow-up for cancer occurrence among children conceived via IVF is warranted.
In vitro fertilization (IVF) is associated with birth defects and imprinting disorders. Because these conditions are associated with an increased risk of childhood cancer, many of which originate in utero, descriptions of cancers among children conceived via IVF are imperative.
To compare the incidence of childhood cancers among children conceived in vitro with those conceived naturally.
Design, Setting, and Participants
A retrospective, population-based cohort study linking cycles reported to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System from January 1, 2004, to December 31, 2012, that resulted in live births from September 1, 2004, to December 31, 2013, to the birth and cancer registries of 14 states, comprising 66% of United States births and 75% of IVF-conceived births, with follow-up from September 1, 2004, to December 31, 2014. The study included 275 686 children conceived via IVF and a cohort of 2 266 847 children, in which 10 births were randomly selected for each IVF birth. Statistical analysis was performed from April 1, 2017, to October 1, 2018.
In vitro fertilization.
Main Outcomes and Measures
Cancer diagnosed in the first decade of life.
A total of 321 cancers were detected among the children conceived via IVF (49.1% girls and 50.9% boys; mean [SD] age, 4.6 [2.5] years for singleton births and 5.9 [2.4] years for multiple births), and a total of 2042 cancers were detected among the children not conceived via IVF (49.2% girls and 50.8% boys; mean [SD] age, 6.1 [2.6] years for singleton births and 4.7 [2.6] years for multiple births). The overall cancer rate (per 1 000 000 person-years) was 251.9 for the IVF group and 192.7 for the non-IVF group (hazard ratio, 1.17; 95% CI, 1.00-1.36). The rate of hepatic tumors was higher among the IVF group than the non-IVF group (hepatic tumor rate: 18.1 vs 5.7; hazard ratio, 2.46; 95% CI, 1.29-4.70); the rates of other cancers did not differ between the 2 groups. There were no associations with specific IVF treatment modalities or indication for IVF.
Conclusions and Relevance
This study found a small association of IVF with overall cancers of early childhood, but it did observe an increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility. Continued follow-up for cancer occurrence among children conceived via IVF is warranted.
In vitro fertilization (IVF) involves the ex vivo manipulation of both sexes’ gametes to achieve conception and accounted for 1.7% of US births in 2015.1 It is well established that IVF is associated with adverse pregnancy outcomes, including greater risks for preterm birth, lower birth weight, structural birth defects, and imprinting disorders.2-9 Because the latter 2 conditions confer excess risk of childhood cancer10-13 and because many childhood cancers originate in utero,14 describing the occurrence of cancer among children conceived by IVF is imperative.
We report the results of the linkage of the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System (SART CORS) to the birth and cancer registries of 14 states to create the largest cohort study to date and the first in the United States, to our knowledge, of the association of IVF with childhood cancer.
The SART CORS contains comprehensive data from more than 83% of all clinics providing IVF and 91% of all IVF cycles performed in the United States. Data were collected and verified by SART and reported to the Centers for Disease Control and Prevention in compliance with the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493).15 The society makes data available for research purposes to entities that have agreed to comply with SART research guidelines. Data are submitted by individual clinics and vouched for by the medical director of each clinic. Approximately 10% of the clinics are audited each year to validate the accuracy of reported data.16 The study was approved by the institutional review boards at Michigan State University, the University of Minnesota, the University of Michigan, and each participating state department of health (California, Colorado, Connecticut, Florida, Illinois, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, and Virginia). Patients undergoing assisted reproductive technology at SART-associated clinics sign clinical consent forms that include permission to use their deidentified data for research.
The states in this study had at least 1000 IVF births annually. States that agreed to participate and contributed data were California, Colorado, Connecticut, Florida, Illinois, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, and Virginia.
The SART CORS data are sufficient to link to state birth registries, which contain both maternal and child information, but not to cancer registries, which contain only child information. Therefore, the first linkage was between SART CORS data and birth registries. To maintain data quality and to ensure anonymity of the final linked file provided to the investigators, the SART CORS data were sent directly from the contract organization charged with maintaining these data (ie, Redshift Technologies Inc) to each participating state. Participating states were not provided with data on IVF treatment but only with a unique identifier created by Redshift Technologies Inc.
The encrypted, password-protected linkage file provided by SART CORS contained the names, dates of birth, social security numbers (when present), zip codes of residence, and approximate dates of delivery for all women who resided in each respective state with records of IVF cycles from January 1, 2004, to December 31, 2012, that resulted in a live birth. Because only mothers’ names, but not offspring’s names, were available in the SART CORS, cycles were linked to birth records based on mothers’ information by the health departments of the participating states using probabilistic record linkage. To achieve uniform results, states were encouraged to use Link Plus software published by the Centers for Disease Control and Prevention’s National Program of Cancer Registries; however, some states opted to use their existing proprietary code. Across all participating states, 91.8% of SART CORS records of live birth after IVF matched to a birth record. All live-born children from each birth, including multiple births, identified by the linkage were included in the resulting files (IVF births). Ten births resulting in live-born children were randomly selected from among those that did not link to SART CORS records (non-IVF births) to serve as comparison for each IVF birth.
The IVF birth files and non-IVF birth files were next concatenated for subsequent linkage to each state’s cancer registry. Children’s names, dates of birth, and sex obtained from birth registries were used to identify those with a diagnosis of malignant neoplasm during the follow-up period. Because the latest available years of cancer registry data varied, as did the timing of linkage, states had different years of follow-up from December 31, 2010, to December 31, 2014.
The final file was stripped of identifying information before being provided to the investigators. It contained the unique SART CORS woman and cycle identifiers, birth certificate variables (birth weight, gestational age, plurality, race/ethnicity, parental ages, and parental educational level), and cancer variables (text description of cancer, morphology and topography codes, age at diagnosis in months, staging information, and laterality). It further contained age at death if it occurred during infancy because infant deaths are routinely linked to births by vital statistics departments.17 These files were then merged by the investigators with the SART CORS data using the unique identifiers.
Cancers were categorized according to the International Classification of Childhood Cancers, third edition.18 All models were repeated for combined childhood cancers and for individual cancers with a minimum of 5 cases among the IVF group and non-IVF group, each with multiple and singleton births combined. Embryonal cancers, including neuroblastoma, retinoblastoma, Wilms tumor (nephroblastoma), hepatoblastoma, embryonal rhabdomyosarcoma, pulmonary and pleuropulmonary blastoma, medulloblastoma, primitive neuroectodermal tumors, medulloepithelioma, and atypical teratoid rhabdoid tumors, were also examined as a single tumor class. Intracranial embryonal tumors (medulloblastoma, primitive neuroectodermal tumors, and medulloepithelioma) were also included in the combined central nervous system tumors. When fewer than 10 cases of an individual tumor type occurred among the IVF group, we reported rates and relative risks for the general tumor class.
Statistical analysis was performed from April 1, 2017, to October 1, 2018. Data from each state were processed to generate a common data set. The only exclusions were as follows: a mother or father who was younger than 18 years or a nonviable birth (gestational age <22 weeks or birth weight <300 g even if indicated as a live birth). Because most independent variables were categorized, missing values were included as a separate category. The final population included 275 686 children in the IVF group (1 274 070 person-years; 209 586 births) and 2 266 847 children in the non-IVF group (10 596 144 person-years; 2 230 378 births). Person-years at risk were calculated as the time from birth to the earliest age at cancer diagnosis, age at death (if during infancy), or December 31 of the last year of complete cancer registry follow-up. We received dates as month and year. Therefore, we treated all observations as arriving at the middle of the month (0.5 months). When the month was not received (1 state), we treated the observation as arriving at the middle of the year (0.5 years).
We compared the incidence of childhood cancer between the IVF and non-IVF groups overall; in addition, we compared IVF treatment modalities (donor source, embryo state, use of intracytoplasmic sperm injection, assisted hatching, and day of transfer) and indication for IVF (male factor, diminished ovarian reserve, ovulation disorders, endometriosis, uterine factors, tubal factors, other, or unexplained) within the IVF group. Adjusted hazard ratios (HRs) and 2-sided 95% CIs were calculated by Cox proportional hazards regression using SAS, version 9.4 (SAS Institute Inc). P < .05 was considered significant. Covariates were selected a priori for inclusion based on established associations with childhood cancers19-23 and/or IVF24,25: sex, plurality (singleton or multiple births), maternal educational level (high school or less, some college, college graduate, or unknown), maternal race/ethnicity (white, black, native American, Asian, or unknown; Hispanic or not Hispanic), maternal age, and state of birth. Birth weight and gestational age were not adjusted for because they may lie on the causal pathway.
In a second analysis, we selected a 1:1 match between children in the IVF group and those in the non-IVF group who matched on sex, plurality (singleton or multiple birth), race/ethnicity, maternal age categories, maternal educational level, and state of birth. This analysis (141 959 singleton births and 48 821 children from multiple births in each group) is presented in eTable 5 in the Supplement.
We could not properly account for correlation within twin pairs because data on twinship were inconsistently provided by the states; hence, we reported all HRs among singleton births and multiple births separately as well as combined. The analyses, including multiple births, should be considered as providing valid estimates of the rates, while the 95% CIs are very slightly narrower than if we could account for twinship.
The characteristics of the IVF and non-IVF groups by plurality are presented in Table 1. Because of the large sample size, nearly all comparisons were significant, even if differences were small. The most notable differences reflected well-known attributes of IVF pregnancies.26 In particular, mothers whose children were conceived by IVF were substantially older (singleton births: mean [SD] age, 35.9 [5.0] vs 28.7 [5.9] years; multiple births: mean [SD] age, 35.2 [5.1] vs 30.3 [5.9] years), more educated (singleton births: college or postgraduate education, 73.4% vs 32.9%; multiple births: college or postgraduate education, 71.6% vs 40.0%), and more often white (singleton births, 82.5% vs 76.0%; multiple births, 84.2% vs 75.9%) than those of children conceived naturally; among both singletons and multiple births, children conceived by IVF had a mean (SD) lower birth weight (singleton births, 3264  vs 3315  g; multiple births, 2314  vs 2335  g) and shorter mean (SD) gestation (singleton births, 38.4 [2.3] vs 38.7 [2.0] weeks; multiple births, 35.1 [3.1] vs 35.2 [3.2] weeks) than those conceived naturally. The mean (SD) length of follow-up was 4.5 (2.5) years for singleton births conceived via IVF, 4.7 (2.5) years for singleton births conceived naturally, 4.7 (2.54) years for multiple births conceived via IVF, and 4.6 (2.6) years for multiple births conceived naturally.
There were 321 cancers detected among the IVF group and 2042 cancers among the non-IVF group (Table 2). The overall cancer rate (per 1 000 000 person-years) was 251.9 in the IVF group and 192.7 in the non-IVF group (HR, 1.17; 95% CI, 1.00-1.36). The rate of embryonal tumors was slightly higher among the IVF group (102.8 vs 70.4; HR, 1.28; 95% CI, 1.01-1.63), which seemed to be driven mainly by an elevated rate of hepatic tumors (18.1 vs 5.7; HR, 2.46; 95% CI, 1.29-4.70), most of which were hepatoblastoma. The results for singleton births and multiple births separately are presented in eTable 1 in the Supplement. The magnitude and direction of HRs seen in the matched subset are similar to those in the unmatched sample (eTables 4 and 5 in the Supplement); however, the 95% CIs are wider because of the smaller sample size.
There were no significant differences in the rate of either all cancers or embryonal tumors comparing children conceived by donor egg vs autologous egg, frozen embryos vs fresh embryos, use of intracytoplasmic sperm injection vs none, assisted hatching vs none, and day 2 to 3 embryo transfer vs day 5 to 6 embryo transfer (eTable 2 in the Supplement). Similarly, there was no difference in the rate of either all cancers or embryonal tumors by indication for IVF (eTable 3 in the Supplement).
These findings are from the first cohort study of the association between IVF and the risk of childhood cancer in the United States, and it is the largest cohort published to date. We observed little evidence of excess risk of most cancers comparing children conceived by IVF with children conceived naturally. There was a significant 28% increase in the rate of embryonal tumors as a class, which seemed to be due to the elevated risk of hepatic tumors, most of which were hepatoblastoma. We estimated that an excess of 8 embryonal cancer cases would occur between birth and 5 years of age among the 68 000 children conceived via IVF who were born in 201316 if the higher rates applied. However, because we were not able to compare the risk of cancer in children conceived via IVF with the risk in children of subfertile women who did not undergo IVF, we cannot attribute the observed small elevated risks to IVF itself rather than the underlying causes of infertility.
Our results both contrast and concur with those of several relevant studies. A meta-analysis that compiled 9 studies of IVF and childhood cancer published through 2012 reported a significant increased risk of overall cancer (relative risk, 1.33; 95% CI, 1.02-1.98), including leukemia, central nervous system cancers, neuroblastoma, and other solid cancers.27 We did not detect associations as pervasive or as large, nor did 2 prospective studies conducted in the United Kingdom28 and Nordic countries.29 Because the meta-analysis included mainly case-control studies with few exposed cases, prospective studies with few exposed children, and several hypothetical cohorts, it must be considered that their results may be due to systematic bias.
The UK and Nordic studies were conducted with methods more comparable to our study. Williams et al28 linked 106 381 records of nondonor IVF identified by the UK Human Fertilisation and Embryology Authority between 1992 and 2008, inclusive, to the National Registry of Childhood Tumours. Observed cancers were compared vs the number expected based on population rates to produce standardized incidence ratios. An important difference between the study by Williams et al28 and our study is our inclusion of a comparison cohort of children not conceived via IVF with covariates available for statistical adjustment. Two cancers in the UK study had a significantly higher incidence than in each study’s reference population: hepatoblastoma (standardized incidence ratio, 3.27; 95% CI, 1.20-7.12), which appeared to be associated specifically with low birth weight (≤2500 g, a known, strong risk factor for this tumor30), and rhabdomyosarcoma (standardized incidence ratio, 2.62; 95% CI, 1.26-4.82).28 We similarly detected increased rates of hepatic tumors, which are composed largely of hepatoblastoma, and soft tissue sarcomas, which are composed largely of rhabdomyosarcoma. The study by Williams et al28 included cancers diagnosed in individuals up to 15 years of age vs our study, in which the longest follow-up attained was 8 years. Another difference between studies is the possibility of changing clinical practices in IVF treatment during the 17-year inclusion period in the study by Williams et al.28
The Nordic study linked 91 796 children conceived via IVF and 358 419 children conceived naturally with records in the population-based birth and cancer registries of Denmark, Finland, Norway, and Sweden during the period from 1982 to 2007.29 Similar to our study, statistical adjustment was made for covariates, but the Nordic study covered a 25-year time span and had a longer mean follow-up of 9.5 years, as well as an unambiguous length of follow-up. In vitro fertilization was not associated with either overall cancers (HR, 1.08; 95% CI, 0.91-1.27) or most specific cancers; however, central nervous system tumors (HR, 1.44; 95% CI, 1.01-2.05) and combined carcinomas (HR, 2.03; 95% CI, 1.06-3.89) were significantly more prevalent.
In our study, we observed an increased risk mainly of embryonal cancers, which was a hypothesis at the outset of the study because IVF has previously been associated with epigenetic disruption. Large offspring syndrome occurs after in vitro embryo culture of ruminant animals31 and is characterized by multilocus loss of imprinting.32 Beckwith-Wiedemann syndrome is a human analogue of large-offspring syndrome33 that occurs more frequently in children conceived by intracytoplasmic sperm injection34,35 and that predisposes children especially to embryonal tumors, including hepatoblastoma.13,36 Excess occurrence of Beckwith-Wiedemann syndrome among children conceived via IVF could be one mechanism to explain a portion of the excess risk of embryonal tumors in our study. However, no information on Beckwith-Wiedemann syndrome among children conceived via IVF was available to assess this possibility.
This data set presents a strong foundation in which to examine the risk of childhood cancer after IVF. The SART CORS represents the single largest source of data available for linkage in the United States. Participating state departments of health matched approximately 85% of the records supplied by the SART CORS, and participating states represented 66% of US births and 75% of IVF-conceived births during the study period. Critical covariates recorded with high validity by birth registries37 were available for multivariate analysis.
Several weaknesses of the data set must also be considered. A common problem in observational studies is unmeasured confounders. As can be seen in Table 1, mothers who conceived via IVF were more likely to be white, non-Hispanic, more educated, and older than the mothers who conceived naturally. These differences may be indicative of unmeasured confounders, such as income, medical insurance, and prenatal care, which may affect the risk of adverse perinatal outcomes and the risk of childhood cancer. Although race, ethnicity, educational level, and age were included in the models, it is not possible to estimate the effect of unmeasured confounders on the HRs. However, the analysis in eTable 5 in the Supplement that matched on race, educational level, age, and state produced similar HRs but wider 95% CIs owing to the smaller sample size.
We could not account for non-IVF treatments for infertility, such as intrauterine insemination or ovulation induction, although their prevalence in the non-IVF cohort would be small (about 4% in a nationally representative survey38). We also had no way to detect when children moved out of participating states or died after infancy, with the result that person-time in our study may be slightly overestimated. A small number of cancer cases may also have not been detected, although, because childhood cancer is very rare, this is likely not a large problem. Overestimation of person-time would lead to underestimation of absolute cancer rates, but so long as denominator error did not differ by group, it should not have biased the HRs. We have no data available to assess this contention but note that gross person-time misspecification particular to children conceived via IVF would have been required to produce effects of the size observed.
Although we controlled for several potential confounders, the IVF and non-IVF groups may have varied in unmeasured ways. We were unable to account for Beckwith-Wiedemann syndrome or structural birth defects, which were also associated with both IVF and an increased risk of childhood cancer.10,11 It is common to all studies of sequelae of IVF that observed risks cannot easily be separated from the underlying causes of infertility.39 A large Scandinavian study found about a 20% increased rate of childhood cancer among offspring of women who had ever been evaluated for infertility,40 and the TP53 gene that, when mutated, causes the cancer-predisposing Li-Fraumeni syndrome has also been implicated in the regulation of fertility.41 Although our study had the largest number of children conceived via IVF followed up for cancer occurrence, to date, the absolute number of observed cancers was relatively small, and the association of IVF with especially rare types of cancer was not evaluable. Follow-up was shorter in our study than in 2 comparable studies28,29; however, it was long enough to capture many of the cancers that occur prior to 5 years of age. We did not adjust for multiple comparisons.
We found, at most, a small, marginally significant association between IVF and overall cancer in childhood. We found no association of specific modes of IVF treatment or indication for IVF with overall cancer or embryonal tumors. Although we observed increased rates of embryonal cancers, particularly hepatic tumors, these cancers remained rare in absolute terms. We also could not attribute the increased rate to treatment per se rather than to underlying infertility. Despite the large size of the study, these results do not definitively establish an association between IVF and embryonal tumors. These results suggest that continued follow-up of children conceived via IVF for cancer occurrence is warranted, while other approaches to understanding potential mechanisms should also be pursued, for instance, by comparing the somatic epigenetic landscape of tumors in children conceived via IVF with children conceived naturally.
Accepted for Publication: January 29, 2019.
Corresponding Author: Logan G. Spector, PhD, Division of Epidemiology/Clinical Research, Department of Pediatrics, University of Minnesota, 420 Delaware St, SE, MMC 715, Minneapolis, MN 55455 (firstname.lastname@example.org).
Published Online: April 1, 2019. doi:10.1001/jamapediatrics.2019.0392
Author Contributions: Drs Brown and Luke had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Spector, Brown, Luke.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Spector, Brown, Letterie, Luke.
Critical revision of the manuscript for important intellectual content: Brown, Wantman, Letterie, Toner, Doody, Ginsburg, Williams, Koch, Schymura, Luke.
Statistical analysis: Spector, Brown, Luke.
Obtained funding: Spector, Luke.
Administrative, technical, or material support: Spector, Wantman, Letterie, Toner, Williams, Koch, Schymura, Luke.
Supervision: Spector, Letterie.
Conflict of Interest Disclosures: Dr Spector reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Brown reported receiving a grant from the National Institutes of Health. Dr Wantman reported serving as a contractor for the Society for Assisted Reproductive Technology outside the submitted work. Dr Luke reported receiving personal fees from the Society for Assisted Reproductive Technology outside the submitted work and reported receiving a grant from the National Institutes of Health. No other disclosures were reported.
Funding/Support: The study was supported by award number R01 CA151973 from the National Cancer Institute, National Institutes of Health.
Role of the Funder/Sponsor: The funding source 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; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.
Additional Contributions: We thank the Society for Assisted Reproductive Technology and all of its members for providing clinical information to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database for use by patients and researchers. Without the efforts of our members, this research would not have been possible. We also wish to acknowledge the help and expertise of each agency of participating states as follows. All analyses, interpretations, and conclusions are the authors’ and not those of data contributors. California: California birth data were supplied by the California Department of Public Health Office of Health Information and Research (CDPH/HIRS). California Cancer Registry data were obtained through the California Cancer Reporting and Epidemiologic Surveillance (CalCARES) Program, Institute for Population Health Improvement, University of California Davis Health. Technical descriptions of the data are consistent with those provided by CalCARES/HIRS. Colorado: Colorado birth and cancer data were supplied by the Colorado Department of Public Health and Environment. Connecticut: Connecticut birth and cancer data were supplied by the Office of Vital Records and the Connecticut Tumor Registry at the Connecticut Department of Public Health (DPH). This study was approved by the DPH Health Investigation Committee. Certain data used in this study were obtained from the DPH. Florida: Florida birth and cancer data were supplied by the Florida Department of Health. Illinois: Illinois birth and cancer data were provided by the Illinois DPH, Springfield, Illinois. Massachusetts: Massachusetts birth and cancer data were supplied by the Massachusetts Pregnancy to Early Life Longitudinal Data System and the Massachusetts Cancer Registry, Massachusetts DPH. Michigan: Michigan birth and cancer data were supplied by the Division for Vital Records and Health Statistics, Michigan Department of Health and Human Services. New York: New York state birth data were supplied by the Vital Statistics Unit, Bureau of Health Informatics, New York State Department of Health. Birth data for New York City were derived from data provided by the Bureau of Vital Statistics, New York City Department of Health and Mental Hygiene to the state. Cancer data were supplied by the New York State Cancer Registry, New York State Department of Health. New Jersey: New Jersey birth and cancer data were supplied by the Bureau of Vital Statistics and Registration, New Jersey Department of Health, and the New Jersey State Cancer Registry, The Cancer Institute of New Jersey, with linkage performed by Xiaoling Niu, MS. Cancer Epidemiology Services, including the New Jersey State Cancer Registry, receives support from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute under contract HHSN 261201300021I and control No. N01PC-2013-00021, the National Program of Cancer Registries, Centers for Disease Control and Prevention under cooperative agreement 5U58DP003931-02, the State of New Jersey, and the Rutgers Cancer Institute of New Jersey. Linkage was conducted by Ji Lie, MPH. North Carolina: Birth and cancer data were supplied by the Vital Statistics team and the Central Cancer Registry Branch of the State Center for Health Statistics. Linkage was conducted by Gary Y. Leung, PhD. We thank Dr Leung for sharing his linkage programming with other study states. Ohio: Ohio birth data were supplied by the Bureau of Vital Statistics, Ohio Department of Health. Ohio cancer data were supplied by the Ohio Cancer Incidence Surveillance System at the Ohio Department of Health, a cancer registry partially supported by the National Program of Cancer Registries at the Centers for Disease Control and Prevention. Use of these data does not imply that the Ohio Department of Health or Centers for Disease Control and Prevention agrees or disagrees with the analyses, interpretations, or conclusions in this publication. Pennsylvania: Pennsylvania birth and cancer data were supplied by the Bureau of Health Statistics & Registries, Pennsylvania Department of Health, Harrisburg, Pennsylvania. Texas: Texas birth and cancer data were supplied by the Center for Health Statistics and the Texas Cancer Registry of the Texas Department of State Health Services. Virginia: Virginia birth and cancer data were supplied by the Virginia Department of Health.
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