Treating Cancer as a Public Health Problem
Bailar, John C.,, III, Issues in Science and Technology
As a result of the growth and aging of the U.S. population, more Americans died of cancer in 1999 than in any previous year. Yet mere numbers do not by any means reflect the true state of our war against cancer. I have long argued that cancer statistics can be quite misleading and that only an age-adjusted mortality rate--one that takes into account the growth and aging of the population--allows for fair comparisons between different populations and different years.
According to National Cancer Institute data that have been age-adjusted to reflect the composition of the U.S. population in 2000, mortality rates in the United States peaked in 1991. They then declined, albeit at less than 1 percent per year, throughout the 1990s. (The most recent available data are from 1999.)
Most of the recent declines have been for men. In 1984, age-adjusted mortality for all cancers in the United States combined was 210 per 100,000 population (275.1 in men and 170.5 in women). The rate reached a high of 215.4 in 1991 (279.1 in men and 175.6 for women) and then dipped to 202.8 in 1999 (252.6 in men and 169.6 in women). Very little further change occurred between 1998 and 1999, so it may be several years before we know if whether the tide of cancer deaths has truly turned.
Despite signs of progress, however, it is clear that we could be doing more to stem death rates from cancer. For many types of cancer, the reasons for the drop in mortality have yet to be uncovered, meaning that it will be difficult to accelerate the downward trend. For others, such as lung cancer, gains are distributed unevenly throughout the population. Here is a glimpse of how we are doing on some important cancer fronts, focusing on data from 1984, 1991, and 1999:
Lung cancer. Of all the changes in cancer mortality rates, the biggest is for in lung cancer mortality in men. It stood at 88.2 per 100,000 population in 1984, reached 89.9 in 1991, and then fell to 77.2 in 1999, a more than 14 percent decrease. This is quite clearly a result of the long anti-tobacco campaign, which caused many men to give up smoking cigarettes (or not to start) in the 1970s and 1980s. Unfortunately, many women began to smoke at about the same time; their increase in deaths from lung cancer (28.9 in 1984, 37.7 in 1991, and 40.7 in 1999) erases much of the gain in men. A worldwide commitment to reduce smoking in adults and to prevent children from starting would pay great dividends in many aspects of health, among them the fight against cancer.
Childhood cancers. Cancer in children and young adults (up to age 20) fell from 3.9 to 3.4 to 2.9. The drop has been substantial for every form of childhood cancer. The decline in cancer mortality in the U.S. population as a whole first began in persons under 20 and has been largest in young adults and children, with progressively smaller decreases in older and older age groups. (Indeed, cancer risks for the oldest Americans might actually be rising.) Of course, cancer in children is uncommon and has little effect on death rates in the population as a whole. But even so, despite much discussion and investigation, reasons for the greater success in treating cancer in children have not been firmly established. …