Trends in Cause-Specific Mortality by Race and Hispanic Origin, 1999–2019

Neoplasms

In 2019, neoplasms (cancers) were the second most common cause of death after circulatory system diseases, accounting for at least one-fifth of all deaths. This section examines the 15 neoplastic disease subcategories listed in Box 3.

Chart 14 shows the number and percentage distribution of cancer deaths by subcategory in 1999 and 2019, with detail by RE group and age. The composition of cancer deaths among males and females differs substantially (not shown). For females at all ages, breast cancer is a leading cause of cancer deaths. For males, however, breast cancer is a negligible subcategory. For instance, in 2019, breast cancer caused 467 deaths among men and 42,281 deaths among women. Moreover, although neoplasms of the genital organs represent a sizable subcategory of neoplastic mortality among males, prostate cancer typically develops slowly and has a much later age of onset than cervical, uterine, and ovarian cancers. As a result, among people aged 25–64, neoplasms of the genital organs account for a significantly larger share of cancer deaths in women than men, while the opposite is true at older ages. For example, cancer of the genital organs in 2019 accounted for 19.0 percent and 12.6 percent of all cancer deaths, respectively, among Black men and women aged 65 or older. At ages 25–64, however, this cause accounted for 7.9 percent of cancer deaths in Black men, but 14.7 percent among Black women.

At ages 0–24, the three subcategories that accounted for the highest shares of cancer deaths were neoplasms of lymphoid, hematopoietic, and related tissue (such as leukemia and lymphoma); neoplasms of the eye, brain, and other parts of the central nervous system; and the residual “all other cancers” subcategory. In 2019, neoplasms of lymphoid, hematopoietic, and related tissue caused almost one-third of cancer deaths among Hispanic individuals aged 0–24 and about one-quarter of cancer deaths at those ages in the other RE groups. The shares of cancer deaths at ages 0–24 that were caused by neoplasms of the eye, brain, and nervous system ranged from 19.2 percent in the Hispanic population to 24.9 percent among WNH individuals in 2019. Also in 2019, the shares of neoplasm deaths at ages 0–24 that were attributed to the “all other cancers” subcategory ranged from 28.9 percent among Hispanic people to 36.7 percent in the API community.

At ages 65 or older, neoplasms of the organs of the respiratory system (lung cancers) were the leading cause of cancer deaths in every RE group and both sexes. At ages 25–64, breast cancer was the leading cause of neoplasm death in 2019 for Black, Hispanic, and API women; but for WNH women, lung cancer caused a higher percentage of cancer deaths. Cancers of the genital organs were the second leading cause of neoplastic death at ages 25–64 for API and Hispanic women and the third leading cause of cancer death among Black and WNH women. Neoplasms of the liver were the second leading cause of cancer death among API and Hispanic men aged 25–64. Several cancer subcategories encompass one or more of the components of the digestive system, such as neoplasms of the liver and intrahepatic bile ducts, neoplasms of the pancreas, and neoplasms of the colon. Another of these subcategories comprises neoplasms of “other organs of the digestive system” (which include the esophagus, stomach, small intestine, rectum, and gallbladder), and this subcategory represented the leading cause of cancer death at ages 25–64 among Hispanic men, the second leading cause among WNH and Black men, and the third leading cause among API men.

The distribution by type in cancer-related deaths varied significantly by RE group. The shares of cancer deaths that were caused by neoplasms of respiratory and intrathoracic organs were greater among WNH and Black individuals than for other RE groups. The Black community experienced higher percentages of neoplastic deaths from cancers of the genital organs and breast cancer than other RE groups. Relative to other RE groups, the Hispanic community tended to have a higher proportion of cancer deaths that were caused by neoplasms of lymphoid, hematopoietic, and related tissue, and the API and Hispanic populations experienced higher percentages of cancer deaths from neoplasms of the liver and intrahepatic bile ducts and cancers associated with other organs of the digestive system. Neoplasms of the eye, brain, and other parts of the central nervous system and neoplasms of the urinary tract accounted for higher proportions of cancer deaths for the WNH and Hispanic populations than for other RE groups.

Chart 15 shows age-adjusted death rates for 1999–2019 by RE group, sex, and age group. Panel A shows the rates for neoplasms overall.

Neoplasms of respiratory and intrathoracic organs (lung cancers for brevity) were the leading cause of cancer death at all ages. Across RE groups in 2019, the shares of cancer death caused by lung cancers ranged from 13.6 percent among Hispanic people to 24.8 percent for WNH people. The share of neoplastic deaths attributable to lung cancers was lower in 2019 than it had been in 1999. That share typically increases with age until ages 65–75, then declines as other types of cancer contribute a greater percentage of deaths.

Chart 15, Panel B shows that Black males had the highest all-ages lung cancer mortality rate (50.2) in 2019, followed by WNH males (44.5) and WNH females (32.2). The all-ages lung cancer death rate for Black females was lower than that of WNH females, unlike the all-cancer mortality rates. All-ages lung cancer mortality rates are considerably lower for API individuals, and lower still for the Hispanic population. Over the period 1999–2019, the all-ages mortality gap between Black and WNH males declined, as the death rate dropped by more than half for Black males. Lung cancer mortality rates declined in both the 25–64 and 65 or older age groups among all RE groups and especially for men, narrowing the gender gap. For instance, in 1999, the all-ages male-to-female mortality ratio for the WNH and Black communities were 1.9 and 2.6, respectively. By 2019, the respective ratios were 1.4 and 1.9. Preston and Wang (2006) found that differences in mortality by sex are closely linked to cohort smoking patterns. The decline in smoking rates has affected not only lung cancer death rates, but also those for other smoking-related cancers, as well as circulatory system disorders such as coronary heart disease, chronic obstructive lung disease, and stroke.

In 2019, the percentage of cancer deaths at all ages that was caused by neoplasms of lymphoid, hematopoietic, and related tissue (leukemia and lymphoma for brevity) ranged from 8.3 percent among Black people to 10.4 percent among Hispanic people. At all ages, it was the second leading cause of cancer deaths among WNH males, the third leading cause among Hispanic males, and the fourth leading cause among Black and API males. Leukemia and lymphoma accounted for a greater share of cancer deaths among people aged 0–24 than for those in the other age groups, with people aged 25–64 having the lowest shares. For those aged 0–24, leukemia and lymphoma accounted for one-third of neoplastic deaths in the Hispanic population and about one-quarter of cancer deaths among the other RE groups.

Chart 15, Panel C shows that leukemia/lymphoma and related cancer mortality rates were lower in 2019 than in 1999 for all RE/sex and age groups. WNH males had the highest all-ages leukemia/lymphoma death rate, followed by Black and Hispanic males, while API and Hispanic females had the lowest mortality rates. At ages 25–64, however, Black men had higher leukemia/lymphoma mortality rates than WNH men, followed by Black women and Hispanic men, who had similar rates. At ages 0–24, Hispanic males had substantially higher leukemia/lymphoma mortality rates than any other RE/sex group. The higher prevalence of childhood leukemia among Hispanics is thought to be related to differences in exposure to environmental risk factors and to a higher risk associated with Native American ancestry (Hsu and others 2016).

In 2019, neoplasms of the breast represented the leading cause of all-ages cancer deaths for Hispanic females and the second leading cause of cancer death for females in all other RE groups. The percentages of all-ages cancer deaths that were caused by breast cancer ranged from 13.8 percent for WNH females to 18.3 percent among Black females. At ages 25–64, breast cancer accounted for almost one-quarter of cancer deaths among Black women. It was the leading cause of neoplastic-related deaths for Black, Hispanic, and API women at those ages.

Chart 15, Panel D shows that breast cancer mortality rates improved from 1999 to 2019 in all female populations, particularly at ages 25–64 and among the WNH and Black communities. In 2019, Black females had the highest all-ages mortality rate (26.8), followed by WNH and Hispanic females (19.4 and 13.9, respectively). API females had the lowest all-ages death rate (11.4), but a slower rate of improvement over time than those of the other RE groups.

In 2019, the shares of all-ages cancer deaths that were caused by neoplasms of the male genital organs ranged from 6.7 percent among the API population to 14.5 percent among the Black community. Prostate cancer was involved in more than 97 percent of deaths within this category. For females, malignant neoplasms of the genital organs accounted for 10–13 percent of cancer deaths across RE groups, with cervical, uterine, and ovarian cancers representing about 70 percent of these deaths. The percentage of cancer deaths among females caused by genital organs neoplasms peaks at ages 25–64; yet for males, it is highest at old ages, representing, for instance, 31.8 percent of cancer deaths in Black men aged 85 or older.

Chart 15, Panel E shows that the all-ages genital-organs cancer death rate in 1999 for Black males was 69.5, which was more than double the rate among WNH males (29.5), about triple the mortality rate of Hispanic males (23.6), and almost five times the rate for API males (14.1). By 2019, the mortality rate had improved more rapidly for Black males than for any other RE group, dropping by almost half to 35.7, but it remained substantially higher than that of WNH males (17.9). Among females, the RE groups with the highest all-ages genital-organ cancer mortality rate in 2019 were Black (18.9) and WNH (14.3). The disparity in mortality rates between Black and WNH females increased slightly over the 1999–2019 period but was significantly smaller than that for males in any year. As mentioned earlier, prostate cancer generally develops more slowly and has a later age of onset than many cancers involving the female genital organs. Thus, women had higher genital organ cancer mortality rates at ages 25–64 than men. For instance, in 2019, the genital organ cancer death rates for API women and Black men aged 25–64 were 8.6 and 7.6, respectively. The genital organ cancer mortality rate for Black women aged 25–64 nearly doubled that of Black men, and the mortality rate among API women was seven times higher than that of API men. At ages 65 or older, the situation reversed, with men experiencing far higher genital-organ cancer mortality rates than women.

As a share of all cancer deaths in 2019, neoplasms of the urinary tract ranged from 3.5 percent in the API population to 5.5 percent among the WNH population. About 96 percent of these deaths involved cancers of the kidney and bladder. This subcategory's share of cancer deaths peaks at older ages and is more prevalent among males than females and for WNH and Hispanic individuals than for Black and API people. For instance, in 2019, 10.3 percent of cancer deaths at ages 85 or older in WNH males involved neoplasms of the urinary tract, compared with 5.4 percent among WNH females.

Chart 15, Panel F shows that WNH males had the highest all-ages urinary-tract cancer mortality rate in 2019 (13.3), followed by Black males (9.9) and Hispanic males (8.6). API males had a higher mortality rate (5.1) than females in any RE group. Among females, those who are WNH had slightly higher all-ages mortality rates than those who are Black (4.5 versus 4.1), while API females had the lowest death rate (2.0). Black males and females experienced the fastest urinary-tract cancer mortality rate improvement over the 1999–2019 period. At ages 25–64, WNH and Black men had similar mortality rates. However, at ages 65 or older, the death rate for WNH men (86.5) was significantly higher than that of Black men (60.2).

Neoplasms of the pancreas in 2019 caused less than 8 percent of all-ages cancer deaths. That share was greater than it had been in 1999 for all RE groups and was higher for females than males and at ages 65 or older than at ages 0–64.

Chart 15, Panel G shows that from 1999 to 2019, all-ages pancreatic cancer mortality rates improved slightly among Black males and Black and API females and remained flat for API males. The death rate was higher in 2019 than in 1999 for WNH and Hispanic males and females. Throughout the period, Black males had the highest mortality rates, followed by Black females until 2008, when their rate was surpassed by that of WNH males. Hispanic males and WNH females had similar pancreatic cancer mortality rates in 2019 (9.8 and 9.7, respectively), and the experience of API males and Hispanic females was likewise fairly similar (8.3 and 7.9, respectively).

From 1999 to 2019, the share of cancer deaths caused by neoplasms of the liver and intrahepatic bile ducts rose substantially in all population groups. By 2019, those shares ranged from 3.9 percent of cancer deaths for WNH people to 8.9 percent of cancer deaths for API people. The percentages are significantly higher for males than females and among the API and Hispanic populations than in the other RE groups. For instance, liver cancer accounted for 11.6 percent of all cancer deaths among API males in 2019, becoming the third most prevalent cause of cancer deaths for that group, after lung cancer and neoplasms of “other organs of the digestive system.”

Chart 15, Panel H shows that in 1999, API males had the highest all-ages liver cancer mortality rate of any RE/sex group (14.8), while API females had a higher death rate (6.5) than all other female RE groups. By contrast, WNH individuals had the lowest all-ages liver cancer mortality rates of any RE group regardless of sex. From 1999 to 2019, all-ages liver cancer mortality rates increased significantly among WNH, Black, and Hispanic people of either sex, while they declined among API individuals. Chang and others (2007) elaborated:

The increasing liver cancer incidence rates in Hispanics, Whites, and Blacks have generally been attributed to the spread of hepatitis C virus (HCV) infection in the U.S., as reflected by the two- to four-fold increase in the incidence of acute HCV infection between the early 1960s and the late 1980s. In contrast, the disproportionately high rate of liver cancer incidence in APIs is ascribed primarily to the high prevalence of chronic hepatitis B virus (HBV) infection, which is etiologically associated with the majority of liver cancer in Asian natives and migrants. Chronic HBV infection is carried by approximately 10% of the population in eastern and southeastern Asia and sub-Saharan Africa, as well as immigrants from those regions, whereas the prevalence is estimated at below 0.5% in the overall U.S. population.

In 2019, the shares of cancer deaths attributed to neoplasms of the colon ranged from 6.3 percent for WNH individuals to 7.8 percent among Hispanic people. Those shares had declined since 1999 and were higher in the midlife years than for the other age groups, representing, for example, 10.3 percent of cancer deaths among Hispanic men aged 25–64.

Chart 15, Panel I shows that from 1999 to 2019, all-ages colon cancer mortality rates declined in all RE/sex groups, especially among WNH and Black males and females. Over the observation period, Black males had the highest all-ages colon cancer mortality rates, followed by Black females until 2018, when their death rate was surpassed by that of WNH males. At ages 65 or older, WNH men had a higher colon cancer mortality rate in 2019 (61.4) than did Black women (58.1). At ages 25–64, Black women had higher colon cancer mortality rates than WNH men from 1999 to 2018; but in 2019, the groups' death rates converged at 7.0.

As noted earlier, the subcategory “neoplasms of other organs of the digestive system” includes cancers of the esophagus, stomach, small intestine, and rectum, but excludes liver, pancreatic, and colon cancers, which constitute separate subcategories. In 2019, the shares of neoplasm deaths that were caused by other digestive system organ cancers ranged from 7.3 percent for WNH individuals to 10.5 percent in the API community. The share of deaths is higher among males than females, in the midlife years than at older ages, and among the API and Hispanic communities than in the other RE groups. Other digestive system organ cancers were the second leading cause of all-ages cancer deaths for API and Hispanic males and the third leading cause among WNH and Black males.

Chart 15, Panel J shows that from 1999 to 2019, all-ages mortality rates from other digestive system organ cancer declined among all RE/sex groups and, for both sexes, the improvement in mortality rates was greatest for the API and Black populations and lowest among WNH individuals. Black males had the highest all-ages other digestive system organ cancer mortality rate in 2019 (18.3), followed by WNH males (16.5) and Hispanic males (14.1). Among females, those who are Black had the highest all-ages mortality rate in 2019 (9.6), while those who are WNH had the lowest rate (7.2). Unlike their outcomes for colon cancer, Black females had lower mortality rates from other digestive system organ cancers than Hispanic and API males.

In 2019, the shares of cancer deaths that were caused by neoplasms of the eye, brain, and other parts of the central nervous system ranged from 1.7 percent for Black individuals to more than 3 percent among the WNH and Hispanic populations. About 96 percent of deaths in this subcategory involved neoplasms of the brain. This subcategory represents one of the most common causes of cancer death at ages 0–24 and, in any age group, the percentages tend to be higher among males than females.

Chart 15, Panel K shows that WNH males and females had the highest all-ages mortality rates for eye, brain, and other nervous system cancers in 2019 (6.2 and 4.1, respectively). Hispanic males followed, with a slightly higher mortality rate than Black males (3.8 and 3.5, respectively). Of the eight RE/sex groups, Black and API females had the lowest all-ages mortality rates. At ages 65 or older, the death rate from eye, brain, and other nervous system cancers for WNH men was about twice that of Black men (25.6 versus 13.2) in 2019. Over the observation period, mortality rates associated with eye, brain, and other nervous system cancers remained flat for most RE/sex groups. The all-ages death rate was higher in 2019 than in 1999 among Black, API, and Hispanic males and for API and Hispanic females.

In 2019, neoplasms of the lip, oral cavity, and pharynx represented 1–2 percent of all cancer deaths among the RE groups. Risk factors for oral cancer include tobacco use, excessive alcohol consumption, and human papillomavirus (HPV) infection. Oral cancer accounts for higher shares of cancer deaths among males than females and in the midlife years than at other ages. For instance, in 2019, 4.6 percent of cancer deaths among API men aged 25–64 were attributed to oral cancer.

Chart 15, Panel L shows that in 1999, the all-ages oral cancer death rate for Black males (7.5) was nearly twice that of WNH males (3.8). However, by 2019, the rate for both groups was 4.1. Among males, the Hispanic RE group had the lowest all-ages oral cancer mortality rate. Among females, the WNH group had the highest all-ages oral cancer mortality rate and the Hispanic group had the lowest rate. From 2010 to 2019, the incidence rates of HPV-associated oral cancers increased, and differences in sexual behavior may partially account for observed variations in those increases by RE group (Ellington and others 2020).

In 2019, melanoma and other neoplasms of the skin accounted for 0.4 percent of cancer deaths among Black people, 1.0 percent of those in the Hispanic community, and 2.4 percent of cancer deaths in the WNH population. The skin-cancer share of neoplasm deaths was higher for people aged 25–64 than those in other age groups and for males than females.

Chart 15, Panel M shows that in 2019, the all-ages skin cancer mortality rate for WNH males was 5.7 times that of Black males and the rate for WNH females was 4.6 times that of Black females. Although the incidence rate of melanoma in the Black population is very low, survival outcomes are poorer than those of the WNH population (Culp and Lunsford 2019).²¹

Neoplasms of “ill-defined, other secondary, and unspecified sites” caused 5–6 percent of cancer deaths across the RE groups for all ages combined. This subcategory's share of cancer deaths is typically higher at older ages than in the midlife years and in the WNH and Black communities than for the other RE groups.

Chart 15, Panel N shows that from 1999 to 2019, all-ages ill-defined and unspecified-site cancer mortality rates declined in every RE/sex group, particularly among Black males. In 1999, the mortality rate for Black males (22.9) was 1.4 times higher than that of the RE/sex group with the second highest rate, WNH males. By 2019, the mortality ratio between the two populations (which still had the two highest rates among the RE/sex groups) had dropped to 1.1. Both Black and WNH females had higher all-ages ill-defined and unspecified-site cancer mortality rates than Hispanic and API males. Over the observation period, the male-to-female mortality gap declined for the Hispanic and Black populations but increased among WNH and API individuals.

The final subcategory, all other neoplasms, includes neoplasms of the thyroid gland, endocrine glands, bone and articular cartilage, and mesothelial and soft tissue; neoplasms of uncertain or unknown behavior; and in situ and benign neoplasms. Across the RE groups, this subcategory accounts for 4.5–6.0 percent of cancer deaths at all ages combined, and is one of the leading causes of cancer deaths at ages 0–24.

Chart 15, Panel O shows that from 1999 to 2019, other-cancer mortality rates declined in 31 of the 32 population groups (API males aged 0–24 were the lone exception). WNH males had the highest all-ages mortality rates each year, followed by Black males. In 2019, Black females had a lower all-ages other-cancer mortality rate than both WNH females and Hispanic males.

In summary, with a few exceptions (mainly liver cancer), the death rates associated with most neoplasm subcategories declined throughout the 1999–2019 period, resulting in substantial mortality rate improvement for all RE/sex groups. This is evident in Chart 16, which shows the all-ages neoplasm mortality rates by cause-of-death subcategory, RE group, and sex in 1999 and 2019. In 1999, of the eight RE/sex groups, Black males had significantly higher mortality rates for most cancers (the exceptions were liver and urinary tract cancers; cancer of the eye, brain, or nervous system; leukemia and lymphoma; skin cancer; and the “all other neoplasms” subcategory). The disparity was so substantial that the combined mortality rate from only two cancer subcategories (neoplasms of the respiratory system and the genital organs) was higher for Black males (178.0) than the total cancer mortality rates for Hispanic and API males. Similarly, for Black females, the mortality rate from a combination of four types of cancer (lung, breast, genital organs, and colon) outstripped the all-cancer mortality rates of Hispanic and API females. Over the 20 years that followed, the cancer mortality rates of Black males and females improved more rapidly than those of all other RE/sex groups, narrowing the gaps.