Cancer statistics, 2020

Incidence and Mortality Data

Mortality data from 1930 to 2017 were provided by the National Center for Health Statistics (NCHS).1, 2 Forty-seven states and the District of Columbia met data quality requirements for reporting to the national vital statistics system in 1930, and Texas, Alaska, and Hawaii began reporting in 1933, 1959, and 1960, respectively. The methods for abstraction and age adjustment of historic mortality data are described elsewhere.2, 3 Five-year mortality rates (2012-2016) for Puerto Rico were previously published in volume 3 of the North American Association of Central Cancer Registries' (NAACCR's) Cancer in North America: 2012-2016.4

Population-based cancer incidence data in the United States have been collected by the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program since 1973 and by the Centers for Disease Control and Prevention's (CDC's) National Program of Cancer Registries (NPCR) since 1995. The SEER program is the only source for historic population-based incidence data. Long-term (1975-2016) incidence and survival trends were based on data from the 9 oldest SEER areas (Connecticut, Hawaii, Iowa, New Mexico, Utah, and the metropolitan areas of Atlanta, Detroit, San Francisco–Oakland, and Seattle–Puget Sound), representing approximately 9% of the US population.5 Contemporary stage distribution and survival statistics were based on data from all 18 SEER registries (the SEER 9 registries plus Alaska Natives, California, Georgia, Kentucky, Louisiana, and New Jersey).6 The probability of developing cancer was based on all 21 SEER registries (the SEER 18 registries plus Idaho, Massachusetts, and New York) and calculated using the NCI's DevCan software (version 6.7.7).7 Some of the statistical information presented herein was adapted from data previously published in the SEER Cancer Statistics Review 1975-2016.8

The NAACCR compiles and reports incidence data from 1995 onward for registries that participate in the SEER program and/or the NPCR. These data approach 100% coverage of the US population for the most recent years and were the source for the projected new cancer cases in 2020 and cross-sectional incidence rates by state and race/ethnicity.9, 10 Some of the incidence data presented herein were previously published in volumes 1 and 2 of Cancer in North America: 2012-2016.11, 12

All cancer cases were classified according to the International Classification of Diseases for Oncology except childhood and adolescent cancers, which were classified according to the International Classification of Childhood Cancer (ICCC).13, 14 Causes of death were classified according to the International Classification of Diseases.15 All incidence and death rates were age standardized to the 2000 US standard population and expressed per 100,000 population, as calculated by the NCI's SEER*Stat software (version 8.3.6).16 The annual percent change in rates was quantified using the NCI's Joinpoint Regression Program (version 4.7.0.0).17

Whenever possible, cancer incidence rates were adjusted for delays in reporting, which occur because of a lag in case capture or data corrections. Delay-adjustment has the largest effect on the most recent data years for cancers that are frequently diagnosed in outpatient settings (eg, melanoma, leukemia, and prostate cancer) and provides the most accurate portrayal of cancer occurrence in the most recent time period.18 For example, the leukemia incidence rate for 2016 in the 9 oldest SEER registries was 10% higher after adjusting for reporting delays (15.2 vs 13.8 per 100,000 population).8

Projected Cancer Cases and Deaths in 2020

The most recent year for which reported incidence and mortality data are available lags 2 to 4 years behind the current year due to the time required for data collection, compilation, quality control, and dissemination. Therefore, we projected the numbers of new cancer cases and deaths in the United States in 2020 to provide an estimate of the contemporary cancer burden.

To calculate the number of invasive cancer cases, a generalized linear mixed model was used to estimate complete counts for each county (or health service area for rare cancers) from 2002 through 2016 using delay-adjusted, high-quality incidence data from 49 states and the District of Columbia (98% population coverage) and geographic variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors.19 (Data were unavailable for all years for Kansas and for a few sporadic years for a limited number of other states.) Modeled counts were aggregated to the national and state level for each year, and a time series projection method (vector autoregression) was applied to all 15 years to estimate cases for 2020. Basal cell and squamous cell skin cancers cannot be estimated because incidence data are not collected by most cancer registries. For complete details of the case projection methodology, please refer to Zhu et al.20

New cases of ductal carcinoma in situ of the female breast and in situ melanoma of the skin diagnosed in 2020 were estimated by first approximating the number of cases occurring annually from 2007 through 2016 based on age-specific NAACCR incidence rates (data from 49 states with high-quality data for all 10 years) and US Census Bureau population estimates obtained via SEER*Stat.9, 21 Counts were then adjusted for delays in reporting using SEER delay factors for invasive disease (delay factors are unavailable for in situ cases) and projected to 2020 based on the average annual percent change generated by the joinpoint regression model.22

The number of cancer deaths expected to occur in 2020 was estimated based on the most recent joinpoint-generated annual percent change in reported cancer deaths from 2003 through 2017 at the state and national levels as reported to the NCHS. For the complete details of this methodology, please refer to Chen et al.23

Other Statistics

The number of cancer deaths averted in men and women due to the reduction in cancer death rates since the early 1990s was estimated by summing the difference between the annual number of recorded cancer deaths from the number that would have been expected if cancer death rates had remained at their peak. The expected number of deaths was estimated by applying the 5-year age- and sex-specific cancer death rates in the peak year for age-standardized cancer death rates (1990 in men and 1991 in women) to the corresponding age- and sex-specific populations in subsequent years through 2017.

Expected Numbers of New Cancer Cases

Table 1 presents the estimated numbers of new invasive cancer cases in the United States in 2020 by sex and cancer type. In total, there will be approximately 1,806,590 cancer cases diagnosed, which is the equivalent of approximately 4,950 new cases each day. In addition, there will be approximately 48,530 new cases of ductal carcinoma in situ of the breast diagnosed in women and 95,710 new cases of melanoma in situ of the skin. The estimated numbers of new cases by state are shown in Table 2.

Figure 1 depicts the most common cancers expected to be diagnosed in men and women in 2020. Prostate, lung and bronchus (referred to as lung hereafter), and colorectal cancers (CRCs) account for 43% of all cases in men, with prostate cancer alone accounting for more than 1 in 5 new diagnoses. For women, the 3 most common cancers are breast, lung, and colorectal, accounting for 50% of all new diagnoses; breast cancer alone accounts for 30% of female cancers.

The lifetime probability of being diagnosed with invasive cancer is slightly higher for men (40.1%) than for women (38.7%) (Table 3). The reasons for the excess risk in men are not fully understood, but probably largely reflect differences in environmental exposures and endogenous hormones, as well as complex interactions between these influences. Recent research suggests that sex differences in immune function and response may also play a role.24 Adult height, which is determined by genetics and childhood nutrition, is positively associated with cancer incidence and mortality in both men and women,25 and has been estimated to account for one-third of the sex disparity.26 Notably, the gender gap varies by age. For example, cancer incidence during childhood (ages birth-14 years) is approximately 10% higher in males than in females (18.2 vs 16.4 per 100,000 population),27 whereas during early adulthood (ages 20-49 years) it is 77% higher in females (203.4 vs 114.9 per 100,000 population), largely because of breast cancer incidence in young women.28

Expected Number of Cancer Deaths

An estimated 606,520 Americans will die from cancer in 2020, corresponding to more than 1,600 deaths per day (Table 1). The greatest number of deaths are from cancers of the lung, prostate, and colorectum in men and the lung, breast, and colorectum in women (Fig. 1). Almost one-quarter of all cancer deaths are due to lung cancer. Table 4 provides the estimated numbers of cancer deaths in 2020 by state.

Trends in Cancer Incidence

Figure 2 illustrates long-term trends in cancer incidence rates for all cancers combined by sex. Cancer incidence patterns reflect trends in behaviors associated with cancer risk and changes in medical practice, such as the use of cancer screening tests. For example, the spike in incidence for males during the early 1990s reflects rapid changes in prostate cancer incidence rates due to a surge in the detection of asymptomatic disease as a result of widespread prostate-specific antigen (PSA) testing among previously unscreened men.29

The overall cancer incidence rate in men declined rapidly from 2007 to 2014, but stabilized through 2016, reflecting slowing declines for CRC and stabilizing rates for prostate cancer (Fig. 3). The sharp drop in prostate cancer incidence from 2007 to 2014 has been attributed to decreased PSA testing in the wake of US Preventive Services Task Force recommendations against the routine use of the test to screen for prostate cancer (Grade D) because of growing concerns about overdiagnosis and overtreatment.30, 31 However, Negoita et al recently reported that the overall decline in prostate cancer incidence masks an increase in distant stage diagnoses since around 2010 across age and race, although improved staging may have contributed.32 In 2017, the Task Force revised their recommendation for men aged 55 to 69 years to informed decision making (Grade C) based on an updated evidence review, noting that “screening offers a small potential benefit” of reduced prostate cancer mortality “in some men.”33-35

The overall cancer incidence rate in women has remained generally stable over the past few decades because lung cancer declines have been offset by a tapering decline for CRC and increasing or stable rates for other common cancers (Fig. 3). The slight rise in breast cancer incidence rates (by approximately 0.3% per year) since 2004 has been attributed at least in part to continued declines in the fertility rate as well as increased obesity,36 factors that may also contribute to the continued increase in incidence for uterine corpus cancer (1.3% per year from 2007-2016).37 However, a recent study indicated that the rise in uterine cancer is driven by nonendometrioid subtypes, which are less strongly associated with obesity than endometrioid carcinoma.38 Thyroid cancer incidence has stabilized after the implementation of more conservative diagnostic practices in response to the sharp uptick in the diagnosis of largely indolent tumors in recent decades.39, 40

Lung cancer incidence continues to decline twice as fast in men as in women, reflecting historical differences in tobacco uptake and cessation, as well as upturns in female smoking prevalence in some birth cohorts.41, 42 However, smoking patterns do not fully explain the higher lung cancer incidence rates recently reported in young women compared with men born around the 1960s.43 In contrast, CRC incidence patterns are generally similar in men and women, with the rapid declines noted during the 2000s in the wake of widespread colonoscopy uptake appearing to taper in more recent years (Fig. 3). Notably, declines in the overall CRC incidence rate mask an increase in adults aged younger than 55 years of 2% per year since the mid-1990s.

Incidence also continues to increase for cancers of the kidney, pancreas, liver, and oral cavity and pharynx (among non-Hispanic whites) and melanoma of the skin, although melanoma has begun to decline in recent birth cohorts.28, 44 Liver cancer is increasing most rapidly, by 2% to 3% annually during 2007 through 2016, although the pace has slowed from previous years.8 The majority of these cases (71%) are potentially preventable because most liver cancer risk factors are modifiable (eg, obesity, excess alcohol consumption, cigarette smoking, and hepatitis B and C viruses).45 Chronic hepatitis C virus (HCV) infection, the most common chronic blood-borne infection in the United States, confers the largest relative risk and accounts for 1 in 4 cases.46 Although well-tolerated antiviral therapies achieve cure rates of >90% and could potentially avert much of the future burden of HCV-associated disease,47 most infected individuals are undiagnosed, and thus untreated. Only 14% of the more than 76 million individuals born during 1945 through 1965 (baby boomers) had received the recommended one-time HCV test in 2015.48 Compounding the challenge is a greater than 3-fold spike in acute HCV infections reported to the CDC between 2010 and 2017 as a consequence of the opioid epidemic, of which 75% to 85% of cases will progress to chronic infection.49

Cancer Survival

The 5-year relative survival rate for all cancers combined diagnosed during 2009 through 2015 was 67% overall, 68% in whites, and 62% in blacks.8 Figure 4 shows 5-year relative survival rates by cancer type, stage at diagnosis, and race. For all stages combined, survival is highest for prostate cancer (98%), melanoma of the skin (92%), and female breast cancer (90%) and lowest for cancers of the pancreas (9%), liver (18%), lung (19%), and esophagus (20%). Survival rates are lower for black patients than for whites for every cancer type shown in Figure 4 except for cancers of the kidney and pancreas, for which they are the same. The largest black-white differences in absolute terms are for melanoma (25%) and cancers of the uterine corpus (22%), oral cavity and pharynx (19%), and urinary bladder (14%). Although these disparities partly reflect a later stage of disease at diagnosis in black patients (Fig. 5), blacks also have lower stage-specific survival for most cancer types (Fig. 4). After adjusting for sex, age, and stage at diagnosis, the relative risk of death after a cancer diagnosis is 33% higher in black patients than in white patients.50 The disparity is even larger for American Indians/Alaska Natives, among whom the risk of cancer death is 51% higher than that for whites.

Cancer survival has improved since the mid-1970s for all of the most common cancers except uterine cervix and uterine corpus.50 Stagnant survival rates for these cancers largely reflect a lack of major treatment advances for patients with recurrent and metastatic disease.51, 52 For cervical cancer, it may also reflect an increasing proportion of adenocarcinoma over time due to the removal of slow-growing squamous lesions through long-term widespread screening.53 On the contrary, survival rates for breast and prostate cancer are likely to be artificially inflated in the screening era due to lead time bias and the detection of indolent cancers in the absence of the capacity to detect and remove premalignant lesions.54 Progress for hematopoietic and lymphoid malignancies has been especially rapid due to improvements in treatment protocols, including the development of targeted therapies. For example, the 5-year relative survival rate for chronic myeloid leukemia increased from 22% in the mid-1970s to 70% for those diagnosed during 2009 through 2015,8 and most patients treated with tyrosine kinase inhibitors experience nearly normal life expectancy.55

Low lung cancer survival rates reflect the large proportion of patients (57%) diagnosed with metastatic disease, for which the 5-year relative survival rate is 5%.8 However, the 5-year survival rate for localized stage disease is 57%, and there is potential for earlier diagnoses among those at high risk through screening with low-dose computed tomography. The National Lung Screening Trial, the largest trial to date, demonstrated a 20% reduction in lung cancer mortality in current/former smokers with a ≥30 pack-year history compared with chest radiography.56 More recently, the Multicentric Italian Lung Detection (MILD) trial, which included more screening rounds, longer follow-up, and a more moderate risk pool (those with a smoking history of ≥20 pack-years) reported a 39% reduction in lung cancer mortality compared with no intervention.57 Although the American Cancer Society and US Preventive Services Task Force recommend low-dose computed tomography lung cancer screening for select current/former heavy smokers, the translation of this benefit to the general population remains challenging. Recent studies have found that millions of individuals are inappropriately screened whereas fewer than 500,000 are screened according to guidelines.58, 59 Broad implementation of recommended lung cancer screening will require new systems to facilitate unique aspects of the process, including the identification of eligible patients and the education of physicians regarding details of the shared decision-making conversation required by the Centers for Medicaid and Medicare Services.

Trends in Cancer Mortality

Mortality rates are a better indicator of progress against cancer than incidence or survival rates because they are less affected by biases resulting from changes in detection practices.60 The cancer death rate rose during most of the 20th century, largely because of a rapid increase in lung cancer deaths among men as a consequence of the tobacco epidemic. However, declines in smoking, as well as improvements in early detection and treatment, have resulted in a continuous decline in the cancer death rate since its peak of 215.1 deaths (per 100,000 population) in 1991. The overall drop of 29% as of 2017 (152.4 per 100,000 population) translates into an estimated 2,902,200 fewer cancer deaths (1,983,000 in men and 919,200 in women) than what would have occurred if mortality rates had remained at their peak (Fig. 6). The number of averted deaths is larger for men than for women because the death rate in men peaked higher and declined faster. During the most recent decade of data (2008-2017), the death rate declined by 1.5% per year for cancer while remaining stable for all other causes of death combined, reflecting a slowing decline for heart disease, stabilizing rates for cerebrovascular disease, and an increasing trend for accidents (unintentional injuries; 2.6% per year) and Alzheimer disease (3.2% per year).

The progress against cancer reflects large declines in mortality for the 4 major cancers (lung, breast, prostate, and colorectum) (Fig. 7). Specifically, as of 2017, the death rate has dropped from its peak for lung cancer by 51% among males (since 1990) and by 26% among females (since 2002); for female breast cancer by 40% (since 1989); for prostate cancer by 52% (since 1993); and for CRC by 53% among males (since 1980) and by 57% among females (since 1969). The CRC death rate in women was declining prior to 1969, but that is the first year for which data exclusive of the small intestine are available. Two decades of steep (4% per year on average) declines for prostate cancer are attributed to an earlier stage at diagnosis through PSA testing, as well as advances in treatments.61, 62 However, prostate cancer death rates stabilized in recent years (Table 5), possibly related to declines in PSA testing and an uptick in the diagnosis of distant stage disease.32 Declines in mortality have also slowed for female breast and CRC. In contrast, declines in lung cancer mortality have accelerated, from approximately 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women.

Recent mortality declines are even more rapid for melanoma of the skin, most likely reflecting improved survival in the wake of promising new treatments for metastatic disease. In 2011, the US Food and Drug Administration approved ipilimumab, the first immune checkpoint inhibitor approved for cancer therapy,63 and vemurafenib, a BRAF inhibitor, for the treatment of advanced melanoma.64 Subsequently, the 1-year relative survival rate for metastatic melanoma escalated from 42% for patients diagnosed during 2008 through 2010 to 55% for those diagnosed during 2013 through 2015.65 Likewise, the overall melanoma mortality rate dropped by 7% annually during 2013 through 2017 in men and women aged 20 to 64 years compared with declines during 2006 through 2010 of approximately 1% annually among individuals aged 50 to 64 years and 2% to 3% among those aged 20 to 49 years (Fig. 8). The impact was even more striking for individuals aged 65 years and older, among whom rates were increasing prior to 2013 but are now declining by 5% to 6% per year. We also examined melanoma mortality trends stratified by age and county-level poverty because dissemination of newly approved therapies has been slower among the uninsured, who are more likely to be of lower socioeconomic status.64, 66 Trends were similar in poor versus affluent counties among individuals aged 65 years and older, who are universally insured, as well as among women aged younger than 65 years. However, among men aged younger than 65 years residing in poor counties, there was no acceleration in the decline following drug approval (Fig. 8). Our inability to detect a difference in the trend by poverty status among women may reflect their melanoma survival advantage over men67 and/or their higher prevalence of health insurance coverage.68

Death rates rose over the past decade for cancers of the liver, pancreas (among males), and uterine corpus (Table 5), as well as for cancers of the small intestine, anus, penis, brain and other nervous system, eye and orbit, and sites within the oral cavity and pharynx associated with the human papillomavirus (HPV).8 However, the sustained rapid increases in liver cancer mortality appear to be slowing in women and stabilizing in men.

Recorded Number of Deaths in 2017

A total of 2,820,034 deaths were recorded in the United States in 2017, 21% of which were from cancer (Table 6). In contrast to stable or increasing trends for most leading causes of death, the cancer death rate declined by 2.2% from 2016 to 2017, the largest single-year drop since rates began declining in 1992. This progress is largely driven by recent rapid declines in lung cancer mortality. Cancer is the second leading cause of death after heart disease in both men and women nationally, but is the leading cause of death in many states,69 in Hispanic and Asian Americans,70, 71 and in individuals aged younger than 80 years. However, those aged 80 years and older are nearly 2 times more likely to die from heart disease than from cancer. Among females, cancer is the first or second leading cause of death for every age group shown in Table 7, whereas among males, accidents and suicide predominate before age 40 years.

Table 8 presents the number of deaths in 2017 for the 5 leading cancer types by age and sex. Brain and other nervous system tumors and leukemia are the first and second leading causes of cancer death among men aged younger than 40 years and women aged younger than 20 years, whereas breast cancer leads among women aged 20 to 59 years. Lung cancer leads in cancer deaths among men aged 40 years and older and women aged 60 years and older, causing 145,849 total deaths in 2017, more than breast, prostate, colorectal, and brain cancers combined. There were 17% more lung cancer deaths in men (78,694) than in women (67,155) in 2017, but this pattern is projected to reverse by 2045 if current smoking trends continue.72

Cervical cancer continues to be the second leading cause of cancer death in women aged 20 to 39 years, causing 10 premature deaths per week in this age group. This finding, coupled with increasing trends for distant stage diagnoses and cervical adenocarcinoma,73 which is often undetected by cytology, underscores the need for increased HPV vaccination uptake and Papanicolaou/HPV DNA cotesting, which is the preferred screening method for women aged 30 to 65 years.74 Approximately one-half of adolescent girls have not been fully vaccinated,75 and only 43% of women in their 30s received recent Papanicolaou/HPV DNA screening tests in 2015.76

Cancer Disparities by Race/Ethnicity

Cancer occurrence and outcomes vary considerably between racial and ethnic groups, largely because of inequalities in wealth that lead to differences in risk factor exposures and barriers to high-quality cancer prevention, early detection, and treatment.77, 78 Overall cancer incidence rates are highest among non-Hispanic whites (NHWs) because of their high rate of lung and female breast cancer (Table 9). However, sex-specific incidence is highest in non-Hispanic black (NHB) men, among whom rates during 2012 through 2016 were 85% higher than those in Asian/Pacific Islander men, who have the lowest rates, and 8% higher than those in NHW men, who rank second. Among women, NHWs have the highest incidence, 8% higher than NHBs (who rank second); however, NHB women have the highest cancer mortality rates–13% higher than those for NHW women. The mortality disparity among men is likewise larger, with the death rate in NHB men double that in Asian/Pacific Islander men and 20% higher than that in NHW men. However, the black-white disparity in overall cancer mortality among men and women combined has declined from a peak of 33% in 1993 (279.0 vs 210.5 per 100,000 population) to 13% in 2017 (178.5 vs 157.5 per 100,000 population). This progress is largely due to more rapid declines in deaths from smoking-related cancers among blacks because of the steep drop in smoking prevalence unique to black teens from the late 1970s to early 1990s.79

Geographic Variation in Cancer Occurrence

Tables 10 and 11 show cancer incidence and mortality rates for selected cancers by state. State variation in cancer incidence reflects differences in medical detection practices and the prevalence of risk factors, such as smoking, obesity, and other health behaviors. The largest geographic variation in cancer occurrence is for cancers that are potentially the most preventable,45 such as lung cancer, cervical cancer, and melanoma of the skin.44 For example, lung cancer incidence and mortality rates in Kentucky, where smoking prevalence was historically highest, are 3 to 4 times higher than those in Utah, where it was lowest. Even in 2018, 1 in 4 residents of Kentucky, Arkansas, and West Virginia were current smokers compared with 1 in 10 in Utah and California.80

Similarly, cervical cancer incidence and mortality currently vary by 2-fold to 3-fold between states, with incidence rates ranging from <5 per 100,000 population in Vermont and New Hampshire to 10 per 100,000 population in Arkansas (Table 10). Ironically, advances in cancer control often exacerbate disparities, and state gaps for cervical and other HPV-associated cancers may widen in the wake of unequal uptake of the HPV vaccine, which has already shown efficacy in reducing the burden of cervical intraepithelial neoplasia of grade 2 or higher.81 In 2018, up-to-date HPV vaccination among adolescents (those aged 13-17 years) ranged from 38% in Kansas and Mississippi to >70% in North Dakota and Rhode Island among girls and from 27% in Mississippi to >70% in Massachusetts and Rhode Island among boys.75 State/territory differences in other initiatives to improve health, including Medicaid expansion, may also contribute to future geographic disparities.82, 83

Cancer in Children and Adolescents

Cancer is the second most common cause of death among children aged 1 to 14 years in the United States, surpassed only by accidents. In 2020, an estimated 11,050 children (aged birth to 14 years) and 5,800 adolescents (aged 15-19 years) will be diagnosed with cancer, and 1,190 and 540, respectively, will die from the disease. These estimates exclude benign and borderline malignant brain tumors, which were not required to be reported to cancer registries until 2004, because the projection methodology requires 15 years of historical data.

Leukemia is the most common childhood cancer, accounting for 28% of cases, followed by brain and other nervous system tumors (26%), greater than one-quarter of which are benign/borderline malignant (Table 12). The types of cancer that commonly occur in adolescents (those aged 15-19 years) and their distribution differ from that in children. In adolescents, for example, brain and other nervous system tumors are most common (21%), greater than one-half of which are benign/borderline malignant, followed closely by lymphoma (20%). In addition, there are almost twice as many cases of Hodgkin as non-Hodgkin lymphoma, whereas among children, the reverse is true. Thyroid carcinoma and melanoma of the skin account for 11% and 4%, respectively, of cancers in adolescents, but only 2% and 1%, respectively, in children.

The overall cancer incidence rate in children and adolescents has been increasing slightly (by 0.7% per year) since 1975 for reasons that remain unclear. In contrast, death rates have declined continuously for decades, from 6.3 (per 100,000 population) in children and 7.1 in adolescents in 1970 to 2.0 and 2.7, respectively, in 2017, for overall cancer mortality reductions of 68% in children and 63% in adolescents. Much of this progress reflects the dramatic declines in leukemia mortality of 83% in children and 68% in adolescents. Remission rates of 90% to 100% for childhood acute lymphocytic leukemia over the past 4 decades have been achieved primarily through the optimization of established chemotherapeutic agents as opposed to the development of new therapies.84 Substantial mortality reductions also occurred from 1970 to 2017 for lymphoma (80% in children and 82% in adolescents) and brain and other nervous system tumors (36% and 38%, respectively). The 5-year relative survival rate for all cancers combined improved from 58% during the mid-1970s to 84% during 2009 through 2015 for children and from 68% to 85% for adolescents.8 However, survival varies substantially by cancer type and age at diagnosis (Table 12).