Abstract
This cohort study uses population-based data from the National Cancer Institute Surveillance, Epidemiology, and End Results program of cancer registries to estimate prevalence of prior cancer among adults diagnosed with an incident cancer in 2019.
The population of cancer survivors in the US continues to increase.1 Three authors of the present study reported in 2018 that 18.4% of adults newly diagnosed with cancer (2009-2013) survived a previous cancer and may therefore be excluded from cancer clinical trials.2 Many organizations3 have since recommended considering cancer survivors who are newly diagnosed with cancer for enrollment in trials. We provide an update on the prevalence of prior cancer, including differences by age, sex, and race and ethnicity.
Methods
We used population-based data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program of cancer registries to estimate prevalence of prior cancer among adults (age ≥18 years) diagnosed with an incident cancer in 2019. Demographic information, including race and ethnicity, was abstracted from SEER registry data. Details are in eMethods in Supplement 1. The institutional review board at the University of Texas Southwestern Medical Center approved this study with a waiver of informed patient consent because the research involved no more than minimal risk and could not practicably be carried out without a waiver; data are deidentified and publicly available. All analyses were conducted using SAS, version 9.4 (SAS Institute Inc) between August and October 2022.
Results
There were 135 117 persons diagnosed with an incident cancer in 2019, of whom 1.9% had a prior cancer of the same type, 8.6% of a different type, and 8.9% of an unknown type (19.4% with any prior cancer). Prior cancer of a different type was more common for age 65 years or older (14.1%; 95% CI, 13.8%-14.4%) vs ages 18 to 49 years (1.6%; 95% CI, 1.4%-1.8%), men (10.3%; 95% CI, 10.1%-10.6%) vs women (8.9%; 95% CI, 8.7%-9.2%), and non-Hispanic White (11.0%; 95% CI, 10.8%-11.2%) vs non-Hispanic Black (5.7%; 95% CI, 5.2%-6.1%) persons (Table 1). Prevalence also differed by incident cancer type.
Table 1. Prevalence of Prior Cancer of a Different Type by Incident Cancer Type, Age, Sex, Race and Ethnicity, and Stage at Diagnosis.
| Variable | Prior cancer of a different type (n = 11 629)a | No prior cancer (n = 108 940) | Total (N = 120 569) | |
|---|---|---|---|---|
| No. | % (95% CI) | |||
| Incident cancer typeb | ||||
| Myeloid and monocytic leukemia | 323 | 21.1 (19.1-23.1) | 1208 | 1531 |
| Mesothelioma | 35 | 18.0 (12.6-23.5) | 159 | 194 |
| Penis and other male genital organs | 24 | 17.4 (11.1-23.7) | 114 | 138 |
| Urinary bladder and other urinary organs | 892 | 17.0 (16.0-18.1) | 4344 | 5236 |
| Lung and other respiratory | 1812 | 14.7 (14.1-15.3) | 10 532 | 12 344 |
| Pancreas | 520 | 14.1 (13.0-15.2) | 3169 | 3689 |
| Bone and joints, including soft tissue | 135 | 13.6 (11.4-15.7) | 861 | 996 |
| Esophagus | 155 | 13.1 (11.2-15.0) | 1030 | 1185 |
| Eye and orbit | 27 | 12.7 (8.2-17.1) | 186 | 213 |
| Miscellaneous | 490 | 12.5 (11.5-13.6) | 3425 | 3915 |
| Melanoma | 875 | 12.2 (11.4-12.9) | 6323 | 7198 |
| Anus, anal canal, anorectum | 65 | 12.1 (9.3-14.8) | 474 | 539 |
| Stomach | 234 | 11.8 (10.4-13.3) | 1741 | 1975 |
| Lymphoma | 621 | 11.0 (10.2-11.9) | 5007 | 5628 |
| Oral cavity and pharynx | 439 | 10.9 (10.0-11.9) | 3574 | 4013 |
| Liver and intrahepatic bile duct | 379 | 10.7 (9.7-11.7) | 3165 | 3544 |
| Kidney and renal pelvis | 437 | 10.3 (9.3-11.2) | 3822 | 4259 |
| Myeloma | 201 | 9.8 (8.5-11.1) | 1843 | 2044 |
| Colon and rectum | 948 | 9.4 (8.8-10.0) | 9123 | 10 071 |
| Lymphocytic leukemia | 144 | 8.8 (7.4-10.2) | 1488 | 1632 |
| Cervix and other female genital organs | 131 | 7.9 (6.6-9.1) | 1537 | 1668 |
| Brain and other nervous system | 117 | 7.8 (6.5-9.2) | 1380 | 1497 |
| Ovary | 104 | 7.6 (6.2-9.0) | 1259 | 1363 |
| Corpus and uterus | 334 | 7.3 (6.6-8.1) | 4216 | 4550 |
| Thyroid and other endocrine | 210 | 5.6 (4.9-6.4) | 3518 | 3728 |
| Prostate | 955 | 5.4 (5.0-5.7) | 16 796 | 17 751 |
| Breast (female only) | 958 | 5.2 (4.9-5.5) | 17 517 | 18 475 |
| Kaposi sarcoma | 5 | 4.7 (0.7-8.7) | 102 | 107 |
| Testis | 9 | 1.2 (0.4-2.0) | 750 | 759 |
| Age at incident cancer, y | ||||
| 18-49 | 255 | 1.6 (1.4-1.8) | 15 748 | 16 003 |
| 50-64 | 1922 | 5.1 (4.9-5.3) | 35 622 | 37 544 |
| ≥65 | 9452 | 14.1 (13.8-14.4) | 57 570 | 67 022 |
| Sex | ||||
| Female | 5267 | 8.9 (8.7-9.2) | 53 735 | 59 002 |
| Male | 6362 | 10.3 (10.1-10.6) | 55 205 | 6362 |
| Race and ethnicityc | ||||
| Hispanic (any race) | 690 | 6.6 (6.2-7.1) | 9700 | 10 390 |
| Non-Hispanic Asian or Pacific Islander | 1024 | 8.2 (7.7-8.7) | 11 419 | 12 443 |
| Non-Hispanic Black | 598 | 5.7 (5.2-6.1) | 9970 | 10 568 |
| Non-Hispanic White | 9235 | 11.0 (10.8-11.2) | 74 892 | 84 127 |
| Otherd | 82 | 2.7 (2.1-3.3) | 2959 | 3041 |
| Stage of incident cancere | ||||
| Local | 5471 | 9.2 (9.0-9.5) | 53 697 | 59 168 |
| Regional | 2057 | 8.3 (8.0-8.7) | 22 582 | 24 639 |
| Distant | 3244 | 11.1 (10.8-11.5) | 25 856 | 29 100 |
Of 135 117 persons diagnosed with an incident cancer in 2019, 108 940 (80.6%) had no prior cancer and 26 177 (19.4%) had any prior cancer. Those with any prior cancer included 2539 (1.9%) with a prior cancer of the same type, 11 629 (8.6%) with a prior cancer of a different type, and 12 009 (8.9%) with a prior cancer of an unknown type. Only those with no prior cancer or a prior cancer of a different type are displayed in the table.
Incident cancer type is listed in order of prevalence of prior cancer of a different type.
Race and ethnicity information was abstracted from Surveillance, Epidemiology, and End Results registry data.
Other includes American Indian or Alaska Native and “some other race” as coded according to the North American Association of Central Cancer Registries item 160 (described in detail at http://datadictionary.naaccr.org/).
Does not include missing, not staged, or not applicable (n = 7662).
Findings were generally similar for female breast, colorectal, lung, and prostate cancers and melanoma (Table 2), the 5 most common incident cancers. For example, persons diagnosed with local (vs distant) stage colorectal (adjusted odds ratio [AOR], 1.33; 95% CI, 1.11-1.60) or lung (AOR, 1.59; 95% CI, 1.41-1.79) cancer were more likely to have prior cancer of a different type.
Table 2. Adjusted Associations of Prior Cancer of a Different Type and Age, Sex, Race and Ethnicity, and Stage at Diagnosis for Persons Diagnosed With 1 of the 5 Most Common Cancers in 2019a,b.
| Variable | Five most common incident cancers, AOR (95% CI) | ||||
|---|---|---|---|---|---|
| Female breast (n = 18 475) | Colorectal (n = 10 071) | Lung (n = 12 344) | Prostate (n = 17 751) | Melanoma (n = 7198) | |
| Age at incident cancer, y | |||||
| 18-49 | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 50-64 | 2.79 (2.06-3.79) | 2.07 (1.34-3.20) | 1.92 (1.11-3.34) | 4.09 (1.01-16.59) | 5.43 (3.15-9.38) |
| ≥65 | 5.94 (4.44-7.94) | 8.93 (5.69-13.38) | 4.64 (2.70-7.95) | 9.17 (2.28-36.98) | 23.52 (14.01-39.49) |
| Sex | |||||
| Female | NA | 1 [Reference] | 1 [Reference] | NA | 1 [Reference] |
| Male | NA | 0.99 (0.86-1.14) | 1.08 (0.97-1.20) | NA | 1.12 (0.96-1.32) |
| Race and ethnicityc | |||||
| Hispanic (any race) | 0.89 (0.69-1.14) | 0.85 (0.65-1.12) | 0.86 (0.68-1.09) | 0.66 (0.48-0.89) | 1.03 (0.62-1.73) |
| Non-Hispanic Asian or Pacific Islander | 0.82 (0.66-1.02) | 0.84 (0.66-1.06) | 0.74 (0.61-0.88) | 1.04 (0.82-1.33) | 1.11 (0.58-2.11) |
| Non-Hispanic Black | 0.41 (0.29-0.58) | 0.63 (0.48-0.84) | 0.65 (0.52-0.80) | 0.40 (0.30-0.53) | NA |
| Non-Hispanic White | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Otherd | 0.71 (0.38-1.30) | 0.11 (0.03-0.43) | 0.56 (0.28-1.11) | 0.14 (0.06-0.34) | NA |
| Stage of incident cancer | |||||
| Local | 1.17 (0.85-1.60) | 1.33 (1.11-1.60) | 1.59 (1.41-1.79) | 0.75 (0.61-0.92) | 1.16 (0.78-1.70) |
| Regional | 0.96 (0.69-1.35) | 0.97 (0.80-1.17) | 1.27 (1.11-1.46) | 0.53 (0.40-0.70) | 1.25 (0.80-1.96) |
| Distant | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
Abbreviations: AOR, adjusted odds ratio; NA, not applicable.
Observations missing stage not included in adjusted models; by incident cancer type, the analytic sample size was 18 148 (female breast); 9467 (colorectal); 11 619 (lung); 16 888 (prostate); and 6773 (melanoma).
By incident cancer type, Akaike information criteria was 7012.8 (female breast); 5402.6 (colorectal); 9472.7.9 (lung); 6835.5 (prostate); and 4333.3 (melanoma).
Race and ethnicity information was abstracted from Surveillance, Epidemiology, and End Results registry data.
Other includes American Indian or Alaska Native and “some other race” as coded according to the North American Association of Central Cancer Registries item 160 (described in detail at http://datadictionary.naaccr.org/).
Discussion
The increase in number of persons newly diagnosed with cancer in the US (from 1 618 263 in 2013 to 1 737 969 in 2019), combined with the increasing prevalence of prior cancer (from 18.4% in a previous study to 19.4%), show an approximately 15% increase in the number of cancer survivors diagnosed with a new cancer in 6 years.
Recommendations against excluding patients from clinical trials solely on the basis of prior cancer are supported by growing evidence that persons newly diagnosed with cancer who have survived a prior cancer of a different type have equivalent survival compared with those without prior cancer.3,4 Yet implementation of these recommendations has been slow. Two-thirds of NCI-supported trials from 2018 to 2020 exclude patients with prior or concurrent cancers.5
White persons were more likely to have prior cancers of a different type compared with Black persons, perhaps associated with survival long enough to be diagnosed with multiple cancers. Understanding multiple cancer diagnoses by race and ethnicity may help achieve equity in cancer care.6
In addition, our findings point to unique needs of cancer survivors. The American Cancer Society, American Society of Clinical Oncology, and National Comprehensive Cancer Network provide care guidelines for survivors, but only for a few specific cancers. Developing evidence-based guidelines for long-term care of this population is critical to improving outcomes and mitigating risk of multiple cancers. Limitations include that nearly 10% of persons newly diagnosed with cancer had a prior cancer of an unknown type, likely representing prior cancers diagnosed outside of SEER-defined regions and for which information on tumor site and histology was not available.
Conclusions
Increasing prevalence of prior cancer underscores the continued importance of evaluating exclusion criteria of clinical trials, improving equity in cancer care, and addressing the unique needs of this large and growing population.
eMethods
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eMethods
Data Sharing Statement