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Published in final edited form as: Int J Cancer. 2024 Nov 21;156(9):1716–1725. doi: 10.1002/ijc.35268

Sex-based Differences in Histologic Lung Cancer Incidence Trends in the United States, 2005–2019

Todd Burus a, Manali I Patel b, W Jay Christian c, Bin Huang a,d,e, Krystle A Lang Kuhs a,c
PMCID: PMC12372523  NIHMSID: NIHMS2102953  PMID: 39572890

Abstract

Decreases in lung cancer incidence in the United States (US) have paralleled decreasing smoking prevalence for several decades; however, recent data has revealed slower declines among females than males. Sex-based differences in histologic lung cancer—and specifically adenocarcinoma—for all 50 US states and the District of Columbia have never been investigated.

Using population-based cancer registry data from the US Cancer Statistics, we examined age-adjusted histologic lung cancer incidence rates and trends by sex and state of residence at diagnosis. We compared state-level adenocarcinoma incidence to lung cancer screening (LCS) adherence and smoking prevalence estimates. Average annual percentage change (AAPC) and incidence rate ratios (IRR) were used to assess changes over time.

Nationally, females experienced faster increases in adenocarcinoma incidence than males (1.75%/year versus 0.35%/year), and slower decreases in incidence of squamous cell (−0.06%/year versus −1.58%/year) and small cell carcinoma (−2.06%/year versus −3.19%/year). Adenocarcinoma incidence increased significantly (AAPC>0) in 41 states among females compared to 10 among males. Significant adenocarcinoma increases in individuals under age 55 (IRR>1) occurred among females in six states (four in the southeastern US) and none among males. State-level LCS adherence was significantly associated with adenocarcinoma incidence among females (r=0.39; P<0.01) but not males, though screening cannot account for increases among females under age 55.

Our results highlight sex-based differences in histologic lung cancer incidence trends, with specific concern for increases in adenocarcinoma in the southeastern US. Further research is needed into appropriate LCS eligibility criteria and the risk factors driving sex-based disparities.

Keywords: Lung cancer, Histology, Adenocarcinoma, Incidence, Health disparities

Introduction

The prevalence of smoking among adults in the United States (US) has steadily decreased for several decades, from 42.6% in 1965 to 11.6% in 2022.1 Correspondingly, lung cancer incidence has also decreased.2 However, recent data indicates slower declines in female lung cancer incidence, with age-specific rates among females aged 30–54 years now exceeding those among same-aged males.3,4 No obvious explanation for this difference has been found.

Lung cancer is classified into two major histologic types—small cell and non-small cell. Non-small cell lung cancers (NSCLC) can be broken down further into subtypes, the most common being adenocarcinomas, squamous cell carcinomas, and large cell carcinomas. Research suggests differences in etiology between types of lung cancer, with some possibly sex-related.5,6 For example, studies have consistently shown a higher prevalence among females of certain epidermal growth factor mutations tied to lung adenocarcinoma.7

Previous studies have separately explored sex-based differences in US lung cancer rates by histologic type and sex-based differences in total lung cancer incidence by US state.8–10 However, to our knowledge, sex-based differences by state and lung cancer type have not been evaluated together. In this study we examined both US national and state-level trends in sex-specific lung cancer incidence by histologic type, describing patterns overall and among various patient and diagnostic characteristics, in an effort to better understand sex-based differences in lung cancer incidence.

Materials and Methods

Data Sources

We analyzed incident lung cancer cases between 2005 and 2019 from the US Cancer Statistics (USCS) Public Use Database, 2022 Submission.11 This database contains records from the Center for Disease Control and Prevention’s (CDC) National Program of Cancer Registries (NPCR) and the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) program. Though the 2022 Submission included cases from 2001 through 2020, we excluded cases from 2020 due to documented underdiagnosis of cancer during the COVID-19 pandemic.12 We excluded cases diagnosed between 2001 and 2004 to allow for five-year intervals that aligned with consistent smoking prevalence data collection methods in the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). The USCS Public Use Database covers 100% of the US population between 2005 and 2019.

For correlation analysis, we obtained state-level lung cancer screening (LCS) adherence estimates for 2016 through 2018 from work previously published by Fedewa, et al.13 During the study period, the United States Preventive Service Task Force recommended annual LCS for individuals of age 55–80 with a 30-pack-year smoking history who currently smoked or had quit smoking within the previous 15 years.14 We calculated state-level smoking prevalence from BRFSS data for the five-year ranges of 2005–2009 and 2015–2019.15

Study Population

We used International Classification of Diseases for Oncology, Third Edition (ICD-O-3) morphology codes to identify distinct lung cancer histologic types (Supplementary Table 1). We included only malignant and microscopically confirmed cases. Stage at diagnosis was determined using the Merged Summary Stage variable.16 Localized cases were classified as “early-stage”, while regional and distant cases were classified as “late-stage.”

We analyzed patient demographics according to sex, race and ethnicity, age at diagnosis, urbanicity, and state of residence at diagnosis. We used a binary age grouping for patients 55 years or older at diagnosis to differentiate among populations eligible for LCS during the study period. We used Rural-Urban Continuum Codes (RUCC) 2013 for the county of residence at time of diagnosis to determine urbanicity, with RUCC 1–3 classified as “metropolitan” and RUCC 4–9 classified as “non-metropolitan.”17 Race and ethnicity were classified as Hispanic (all races), non-Hispanic Black, non-Hispanic White, and other non-Hispanic races. Other non-Hispanic races included American Indian/Alaska Native and Asian and Other Pacific Islander, and were aggregated to reduce suppression at the state level. Data from North Dakota and Wisconsin were suppressed in all analyses including race and ethnicity due to not having Hispanic Origin reporting.

Statistical Analysis

We collected annual lung cancer incidence data for 2005–2019, stratified by histologic type and sex, for the entire US and for each individual state and the District of Columbia (DC). Lung cancer types examined included three NSCLC subtypes—adenocarcinoma, squamous cell carcinoma, and large cell carcinoma—as well as small cell carcinoma. Remaining NSCLC subtypes were excluded due to small case counts. Additionally, we collected lung adenocarcinoma rates for the five-year periods of 2005–2009 and 2015–2019 for all US states plus DC, stratified by sex and one of either race and ethnicity, age at diagnosis, stage at diagnosis, age and stage at diagnosis, or urbanicity. All incidence rates were calculated using SEER*Stat version 8.4.3 and age-adjusted per 100,000 persons to the 2000 US standard population.18 Rates were suppressed for any category of persons containing fewer than 16 cases.

We assessed temporal trends in annual cancer rates by estimating average annual percentage change (AAPC) using Joinpoint software version 5.0.2 (Supplementary Methods).19 We used incidence rate ratios (IRR) for 2015–2019 versus 2005–2009 to assess changes in five-year rates. The Tiwari method was used to calculate IRRs and corresponding 95% confidence intervals (CI).20

Additional variables were calculated to perform correlation analysis with incidence rates. We aggregated state-level LCS adherence estimates for 2016–2018 into a three-year average. Age-adjusted sex- and state-specific current smoking status estimates were calculated for 2005–2009 using BRFSS survey data. We used Spearman rank correlation to perform comparisons.

Statistical significance was assessed at a level of P < 0.05, and all hypotheses were two-sided. All analyses were performed using the R statistical programming language (version 4.3.3).21

Results

Lung Cancer Cases by Histologic Type

Between 2005 and 2019, there were 1,250,530 cases of lung adenocarcinoma, 680,641 cases of squamous cell carcinoma, 57,453 cases of large cell carcinoma, and 408,423 cases of small cell carcinoma. Females accounted for 51.9%, 37.5%, 43.1% and 50.6% of cases by type, respectively.

Trends in Lung Cancer Incidence by Histologic Type

We estimated significant annual increases in rates of lung adenocarcinoma incidence among females (1.75%/year; 95% CI, 1.60–1.89%) and males (0.35%/year; 95% CI, 0.03–0.66%) (Table 1). In contrast, there were significant decreases among females and males for large cell and small cell carcinomas, and among males for squamous cell carcinoma, with large cell carcinoma showing the fastest decreases among both sexes. Comparing type-specific annual trends between sexes, we estimated significantly faster year-to-year increases in adenocarcinoma (AAPC difference, 1.40%/year; 95% CI, 1.05%−1.75%), and significantly slower year-to-year decreases in squamous cell carcinoma (1.52%/year; 95% CI, 0.67%−2.37%) and small cell carcinoma (1.12%/year; 95% CI, 0.98%−1.26%), among females compared to males. Trends between females and males were similar for large cell carcinoma. Given that adenocarcinoma is the only lung cancer type examined showing increases over time, we restricted all remaining analyses to this type. State-level data on other lung cancer types are included in the supplement (Supplementary Figures 1–5).

Table 1.

Annual increases in lung cancer incidence in the United States by histologic subtype and sex, 2005–2019.

Subtype Sex Years APC (95% CI) AAPC (95% CI) Difference in AAPCs (95% CI)
NSCLC Adenocarcinoma Female 2005–2011 3.38 (3.20, 3.56)* 1.75 (1.60, 1.89)* 1.40 (1.05, 1.75)*
2011–2015 0.88 (0.41, 1.35)*
2015–2019 0.21 (−0.07, 0.49)
Male 2005–2011 2.08 (1.69, 2.47)* 0.35 (0.03, 0.66)* Ref
2011–2015 −0.45 (−1.47, 0.59)
2015–2019 −1.42 (−2.04, −0.80)*
NSCLC Large cell carcinoma Female 2005–2008 −8.19 (−13.45, −2.60)* −9.11 (−11.18, −6.99)* 1.18 (−1.21, 3.58)
2008–2012 −15.51 (−21.62, −8.94)*
2012–2019 −5.64 (−7.93, −3.30)*
Male 2005–2008 −10.23 (−13.18, −7.18)* −10.29 (−11.45, −9.12)* Ref
2008–2012 −15.53 (−19.02, −11.88)*
2012–2019 −7.19 (−8.49, −5.87)*
NSCLC Squamous cell carcinoma Female 2005–2010 2.02 (1.02, 3.03)* −0.06 (−0.88, 0.77) 1.52 (0.67, 2.37)*
2010–2013 −0.04 (−4.08, 4.17)
2013–2019 −1.76 (−2.42, −1.10)*
Male 2005–2012 0.16 (−0.21, 0.54) −1.58 (−1.80, −1.35)* Ref
2012–2019 −3.28 (−3.63, −2.94)*
Small cell carcinoma Female 2005–2019 −2.06 (−2.20, −1.92)* −2.06 (−2.20, −1.92)* 1.12 (0.98, 1.26)*
Male 2005–2019 −3.19 (−3.25, −3.12)* −3.19 (−3.25, −3.12)* Ref
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Abbreviations: APC = Annual percentage change; AAPC = Average APC; CI = Confidence interval; NSCLC = Non-small cell lung cancer; Ref = Reference

*

Indicates statistically significant result, P<0.05

Trends in Lung Adenocarcinoma Incidence by State

State-level lung adenocarcinoma incidence rates among females ranged from 8.8 (Utah) to 27.9 (Rhode Island) per 100,000 population in 2005 and 11.1 (Utah) to 31.3 (Massachusetts) in 2019 (Figure 1). Among males, incidence rates ranged from 11.4 (Utah) to 31.8 (Rhode Island) in 2005 and 10.9 (Utah) to 33.0 (Arkansas) in 2019. Between 2005 and 2019, state-specific incidence rates of lung adenocarcinoma increased significantly in 41 states among females and 10 states among males (Supplementary Table 2). There was only one state where annual lung adenocarcinoma rates had significant decreases among both males and females (Nevada). Females had significantly different rates from males in 21 states, with diverging trends (increasing rates among females versus static or declining rates among males) in 14 states (Supplementary Figure 6). The highest state-level AAPCs for adenocarcinoma incidence all occurred among females: Maine (4.88%/year; 95% CI, 2.57–7.24%), South Dakota (4.75%/year; 95% CI, 3.21–6.32%), North Dakota (3.97%/year; 95% CI, 2.60–5.36%), Arkansas (3.85%/year; 95% CI, 2.04–5.70%), and Kentucky (3.21%/year; 95% CI, 2.36–4.07%).

Figure 1.

Figure 1.

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State-level lung adenocarcinoma incidence rates and average annual percentage change (AAPC) by sex, 2005–2019. (A) Female incidence rates, 2005, (B) female incidence rates, 2019, (C) females AAPCs, 2005–2019, (D) male incidence rates, 2005, (E) male incidence rates, 2019, (F) males AAPCs, 2005–2019.

Trends in Lung Adenocarcinoma Incidence by Population Subgroups

Annual lung adenocarcinoma incidence in the US increased significantly among females of all racial and ethnic categories considered, while rates were stable for males except among non-Hispanic males of other races (Supplementary Table 3). National trends were reflected at the state level, with significant increases being roughly twice as frequent among females across all racial and ethnic categories (Supplementary Figure 7).

Lung adenocarcinoma rates increased significantly for metropolitan and non-metropolitan populations among both sexes, with significantly faster increases among non-metropolitan individuals and females (Supplementary Table 3). Rates were stable or increasing for non-metropolitan females and males in every state, and for metropolitan females in every state except Nevada (Supplementary Table 4).

Annual incidence rates of lung adenocarcinoma diagnosed at age 55 years or older increased significantly among both females (2.11%/year; 95% CI, 2.05–2.17%) and males (0.56%/year; 95% CI, 0.24–0.89%) (Supplementary Table 3). Nearly every state (47 out of 51) had significant increases in females diagnosed at age 55 or older (Figure 2). Significant increases among males diagnosed at age 55 or older occurred in 63% of states, with a significant decrease only observed in Nevada (IRR=0.78; 95% CI, 0.72–0.85). In contrast, annual rates of lung adenocarcinoma incidence among persons diagnosed under age 55 years were stable or decreasing nationally (females, −0.64%/year; 95% CI, −1.46–0.19%; males, −1.67%; 95% CI, −2.07 to −1.27%) (Supplementary Table 3). Nevertheless, we observed a handful of states—including four in the southeastern US—with significantly increasing rates of females diagnosed before age 55: North Dakota (IRR=2.20; 95% CI, 1.28–3.85), Maine (1.51; 95% CI, 1.21–1.90), Arkansas (1.32; 95% CI, 1.10–1.59), West Virginia (1.24; 95% CI, 1.02–1.52), Kentucky (1.23; 95% CI, 1.08–1.39), and North Carolina (1.12; 95% CI, 1.01–1.24). No states had significant IRR increases among males diagnosed under age 55.

Figure 2.

Figure 2.

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State-level lung adenocarcinoma incidence rate ratio (IRR) for 2015–2019 versus 2005–2009 by sex and age at diagnosis. (A) Female, under 55 years old, (B) Male, under 55 years old, (C) Female, 55 years or older, (D) Male, 55 years or older.

Trends in Lung Adenocarcinoma Incidence by Stage at Diagnosis

Nationally, early-stage lung adenocarcinoma incidence increased significantly among both females (3.18%/year; 95% CI, 1.95%−4.41%) and males (2.00%/year; 95% CI, 0.10%−3.94%) between 2005 and 2019, with significant state-level increases in almost every state (47 states among females, 45 states among males) (Figures 3 and 4; Supplementary Table 3). Late-stage diagnoses also increased significantly among US females (1.09%/year; 95% CI, 0.59%−1.60%), while rates among US males were stable (−0.21%/year; 95% CI, −0.68%−0.27%). Significant state-specific increases in late-stage adenocarcinoma among females occurred in 33 states, with no states experiencing a significant decrease. In comparison, late-stage diagnoses among males increased significantly in just 10 states and decreased significantly in 14 states. Of particular concern are the seven states for females (Arkansas, Kentucky, Maine, Mississippi, North Carolina, Tennessee, and West Virginia) and one state for males (Maine) where significant late-stage increases occurred among patients diagnosed under 55 years of age (Supplementary Table 5). It is also worth noting that early- and late-stage lung adenocarcinoma incidence were increasing significantly among both sexes prior to the official recommendation of LCS in 2014 (Figure 3).14

Figure 3.

Figure 3.

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Annual lung adenocarcinoma incidence rates and trends by stage and sex, 2005–2019. (A) Early stage at diagnosis, (B) Late stage at diagnosis. Trends measured using Joinpoint regression with annual percentage change (APC) of segments displayed.19 (*) indicates statistically significant APC for segment (P<0.05).

Figure 4.

Figure 4.

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State-level lung adenocarcinoma incidence rate ratio (IRR) for 2015–2019 versus 2005–2009 by sex and stage at diagnosis. (A) Female, early-stage, (B) Male, early-stage, (C) Female, late-stage, (D) Male, late-stage. Stage at diagnosis was determined using the Merged Summary Stage variable.16 Localized cases were classified as “early-stage.” Regional and distant cases were classified as “late-stage.”

Correlations with Lung Adenocarcinoma Incidence

The average of state-level LCS adherence estimates for 2016–2018 ranged between 0.6% (Nevada) and 12.5% (Massachusetts) of the eligible population. LCS adherence was significantly correlated with state-level lung adenocarcinoma incidence changes among females (r=0.39; P<0.01) but not males (r=0.27; P=0.06) (Figure 5). Correlations with changes in diagnoses at age 55 years or older (the beginning of LCS eligibility during the study period) follow the same pattern (among females, r=0.39 [P<0.01]; among males, r=0.27 [P=0.06]). In contrast, changes in diagnoses of individuals under 55 years of age were not significantly correlated with LCS rate estimates among either sex. By stage at diagnosis, LCS adherence was significantly associated with early-stage incidence changes among females (P<0.01) and males (P=0.04), but not with changes in late-stage incidence among either sex.

Figure 5.

Figure 5.

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Association between sex-specific lung adenocarcinoma incidence rate ratio (IRR) for 2015–2019 versus 2005–2009 and average lung cancer screening recommendations adherence for 2016–2018. (A) Female, (B) Male. Correlation measured on the basis of Spearman’s rank correlation coefficient.

An association was observed between age-adjusted state-level smoking prevalence in 2005–2009 and lung adenocarcinoma incidence in 2015–2019 among males (r=0.60; P<.001) but not among females (r=0.21; P=0.1316) (Supplementary Figure 8).

Discussion

In this study, we found significantly faster increases in lung adenocarcinoma incidence, and significantly slower decreases in squamous cell and small cell carcinoma incidences, among US females compared to US males. Focusing on lung adenocarcinoma, substantial state-level incidence rate increases were found among both sexes between 2005 and 2019, with more pronounced changes occurring among females regardless of patient and diagnostic characteristics considered. A pattern of notable increases emerged among females living in the southeastern region of the US—including six of the seven states demonstrating significant increases in the diagnosis of late-stage lung adenocarcinoma among younger females. While some significant correlations exist between adenocarcinoma incidence rate changes and state-level LCS adherence, this alone does not appear sufficient to explain all of the changes observed. Further exploration is necessary to uncover the etiology of current increases and sex-based differences in lung adenocarcinoma incidence in the US. To our knowledge, this is the first study to examine nationwide lung adenocarcinoma incidence trends at the state-level using a dataset that covers 100% of the US population during the study period.

Lung adenocarcinoma is the most prevalent type of lung cancer in the US, though the distribution of histologic types varies globally. Aside from a personal history of smoking, other known or suspected risk factors for lung adenocarcinoma are second-hand exposure to tobacco smoke, exposure to air pollution, personal and family history of lung disease, length between menarche and menopause, and certain genetic variations.22–26 A recent spatial analysis of lung cancer cases in Taiwan found diverging incidence trends between adenocarcinoma and squamous cell carcinoma (with adenocarcinoma increasing) and lung adenocarcinoma hotspots correlated with areas having high volumes of certain air pollutants.27 A different study using data from Taiwan concluded that rates of lung adenocarcinoma among females exceeded those among males regardless of status as a never or ever smoker.28 A study of lung cancer histologic types in the US featuring data from 2004 to 2009 found increasing rates of adenocarcinoma among both males and females, increasing rates of squamous cell carcinoma in females, and differences by demographic categories and Census regions.29 Using 10 additional years of data, we found that rates of squamous cell carcinoma among females had moderated, while lung adenocarcinoma rates continued to increase. A spatiotemporal study of histologic types using registry data in Kentucky found greater prevalence of lung adenocarcinoma in areas of the state with lower smoking and obesity prevalence, positing that environmental exposures may be responsible for increased risk of adenocarcinoma.30

Our findings of a significant association between LCS adherence and lung adenocarcinoma incidence increases among females but not males are consistent with prior studies indicating better LCS adherence among the female population.31–33 This may explain some of the observed increases in states like North Dakota and Maine having greater uptake of LCS despite lower current smoking prevalence. Nevertheless, screening alone cannot account for the observed levels of increase in females, particularly among those diagnosed before the eligible screening age (55 years old during study period).14 Moreover, the lack of significant association between state-level female smoking prevalence and rates of lung adenocarcinoma diagnoses indicates a need to consider other risk factors for understanding incidence rate patterns. More detailed analyses into how sex-based differences in age at smoking initiation, smoking duration, and smoking intensity may impact lung adenocarcinoma development are necessary.34–38 Furthermore, sex-based differences in adenocarcinoma incidence suggest that there may be additional non-tobacco-related exposures or behaviors that are more common among females, or that somehow confer greater risk to females.39,40 Etiologies such as exposure to radon and wildfire smoke should also be explored.41–43

These findings have particular importance for ensuring adequate detection and treatment of lung adenocarcinoma among females, with specific emphasis on states with disparities in incidence trends. Since estimates of LCS adherence among eligible populations remain low nearly a decade after its introduction, some interventions have begun to pair LCS with mammography.44–46 Such interventions have been found to be more effective in improving screening awareness and uptake among females. Furthermore, these results demonstrate increased incidence in particular states among younger age groups. This, combined with differences in smoking patterns among females compared to male (such as lower pack-years smoking and later age at initiation) indicate that current screening guidelines may not appropriately capture the female population most at-risk for lung cancer development.34,47,48 These findings suggest revisiting current screening guidelines to ensure appropriate detection, especially in states where the incidence among females continues to rise. Further research is also needed to understand other potential etiologies as described above, including environmental exposures, which can help to target interventions to overcome the sex-based incidence disparities reported. Finally, our findings point to the needs for focused funding mechanisms to support additional research aimed at understanding sex-based disparities in lung cancer incidence.

This study contains certain limitations. Information about personal behavioral risk factors, environmental exposures, and molecular subtypes are not available for lung cancer cases in the USCS Public Use dataset, and state-level trends could be influenced by variation in coding of histologic types. However, we performed an analysis of changes in the proportion of microscopically confirmed cases receiving broad, non-specific categories (histology codes 8000, 8001, 8010 and 8020) between 2005–2009 and 2015–2019 and found the majority of states (n=27) had less than a 1% difference. Only one state (Minnesota) had a change of over 5% (Supplementary Table 6). Analyzing differences by race and ethnicity was limited by significant suppression of certain racial and ethnic combinations at the state-level due to low case counts. Use of BRFSS data to estimate state- and sex-specific smoking prevalence is subject to self-reporting biases.

Conclusion

In conclusion, we found that the incidence of lung adenocarcinoma is increasing faster, and lung squamous cell carcinoma and small cell carcinoma are decreasing slower, among females compared to males. In particular, we observed near nationwide increases in state-level lung adenocarcinoma incidence among females that cannot be fully explained by increases in LCS uptake. Special attention should be paid to the southeastern region of the US where increasing incidence of late-stage lung adenocarcinoma diagnoses among females under age 55 was observed in several states. These findings provide further detail to previously observed differences in sex-specific lung cancer incidence trends in the US. This information can be used to better target public health interventions to increase smoking cessation and lung cancer detection, as well as to support research into other factors that may be driving sex-based differences in lung adenocarcinoma etiology.

Supplementary Material

Supplementary Material

Novelty and Impact:

While sex-based differences in lung cancer incidence trends have been observed in the US, trends by histologic subtype have not been assessed. Using data from 2005–2019, we found that incidence of lung adenocarcinoma increased significantly faster among females than males. Concerning temporal, regional, and age-specific trends that cannot be fully explained by smoking prevalence or lung cancer screening point to the need for further investigation into the etiologic origins of incidence rate disparities.

Abbreviations List:

AAPC

Average annual percentage change

BRFSS

Behavioral Risk Factor Surveillance System

CDC

Center for Disease Control and Prevention

CI

Confidence interval

DC

District of Columbia

IRR

Incidence rate ratio

LCS

Lung cancer screening

NCI

National Cancer Institute

NPCR

National Program of Cancer Registries

NSCLC

Non-small cell lung cancer

RUCC

Rural-Urban Continuum Codes

SEER

Surveillance, Epidemiology, and End Results program

US

United States

USCS

U.S. Cancer Statistics

Footnotes

CONFLICT OF INTEREST

None to report.

ETHICS STATEMENT

This study was deemed exempt from review by the University of Kentucky Institutional Review Board because it was not human subjects research. The need for informed consent was waived because data were deidentified.

DATA AVAILABILITY STATEMENT

The data used for this study is from the U.S. Cancer Statistics (USCS) Public Use Database. Investigators can access this data through a data use agreement with USCS. Further information is available from the corresponding author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material
NIHMS2102953-supplement-Supplementary_Material.docx (2.8MB, docx)

Data Availability Statement

The data used for this study is from the U.S. Cancer Statistics (USCS) Public Use Database. Investigators can access this data through a data use agreement with USCS. Further information is available from the corresponding author upon request.

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