Abstract
This study uses National Center for Health Statistics data to analyze colorectal cancer mortality rates among US adults aged 20 to 54 years by race from 1970 through 2014.
Colorectal cancer (CRC) incidence has been increasing in the United States among adults younger than 55 years since at least the mid-1990s, with the increase confined to white men and women and most rapid for metastatic disease. Although CRC mortality is declining overall, trends for all ages combined mask patterns in young adults, which have not been comprehensively examined. We analyzed CRC mortality among persons aged 20 to 54 years by race from 1970 through 2014.
Methods
This study did not require institutional review board approval based on guidelines from the National Human Research Protections Advisory Committee because it was based on government-issued, deidentified, public use data. CRC mortality rates per 100 000 population (age-adjusted to the 2000 US standard population) from 1970 through 2014 were obtained from SEER*Stat (National Cancer Institute), version 8.3.4, for decedents who were aged 20 to 54 years, as reported by the National Center for Health Statistics (NCHS). NCHS mortality data are based on the underlying cause of death reported on death certificates filed in all 50 states and the District of Columbia reflecting more than 99% of deaths. Deaths were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes 153, 154, and 159 during 1970-1998 and ICD-10 codes C18 to C20 and C26 during 1999-2014. Rates were stratified by race (black, white, and other) and age (20-29, 30-39, 40-49, and 50-54 years). Trends were quantified using the Joinpoint Regression Program (National Cancer Institute), version 4.4.0.0, which uses permutation analysis to fit a series of straight lines on a logarithmic scale to observed rates to estimate annual percent change (APC), resulting in trends of variable length. Trends were only described as increasing or decreasing when the APC was significantly different from 0 (P < .05) using a 2-sided test.
Results
During 1970-2014, 242 637 people aged 20 to 54 years died from CRC at a median age of 49 years (interquartile range, 44-52). Decedents were 54% male, 80% white, 17% black, and 3% other race. CRC mortality rates per 100 000 population among individuals aged 20 to 54 years declined from 6.3 in 1970 to 3.9 in 2004, then increased by 1.0% annually (95% CI, 0.7% to 1.4%) to 4.3 in 2014 (Figure). The increase was confined to white individuals, among whom mortality rates increased by 1.4% annually (95% CI, 1.1% to 1.8%), from 3.6 in 2004 to 4.1 in 2014. Among black individuals, mortality rates declined by 0.4% annually (95% CI, −0.6% to −0.3%) to 1.1% annually (95% CI, −1.5% to −0.7%), from 8.1 in 1970 to 6.1 in 2014. Among other races combined, mortality rates declined from 1970-2006 and were stable thereafter.
Figure. Annual Percent Change (APC) in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years in the United States by Race, 1970-2014.
Lines were fitted according to the Joinpoint Regression Program (National Cancer Institute), version 4.4.0.0, which uses permutation analysis to fit a series of straight lines on a logarithmic scale to observed rates, indicated by circles; up to 4 joinpoints (5 line segments) were allowed.
aThe APC is statistically significantly different from 0 (2-sided P < .05), based on the permutation method.
bAge-adjusted to the 2000 US standard population.
In age-stratified analyses, mortality trends in white individuals during the most recent period defined by joinpoint were stable for those aged 20 to 29 years from 1988-2014, but increased by 1.6% annually (95% CI, 1.2% to 2.1%) for those aged 30 to 39 years from 1995-2014, by 1.9% annually (95% CI, 1.2% to 2.5%) for those aged 40 to 49 years, and by 0.9% annually (95% CI, 0.1% to 1.6%) for those aged 50 to 54 years from 2005-2014 (Table). In contrast, rates in black individuals decreased over the entire study period among those aged 20 to 49 and since 1993 among those aged 50 to 54 years.
Table. Trends in Colorectal Cancer Mortality Rates Among Adults Aged 20 to 54 Years by Race and Age in the United States, 1970-2014a.
| Age Range, y |
Total Deaths, No. |
Trend 1b | Trend 2b | Trend 3b | Trend 4b | Trend 5b | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Period | APC (95% CI) | Period | APC (95% CI) | Period | APC (95% CI) | Period | APC (95% CI) | Period | APC (95% CI) | ||
| All Races | |||||||||||
| 20-29 | 6281 | 1970- 1988 |
−2.5 (−3.2 to −1.8)c |
1988- 2014 |
0.1 (−0.3 to 0.5) |
||||||
| 30-39 | 26 900 | 1970- 1994 |
−2.0 (−2.3 to −1.8)c |
1994- 2014 |
1.0 (0.7 to 1.4)c |
||||||
| 40-49 | 98 422 | 1970- 1996 |
−1.7 (−1.9 to −1.6)c |
1996- 2001 |
1.1 (−1.2 to 3.4) |
2001- 2004 |
−3.0 (−9.5 to 3.9) |
2004- 2014 |
1.4 (0.8 to 1.9)c |
||
| 50-54 | 111 034 | 1970- 1993 |
−1.3 (−1.5 to −1.2)c |
1993- 1996 |
−4.7 (−11.2 to 2.3) |
1996- 2002 |
0.1 (−1.4 to 1.5) |
2002- 2005 |
−3.5 (−9.5 to 2.9) |
2005- 2014 |
0.8 (0.2 to 1.3)c |
| White Race | |||||||||||
| 20-29 | 4642 | 1970- 1988 |
−2.7 (−3.4 to −1.9)c |
1988- 2014 |
0.5 (0 to 1.0) |
||||||
| 30-39 | 20 868 | 1970- 1995 |
−2.2 (−2.5 to −2.0)c |
1995- 2014 |
1.6 (1.2 to 2.1)c |
||||||
| 40-49 | 78 377 | 1970- 1975 |
−0.3 (−1.9 to 1.4) |
1975- 1993 |
−2.2 (−2.5 to −2.0)c |
1993- 2005 |
−0.5 (−1.0 to 0) |
2005- 2014 |
1.9 (1.2 to 2.5)c |
||
| 50-54 | 90 678 | 1970- 1984 |
−1.3 (−1.7 to −0.9)c |
1984- 2005 |
−2.0 (−2.2 to −1.7)c |
2005- 2014 |
0.9 (0.1 to 1.6)c |
||||
| Black Race | |||||||||||
| 20-29 | 1325 | 1970- 2014 |
−2.1 (−2.5 to −1.6)c |
||||||||
| 30-39 | 4985 | 1970- 2014 |
−0.8 (−1.1 to −0.5)c |
||||||||
| 40-49 | 16 989 | 1970- 2014 |
−0.5 (−0.6 to −0.4)c |
||||||||
| 50-54 | 17 499 | 1970- 1993 |
−0.1 (−0.5 to 0.3) |
1993- 2014 |
−1.1 (−1.5 to −0.7)c |
||||||
Abbreviation: APC, annual percent change.
Race information on death certificates was reported by funeral directors as provided by an informant, or in the absence of an informant, based on observation. Mortality rates were analyzed separately for black and white populations because of racial differences in colorectal cancer incidence trends. Colorectal cancer was identified by International Classification of Diseases, Ninth Revision (ICD-9), codes 153, 154, 159 for deaths from 1970-1998 and ICD-10 codes C18 to C20 and C26 for deaths from 1999-2014.
Trends were analyzed by Joinpoint Regression Program (National Cancer Institute), version 4.4.0.0, with a maximum of 4 joinpoints (ie, 5 line segments) that vary in length to reflect differences in the pattern of observed rates.
Indicates the APC is statistically significantly different from 0 (P < .05) using a 2-sided test based on the permutation method.
Discussion
CRC mortality rates decreased since 1970 in black individuals aged 20 to 54 years, but increased in white individuals since 1995 among those aged 30 to 39 years and since 2005 among those aged 40 to 54 years following decades of decline. These trends are consistent with CRC incidence from 1998-2009 among those younger than 50 years, which was stable in black individuals, but increased in white individuals by 1.5% annually for local-stage and regional-stage disease and by 3% annually for distant-stage disease. Disparate racial patterns conflict with trends in major CRC risk factors like obesity, which are similar in white and black individuals.
Although 5-year survival in persons aged 15 to 64 years has improved, mortality is a function of incidence and survival and can increase if increased CRC occurrence is of sufficient magnitude to outweigh improvements in survival. Increased mortality is particularly unexpected among those aged 50 to 54 years, for whom screening has been recommended since the 1970s.
This study is limited by its ecologic nature and inaccuracies in about 5% of all death certificates listing CRC as the underlying cause of death. Escalating mortality rates in young and middle-aged adults highlight the need for earlier CRC detection through age-appropriate screening and more timely follow-up of symptoms.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
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