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Chapter 1. The Burden of Cancer in Utah1.1 Cancer diagnoses and deaths in Utah, 2017In 2017, 13,604 new cancers were diagnosed amongUtah residents. Of these, 10,942 were invasivecancers and 2,662 were in situ or benign. The cancersite with the largest number of new invasive cases in2017 was breast cancer. The other most commonlydiagnosed invasive cancers included prostatecancer, melanoma of the skin, colorectal cancer, andlung cancer (Figure 1.1 and Appendix C1). In situtumors, which are non-invasive and therefore moreeasily treated, were frequent for melanoma,accounting for over half of the in situ diagnoses, andbreast cancer. Tumors that are classified as benignare not reportable to the cancer registry unless theyoccur in the brain or elsewhere in the centralnervous system. In 2017, 732 benign brain andnervous system cases were diagnosed in Utah. Dataprovided throughout this report include allreportable tumors, i.e. invasive, in situ, and benignbrain and central nervous system, except whenotherwise noted.In 2017, 3,160 Utahns died due to cancer. Cancer isthe second most common cause of death in Utah,after heart disease,1 accounting for 17.5% of alldeaths in the state.2 The leading causes of cancerdeath were lung cancer, breast cancer, colorectalcancer, and pancreatic cancer (Figure 1.1 andAppendix C1). Cancer survival varies considerablyby cancer site and is highly dependent upon thestage at which the cancer is diagnosed (AppendixC3). Those diagnosed with cancer at in situ and localstages had overall 95.8% five-year survival relativeto comparable-age individuals. On January 1, 2017,there were an estimated 113,722 cancer survivors inthe state of Utah. These survivors represented 3.7%of the state’s population. There were over 22,000breast cancer survivors, over 21,000 prostate cancersurvivors, and over 17,000 melanoma survivors.The median age of Utahns in 2017 was 30.9 years,which is younger than in any other state in the U.S.3Cancer incidence is highly related to age, withdiagnoses being much less frequent among children,adolescents, and young adults than in the olderpopulation (Figure 1.2). Utah’s relatively youngpopulation means that a smaller proportion ofindividuals are in the older age groups in whichcancer diagnoses are more common. In 2017 therewere 256 incident cancers among the over 1 millionUtahns younger than 20 years of age. Thus residentsaged less than 20 years, who represent nearly 33%of Utahns, experience fewer than 2% of cancerdiagnoses. Conversely, residents aged 60 and older,who represent only 15% of the Utah population,account for nearly 63% of cancer diagnoses.Figure 1.2 Age distribution of the Utah population and cancer incidence by age, 2017CANCER IN UTAH I 2008-20173

Table 1.1 The ten most commonly diagnosed incident cancersamong Utah women2017 casesCancer TypeBreastMelanoma of the skinBrain and nervous systemColorectalUterineThyroidLungNon-Hodgkin lymphomaLeukemiaOvaryInvasive In Situ1,58245185384373322306186173163309537482b000 10.611.32017Deaths280174612958 2014968101 Number suppressed due to small cell size.aIncidence rate per 100,000 population per year for all reportable tumors, i.e.invasive, in situ, and benign brain and nervous system. Age-adjusted, for fiveyears 2013-2017.bIncludes benign brain and nervous system tumors.Table 1.2 The ten most commonly diagnosed incident cancersamong Utah men2017 casesCancer TypeProstateMelanoma of the skinColorectalBladderBrain and nervous systemLungNon-Hodgkin lymphomaKidneyLeukemiaPancreasInvasive In .512.52017Deaths212511436380250834792141aIncidence rate per 100,000 population per year for all reportable tumors, i.e.invasive, in situ, and benign brain and nervous system. Age-adjusted, for fiveyears 2013-2017.bIncludes benign brain and nervous system tumors.CANCER IN UTAH I 2008-20174

1.2 Cancer in Utah by sexThe most commonly diagnosed cancer sites varyaccording to sex. In 2017, there were 6,700 cancerdiagnoses in Utah women (Appendix C1). Amongwomen in Utah, breast cancer was the mostcommonly diagnosed cancer, with 1,582 invasivediagnoses and 309 in situ diagnoses, and ageadjusted incidence of 137.0 per 100,000 per year(Table 1.1). Breast cancer comprised 28.2% of alldiagnoses among Utah women in 2017. Melanoma ofthe skin, including 451 invasive and 537 in situ cases,was the second most common cancer diagnosisamong women, with age-adjusted incidence of 59.6per 100,000 per year. The next most commonlydiagnosed cancers among Utah women were brainand nervous system, the majority of which werebenign, followed by colorectal cancers.In 2017, 1,478 Utah women died of cancer. Therewere 280 deaths due to breast cancer, representing18.9% of all cancer deaths among Utah women. Lungcancer and colorectal cancer were the second andthird most common causes of cancer deaths amongwomen, accounting for 13.6% and 8.7% of cancerdeaths, respectively. Although melanoma diagnoseswere common among Utah women, there were only17 deaths from melanoma in 2017.Among Utah men, there were 6,904 cancer diagnosesin 2017. Prostate cancer was the most frequentlydiagnosed cancer for men, with 1,525 cases and anage-adjusted incidence rate of 112.8 cases per100,000 per year (Table 1.2). Prostate cancerdiagnoses accounted for 22.1% of cancer diagnosesamong Utah men in 2017. The second mostcommonly diagnosed cancer among men wasmelanoma, with 616 invasive and 764 in situ cases,and an age-adjusted incidence rate of 98.6 cases per100,000 per year. The third most commonlydiagnosed cancer among Utah men was colorectalcancer.In 2017, 1,682 Utah men died from cancer. Whilelung cancer was only the fifth most commonlydiagnosed cancer among men in Utah, it was theleading cause of cancer death among Utah men,accounting for 14.9% of cancer deaths. The secondmost common cause of cancer death among Utahmen was prostate cancer, representing 12.6% ofcancer deaths. Colorectal cancer had the third largestnumber of deaths among men in the state,accounting for 8.5% of cancer deaths.Numbers of cancer diagnoses and deaths amongUtah men and women for other sites are provided inFigure 1.3 Race and Hispanic/Latino ethnicity by age in Utah, 2017 A) total population and B)incident cancer casesCANCER IN UTAH I 2008-20175

Appendix C1, and incidence and mortality rates bycancer site are in Appendix C2.1.3 Cancer in Utah by race and ethnicityA majority of Utah residents are non-Hispanicwhites, who were 80.0% of Utah’s 2017 population4(Figure 1.3 A). Utah’s Hispanic/Latino populationhas been growing rapidly and Hispanics/Latinos ofany race comprised 14.0% of Utah’s 2017population. The next largest group in Utah is theAsian and Pacific Islander population, 3.8% ofUtahns. Black or African American residents makeup 1.4% of the population and American Indian andAlaska Natives represent 0.6%.The Utah Hispanic/Latino population is youngerthan the non-Hispanic white population,representing 17.6% of the population younger thanage 20 years but only 6.2% of the population ages 60and older (Figure 1.3 A). With relatively fewHispanics/Latinos in the older age groups that havehigh cancer incidence rates, only 7.0% of newcancers in the state were diagnosed amongHispanics/Latinos. Hispanics/Latinos account for18.8% of incident cancer cases aged 19 and younger,but only 5.3% of cases aged 60 and older (Figure 1.3B). Even when the difference in age distribution istaken into account, Hispanics/Latinos in Utah havelower cancer incidence than non-Hispanic whites;the 2013-2017 age-adjusted cancer incidence rate of425.7 per 100,000 per year among UtahHispanics/Latinos was statistically significantlylower than the incidence for Utah non-Hispanicwhites (Table 1.3 and Appendix C4). Age-adjustedcancer mortality, 109.1 deaths per 100,000 per yearamong Hispanics/Latinos, is also statisticallysignificantly lower than the 126.8 per 100,000 peryear observed among non-Hispanic whites(Appendix C5).Figure 1.4 Cancer sites with statistically significant differences in age-adjusted incidence ormortality between Hispanics/Latinos and non-Hispanic whites, Utah 2013-2017. Positive percentdifference indicates rate higher among Hispanics/Latinos compared to non-Hispanic whites. Negativepercent difference indicates lower rate among Hispanics/Latinos.CANCER IN UTAH I 2008-20176

Table 1.3 Cancer incidence by race andHispanic/Latino ethnicity in UtahRace and ethnicity2017 IncidenceCasesrateaWhite, non-HispanicHispanic/LatinoBlack or African AmericanAsian or Pacific IslanderAmerican Indian or 293.4Incidence per 100,000 per year for the period 2013-2017.When cancer for specific sites is compared betweenHispanics/Latinos and non-Hispanic whites in Utah,several differences are noted. Cancer sites withstatistically significant differences in incidence ormortality between Utah Hispanics/Latinos and nonHispanic whites are shown in Figure 1.4.Hispanics/Latinos had significantly lower ageadjusted incidence rates for melanoma, urinarybladder, brain and nervous system, and prostatecancers. Conversely, the 2013 through 2017incidence rates for liver, stomach, cervical, andkidney and renal pelvis cancers were statisticallysignificantly higher among Hispanics/Latinoscompared to non-Hispanic whites. Mortality ratesfor liver and stomach cancers were also higheramong Hispanics/Latinos. Higher incidence ofstomach, cervical, and liver cancers amongHispanics/Latinos compared to non-Hispanic whitesis consistent with a pattern reported throughout theU.S.5 Hepatitis C infection, which is known to havehigh prevalence among Hispanic/Latino immigrants,is thought to contribute to the higher liver cancerincidence among Hispanics/Latinos.6 Higherstomach cancer incidence in Hispanics/Latinos hasbeen suggested to be related to higher prevalence ofH. pylori infection and differences in diet.5,7 Humanpapilloma virus (HPV), an important factorinfluencing cervical cancer incidence, is discussed inChapter 3.4. Incidence and mortality rates by cancersite for Hispanics/Latinos in Utah are shown in detailin Appendix C4 and Appendix C5.Utah's residents who are black or African Americanare another population with an age distribution thatis markedly young compared to the state's majoritynon-Hispanic whites. In contrast to the populationaged 0 to 19 years, among whom 1.8% are black,only 0.6% of Utah residents who are ages 60 yearsand older are black (Figure 1.3 A). Because there arerelatively few black individuals in the older agegroups that have high cancer incidence, there wereonly 100 incident cancers reported in black Utahnsin 2017 (Table 1.3).Figure 1.5 Cancer incidence for five major sites by race and ethnicity, Utah 2013-2017CANCER IN UTAH I 2008-20177

The age-adjusted cancer incidence rate of 474.7 per non-white races is so small that it is not feasible to100,000 for black Utahns in 2013-2017 did not interpret differences across racial groups in Utah.significantly differ from the rate for non-Hispanic1.4 Cancer in Utah by geographywhites. Cancer incidence among Utah Asian andPacific Islanders was statistically significantly lower Utah is a geographically large state of 84,899 squarethan for non-Hispanic whites. The race group with miles. Roughly 85% of the state’s population of overthe lowest overall cancer incidence were Utah 3.1 million lives in six urban counties along theresidents who were American Indian or Alaska Wasatch Front. Population size and cancer incidencenatives. American Indians in the U.S. Southwest for rural and urban counties are shown in Appendixregion, including Utah, have been reported to have C6 and C7. Variation in cancer incidence andsignificantly lower incidence of cancer overall and mortality between metropolitan and nonlower incidence of breast, prostate, and lung metropolitan areas in the U.S. and in Utah has beendescribed.10,11 The age-adjusted incidence rates forcancers8,9 compared to non-Hispanic whites.all cancer sites combined from 2013 through 2017 inComparing cancers with high incidence in the state urban counties was 488.6 per 100,000 per year,by race (Figure 1.5), a high incidence of prostate somewhat higher than the incidence of 476.0 percancer among black individuals and a low incidence 100,000 for rural counties. Cancers with statisticallyof breast cancer among American Indians or Alaska significant differences in age-adjusted incidence orNative individuals are apparent. Incidence of mortality between rural and urban counties aremelanoma of the skin is low in all other groups shown in Figure 1.6. The cancer sites that exhibitedrelative to non-Hispanic whites. Because of the small the strongest contrast of higher age-adjustednumber of annual incident cancers among the non- incidence in rural counties compared to urbanwhite race groups in Utah, the estimates of incidence counties were lung cancer and leukemia. Thefor each of these five cancer sites are imprecise, as cancers with higher incidence rates in urbanindicated by the wide 95% confidence intervals in counties compared to rural counties include brainFigure 1.5. For cancers of other sites with even lower and nervous system tumors, uterine cancer, breastin

Registry, Utah's statewide, population-based cancer registry, as part of its activities to disseminate cancer information for the state. The registry collects and manages data used to monitor trends in cancer incidence and mortality, evaluate cancer prevention and control measures, and facilitate cancer research. .