Chapter 4: Digestive Cancers

The Burden of Digestive Diseases in the United States

James E. Everhart, M.D., M.P.H.

The Surveillance, Epidemiology, and End Results (SEER) program provides considerable information on cancer burden not available for other digestive diseases. SEER statistics used in this report are number of cases and incidence in 2004, and the time trends for incidence and 5-year survival following diagnosis between 1979 and 2004. The codes used by ICD-9, ICD-10, and SEER are listed in Appendix 1.

ALL DIGESTIVE SYSTEM CANCERS

In 2004, approximately 233,000 persons were diagnosed with digestive system cancers (Table 1), which represented 18 percent of all cancers and was second only to genital system cancers for the most commonly affected organ system. Two-thirds of digestive system cancers occurred among persons age 65 years and older. The median age of diagnosis was 70 years, compared with 67 years for all cancers (PDF, 28KB) . Age-adjusted rates were highest among non-Hispanic blacks and lowest among American Indians. Males had slightly higher rates than females. Age-adjusted incidence declined by 13.2 percent between 1979 and 2004, with the entire decline coming after 1986 (Figure 1). Survival for all cancers and for individual cancers was calculated as absolute survival. Other reports may calculate survival relative to the general population with the same age and sex distribution, which would result in higher apparent survival. The same trends, however, would be seen for either approach. Five-year survival increased an absolute 6 percent to 34.6 percent; thus, for every 100 persons diagnosed with a digestive system cancer in 1999, 6 more survived at least 5 years longer than did those diagnosed 20 years earlier.

There were approximately 3.5 million ambulatory care visits for first-listed digestive system cancer in 2004 and 4.2 million all-listed visits. The elderly, whites, and males had the highest rates of ambulatory care visits (Table 2). Among all hospital discharges with digestive system cancers, about half were first-listed. The main demographic difference between ambulatory care diagnoses and hospital diagnoses was that blacks had a higher age-adjusted rate of hospital diagnoses. Rates of ambulatory care visits for digestive system cancers did not change appreciably over the period 1992–2004, but hospitalizations rates declined by 13.6 percent over that period (Figure 2).

In 2004, there were approximately 135,000 deaths due to digestive system cancers (Table 3), which represented 24 percent of all cancers and were second only to respiratory system cancers as cause of death due to cancer. As underlying cause, digestive system cancers constituted 57.2 percent of all digestive disease deaths. Death rates among persons 65 years and older were 5 times that of those aged 45–64 years. Age-adjusted death rates were higher among blacks and men. There were 945,000 YPLL due to digestive system cancer, the large majority occurring among males. Death rates from digestive system cancer declined steadily between 1979 and 2004 by an overall 19.8 percent (Figure 3).

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for digestive system malignancies in 2004, according to the Verispan database (Appendix 2), are shown in Table 4. An estimated 879,000 outpatient prescriptions were filled. The costliest agents were either anti-neoplastic agents, such as capecitabine, or nonspecific pain and anti-nausea medications, such as fentanyl. Because the prescriptions were filled at retail pharmacies and do not capture all the settings where anti-cancer treatment is prescribed, this table both underestimates the number of prescriptions and likely misses many of the drugs used to treat digestive system malignancies. Medications are not shown for the individual malignancies in the following chapters.

Table 1. All Digestive Cancers: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
293 0.5
AGE (Years)
15–44
10,927 9.1
AGE (Years)
45–64
78,215 111.6
AGE (Years)
65+
154,886 452.8
RACE/ETHNICITY
Non-Hispanic White
191,668 99.6 83.5
RACE/ETHNICITY
Non-Hispanic Black
26,748 78.3 109.0
RACE/ETHNICITY
Hispanic
15,921 39.3 81.8
RACE/ETHNICITY
Asian/Pacific Islander
8,914 72.4 84.4
RACE/ETHNICITY
American Indian/Alaska Native
1,009 54.5 75.0
Sex
Female
109,058 74.7 70.0
Sex
Male
123,967 88.7 105.1
Total 233,239 81.6

Figure 1. All Digestive Cancers: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 decreased from 99.6 in 1979 to 86.5 in 2004, with the entire decline coming after 1985. Five-year survival increased from 28.6 percent in 1979 to 34.6 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

Table 2. All Digestive Cancers: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 1 5 7
AGE (Years)
15–44
110 87 145 115 19 15 47 37
AGE (Years)
45–64
1,293 1,829 1,537 2,174 115 163 257 364
AGE (Years)
65+
2,034 5,600 2,472 6,805 200 550 418 1,149
Race
White
3,149 1,235 3,771 1,479 263 102 572 222
Race
Black
240 802 313 1,040 40 141 89 307
Sex
Female
1,740 1,081 2,218 1,375 167 100 374 226
Sex
Male
1,741 1,309 1,980 1,485 168 128 351 267
Total 3,481 1,185 4,198 1,429 335 114 726 247

Figure 2. All Digestive Cancers: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of ambulatory care visits did not change appreciably over the period, but hospitalization rates declined since the early 1990s. Ambulatory care visits per 100,000 were 1,032 in 1992-1993 and 1,395 in 2003-2005. Hospitalizations per 100,000 increased from 224 in 1979 to 260 in 1984, remained relatively stable through 1992, and then declined to 216 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Table 3. All Digestive Cancers: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
43 0.1 3.0 57 0.1
AGE (Years)
15–44
3,972 3.2 142.7 4,549 3.6
AGE (Years)
45–64
35,968 50.9 648.1 41,599 58.8
AGE (Years)
65+
95,123 261.8 151.5 114,984 316.5
Race
White
113,468 43.5 737.8 136,231 52.2
Race
Black
16,907 62.2 161.7 19,587 72.3
Sex
Female
61,515 35.4 346.5 74,315 42.7
Sex
Male
73,592 57.9 598.7 86,876 68.8
Total 135,107 46.0 945.2 161,191 54.9

Figure 3. All Digestive Cancers: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates declined steadily between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 55.6 in 1979 to 44.6 in 2004. All-cause mortality per 100,000 decreased from 69.9 in 1979 to 53.1 in 2004.
Source: Vital Statistics of the United States

Table 4. All Digestive Cancers: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Capecitabine 77,376 8.8% $76,943,103 53.6%
Fentanyl 80,768 9.2 21,519,990 15.0
Oxycodone 92,577 10.5 20,027,456 14.0
Hydromorphone 371,312 42.2 16,110,590 11.2
Oxycodone/Acetaminophen 215,506 24.5 4,516,077 3.1
Morphine 17,890 2.0 3,690,323 2.6
Gemcitabine 379 0.0 361,858 0.3
Hydrocodone/Acetaminophen 4,285 0.5 249,901 0.2
Bevacizumab 18 0.0 45,962 0.0
Cetuximab 15 0.0 27,876 0.0
Other 18,557 2.0 14,683 0.0
Total 878,683 100.0% $143,507,819 100.0%