Trends in cancer mortality among people with vs without diabetes in the USA, 1988–2015
Cancer-related death is higher among people with vs without diabetes. However, it is not known if this excess risk has changed over time or what types of cancer may be driving these changes.
To estimate rates of site-specific cancer mortality in adults with vs without self-reported diagnosed diabetes, we used data from adults aged ≥18 years at the time of the interview who participated in the 1985—2012 National Health Interview Survey. Participants’ data were linked to the National Death Index by the National Center for Health Statistics to determine vital status and cause of death through to the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988–1994, 1995–1999, 2000–2004, 2005–2009, 2010–2015) were estimated using discrete Poisson regression models adjusted for age, sex and race/ethnicity with p for linear trend reported (ptrend). Site-specific cancer mortality rates were stratified by diabetes status and period, and total cancer mortality rates were additionally stratified by sex, race/ethnicity, education and BMI status.
Among adults with diabetes, age-adjusted cancer mortality rates (per 10,000 person-years) declined 25.5% from 39.1 (95% CI 30.1, 50.8) in 1988–1994 to 29.7 (26.6, 33.1) in 2010–2015, ptrend < 0.001. Among adults without diabetes, rates declined 25.2% from 30.9 (28.6, 33.4) in 1988–1994 to 23.2 (22.1, 24.2) in 2010–2015, ptrend < 0.01. Adults with diabetes remained approximately 30% more likely to die from cancer than people without diabetes, and this excess risk did not improve over time. In adults with diabetes, cancer mortality rates did not decline in some population subgroups (including black people, people with lower levels of education and obese people), and the excess risk increased for obese adults with vs without diabetes. Declines in total cancer mortality rates in adults with diabetes appear to be driven by large relative declines in cancers of the pancreas (55%) and breast (65%), while for lung cancer, declines are modest (7%).
Declines in cancer mortality rates were observed in adults with and without diabetes. However, adults with diabetes continue to be more likely to die from cancer than people without diabetes. This study highlights the continued need for greater cancer risk-factor mitigation, especially in adults with diabetes.
KeywordsCancer Diabetes Epidemiology Mortality Trends
National Center for Health Statistics
National Death Index
National Health Interview Survey
The authors thank the women and men who participated in the study, as well as all of the staff involved at the NCHS for the study design, data collection and data dissemination.
JLH conducted the literature search, contributed to the conception and design of the study, interpreted the data and wrote the article. LJA contributed to the design of the study, performed the statistical analysis, assisted in drafting the article and revised the article for important intellectual content. YJC provided technical statistical support and revised the article for important intellectual content. KMB, EWG, HKW and NRB contributed to the design of the study and revised the manuscript for important intellectual content. GI conceived and designed the study and revised the manuscript for important intellectual content. JLH is the guarantor of this work and, as such, had full access to the all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version of the manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Duality of interest
The authors declare that there is no duality of interest associated with this manuscript.
- 5.Gregg EW, Cheng YJ, Srinivasan M et al (2018) Trends in cause-specific mortality among adults with and without diagnosed diabetes in the USA: an epidemiological analysis of linked national survey and vital statistics data. Lancet 391(10138):2430–2440. https://doi.org/10.1016/S0140-6736(18)30314-3 CrossRefGoogle Scholar
- 11.National Center for Health Statistics. Office of Analysis and Epidemiology. The Linkage of National Center for Health Statistics Survey Data to the National Death Index – 2015 Linked Mortality File (LMF): methodology overview and analytic considerations, March 2019. Hyattsville, Maryland. Accessed 30 July 2019 from: www.cdc.gov/nchs/data/datalinkage/LMF2015_Methodology_Analytic_Considerations.pdf
- 12.National Center for Health Statisics. Centers for Disease Control and Prevention. About the National Health Interview Survey. Accessed 30 July 2019 from: www.cdc.gov/nchs/nhis/about_nhis.htm#sample_design
- 14.National Center for Health Statistics, Office of Analysis and Epidemiology (2013) Use of survey weights for linked data files – preliminary guidance. Hyattsville, Maryland. Accessed 30 July 2019 from: www.cdc.gov/nchs/data/datalinkage/use_of_survey_weights_for_linked_data_files.pdf
- 15.Cheng YJ, Gregg EW, Rolka DB, Thompson TJ (2016) Using multi-year national survey cohorts for period estimates: an application of weighted discrete Poisson regression for assessing annual national mortality in US adults with and without diabetes, 2000—2006. Popul Health Metr 14(1):48. https://doi.org/10.1186/s12963-016-0117-x CrossRefGoogle Scholar
- 20.van de Poll-Franse LV, Houterman S, Janssen-Heijnen ML, Dercksen MW, Coebergh JW, Haak HR (2007) Less aggressive treatment and worse overall survival in cancer patients with diabetes: a large population based analysis. Int J Cancer 120(9):1986–1992. https://doi.org/10.1002/ijc.22532 CrossRefGoogle Scholar
- 25.Harding JL, Shaw JE, Peeters A, Davidson S, Magliano DJ (2016) Age-specific trends from 2000-2011 in all-cause and cause-specific mortality in type 1 and type 2 diabetes: a cohort study of more than one million people. Diabetes Care 39(6):1018–1026. https://doi.org/10.2337/dc15-2308 CrossRefGoogle Scholar
- 30.Howlader N, Noone AK, Krapcho M, et al. (2019) SEER Cancer Statistics Review, 1975–2011 National Cancer Institute. Bethesda, MD, USA, 2014. Accessed 30 July 2019 from: https://seer.cancer.gov/archive/csr/1975_2011/
- 36.Smith-Warner SA, Spiegelman D, Adami HO et al (2001) Types of dietary fat and breast cancer: a pooled analysis of cohort studies. Int J Cancer 92(5):767–774. https://doi.org/10.1002/1097-0215(20010601)92:5<767::AID-IJC1247>3.0.CO;2-0 CrossRefGoogle Scholar
- 45.Little SA, Jarnagin WR, DeMatteo RP, Blumgart LH, Fong Y (2002) Diabetes is associated with increased perioperative mortality but equivalent long-term outcome after hepatic resection for colorectal cancer. J Gastrointest Surg 6(1):88–94. https://doi.org/10.1016/S1091-255X(01)00019-1 CrossRefGoogle Scholar
- 46.Wilt TJ, Cowper DC, Gammack JK, Going DR, Nugent S, Borowsky SJ (1999) An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: time trends and geographic variation in utilization and outcomes. Med Care 37(10):1046–1056. https://doi.org/10.1097/00005650-199910000-00008 CrossRefGoogle Scholar
- 48.Centers for Disease Control and Prevention. National Diabetes Surveillance System (2016) Available from https://www.cdc.gov/diabetes/data/index.html. Accessed 30 July 2019
- 49.Centers for Disease Control and Prevention (2017) National Diabetes Statistics Report. Available from https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed 30 July 2019