published by the Cancer Prevention and Research Institute of Texas
In Texas, cancer is the second leading cause of death, behind only heart disease. It is the leading cause of death in 37 Texas counties. In 2024, healthcare providers will diagnose an estimated 143,349 Texans with cancer (69,583 women and 73,766 men). The most common cancers are breast, prostate, lung, and colorectal cancers, which account for approximately 47% of all cancer diagnoses.1
Although there has been substantial progress in cancer screening, prevention, diagnosis, and research in recent years, cancer continues to affect some populations in Texas disproportionally. Geographically isolated people, certain racial/ethnic groups, and individuals with a lower socioeconomic status have higher cancer death rates, less frequent use of proven screening tests, and greater rates of advanced cancer diagnoses.
The term “cancer disparities” refers to the unequal burden of cancer and its outcomes among different populations. Factors that contribute to cancer disparities are often interrelated and include both biological and social determinants. The Texas Department of Health and Human Services defines social determinants of health as the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect health, functioning, and quality of life.2 Social determinants that drive health disparities include inadequate access to transportation, environmental contamination, and poor access to healthy food. Inadequate access to cancer screening tests, preventive interventions, and high-quality cancer care, exacerbate these factors.3
Researchers do not fully understand the biological factors - such as response to treatment - that contribute to cancer disparities. Biological factors may interact with social determinants, potentially exacerbating differences in health outcomes. With an increasing population, Texas must address these widening cancer disparities in a strategic manner.
This section highlights the cancer burden in Texas, including rurality, the disparities in the incidence and survivability of cancer among racial/ethnic groups, and the impact of cancer among children, adolescents, and young adults.
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Cancer incidence and mortality rates vary by geographic area. Rural communities in the United States and in Texas face disadvantages compared with urban areas, including higher poverty rates, lower formal educational levels, and lack of access to health services. Compared to urban residents, rural Texans are more likely to be older, have smaller incomes, and are less likely to have health insurance. Rural/non-metropolitan counties in Texas also have a higher cancer mortality burden than their urban/metropolitan counterparts.
Access to care and preventative medicine are essential to reducing the cancer burden in Texas, but these services are not readily available in many rural settings. Residents of rural areas often have less contact and fewer visits with physicians, in part due to the distance individuals must travel to receive specialized care delivered by large sites, such as NCI-designated cancer centers. Most rural communities lack public transportation, making in-person medical appointments more challenging for elderly patients who do not drive, patients in single-car households, and those lacking social support that could provide transportation.1
Healthcare providers report that many of their rural patients are hesitant to obtain specialty health care in urban areas due to the distance, expense, and inconvenience, as well as a desire to receive care closer to home. Although telehealth is an option for follow-up visits, ensuring broadband coverage in many of these rural areas is difficult. Texas ranks 46th out of 50 states for its internet connectivity rate, and 85% of Texans who lack high-speed internet live in rural communities.2
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In 2022, the overall Texas poverty rate was 14%. Most populations of color experience poverty at higher rates than the state average. Hispanic Texans living in poverty (2.22 million ) make up the largest group of people experiencing poverty in the state, despite having the third-highest poverty rate at 18.6%. In 2022, 19.7% of Blacks, 16.6% of American Indian and Alaska Natives (AIAN), 9.2% of Asians, and 8.4% of non-Hispanic Whites lived in poverty in Texas.1
An extreme form of poverty, persistent poverty, includes areas where more than 20% of the population has lived in poverty for more than 30 years.2 Thirty Texas counties, primarily those along or close to the U.S.-Mexico border, sustained persistent poverty rates at or above 20%, the past three decades. People living in persistent poverty areas have an increased risk of cancer due to multiple factors, including greater carcinogen exposure, multiple non-medical drivers of health, and the lack of access to care.1 A combination of these factors results in increased cancer incidence and delayed cancer diagnosis, treatment, and, subsequently, lower rates of survival.3 The National Cancer Plan recommends that researchers study areas of persistent poverty to eliminate cancer disparities.
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Certain populations, defined by demographic factors, such as specific racial and ethnic groups, continue to suffer disproportionately from cancer. In the United States, overall death rates for cancer are highest for non-Hispanic Black people, followed by American Indian and Alaska Native (AIAN) people. In Texas, we see a similar trend for non-Hispanic Black people.
Texas is one of only four states that is a “majority-minority” state where the non-Hispanic White population is less than 50%. In 2023, Texas’ racial/ethnic demographic breakdown was 39.6% non-Hispanic White, 39.8% Hispanic or Latino, 13.6% Black/African American, 6.0% Asian, and 1.3% AIAN.1 The Hispanic population in Texas is the second largest in the nation and includes immigrants from Mexico, Central America, and South America, as well as Tejanos.
For most types of cancer, Black people have the highest death rate and shortest survival of any racial/ethnic group in the United States. Black men have 6% higher cancer incidence but 19% higher cancer mortality than White men. Even more striking, Black women have 8% lower cancer incidence than White women, but 12% higher cancer mortality.2 Prostate and lung are the most diagnosed cancers in Black men in Texas. Among Texan Black women, breast and lung cancers are the most common.
In the United States, AIAN populations have higher rates of lung, colorectal, liver, stomach, and kidney cancers compared to non-Hispanic White people. However, researchers nationally and in Texas struggle to identify baseline information for AIAN populations due to a lack of accurate reporting and data collection specific to these groups. As a state, we must continue to work with the AIAN populations in Texas to ensure we are culturally receptive to their needs.3
Gender and Sexual Diversity (GSD) populations have higher rates of certain cancers. Evidence suggests that these populations experience worse physical and mental health after a cancer diagnosis compared to non-GSD populations. The fear of stigmatization and discrimination, as well as inadequate recognition of specific risk factors and medical care considerations often lead to poor prevention, screening, treatment, and survivorship care. A major barrier to fully determining existing disparities is the lack of data collected in surveillance, research, and clinical settings.4
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Over 95% of cancer deaths occur among Texans who are 45 years or older. The incidence rate for cancer climbs steadily as age increases. According to the most recent data from NCI’s Surveillance, Epidemiology, and End Results (SEER) Program, the median age of cancer diagnosis is 66 years. A similar pattern exists for many common cancer types. The median age at diagnosis is 62 years for breast cancer, 67 years for colorectal cancer, 71 years for lung cancer, and 66 years for prostate cancer.1
Texas has the third largest population of people 50 years of age and older in the United States, with nine million Texans in 2020. Researchers project that this population will grow to 16.4 million by 2050, an 82% growth rate.2 As the state’s population grows and ages, the number of people living with cancer increases,3 making prevention and early detection efforts imperative.
While advancing age is the most important risk factor for cancer overall and for many individual cancer types, researchers report a recent trend in “early-onset cancers,” cancers diagnosed in adults under 50. Early-onset cancers, including breast, colorectal, endometrium, esophagus, head and neck, kidney, liver, bone marrow, pancreas, prostate, stomach, and thyroid cancers, have increased in numbers in the United States between 1995 and 2020,4 with a similar trend seen in Texas. For instance, colorectal cancer incidence rates have increased in the last decade among young adult Texans aged 20-49.5
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In Texas, healthcare providers will diagnose approximately 1,212 children (0 to 14 years) with cancer in 2024 and almost 200 children will die from the disease. Leukemias (28%) and brain/central nervous system cancers (26%) make up more than half of childhood cancers.1
Cancer manifests differently in children and adolescents than in adult cancer. Researchers do not link most childhood cancers to lifestyle or environmental risk factors. Similarly, genetic changes that a parent passes to their child through DNA are responsible for only a small number of childhood cancers.
Although children and adolescents may be healthier than adults and tend to respond better to certain treatments, their bodies are still growing, and they are more likely to experience side effects from certain types of treatment.2 Other issues that the cancer care community must examine and address for childhood and adolescent cancer patients include the physical and psychological effects of treatment, integration back into social and educational systems, insurance coverage needs, long-term care, and continuing risks of treatment, including late effects and development of other cancers.
To ensure that Texas children with cancer have access to state-of-the-art care, it is critically important that policy makers remove current barriers to participation in clinical trials by providing infrastructure and resources available statewide.
Nearly 8,000 adolescents and young adults (AYA), aged 15 to 39 years, in Texas will receive a cancer diagnosis in 2024, with the largest number of deaths from leukemia, breast, and colorectal cancers.1 The incidence of specific cancer types within the AYA community varies according to age. The most frequently diagnosed cancers among adolescent Texans aged 15 to 19 years include thyroid cancer, Hodgkin lymphoma, brain and central nervous system tumors, and non-Hodgkin lymphoma. For young adults living in Texas aged 20 to 29 years, thyroid cancer, testicular cancer, melanoma, and Hodgkin lymphoma diagnoses are most common. Breast cancer, thyroid cancer, melanoma, and colorectal cancer have the highest diagnosis rate for Texans between 30 and 39 years.3
The AYA community faces a unique set of challenges related to social determinants of health (SDOH), the non-medical factors that affect health outcomes. These challenges include difficulty with access to health care, finances, employment, social support, and housing. The non-medical factors greatly affect survival and implicate SDOH as an important variable to study in the context of cancer outcomes for AYA patients. Research has shown that certain interventions taken in childhood and adolescence will prevent cancer from developing later in life. These include limiting exposure to ultraviolet radiation, tobacco, and certain viruses (HPV and Hepatitis B), as well as avoiding or reversing childhood obesity.
Researchers have shown that race, socioeconomic status and lack of adequate health insurance are among factors that negatively affect overall survival and other outcomes in AYA cancer patients. Black AYA cancer patients have poorer five-year survival rates than White AYA patients diagnosed with the same cancer. AYA cancer patients residing in disadvantaged neighborhoods and other areas with worse non-medical drivers of health are nearly 10% more likely to die than AYA cancer patients living in less disadvantaged neighborhoods.4
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The economic burden of cancer care and lost productivity are staggering, bankrupting families and burdening health care systems. In 2023, the direct cost of cancer in Texas totaled nearly $56.3 billion, with total economic losses including multiplier effects amounting to $148 million in lost output and 1.3 million jobs.1 The Centers for Disease Control and Prevention expects the annual cost of cancer care in the United States to exceed $240 billion by 2030.2
Financial costs along the cancer continuum, especially the increased cancer treatment costs, continue to be a challenge. The National Cancer Plan reports that financial toxicity - the personal and family stress and hardships created by the prohibitive cost of cancer care - can delay diagnosis, disrupt treatment, and cause other problems that lead to early mortality.3 These financial burdens tend to have a greater effect on populations already experiencing a disproportionate cancer impact.
Low-income populations face financial barriers to accessing cancer prevention and treatment options. Socioeconomic factors, such as education, income, and insurance status, influence the challenges related to access to cancer care in Texas. Other barriers to care arise from immigration status, access to full-time work, and level of English language fluency.
Texas is the fifth most expensive state for healthcare in 2024 according to a Forbes report.4 Texas has the highest percentage of families who struggled to pay for their child’s medical bills in the past 12 months (14.9%), the highest percentage of adults who chose not to see a doctor at some point in the past 12 months due to cost (16%), and the fourth highest annual premium for both plus-one health insurance coverage ($4,626) and family health insurance coverage ($7,051.33) through an employer.5
More than 16% of Texans have no health insurance, the largest percentage of any state and almost double the national average. This translates to 4.9 million uninsured Texans who are likely postponing medical care or visiting clinics and hospitals only when necessary.
Texas 2036 conducted a multi-year study to identify obstacles blocking affordable coverage for Texans.6 They found that the two primary challenges faced by uninsured Texans are inability to access insurance through work and prioritizing other household costs.
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To address the cancer burden in Texas, it is crucial that both individuals and organizations take proactive steps to reduce cancer disparities that persist across our communities. By increasing access to preventive care, promoting health education, and ensuring equitable availability of treatment options, Texas can begin to close gaps that disproportionately affect underserved populations.
Stakeholders and collaborators should work together across sectors to support research and share resources and expertise to understand and address the root causes of cancer disparities. Together, through coordinated efforts, such as those listed below, we can make significant strides in reducing cancer disparities and improving health outcomes for all Texans.
Implement:
Increase:
Expand:
Advocate: