Trends in Childhood Cancer Incidence in the U.S.
(1992–2004)
Amy M. Linabery, MS, MPH
1
Julie A. Ross, PhD
1,2
1
Division of Pediatric Epidemiology and Clinical
Research, Department of Pediatrics, University of
Minnesota, Minneapolis, Minnesota.
2
University of Minnesota Cancer Center, Minnea-
polis, Minnesota.
BACKGROUND. The etiology of most pediatric neoplasms remains elusive. Exami-
nation of population-based incidence data provides insight regarding etiology
among various demographic groups and may result in new hypotheses. The
objective of the current study was to present updated information regarding
childhood cancer incidence and trends in the U.S. overall and among demo-
graphic subgroups, including Asian/Pacific Islanders and Hispanics, for whom to
the authors’ knowledge trends have not been previously examined.
METHODS. Data obtained by 13 registries of the National Cancer Institute’s Surveil-
lance, Epidemiology, and End Results (SEER) program were evaluated to assess
incidence and trends of common primary cancers diagnosed between 1992 and
2004 among children aged birth to 19 years. Frequencies, age-adjusted incidence
rates, and joinpoint regression results, including annual percent change (APC) in
incidence rates (and 95% confidence intervals [95% CI]), were calculated.
RESULTS. Between 1992 and 2004, a modest, nonsignificant increase in the average
annual incidence rate (APC, 0.4%; 95% CI, 20.1%–0.8%) was observed for all pedi-
atric cancer diagnoses combined. There was a suggestion of an increase in leuke-
mia (APC, 0.7%; 95% CI, 20.1%–1.5%), and acute lymphoblastic leukemia in
particular (APC, 0.8%; 95% CI, 20.4%–1.9%), whereas rates for central nervous sys-

With an estimated 98% case
Address for reprints: Julie A. Ross, PhD, Depart-
ment of Pediatrics, University of Minnesota, 420
Delaware Street SE, MMC 422, Minneapolis, MN
55455; Fax: (612) 626-4842; E-mail: rossx014@
umn.edu
Supported by National Institutes of Health Grant
T32 CA099936 and the Children’s Cancer
Research Fund.
Received December 27, 2006; revision received
August 14, 2007; accepted August 16, 2007.
ª 2007 American Cancer Society
DOI 10.1002/cncr.23169
Published online 11 December 2007 in Wiley InterScience (www.interscience.wiley.com).
416
ascertainment rate,
11
the SEER 13 registries capture
information regarding demographics, tumor site and
morphology, stage at diagnosis, treatment, and vital
status, representing approximately 14% of the U.S.
population.
10
Between 1992 and 2004, SEER actively
collected data on all cancer cases (excluding nonme-
lanoma skin cancers) in Connecticut, Hawaii, Iowa,
New Mexico, and Utah; in the metropolitan areas of
Atlanta, Detroit, Los Angeles, San Francisco-Oakland,
San Jose-Monterey, and Seattle-Puget Sound; and
from rural Georgia and the Alaskan Native Tumor

14
to perform weighted
least-squares regression, in which the independent
variable was calendar year and the dependent vari-
able was the natural logarithm of the age-adjusted
incidence rate.
9
Joinpoint models were employed to
determine when the trend changed in magnitude
and/or direction during the period 1992 through
2004, allowing a maximum of 3 joinpoints and a
minimum of 2 years between consecutive joinpoints
and between joinpoints and endpoints.
9,14,15
The
Joinpoint permutation test adjusts for multiple com-
parisons to ensure an overall type I error rate of 0.05
for a given trend.
14
Rates and trends within sex (male and female),
age group (age <1 year, ages 1–4 years, ages 5–9
years, ages 10–14 years, and ages 15–19 years), race
(white, black, and Asian/Pacific Islander) and ethni-
city (Spanish Hispanic-Latino and non-Spanish His-
panic-Latino) were evaluated. Trends involving 1
years with <10 cases, as denoted in Table 2, should
be interpreted with caution. Cases indicating Ameri-
can Indian/Alaskan Native and those with an
unknown/unspecified race were excluded from sub-
group analysis because there were too few cases to

for other/unspecified leukemias; a significant
decrease was observed between 1992 and 1996 (APC,
218.6%; 95% CI, 231.6%–23.2%) and a significant
increase was detected thereafter (APC, 7.0%; 95% CI,
0.1%–14.3%). The trends for other cancer subgroups
were indistinguishable from a slope of 0, although
the data indicate a possible increase for leukemia
overall (acute lymphoblastic leukemia [ALL] and
acute myeloid leukemia [AML]) and non-Hodgkin
lymphoma (NHL), and suggest a decrease for Wilms
tumor and Ewing sarcoma. Notably, the rate of CNS
tumors overall remained steady over the time period
examined (APC, 20.1%; 95% CI, 21.1%–1.0%). The
observed and expected rates, as determined by join-
Childhood Cancer Incidence Trends/Linabery et al. 417
TABLE 1
International Classification of Diseases for Oncology, Third Edition Histology and Topography Codes
Disease Code
Any leukemia 9800–9801, 9805, 9820, 9823, 9826–9827, 9831–9837, 9840, 9860–9861, 9863, 9866–9867, 9870–9876, 9891, 9895–9897, 9910,
9920, 9930–9931, 9940, 9945–9946, 9948
Acute lymphocytic leukemia 9826, 9835–9837
Acute myeloid leukemia 9840, 9861, 9866–9867, 9870–9874, 9891, 9895–9897, 9910, 9920, 9931
Other leukemias (lymphoid leukemias other than ALL/other specified and unspecified leukemias) 9800–9801, 9805, 9820, 9823, 9827, 9831–9834, 9860, 9863, 9875–9876, 9930, 9940, 9945–9946, 9948
Hodgkin disease 9650–9655, 9659, 9661–9665, 9667
Non-Hodgkin lymphoma 9590–9591, 9596, 9670–9671, 9673, 9675, 9678–9680, 9684, 9687, 9689–9691, 9695, 9698–9702, 9705, 9708–9709, 9714, 9716–
9719, 9727–9729, 9731–9734, 9760–9762, 9764–9769, 9970
Any CNS tumor 8000–8005(C70.0–C72.9, C75.1–C75.3), 8270–8281, 8300, 9350–9352, 9360–9362, 9380(C70.0–C72.9, C75.1, C75.3), 9381–9384,
9390–9394, 9400–9413, 9420–9424, 9430, 9440–9442, 9444, 9450–9451, 9460, 9470–9474, 9480, 9492–9493, 9500(C71.0–
C71.9), 9501–9504(C70.0–C72.9), 9505–9508, 9530–9539, 9582
Ependymoma 9383, 9391–9394

TABLE 2
Frequencies, Incidence Rates, and Annual Percent Change in 13 SEER Registries From 1992–2004
Total Cases
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total
{
22,694 (100%) 157.9 1992–2004 0.4 (20.1–0.8)
Leukemias 6129 (27%) 41.9 1992–2004 0.7 (20.1–1.5)
ALL 4697 (21%) 31.9 1992–2004 0.8 (20.4–1.9)
AML 1085 (5%) 7.5 1992–2004 1.0 (20.4–2.4)
Other/unspecified leukemias 347 (2%) 2.4 1992–1996 218.6 (231.6–23.2) 1996–2004 7.0 (0.1–14.3)
Hodgkin disease 1611 (7%) 11.7 1992–2004 20.8 (22.4–0.7)
Non-Hodgkin lymphoma 1472 (6%) 10.4 1992–2004 1.4 (20.1–3.0)
CNS tumors 4004 (18%) 27.6 1992–2004 20.1 (21.1–1.0)
Ependymoma 308 (1%) 2.1 1992–2004 20.5 (24.1–3.3)

4
y
(95% CI)
Total
{
12,316 (100%) 167.0 1992–2004 0.4 (20.1–1.0)
Leukemias 3456 (28%) 46.1 1992–2004 0.7 (20.4–1.9)
ALL 2678 (22%) 35.6 1992–2004 0.6 (20.9–2.0)
AML 579 (5%) 7.8 1992–2004 1.9 (0.2–3.7)
Other/unspecified leukemias 199 (2%) 2.7 1992–1997 218.4 (230.5–24.1)
k
1997–2004 14.0 (2.4–26.9)
(continued )
Childhood Cancer Incidence Trends/Linabery et al. 419
TABLE 2
(continued )
Sex Male
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC

Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total
{
10,378 (100%) 148.2 1992–2004 0.3 (20.3–0.9)
Leukemias 2673 (26%) 37.4 1992–2004 0.6 (20.8–2.0)
ALL 2019 (19%) 28.0 1992–2004 1.1 (20.6–2.8)
AML 506 (5%) 7.2 1992–2004 20.1 (21.9–1.8)
Other/unspecified leukemias 148 (1%) 2.1 1992–2004 23.3 (27.7–1.4)
k
Hodgkin disease 793 (8%) 11.9 1992–2004 22.4 (24.5–20.3)
Non-Hodgkin lymphoma 475 (5%) 6.9 1992–2004 2.8 (20.3–6.0)
CNS tumors 1780 (17%) 25.1 1992–2004 0.4 (20.8–1.6)
Ependymoma 131 (1%) 1.8 1992–1995 45.8 (9.3–94.5)
k
1995–1998 227.3 (255.4–18.4) 1998–2001 35.9 (216.4–121.0) 2001–2004 27.0 (224.6–14.7)
Astrocytoma 897 (9%) 12.7 1992–2004 20.2 (22.0–1.7)
PNET 387 (4%) 5.4 1992–2004 21.3 (24.4–1.9)

Ewing sarcoma 125 (1%) 1.8 1992–2004 21.2 (26.2–4.1)
k
Rhabdomyosarcoma 271 (3%) 3.8 1992–2004 1.7 (21.5–5.0)
Nonrhabdomyosarcoma soft tissue sarcoma 423 (4%) 6.2 1992–1999 5.1 (0.1–10.5) 1999–2002 216.9 (243.4–21.9) 2002–2004 19.0 (218.8–74.4)
Germ cell tumors 623 (6%) 9.1 1992–2004 20.3 (22.6–2.2)
Thyroid carcinoma 634 (6%) 9.5 1992–2004 1.6 (20.2–3.5)
Melanoma 390 (4%) 5.9 1992–2004 2.2 (20.9–5.5)
Age Group <1 Year
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total
{
1677 (100%) 225.9 1992–2004 0.1 (21.3–1.4)
Leukemias 296 (18%) 39.9 1992–2004 0.8 (22.5–4.2)
ALL 139 (8%) 18.7 1992–2004 20.4 (25.3–4.7)
k

(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Hepatoblastoma 78 (5%) 10.5 1992–2004 4.2 (21.9–10.7)
k
Osteosarcoma 1 (0.06%) 0.1 —
Ewing sarcoma 1 (0.06%) 0.1 —
Rhabdomyosarcoma 39 (2%) 5.3 —
Nonrhabdomyosarcoma soft tissue sarcoma 76 (5%) 10.2 1992–2004 10.4 (4.9–16.3)
k
Germ cell tumors 156 (9%) 21.0 1992–2004 0.3 (25.0–5.9)
k
Thyroid carcinoma 0 (0%) 0.0 —
Melanoma 5 (0.3%) 0.7 —
Age Group 1–4 Years
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2

Hepatoblastoma 120 (2%) 4.1 1992–2004 4.8 (0.9–8.8)
k
Osteosarcoma 9 (0.2%) 0.3 —
Ewing sarcoma 17 (0.3%) 0.6 —
Rhabdomyosarcoma 200 (3%) 6.8 1992–2004 21.7 (25.6–2.5)
k
Nonrhabdomyosarcoma soft tissue sarcoma 70 (1%) 2.4 1992–2004 1.0 (27.0–9.7)
k
Germ cell tumors 117 (2%) 3.9 1992–2004 0.7 (25.1–6.7)
k
(continued )
422 CANCER January 15, 2008 / Volume 112 / Number 2
TABLE 2
(continued )
Age Group 1–4 Years
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y

k
Non-Hodgkin lymphoma 302 (8%) 8.3 1992–2004 2.0 (20.7–4.8)
CNS tumors 1087 (28%) 29.7 1992–2004 0.6 (21.2–2.4)
Ependymoma 63 (2%) 1.7 1992–2004 4.9 (23.8–14.4)
k
Astrocytoma 515 (13%) 14.1 1992–2004 20.9 (23.8–2.1)
PNET 271 (7%) 7.4 1992–2004 1.3 (23.2–6.0)
Other gliomas 219 (6%) 6.0 1992–2004 3.1 (23.0–9.7)
k
Other/unspecified CNS tumors 19 (0.5%) 0.5 —
Neuroblastoma 108 (3%) 3.0 1992–2004 1.6 (23.5–7.0)
k
Retinoblastoma 19 (0.5%) 0.5 —
Wilms tumor 164 (4%) 4.5 1992–2004 23.5 (28.4–1.6)
k
Hepatoblastoma 15 (0.4%) 0.4 —
Osteosarcoma 90 (2%) 2.5 1992–2004 20.6 (25.5–4.5)
k
Ewing sarcoma 58 (1%) 1.6 1992–2004 21.6 (28.8–6.1)
k
Rhabdomyosarcoma 161 (4%) 4.4 1992–2002 3.5 (0.3–6.9)
k
2002–2004 226.7 (255.1–19.5)
Nonrhabdomyosarcoma soft tissue sarcoma 118 (3%) 3.2 1992–2004 21.1 (27.3–5.5)
k
Germ cell tumors 80 (2%) 2.2 1992–2004 1.7 (24.2–7.9)
k
Thyroid carcinoma 41 (1%) 1.1 —
Melanoma 38 (1%) 1.0 —
(continued )

CNS tumors 906 (21%) 25.2 1992–2004 21.1 (23.0–1.0)
Ependymoma 52 (1%) 1.4 1992–2002 22.5 (26.9–2.1)
k
2002–2004 252.2 (284.3–45.1)
Astrocytoma 483 (11%) 13.5 1992–2004 21.9 (24.4–0.8)
PNET 190 (4%) 5.3 1992–2004 22.0 (25.4–1.6)
Other gliomas 159 (4%) 4.4 1992–2004 4.3 (22.4–11.5)
k
Other/unspecified CNS tumors 22 (0.5%) 0.6 —
Neuroblastoma 29 (0.7%) 0.8 —
Retinoblastoma 1 (0.02%) 0.0 —
Wilms tumor 19 (0.4%) 0.5 —
Hepatoblastoma 3 (0.07%) 0.1 —
Osteosarcoma 267 (6%) 7.4 1992–2004 0.2 (22.5–3.0)
Ewing sarcoma 109 (3%) 3.0 1992–2004 24.3 (27.7–20.7)
k
Rhabdomyosarcoma 117 (3%) 3.3 1992–2004 1.5 (24.8–8.3)
k
Nonrhabdomyosarcoma soft tissue sarcoma 276 (6%) 7.7 1992–2004 0.0 (23.3–3.4)
Germ cell tumors 266 (6%) 7.4 1992–2004 2.1 (21.3–5.5)
Thyroid carcinoma 160 (4%) 4.5 1992–2004 20.6 (25.3–4.3)
k
Melanoma 108 (2%) 3.0 1992–2004 6.7 (1.8–11.9)
k
Age Group 15–19 Years
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1

1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
CNS tumors 646 (9%) 19.0 1992–2004 21.3 (24.1–1.5)
Ependymoma 40 (0.6%) 1.2 1992–2004 2.0 (29.0–14.4)
k
Astrocytoma 350 (5%) 10.3 1992–2004 21.2 (25.0–2.7)
PNET 108 (2%) 3.2 1992–1997 219.3 (238.5–5.9)
k
1997–2001 34.0 (222.6–132.2) 2001–2004 228.5 (259.8–27.1)
Other gliomas 134 (2%) 3.9 1992–2004 21.4 (27.0–4.6)
k
Other/unspecified CNS tumors 14 (0.2%) 0.4 —
Neuroblastoma 11 (0.2%) 0.3 —
Retinoblastoma 2 (0.03%) 0.1 —
Wilms tumor 4 (0.06%) 0.1 —
Hepatoblastoma 0 (0%) 0.0 —
Osteosarcoma 293 (4%) 8.6 1992–2004 0.7 (23.1–4.5)
Ewing sarcoma 142 (2%) 4.2 1992–2004 24.1 (28.9–0.9)
k
Rhabdomyosarcoma 126 (2%) 3.7 1992–2004 2.8 (21.5–7.2)

Other/unspecified leukemias 250 (1%) 2.3 1992–1996 219.1 (233.6–21.5)
k
1996–2004 6.5 (21.5–15.1)
Hodgkin disease 1354 (8%) 13.2 1992–2004 21.0 (23.0–1.0)
Non-Hodgkin lymphoma 1125 (6%) 10.8 1992–2004 1.4 (20.5–3.2)
CNS tumors 3179 (18%) 29.5 1992–2004 0.1 (21.3–1.4)
Ependymoma 241 (1%) 2.2 1992–2004 21.1 (25.5–3.6)
Astrocytoma 1548 (9%) 14.4 1992–2004 20.3 (21.9–1.4)
PNET 783 (4%) 7.2 1992–2004 21.0 (23.1–1.2)
Other gliomas 498 (3%) 4.7 1992–2004 2.0 (20.6–4.7)
Other/unspecified CNS tumors 109 (0.6%) 1.0 1992–2004 6.6 (0.2–13.4)
k
Neuroblastoma 864 (5%) 7.6 1992–2004 20.3 (22.6–2.2)
(continued )
Childhood Cancer Incidence Trends/Linabery et al. 425
TABLE 2
(continued )
Race
§
White
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC

(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total
{
2228 (100%) 116.8 1992–2004 20.4 (21.5–0.8)
Leukemias 471 (21%) 24.2 1992–2004 20.6 (22.8–1.6)
ALL 292 (13%) 14.8 1992–2004 22.1 ( 25.7–1.7)
AML 125 (6%) 6.6 1992–2004 3.5 (20.9–8.1)
k
Other/unspecified leukemias 54 (2%) 2.8 —
Hodgkin disease 167 (7%) 9.3 1992–1999 29.1 (215.7–22.0)
k
1999–2004 9.4 (22.8–23.3)
Non-Hodgkin lymphoma 163 (7%) 8.7 1992–2004 3.3 (20.4–7.1)
k
CNS tumors 431 (19%) 22.1 1992–2004 21.0 (22.6–0.6)
Ependymoma 34 (2%) 1.7 —
Astrocytoma 194 (9%) 10.0 1992–2004 23.4 (26.5–20.3)
k
PNET 93 (4%) 4.7 1992–2004 20.6 (25.5–4.5)
k
Other gliomas 94 (4%) 4.8 1992–2004 0.0 (25.6–5.8)
k
Other/unspecified CNS tumors 16 (0.7%) 0.8 —
Neuroblastoma 131 (6%) 6.6 1992–2004 21.3 (28.0–5.9)

3
y
(95% CI) Years APC
4
y
(95% CI)
Germ cell tumors 118 (5%) 6.4 1992–2004 22.1 (27.5–3.7)
k
Thyroid carcinoma 33 (1%) 1.8 —
Melanoma 7 (0.3%) 0.4 —
Race
§
Asian/Pacific Islander
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total

Rhabdomyosarcoma 44 (2%) 2.9 —
Nonrhabdomyosarcoma soft tissue sarcoma 76 (4%) 5.2 1992–2004 29.6 (216.3–22.4)
k
Germ cell tumors 182 (10%) 12.3 1992–2004 0.6 (23.9–5.3)
k
Thyroid carcinoma 87 (5%) 6.0 1992–2004 24.0 (29.0–1.3)
k
Melanoma 18 (0.9%) 1.2 —
(continued )
Childhood Cancer Incidence Trends/Linabery et al. 427
TABLE 2
(continued )
Ethnicity Spanish/Hispanic/Latino
1992–2004
Cancer No. (%)
Incidence
rate* Years APC
1
y
(95% CI) Years APC
2
y
(95% CI) Years APC
3
y
(95% CI) Years APC
4
y
(95% CI)
Total

Nonrhabdomyosarcoma soft tissue sarcoma 209 (4%) 5.9 1992–2004 2.4 (22.2–7.3)
Germ cell tumors 434 (8%) 12.6 1992–2004 0.8 (21.1–2.8)
Thyroid carcinoma 158 (3%) 4.8 1992–2004 0.3 (23.6–4.3)
k
Melanoma 34 (0.6%) 1.0 1992–2004 7.5 (0.4–15.0)
k
APC indicates annual percentage change; 95% CI, 95% confidence interval; ALL, acute lymphocytic leukemia; AML, acute myeloid leukemia; CNS, central nervous system; PNET, primitive neuroectodermal tumor.
Bold type indicates statistical significance at the .05 level.
* Incidence rate per 1,000,000 person-years, age-adjusted to the 2000 US Standard population.
y
The APC was calculated via weighted least-squares regression.
{
The frequencies and percentages in a column will not sum to those found in the ‘‘Total’’ row because only the most common cancers are reported.
§
Excludes 266 Alaskan Natives and 310 cases with race unknown.
k
Trend calculation involves 1 years with <10 cases and should be interpreted with caution.
428 CANCER January 15, 2008 / Volume 112 / Number 2
point regression, for leukemias and CNS tumors are
shown in Figure 1.
Frequencies, incidence rates, and joinpoint
results for the demographic subgroups for each of
the cancers analyzed are listed in Table 2. The trends
were generally similar across strata of demographic
variables examined; noteworthy trends are discussed.
Sex
A significantly positive trend (APC, 1.9%; 95% CI,
0.2%–3.7%) for AML was observed among males,
whereas no concomitant trend was apparent among
females. For other/unspecified leukemias, the rate in

rate of ependymomas in patients ages 10 to 14 years
was more rapid later in the period; this pattern was
restricted to this age group and was based on few
cases (N 5 52). Astrocytoma rates increased in the
younger age groups (aged <5 years) and declined in
older age groups, although rates were imprecise in
all groups. No change was observed in the incidence
of primitive neuroectodermal tumor, except in
patients ages 15 to 19 years, in whom 2 joinpoints
were identified, resulting in sharp changes in the
direction of the trend.
A significant increase occurred in the 1990s for
rhabdomyosarcoma among those ages 5 to 9 years
(APC, 3.5%; 95% CI, 0.3%–6.9%), followed by a sharp
decline. For other soft tissue sarcomas, a significant
rise was found in infants (APC, 10.4%; 95% CI, 4.9%–
16.3%), with little or no change noted in other
groups. An increase in patients ages 15 to 19 years
was suggested for thyroid carcinoma.
Race
For leukemias overall and ALL, increases were
observed in whites (leukemias: APC, 1.0%; 95% CI,
0.1%–2.0%; ALL: APC, 1.1%; 95% CI, 0.0%–2.3%),
whereas there was no evidence of change in blacks
and Asian/Pacific Islanders. The trend for other leu-
kemias and other CNS tumors among the white
FIGURE 1. Observed (data points) and expected (joinpoint regression lines)
incidence rates from Surveillance, Epidemiology, and End Results (SEER)
13 registries from 1992 through 2004 for (A) leukemias and (B) central nervous
system (CNS) tumors. ALL indicates acute lymphoblastic leukemia; AML, acute

gliomas among Hispanic children (APC, 7.7%; 95%
CI, 1.9%–13.8%) and a substantial increase in mela-
nomas (APC, 7.5%; 95% CI, 0.4%–15.0%), which was
also observed in non-Hispanic children. Rates of Ewing
sarcoma decreased between 1992 and 2000 (APC,
210.4%; 95% CI, 217.2%–23.0%) and incr eased there-
after (APC, 21.8%; 95% CI, 0.2%–48.1%); this trend was
based on a very small number of case s ( N 5 67).
DISCUSSION
Recent reports from the U.S. and Europe
16,17
indicate
that rates of childhood cancers are increasing
between 0.6% to 1.1% annually; however, these
reports include data beginning in the 1970s, and
therefore described trends may be due in large part
to rate increases in previous decades. The current
analysis indicates a modest, nonsignificant increase
(0.4% annually) in all childhood cancers diagnosed
since the early 1990s, with evidence of increases in
select malignancies and shifting trends in others.
The results of the current study corroborate
those from prior SEER reports, in which the overall
rates of CNS tumors stabilized after 1986.
8,18
Although not significant, there is a suggestion of an
overall increase in leukemia, especially ALL. Changes
in the rates of other/unspecified leukemias and CNS
tumors, respectively, account for relatively few cases
and may primarily reflect changes in classification,

and
parallel increases have been observed in adults.
22,23
The differences by demographic subgroup are
unlikely explained by changes in classification or di-
agnosis because changes should have been applied
equally across demographic subgroups. The signifi-
cant increase in AML among males, but not females,
is of interest and should be followed closely to deter-
mine whether this pattern continues. The decrease
in HD noted among females contradicts prior reports
of increasing rates among adolescents and young
adults, but is consistent with results observed in
older adults.
24–26
A concomitant increase in NHL was
suggested; however, a corresponding decline in males
was not detected, ruling out changes in classification
as a likely explanation. The dramatic increase in
ependymomas noted between 1992 and 1995 occur-
ring among females involved a small number of
cases (N 5 131), and therefore may be due to
chance. Categorizing ependymomas as borderline
benign or malignant can be difficult
27
; however, there
is no reason to suspect classification differences by
sex and across different registries. A positive trend in
infantile fibrosarcoma accounts for the rise in non-
rhabdomyosarcoma soft tissue sarcomas noted

graphic subgroups provide starting points for etiolo-
gic research. Testable hypotheses, including birth
characteristics and environmental/exogenous expo-
sures,canbeinvestigatedinrelationtospecific
cancers via rigorous case-control studies. The devel-
opment of a national pediatric cancer registry, such
as that being implemented by the Children’s Oncol-
ogy Group,
30
may facilitate such studies.
The principal strength of SEER is the high rate of
case ascertainment and high data quality. Our analy-
sis provides current trends in childhood cancer inci-
dence, and to our knowledge represents the first
report from the 13 SEER registries and the first report
regarding trends in Asian/Pacific Islanders and His-
panics. One limitation of the current study is that
important demographic and/or etiologic differences
could potentially exist between the population moni-
tored by the 13 SEER registries and the 86% not
under surveillance simply by chance.
31
Furthermore,
childhood cancers represent a heterogeneous group
of diseases with specific etiologies. Because each
cancer diagnosis is rare, random fluctuations may
erroneously appear as noteworthy trends; a large
number of statistical tests, using an overall type I
error rate of 5% per trend, were performed in the
joinpoint regression analyses and the results there-

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