Geographic Variation in Pediatric Cancer Incidence — United States, 2003–2014

Abstract

Approximately 15,000 persons aged <20 years receive a cancer diagnosis each year in the United States ( 1 ). National surveillance data could provide understanding of geographic variation in occurrence of new cases to guide public health planning and investigation ( 2 , 3 ). Past research on pediatric cancer incidence described differences by U.S. Census region but did not provide state-level estimates ( 4 ). To adequately describe geographic variation in cancer incidence among persons aged <20 years in the United States, CDC analyzed data from United States Cancer Statistics (USCS) during 2003–2014 and identified 171,432 cases of pediatric cancer during this period (incidence = 173.7 cases per 1 million persons). The cancer types with the highest incidence rates were leukemias (45.7), brain tumors (30.9), and lymphomas (26.2). By U.S. Census region, pediatric cancer incidence was highest in the Northeast (188.0) and lowest in the South (168.0), whereas by state (including the District of Columbia [DC]), rates were highest in New Hampshire, DC, and New Jersey. Among non-Hispanic whites (whites) and non-Hispanic blacks (blacks), pediatric cancer incidence was highest in the Northeast, and the highest rates among Hispanics were in the South. The highest rates of leukemia were in the West, and the highest rates of lymphoma and brain tumors were in the Northeast. State-based differences in pediatric cancer incidence could guide interventions related to accessing care (e.g., in states with large distances to pediatric oncology centers), clinical trial enrollment, and state or regional studies designed to further explore variations in cancer incidence. USCS includes incidence data from CDC’s National Program of Cancer Registries (NPCR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program ( 1 ). Data on new cases of cancer diagnosed during 2003–2014 were obtained from population-based cancer registries affiliated with NPCR and SEER programs in all U.S. states and DC. This study included incidence data for all registries that met USCS publication criteria* during 2003–2014, which represented >99% of the U.S. population, excluding data only from Nevada, which did not meet criteria in 2011. This report includes all cases of malignant † cancer diagnosed among persons aged <20 years; it includes first primary cases only and excludes recurrent cases. Diagnosis histology and primary site were grouped according to the International Classification of Childhood Cancer (ICCC). § Pediatric cancer rates were expressed per 1 million persons and were age-adjusted to the 2000 U.S. standard population. ¶ Rates were estimated by sex, age group, race/ethnicity, state, U.S. Census region,** county-level economic status, county-level rural/urban classification, and ICCC group. During 2003–2014, CDC identified 171,432 new cases of pediatric cancer (Table 1). Overall incidence was 173.7 cases per 1 million population. The cancer types with the highest incidence rates were leukemias (45.7 per 1 million), brain tumors (30.9), and lymphomas (26.2). Rates were higher in males (181.5) than in females (165.5) and in persons aged 0–4 years (228.9) and 15–19 years (213.3) than in persons aged 5–9 years (122.6) and 10–14 years (133.0). Among all racial/ethnic groups, the highest incidence rate was among whites (184.4), and the lowest was among blacks (133.3). TABLE 1 Age-adjusted incidence rate* of cancer † among persons aged <20 years, by U.S. Census region § — United States, ¶ 2003–2014 U.S. Census region Total Northeast Midwest South West Characteristic No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) Overall 171,432 173.7 (172.9–174.5) 31,893 188.0 (185.9–190.0) 37,702 172.9 (171.1–174.6) 61,998 168.0 (166.7–169.3) 39,839 172.9 (171.2–174.6) Sex Male 91,667 181.5 (180.3–182.7) 16,860 194.5 (191.6–197.5) 20,228 180.3 (178.8–182.8) 33,045 175.1 (173.3–177.0) 21,534 182.3 (179.9–184.8) Female 79,765 165.5 (164.3–166.6) 15,033 181.1 (178.2–184.0) 17,474 164.3 (161.6–166.5) 28,953 160.6 (158.7–162.4) 18,305 163.0 (160.7–165.4) Age group (yrs) 0–4 54,419 228.9 (227.0–230.8) 9,467 242.7 (237.9–247.7) 12,001 227.0 (228.3–230.6) 20,161 222.7 (219.7–225.8) 12,790 226.1 (222.2–230.0) 5–9 29,181 122.6 (121.2–124.1) 5,161 128.7 (125.2–132.3) 6,323 121.2 (116.7–124.6) 10,862 121.4 (119.1–123.7) 6,835 123.2 (120.3–126.1) 10–14 33,042 133.0 (131.5–134.4) 6,256 145.1 (141.5–148.7) 7,128 131.5 (126.0–134.0) 12,042 130.4 (128.1–132.7) 7,616 131.9 (128.9–134.8) 15–19 54,790 213.3 (211.5–215.1) 11,009 238.5 (234.0–243.0) 12,250 211.5 (210.0–215.5) 18,933 200.5 (197.7–203.4) 12,598 213.5 (209.8–217.3) Race/Ethnicity** White 103,650 184.4 (183.3–185.5) 21,580 200.8 (198.1–203.5) 28,309 183.3 (177.7–185.9) 34,798 178.9 (177.0–180.8) 18,963 184.9 (182.3–187.5) Black 20,188 133.3 (131.5–135.2) 3,402 143.6 (138.8–148.5) 3,894 131.5 (125.4–135.6) 11,194 131.9 (129.5–134.4) 1,698 132.7 (126.4–139.1) Hispanic 36,197 168.9 (167.2–170.7) 4,758 170.0 (165.2–175.0) 3,473 167.2 (153.5–170.2) 13,250 175.5 (172.5–178.5) 14,716 165.6 (162.9–168.3) AI/AN 1,507 147.6 (140.2–155.2) 53 93.1 (69.7–121.9) 262 140.2 (118.9–155.2) 450 143.7 (130.7–157.6) 742 162.3 (150.8–174.5) API 7,089 144.6 (141.2–148.0) 1,488 151.8 (144.2–159.8) 937 141.2 (133.6–148.0) 1,402 127.7 (121.1–134.6) 3,262 150.4 (145.3–155.7) County-level economic status by percentile†† ≤25% 19,536 165.7 (163.4–168.0) 1,848 173.7 (165.9–181.9) 2,888 163.4 (162.3–168.7) 9,902 164.6 (161.3–167.8) 4,898 163.9 (159.3–168.5) 25–75% 98,385 171.3 (170.2–172.4) 15,032 182.2 (179.3–185.1) 21,073 170.2 (167.2–172.8) 38,515 167.8 (166.2–169.5) 23,765 172.1 (169.9–174.3) ≥75% 48,268 181.8 (180.2–183.4) 14,996 196.1 (193.0–199.3) 8,894 180.2 (175.8–183.3) 13,252 171.7 (168.8–174.7) 11,126 178.5 (175.2–181.9) County-level rural/urban continuum†† Metropolitan population ≥1 million 93,181 177.1 (176.0–178.3) 21,451 189.2 (186.6–191.7) 15,634 176.0 (171.5–178.0) 31,810 172.0 (170.2–173.9) 24,286 175.9 (173.6–178.1) Metropolitan population 250,000 to <1 million 35,919 171.1 (169.4–172.9) 6,283 184.7 (180.2–189.4) 6,290 169.4 (169.1–172.7) 14,186 164.3 (161.6–167.0) 9,160 172.0 (168.5–175.6) Metropolitan population <250,000 14,349 165.7 (163.0–168.4) 1,556 183.3 (174.2–192.7) 3,958 163.0 (161.0–168.4) 5,721 162.2 (158.0–166.5) 3,114 164.0 (158.3–169.8) Nonmetropolitan counties 22,962 167.2 (165.0–169.3) 2,586 188.8 (181.5–196.3) 6,982 165.0 (165.3–169.3) 10,173 163.0 (159.9–166.2) 3,221 160.8 (155.3–166.4) Sources: CDC’s National Program of Cancer Registries; National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Abbreviations: AI/AN = American Indian/Alaska Native; API = Asian/Pacific Islander; CI = confidence interval. * Rates are per 1 million persons and age-adjusted to the 2000 U.S. standard population. † Cases included all malignant cancers (with behavior code = 3) as grouped by the International Classification of Childhood Cancer. § Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. ¶ Incidence data are compiled from cancer registries that meet the data quality criteria for all years 2003–2014 (covering >99% of the U.S. population). Nevada is excluded. Registry-specific data quality information is available at https://www.cdc.gov/cancer/npcr/uscs/pdf/uscs-2014-technical-notes.pdf. Characteristic values with other, missing, or blank results are not included in this table. ** White, black, AI/AN, and API persons are non-Hispanic. Hispanic persons might be of any race. Counts exclude unspecified or unknown race/ethnicity. †† Excludes Kansas, Minnesota, and Nevada. Rates were highest in the Northeast U.S. Census region, followed by the Midwest, the West, and the South. Rates were highest in the Northeast across all age groups and among whites and blacks. Among Hispanics, rates were highest in the South. Pediatric cancer incidence rates were highest in the 25% of counties with the highest economic status and were higher in metropolitan areas with populations ≥1 million than in nonmetropolitan areas. By state, pediatric cancer incidence rates ranged from 145.2–205.5 per 1 million. Rates were highest in New Hampshire (205.5), DC (194.0), and New Jersey (192.3) and lowest in South Carolina (149.3) and Mississippi (145.2) (Table 2). Incidence among whites ranged from 157.0 in Montana to 255.2 in Hawaii; among blacks, from 105.8 in Rhode Island to 161.3 in Nebraska; and among Hispanics, from 75.0 in Hawaii to 191.8 in Florida. †† Although incidence rates were highest among children aged 0–4 years overall, in some states (e.g., New Jersey, New York, and Illinois), the highest rates were among persons aged 15–19 years (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/53585). TABLE 2 Age-adjusted incidence rate* of cancer † among persons aged <20 years, by state, overall and by race/ethnicity — United States, § 2003–2014 Total Race/Ethnicity¶ White Black Hispanic AI/AN API State** No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) Northeast Connecticut 2,060 185.8 (177.8–194.0) 1,399 194.8 (184.7–205.4) 199 144.6 (125.2–166.3) 361 176.8 (159.0–196.1) —†† —†† 63 133.1 (102.2–170.5) Maine 725 190.5 (176.9–205.0) 685 194.8 (180.4–210.0) —†† —†† —†† —†† —†† —†† —†† —†† Massachusetts 3,584 181.5 (175.6–187.5) —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ New Hampshire 816 205.5 (191.6–220.2) 746 207.6 (192.9–223.2) —†† —†† 31 177.8 (120.6–252.5) —†† —†† 18 157.1 (92.6–249.7) New Jersey 5,308 192.3 (187.1–197.5) 3,168 211.8 (204.4–219.3) 633 148.6 (137.2–160.6) 1,043 175.2 (164.7–186.2) —§§ —§§ 345 145.7 (130.7–162.0) New York 11,378 190.0 (186.5–193.5) 6,679 209.3 (204.3–214.4) 1,538 147.9 (140.6–155.5) 2,290 175.9 (168.7–183.2) —§§ —§§ 701 164.5 (152.5–177.1) Pennsylvania 7,167 186.6 (182.3–191.0) —§§ —§§ —§§ —§§ 494 150.6 (137.6–164.6) —§§ —§§ —§§ —§§ Rhode Island 547 170.0 (156.0–185.0) 429 196.3 (177.9–216.0) 28 105.8 (70.2–153.0) 59 96.8 (73.7–124.9) —†† —†† —†† —†† Vermont 308 164.2 (146.2–183.9) 299 171.1 (152.0–191.9) —†† —†† —†† —†† —†† —†† —†† —†† Midwest Illinois 7,227 171.8 (167.9–175.8) 4,320 183.9 (178.4–189.4) 934 124.4 (116.5–132.7) 1,548 171.2 (162.8–180.0) —§§ —§§ 273 146.7 (129.7–165.2) Indiana 3,691 171.5 (166.0–177.2) 2,957 178.4 (172.0–185.0) 336 127.6 (114.4–142.1) 296 160.7 (142.7–180.4) —†† —†† 55 139.2 (104.7–181.3) Iowa 1,762 178.6 (170.4–187.2) 1,508 181.2 (172.1–190.6) 60 115.7 (88.2–149.1) 130 166.2 (138.6–197.8) —†† —†† 30 140.0 (94.3–200.1) Kansas 1,713 177.0 (168.8–185.6) —§§ —§§ —§§ —§§ 254 172.8 (152.0–195.7) —§§ —§§ —§§ —§§ Michigan 5,786 178.9 (174.3–183.6) 4,339 188.1 (182.6–193.8) 826 140.5 (131.1–150.4) 296 135.8 (120.7–152.3) 34 127.1 (87.8–178.1) 116 122.3 (101.1–146.8) Minnesota 3,109 179.9 (173.6–186.3) 2,420 181.4 (174.3–188.8) 177 122.8 (105.2–142.4) 203 162.6 (140.6–187.0) 46 159.1 (116.4–212.2) 159 162.2 (137.9–189.5) Missouri 3,120 163.1 (157.4–168.9) 2,481 168.9 (162.3–175.6) 400 135.8 (122.8–149.8) 139 137.2 (115.0–162.3) —†† —†† 44 116.5 (84.6–156.5) Nebraska 1,133 183.2 (172.7–194.2) 868 184.9 (172.8–197.7) 69 161.3 (125.3–204.2) 142 165.8 (139.2–196.0) —†† —†† 20 151.2 (92.2–233.7) North Dakota 341 158.7 (142.3–176.6) 295 163.4 (145.2–183.2) —†† —†† —†† —†† 33 174.0 (119.6–244.7) —†† —†† Ohio 6,225 168.3 (164.1–172.5) 4,999 175.6 (170.8–180.6) 751 124.5 (115.8–133.7) 206 122.2 (105.9–140.3) —†† —†† 106 147.5 (120.7–178.6) South Dakota 413 150.3 (136.1–165.5) 347 162.4 (145.8–180.5) —†† —†† —†† —†† 49 126.9 (93.8–167.8) —†† —†† Wisconsin 3,182 175.6 (169.5–181.8) 2,525 181.9 (174.8–189.1) 220 125.1 (109.1–142.7) 247 154.7 (135.7–175.4) 41 181.8 (130.3–246.7) 92 150.1 (120.9–184.1) South Alabama 2,377 157.0 (150.7–163.4) 1,600 172.2 (163.8–180.8) 619 129.4 (119.4–140.1) 102 124.4 (100.7–152.0) —†† —†† 25 133.2 (86.1–196.8) Arkansas 1,523 161.7 (153.7–170.1) —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ Delaware 504 180.9 (165.5–197.5) —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ District of Columbia 306 194.0 (172.6–217.3) 77 215.2 (165.9–274.7) 152 152.0 (128.7–178.2) 28 159.2 (104.6–231.4) —†† —†† —†† —†† Florida 9,160 169.9 (166.4–173.4) 4,625 174.8 (169.8–179.9) 1,526 130.9 (124.4–137.6) 2,714 191.8 (184.7–199.2) —†† —†† 165 111.9 (95.5–130.4) Georgia 5,291 161.9 (157.6–166.3) 2,884 177.1 (170.7–183.6) 1,556 136.2 (129.5–143.2) 634 166.9 (153.8–180.7) —†† —†† 159 144.2 (122.6–168.4) Kentucky 2,377 174.4 (167.4–181.5) —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ —§§ Louisiana 2,378 156.9 (150.7–163.4) 1,453 177.7 (168.7–187.1) 753 127.1 (118.2–136.5) 113 164.2 (134.8–198.0) —†† —†† 42 173.9 (125.3–235.1) Maryland 2,942 160.0 (154.2–165.9) 1,664 179.7 (171.2–188.6) 773 125.1 (116.4–134.3) 286 156.0 (138.1–175.4) —†† —†† 99 95.1 (77.2–115.8) Mississippi 1,476 145.2 (137.9–152.8) 860 166.0 (155.1–177.5) 548 121.7 (111.7–132.4) 45 138.5 (100.2–186.3) —†† —†† —†† —†† North Carolina 4,834 161.6 (157.1–166.2) 3,052 175.2 (169.0–181.5) 991 129.3 (121.4–137.7) 560 155.6 (142.6–169.4) 38 88.7 (62.8–121.8) 111 138.6 (113.9–167.1) Oklahoma 2,082 168.3 (161.1–175.6) 1,273 166.1 (157.0–175.4) 170 131.0 (112.0–152.2) 276 168.9 (149.2–190.4) 296 194.1 (172.6–217.5) 36 142.5 (99.8–197.4) South Carolina 2,162 149.3 (143.1–155.8) 1,370 164.7 (156.1–173.6) 600 122.2 (112.6–132.4) 149 154.4 (130.0–182.0) —†† —†† 24 114.2 (73.1–170.0) Tennessee 3,411 172.1 (166.4–178.0) 2,500 180.4 (173.4–187.6) 614 144.5 (133.3–156.4) 211 160.4 (138.7–184.4) —†† —†† 48 142.2 (104.7–188.6) Texas 16,368 183.2 (180.4–186.0) 6,598 200.7 (195.8–205.6) 1,571 140.0 (133.1–147.1) 7,503 179.7 (175.6–183.8) 47 162.0 (118.8–216.0) 431 134.0 (121.6–147.3) Virginia 3,899 156.4 (151.5–161.4) 2,553 169.2 (162.7–175.9) 710 124.1 (115.1–133.6) 355 139.1 (124.8–154.5) —†† —†† 175 118.2 (101.3–137.1) West Virginia 908 172.0 (160.9–183.5) 855 175.4 (163.8–187.5) 28 110.2 (73.1–159.3) —†† —†† —†† —†† —†† —†† West Alaska 424 169.4 (153.6–186.3) 232 158.0 (138.3–179.7) —†† —†† 25 138.7 (89.5–204.3) 115 217.2 (179.3–260.7) 40 232.0 (165.7–316.0) Arizona 3,590 168.8 (163.3–174.4) 1,683 176.1 (167.8–184.7) 130 122.4 (102.2–145.3) 1,454 164.4 (156.1–173.1) 199 164.2 (142.1–188.7) 79 132.7 (105.0–165.5) California 21,725 173.2 (170.9–175.6) 7,505 189.9 (185.6–194.2) 1,184 137.9 (130.1–146.0) 10,525 170.1 (166.9–173.4) 101 138.7 (112.8–168.8) 2,187 148.3 (142.1–154.6) Colorado 2,767 171.3 (165.0–177.8) 1,754 175.6 (167.4–184.0) 103 121.7 (99.3–147.6) 762 162.4 (151.1–174.5) 20 153.2 (93.2–237.6) 88 171.8 Hawaii 652 160.1 (148.0–172.9) 134 255.2 (213.7–302.4) —†† —†† 46 75.0 (54.3–101.0) —†† —†† 439 155.6 Idaho 941 170.0 (159.3–181.3) 789 178.3 (166.0–191.2) —†† —†† 121 136.5 (113.1–163.3) —†† —†† —†† —†† Montana 488 160.2 (146.2–175.0) 398 157.0 (141.9–173.2) —†† —†† 24 162.8 (104.0–242.7) 56 182.4 (137.7–237.0) —†† —†† New Mexico 1,077 157.0 (147.7–166.6) 393 198.7 (179.5–219.4) 20 126.9 (77.5–196.1) 539 139.7 (128.2–152.0) 101 131.0 (106.7–159.2) 16 186.7 (106.6–303.7) Oregon 2,114 182.6 (174.9–190.6) 1,591 192.1 (182.7–201.8) 40 111.6 (79.7–152.0) 343 155.1 (139.0–172.6) 27 134.5 (88.5–196.4) 81 146.1 (116.0–181.6) Utah 1,984 178.3 (170.5–186.4) 1,596 182.2 (173.3–191.3) 23 130.1 (82.1–195.9) 309 180.9 (161.1–202.5) —†† —†† 40 120.5 (86.0–164.0) Washington 3,797 180.7 (175.0–186.5) 2,656 189.8 (182.6–197.2) 163 135.8 (115.8–158.4) 542 146.9 (134.6–159.9) 83 200.1 (159.3–248.2) 276 158.1 (140.0–177.9) Wyoming 280 156.8 (139.0–176.3) 232 159.1 (139.3–181.0) —†† —†† 26 118.1 (76.8–173.4) —†† —†† —†† —†† Sources: CDC’s National Program of Cancer Registries; National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Abbreviations: AI/AN = American Indian/Alaska Native; API = Asian/Pacific Islander; CI = confidence interval. * Rates are per 1 million persons and age-adjusted to the 2000 U.S. standard population. † Cases included all malignant cancers (with behavior code = 3) as grouped by the International Classification of Childhood Cancer. § Incidence data are compiled from cancer registries that meet the data quality criteria for all years 2003–2014 (covering >99% of the U.S. population). Nevada is excluded. Registry-specific data quality information is available at https://www.cdc.gov/cancer/npcr/uscs/pdf/uscs-2014-technical-notes.pdf. ¶ White, black, AI/AN, and API are non-Hispanic. Hispanic persons might be of any race. Counts exclude unspecified or unknown race/ethnicity; the counts in the total column may not equal the sum of the individual race/ethnicity columns. ** States are grouped by U.S. Census region. †† Case counts <16 are suppressed. §§ Race/ethnicity data was suppressed for states that elected to be excluded from race/ethnicity analysis. Pediatric cancer incidence rates varied by state within each cancer type (Figure). Incidence rates were highest in the West for leukemias, myeloproliferative diseases, and myelodysplastic diseases (ICCC group I) and in the Northeast for lymphomas and reticuloendothelial neoplasms (group II) and central nervous system cancers (group III). Rates were also highest in the Northeast for neuroblastoma, retinoblastoma, bone tumors, soft tissue sarcomas, and thyroid cancer (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/53586). Renal cancer rates were highest in the Northeast and South; hepatic tumor rates were highest in the Northeast and West. Germ cell tumor rates were highest in the West (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/53586). FIGURE Age-adjusted incidence* of cancer † among persons aged <20 years, by U.S. state and ICCC type — United States, § 2003–2014 ¶ Sources: CDC’s National Program of Cancer Registries; National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Abbreviation: ICCC = International Classification of Childhood Cancer. * Rates are per 1 million persons and age-adjusted to the 2000 U.S. standard population. † Cases included all malignant cancers (with behavior code = 3) as grouped by the ICCC. § Solid tumors (Groups IV–XI) include neuroblastoma and other peripheral nervous cell tumors, retinoblastoma, renal tumors, hepatic tumors, malignant bone tumors, soft tissue and other extraosseous sarcomas, germ cell and trophoblastic tumors and neoplasms of gonads, and other malignant epithelial neoplasms and melanomas. The ICCC group total map includes 258 cases not classified by ICCC. ¶ Incidence data are compiled from cancer registries that meet the data quality criteria for all years 2003–2014 (covering >99% of the U.S. population). Nevada is excluded. Registry-specific data quality information is available at https://www.cdc.gov/cancer/npcr/uscs/pdf/uscs-2014-technical-notes.pdf. The figure above is a series of maps showing age-adjusted incidence rate of cancer among persons aged <20 years, by U.S. state and International Classification of Childhood Cancer type in the United States, during 2003–2014. Discussion This study used recent data with greater population coverage than past studies ( 4 , 5 ) to document geographic variation in pediatric cancer incidence rates by sex, age, type, and race/ethnicity. Consistent with past reports ( 1 , 4 , 5 ), pediatric cancer rates were highest in males, persons aged 0–4 years and 15–19 years, whites, and the Northeast U.S. Census region. Rates were highest in metropolitan areas with populations ≥1 million; state-based rates were highest in New Hampshire, DC, and New Jersey. A strength of this report is the use of extensive population-based surveillance data (>99% coverage §§ ), which permits a detailed description of state-based cancer incidence variation. Geographic variation in rates might account for differences in results from previous studies that were based on different populations such as state data ( 2 , 3 ), SEER registries (which cover 9%–28% of the U.S. population), ¶¶ or other large data sets ( 6 ). A 2016 study specific to Delaware assessed pediatric cancer incidence by demographic group and ZIP Code; the study commented on local environmental exposures and possible incidence disparities based upon sex, age, race/ethnicity, geographic location, and economic status ( 2 ). USCS data provide states with a standardized way to gauge whether local pediatric cancer incidence rates differ relative to other states and might prompt states to conduct investigations similar to the one performed in Delaware. Geographic variation in pediatric cancer incidence might be influenced by several factors.*** First, variation in childhood cancer incidence might be related to differences in exposures to carcinogenic chemicals (e.g., air pollution, secondhand smoke, food, or drinking water) or radiation ( 7 ). Second, genetic variation in certain populations (e.g., prevalence of cancer predisposition genes) ( 2 , 4 , 5 ) might contribute to geographic differences in cancer incidence. Third, the rates of certain cancer types might vary by race/ethnicity. For example, Hispanic children have the highest rate of the most common type of leukemia, pediatric acute lymphoblastic leukemia, and states with a higher proportion of Hispanics might have higher rates of acute lymphoblastic leukemia ( 8 ). Fourth, incidence of some types of cancer (e.g., thyroid carcinoma) might be related to enhanced detection and access to care, which can vary by geographic location ( 5 , 9 ). In addition, geographic variation might be affected by age, economic status, or rural/urban classification ( 4 , 8 , 10 ). Similar to the findings from this report, recent data detailing adult cancers also indicate that the highest cancer incidence rates are in the Northeast ( 10 ). Rates of cancer types mostly affecting adults also varied by rural/urban status; some of these differences in adults might be related to factors such as obesity or smoking ( 10 ), which might or might not also explain rural/urban variation in pediatric cancer. The findings in this report are subject to at least three limitations. First, Nevada was excluded because data for 2011 did not meet quality criteria, which limits the representativeness of the findings. Second, differences in diagnosis and cancer reporting among states might contribute to variation in cancer incidence rates ( 8 ). For example, states that were early adopters of electronic pathology reporting might report increased rates because of increased case ascertainment compared with other states. Finally, misrepresentation of race and ethnicity might exist; rate numerators might underestimate American Indians, Alaska Natives, and Hispanics, which could artificially lower rates among these groups; and U.S. Census populations used in rate denominators might undercount children and Hispanics, which could artificially increase rates in these populations ( 8 ). ††† Knowledge of pediatric cancer incidence variation by state and cancer type can prompt local and state cancer registries to evaluate reporting and diagnostic standards. Understanding geographic variation in incidence rates can help cancer control planners and clinicians address obstacles in access to care, which is especially relevant to states with large distances to pediatric oncology centers ( 3 ). Because 5-year pediatric cancer survival is >80%, and most cancer survivors require close monitoring by specialists throughout life ( 5 ), state-specific data by cancer type and patient age might help public health planners address ongoing chronic care needs. In addition, state-specific data by cancer type and patient age might help clinical trial organizers predict patient accrual. Finally, health care practitioners and researchers can use these data to guide investigations related to causes of pediatric cancer incidence variation ( 2 , 3 ). Continued surveillance will be needed to further validate findings and track geographic incidence patterns over time. Summary What is already known about this topic? Past research on nationwide pediatric cancer incidence described differences by U.S. Census region but did not provide state-level estimates. What is added by this report? During 2003–2014, the pediatric cancer rate was highest in the Northeast, lowest in the South, and highest in metropolitan areas with populations ≥1 million and counties in the top 25% economic status. Incidence rates by state ranged from 145 to 206 per million and were highest in New Hampshire, the District of Columbia, and New Jersey. The highest rate of leukemia was in the West; the highest rates of lymphoma and brain cancer were in the Northeast. What are the implications for public health practice? Knowledge of these geographic differences in childhood cancer incidence can be used to enhance provider awareness, treatment capacity, survivorship care, and cancer surveillance.