Cancer statistics, 2025: A hinge moment for optimism to morph into hope?

Abstract

Since 1951, the American Cancer Society has compiled and published data on an annual basis pertaining to the incidence and outcomes of most malignancies in the United States. This meticulous effort consistently manifests as one of the most cited articles in the literature, extensively referenced not only by oncologists but also by health scientists at large. The influence of this reporting is attributable to its comprehensiveness, readability, and the establishment of benchmarks for where we are, where we have been, and where we ought to be headed.

This year's article by Siegel et al.,¹ once again, provides important insights. Five-year relative all-cancer survival rates increased from 49% between 1975 and 1977 to approximately 69% between 2014 and 2020. Moreover, the general cancer mortality rate continues to fall. However, closer scrutiny reveals dramatic disparities. For instance, overall cancer incidence has declined in men but has been persistently rising in women. In addition, disproportionate cancer mortality is borne by Native Americans (particularly with regard to primary tumors of the colorectum, kidney, liver, lung, stomach, and uterine cervix), Black men (especially in the setting of prostate cancer), and Black women (for breast and uterine corpus cancers). Driving these disparities, Siegel et al. point to socioeconomic deprivation resulting from structural racism, including (but not limited to) inequities in access to screening and treatment.

The authors assert identifiable factors linked to other statistical trends as well. Although some of the apparent spikes in cancer burden may be attributable to a return to previous levels of screening and incidental detection after a dip in provider visits because of the coronavirus disease 2019 pandemic, simultaneously, there is concern about the growing popularity of electronic cigarettes and vaping. Meanwhile, although there has been an increase in overall cancer incidence among women, it is encouraging to learn that national human papillomavirus vaccination programs have gained traction and—when conjoined with punctilious screening as well as aggressive treatment of precursor lesions—have reduced the incidence of cervical cancer in people with a cervix. Furthermore, Siegel and colleagues comment on the association between increased research funding and improved rates of survival for hematopoietic and lymphoid malignancies. This contrasts with the underfunding of research regarding uterine corpus cancer, the only malignancy for which survival has steadfastly decreased during the past 4 decades.

Given the increased relative cancer survival rate, it is not uncommon for oncologists and the general public to express optimism. There is a theme that emerges from these numbers building on the prior reports of recent years: most cancers are potentially controllable, provided there is appropriate investment of research dollars, sufficient screening, and access to care. Yet, because these advantages are not afforded to all, the picture is considerably more complicated. In fact, we submit that it is not a time for optimism (nor pessimism, thankfully) but, rather, a time for a realistic, grounded, and animating sense of hope.

Although sometimes treated as synonyms, hope and optimism are distinct mindsets. Optimism involves an expectation that positive outcomes will occur independent of whether anyone takes steps to make them happen. It presumes that the future will be positive,² a belief that can be based on an unrealistic appraisal of the challenges that lie before individuals.³ Hope, in contrast, is more deliberate and grounded. According to Hope Theory, the most widely researched model of the phenomenon in the field of psychology, it emerges when people set three conditions in their lives: they have goals (which, ideally, are both meaningful and plausible), they imagine pathways (i.e., strategies) for pursuing those goals, and they are able to generate sufficient agency (i.e., determination or drive) to embark on those pathways.² To paraphrase British philosopher Lord Jonathan Sacks, optimism involves trusting that the world is improving on its own, whereas hope involves the conviction that, together, we can improve the world. So, while optimism is passive, hope is active.⁴

Perhaps readers will agree that, before the inflection point when cancer mortality rates began their descent (circa, 1991, according to Siegel and colleagues' Figure 7.), oncology professionals often encouraged patients to assume an optimistic attitude (“think positive,” “tell yourself everything is going to be okay,” etc.). At that juncture, this may have been wise. Some of our colleagues in psychology, for instance, have suggested that dispositional optimism can be an important predictor of coping when situations are relatively uncontrollable.⁵ When there is little we can do to actively control an outcome, at least we can maintain a positive outlook.

But this strong lack of controllability may no longer be the case for many people with cancer. Although obviously there are still many uncontrollable factors in cancer, the past 3 decades have seen outcomes become more controllable than previously. In this regard, investigators have observed that hope appears to become more relevant as situations afford greater levels of control.⁶ Indeed, Shanahan et al.⁷ observed that hope predicted specific expectancies in controllable situations, whereas optimism was more predictive in uncontrollable contexts. There are even hints that patients with higher levels of hope experience improved cancer outcomes compared with their lower hope counterparts.⁸ When a situation is more controllable—particularly when facing such a challenging foe as cancer—the ability to set goals, plot pathways, and summon a sense of agency becomes critical.

As an important aside, although cure is a worthy goal, we caution against limiting the aspirations of patients diagnosed with cancer to the singular goal of cure. Physically healthy individuals harbor many hopes, and there is no reason to believe that this is any different for patients with cancer. Even within the subpopulations identified by Siegel et al. for whom cure is improbable, Hope Theory can be adopted to pursue a wide spectrum of objectives, including symptom palliation, as well as a host of nonmedical goals that we cherish as the essence of our humanity.

Fortunately, hope appears to be a teachable and measurable skill. Investigators have developed several valid and reliable self-report instruments to measure hope.⁹ By using these instruments, we and others^10-12 have demonstrated that simple workshops can be implemented to assist individuals—including patients and carers—in acquiring skills to help them become more hopeful. Indeed, physicians and other health care professionals have indicated that there is value in learning how to harness the tools embedded in Hope Theory.¹³ Such tools are perhaps more meaningful than ever in an oncologic environment that offers greater controllability thanks to promising developments such as the advent of therapies that are innovative as well as effective,¹⁴ long-term follow-up justifying the value of early detection programs,¹⁵ and consensus regarding the value of adherence to these conceptions.¹⁶

As noted, however, gains in outcomes after a cancer diagnosis, including innovations across the cancer trajectory, are not yet equitably distributed, creating stark disparities and social justice concerns. These may also create disparities in hope. For many marginalized communities, past experiences and structural barriers, including limited access to quality health care, may lower or even eliminate the ability to find hope. Individuals with minoritized identities often harbor mistrust toward the medical system because of historical and contemporary systemic injustices as well as negative health care experiences, which may affect their hope.^17-19 This may have real-world impact; for example, there is emerging evidence that hope is related to treatment adherence in the context of various medical conditions.^{20, 21} As societies, we must work to acknowledge and remedy these disparities, and our health care systems must continue to address the underlying inequities that result in diminished hope and, ultimately, outcomes. Put differently, it is not merely patients' task to “keep their hope up,” but it also falls on the profession to provide reasons for them to do so.

As cancer becomes an increasingly controllable set of diseases, hope—rather than optimism—becomes the more relevant psychological construct. But the fact that such hope is not yet available to all our patients indicates a need for continued research and activism. Importantly, hope is a dynamic phenomenon, not a static one—it pushes us to set goals, find pathways for striving toward a better future, and ask ourselves, “What will we do now?”

The authors disclosed no conflicts of interest.