Cumulative Risk for Developing End-Stage Renal Disease in the US Population

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1 J Am Soc Nephrol 13: , 2002 Cumulative Risk for Developing End-Stage Renal Disease in the US Population BRYCE A. KIBERD* and CATHERINE M. CLASE *Departments of Medicine, Dalhousie University, Halifax, Nova Scotia; and McMaster University, Hamilton, Ontario, Canada Abstract. The individual risk of developing end-stage renal disease (ESRD) and its overall impact on life expectancy is not known. This study s objectives were to determine the effect of ESRD on life expectancy for a cohort of 20-yr-olds and to compare this impact to that of several cancers for which populationbased screening programs exist. A computer simulation, stratified by race (white, black) and by gender was used to calculate cumulative lifetime risk of ESRD, life-years lost to ESRD, and cumulative Medicare payments for ESRD. Similar calculations were made for breast, prostate, and colorectal cancer. The cumulative lifetime risk of ESRD for a 20-yr-old black woman is 7.8%. Equivalent risks for black men are 7.3%, white men 2.5%, and white women 1.8%. Lost years of life attributable to ESRD are 1.09, 1.10, 0.40, and 0.32 yr for black women, black men, white men, and white women, respectively. In blacks, ESRD is responsible for nearly as much loss of life-years as breast cancer in women and more loss of life-years than colorectal or prostate cancer in men. In addition, treatment costs for ESRD in this population are many-fold more expensive than cumulative treatment costs of these cancers. Exploring new screening and treatment strategies may be warranted to prevent ESRD, particularly in the US black population. In the United States, 86,825 patients began treatment for endstage renal disease (ESRD) in 1998, and there were 326,217 prevalent patients. With the current rate of growth, there will be 172,667 incident and 661,330 prevalent patients by the year 2010 (1). The Medicare costs for care of ESRD will increase from $12 billion to $28.3 billion over this time period (1). However, survival on ESRD is relatively short; therefore, incidence and prevalence data do not capture the full impact that the disease has on overall health in the population. Estimates of average years of life lost to ESRD and cumulative lifetime risks and treatment costs for a cohort of young individuals would better capture the societal, individual, and economic impact of this problem. Similarly, comparing these risks to those associated with common malignancies for which established screening programs exist would help relate the importance of ESRD to overall health. Received December 13, Accepted February 8, Correspondence to: Dr. Bryce A. Kiberd, 5077 AC Dickson Building, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada B3H 2Y9. Phone: ; Fax: ; bkiberd@is.dal.ca / Journal of the American Society of Nephrology Copyright 2002 by the American Society of Nephrology DOI: /01.ASN Materials and Methods The life expectancy of 20-yr-old men and women of black or white race was calculated using a Markov model in a commercial software package (Decision Analysis by TreeAge [DATA] 3.5, TreeAge, Williamstown, MA) (Figure 1). Annual (1998) death rates were obtained from the Report of the United States Department of Vital Statistics (2). Few individuals survive beyond 100 yr; therefore, the analysis was truncated at this age. Cumulative risk of ESRD was then calculated by the Markov analysis output, (see Figure 1, upper tree) created in TreeAge using the following methodology in Excel 4.0 (Microsoft, Redmond, WA). The proportion of the population at each time interval x, is at risk of developing ESRD. The proportion developing ESRD can be calculated by multiplying the proportion of the population surviving to interval x by the annual probability of developing ESRD, denoted here as pesrdx. The probability, pesrdx, was calculated from the age-, gender-, and race-specific ESRD incidence rate per million population (resrdx), taken from the United States Renal Data System 2000 Annual Report (see Appendix for input values), by the formula used to convert rates to probabilities (3,4), pesrdx resrdx/(1 0.5([rESRDx]) (1) The proportion of the population developing new-onset ESRD for each interval (x to x 1) was summed over the cohort lifetime (truncated at 100 yr) to estimate the cumulative lifetime risk of ESRD. To calculate the years of life lost for a disease, a disease elimination strategy was performed (3). This estimates the increase in life expectancy if ESRD is eliminated from the general population and takes into account death from competing diseases. Figure 1 also shows the model created in TreeAge. The Markov analysis output (life table) from TreeAge was exported to an Excel spreadsheet. The total mortality, dx, during the interval x to x 1 is calculated as the reduction in population over the 1-yr interval. This includes patients with ESRD. To eliminate those who die due to the excess risks associated with ESRD, several steps are required. First the excess mortality or disease-specific mortality due to ESRD is determined by subtracting the general population mortality rate from the observed mortality rate with ESRD (for all modalities, including dialysis and transplantation) (5). Observed ESRD mortality rate general population mortality rate disease-specific ESRD mortality rate. (2) Disease-specific ESRD mortality rate is converted to a probability by an equation similar to Equation 1. This disease-specific probability

2 1636 Journal of the American Society of Nephrology J Am Soc Nephrol 13: , 2002 Figure 1. Data 3.5 (TreeAge) medical decision analysis software was used to estimate life expectancy for a 20-yr-old black male from general population mortality rates (upper tree). This upper tree was used to calculate (see text) the cumulative risk of disease (end-stage renal disease [ESRD] or cancer). The lower tree was used to create a life table that included an estimate of patients with ESRD (or cancer) at each time interval. This information was used to calculate the excess death from disease (ESRD or cancer) at each interval for adjustments in a disease elimination mortality rate calculation. is then multiplied by the proportion of patients with ESRD from the life table to calculate excess ESRD death (desrdx) for the interval x. To calculate the new population mortality rate with ESRD eliminated, Qx, the formula used is, Qx 1 (1 qx) (dx-desrdx)/dx (3) Where qx is the mortality probability for interval x with ESRD included, dx is the total deaths in the interval x, and desrdx is excess deaths from ESRD. The new life expectancy for the four (black/white, male/female) cohorts, starting at age 20, are then recalculated using the new probabilities (Qx) in the model. Loss of life-years was calculated by subtracting life expectancy calculated with published general mortality rates from the life expectancy calculated with the new ESRD eliminated rates (Figure 2). For comparative purposes, we performed a similar analysis for breast cancer in women and for prostate and colorectal cancer in men. Incidence rates for malignancy (breast, prostate, and colorectal) were taken from Surveillance, Epidemiology and End Results (SEER) Cancer Statistics Review, (6). Five-year observed survival data (gender-, age-, and race-specific) from this registry (1992 to 1998) were converted to annual mortality probabilities by the declining exponential approximation Figure 2. Data 3.5 (TreeAge) medical decision analysis software was used to estimate life expectancies derived from general population mortality rates (upper tree) and from disease-specific (ESRD or cancer) death eliminated mortality rates (lower tree). Here, an example for black males is shown.

3 J Am Soc Nephrol 13: , 2002 Cumulative ESRD Risk in the United States 1637 of life expectancy method (5). As above, the model calculated the cumulative risk and reduced life expectancy of cancer. Data from this model were also used to calculate the cumulative costs from a third party payer s perspective for ESRD using Medicare payments as reported by the USRDS Annual report (1). Lifetime direct treatment costs for the three malignancies were taken from the literature (7). These costs were converted to 1998 US$ by the medical component of the consumer price index from the original 1992 US$ values (8). This source of cancer treatment cost information has been used in recent published cost-effectiveness analyses (9,10), provides cost estimates that are similar to those reported elsewhere (11,12), and provides more complete follow-up costs than other sources (13,14). Most of these cost derivations are based on Medicare cost estimates and are therefore comparable with ESRD Medicare treatment costs in terms of the third party payer s perspective (12,13,14). In a sensitivity analysis, we explored the uncertainty of these values on our conclusions. The model incorporated incidence rates, mortality rates, and cancer costs that were 2 standard errors. The standard errors for ESRD incidence and mortality rates were taken directly from USRDS registry (1). The SEER*Stat program was used to calculate standard errors for 1-yr cancer mortality rates and incidence rates from the 1992 through 1998 submission (6). Cumulative risks, years of life lost, and costs require the summation of 80 intervals (age, 20 to 100); therefore, the reported upper and lower bounds are much broader than a 95% confidence interval (3). Future costs, and to the same degree future outcomes, should be discounted; however, the recommended base discount rate differs among experts (15). Therefore, the results are presented as undiscounted (0%) and discounted at 3%, 5%, and 7%. This model assumes that incidence and mortality rates for the general population and diseases will not change over the next 80 yr. There will be inevitable growth in the rates of ESRD and cancer along with an aging population. We did not model growth due to the speculative nature of these projections. We believe that even a conservative analysis such as this will be informative. Results Cumulative risk and lost years of life and for each cohort are shown in Tables 1 and 2. Figure 3 graphically depicts the cumulative risk of ESRD. By age 56, the cumulative risk of ESRD in black men and women already exceeds the lifetime risk of ESRD in white men and women, respectively. The loss of life due to ESRD for whites is small compared with that for blacks. The lost life-years from ESRD in black women is 2.9 (1.09/0.32) times greater than that of white women. The lost life-years from ESRD in black men is 2.75 (1.10/0.40) times greater than that of white men. In our model of breast cancer, loss of 1.25 yr and 0.98 yr of life in black and white women is respectively predicted (Table 2). The impact of ESRD in black women is comparable with that of breast cancer ( lost years of life from breast cancer versus from ESRD). The large range in the estimate for lost life from breast cancer is due to the high standard errors for mortality in black women with breast cancer (Table 2). In white women, the impact of breast cancer is 3.1 (0.98/0.32) times greater than that of ESRD. For both groups, the modeled cumulative risk for breast cancer is greater than the risk for ESRD. Tables 1 and 2 also show the comparable data for prostate and colorectal cancer in men. Though cumulative risk for prostate cancer is very high in both white and black men, its impact assessed as years of life lost to prostate cancer is less than that attributable to ESRD in both groups. In black men, Table 1. Cumulative risk (%) of ESRD and common malignancies a Race ESRD Women Breast Cancer ESRD Men Prostate Cancer Colorectal Cancer Black White a One-way sensitivity analysis. Mean upper and lower bounds. The upper bound was calculated using disease incidence rates that were mean 2 SE, and the lower bound was calculated using rates that were mean 2 SE. Current SEER (1998) cumulative risk projections for 20-yr-olds for the above cancers are as follows. Breast cancer: 10.38% for black women, 13.96% for white women; prostate cancer: 18.4% for black men, 15.75% for white men; colorectal cancer: 6.08% for white men, 4.88% for black men (6). Our cumulative risks tended to be higher in the black population and only slightly lower in the white population. Small differences in our results and current cumulative rates can be accounted for methodology, rounding, and updated general population mortality rates. ESRD, end-stage renal disease. Table 2. Reduction in life expectancy (years of life lost) for ESRD and common malignancies a Race Women ESRD Breast Cancer ESRD Men Prostate Cancer Colorectal Cancer Black White a One-way sensitivity analysis. Mean upper and lower bounds. The upper bound was calculated using disease mortality rates that were mean 2 SE, and the lower bound was calculated using rates that were mean 2 SE.

4 1638 Journal of the American Society of Nephrology J Am Soc Nephrol 13: , 2002 adjusted for discount rates and over the mean 2 standard errors for the cancer treatment costs. For black women and men, cumulative ESRD costs were several to many-fold higher than breast, colorectal, and prostate cancer. The cumulative costs of breast cancer treatment in white women were the only cancer to exceed the cumulative costs of ESRD therapy. Figure 3. Cumulative with ESRD with advancing age for black females, black males, white males, and white females. colorectal cancer is responsible for slightly more than half the loss of years of life expected from ESRD; in white men, lost years due to colorectal cancer exceed those lost to ESRD. Cancer and ESRD may occur at different ages; therefore, we examined the impact of discount rates up to 7%, to weight early outcomes more heavily than distant outcomes. The relative importance of ESRD and breast cancer in white and black women was relatively stable over the range of discount rates (Table 3). In black men, ESRD is responsible for 1.2 times more undiscounted lost years of life than that attributable to prostate cancer. This increases to a ratio of 2.75 with a discount rate of 7%. The effect of ESRD on loss of life in white men is 1.42 to 2.8 times greater than prostate cancer over the range of discount rates. To estimate of costs of healthcare resource use for ESRD, we calculated the cumulative Medicare payments, discounted and undiscounted, for maintenance therapy per US citizen on the basis of the model s predictions of lifetime ESRD probability. In discounted models, the cumulative costs for whites are relatively modest when calculated for 20-yr olds, whereas the costs per black citizen are substantially higher (Table 4). Differences between whites and blacks, and absolute costs, are all more pronounced at lower discount rates. Table 5 shows the relative cumulative treatment costs of ESRD relative to the cancers for each of the four cohorts Discussion The ESRD risk, assuming no future increase in ESRD incidence rates, is 1 in 40 for white men and nearly 1 in 50 for white women. For black men and women, the cumulative risk of ESRD is nearly 1 in 12. We are not aware of any previously published estimates of the cumulative risk of ESRD. We suspect that the above estimates of cumulative risk are much higher than appreciated by most nephrologists, and this risk will increase in the future (1). This study also shows that white men and women are at a comparatively higher risk of cancer in this analysis than ESRD. Colorectal and breast cancer also cause more loss of life than ESRD for white men and women, respectively. On the other hand the cumulative incidence of ESRD is greater than colorectal cancer for black men. ESRD also causes more loss of life than either colorectal or prostate cancer in black men and nearly as much loss of life as breast cancer in black women. The incidence rates for both cancer and ESRD increase in the older persons but not always at the same rate. Diseases that develop early may have a greater impact on potential life lost than more prevalent diseases in the aged. To account for the impact of early events relative to late events, the effects of various discount rates were examined. Prostate cancer is a good example of a very common malignancy in white men with a relatively low impact on life years lost. Even without discounting, ESRD causes more life lost than prostate cancer for both black and white men. With discounting, this difference is accentuated, as quantified by the higher ratio of lost lifeyears for ESRD to those lost to prostate cancer. Simply put, ESRD occurs early and has a higher disease-specific mortality than prostate cancer. A small effect with discounting is also seen for colorectal cancer in black and white men (and breast cancer in white women), with an increase in the ratio of lost Table 3. Relative loss of life from ESRD compared with cancer a Group 0% 3% 5% 7% Women ESRD/Breast Cancer black 0.87 (0.65 to 1.37) 0.84 (0.63 to 1.27) 0.81 (0.61 to 1.20) 0.76 (0.6 to 1.14) white 0.33 (0.31 to 0.35) 0.34 (0.32 to 0.36) 0.34 (0.32 to 0.36) 0.34 (0.30 to 0.39) Men ESRD/prostate cancer black 1.20 (0.82 to 2.37) 1.66 (1.12 to 3.36) 2.13 (1.41 to 4.59) 2.75 (1.76 to 5.90) white 1.42 (0.74 to 1.04) 1.79 (1.3 to 2.7) 2.2 (1.52 to 3.5) 2.80 (1.86 to 5.0) Men ESRD/colorectal cancer black 1.71 (1.06 to 2.07) 1.83 (1.27 to 3.45) 1.89 (1.3 to 3.65) 1.96 (1.34 to 4.92) white 0.87 (0.74 to 1.04) 0.95 (0.80 to 1.11) 1.0 (0.84 to 1.21) 1.08 (0.87 to 1.25) a Two-way sensitivity analysis over the range of discount rates. Mean loss of life ESRD/mean loss of life cancer (lower bound ESRD loss of life/upper bound cancer loss of life upper bound ESRD loss of life/lower bound cancer loss of life).

5 J Am Soc Nephrol 13: , 2002 Cumulative ESRD Risk in the United States 1639 Table 4. Cumulative Medicare payments (1998 US dollars) for ESRD per US citizen Group Discount Rate 0% 3% 5% 7% White women White men Black women 23, Black men 22, life for ESRD to lost life for cancer with higher discount rates. On the other hand this ratio decreases only slightly with higher discount rates for black women, and it is stable in white women. This lack of an effect on life loss with higher discount rates suggests that breast cancer and ESRD impact the life of women proportionately at similar time points. ESRD therapy is expensive and is a replacement therapy rather than curative. This study shows that the cumulative ESRD costs in blacks (including the mix of dialysis and transplantation) are much greater than the direct treatment costs (initial, maintenance, and terminal care) of cancer. Depending on the discount rate, ESRD is about 5 times more expensive than breast cancer for black women, fourfold higher than for prostate cancer for black men and 10- to 20-fold higher than for colorectal cancer. Even large errors in cost estimates cannot account for these differences. The cumulative costs of colorectal and prostate cancer are also significantly less than those incurred due to ESRD for white men. Only the cumulative costs of breast cancer in white women are higher than (or equivalent to) the cumulative costs of ESRD. Cancer screening programs for breast, prostate, and colon have traditionally had a high public profile, and special efforts have been made to increase screening in blacks. Not all diseases that have a significant impact on life are suitable for screening. Lung cancer is a prime example. Screening for renal disease is not presently recommended by the US Preventive Services Task Force (16). The types of evidence required for such a recommendation are not available (17). However, ESRD has a comparable or greater impact on loss of life in black people than the cancers studied in this report. This impact on life, together with high cumulative ESRD costs, suggest that concerted efforts at prevention may be warranted in this group. A recently published analysis suggests that screening for diabetes mellitus (a significant cause of ESRD) could be very costeffective in young ( 45 yr old) black Americans (18), but this has not been tested clinically. Cost-effective models examining the effect of delaying diabetic complications rely heavily on preventing ESRD (19). Renal disease is screened for in nondiabetic subjects detected to have hypertension, but not all patients with an elevated creatinine have hypertension (20). It has been suggested renal impairment may predate overt hypertension and that hypertensive nephrosclerosis is over-diagnosed in black Americans (21). Furthermore renal disease may cluster in families, especially black Americans (22). In an attempt to model renal loss in the US population (Third National Health and Nutrition Examination Survey), we found that there are a small portion of young blacks in their forties (and probably younger) with mild renal impairment, who may be at great risk of progression (23). From the above and because the cumulative risk of ESRD in blacks already exceeds the lifetime risk in whites by age 56, appropriately timed and more novel screening strategies should be studied in this population. Screening alone is not, however, sufficient. A more recent report suggests that a large part of renal disease progression in diabetic blacks is related to socioeconomic status, suboptimal health-related behavior, and poor BP and glucose control rather than race per se (24). Not only is research into cost-effective identification of individuals at risk therefore lacking, but there is the lack of information on the efficacy of aggressive therapy in early renal disease. This should soon be answered by the African American Study of Kidney Disease and Hypertension (25). Even if this study is favorable, developing strategies to implement early treatment effectively into the general population will be critical to reduce the burden of illness due to ESRD. This analysis has several limitations. Its assumptions are a fixed age and demographic structure for the general population and stable ESRD and cancer incidence rates and mortality. The Table 5. Relative cumulative treatment costs of ESRD compared with cancers a Group 0% 3% 5% 7% Women ESRD/Breast Cancer black 5.5 (4.5 to 7.1) 5.5 (4.5 to 7.0) 5.5 (4.5 to 7.0) 5.5 (4.6 to 7.0) white 0.87 (0.71 to 1.12) 0.80 (0.66 to 1.02) 0.78 (0.64 to 0.99) 0.78 (0.64 to 0.99) Men ESRD/prostate cancer black 3.8 (3.1 to 4.7) 4.5 (3.8 to 5.7) 5.6 (4.6 to 7.0) 7.2 (6.0 to 9.1) white 1.3 (1.1 to 1.6) 1.6 (1.3 to 1.9) 1.9 (1.6 to 2.4) 2.4 (2.0 to 3.1) Men ESRD/colorectal cancer black 13 (10 to 16) 15 (12 to 19) 17 (14 to 22) 21 (17 to 26) white 2.9 (2.4 to 3.7) 3.5 (2.9 to 4.4) 4.1 (3.4 to 5.2) 4.9 (4.0 to 6.2) a One-way sensitivity analysis over the range of discount rates. Mean cumulative costs of ESRD/mean cumulative costs of cancer (mean ESRD costs/upper bound (mean 2 SE) cancer costs to mean ESRD/lower bound (mean 2 SE) cancer costs).

6 1640 Journal of the American Society of Nephrology J Am Soc Nephrol 13: , 2002 ESRD incidence rates do not include those who are not referred for therapy, but could benefit or those who decline therapy. Each of these assumptions leads to bias in the direction of underestimation of cumulative risk of ESRD. If mortality rates for ESRD patients decrease over time, the impact of ESRD on life expectancy may be less than that predicted. This will not affect cumulative incidence rates and will increase cost projections, as each patient survives longer on renal replacement therapy. We have chosen this conservative approach rather than attempting to project future incidence and mortality rates in view of the difficulties associated with making accurate predications in this area for both ESRD and cancer. This article is not intended to be a self-serving message to nephrologists that a new screening strategy is required for the prevention of ESRD over current preventive health recommendations. Nor is it intended to support a shift in research support from cancer to renal disease. Our recommendations are more measured. Given the higher cumulative risk, early onset of disease and large cumulative costs of ESRD, we suggest greater attention toward implementing existing treatment strategies and more research into novel screening strategies in the black population. Depending on the growth of ESRD and the feasibility, investigating new screening strategies in other populations may then be warranted. References 1. US Renal Data System: USRDS 2000 Annual Data Report, Bethesda MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, National Center for Health Statistics: US Vital and Health Statistics, Hyattsville, MD, National Center for Health Statistics, Steve Selvin: Monographs in Epidemiology and Bioststistics: Statistical Analysis of Epidemiologic Data, Vol. 17, Oxford, Oxford University Press, 1991, pp Anderson RN: A method for constructing complete annual US life tables. National Center for Health Statistics. Vital Health Stat 2, 1999, pp Beck JR, Kassirer JP, Pauker SG, Gottlieb JE, Klein K: A convenient approximation of life expectancy. Am J Med 73: , Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards: SEER Cancer Statistics Review, , Bethesda, MD, National Cancer Institute, Taplin SH, Barlow W, Urban N, Mandelson MT, Timlin DJ, Ichikawa L, Nefcy P: Stage, age comorbidity and direct costs of colon, prostate and breast cancer care. J Natl Cancer Inst 87: , Stewart KJ, Reed SB: Consumer price index research series using current methods, Monthly Labor Review 122(6): 29 38, Salzman P, Kerlikowske K, Phillips K: Cost-effectiveness of extending screening mammography guidelines to include 40 to 49 years of age. Ann Intern Med 127: , Frazier AL, Colditz GA, Fuchs CS, Kuntz KM: Cost-effectiveness of screening for colorectal cancer in the general population. JAMA 284: , Krahn MD, Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS: Screening for prostate cancer: A decision analysis. 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Transplantation 70: , Coresh J, Wei GL, McQuillan G, Brancati FL, Levey AS, Jones C, Klag MJ: Prevalence of high blood pressure and elevated serum creatinine level in the United States: findings from the third National Health and Nutrition Examination Survey, Arch Intern Med 161: , Schlessinger SD, Tankersley MR, Curtis JJ: Clinical documentation of end-stage renal disease due to hypertension. Am J Kidney Dis 23: , Freedman BI, Soucie JM, McClellan WM: Family history of end-stage renal disease among incident dialysis patients. JAm Soc Nephrol 8: , Kiberd BA, Clase CM: Modelling renal function loss in the US population [Abstract]. J Am Soc Nephrol 11: 153A, Krop JS, Coresh J, Chambless LE, Shahar E, Watson RL, Szklo M, Brancati FL: A community-based study of the explanatory factors for the excess risk for early renal function decline in blacks and whites with diabetes. 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7 J Am Soc Nephrol 13: , 2002 Cumulative ESRD Risk in the United States 1641 Appendix White Male Annual ESRD incidence rate per million ( SE) (1) Annual prostate cancer million ( SE) (6) Annual colon/rectal cancer incidence rate per million ( SE) Annual all-modality ESRD mortality rate ( SE) (1) Annual prostate cancer mortality probability ( SE) Annual colon/rectal cancer mortality probability ( SE) (6) General population annual mortality rate (2) Annual ESRD costs 1998 US$ (1) Lifetime prostate cancer costs 1998 US$ ( SE) (7) Lifetime colon cancer costs ( SE) (7)

8 1642 Journal of the American Society of Nephrology J Am Soc Nephrol 13: , 2002 Black Female Annual ESRD million ( SE) (1) Annual breast cancer million ( SE) (6) Annual all-modality ESRD mortality rate ( SE) (1) Annual breast cancer mortality probability ( SE) (6) General population annual mortality rate (2) Annual ESRD costs 1998 US$ Lifetime breast cancer costs 1998 US$ ( SE) (7)

9 J Am Soc Nephrol 13: , 2002 Cumulative ESRD Risk in the United States 1643 White Female Annual ESRD million ( SE) (1) Annual breast cancer million ( SE) (6) Annual all-modality ESRD mortality rate ( SE) (1) Annual breast cancer mortality probability ( SE) (6) General population annual mortality rate (2) Annual ESRD costs 1998 US$ Lifetime breast cancer costs 1998 US$ ( SE) (7)

10 1644 Journal of the American Society of Nephrology J Am Soc Nephrol 13: , 2002 Black Male Annual ESRD incidence rate per million ( SE) (1) Annual prostate cancer million ( SE) (6) Annual colorectal cancer million ( SE) (6) Annual all-modality ESRD mortality rate ( SE) (1) Annual prostate cancer mortality probability ( SE) (6) Colorectal annual mortality probability ( SE) (6) General population annual mortality rate (2) Annual ESRD costs 1998 US$ Lifetime prostate cancer costs 1998 US$ ( SE) (7) Lifetime colon cancer costs ( SE) (7)