Trends and disparities in neoplasm-related mortality with death-certificate-documented protein-energy malnutrition in the United States, 1999-2024: a CDC WONDER multiple cause of death study.

BACKGROUND: Malnutrition is clinically important but often underrecognized among patients with neoplasms. National temporal patterns of neoplasm-related deaths with death-certificate-documented protein-energy malnutrition (PEM) remain unclear. METHODS: We conducted a population-based serial cross-sectional study using CDC WONDER Multiple Cause of Death data. Deaths among persons aged ≥15 years with neoplasms as the underlying cause (ICD-10 C00-D48) and PEM in multiple-cause-of-death fields (E40-E46) were identified for 1999-2024. Annual death counts and age-adjusted mortality rates (AAMRs) per 100,000 population, standardized to the 2000 US population, were assessed using Joinpoint regression. Trends were examined overall and across demographic, geographic, neoplasm-category, and state strata. We also calculated the annual proportion of all neoplasm-related deaths with documented PEM. RESULTS: Annual neoplasm-related deaths with death-certificate-documented PEM increased from 5,024 in 1999 to 18,410 in 2024, while the AAMR increased from 2.32 (95% CI, 2.26-2.38) to 5.26 (95% CI, 5.19-5.34) per 100,000 population. The proportion of all neoplasm-related deaths with documented PEM increased from 0.90% (95% CI, 0.87%-0.92%) to 2.90% (95% CI, 2.86%-2.94%). Joinpoint analysis identified inflection points in 2006 and 2013, with an early decline, an intermediate stable period, and a marked subsequent increase; the overall AAPC was 3.54%. In 2024, AAMRs were higher among males than females (6.32 vs. 4.43), Black than White individuals (6.42 vs. 5.32), and adults aged ≥65 years than those aged 15-64 years (24.47 vs. 1.58 per 100,000). Nonmetropolitan areas had higher rates than metropolitan areas through 2020. Digestive neoplasms represented the largest observed broad-category burden in both years. CONCLUSION: Death-certificate-documented PEM among neoplasm-related deaths increased substantially in the United States from 1999 to 2024 and showed marked demographic, geographic, and neoplasm-category disparities. The rising proportion of all neoplasm-related deaths with documented PEM suggests that the trend was not explained solely by changes in overall neoplasm mortality. However, these descriptive data cannot distinguish changes in underlying nutritional vulnerability from changes in clinical recognition and death-certificate documentation.