Interpretation of Incidence Rates Data
Incidence Rate Report by State
All Cancer Sites (All Stages^), 2014-2018
All Races (includes Hispanic), Both Sexes, Ages <65
Sorted by Count
Explanation of Column HeadersObjective - The objective of *** is from the Healthy People 2020 project done by the Centers for Disease Control and Prevention.
Incidence Rate (95% Confidence Interval) - The incidence rate is based upon 100,000 people and is an annual rate (or average annual rate) based on the time period indicated. Rates are age-adjusted by 5-year age groups to the 2000 U.S. standard million population.Recent Trends - This is an interpretation of the AAPC/APC:
- Rising when 95% confidence interval of AAPC/APC is above 0.
- Stable when 95% confidence interval of AAPC/APC includes 0.
- Falling when 95% confidence interval of AAPC/APC is below 0.
AAPC/APC (95% Confidence Interval) - the change in rate over time
- Average Annual Percent Change - AAPCs are based upon APCs that were calculated by Joinpoint Regression Program
- Annual Percent Change - APCs calculated in SEER*Stat.
Other Notes
- Larger confidence intervals indicate less stability of the data. This is often due to low counts that are not quite low enough to be suppressed.
- Data is currently being suppressed if there are fewer than 16 counts for the time period.
Line by Line Interpretation of the Report
US (SEER+NPCR)1
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 227.6 with a 95% confidence interval from 227.4 to 227.9 and 750,329 average annual cases over 2014-2018.
- CI*Rank⋔ : N/A
- Recent Trend : The trend is stable
because the trend is -0.7 with a 95% confidence interval from -1.8 to 0.5.
California7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 198.8 with a 95% confidence interval from 198.1 to 199.4 and 76,863 average annual cases over 2014-2018.
- CI*Rank⋔ : 47 (46, 49)
- Recent Trend : The trend is falling
because the trend is -0.5 with a 95% confidence interval from -0.7 to -0.4.
Texas6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 205.9 with a 95% confidence interval from 205.1 to 206.7 and 54,410 average annual cases over 2014-2018.
- CI*Rank⋔ : 44 (43, 46)
- Recent Trend : The trend is stable
because the trend is -0.2 with a 95% confidence interval from -0.5 to 0.0.
Florida6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 239.7 with a 95% confidence interval from 238.7 to 240.7 and 50,951 average annual cases over 2014-2018.
- CI*Rank⋔ : 15 (12, 19)
- Recent Trend : The trend is falling
because the trend is -1.5 with a 95% confidence interval from -2.9 to -0.1.
New York7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 248.3 with a 95% confidence interval from 247.3 to 249.3 and 50,506 average annual cases over 2014-2018.
- CI*Rank⋔ : 6 (4, 8)
- Recent Trend : The trend is stable
because the trend is -0.2 with a 95% confidence interval from -0.5 to 0.0.
Pennsylvania6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 247.0 with a 95% confidence interval from 245.8 to 248.2 and 33,835 average annual cases over 2014-2018.
- CI*Rank⋔ : 7 (5, 9)
- Recent Trend : The trend is stable
because the trend is -1.5 with a 95% confidence interval from -3.2 to 0.2.
Illinois6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 234.1 with a 95% confidence interval from 232.9 to 235.3 and 30,984 average annual cases over 2014-2018.
- CI*Rank⋔ : 23 (19, 29)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.2 to 0.1.
Ohio6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 242.9 with a 95% confidence interval from 241.6 to 244.1 and 29,925 average annual cases over 2014-2018.
- CI*Rank⋔ : 11 (8, 13)
- Recent Trend : The trend is rising
because the trend is 0.3 with a 95% confidence interval from 0.2 to 0.5.
North Carolina6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 240.1 with a 95% confidence interval from 238.8 to 241.5 and 25,181 average annual cases over 2014-2018.
- CI*Rank⋔ : 13 (11, 19)
- Recent Trend : The trend is falling
because the trend is -0.5 with a 95% confidence interval from -0.7 to -0.2.
Georgia7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 236.3 with a 95% confidence interval from 235.0 to 237.7 and 24,516 average annual cases over 2014-2018.
- CI*Rank⋔ : 20 (17, 23)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.2 to 0.1.
Michigan5
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 229.3 with a 95% confidence interval from 227.9 to 230.6 and 24,481 average annual cases over 2014-2018.
- CI*Rank⋔ : 34 (30, 37)
- Recent Trend : The trend is falling
because the trend is -0.6 with a 95% confidence interval from -0.8 to -0.4.
New Jersey7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 241.3 with a 95% confidence interval from 239.9 to 242.8 and 22,904 average annual cases over 2014-2018.
- CI*Rank⋔ : 12 (9, 17)
- Recent Trend : The trend is falling
because the trend is -0.4 with a 95% confidence interval from -0.5 to -0.2.
Virginia6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 209.0 with a 95% confidence interval from 207.6 to 210.4 and 18,315 average annual cases over 2014-2018.
- CI*Rank⋔ : 43 (41, 45)
- Recent Trend : The trend is stable
because the trend is -1.5 with a 95% confidence interval from -3.3 to 0.3.
Tennessee6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 243.1 with a 95% confidence interval from 241.4 to 244.8 and 16,835 average annual cases over 2014-2018.
- CI*Rank⋔ : 10 (8, 14)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.4 to 0.2.
Massachusetts7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 232.1 with a 95% confidence interval from 230.5 to 233.8 and 16,822 average annual cases over 2014-2018.
- CI*Rank⋔ : 30 (21, 34)
- Recent Trend : The trend is stable
because the trend is -1.4 with a 95% confidence interval from -4.4 to 1.8.
Washington5
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 217.3 with a 95% confidence interval from 215.8 to 218.9 and 16,305 average annual cases over 2014-2018.
- CI*Rank⋔ : 39 (38, 40)
- Recent Trend : The trend is falling
because the trend is -0.7 with a 95% confidence interval from -0.9 to -0.5.
Indiana6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 231.2 with a 95% confidence interval from 229.6 to 232.9 and 15,744 average annual cases over 2014-2018.
- CI*Rank⋔ : 31 (23, 35)
- Recent Trend : The trend is stable
because the trend is -1.0 with a 95% confidence interval from -2.3 to 0.4.
Missouri6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 233.2 with a 95% confidence interval from 231.4 to 234.9 and 14,760 average annual cases over 2014-2018.
- CI*Rank⋔ : 25 (20, 32)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.3 to 0.1.
Maryland6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 230.2 with a 95% confidence interval from 228.5 to 232.0 and 14,729 average annual cases over 2014-2018.
- CI*Rank⋔ : 32 (26, 36)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.3 to 0.1.
Wisconsin6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 232.3 with a 95% confidence interval from 230.5 to 234.1 and 14,362 average annual cases over 2014-2018.
- CI*Rank⋔ : 29 (21, 34)
- Recent Trend : The trend is stable
because the trend is 0.1 with a 95% confidence interval from 0.0 to 0.2.
Minnesota6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 233.0 with a 95% confidence interval from 231.2 to 234.9 and 13,361 average annual cases over 2014-2018.
- CI*Rank⋔ : 27 (20, 33)
- Recent Trend : The trend is stable
because the trend is 0.1 with a 95% confidence interval from -0.2 to 0.3.
Arizona6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 194.5 with a 95% confidence interval from 192.9 to 196.0 and 12,960 average annual cases over 2014-2018.
- CI*Rank⋔ : 51 (49, 51)
- Recent Trend : The trend is falling
because the trend is -0.5 with a 95% confidence interval from -0.7 to -0.3.
Kentucky7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 272.0 with a 95% confidence interval from 269.8 to 274.2 and 12,604 average annual cases over 2014-2018.
- CI*Rank⋔ : 1 (1, 1)
- Recent Trend : The trend is rising
because the trend is 0.4 with a 95% confidence interval from 0.2 to 0.5.
Alabama6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 239.7 with a 95% confidence interval from 237.7 to 241.7 and 12,159 average annual cases over 2014-2018.
- CI*Rank⋔ : 14 (10, 20)
- Recent Trend : The trend is stable
because the trend is -0.3 with a 95% confidence interval from -4.4 to 3.9.
Louisiana7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 254.0 with a 95% confidence interval from 251.9 to 256.1 and 12,132 average annual cases over 2014-2018.
- CI*Rank⋔ : 3 (3, 4)
- Recent Trend : The trend is stable
because the trend is 1.0 with a 95% confidence interval from -0.6 to 2.6.
South Carolina6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 233.1 with a 95% confidence interval from 231.1 to 235.0 and 12,042 average annual cases over 2014-2018.
- CI*Rank⋔ : 26 (20, 33)
- Recent Trend : The trend is stable
because the trend is -1.4 with a 95% confidence interval from -2.9 to 0.0.
Colorado6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 198.6 with a 95% confidence interval from 196.9 to 200.3 and 11,138 average annual cases over 2014-2018.
- CI*Rank⋔ : 48 (46, 49)
- Recent Trend : The trend is falling
because the trend is -0.6 with a 95% confidence interval from -0.8 to -0.4.
Oregon6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 215.5 with a 95% confidence interval from 213.5 to 217.6 and 9,167 average annual cases over 2014-2018.
- CI*Rank⋔ : 40 (38, 41)
- Recent Trend : The trend is falling
because the trend is -0.4 with a 95% confidence interval from -0.7 to -0.2.
Connecticut7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 232.5 with a 95% confidence interval from 230.3 to 234.8 and 9,057 average annual cases over 2014-2018.
- CI*Rank⋔ : 28 (20, 34)
- Recent Trend : The trend is falling
because the trend is -0.6 with a 95% confidence interval from -0.7 to -0.4.
Oklahoma6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 229.9 with a 95% confidence interval from 227.7 to 232.1 and 8,891 average annual cases over 2014-2018.
- CI*Rank⋔ : 33 (25, 37)
- Recent Trend : The trend is stable
because the trend is -0.9 with a 95% confidence interval from -2.9 to 1.1.
Iowa7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 245.1 with a 95% confidence interval from 242.6 to 247.7 and 7,797 average annual cases over 2014-2018.
- CI*Rank⋔ : 8 (5, 12)
- Recent Trend : The trend is rising
because the trend is 0.5 with a 95% confidence interval from 0.4 to 0.6.
Mississippi6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 249.5 with a 95% confidence interval from 246.9 to 252.1 and 7,604 average annual cases over 2014-2018.
- CI*Rank⋔ : 5 (3, 8)
- Recent Trend : * Data has been suppressed to ensure confidentiality and stability of rate estimates. Counts are suppressed if fewer than 16 records were reported in a specific area-sex-race category. If an average count of 3 is shown, the total number of cases for the time period is 16 or more which exceeds suppression threshold (but is rounded to 3).
Arkansas6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 250.3 with a 95% confidence interval from 247.7 to 252.9 and 7,550 average annual cases over 2014-2018.
- CI*Rank⋔ : 4 (3, 8)
- Recent Trend : The trend is stable
because the trend is 0.3 with a 95% confidence interval from -1.2 to 1.7.
Puerto Rico6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 203.0 with a 95% confidence interval from 200.7 to 205.2 and 6,811 average annual cases over 2014-2018.
- CI*Rank⋔ : N/A
- Recent Trend : The trend is stable
because the trend is -0.5 with a 95% confidence interval from -7.1 to 6.6.
Kansas6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 234.2 with a 95% confidence interval from 231.6 to 236.8 and 6,764 average annual cases over 2014-2018.
- CI*Rank⋔ : 22 (17, 32)
- Recent Trend : The trend is stable
because the trend is -0.3 with a 95% confidence interval from -0.8 to 0.1.
Utah7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 209.4 with a 95% confidence interval from 206.9 to 212.0 and 5,305 average annual cases over 2014-2018.
- CI*Rank⋔ : 42 (41, 45)
- Recent Trend : The trend is stable
because the trend is -0.4 with a 95% confidence interval from -0.8 to 0.1.
West Virginia6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 262.2 with a 95% confidence interval from 258.9 to 265.6 and 5,199 average annual cases over 2014-2018.
- CI*Rank⋔ : 2 (2, 2)
- Recent Trend : The trend is rising
because the trend is 0.5 with a 95% confidence interval from 0.3 to 0.7.
Nevada6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 194.7 with a 95% confidence interval from 192.1 to 197.3 and 4,551 average annual cases over 2014-2018.
- CI*Rank⋔ : 50 (48, 51)
- Recent Trend : * Data has been suppressed to ensure confidentiality and stability of rate estimates. Counts are suppressed if fewer than 16 records were reported in a specific area-sex-race category. If an average count of 3 is shown, the total number of cases for the time period is 16 or more which exceeds suppression threshold (but is rounded to 3).
Nebraska6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 237.1 with a 95% confidence interval from 233.8 to 240.3 and 4,456 average annual cases over 2014-2018.
- CI*Rank⋔ : 19 (12, 28)
- Recent Trend : The trend is rising
because the trend is 1.4 with a 95% confidence interval from 1.0 to 1.9.
New Mexico7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 195.8 with a 95% confidence interval from 193.0 to 198.7 and 4,095 average annual cases over 2014-2018.
- CI*Rank⋔ : 49 (47, 51)
- Recent Trend : The trend is stable
because the trend is -0.8 with a 95% confidence interval from -2.8 to 1.3.
New Hampshire6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 239.6 with a 95% confidence interval from 236.0 to 243.3 and 3,699 average annual cases over 2014-2018.
- CI*Rank⋔ : 16 (8, 23)
- Recent Trend : The trend is falling
because the trend is -0.5 with a 95% confidence interval from -0.8 to -0.3.
Maine6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 238.8 with a 95% confidence interval from 235.1 to 242.5 and 3,654 average annual cases over 2014-2018.
- CI*Rank⋔ : 17 (9, 24)
- Recent Trend : The trend is falling
because the trend is -0.5 with a 95% confidence interval from -0.7 to -0.2.
Idaho7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 212.7 with a 95% confidence interval from 209.4 to 216.0 and 3,480 average annual cases over 2014-2018.
- CI*Rank⋔ : 41 (39, 44)
- Recent Trend : The trend is stable
because the trend is -0.1 with a 95% confidence interval from -0.3 to 0.0.
Hawaii7
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 220.9 with a 95% confidence interval from 217.3 to 224.5 and 3,147 average annual cases over 2014-2018.
- CI*Rank⋔ : 38 (36, 40)
- Recent Trend : The trend is stable
because the trend is -0.3 with a 95% confidence interval from -0.8 to 0.2.
Rhode Island6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 238.2 with a 95% confidence interval from 234.1 to 242.5 and 2,713 average annual cases over 2014-2018.
- CI*Rank⋔ : 18 (9, 28)
- Recent Trend : The trend is falling
because the trend is -0.8 with a 95% confidence interval from -1.1 to -0.5.
Montana6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 228.1 with a 95% confidence interval from 223.8 to 232.3 and 2,532 average annual cases over 2014-2018.
- CI*Rank⋔ : 35 (22, 38)
- Recent Trend : The trend is stable
because the trend is 0.1 with a 95% confidence interval from -0.3 to 0.4.
Delaware6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 244.8 with a 95% confidence interval from 240.2 to 249.4 and 2,448 average annual cases over 2014-2018.
- CI*Rank⋔ : 9 (4, 18)
- Recent Trend : The trend is falling
because the trend is -1.0 with a 95% confidence interval from -1.6 to -0.4.
South Dakota6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 225.3 with a 95% confidence interval from 220.6 to 230.1 and 1,949 average annual cases over 2014-2018.
- CI*Rank⋔ : 37 (28, 38)
- Recent Trend : The trend is stable
because the trend is -0.5 with a 95% confidence interval from -1.5 to 0.5.
North Dakota6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 226.3 with a 95% confidence interval from 221.2 to 231.5 and 1,645 average annual cases over 2014-2018.
- CI*Rank⋔ : 36 (24, 38)
- Recent Trend : The trend is stable
because the trend is 0.2 with a 95% confidence interval from -0.1 to 0.5.
Vermont6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 233.3 with a 95% confidence interval from 227.9 to 238.8 and 1,638 average annual cases over 2014-2018.
- CI*Rank⋔ : 24 (12, 37)
- Recent Trend : The trend is falling
because the trend is -0.7 with a 95% confidence interval from -0.9 to -0.4.
Alaska6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 205.6 with a 95% confidence interval from 200.9 to 210.4 and 1,544 average annual cases over 2014-2018.
- CI*Rank⋔ : 45 (41, 47)
- Recent Trend : The trend is falling
because the trend is -0.9 with a 95% confidence interval from -1.2 to -0.5.
District of Columbia6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 234.8 with a 95% confidence interval from 229.3 to 240.4 and 1,461 average annual cases over 2014-2018.
- CI*Rank⋔ : 21 (11, 36)
- Recent Trend : The trend is falling
because the trend is -1.6 with a 95% confidence interval from -2.2 to -1.0.
Wyoming6
- Met Healthy People Objective of ***? : ***
- Rate : The incidence rate is 203.4 with a 95% confidence interval from 198.1 to 208.8 and 1,229 average annual cases over 2014-2018.
- CI*Rank⋔ : 46 (42, 49)
- Recent Trend : The trend is falling
because the trend is -0.4 with a 95% confidence interval from -0.8 to -0.1.
Notes:
Created by statecancerprofiles.cancer.gov on 06/27/2022 1:12 am.
State Cancer Registries may provide more current or more local data.
Trend
Rising when 95% confidence interval of average annual percent change is above 0.
Stable when 95% confidence interval of average annual percent change includes 0.
Falling when 95% confidence interval of average annual percent change is below 0.
Rising when 95% confidence interval of average annual percent change is above 0.
Stable when 95% confidence interval of average annual percent change includes 0.
Falling when 95% confidence interval of average annual percent change is below 0.
⋔ Results presented with the CI*Rank statistics help show the usefulness of ranks. For example, ranks for relatively rare diseases or less populated areas may be essentially meaningless because of their large variability, but ranks for more common diseases in densely populated regions can be very useful. More information about methodology can be found on the CI*Rank website.
† Incidence rates (cases per 100,000 population per year) are age-adjusted to the 2000 US standard population (19 age groups: <1, 1-4, 5-9, ... , 80-84, 85+). Rates are for invasive cancer only (except for bladder cancer which is invasive and in situ) or unless otherwise specified. Rates calculated using SEER*Stat. Population counts for denominators are based on Census populations as modified by NCI. The 1969-2018 US Population Data File is used for SEER and NPCR incidence rates.
‡ Incidence data come from different sources. Due to different years of data availability, most of the trends are AAPCs based on APCs but some are APCs calculated in SEER*Stat. Please refer to the source for each area for additional information.
Rates and trends are computed using different standards for malignancy. For more information see malignant.html.
^ All Stages refers to any stage in the Surveillance, Epidemiology, and End Results (SEER) summary stage.
*** No Healthy People 2020 Objective for this cancer.
Healthy People 2020 Objectives provided by the Centers for Disease Control and Prevention.
* Data has been suppressed to ensure confidentiality and stability of rate estimates. Counts are suppressed if fewer than 16 records were reported in a specific area-sex-race category. If an average count of 3 is shown, the total number of cases for the time period is 16 or more which exceeds suppression threshold (but is rounded to 3).
1 Source: National Program of Cancer Registries and Surveillance, Epidemiology, and End Results SEER*Stat Database (2001-2018) - United States Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Based on the 2020 submission.
5 Source: National Program of Cancer Registries and Surveillance, Epidemiology, and End Results SEER*Stat Database (2001-2018) - United States Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Based on the 2020 submission.
6 Source: National Program of Cancer Registries SEER*Stat Database (2001-2018) - United States Department of Health and Human Services, Centers for Disease Control and Prevention (based on the 2020 submission).
7 Source: SEER November 2020 submission.
8 Source: Incidence data provided by the SEER Program. AAPCs are calculated by the Joinpoint Regression Program and are based on APCs. Data are age-adjusted to the 2000 US standard population (19 age groups: <1, 1-4, 5-9, ... , 80-84,85+). Rates are for invasive cancer only (except for bladder cancer which is invasive and in situ) or unless otherwise specified. Population counts for denominators are based on Census populations as modifed by NCI. The 1969-2018 US Population Data File is used with SEER November 2020 data.
Interpret Rankings provides insight into interpreting cancer incidence statistics. When the population size for a denominator is small, the rates may be unstable. A rate is unstable when a small change in the numerator (e.g., only one or two additional cases) has a dramatic effect on the calculated rate.
Data for United States does not include Puerto Rico.