Hispanics now represent a majority of residents in Miami-Dade County, Florida. In this report, the authors present new cancer incidence and mortality data for South Florida's Hispanic men for the period 1990–1998 and compare them with data from a previous report from the 1980s. Periodic updating of cancer incidence data, reflecting current population distribution, lifestyle, and environmental risk factors, is necessary to inform cancer prevention and control activities optimally.
The study population consisted of all incidents of cancer (1981–1998) occurring in males from Miami-Dade County, as determined from the Florida Cancer Data System data base; patients were divided into two 9-year periods for analysis. Age-standardized incidence and mortality rates were computed for 14 common cancer sites, and rates for Hispanic men were compared with the rates for non-Hispanic white men as standardized rate ratios (SRRs) with 95% confidence intervals (95% CIs). Incidence and mortality trends were determined using linear regression analysis.
Nearly 70,000 incident cancer cases were analyzed. For 1990–1998, the top five incident cancers for both race/ethnic groups were the same. The overall decreased cancer risk for Hispanic men (SRR, 0.80; 95% CI, 0.79–0.82), compared with non-Hispanic white men, remained essentially constant over the two study periods. Cancer incidence increased similarly for the two race-ethnic groups; cancer mortality decreased, with a sharper decrease for non-Hispanic white men, resulting in apparent convergence of mortality trends recently.
The Hispanic population is the fastest growing minority population in the United States. There were over 2.5 million Hispanics living in Florida as of the year 2000, a 70.4% increase since 1990.1 Miami-Dade County is home to nearly half (49%) of Florida's Hispanic population, and they make up 57% of the county population. The majority of Hispanics in Miami are of Cuban origin (51%), but immigration from other countries is increasing. To date, most reports of cancer in Hispanics in the United States have concerned persons of Mexican or Puerto Rican ancestry. These two groups represent < 10% of Miami-Dade County's Hispanic population.
Although publications of cancer incidence and mortality data for Hispanics have increased recently, our knowledge of the distribution and determinants of cancer in this rapidly growing population remains far less than for non-Hispanic whites or African Americans. Hispanics in the United States are a diverse group with regional concentrations based on national origin: Mexican Americans in California, Texas, and the Southwest; Puerto Ricans in New York and New Jersey; and Cuban Americans in Florida. Demographic characteristics, such as median income, educational level, household size, and unemployment, differ significantly among these groups. More importantly, it has been demonstrated that incidence rates for some common carcinomas (lung, breast, and prostate) may vary by as much as 40–50% among Hispanics from different regions of the United States.2 Although some of these differences may be related to factors like rural versus urban residence,3 even when cancer incidence rates for major U.S. metropolitan areas are compared, these differences persist.
In general, the tumor burden for U.S. Hispanics has been less than for non-Hispanic whites. However, concerns have been expressed recently that incidence rates may increase due to changing exposures for lifestyle and environmental risk factors associated with the increased acculturation of Hispanics in this country.
We previously reported cancer incidence data for both Hispanic men and Hispanic women in South Florida for the period 1981–1989.4–7 Periodic updating of cancer incidence data that reflects current population distribution and lifestyle and environmental risk factors is necessary to inform optimally public health activities concerned with cancer prevention and control. This report presents new cancer incidence data for the South Florida Hispanic population for the period 1990–1999, including temporal trends for some of the more common cancers. Reports like this are important to the development of cancer prevention and control strategies not only for the Hispanic population of Miami-Dade County but also for the Hispanic population in Florida and in the rest of the nation. This study also is consistent with the Institute of Medicine's recommendation of an increased emphasis on ethnic groups (i.e., cultural, behavioral, and lifestyle factors) rather than race (i.e., biologic differences) in cancer surveillance.8
MATERIALS AND METHODS
This study was performed in collaboration with the Florida Cancer Data System (FCDS), which is the State of Florida population-based cancer registry. The FCDS was established in 1981 and is supported by the Florida Department of Health and the Centers for Disease Control and Prevention. Over 140,000 case reports are processed by the FCDS annually, with approximately 75,000 new incident cancer cases per year. Florida has the highest crude rate of cancer in the nation. FCDS is the second largest population-based cancer incidence registry in the nation. In addition to collecting data from all 205 hospitals in Florida, the FCDS also collects data from over 350 freestanding ambulatory surgical and radiation therapy centers in Florida and approximately 100 pathology laboratories. Approximately 2.5% of incident cases are identified from death certificates. Case-finding audits have demonstrated a > 95% completeness in cancer case identification throughout the state of Florida.
The study population was drawn from all incident cancer cases that occurred in males from Miami-Dade County for the years 1981–1998, as determined from the FCDS data base. Cases were then divided into two 9-year periods for analysis: 1981–1989 and 1990–1998. Although the results for the earlier period were reported previously,4, 5 rates and rate ratios were recalculated for this set of cases to reflect the most current information available in the FCDS data base.
Consistent with the study objective of comparing cancer rates in Hispanic men with non-Hispanic white men (as the reference group), the study population itself consisted of patients classified either as non-Hispanic white or Hispanic. Less than 10% of the FCDS population is designated both as a race other than White and as Hispanic; these nonwhite Hispanics were included in the race-ethnic group of Hispanic for study purposes. This is consistent with previous reports from the FCDS9, 10 and the taxonomy used by the National Center for Health Statistics. Patients for whom Hispanic ethnicity was unknown (< 3%) were excluded from further analysis.
Fourteen cancer sites were selected to represent the most common and important cancers and to be consistent with reports from other investigators. Specific cancer sites according to International Classification of Diseases (ICD)-Oncology codes were grouped according to the standards published by the North American Association of Central Cancer Registries.11 Although melanoma is an important cancer in Florida, it was not reported in this study as a result of concerns by FCDS personnel related to known inconsistent and incomplete reporting of melanoma cases over the study period.
Results were calculated and expressed as age-standardized incidence rates using the 1970 United States standard million population and Florida intercensal population projections (by year) for the race-ethnic groups defined above. Florida race-ethnic population projections were developed using a model from the University of Florida Bureau of Business and Economic Research.12 The standard errors for the age-adjusted rates were calculated after the method of Breslow and Day.13 The incidence rates for the Hispanic groups were compared with the rates for the non-Hispanic white group and are expressed as standardized rate ratios (SRRs) with two-sided 95% confidence intervals (95% CIs).
Mortality data for the State of Florida were obtained from the State of Florida Bureau of Vital Statistics, and estimates of population for the State of Florida and individual Florida counties were obtained from the Florida Department of Health. Only the underlying cause of death was used in the calculation of mortality rates. The ICD ninth revision codes 140.0–208.9 for mortality records were converted to the SEER cancer site groups. Cancer deaths from non-Florida residents were omitted from all calculations. Rates were calculated per 100,000 population and age-adjusted by the direct method to the 1970 United States standards.
Incidence and mortality trends were determined using linear regression analysis based on 3-year moving averages. The incidence regressions were calculated for the entire study period. However, the mortality regressions were only for the period 1989–1998, because separate mortality rates for Hispanic men were not available before 1989. Statistical significance for the regressions was set at α = 0.05. The data were analyzed using SAS software (version 8.2; SAS Institute, Cary, NC) and were exported to Microsoft Excel 97 (Microsoft Corp., Redmond, WA) for presentation purposes. The FCDS has received approval from the University of Miami School of Medicine Human Subjects Institutional Review Board for data base maintenance and reporting of aggregated data sets.
For the study years 1981–1998, a total of 69,380 incident cancers were identified in non-Hispanic white men and Hispanic men in Miami-Dade County, Florida. In the earlier period, there were 30,036 incident cancers: 62% (18,637) occurred in non-Hispanic white men, and 38% (11,399) occurred in Hispanic men. In the later period, there were 39,344 incident cancers: 43% (17,107) in non-Hispanic white men and 57% (22,237) in Hispanic men. Recalculation of results for the earlier period (1981–1989) using the most recent FCDS data resulted in the inclusion of an additional 1624 cases (10%) for non-Hispanic white men and 982 cases (9%) for Hispanic men in the analysis and rate calculation for the period 1981–1989 compared with our previous report. These additional cases were distributed fairly evenly among the disease sites, and, although some rates were altered from those previously reported, none was altered significantly.
Total Cancer Cases and Age-Adjusted Rates
The number of incident cancer cases and age-adjusted rates per 105 population for the cancer sites by race/ethnicity and study period are shown in Table 1. The total number of incident cases increased by 9308 from the earlier study period to the more recent study period. This increase was due primarily to increased Hispanic cases offset by a slight decrease in non-Hispanic white cases. Consistent with the marked demographic changes in Miami-Dade County, the absolute number of incident cancers in Hispanic men increased greatly over the two study periods. During the period from 1981 to 1989, Hispanic cases accounted for 38% of the total; whereas, in the later period (1990–1998), Hispanic cases accounted for 56% of the total. In the earlier study period, the top five cancers were different between the two race/ethnic groups. In the most recent study period (1990–1998), the top five incident cancers for Hispanic men and non-Hispanic white men were the same (prostate, lung, colorectal, bladder, and non-Hodgkin lymphoma). The three most common cancers (prostate, lung, and colorectal) accounted for about 55% of all incident cancers in the most recent study period. This proportion was similar for the two race/ethnic groups: 53% for non-Hispanic white men and 57% for Hispanic men.
Table 1. Common Cancer Sites among Non-Hispanic White and Hispanic Males in Miami-Dade County, Florida 1981–1998a
No. of Hispanic patients
No. of WNH patients
No. of Hispanic patients
No. of WNH patients
Rates, shown are age-adjusted rates per 105 population, with standard errors shown in parentheses.
Head and neck
Lung and bronchus
SRRs with 95% CIs for Hispanic males compared with non-Hispanic white males (reference group) for the two study periods are shown in Table 2. The overall decreased cancer risk for Hispanic males remained fairly constant over the two study periods, with SRRs of 0.77 and 0.80, respectively. Of the 14 major disease sites, 11 sites showed no significant change in the SRR for Hispanics over the 2 study periods; all of these sites had SRRs that showed a lower risk for Hispanic men (10 sites) or no difference (Hodgkin lymphoma) compared with non-Hispanic white men. For the 10 sites with lower risk, the SRRs generally were in the range of 0.60–0.80. Carcinoma of the testes had the lowest SRR of approximately 0.40 for Hispanic males compared with non-Hispanic white males.
Table 2. Standardized Rate Ratios for Hispanic Patients and White Non-Hispanic Patients with 95% Confidence Intervals for Common Cancer Sites for Males in Miami-Dade County, Florida for the Periods 1981–1989 and 1990–1998
Three disease sites—liver, prostate, and brain—showed a significant change in SRR from the first study period to the second study period. Carcinoma of the liver had been the only major site to show an increased risk for Hispanic men in the earlier study period (SRR, 1.42; 95% CI, 1.11–1.82); however, in the later study period, the SRR decreased to 1.08 (95% CI, 0.88–1.32). The SRR for prostate carcinoma increased from 0.91 (95% CI, 0.86–0.96) to 0.99 (95% CI, 0.95–1.03), a change from a small but significant decreased risk to no difference compared with non-Hispanic white men. From Table 1, it should be noted that the age-adjusted rates for prostate carcinoma for both Hispanic men and non-Hispanic white men more than doubled from the early study period to the later study period, coincident with nationwide increases in prostate carcinoma screening activities and modalities. The risk for carcinoma of the brain decreased over the two study periods, from a nonsignificant SRR of 0.92 (95% CI, 0.76–1.13) to a significantly lower SRR of 0.72 (95% CI, 0.59–0.86). Only carcinoma of the gallbladder showed a persistently increased SRR for Hispanic men over the two study periods, with nearly identical values for the SRR: 1.94 (95% CI, 1.19–3.17) for the early period and 1.99 (95% CI, 1.14–3.46) for the later study period.
During the earlier study period, 1981–1989, in addition to liver and gallbladder carcinoma, three other minor (< 20 incident cases annually) disease sites had a significantly increased risk for Hispanic men: nasal cavity, middle ear, and accessory sinus (SRR, 1.87; 95% CI, 1.19–3.17); acute lymphocytic leukemia (SRR, 2.11; 95% CI, 1.14–3.10); and penis (SRR, 2.11; 95% CI, 1.28–3.46). None of these three sites showed a significantly increased risk for Hispanic males in the more recent period (1990–1998).
Cancer Incidence Trends
The results of the linear regression analyses (using 3-year moving averages) of incidence for the 14 cancer sites by race/ethnic group are shown in Table 3. For both non-Hispanic white men and Hispanic men, the overall cancer incidence increased similarly over the study period. For non-Hispanic white males, prostate carcinoma and non-Hodgkin lymphoma showed the most notable increases in incidence, with lesser increases for nine other disease sites. For Hispanic men, 10 of 14 sites showed a significantly positive incidence trend over the study period. This increase was most marked for prostate carcinoma, followed by colorectal carcinoma, and non-Hodgkin lymphoma. Only bladder carcinoma had a significantly decreasing trend in incidence in both race-ethnic groups.
Table 3. Common Cancer Site Incidence Trends for Males in Miami-Dade County, Florida: Linear Regression Analysis using 3-Year Moving Averages, 1981–1998
WNH: white non-Hispanic; 95% CI: 95% confidence interval.
Head and neck
Lung and bronchus
Some important differences were seen in the site specific trends. Lung carcinoma incidence showed a nonsignificant decrease for non-Hispanic white men while increasing significantly among Hispanic men. A similar pattern was seen for colorectal carcinoma. The incidence of gastric carcinoma among non-Hispanic white men remained level over the two study periods but increased significantly among Hispanic men.
Cancer Mortality Trends
The results of the linear regression analyses (using 3-year moving averages) of mortality for the 14 disease sites by race/ethnic group are shown in Table 4. For both non-Hispanic white men and Hispanic men, overall cancer mortality has decreased similarly over the study period. This similar decrease was seen in specific disease sites, such as the prostate and the stomach. Lung carcinoma mortality also decreased in both groups, but the decrease was much sharper among non-Hispanic white men. Mortality for colorectal carcinoma decreased significantly only for non-Hispanic white men; a similar pattern was seen for carcinoma of the head and neck, carcinoma of the kidney, and Hodgkin lymphoma. Mortality for brain carcinoma and leukemia declined significantly only among Hispanic men. No disease site showed a significant increase in mortality over the study period.
Table 4. Common Cancer Site Mortality Trends for Males in Miami-Dade County, Florida: Linear Regression Analysis using 3-Year Moving Averages, 1989–1998a
WNH: white non-Hispanic; 95% CI: 95% confidence interval.
Mortality rates for Hispanic ethnicity were not available before 1989.
Head and neck
Lung and bronchus
The Institute of Medicine recently recommended that greater emphasis should be placed on ethnic groups, including cultural and behavioral attitudes, dietary patterns, and lifestyle patterns, rather than on biologic differences associated with race.8 It has been found that the South Florida Hispanic population has different dietary and obesity patterns compared with the non-Hispanic population.14, 15 Hispanics are particularly likely to exhibit attitudes such as fatalism and machismo. One author concluded that misconceptions about cancer are more prevalent among Latinos than Anglos and that selected attitudes about cancer among Latinos fit a cultural theme of fatalismo.16 It has been observed that Hispanics fear cancer more than any other diagnosis and that it is considered rude, or even dangerous, to inform a patient of a cancer diagnosis.17 Hispanic women with cancer have been identified as having greater spiritual needs and experiencing more life disruption than other groups.18, 19 Investigators also have found that cultural attitudes and beliefs were better predictors of advanced disease stage at the time of diagnosis than socioeconomic status or race.20 Many authors have cited cultural and language barriers as explanations for the advanced stage of cancer at the time of diagnosis for Hispanics and other minorities compared with non-Hispanic whites.16, 21, 22 Differential participation in cancer prevention and control activities, such as dietary modification, smoking cessation, and cancer screening, may contribute to differences in both incidence and mortality for the Hispanic population.
Although both genetic and environmental risks are of concern, migrant studies have demonstrated that environmental factors dominate in the epidemiology of many cancers, including breast carcinoma and colon carcinoma. With longer residence in the United States and presumably increased acculturation, it might be expected that the cancer risk for South Florida Hispanic men may approach that of native-born non-Hispanic white men. The fact that the top five cancer incidence sites for the two racial/ethnic groups were the same in the more recent period (1990–1998) may be an early indication of acculturation. However, in general, our findings over two consecutive 9-year periods did not definitively show such a pattern.
The overall cancer risk for Hispanic men in Miami-Dade County remained fairly constant over the two study periods, with an SRR of approximately 0.80 compared with non-Hispanic white men. The majority of specific disease sites showed a decreased risk for Hispanic men of a comparable amount compared with non-Hispanic white men. Only gallbladder carcinoma showed a persistent elevated risk for Hispanic men over the course of the study. This finding is consistent with other reports.23 For the three most common cancer sites, the risk for prostate carcinoma is now essentially the same for Hispanic men and non-Hispanic white men in South Florida; for lung carcinoma and colorectal carcinoma, the risk has been increasing slowly for Hispanic men, but the SRR is still about 0.80 compared with non-Hispanic white men.
In the most recent Annual Report to the Nation on the Status of Cancer,24 it was reported that the overall cancer mortality rate in men recently has shown a modest decline (1.6%). According to the National Center for Health Statistics, the contributions of heart disease and cancer to mortality are lower for the Hispanic population compared with the non-Hispanic population (45% vs. 55%, respectively).25 This probably is related to competing causes of mortality for the Hispanic population, such as acquired immunodeficiency syndrome and homicide, consistent with the generally younger urban Hispanic population in Miami-Dade County. In Miami-Dade County, overall cancer mortality is less for Hispanic men compared with non-Hispanic white men; for 1998, the rate per 105 men was 170 for non-Hispanic men and 138 for Hispanic men. The trend analysis shows that cancer mortality for both non-Hispanic white men and Hispanic men has been decreasing over the 18-year study period, although the rate of decrease has been greater for non-Hispanic white men (Fig. 1).
With regard to the study limitations, misclassification of ethnicity is always a potential methodologic problem.26, 27 However, we believe that the FCDS data are of extremely good quality, an assessment that has been supported by the results of the ongoing FCDS quality-control procedures. In terms of mortality rates, although FCDS personnel use many parallel methods to determine cause of death, inaccuracies regarding cause of death and incomplete death registries may affect the rates somewhat. Regarding comparisons of incidence rates, the only variables controlled for were age and major racial and ethnic group. Other pertinent variables, particularly the amount of acculturation and genetic differences, are not addressed in the FCDS data base and, thus, were not addressed by this study. Finally, statistically significant differences should be interpreted cautiously, because they may reflect both the large size of the populations being compared as well as true differences.
There are several possible reasons why a decreased cancer risk for Hispanic men in South Florida persisted over the 18-year study period. First, the risk actually may be increasing, but the change is not yet of sufficient magnitude to be demonstrated statistically. The increasing SRR for lung and colorectal carcinoma may be an indication of such a change. Second, the possibility that, for cancer risk, a migrant population increasingly will resemble the native population over time is most likely to occur in a stable population. The highly migrant and increasingly diverse Hispanic population of South Florida continues to grow rapidly each year, so that, at any given time, the Hispanic population consists of persons with markedly variable time as residents in the United States, with an accompanying markedly variable environmental cancer exposures. Third, the rate of acculturation in terms of harmful lifestyle and cultural risk factors for cancer generally is unknown, even for migrants of relatively long standing residence in the United States. Fourth, decreased participation of Hispanics, compared with non-Hispanic whites, in cancer screening also may lead to artificially decreased cancer incidence rates and apparent decreased relative risk for some specific cancer sites Finally, genetic cancer risks specific to the Hispanic population, although they probably are less important, would be expected to persist much longer that the current study period.
In summary, over the last 20 years, although cancer incidence has been increasing, the cancer incidence risk for Miami-Dade County's Hispanic men has remained consistently about 20% lower than the risk for non-Hispanic white men. Therefore, we still have not been able to demonstrate clearly any effects of acculturation on cancer risk in this population. It is noteworthy that recent cancer mortality rates appear increasingly similar for Hispanic men and non-Hispanic white men. If the incidence continues to be significantly less for Hispanic men and the mortality rate approaches that of non-Hispanic white men, then important public health questions should be raised regarding access and utilization of cancer prevention and control as well as high-quality health services (including state of the art treatment) for cancer patients in the Hispanic community of South Florida.
The authors thank the abstractors of the Florida Cancer Data System and the Florida Department of Health for making this study possible.