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Keywords:

  • cancer;
  • incidence;
  • American Indian;
  • Alaska Native;
  • misclassification;
  • National Program of Cancer Registries;
  • Surveillance;
  • Epidemiology;
  • End Results;
  • United States;
  • health disparity

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

BACKGROUND.

Cancer incidence rates vary among American Indian and Alaska Native (AI/AN) populations and often differ from rates among non-Hispanic whites (NHWs). However, the misclassification of race for AI/AN cancer cases in central cancer registries may have led to underestimates of the AI/AN cancer burden in previous reports.

METHODS.

Cases diagnosed during 1999 through 2004 were identified from population-based cancer registries in the United States. Age-adjusted rates were calculated for the 25 most common sites for AI/ANs and NHWs. To minimize the misclassification of race, cancer registry records were linked with patient registration files from the Indian Health Service (IHS). Analyses were restricted to Contract Health Service Delivery Area (CHSDA) counties and were stratified by IHS region.

RESULTS.

In CHSDA counties, cancer incidence rates among AI/ANs varied widely by region, whereas rates among NHWs did not. For all cancer sites combined, AI/AN rates were higher than NHW rates among both males and females in the Northern and Southern Plains, and among Alaska Native Females; AI/AN rates were lower than NHW rates in the Southwest, the Pacific Coast, and the East. Lung cancer and colorectal cancer rates for AI/ANs exceeded rates for NHWs in Alaska and the Northern Plains. Rates for stomach, gallbladder, kidney, and liver cancer were higher among AI/ANs than among NHWs overall, in Alaska, in the Plains regions, and in the Southwest.

CONCLUSIONS.

Regional differences in cancer incidence rates among AI/AN populations were not obvious from nationwide data and highlighted opportunities for cancer control and prevention. It is unlikely that such differences areexplained by race misclassification. Cancer 2008;113(5 suppl):1142–52. Published 2008 by the American Cancer Society.

There is wide variation in cancer incidence and mortality rates worldwide.1–3 Historically, systematic examination of differences in cancer occurrence by geographic region and among different cultures has yielded important clues about etiology.4 Such differences may also point to opportunities for cancer prevention and control.

Cancer incidence rates for American Indian and Alaska Native (AI/AN) populations vary by geographic region in the United States and often differ from those of non-Hispanic whites (NHWs).5–7 However, the misclassification of AI/AN cancer cases as other races in central cancer registries often has distorted the true burden of disease in these populations.8–12 Systematic linkage of records from central cancer registries with patient registration records from the Indian Health Service (IHS) has been suggested to address this problem.13

The articles assembled in this Cancer supplement provide a comprehensive overview of the burden of cancer among AI/AN populations in the United States at the beginning of the 21st century. The objective of this report is to present incidence rates for the most common types of cancer among AI/ANs, by region and sex, in a format that enables the reader to assess the relative contribution of each type of cancer to the overall burden of the disease both within and between geographic regions. Region-specific rates for NHW populations are presented for comparison.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Data Sources

Incident cancer cases that were diagnosed during the period from 1999 through 2004 were identified from population-based registries that participate in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program14 and/or the Centers for Disease Control and Prevention's National Program of Cancer Registries (NPCR).15 For this study, participating registries classified tumor histology, tumor behavior, and primary cancer site according to the 3rd edition of the International Classification of Diseases for Oncology (ICD-O).16 Detailed descriptions of the data sources and methods used for this analysis are provided in another article in this supplement.17

Incidence rates are presented for all cancer sites combined and for the most common 25 cancer sites among AI/AN populations nationwide; site categories are consistent with prevailing reporting standards.15 Lymphomas (ICD-O histology codes 9590-9729) are presented as 2 separate categories (ie, Hodgkin and non-Hodgkin lymphoma) and are not included with other tumors of specific anatomic sites. Mesothelioma (ICD-O histology codes 9050-9055) and Kaposi sarcoma (ICD-O histology code 9140) are not included with other tumors of specific anatomic sites. In situ and invasive bladder tumors are combined in a single category.18 All other benign and in situ tumors (ICD-O behavior codes 0 and 2, respectively) are excluded from the analysis, as are tumors of uncertain or unknown behavior (ICD-O behavior code 1).

To identify AI/AN cancer cases that were misclassified as other races, states worked with the IHS to link cancer registry records with IHS patient registration files. AI/AN individuals must provide proof of membership in a federally recognized tribe to receive healthcare from the IHS. The provision of healthcare to AI/AN populations by the IHS is greatest in Contract Health Service Delivery Area (CHSDA) counties, which generally are defined as counties that contain or are adjacent to federally recognized tribal reservations and/or trust lands.19 There also is evidence that misclassification of AI/AN race occurs less often in CHSDA counties.20 For this reason, 1 set of incidence rates was calculated for residents of all United States counties, and a second set of rates was calculated for residents of CHSDA counties.

Incidence rates also were calculated for each of 6 IHS regions (Alaska, Pacific Coast, Northern Plains, Southern Plains, Southwest, and East) and for all regions combined (Fig. 1). These IHS regions were chosen because they are consistent with previous reports of regional patterns of specific health outcomes and disease risk factors for AI/ANs.21–23 Rank order of cancer sites by IHS region was based on the value of the respective site-specific incidence rates.

thumbnail image

Figure 1. States and Contract Health Service Delivery Area (CHSDA) counties by Indian Health Service region are illustrated.

Download figure to PowerPoint

Statistical Analyses

Incidence rates were expressed per 100,000 population and were age-adjusted by the direct method24 using the 2000 United States standard population.25 The annual percentage change (APC) was used to describe fixed interval trends from 1999 to 2004. Incidence rates, rate ratios, APC, and 95% confidence limits were calculated with version 6.3 of SEER*Stat software.26 Denominators for rate calculations were derived from population estimates from the U.S. Bureau of the Census.27 Incidence counts were suppressed when fewer than 6 cases were observed to protect confidentiality. The APC was suppressed if it was based on fewer than 10 cases for at least 1 year within the time interval.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Incidence rates for AI/AN populations residing in CHSDA counties were higher than rates for AI/AN residents in all counties combined (Table 1). In contrast, NHW rates did not differ appreciably between CHSDA counties and all counties. These findings are consistent with improved classification of AI/AN cancer cases within CHSDA counties; therefore, the remaining portion of this report will focus on rates calculated for residents of CHSDA counties.

Table 1. Incidence Rates and Annual Percentage Change, Both Sexes Combined, Contract Health Service Delivery Area Counties and All Counties: United States, 1999-2004
Type of CancerAI/ANaNHWAI/AN:NHWa
RatebCountAPCcRatebCountAPCcRR95% CI
  • Source: Cancer registries in Centers for Disease Control and Prevention's National Program of Cancer Registries (NPCR) and/or the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program.

  • CHSDA indicates Contract Health Service Delivery Area; AI/AN, American Indians/Alaska Natives; NHW, non-Hispanic whites; APC, annual percentage change; RR, rate ratio; CI, confidence interval; NOS, not otherwise specified; NHL, non-Hodgkin lymphoma.

  • a

    AI/AN race is reported by NPCR and SEER registries or through linkage with the IHS patient registration database. AI/AN persons of Hispanic origin are included.

  • b

    Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups).

  • c

    The APC is statistically significant (P < .05).

  • d

    The RR is statistically significant (P < .05).

  • Counts <6 are suppressed; if no were cases reported, then rates and RRs could not be calculated.

  • Years of data and registries used: 1999-2004 (41 states and the District of Columbia): Alaska,* Alabama,* Arkansas, Arizona,* California,* Colorado,* Connecticut,* the District of Columbia, Delaware, Florida,* Georgia, Hawaii, Iowa,* Idaho,* Illinois, Indiana,* Kentucky, Louisiana,* Massachusetts,* Maine,* Michigan,* Minnesota,* Missouri, Montana,* North Carolina,* Nebraska,* New Hampshire, New Jersey, New Mexico,* Nevada,* New York,* Ohio, Oklahoma,* Oregon,* Pennsylvania,* Rhode Island,* Texas,* Utah,* Washington,* Wisconsin,* West Virginia, and Wyoming*; 1999 and 2002-2004: North Dakota*; 2001-2004: South Dakota*; 2003-2004: Mississippi* and Virginia; 2004: Tennessee (asterisks indicate states with at least 1 county designated as a CHSDA).

  • Percentage regional coverage of AI/AN in CHSDA counties to AI/AN in all counties: Alaska, 100%; East, 13.1%; Northern Plains, 59.0%; Southern Plains, 64.1%; Pacific Coast, 55.6%; Southwest, 87.5%.

CHSDA Counties
 All sites368.422,165−1.14475.91,311,488−1.32c0.77d0.76–0.78
 Prostate105.62475−1.93154.4194,792−2.620.68d0.66–0.71
 Breast85.33041−1.83134.4195,290−3.03c0.63d0.61–0.66
 Lung and bronchus57.43165−0.2270.3197,074−1.18c0.82d0.79–0.85
 Colon and rectum46.32621−3.0250.8143,160−3.03c0.91d0.87–0.95
 Corpus and uterus, NOS18.16500.3723.634,780−1.210.77d0.71–0.83
 Kidney and renal pelvis18.211523.3112.634,6483.09c1.45d1.36–1.54
 NHL14.1845−0.1319.453,309−0.060.73d0.67–0.78
 Ovary11.5405−5.3214.421,224−3.02c0.80d0.72–0.88
 Urinary bladder9.6518−2.1123.967,366−0.72c0.40d0.37–0.44
 Pancreas9.9540−0.0610.830,5620.000.91d0.83–1.00
 Stomach10.8606−1.495.816,258−1.70c1.88d1.72–2.05
 Cervix uteri9.4381−6.82c7.49374−4.50c1.28d1.15–1.42
 Leukemia9.4673−0.7012.634,025−2.07c0.75d0.69–0.81
 Liver and intrahepatic bile duct9.05294.044.311,8052.64c2.11d1.92–2.32
 Oral cavity and pharynx8.5548−1.6211.030,245−0.74c0.77d0.70–0.84
 Myeloma6.2355−2.514.913,656−0.291.27d1.14–1.42
 Thyroid5.64525.248.320,5677.15c0.67d0.61–0.74
 Melanoma of the skin4.83141.4521.757,2282.040.22d0.20–0.25
 Esophagus4.4248−3.655.114,1660.120.87d0.76–0.99
 Brain3.6299−4.776.917,897−0.020.53d0.46–0.59
 Testis4.1204−2.956.77643−0.040.61d0.53–0.70
 Larynx3.1189−6.113.810,522−4.12c0.81d0.69–0.94
 Gallbladder3.3170−0.550.92618−2.69c3.59d3.04–4.22
 Soft tissue including heart2.1157−2.602.977070.830.70d0.59–0.84
 Other biliary2.21144.121.541774.82c1.48d1.21–1.80
All Counties
 All sites275.528,874−1.92479.06,010,914−1.21c0.58d0.57–0.58
 Prostate83.53429−3.21153.4865,550−3.27c0.54d0.52–0.56
 Breast65.54090−2.34131.7879,456−2.78c0.50d0.48–0.51
 Lung and bronchus43.84166−0.8972.4921,867−0.64c0.61d0.59–0.62
 Colon and rectum33.93316−4.04c53.2681,745−2.72c0.64d0.61–0.66
 Corpus and uterus, NOS13.38291.3124.6166,098−1.25c0.54d0.50–0.58
 Kidney and renal pelvis12.613933.0713.4167,8903.29c0.94d0.89–0.99
 NHL10.51100−0.2719.7246,109−0.040.53d0.50–0.57
 Ovary8.3505−5.1014.396,461−2.82c0.58d0.53–0.64
 Urinary bladder7.6693−4.1823.7304,365−0.43c0.32d0.29–0.34
 Pancreas7.3691−0.2510.9140,4440.260.67d0.62–0.73
 Stomach7.2701−2.556.177,735−2.18c1.19d1.10–1.29
 Cervix uteri6.9502−6.89c7.745,935−4.15c0.90d0.82–0.99
 Leukemia6.8846−2.1012.7156,354−1.480.54d0.50–0.58
 Liver and intrahepatic bile duct6.56812.834.354,3172.03c1.52d1.40–1.64
 Oral cavity and pharynx6.4718−1.2210.9135,624−0.250.59d0.54–0.63
 Myeloma4.6451−5.004.963,283−0.830.930.84–1.02
 Thyroid4.05956.928.598,1446.67c0.47d0.43–0.52
 Melanoma of the skin3.64240.0819.6236,7232.67c0.18d0.16–0.20
 Esophagus3.2309−5.615.063,1760.66c0.63d0.56–0.71
 Brain2.9406−7.13c6.981,271−0.610.42d0.38–0.47
 Testis2.8260−1.866.534,3890.390.43d0.38–0.49
 Larynx2.3246−8.564.252,828−2.74c0.54d0.47–0.61
 Gallbladder2.1189−0.721.013,123−2.54c2.11d1.80–2.44
 Soft tissue including heart1.6207−1.843.035,2400.97c0.53d0.45–0.62
 Other biliary1.51372.731.519,0314.49c1.040.87–1.24

In CHSDA counties, incidence rates for all cancer sites combined among AI/AN males ranged from 256.2 in the Southwest to 636.1 in the Northern Plains (Table 2). Rates for NHW males ranged from 505.0 in the Southwest to 574.4 in the East. Among AI/AN males, the top 5 incident cancers were prostate, lung and bronchus (lung), colon and rectum (colorectal), kidney and renal pelvis (kidney), and urinary bladder (bladder) for all regions except Alaska and the Southwest, although the rankings varied. In Alaska and the Southwest, stomach replaced bladder cancer in the top 5 cancer sites (Table 2). AI/AN prostate cancer rates were highest in the Northern and Southern Plains and were similar to rates for NHW males. Lung and colorectal cancer rates among AI/AN males were highest in the Northern Plains and Alaska, and were significantly higher than those for NHW males. In the Southern Plains, AI/AN males also had high rates of lung cancer that were similar to the rates for NHW males, and colorectal cancer rates among AI/AN males in this region were significantly higher than for NHW males. AI/AN males in the Southwest had the lowest rates for the top 3 sites. AI/AN rates for cancers of the kidney, stomach, and liver/intrahepatic bile ducts (liver) generally were higher than those in NHW males in most regions. Gallbladder cancer rates for AI/AN males were nearly 4-fold greater than for NHW males for all regions combined and were more than 6 times greater in the Southwest and Alaska.

Table 2. Incidence Rates, Ranks, and Rate Ratios of the Top 25 Cancers for American Indian/Alaska Native Males Compared With Non-Hispanic White Males by Indian Health Service Region in Contract Health Service Delivery Area Counties: United States, 1999-2004
Type of CancerAll Regions CombinedNorthern PlainsAlaska
AI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHW
RankRateaRankRateaRRRankRateaRankRateaRRRankRateaRankRateaRR
  • Source: Cancer registries in the Centers for Disease Control and Prevention's National Program of Cancer Registries and/or the National Cancer Institute's Surveillance, Epidemiology and End Results Program (for the states included, see Table 1).

  • AI/AN indicates American Indians/Alaska Natives; NHW, non-Hispanic whites; RR, rate ratio; NHL, non-Hodgkin lymphoma; IHBD, intrahepatic bile ducts.

  • a

    Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups).

  • b

    The RR is statistically significant (P < .05).

All sites/types414.6549.20.75b636.1541.81.17b538.7569.80.95
Prostate1105.61154.40.68b1174.61162.21.08378.31180.70.43b
Lung and bronchus269.6285.90.81b2119.8284.61.42b1115.3285.01.36b
Colon and rectum352.6359.80.88b388.9361.31.45b298.5361.41.60b
Kidney/renal pelvis423.2717.21.35b429.2717.21.70b528.6618.71.53b
Urinary bladder516.5441.50.40b526.8439.40.68b623.0447.30.49b
NHL615.2623.10.65b719.2522.80.841113.2526.30.50b
Stomach714.7128.51.74b818.7128.52.21b434.6147.84.46b
Oral cavity/pharynx813.1816.40.80b622.6915.51.45b820.5815.41.33
Liver/IHBD912.7166.42.00b1016.0175.42.98b917.2128.22.09b
Leukemia1011.5916.30.71b917.6816.31.08128.4915.20.55b
Pancreas119.81012.50.78b139.01011.60.78721.4109.62.22b
Esophagus128.1118.70.931115.2119.31.64b1013.3119.31.43
Myeloma136.7176.31.06148.9146.61.35192.7166.10.44
Melanoma, skin145.8526.60.22b183.5618.80.18b251.6716.40.10b
Larynx155.5156.60.84b129.3166.51.43155.4175.21.04
Brain164.5138.30.54b164.7138.00.58b173.3137.80.42b
Testis174.1146.70.61b155.1146.60.77146.2157.10.86
Gallbladder182.5330.73.69b202.7330.73.97b164.6330.67.38b
Thyroid192.4184.40.55b174.6183.91.17212.4185.10.47
Other biliary202.4241.91.26271.2231.80.64136.5251.44.81b
Soft tissue including heart212.1193.50.59b232.0203.20.63280.9203.90.24b
Hodgkin lymphoma221.7203.30.51b192.9193.30.8300.9213.60.24
Penis231.3310.81.69b212.4290.82.90b261.1310.81.53
Bones and joints241.1271.11.00281.0261.10.89242.1270.92.34
Anorectum251.1261.30.84241.8280.92.09183.0261.22.56
Type of CancerSouthern PlainsPacific CoastEast
AI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHW
RankRateaRankRateaRRRankRateaRankRateaRRRankRateaRankRateaRR
All sites/types573.4547.51.05b338.0557.80.61b308.9574.40.54b
Prostate1156.71146.51.07183.21160.80.52b183.91155.90.54b
Lung and bronchus2111.02108.51.02257.7282.50.70b251.0291.50.56b
Colon and rectum370.3363.21.11344.0356.50.78b331.1365.80.47b
Kidney/renal pelvis425.1817.81.41b415.2816.80.90515.3718.70.82
Urinary bladder525.0435.00.71b514.1442.00.34b422.8444.80.51b
NHL624.2522.11.10712.5624.20.52b135.5624.00.23b
Stomach1210.5147.21.46b812.2138.31.48b107.91110.10.79
Oral cavity/pharynx718.4718.31.00912.2717.10.71b611.3916.30.69
Liver/IHBD1111.1156.11.81b612.8156.61.95b127.3156.81.06
Leukemia817.6916.31.08109.7916.70.58b79.0817.10.53b
Pancreas912.11013.00.94126.81012.80.53b117.91013.40.59
Esophagus148.4137.71.09117.4128.80.8488.9128.91.00
Myeloma158.3165.81.43b145.0166.50.77153.8166.60.57
Melanoma, skin1011.9620.30.58b136.3532.00.20b163.4525.80.13b
Larynx139.0127.71.16163.8175.80.65b98.0147.81.02
Brain167.6118.40.90173.4118.80.38b144.7138.10.57
Testis173.4175.60.62b153.8147.20.53b201.5176.50.23b
Gallbladder231.5330.72.29250.8350.61.43211.3330.81.64
Thyroid241.5193.10.48b182.3184.10.56b191.7184.90.35
Other biliary202.9221.71.65192.3241.91.18250.9232.00.45
Soft tissue including heart183.3202.91.14202.2193.80.58b260.8193.60.22b
Hodgkin lymphoma193.1183.30.93211.4203.30.41b231.2203.50.34
Penis271.4291.01.42260.8340.71.12320.0310.8
Bones and joints261.4261.21.24280.7271.10.58182.0271.11.83
Anorectum251.5281.11.32230.8251.60.53320.0261.3
Type of CancerSouthwest       
AI/ANNHWAI/AN:NHW       
RankRateaRankRateaRR        
All sites/types0256.20505.00.51b        
Prostate165.71133.80.49b        
Lung and bronchus421.2277.30.27b        
Colon and rectum225.7355.10.47b        
Kidney/renal pelvis325.2715.71.60b        
Urinary bladder115.7440.70.14b        
NHL710.9620.40.54b        
Stomach515.3137.12.17b        
Oral cavity/pharynx124.7815.30.30b        
Liver/IHBD612.3156.31.95b        
Leukemia97.0914.20.49b        
Pancreas87.91011.40.69b        
Esophagus134.6118.00.58b        
Myeloma97.0175.31.32        
Melanoma, skin173.3528.60.11b        
Larynx192.1165.90.35b        
Brain163.3127.60.44b        
Testis144.3146.30.68b        
Gallbladder154.1320.76.21b        
Thyroid182.5185.20.48b        
Other biliary202.0231.81.12        
Soft tissue including heart211.7193.50.48b        
Hodgkin lymphoma260.8202.80.27b        
Penis231.3330.62.10        
Bones and joints240.9271.00.84        
Anorectum280.5261.20.43        

Among AI/AN females in CHSDA counties, incidence rates for all sites combined ranged from 218.3 in the Southwest to 500.7 in Alaska (Table 3). Rates for NHW females ranged from 398.9 in the Southwest to 437.9 in both the Pacific Coast and the East. Breast was the most common site among AI/AN females and NHW females in all regions. Breast, colorectal, and uterine cancer were among the top 5 cancers among AI/AN females in all regions. Lung cancer was among the top 5 in all regions except the Southwest. Non-Hodgkin lymphoma was in the top 5 among AI/AN females in the Plains and Pacific Coast; kidney cancer was in the top 5 among AI/AN females in Alaska, the East, and the Southwest; and ovarian cancer was in the top 5 among AI/AN females in the Southwest. Breast cancer was significantly lower among AI/AN females than among NHW females in all regions except Alaska, where the rates were similar. Lung and colorectal cancer rates for AI/AN females were highest in Alaska and the Plains regions and exceeded the rates for NHW females in those areas. Lung cancer rates for AI/AN females were lowest in the Southwest (20% of the rate for NHW females). Cervical cancer was significantly higher among AI/AN than among NHW females in the Plains. Cancers of the kidney, stomach, liver, and gallbladder generally were higher among AI/AN females than among NHW females with some regional variation. Incidence rate tables combining data from males and females for the top 25 cancers and for all cancers collectively, by IHS region, are available at http://www.cdc.gov/cancer/healthdisparities/what_cdc_is_doing/aiansupplement.htm accessed on July 15, 2008.

Table 3. Incidence Rates, Ranks, and Rate Ratios of the Top 25 Cancers for American Indian/Alaska Native Females Compared With Non-Hispanic White Females, by Indian Health Service Region, CHSDA Counties: United States, 1999-2004
Type of CancerAll Regions CombinedNorthern PlainsAlaska
AI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHW
RankRateaRankRateaRRRankRateaRankRateaRRRankRateaRankRateaRR
  • Source: Cancer registries in the Centers for Disease Control and Prevention's National Program of Cancer Registries and/or the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (for the states included, see Table 1).

  • AI/AN indicates American Indians/Alaska Natives; NHW, non-Hispanic whites; RR, rate ratio; NOS, not otherwise specified; NHL, non-Hodgkin lymphoma; IHBD, intrahepatic bile ducts.

  • a

    Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups).

  • b

    The RR is statistically significant (P < .05).

All sites/types0337.60424.00.80b0471.10410.71.15b0500.70417.21.20b
Breast185.31134.40.63b1115.91130.30.89b1134.91136.50.99
Lung and bronchus248.5258.60.83b293.8251.11.83b375.4260.71.24b
Colon and rectum341.6343.60.95359.8345.11.33b2106.2340.62.62b
Corpus/uterus, NOS418.1423.60.77b419.5426.60.74b513.6422.80.60b
Kidney/renal pelvis514.2128.71.62b519.3119.22.10b812.0118.61.39
NHL613.1616.40.80b618.0516.61.08109.9517.90.55b
Ovary711.5714.40.80b911.0614.00.79137.3613.50.54b
Pancreas89.8119.41.04812.5128.91.40b911.91010.71.12
Cervix uteri99.4137.41.28b712.5137.41.69b118.5136.21.37
Thyroid108.5812.10.70b109.7811.80.83612.3812.40.99
Stomach117.9173.62.18b129.2173.42.69b417.7183.05.90b
Leukemia127.6109.70.78b119.6109.90.97185.7910.90.52b
Liver/IHBD135.8202.52.36b146.5212.22.89b156.9192.72.51b
Myeloma145.8163.71.56b165.9164.01.49127.5164.01.88
Oral cavity/pharynx154.8146.30.75b137.6146.21.23712.3155.82.12b
Urinary bladder164.5910.50.43b156.4910.40.62b166.4128.60.74
Melanoma, skin174.0518.00.22b175.3713.80.38b291.1+712.70.08b
Gallbladder183.9281.13.50b222.5261.31.89146.9320.97.91b
Brain193.0155.70.52b202.8155.40.53b222.6146.00.43b
Other biliary202.1271.21.77b291.0+271.20.83193.6241.52.42
Soft tissue including heart212.0192.50.82183.4202.41.42232.4212.40.99
Vulva221.6212.40.67b212.8192.41.17281.1+173.40.32
Esophagus231.6222.10.76193.1222.01.55176.2232.12.98b
Larynx241.2241.50.80242.1231.51.39241.7+261.31.39
Anorectum251.2231.80.68b271.8251.31.38203.0202.51.21
Type of CancerSouthern PlainsPacific CoastEast
AI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHWAI/ANNHWAI/AN:NHW
RankRateaRankRateaRRRankRateaRankRateaRRRankRateaRankRateaRR
All sites/types0440.90402.11.10b0295.10437.90.67b0272.00437.90.62b
Breast1115.71129.70.89b174.71142.60.52b171.41133.60.53b
Lung and bronchus269.9262.61.12b248.0260.90.79b243.5261.70.71b
Colon and rectum353.8343.21.25b335.0342.10.83b339.7347.10.84
Corpus/uterus, NOS422.4419.41.16416.7423.60.71b415.2425.40.60b
Kidney/renal pelvis618.1109.11.99b710.2128.31.23514.0129.21.53
NHL518.5515.61.18512.5616.80.74b68.8516.90.52b
Ovary714.7614.01.05810.0714.90.67b115.9714.80.40b
Pancreas910.1118.71.16611.1109.71.1597.01010.20.69
Cervix uteri814.199.21.54b106.9137.00.9887.1137.30.97
Thyroid119.2138.11.13116.3811.00.57b106.6813.60.49b
Stomach137.6173.42.23b134.7173.51.34134.8164.41.09
Leukemia109.689.71.0097.5119.70.7777.5119.80.77
Liver/IHBD175.1182.81.84b125.8202.62.24b153.8212.51.55
Myeloma156.6163.71.79b154.1163.81.08124.9173.91.25
Oral cavity/pharynx166.0146.01.00173.8146.70.57b163.7146.50.58
Urinary bladder147.3128.50.85144.3910.10.42b144.4912.00.37b
Melanoma, skin127.8712.40.63b164.0522.60.18b191.9+616.70.12b
Gallbladder202.6271.02.65b192.0291.11.80211.8+271.11.61
Brain184.8155.70.84183.1155.90.52b182.4155.80.42b
Other biliary241.6261.11.49231.1281.10.98310.4+261.30.31
Soft tissue including heart192.8212.11.36270.8192.60.32b270.7+202.60.26
Vulva231.8192.60.69201.8222.20.81172.6+192.70.97
Esophagus271.5241.50.96221.1212.20.51241.1+222.20.48
Larynx222.0231.81.10211.4271.31.11250.9+231.80.49
Anorectum212.1221.81.14250.9232.10.41b260.8+241.60.48
Type of CancerSouthwest       
AI/ANNHWAI/AN:NHW       
RankRateaRankRateaRR        
All sites/types0218.30398.90.55b        
Breast150.81125.20.41b        
Lung and bronchus610.4256.30.18b        
Colon and rectum217.3339.70.44b        
Corpus/uterus, NOS316.7419.60.86b        
Kidney/renal pelvis512.4128.21.51b        
NHL88.8714.70.60b        
Ovary412.5813.60.92        
Pancreas117.7118.40.92        
Cervix uteri107.8137.31.07        
Thyroid78.9614.80.60b        
Stomach98.6173.02.86b        
Leukemia155.8109.10.63b        
Liver/IHBD136.3192.32.71b        
Myeloma146.2163.12.04b        
Oral cavity/pharynx172.1145.90.37b        
Urinary bladder211.4910.10.14b        
Melanoma, skin191.8517.80.10b        
Gallbladder126.6290.97.20b        
Brain201.8155.60.32b        
Other biliary163.6271.03.64b        
Soft tissue including heart182.0182.50.83        
Vulva230.8212.20.37b        
Esophagus260.6+231.70.35b        
Larynx390.2+241.40.11b        

DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Results from this report are consistent with previous accounts of AI/AN cancer incidence6, 7 and mortality.21, 23, 28 Regional differences in cancer incidence rates may reflect geographic variation in population screening and/or in risk factors, including tobacco abuse, obesity, physical inactivity, heavy alcohol consumption, dietary factors, and prevalence of infectious agents that are believed to cause cancer. In some instances, there is compelling evidence to link such risk factors with observed cancer rates. For example, high rates of lung cancer in Alaska and in the Northern and Southern Plains regions generally are consistent with high rates of tobacco abuse in these areas.7, 29 For other cancers, additional research is needed to 1) elucidate risk factors and determinants for the regional variations, and 2) develop new approaches for implementing culturally appropriate cancer prevention and control strategies. Risk factors for specific cancers are addressed in detail in other articles included in this supplement.

AI/AN populations generally have a lower prevalence of screening for colorectal, breast, and cervical cancer, which can affect stage at diagnosis, clinical outcomes, and, in some cases, incidence, as reported by Steele et al29 in this supplement and previously. It has been demonstrated that cervical cancer screening programs, coupled with adequate diagnostic follow-up and treatment, clearly benefit AI/AN populations.30 The success of such screening programs underscores the potential for expanding other recommended cancer screening modalities in these communities. Cancer control only recently has become an important concern for many AI/AN communities, because cancer surveillance has revealed substantial increases in cancers that once were rare in this population.31–34 Several governmental, public, and private organizations are collaborating to foster the establishment of comprehensive cancer control programs within tribes and other communities.35

This study also has identified several cancers for which AI/AN incidence rates consistently exceeded the rates in NHW populations. The incidence of kidney cancer was nearly 50% greater for AI/AN populations than for NHW populations in all regions combined and was elevated in 4 of 6 regions examined.36 Stomach and liver cancer incidence rates were higher among AI/ANs than among NHWs in most regions.37, 38 Finally, gallbladder incidence rates were 4 times greater among AI/AN populations than among NHW populations in all regions combined and in 4 of 6 IHS regions.39 Possible contributors to the regional patterns in AI/AN populations for these cancers are explored in separate articles of this supplement.36–39

Similar methods and findings were described recently in the 2007 Annual Report to the Nation on the Status of Cancer7 (ARN); however, the current report differs from the ARN in several respects. First, this report includes rates for 25 of the most common cancer sites, whereas the ARN was restricted to 15 sites. Second, the ARN suppressed publication of rates based on fewer than 16 cases, whereas the current report applied a less restrictive suppression rule to present rates for more cancer sites among AI/AN populations. Finally, for this supplement, the investigators analyzed data from additional states with significant AI/AN populations (Minnesota, North Carolina, and South Dakota) that were not included in the ARN analysis.

Results from this report must be interpreted in the context of the following limitations. The record-linkage methodology used to reduce AI/AN misclassification relied on records of individuals who received healthcare from the IHS; this method does not address misclassification among AI/ANs who were not listed in IHS files. Furthermore, the current analysis was restricted to residents of CHSDA counties, where it is believed that this methodology is most efficacious. The cancer burden among AI/ANs who do not receive healthcare from the IHS and among AI/AN residents of non-CHSDA counties has not been well characterized. For this reason, the direction or extent of possible bias that may have been introduced by the current methodology is not known.

Despite limitations of the data, this and other reports in the supplement offer the most comprehensive examination to date of cancer incidence in AI/AN populations. The inclusion of data from most central cancer registries in the United States strengthens the stability of regional estimates of AI/AN cancer incidence, whereas data linkages and the focus on CHSDA counties improves on the race classification and, thus, on the accuracy of the estimates.

In conclusion, the quality and scope of cancer surveillance in AI/AN populations has been strengthened. Our report and the other reports in this supplement describe disparities in cancer incidence, risk factors, and screening prevalence that provide a clear, albeit challenging, course of action for cancer control partners. Future progress in decreasing the cancer burden in AI/AN populations is necessary and achievable with the implementation of comprehensive cancer control programs. Ideally, these programs would provide direction and would motivate and actively engage partners across the spectrum of cancer control advocates, healthcare providers, policymakers, tribal leaders, and funding agencies.

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
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