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1629
Four Corners Research Consortium for Native
Americans and Cancer Research
Kyle L. Osborn, B.s.’
Sally M. Davis, Ph.o.2
Marty Slattery, ~ h . 0 . ~
Anna Giuliano, Ph.D.4
Nicolette 1. Teufel, Ph.D.4
Jennie Joe, m.4
Cheryl Ritenbaugh, ~ h . 0 . ~
’ University of Colorado Cancer Center, Denver
Colorado.
University of New Mexico, Albuquerque, New
Mexico.
University of Utah, Huntsman Cancer Institute,
Salt Lake City, Utah.
University of Arizona Cancer Center, Tucson,
Arizona.
Cancer morbidity and mortality in Native Americans in the Southwestern fourcorners region of the United States (Arizona, Colorado, New Mexico, and Utah) is
of critical concern to public health workers, health care providers, cancer researchers, and Native American communities of the region. As a follow-up to the national
conference in Seattle, Washington, representatives from the Arizona, Colorado,
New Mexico, and Utah Cancer Centers, the AMC Cancer Research Center, and the
Indian Health Service participated in a regional conference on September 26, 1995.
The primary reason for the “Four Corners Consortium” meeting was to assess
cancer research activities in each state and to determine how Native American
cancer research could be organized in the four-state region. One interest of the
group was to determine strategies to explore why some cancers are more or less
prevalent among Southwest Native American populations and to evaluate how the
group might jointly establish research that would address the cancer needs of
Southwestern tribes. Cancer 1996; 781629-32. 0 1996 American Cancer Society.
KEYWORDS: North American Indians, neoplasrns/prevention and control, research,
epidemiologic studies, community networks.
T
This article summarizes the southwest regional
activities after the Native American Cancer Conference Ill: Risk Factors, Outreach and Intervention Strategies, Seattle, Washington, June 1619, 1995.
Address for reprints: Kyle Osborn, B.S., University of Colorado Cancer Center, Division of Cancer Prevention and Control, 4200 E. 9th Avenue,
Campus Box B160. Denver, CO 80262.
Received May 31, 1996; accepted June 18,
1996.
0 1996 American Cancer Society
o reinforce what was learned after attending the “Native American
Cancer Conference 111: Risk Factors, Outreach and Intervention
Strategies,” Seattle, Washington, June 16- 19, 1995, and to encourage
proactive follow-up, the University of Colorado Cancer Center and
the AMC Cancer Research Center hosted and invited representatives
from the Arizona, New Mexico, and Utah Cancer Centers and the
Indian Health Service (IHS) to participate in a regional conference
on September 26, 1995, in the four corners region of Colorado. Each
state cancer center and the IHS were encouraged to invite other key
people from their regions, with the intention that both scientific and
Native American perspectives would be represented. The goal of this
meeting was to focus on prioritizing projects that could build collaboration between Native American community representatives and state
cancer centers and to identify a common research project.
The resulting “Four Corners Consortium” meeting was held with
20 Native American and non-Native American representatives discussing critical concerns of cancer morbidity and mortality in Native
Americans in our four-corners region. The primary reason for the
meeting was to determine how Native American research could be
organized in a four-state region. One main concern of the group was
to determine a way to explore why some cancers are more or less
prevalent among Southwest Native American populations and how
researchers might jointly go about establishing the research that
would answer that question. The group discussed how to best foster
and strengthen partnerships with tribal communities to address is-
1630
CANCER Supplement October 1, 1996 / Volume 78 I Number 7
sues of poor cancer survival rates and ways to prevent
cancers that are more common in Southwest tribes
(i.e., cervical, stomach, and gallbladder cancers). As a
result, the following 11 areas of research were identified to be explored with tribal communities in the region.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Training.
Health policy research.
Primary prevention of cancer.
Barriers to participation in cancer prevention and
control programs.
Cancer survival.
Cancer occurrence.
Environmental cancers.
Behavioral risk factor surveys.
Cancer risk factors.
Studies of acquired genetic changes in tumor tissue.
Studies of inherited alterations that could cause
or prevent cancer.
It was clear that our goal was a multiphase process, with the first phase being to learn tribal leaders’
views on these areas of research and to determine if
they would be interested in collaborating. The opinions of tribal leaders and health care providers were
sought to establish partnerships in the areas of mutual
interest. Following the “Four Corners Consortium”
meeting, tribal communities within each state were
identified, and a list of tribal leaders and health care
providers was compiled.
A survey highlighting the above 11 areas of potential research was distributed to tribal leaders and
health workers, asking that they prioritize areas of research that would be of interest in their community.
On return of the surveys, the regional conference
group will determine the most appropriate and/or
agreed on areas of research. A second “Four Corners
Consortium” meeting is being planned, which will include tribal leaders, tribal health department directors,
and health care workers. The purpose of the followup meeting is to discuss tribal adoption of the most
appropriate areas of research and to discuss strategies
for implementing the chosen research initiatives.
The “Four Corners Consortium” meeting was a
refreshing first step in building collaboration between
the University of Colorado Cancer Center and the
three neighboring state cancer centers. Concurrently
and independently, each state cancer center has had
activities with and developed plans for native people
in their area. The following summarizes the activities
of the adjacent state cancer centers.
UTAH
Determining the priorities of cancer issues among Native Americans is a major focus of the Epidemiology
and Cancer Control Program at the University of
Utah’s Huntsman Cancer Institute. Utah researchers
believe that a collaborative research program in the
Southwest region should include focus groups of Native Americans to help determine what causes cancer
among tribes and to determine what tools are needed
(i.e., screening, education, etc.) to reduce the incidence of cancer among Native Americans. Toward that
objective, Utah’s program has focused on identifying
resources to faculty and staff to work with Native
Americans in developing a cancer research program
that addresses the needs of Native Americans. We are
also in the process of identifying the most appropriate
person to work with from each Utah tribe.
NEW MEXICO
Since the “Four Corners Consortium” meeting, the
University of New Mexico has developed a New Mexico-specific tribal health directory. This directory was
used to contact 19 Native American Pueblo groups in
New Mexico; 1 Pueblo group from Texas; 2 Apache
tribes in New Mexico; all 8 Navajo Area IHS units in
New Mexico, Arizona, and Utah; and the Director of
the Navajo Division of Health, for a total of 31 contacts.
The survey was sent to all tribes listed in the directory
to assess their interest in working with the university
to identify common strategies to decrease and prevent
cancer mortality in Southwest tribes.
Eight completed surveys were returned. Preliminary results show that all research topics were of interest, except for genetic changes in tumor tissue and
studies of inherited alterations that could cause or prevent cancer. The two major topics of interest were
training followed by primary prevention. These preliminary findings represent only one fourth of those
tribes contacted and may change when the other surveys are returned.
ARIZONA
Although disease risk factor and health behavior data
are collected on a routine basis for most populations
living in the United States, Native Americans have
been systematically excluded from these data collection efforts. Hence, few data are available in the literature regarding prevalence of disease risk factors or the
health status of Native American populations. Four
programs conducted by the University of Arizona Cancer Center that provide cancer data among Native
Americans in Arizona are presented in the following
sections.
Four Corners Research Consortium/Osborn et al.
Southwest Native American Women’s Healing Circle
Scant data are available on breast and cervical cancer
in Native Americans. Therefore, it is difficult to establish baseline cancer screening rates before the development of state-wide cancer screening services or to
develop effective breast and cervical cancer education
outreach programs.
To remedy this situation, the Arizona Cancer Center’s Minority Cancer Prevention and Control program
is working in partnership with local tribal health departments and contract care clinics in urban areas.
We have designed and implemented populationbased breast and cervical cancer knowledge, attitudes,
beliefs, and behaviors surveys: one among Hopi
women living on reservations has been completed,
and one among Native American women living in the
metropolitan Phoenix area is currently underway. Results from these studies will be used to design breast
and cervical cancer education programs for several
Native American communities in Arizona. To ensure
long term sustainability of our educational activities,
community health representatives, health educators,
and public health nurses will participate in one 5-day
cancer prevention workshop held in several communities. This workshop will cover the following topics:
1. What is cancer?
2. Cervical cancer.
3 . Breast cancer.
4. Nutrition and cancer.
5. Brochure writing.
Breast and cervical cancer prevention public education materials in each community will also be developed. Bimonthly continuing education sessions will
he used to provide additional cancer prevention information and to assist in program implementation.
These community-based education outreach efforts
should increase the percentage of Native American
women participating in available cancer screening services and, over time, decrease cervical cancer incidence and breast cancer mortality rates.
Assessing Diet-Cancer Associations in Native Americans
‘TheNative American diet is changing. Accurate assessment of usual dietary intake is critical in understanding the relationships between diet and cancer epidemiology, biology, control, and prevention. For Native
Americans, such quantitative information is limited.
The application of dietary data to cancer studies that
do exist for Native Americans is restricted by several
factors: (1) most reports are based on short term intake, (2) cultural differences in portion sizes have not
been considered a significant variable, (3) micronutrient intake is not reported, (4) micronutrient content
1631
of some seasonally consumed wild foods is unknown,
and (5) interreservation diet diversity limits the validity
of extending results from one population to another.
Within some communities, cultural and economic differences in food choices, availability, preparation, processing techniques, appropriate portion sizes, and
food classification systems impair the applicability
and validity of food frequency questionnaires (FFQ)
used in nation-wide surveys.
FFQ-based epidemiologic studies of diet-cancer
associations in Native American populations are crippled by the absence of culturally appropriate dietary
assessment tools. The goal of this project is to improve
our understanding of diet-cancer associations as observed among Native Americans by developing a dietary assessment technique that allows Native Americans to report their usual food intake accurately.
Working with tribes in the Southwest, project aims are
(1) to use qualitative (focus groups) and quantitative
(multiple 24-hour recalls) techniques to develop valid,
reliable, and culturally competent FFQ templates that
can be adapted to specific cultures, (2) to design and
test a manual that outlines steps for culturally adapting the FFQ templates, and (3) to develop supportive
computer analyses programs to assess nutrient intake
relative to cancer risks. These tools promise to improve
FFQ-based epidemiologic studies of diet-cancer associations and will assist in designing, implementing,
monitoring, and evaluating preventive oncology interventions among Native Americans.
The Arizona Vanguard Women’s Health Initiative Minority
Clinical Center
The Arizona Vanguard Women’s Health Initiative
(WHI) Minority Clinical Center is recruiting Native
American women to participate in the WHI. The WHI
is studying factors related to heart disease, breast and
colorectal cancer, and osteoporosis in women 50-79
years of age. The trial will last until 2005, but recruitment is only occurring until January 1998. The WHI
includes two components, a clinical trial and observational study. The clinical trial includes a randomized
trial of a low-fat dietary pattern to prevent breast and
colorectal cancer and a randomized trial of hormone
replacement therapy to prevent heart disease and 0steoporosis, with careful monitoring of impact on cancer endpoints. The Arizona WHI has received approval
to recruit Native American women from all reservations in the Phoenix and Tucson areas and from the
relevant IHS review boards. Because the WHI is focused on cancer endpoints, Native American women
who volunteer to participate will receive Pap smears,
clinical breast examinations, and screening mammograms. Urban Native American women and Native
1632
CANCER Supplement October 1, 1996 / Volume 78 / Number 7
American women from the Yaqui and Tohono O’odham nations are being recruited to the clinical trial. If
adequate numbers of Native American women from
the reservations volunteer, the WHI will be conducting
diet classes and all other components of the study on
the reservations.
Many of the Native American women from the Salt
and Gila River Reservations are already participating in
an observational study of heart disease (StrongHeart).
For this reason, the WHI is recruiting these women in
particular to participate in the W I observational
study. StrongHeart and WHI are collecting different
types of information and may be able to work together
in the end to learn the most about health risk factors
for older Native American women.
Native American Cancer Training Program
The University of Washington and the Native American Research and Training Center at the University of
Arizona annually sponsor a joint cancer prevention
and control research course for 10- 15 students. This
project, funded by the National Cancer Institute, gives
priority to women who are Native American, Alaska
Native, Native Hawaiian, and/or American Samoan.
Recruitment is in full gear for the 1996 class.
CONCLUSION
The “Four Corners Consortium” meeting was the first
of many steps to bridge the research interests of the
four state cancer centers with the interests of the
Southwest Native American populations. With the inclusion of tribal interests, opinions, and concerns in
the eventual research project, the participants of the
“Four Corners Consortium” will proceed with the survey evaluation of the areas of potential research. This
phase of soliciting Native American perspectives in the
research process was agreed to be a key factor in being
able to continue, with any degree of success, with cancer prevention and control research in Native American populations. The first meeting of tribal leaders and
the four state cancer centers to discuss adoption of the
most appropriate areas of research to be conducted in
the Southwest region is proposed for the summer of
1996.
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