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1687
6th Biennial Symposium on Minorities, the Medically
Underserved & Cancer
Supplement to Cancer
The Disproportionately Lower Cancer Survival Rate
with Increased Incidence and Mortality in Minorities
and Underserved Americans
James W. Hampton,
M.D.
Troy and Dollie Smith Cancer Center, Integris Baptist Medical Center, University of Oklahoma College
of Medicine, Oklahoma City, Oklahoma.
“ . . .all over the earth the faces of living things are all alike. With
tenderness have these come up out of the ground. Look upon these faces
of children without number and with children in their arms, that they
may face the winds and walk the good road to the day of quiet.”
—Black Elk
C
Presented at the 6th Biennial Symposium on Minorities, the Medically Underserved & Cancer,
Washington, DC, April 23–27, 1997.
Address for reprints: James W. Hampton, M.D.,
Troy and Dollie Smith Cancer Center, University of
Oklahoma, 3366 N.W. Expressway, Suite 200,
Oklahoma City, OK 73112.
Received June 22, 1998; accepted June 30, 1998.
© 1998 American Cancer Society
ancer mortality appears to be declining for the population as a
whole, whereas specific populations among the minorities and
underserved people of the United States are suffering disproportionately from increased cancer mortality and poorer survival from cancer.1,2 According to statistics supplied by the National Cancer Institute, the American Cancer Society, and the U.S. Department of Health
and Human Services, there are higher rates for cancer in African
Americans, Hispanic Americans/Latinos, certain American Indians/
Alaska Natives, Pacific Islanders, and Asian Americans as well as
among the poor, rural groups in Appalachia and immigrant groups.
Only when the accuracy of the available statistics are obtained on all
races and ethnicities can appropriate cancer screening and prevention programs be developed to impact the devastating effects of
cancer on all Americans.
Poverty is a risk factor for cancer. Social class causes the barriers
of race and ethnicity to affect all persons in the United States, including whites and immigrants. Poverty levels on the basis of the 1990
Census were cited as 32% for Native Americans, 32% for African
Americans, 28% for Hispanics, 12% for Asians, and 11% for whites.2
Data on the full impact of social class on lifestyle and behavior with
the consequent cancer risk are virtually unknown.
Major improvements in national collection of epidemiologic data
are missing for the special populations. This is true especially for
American Indians: The two states with the largest populations of
Native Americans, i.e., California and Oklahoma, lack accurate epidemiologic statistics to determine their cancer incidence and mortality. Survival statistics from cancer for Native Americans are available
only for Arizona and Alaska. The Centers for Disease Control, working
with state health departments, are making an effort to correct these
data gaps as they seek to emphasize early detection of breast and
cervical cancer in underserved women. The special cancer problems
of minorities and the underserved are outlined in Table 1.
1688
CANCER Supplement October 15, 1998 / Volume 83 / Number 8
TABLE 1
Cancer Problems in Minorities and Underserved—A Guideline for
Health Professionalsa
Cancer
Special populations
Breast
Cervical
Native Hawaiians, African Americans
African Americans, Hispanics, American Indians, Koreans,
Vietnamese
Colorectal
Elder citizens, Alaska Natives, African Americans
Gallbladder
Southwest American Indian women, Hispanics
Gastric
Japanese Americans, Hispanics, American Indians, Native
Hawaiians
Liver
Asian Americans, Alaska Natives
Lung
Asian Americans, African Americans, underserved, Alaska Natives
and American Indians, Native Hawaiians
Nasopharyngeal Asian Americans, Chinese, Alaska Natives
Pancreatic
American Indians, Native Hawaiians, Filipinos
Prostate
African Americans
a
Prepared by the Task Force for Cancer Prevention, Screening, and Early Detection of the Intercultural
Cancer Council, with their permission for publication.
African-American Population
African Americans continue to be diagnosed with cancer at less favorable stages of disease than white Americans and have uniformly lower survival from cancer
for every major site.1 African Americans comprise the
second largest racial group in the United States and,
according to the 1990 Census, account for about 12%
of the population.2 From 1988 to 1992, the SEER incidence rate for cancer of the prostate in African-American men was 180.6 per 100,000 population compared
with 137.0 for white, non-Hispanic men.3 The lung
cancer rate in that same period for African-American
men was 117.0 per 100,000 population compared with
79.0 for white, non-Hispanic men.3 The leading cancer
sites for African-American women include breast, colon and rectum, lung, corpus uteri, and cervix uteri. In
1993, the mortality rate from cervical cancer in African-American women was still more than two times
greater than the rate among white women.2 Fifty-four
percent of cervical cancers among white American
women, compared with 39% of cervical cancers
among African-American women, were diagnosed at a
localized or early stage. High smoking rates and low
participation in breast screening examinations are
major factors for African Americans who develop cancer of the lung and breast.2 The American Cancer
Society reports that, from 1986 to 1992, the 5-year
relative survival rates after breast cancer diagnosis for
all stages was 70% for African-American women compared with 85% for white American women.4 For prostate cancer, from 1974 to 1976 compared with 1986 –
1992, the survival rates had improved for white
Americans from 68% to 89% but for African Americans
from only 58% to 73%. These differences were statis-
tically significant (P , 0.05). For all stages of tobaccorelated cancers, such as oral cavity, pharynx, and urinary bladder, African Americans had a uniformly
lower survival rate from 1986 to 1992. According to the
SEER data, African-American women had uniformly
fewer localized cancers diagnosed than white American women. Only 54.9% of African-American women
over 50 years of age reported that they had a mammogram and a clinical breast examination within the
previous 2 years.2
Asians and Pacific Islanders
This heterogeneous group of people consists, according to the 1990 U.S. Census, of persons with “origins in
the people of the Far East, Southeast Asia, the Indian
subcontinent, or the Pacific Islands.” This diverse
group represents at least 24 ethnic populations who
speak more than 30 major languages or dialects. The
population is increasing rapidly due to immigration
and high birth rates. In the 1990 Census, they represent about 3% of the population. Information is available only for Chinese, Filipino, Hawaiian, Japanese,
Korean, and Vietnamese men and women. Among the
six subpopulations, there is variation in the leading
cancer sites. The top sites for men are prostate, lung,
and colorectal cancers for Chinese, Filipinos, Hawaiians, and Japanese.2 Vietnamese men also have liver
cancer at a higher rate than other ethnic groups. The
stomach is a leading cancer site for Japanese and
Korean women. Cancer of the uterine cervix for Vietnamese women is 2.5 times higher than for any other
racial group. Native Hawaiian women have the highest
incidence rates for breast cancer from 1988 to 1992 of
all minority women.3 Next to African-American
women, Native Hawaiian women in age groups 30 –54
years and 55– 69 years have the highest mortality rates
due to breast cancer.3
Hispanics/Latinos
The U.S. Census describes Hispanics/Latinos as “persons of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin,
regardless of race.”2 The Hispanic/Latino population
is growing rapidly in the United States. By the year
2010, they will represent the “largest U.S. racial/ethnic
group,” and, by the year 2050, they will represent
almost one-fourth of the U.S. population.3 Because
the majority of Hispanics are white (91.3%), the leading cancer sites are prostate, breast, lung, and colorectal, the same as the larger population. The incidence rate for these cancers, however, is about 30%
lower than for whites. Language serves as a barrier for
this population. Cancer of the urinary bladder and
stomach in Hispanic men and cancer of the uteri
Cancer Survival Lower in Underserved/Hampton
cervix and corpus in Hispanic women are diagnosed
commonly.3 Second only to Vietnamese women, cervical cancer rates among Hispanic women are the
highest of any minority group.2 Most of the Hispanic
population in SEER tumor registries live in Los Angeles (60%), followed by New Mexico (10%), San Francisco and San Jose/Monterey (9%), and Connecticut
(4%).3 Mexican Americans account for 84% of the Hispanic population in San Jose/Monterey and 76% in
New Mexico.3 Due to the large numbers of Hispanics
who are employed as rural farm workers and in service
occupations, few of them report having a health care
plan or insurance.
American Indians/Alaska Natives
The U.S. Census defines Native Americans as “any
person having origins” in the indigenous peoples of
North America and who maintain cultural identification through tribal affiliations or community recognition.”3 Cancer incidence and mortality among Native
Americans, according to SEER statistics, are confined
to American Indians living in New Mexico and Alaska
Natives.3 These data cannot be interpreted as “representative of those for American Indians living in other
regions of the country.”3 In 1990, about 2.1 million
American Indian/Alaska Natives were described living
in all 50 states, with one-third on reservations and
one-half in urban centers.2 These people are the descendants of “more than 500 nations, each with
unique cultural, genetic, and social demographic
characteristics,” e.g., over 300 different languages are
spoken. Contrasting the data on Alaska Natives with
American Indians living in New Mexico, it can be
shown that lung cancer incidence is higher in Alaska
Native men (81.1 per 100,000) compared with Southwestern Indian men (14.4 per 100,000). Mortality statistics, as one might assume, are similar. Cancer survival of American Indians is the lowest of all ethnic
groups.5 The Indian Health Service, which serves
about 1.43 million Native Americans (more than onehalf the total American Indian/Alaska Native population), carries out its responsibility through Indian
Health Service and tribally operated hospitals and
health centers.6 Mortality statistics for all Indian
Health Service areas are provided in annual summaries. These data are valuable in providing some insight
into the heterogeneity of cancer patterns among Native Americans nationwide. For certain areas, “including the Northern Plains, north central United States,
Alaska, and south central United States,” American
Indian cancer mortality rates exceed those of all races
in the United States.7 This heterogenity of cancer patterns in American Indians was observed previously in
1976 and again in 1989.8,9 Differences in life style
1689
among American Indians living in different cultures
has been proposed to account for these differences in
cancer patterns.10 –12 Smoking rates for American Indian men ranges from “20% in the Southwest to as
high as 70% in the Northern Plains and Alaska.”11,12
This fact would account for the great discrepancy in
incidence of lung cancer between New Mexico and
Alaska noted in the SEER data. The noteworthy incidence of kidney cancer observed in the SEER data for
Alaska Native men (19.0 per 100,000 population) and
in American Indian men living in New Mexico (15.6
per 100,000 population) may be related to genetic
factors that are not yet understood.3 Kidney cancer is
also related to environmental exposures.12 Life style,
such as tobacco abuse, is likely to play a contributory
role. The high incidence of gallbladder cancer in
Southwestern Indian women (13.2 per 100,000 population) and its high mortality rate (8.9 per 100,000
population) are probably also due to a genetic factor.13
Gallbladder cancer was observed to be high in Alaska
Native women in the sixth to the eighth decade by
Lanier and Key, who also observed a declining rate
from 1969 to 1988.14 According to the SEER data, carcinoma of the stomach is prevalent in both Alaska
Native men (18.9 per 100,000) and Southwestern Indian men (11.2 per 100,000) with equivalent mortality
rates.3 Carcinoma of the pancreas figures prominently
in mortality rates for Alaska Native women and Southwestern Indian women.3 These observations on cancer of the digestive system in Native Americans were
first made by Sievers in 1976.15
Rural Whites in Appalachia
According to the 1990 Census, 20.7 million people live
in rural Appalachia (8% of the population). Most of
these Americans are white (92%). Unemployment
rates are high, and poverty contributes to their low
level of literacy. Cancer is diagnosed in them at later
stages and with poorer survival. Cervical cancer, especially in older women, exceeds the SEER data for white
American women.16 Tumor registry data in this region
are not consistent, and the Kentucky state cancer registry has served as a surrogate data base.17 Later stage
diagnosis due to the barrier of poverty and lack of
education puts these Americans in a rank with the
disadvantaged people of color.17
DISCUSSION
Socioeconomic disadvantages are a powerful handicap for any segment of American society.18 Poverty
reduces the chance of surviving cancer whether the
individual is white or is a person of color.19 Poverty is
a significant barrier to the receipt of “state-of-the-art”
therapy, including clinical trials for cancer therapy.
1690
CANCER Supplement October 15, 1998 / Volume 83 / Number 8
Language barriers, especially for immigrant Hispanic
or Asian Americans, reduce the opportunity for early
detection of cancer. Cultural barriers for both Native
Americans and Appalachian whites alike prevent these
people from realizing that patients survive cancer and
that cancer can be “overcome.” Cancer need not be a
“death sentence” for the socioeconomic disadvantaged. Prevention of cancer will not become a “way of
life” until the mechanisms of acquiring cancer are
widely understood through education of the disadvantaged. The legacy of “racism, exploitation, slavery, segregation, discrimination, suboptimal health care, lack
of resources, lack of role models, and unequal competition” remains with the United States society at the
end of the 20th century.20 Although cancer death rates
are declining nationwide, the minorities and medically underserved individuals are not sharing in this
medical progress. Federal, state, and local policy makers must meet these challenges so that the health
needs of all Americans will be enhanced.
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Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics. CA
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Taylor WR, Nadel MR, Smith RA, Hernandez C, Moser M,
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Fridell GH, Tucker TC, McMannon E, Moser M, Hernandez
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Geiger HS. Race and health care—an American dilemma.
New Engl J Med 1996;335:815– 6.
Freeman HP. Poverty, race, racism and survival. Ann Epidemiol 1993;3:145–9.
Schoenbach VJ, Reynolds GH, Kumanyika SK. Racial and
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