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. REFERENCES 1. 2. 3. 4. 5. 6. 7. Cunningham MP. Giving life to numbers. 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Proceedings of the Third International Symposium on Detection and Prevention of Cancer. New York: Dekker, 1976:291– 6. Hampton JW. The heterogeneity of cancer in Native American populations. In: Jones L, editor. Minorities and Cancer. New York: Springer Verlag, 1989:45–53. Hampton JW. Conquering cancer among Indians requires education, lifestyle changes. NIHB Health Reporter 1984; 3(12):10 –1. Welty TK. Cancer and cancer prevention and control programs in the Aberdeen area Indian Health Service. Am Indian Culture Res J 1992;16:117–38. Cobb N. Environmental causes of cancer among Native Americans. Cancer 1996;78/7(Suppl):1603– 6. Lowenfels AB. Gallstone and gallbladder cancer in Southwestern Native Americans. Am Indian Culture Res J 1992;16: 77– 86. Lanier AP, Key C. Cancer in the Alaska Native population: Eskimo, Aleut and Indians: incidence and trends 1969 –1988. Washington, DC: U.S. Department of Health and Human Services, 1993. Sievers ML. Cancer of the digestive system among American Indians. Arizona Med 1976;33:15–20. Taylor WR, Nadel MR, Smith RA, Hernandez C, Moser M, Fridell GH. Cervical cancer screening and demonstration projects to identify barriers to preventing cervical cancer mortality. Acta Cytol 1989;33:460 –2. Fridell GH, Tucker TC, McMannon E, Moser M, Hernandez C, Nadel MR. Incidence of dysplasia and carcinoma of the uterine cervix in an Appalachian population. J Natl Cancer Inst 1992;84(13):1030 –2. 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 ethnic distribution of Faculty, Students and Fellows in U.S. Epidemiology Degree Programs, 1992, A.E.P. 1994;4: 259 – 64.