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2377
Patterns of Cancer Mortality among Native Americans
Nathaniel Cobb, M.D.
Roberta E. Paisano, M.H.S.A.
Indian Health Service, Cancer Prevention and Control Program, Albuquerque, New Mexico.
BACKGROUND. Native Americans have been reported to have lower cancer incidence and mortality than other racial groups in the U.S., although some have
questioned whether this was due to racial misclassification. This study provides
improved estimates of cancer mortality, determined from a sampling of people
who live on Indian reservations.
METHODS. The authors reviewed death certificates from U.S. counties that contain
Indian lands, excluding certain areas with known problems of racial misclassification. Age-adjusted mortality rates for specific types of cancer were calculated using
U.S. Census population figures, and these rates were compared with rates for all
races in the U.S.
RESULTS. This sample included 38% of the American Indian and Alaska Native
populations. The age-adjusted annual mortality rate for all cancers combined was
148.2 per 100,000 for both genders, 133.1 for females, and 167.2 for males. The rates
for males and for both genders combined, but not for females, were significantly
lower than the U.S. rates for all races (P ⬍ 0.05). Females had significantly lower
rates of death from carcinoma of the lung and breast and significantly higher rates
of death from carcinoma of the cervix and gallbladder (P ⬍ 0.05). Males had
significantly lower rates of death from carcinoma of the lung, colon, and prostate,
and significantly higher rates of liver carcinoma. Both genders combined had
significantly lower rates of death from lung and colon carcinoma and significantly
higher rates of death from stomach, liver, kidney, and gallbladder carcinoma.
Geographic differences were substantial, with the Northern and Plains regions
experiencing much higher mortality from lung, colon, and breast carcinoma than
the Southwest region.
CONCLUSIONS. Compared with the general U.S. population, Native Americans
experience quite different patterns of cancer mortality. Cancer prevention and
control programs should be designed specifically for this minority population. [See
editorial on pages 2247–50, this issue.] Cancer 1998;83:2377– 83.
© 1998 American Cancer Society.
KEYWORDS: American Indian, Native American, Alaska Native, cancer, mortality.
The source data for this article are being prepared
in a different format for an Indian Health Service
chart book.
Address for reprints: Nathaniel Cobb, M.D., Indian
Health Service, Cancer Prevention and Control Program, 5300 Homestead Road, NE, Albuquerque,
NM 87110.
The opinions expressed are the authors’ and do
not reflect the official policy of the Indian Health
Service.
Received July 28, 1997; revisions received December 22, 1997, and April 13, 1998; accepted
April 13, 1998.
© 1998 American Cancer Society
D
uring the last decade, cancer was the third leading cause of death
for American Indians and Alaska Natives, following heart disease
and injuries. In 1993, for the first time, the number of cancer deaths
exceeded accidental deaths, moving into second place.1 Published
reports over the past 40 years have noted that Native Americans have
lower overall cancer incidence2– 4 and mortality5–7 than other racial
groups in the U.S.. At the same time, rates of mortality from certain
cancers, such as those of the cervix, liver, stomach, and gallbladder,
are dramatically higher.7 Accurate estimates of cancer mortality are
important in planning for cancer prevention and control efforts, and
they may serve to generate hypotheses about risk factors and causes
of various types of cancer. In this study, we update and refine estimates of cancer mortality among Native American people in the U.S.,
2378
CANCER December 1, 1998 / Volume 83 / Number 11
particularly those residing in areas served by the Indian Health Service.
Native Americans are a diverse group, with
many distinct cultures and languages. They live in
environments ranging from the deserts of the
Southwest to the Alaskan tundra. Subsistence farming and hunting are still common. Over the past 3
decades, an accelerated rate of acculturation has led
to major changes in diet8,9 and an increase in habits
such as cigarette smoking and a sedentary lifestyle.
Cigarette smoking rates vary considerably; Alaska
Natives and Northern Plains tribes smoke heavily,
whereas the large Indian populations in the Southwest still smoke very little.
The Indian population is young, with a median
age of 24.2 years compared with 32.9 years for all races
in the U.S.1 Many are also poor, with 31.6% of Indians
below the poverty level, in contrast to 13.1% for the
U.S. population (all races).1 Although 44% of Native
Americans live in nonurban areas, which are subject
to less environmental pollution than urban areas,10
many do not have running water, telephones, electricity, or refrigeration, all of which may affect their health
status.
To be eligible for Indian Health Service care, an
American Indian or Alaska Native must be an enrolled
member of a federally recognized tribe or Alaska Native village, and must reside on or near a reservation.
The Indian Health Service is responsible for providing
health care to 1.2 million eligible Native Americans
directly, through contracts with tribes, through contracts with private providers, or through self-governance funding agreements with tribes. The 1990 U.S.
Census enumerated approximately 2 million Native
Americans; thus, there are approximately 800,000 people in the U.S. who identify themselves as Native
Americans but who are not served by the Indian
Health Service. Many in this group live in urban areas
where the Indian Health Service does not maintain
facilities, and health statistics for this widely dispersed
urban population are difficult to obtain.
For this study we used death certificates and U.S.
Census data to determine cancer mortality rates for
Native Americans. Because of concerns about misclassification of race in areas where American Indians are
a small minority, we used as our study sample those
American Indians and Alaska Natives who live in the
service-area counties of the Indian Health Service,
where the concentration of Native Americans is high.
In so doing, we hoped to increase the accuracy of our
estimates of mortality and population, at the risk of
underrepresenting the urban group.
METHODS
By law, every death in the U.S. is recorded on a certificate, which is usually filled out by a coroner, an
attending physician, or a funeral director. Death certificates are compiled in each state and sent to the
National Center for Health Statistics, where they are
stripped of identifiers, edited for consistency, and
combined onto a data tape for public use. The information collected on death certificates includes county
of residence, race, and cause of death. Those death
records identified as American Indian or Alaska Native
are then compiled onto a separate tape, which is the
primary source of data for this report. To reduce the
likelihood of racial misclassification in both death certificates and census counts, we included in our sample
only death certificates of Native Americans who resided at the time of death within the Indian Health
Service “service area.” This area includes counties that
contain federally recognized reservation lands, and all
adjacent counties.11 Because a large part of the population of these counties is American Indian or Alaska
Native, we felt that racial coding on death certificates
in those counties would accurately reflect the actual
race of the deceased. Cancer patients may die in urban
referral hospitals far from their homes, but because
Native people from reservation areas generally have
their care paid for by the Indian Health Service, the
hospital record will have a clear indication of race,
which will be reflected on the death certificate.
Three of the 12 administrative areas of the Indian
Health Service are known to have underreporting of
race on death certificates: the Portland area12 (Washington, Oregon, and Idaho), the Oklahoma City area13
(Oklahoma, Texas, and Kansas), and the California
area14 (California only). To provide as reliable a sample as possible, we excluded all counties in these three
areas from this study. It should be noted that two of
these areas (California and Oklahoma) contain large
numbers of American Indians, who comprise almost
30% of the reported U.S. Native population.
Because American Indians from the southwestern
U.S. are known to have low rates of some cancers
compared with other Native groups, we divided our
sample into two geographic regions: Southwest (Albuquerque, Tucson, Phoenix, and Navajo areas) and
Northern/Plains (Alaska, Billings, Aberdeen, Bemidji,
and Nashville areas). We calculated rates separately
for the most common cancers in these two regions.
We obtained population denominators from U.S.
Census figures for American Indians and Alaska Natives residing in the same counties, using intercensal
estimates as revised in February of 1994. Race on the
U.S. Census is self-identified by the individual.
Native American Cancer Mortality/Cobb and Paisano
TABLE 1
Native American Cancer Deaths, Both Genders, 1989–1993
2379
TABLE 3
Native American Cancer Deaths, Females, 1989–1993
Cancer site
n
Ratea
U.S. rate
(all races)
Cancer site
n
Ratea
U.S. rate
(all races)
All sites
Lung
Colon
Breast
Prostate
Stomach
Pancreas
Kidney
Liver
Cervix
Non-Hodgkin’s
Gallbladder
Multiple myeloma
Ovary
Unspecified
3043
633
263
184
155
167
150
135
131
89
81
73
72
67
326
148.2 (136.3–160.2)
32.3 (26.6–37.9)
13.1 (9.5–16.7)
8.2 (5.5–10.9)
8.2 (5.3–11.1)
7.9 (5.2–10.7)
7.7 (4.9–10.4)
6.7 (4.2–9.3)
6.5 (4.0–9.1)
4.0 (2.1–5.9)
3.8 (1.9–5.7)
3.8 (1.8–5.7)
3.6 (1.7–5.4)
3.1 (1.4–4.9)
16.2 (12.2–20.2)
172.8
49.6
18.7
15.2
9.9
4.7
8.4
3.5
2.9
1.6
6.3
0.7
3.0
4.4
11.9
All sites
Lung
Breast
Colon
Pancreas
Cervix
Ovary
Stomach
Kidney
Gallbladder
Liver
Non-Hodgkin’s
Multiple myeloma
Biliary
Unspecified
1508
257
184
130
85
89
67
67
60
52
51
38
30
19
173
133.1 (117.9–148.3)
23.8 (17.3–30.4)
15.2 (10.2–20.2)
11.9 (7.3–16.5)
7.9 (4.1–11.7)
7.4 (3.8–10.9)
5.8 (2.6–9.0)
5.8 (2.6–9.0)
5.4 (2.3–8.4)
4.8 (1.9–7.8)
4.5 (1.7–7.4)
3.5 (1.0–5.9)
2.7 (0.5–4.9)
1.7 (0.0–3.5)
15.7 (10.4–21.0)
141.5
31.4
27.1
15.6
7.2
3.0
7.8
3.1
2.3
0.9
1.9
5.1
2.5
0.5
9.7
a
95% confidence interval in parentheses. Rate per 100,000, age-adjusted to the U.S. 1970 population.
TABLE 2
Native American Cancer Deaths, Males, 1989–1993
Cancer site
n
Ratea
U.S. rate
(all races)
All sites
Lung
Prostate
Colon
Stomach
Liver
Kidney
Pancreas
Non-Hodgkin’s
Multiple myeloma
Esophagus
Brain
Nasopharynx
Gallbladder
Unspecified
1535
376
155
133
100
80
75
65
43
42
35
27
24
21
153
167.2 (148.2–186.2)
42.6 (33.0–52.3)
18.6 (12.1–25.2)
14.5 (8.9–20.1)
10.5 (5.8–15.2)
9.0 (4.5–13.4)
8.3 (4.1–12.6)
7.3 (3.3–11.3)
4.2 (1.2–7.1)
4.6 (1.4–7.7)
3.8 (0.9–6.7)
2.3 (0.2–4.3)
2.4 (0.2–4.6)
2.5 (0.1–4.9)
16.8 (10.7–22.9)
219.6
74.4
26.0
23.1
6.8
4.2
5.0
10.0
7.8
3.7
6.0
5.1
0.4
0.5
14.9
a
95% confidence interval in parentheses. Rate per 100,000, age-adjusted to the U.S. 1970 population.
For cancer deaths, we used death records with the
underlying cause of death ICD-9 (International Classification of Diseases, 9th revision) codes 140.0 –208.9
for the years 1989 –1993. In accordance with popular
convention, we combined sites for these common
cancer types: colon, rectosigmoid, and rectum; liver
and intrahepatic duct; lung and bronchus; and kidney
and renal pelvis. Some cancer deaths were not specified as to site. We combined these records, including
ICD-9 codes 159.1, 195.0 –195.8, 196.1–196.9, 199.0 –
a
95% confidence interval in parentheses. Rate per 100,000, age-adjusted to the U.S. 1970 population.
199.1, 202.3, and 202.5–202.6 into the category of “Unspecified.”
Death rates were age-adjusted by the direct
method to the 1970 U.S. population. We used comparison rates for cancer mortality in the U.S. all-races
population from National Cancer Institute15 for the
years 1988 –1992.
To compute 95% confidence intervals for each
rate, we used the method described by Armitage.16 If
the U.S. all-races rate was not included in the calculated 95% confidence interval, we considered the rates
significantly different at the P ⬍ 0.05 level.
RESULTS
The average annual population for the sample of this
study was 735,049. This represented 59% of the 1990
Indian Health Service “service” population (1,238,937)
and 38% of the 1990 U.S. Census American Indian/
Alaska Native population (1,959,234). The Northern/
Plains region had a population of 331,849, and the
Southwest region had a population of 403,200.
The number of cancer deaths, age-adjusted mortality rates, and comparison rates for the entire U.S.
are shown in Tables 1–3. During the study period,
there were 3043 deaths from cancer in the study sample; 1535 males and 1508 females died. The age-adjusted annual mortality rate for all sites was 148.2 per
100,000 for both genders combined, 133.1 for females,
and 167.2 for males. The rates for males and for both
genders combined, but not for females, were significantly lower than the U.S. all-races rates (P ⬍ 0.05).
The five most common causes of cancer death for
2380
CANCER December 1, 1998 / Volume 83 / Number 11
FIGURE 1. The cancer mortality ratio of Native
American males to U.S. males of all races is
shown. Cancers are listed in order of their prevalence in the Native American population.
FIGURE 2. The cancer mortality ratio of Native
American females to U.S. females of all races is
shown. Cancers are listed in order of their prevalence in the Native American population.
FIGURE 3. The cancer mortality ratio of Native
Americans of both genders to both genders of all
races in the U.S. is shown. Cancers are listed in
order of their prevalence in the Native American
population.
females were carcinoma of the lung, breast, colon,
pancreas, and cervix; for males, the top five were carcinoma of the lung, prostate, colon, stomach, and
liver. For both genders combined, the top five were
carcinoma of the lung, colon, breast, prostate, and
stomach.
Compared with the all-races U.S. mortality rates,
Native American females experienced significantly
Native American Cancer Mortality/Cobb and Paisano
2381
TABLE 4
Native American Cancer Mortality Ratesa by Region
Cancer
site
Southwest
females
Northern/Plains
females
Southwest
males
Northern/Plains
males
All sites
Lung
Colon
Breast
Prostate
102 (84–120)
7.3 (2.3–12.2)
4.8 (0.9–8.8)
9.8 (4.4–15.3)
—
170 (144–195)
43.2 (30.3–56.2)
20.3 (11.3–29.2)
21.5 (12.7–30.3)
—
113 (92–134)
13.3 (5.9–20.6)
6.5 (1.4–11.6)
—
17.3 (8.8–25.8)
230 (197–263)
77.1 (57.8–96.4)
23.9 (13.3–34.6)
—
20.4 (10.0–30.7)
a
95% confidence interval in parentheses. Rate per 100,000, age-adjusted to the U.S. 1970 population.
FIGURE 5. Cancer death rates for Native American males (American Indians
and Alaska Natives) are shown by region. Rates are per 100,000, age-adjusted
to the 1970 U.S. Census.
were six times greater than in the Southwest, and
colon carcinoma mortality was four times greater.
Breast carcinoma mortality in the Northern/Plains region was double that in the Southwest region, whereas
prostate carcinoma mortality was the same in the two
regions.
FIGURE 4.
DISCUSSION
(P ⬍ 0.05) lower rates of death from carcinoma of the
lung and breast, and significantly higher rates of death
from carcinoma of the cervix and gallbladder. Males
had significantly lower rates of death from carcinoma
of the lung, colon, and prostate, and significantly
higher rates of death from liver carcinoma. Both genders combined had significantly lower rates of death
from lung and colon carcinoma, and significantly
higher rates of death from stomach, liver, kidney, and
gallbladder carcinoma. The ratio of Native American
rates to U.S. all-races rates are shown in Figures 1–3.
Deaths coded as “Unspecified” accounted for 326
(10.7%) of the total, 173 (11.5%) among females and
153 (9.9%) among males. For comparison, 6.9% of all
recorded cancer deaths in the U.S. were coded as
“Unspecified.” This difference was statistically significant for females and for both genders combined.
A comparison between mortality rates in the
Southwest region and the Northern/Plains region is
shown in Table 4 and Figures 4 and 5. There were 1836
cancer deaths in the Northern/Plains region and 1207
cancer deaths in the Southwest region during the
study period. For both males and females in the
Northern/Plains region, lung carcinoma death rates
The pattern of cancer death among Native Americans
is quite distinct from that of the general U.S. population. The pattern of cancer mortality that we have
observed is consistent with data from the previous 5
years7 and with other reports in the literature.2,3 The
overall low rate is primarily determined by low rates of
lung, breast, prostate, and colon carcinoma. The low
lung carcinoma rate is easily explained by the rarity of
habitual cigarette smoking among tribes in the Southwest,17,18 but reasons for the other low rates are not as
evident. Breast carcinoma rates may be influenced by
early pregnancy, breast-feeding, and large families,
but this is unlikely to explain all of the deficit. Risk
factors for prostate carcinoma are not well enough
understood to allow speculation regarding the reason
for such low rates. Subsistence farming and hunting
cultures may have a low rate of colon carcinoma because of the large amount of fiber in their diet.
Changes in diet19 and increased smoking among
teens20,21 suggest that lung and colon carcinoma rates
may soon match the general U.S. rate. Clearly, there is
a need for research into the factors that have protected
some groups of Native Americans from cancer.
Similar to the patterns observed in many developing nations, the Native American population has
high rates of death from carcinoma of the cervix, liver,
and stomach. We have evidence that aggressive Papa-
Cancer death rates for Native American females (American
Indians and Alaska Natives) are shown by region. Rates are per 100,000,
age-adjusted to the 1970 U.S. Census.
2382
CANCER December 1, 1998 / Volume 83 / Number 11
nicolaou screening has reduced the rate of invasive
cervical carcinoma in several areas served by Indian
Health Service.22,23 Liver carcinoma is closely related
to high rates of hepatitis B infection24 and may be
expected to fall as the national program of hepatitis B
immunization matures. A growing body of knowledge
suggests that chronic Helicobacter pylori infection
may be related to the high rates of stomach carcinoma
in Alaska Native communities. The epidemiology of H.
pylori infection and its link to stomach carcinoma
need further study before preventive measures can be
recommended.
The contribution of genetic factors to cancer in
the Native American population is not well understood. The remarkably high rate of gallbladder carcinoma could be an indication of a cancer with genetic
determinants,25 although diet may also be a factor.
Could the observed low cancer mortality rates be
artifacts of improper coding of race on death certificates? Although several authors have demonstrated
that racial ascertainment is poor in some areas,26 –28
cancer registries with adequate procedures for ascertaining race, such as the New Mexico Tumor Registry,
consistently find low rates for most cancers in the
Native American population.3 By including only counties with known high percentages of American Indian
or Alaska Native people, and excluding areas that have
known problems with racial reporting, we believe that
this study is the most accurate to date. We recalculated mortality rates for all 12 Indian Health Service
areas, including the ones with known problems of
racial misclassification, and found a 5–15% decrease
in all death rates. This consistent result supports the
idea that the American Indian/Alaska Native racial
category is underreported on death certificates in
those areas.
Cancers in the “Unspecified” group were significantly higher among Native Americans. The reasons
for this are not well understood. Autopsy rates are low
among Native Americans, probably for both economic
and cultural reasons, so definitive diagnosis may not
be available in some cases. It may be that Native
Americans refuse diagnostic procedures more often
than others. Presentation at late stages may make it
more difficult to assign a primary site. This topic certainly deserves more focused research.
Is the sample in this study representative of all
Native American people? Possibly not; as already
noted, this sample includes a more rural and less
urban group than the entire Native population. This
sample was selected because it most closely represents the population served by the Indian Health Service, and because we do not have reliable health data
on the urban Indian population. A careful survey of
cancer mortality among urban Indians would be a
valuable adjunct to this study.
There is enormous geographic variation in cancer
mortality rates,29 with the Southwest showing lower
rates of colon, lung, and breast carcinoma. The variation in lung carcinoma mortality can be attributed to
the different smoking habits between the regions. The
differences in colon and breast carcinoma are not so
easily explained. Further research will have to be done
to elucidate whether some protective factors have
been at work in the Southwest. Such research could
have important implications for cancer prevention in
all racial and ethnic groups.
CONCLUSIONS
This study has demonstrated that Native Americans
experience a unique pattern of cancer mortality. Prevention and screening programs should be specifically
designed for this population. The relatively lower burden of cancer in this population seems to be real, not
an artifact of ascertainment. The observed differences
in mortality present a unique opportunity for research
into both risk factors and protective factors in this
population.
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