Introduction to the supplement on cancer in the American Indian and Alaska Native populations in the United States.
ABSTRACT The collection of papers in this Supplement combines cancer incidence data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program, enhanced by record linkages and geographic factors, to provide a comprehensive description of the cancer burden in the American Indian/Alaska Native population in the United States. Cancer incidence rates among this population varied widely, sometimes more than 5-fold, by geographic region.
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ABSTRACT: American Indian communities have a high prevalence of chronic diseases including diabetes, obesity, cardiovascular disease, and cancer. Innovative community-based approaches are needed to identify, prioritize, and create sustainable interventions to reduce environmental barriers to healthy lifestyles and ultimately improve health.Preventing chronic disease 09/2014; 11:E160. · 1.96 Impact Factor
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ABSTRACT: Cancer is the leading cause of death among Alaska Native people. The objective of this study was to examine cancer incidence data for 2007-2011, age-specific rates for a 15-year period, incidence trends for 1970-2011, and mortality trends for 1990-2011. US data were from the Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat database and from the SEER Alaska Native Tumor Registry. Age-adjusted cancer incidence rates among Alaska Native people and US whites were compared using rate ratios. Trend analyses were performed using the Joinpoint Regression Program. Mortality data were from National Center for Health Statistics. During 2007-2011 the cancer incidence rate among Alaska Native women was 16% higher than the rate among US white women and was similar among Alaska Native men and US white men. Incidence rates among Alaska Native people exceeded rates among US whites for nasopharyngeal, stomach, colorectal, lung, and kidney cancer. A downward trend in colorectal cancer incidence among Alaska Native people occurred from 1999 to 2011. Significant declines in rates were not observed for other frequently diagnosed cancers or for all sites combined. Cancer mortality rates among Alaska Native people during 2 periods, 1990-2000 and 2001-2011, did not decline. Cancer mortality rates among Alaska Native people exceeded rates among US whites for all cancers combined; for cancers of the lung, stomach, pancreas, kidney, and cervix; and for colorectal cancer. Increases in colorectal screening among Alaska Native people may be responsible for current declines in colorectal cancer incidence; however; improvements in treatment of colon and rectal cancers may also be contributing factors.Preventing chronic disease 01/2014; 11:E221. · 1.96 Impact Factor
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ABSTRACT: In response to a Request for Proposals from the National Cancer Institute (NCI), the Inter Tribal Council of Arizona (ITCA) along with health care partners from the Phoenix Indian medical Center (PIMC) and academic partners from the Arizona Cancer Center (ACC) at the University of Arizona (UA), and the University of Nevada Las Vegas (UNLV) established a Community Network Program entitled the Southwest American Indian Collaborative Network (SAICN). The ultimate goal of the SAICN project was to "eliminate cancer health disparities by closing the gap between the health needs of the community and cancer prevention and control made possible by a responsive health delivery and research system. " At the close of the 5-year funding period for the SAICN project, a RE-AIM framework provided an important evaluative tool for identifying areas of potential long-term impact.
An Update on Cancer in American Indians and Alaska
Supplement to Cancer
Introduction to the Supplement on Cancer in the
American Indian and Alaska Native Populations
in the United States
Nathaniel Cobb, MD1
Phyllis A. Wingo, PhD2
Brenda K. Edwards, PhD3
1Division of Epidemiology and Disease Prevention,
Indian Health Service, Albuquerque, New Mexico.
2Division of Cancer Prevention and Control,
National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Con-
trol and Prevention, Atlanta, Georgia.
3Division of Cancer Control and Population
Sciences, National Cancer Institute, Bethesda,
The collection of papers in this Supplement combines cancer incidence data
from the National Program of Cancer Registries and the Surveillance, Epidemiol-
ogy, and End Results program, enhanced by record linkages and geographic
factors, to provide a comprehensive description of the cancer burden in the
American Indian/Alaska Native population in the United States. Cancer incidence
rates among this population varied widely, sometimes more than 5-fold, by
geographic region. Cancer 2008;113(5 supp):1113–6. Published 2008 by the Ameri-
can Cancer Society.*
KEYWORDS: cancer incidence, American Indian, Alaska Native, race, misclassifi-
among American Indians and Alaska Natives (AI/AN) in the United
States.1Although there is great diversity among the hundreds of
tribes and linguistic groups that comprise the AI/AN population,
they share many features, including a history of defeat, displace-
ment, and cultural trauma in the not-so-distant past, as well as a
rich cultural heritage that can be a source of strength in the present.
Many AI/AN live on reservation lands or in remote rural areas, with
primary healthcare needs provided only by the Indian Health Ser-
vice (IHS) or tribally operated health programs.2,3Both rural and
urban AI/AN populations experience greater poverty, lower levels of
education, and poorer housing conditions than the general US
population.4The risk factor profile for many AI/AN communities is
quite different from others, including use of tobacco and alcohol,
physical activity level, and obesity.5,6Dietary practices and exposure
to harmful environmental agents are less well documented, yet may
also be important risk factors. Many of these influences on the bur-
den of cancer for this group tend to be lost when data from AI/AN
cancer cases from all regions of the United States are combined into
composite rates. Careful study of the incidence of cancer among AI/
AN can be helpful in understanding the influence of different expo-
sures, in addition to quantifying the burden of disease for this
population. The special collection of papers in this Supplement uses
nique circumstances of culture, location, history, and healthcare
combine to produce unusual patterns of cancer occurrence
This supplement was sponsored by Cooperative
Agreement Number U50 DP424071-04 from the
Centers for Disease Control and Prevention, Divi-
sion of Cancer Prevention and Control.
Phyllis A. Wingo is employed by the Arctic Slope
Regional Corporation, Inc., which is a contractor
to the Indian Health Service.
Address for reprints: Nat Cobb, MD, Indian Health
Service Division of Epidemiology and Disease Pre-
vention, 5300 Homestead NE, Albuquerque, NM
87110; Fax: 505-248-4393; E-mail: nathaniel.
*This article is a US Government work and, as
such, is in the public domain in the United
States of America.
Received May 5, 2008; accepted June 3, 2008.
Published 2008 by the American Cancer Society*
Published online 20 August 2008 in Wiley InterScience (www.interscience.wiley.com).
combined cancer incidence data from the 2 major
US cancer registry systems, enhanced by record
linkages and geographic factors, to improve racial
classification.1,6-17The 2004 diagnosis year represents
the first time that population-based cancer incidence
data for AI/AN have been available regionally and
nationwide for analysis.1,6-17
The unusual risk factor profile of AI/AN communities
is the topic of 1 of the papers in this collection.6
American Indians have used tobacco for many gen-
erations, and it is considered by many to have me-
dicinal and spiritual properties. Historically, use of
tobacco was limited to small quantities and specific
ceremonial settings. Since WWII, however, the habit-
ual use of commercial tobacco products has greatly
increased, and AI/AN now have the highest smoking
prevalence in the country, over 50% in some commu-
nities.5,6,19A notable exception is the tribes of the
Southwest, who have remarkably low prevalence of
For a surprising number of AI/AN, traditional
food sources from farming, hunting, and fishing
make up a significant portion of their diet, which
may serve to protect against the possible harmful
effects of a modern Western diet but leaves them
vulnerable to higher levels of contaminants, such as
heavy metals, that are concentrated in wild food
Sources of Healthcare
AI/AN who are enrolled members of federally recog-
nized tribes are eligible to receive, without charge,
primary healthcare from the IHS system of Federal
and Tribal hospitals and clinics. Those who do not
live close to an IHS facility may need to travel great
distances to receive even basic primary care. Cancer
treatment, like most specialty care, is purchased
from non-Federal providers through the IHS Contract
Health Service, which is available only to IHS benefi-
ciaries who live in certain US counties (the Contract
Health Service Delivery Area, or CHSDA). Restrictions
on eligibility for the Contract Health Service mean
that modern cancer treatment for many is logistically
difficult and unaffordable.
Cancer Incidence Data
The entire Native population is only about 1.1% of
the US population,20and they are dispersed through-
out the country, making it difficult to collect aggre-
gate data on cancer incidence in AI/AN populations.
Most previous publications have relied on mortality
data from death certificates21or have reported on
incidence in limited areas covered by state or local
cancer surveillance systems, notably those in the
Surveillance, Epidemiology, and End Results (SEER)
cancer registry system.22-26
The National Cancer Institute (NCI) has funded
and supported the SEER Program since 1973.27SEER
routinely collects data on patient demographics, pri-
mary tumor site, tumor morphology and stage at
diagnosis, first course of treatment, and follow-up for
vital status. Recognizing the importance of under-
standing cancer patterns in minority populations,
NCI provides data for American Indians in Arizona
and New Mexico and Alaska Natives in the SEER sys-
tem, and more recently has begun to develop tribally
based cancer registries at the Cherokee Nation of
Oklahoma and in the Northwest. SEER registries cur-
rently cover 26% of the total US population, inclu-
ding 42% of AI/AN. The cancer data from these
sources has been intriguing, showing that Alaska
Natives have rates of lung, colon, and breast cancer
5 times or more higher than those of Southwestern
Indians, whereas rates of stomach, kidney, uterine
cervix, and liver cancer are similar in the 2 regions,
and higher than in non-Hispanic whites (NHW).
Studies using death certificates21and IHS hospi-
tal data28indicated that cancer rates in the Northern
Plains and other regions were as high as in Alaska.
However, population-based cancer incidence data
were not available for American Indians outside of
the Southwest until recently.
Established by Congress through the Cancer
Registries Amendment Act in 1992, and supported by
the Centers for Disease Control and Prevention
(CDC), the National Program of Cancer Registries
(NPCR) collects data on the occurrence of cancer,
including demographics, tumor characteristics, stage
of disease at diagnosis, and type of initial treat-
ment.29,30Today, NPCR supports central cancer regis-
tries in 45 states, the District of Columbia, Puerto
Rico, the Republic of Palau, and the Virgin Islands.
NPCR data are used by states to monitor the cancer
burden, identify cancer incidence variation for racial
and ethnic populations, provide data for research,
provide guidance for health resource allocation,
respond to public concerns and inquiries about
cancer, and evaluate cancer prevention and control
activities. NPCR currently covers 96% of the US
population, including 90% of the AI/AN population.
NPCR and SEER cover 100% of the US popula-
tion and together represent an opportunity to report
nationally and regionally.18This collection of papers
addresses site-specific cancers of interest, risk factors
1114CANCER SupplementSeptember 1, 2008 / Volume 113 / Number 5
among AI/AN, and methods used by the collaborat-
ing authors to improve racial classification in cancer
Correcting Misclassification of Race
In the past, few central cancer registries were con-
cerned about correctly identifying AI/AN in their
databases, where race and ethnicity were abstracted
demonstrated that many AI/AN persons were mis-
classified as another race in cancer registry data, and
that the extent of the misclassification varied by reg-
istry.31-36When coupled with population denomina-
tors from the US Census Bureau, where race is self-
identified, this had the effect of lowering apparent
cancer rates for AI/AN. To address this problem, IHS,
NCI, CDC, and all NPCR and SEER cancer registries
launched a unique collaboration to link IHS benefici-
ary records with cancer registry databases. Linkages
to identify AI/AN cases misclassified as non-Native
were conducted using LinkPlus, a probabilistic link-
age software program developed by the CDC that
identifies records representing the same individual in
the IHS and registry databases.37,38
In addition, CHSDA counties and IHS regions
were geographic factors used to further elucidate the
burden of cancer incidence in the AI/AN popula-
tion.37CHSDA counties, in general, contain federally
recognized tribal lands or are adjacent to tribal lands.
The proportion of AI/AN relative to the total popula-
tion is higher in CHSDA counties, with less misclassi-
fication than in non-CHSDA counties. The analysis
of AI/AN data by IHS region conforms with known
regional patterns of specific health outcomes and
disease risk factors for AI/AN. These processes
greatly improved the identification of race and the
description of the cancer burden in NPCR and SEER
registries for AI/AN populations in the United States.
Key Findings and Questions
In these reports, cancer incidence rates in AI/AN
were lower than rates in NHW for most cancer sites.
Notable exceptions included higher rates of cancers
occurring in the kidney, stomach, cervix uteri, liver,
and gallbladder. Are these differences because of
shared risk factors, genetic predisposition, or lack of
screening and preventive services? Although rates
were significantly declining for most sites among
non-Hispanic whites (including the leading cancer
sites), the declines among AI/AN were generally
smaller and not statistically significant. This raises
questions about whether AI/AN people with cancer
have access to appropriate and timely screening and
Cancer incidence rates among AI/AN varied
widely (sometimes 5-fold) by IHS region. Lung, col-
orectal and breast cancers occurred at rates higher or
similar to the NHW population in Alaska and the
Northern Plains, but were dramatically lower in the
Southwest. Lung cancer tracks closely with the smok-
ing rates in those regions, but how can we explain
the differences in breast and colon cancer?
The culmination of this collaborative work repre-
sents important progress in providing accurate data
on the burden of cancer in the AI/AN population
nationwide and by region. We hope that this infor-
mation will be useful to guide public health and
clinical policy for cancer control, and to generate
hypotheses for etiologic research.
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