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
on cancer incidencefor
nationally and regionally.18This collection of papers
addresses site-specific cancers of interest, risk factors
1114 CANCER Supplement September 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.
1.Wiggins C, Espey D, Wingo PA, et al. Cancer among Ameri-
can Indians and Alaska Natives in the United States, 1999-
2004. Cancer. 2008;113(5 suppl):1142-1152.
2.Ogunwole SU. We the people: American Indians and Alaska
Natives in the United States Census 2000. US Census
3.Seattle Indian Health Board—Urban Indian Health Insti-
tute. The health status of urban American Indians and
Alaska Natives: an analysis of select vital records and
census data sources 2004. Seattle, WA. Available at: www.
HealthStatusReport.pdf. Accessed on May 1, 2008.
4.Indian Health Service. Trends in Indian health 2000-2001.
Department of Health and Human Services; 2002. Avail-
able at: http://www.ihs.gov/NonMedicalPrograms/IHS_Stats/
Trends00.asp 2002. Accessedon May 1, 2008.
5.Denny CH, Holtzman D, Cobb N. Surveillance for health
behaviors of American Indians and Alaska Natives. Find-
ings from the Behavioral Risk Factor Surveillance System,
1997-2000. MMWR Surveill Summ. 2003;52:1-13.
6.Steele C, Cardinez C, Richardson L, Tom-Orme L, Shaw K.
Surveillance for health behaviors of American Indians and
Alaska Natives: findings from the Behavioral Risk Factor
Surveillance System, 2000-2006.
7.Weir H, Jim M, Marrett L, Fairley T. Cancer in American
Indian and Alaska Native young adults: US, 1999-2004.
Cancer. 2008;113(5 suppl):1153-1167.
8.Henderson J, Espey D, Jim M, German RR, Shaw K, Hoff-
man R. Prostate cancer incidence among American Indian
and Alaska Native men, US, 1999-2004. Cancer. 2008;113(5
9. Wingo PA, King J, Swan J, et al. Breast cancer incidence
among American Indian and Alaska Native women: US,
1999-2004. Cancer. 2008;113(5 suppl):1191-1202.
10. Bliss A, Cobb N, Soloman T, Cravatt K, Marshall L, Camp-
bell J. Lung cancer incidence among American Indians and
Alaska Natives in the United States, 1999-2004. Cancer.
11. Perdue D, Perkins C, Jackson-Thompson J, et al. Regional
differences in colorectal cancer incidence, stage, and sub-
site among American Indians and Alaska Natives, 1999-
2004. Cancer. 2008;113(5 suppl):1179-1190.
Introduction to AI/AN Cancer Supplement/Cobb et al1115
12. Wilson R, Richardson LC, Kelly JJ, Kaur JS, Jim MA, Lanier
AP . Cancers of the urinary tract among American Indian
and Alaska Natives in the United States, 1999-2004. Cancer.
13. Wiggins C, Perdue D, Henderson J, et al. Gastric cancer
among American Indians and Alaska Natives in the United
States, 1999-2004. Cancer. 2008;113(5 suppl):1225-1233.
14. Becker TM, DK E, Lawson H, Saraiya M, Jim M, Waxman
A. Regional differences in cervical cancer incidence among
American Indians and Alaska Natives, 1999-2004. Cancer.
15. Jim M, Perdue D, Richardson LC, et al. Primary liver cancer
incidence among American Indians and Alaska Natives,
US, 1999-2004. Cancer. 2008;113(5 suppl):1244-1255.
16. Reichman M, Kelly JJ, Kosary C, Coughlin SS, Kohn W,
Lanier AP . Incidence of cancers of the oral cavity and pharynx
among American Indians and Alaska Natives, 1999-2004.
Cancer. 2008;113(5 suppl):1256-1265.
17. Lemrow S, Perdue D, French H, et al. Regional differences in
gallbladder cancer incidence and stage among American
Indians and Alaska Natives, 1999-2004. Cancer. 2008;113
18. Espey DK, Wu XC, Swan J, et al. Annual report to the
nation on the status of cancer, 1975-2004, featuring cancer
in American Indians and Alaska Natives. Cancer 2007;110:
19. USDHHS. Tobacco use among U.S. racial/ethnic minority
groups—African Americans, American Indians and Alaska
Natives, Asian Americans and Pacific Islanders, and Hispa-
nics: a report of the Surgeon General. Atlanta, GA: Centers
for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office
on Smoking and Health; 1998.
20. National Center for Health Statistics. U.S. Census Popula-
tions with Bridged Race Categories. Available at: ftp://ftp.cdc.
21. Espey D, Paisano R, Cobb N. Regional patterns and trends
in cancer mortality among American Indians and Alaska
Natives, 1990-2001. Cancer. 2005;103:1045-1053.
22. Swan J, Edwards BK. Cancer rates among American Indians
and Alaska Natives: is there a national perspective. Cancer.
23. Brown MO, Lanier AP , Becker TM. Colorectal cancer inci-
dence and survival among Alaska Natives, 1969-1993. Int J
24. Paltoo DN, Chu KC. Patterns in cancer incidence among
American Indians/Alaska Natives, United States, 1992-1999.
Public Health Rep. 2004;119:443-451.
25. Wampler NS, Lash TL, Silliman RA, Heeren TC. Breast can-
cer survival of American Indian/Alaska Native women,
1973-1996. Soz Praventivmed. 2005;50:230-237.
26. Kelly JJ, Lanier AP , Alberts S, Wiggins CL. Differences in
cancer incidence among Indians in Alaska and New Mex-
ico and U.S. Whites, 1993-2002. Cancer Epidemiol Biomar-
kers Prev. 2006;15:1515-1519.
27. Ries L, Melbert D, Krapcho M, et al. SEER Cancer Statistics
Review, 1975-2004, National Cancer Institute. Bethesda,
MD: National Cancer Institute; 2007. Available at: http://
seer.cancer.gov/csr/1975_2004/. Accessed on May 1, 2008.
28. Nutting PA, Freeman WL, Risser DR, et al. Cancer inci-
dence among American Indians and Alaska Natives, 1980
through 1987. Am J Public Health. 1993;83:1589-1598.
29. Cancer Registries Amendment Act, Public Law No. 102-515,
Stat. 3312, (October 22, 1992). Available at: http://www.
May 1, 2008.
30. U.S. Cancer Statistics Working Group. United States cancer
statistics: 2004 incidence. Atlanta, GA: Department of
Health and Human Services, Centers for Disease Control
and Prevention and National Cancer Institute; 2007.
31. Frost F, Taylor V, Fries E. Racial misclassification of Native
Americans in a surveillance, epidemiology, and end results
cancer registry. J Natl Cancer Inst. 1992;84:957-962.
32. Partin MR, Rith-Najarian SJ, Slater JS, Korn JE, Cobb N,
Soler JT. Improving cancer incidence estimates for Ameri-
can Indians in Minnesota. Am J Public Health. 1999;89:
33. Kwong S, Perkings C, Snipes K, Wright W. Improving Amer-
ican Indian cancer data in the California Cancer Registry
by linkage with the Indian Health Service. J Regist Manage.
34. Sugarman JR, Holliday M, Ross A, Castorina J, Hui Y.
Improving American Indian cancer data in the Washington
State Cancer Registry using linkages with the Indian Health
Service and tribal records. Cancer. 1996;78(7 suppl):1564-
35. Becker TM, Bettles J, Lapidus J, et al. Improving cancer
incidence estimates for American Indians and Alaska
Natives in the Pacific Northwest. Am J Public Health. 2002;
36. Harwell TS, Miller SH, Lemons DL, Helgerson SD, Gohdes
D. Cancer incidence in Montana: rates for American
Indians exceed those for whites. Am J Prev Med. 2006;30:
37. Espey DK, C W, MA J, Miller BA, Johnson C, Becker TM.
Methods for improving cancer surveillance data in Ameri-
can Indianand Alaska
38. NAACCR. Guideline for enhancing Hispanic/Latino iden-
tification: revised NAACCR Hispanic/Latino identifica-
tion algorithm [NHIA v2]. vol. 2005. Springfield, IL:
North American Association of Central Cancer Registries;
1116 CANCER Supplement September 1, 2008 / Volume 113 / Number 5