Volume III:
Cancer
Report of the
Secretary's Task
Force on
Minority
Health
U.S. Department of Health and
Human Services
Volume III ^^^^^^^^m^^^^^^^^^^mm^^^mi^^^m^^mBa^^^^^^^m^^
Cancer
Report of the
Secretary's Task
Force on
Black &
Minority
Health
U.S. Department of Health and
Human Services
January 1986
SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH
MEMBERS
Thomas E. Malone, Ph.D., Chairperson
Katrina W. Johnson, Ph.D., Study Director
Wendy Baldwin, Ph.D
Betty Lou Dotson, J.D.
Manning Feinleib, M.D., Dr.P.H.
William T. Friedewald, M.D.
Robert Graham, M.D.
M. Gene Handelsman
Jane E. Henney, M.D.
Donald R. Hopkins, M.D.
Stephanie Lee-Miller
Jaime Manzano
J. Michael McGinnis, M.D.
Mark Novitch, M.D.
Clarice D. Reid, M.D.
Everett R. Rhoades , M.D.
William A. Robinson, M.D.,
James L. Scott
Robert L. Trachtenberg
T. Franklin Williams, M.D.
M.P.H.
ALTERNATES
Shirley P. Bagley, M.S.
Claudia Baquet, M.D. , M.
Howard M. Bennett
Cheryl Damberg, M.P.H.
Mary Ann Danello, Ph.D.
Jacob Feldman, Ph.D.
Marilyn Gaston, M.D.
George Hardy, M.D.
John H. Kelso
P.H.
James A. Kissko
Robert C. Kreuzburg, M.D.
Barbara J. Lake
Patricia L. Mackey, J.D.
Delores Parron, Ph.D.
Gerald H. Payne, M.D.
Caroline I. Renter
Clay Simpson, Jr. , Ph.D.
Ronald J. Wylie
TABLE OF CONTENTS
Introduction to the Task Force Report v
Members of the Subcommittee on Cancer ix
Report of the Subcommittee on Cancer in Minorities
PART I
Introduction 1
General Overview 4
Blacks 13
Hispanics 21
Asian/Pacific Islanders 24
American Indians 29
Tables:
Smoking and Cancer 35
Alcohol and Tobacco 45
Nutrition 49
Occupation 68
Bibliography 73
PART II
Cancer Statistics Review: Black, White, and Other
Group Comparisons 105
lU
IV
INTRODUCTION TO THE TASK FORCE REPORT
Background
The Task Force on Black and Minority Health was established by
Secretary of Health and Human Services Margaret M. Heckler in response
to the striking differences in health status between many minority
populations in the United States and the nonminority population.
In January 1984, when Secretary Heckler released the annual report
of the Nation's health, Health, United States, 1983, she noted that the
health and longevity of all Americans have continued to improve, but the
prospects for living full and healthy lives were not shared equally by
many minority Americans. Mrs. Heckler called attention to the longstanding
and persistent burden of death, disease, and disability experienced by
those of Black, Hispanic, Native American, and Asian/Pacific Islander
heritage in the United States. Among the most striking differentials
are the gap of more than 5 years in life expectancy between Blacks and
Whites and the infant mortality rate, which for Blacks has continued to
be twice that of Whites. While the differences are particularly evident
for Blacks, a group for whom information is most accurate, they are
clear for Hispanics, Native Americans, and some groups of Asian/Pacific
Islanders as well.
By creating a special Secretarial Task Force to investigate this
grave health discrepancy and by establishing an Office of Minority Health
to implement the recommendations of the Task Force, Secretary Heckler
has taken significant measures toward developing a coordinated strategy
to improve the health status of all minority groups.
Dr. Thomas E. Malone, Deputy Director of the National Institutes of
Health, was appointed to head the Task Force and 18 senior DHHS executives
whose programs affect minority health were selected to serve as primary
members of the Task Force. While many DHHS programs significantly benefit
minority groups, the formation of this Task Force was unique in that it
was the first time that attention was given to an integrated, comprehensive
study of minority health concerns.
Charge
Secretary Heckler charged the Task Force with the following duties:
• Study the current health status of Blacks, Hispanics, Native
Americans, and Asian/Pacific Islanders.
• Review their ability to gain access to and utilize the health
care system.
• Assess factors contributing to the long-term disparities in
health status between the minority and nonminority populations.
• Review existing DHHS research and service programs relative to
minority health.
• Recommend strategies to redirect Federal resources and programs to
narrow the health differences between minorities and nonminorities.
• Suggest strategies by which the public and private sectors can
cooperate to bring about improvements in minority health.
Approach
After initial review of national data, the Task Force adopted a
study approach based on the statistical technique of "excess deaths"
to define the differences in minority health in relation to nonminority
health. This method dramatically demonstrated the number of deaths among
minorities that would not have occurred had mortality rates for minorities
equalled those of nonminorities. The analysis of excess deaths revealed
that six specific health areas accounted for more than 80 percent of the
higher annual proportion of minority deaths. These areas are:
• Cardiovascular and cerebrovascular diseases
• Cancer
• Chemical dependency
• Diabetes
• Homicide, suicide, and unintentional injuries
• Infant mortality and low birthweight.
Subcommittees were formed to explore why and to what extent these
health differences occur and what DHHS can do to reduce the disparity.
The subcommittees examined the most recent scientific data available
in their specific areas and the physiological, cultural, and societal
factors that might contribute to health problems in minority populations.
The Task Force also investigated a number of issues that cut across
specific health problem areas yet influence the overall health status of
minority groups. Among those reviewed were demographic and social
characteristics of Blacks, Hispanics , Native Americans, and Asian/Pacific
Islanders; minority needs in health information and education; access to
health care services by minorities; and an assessment of health professionals
available to minority populations. Special analyses of mortality and
morbidity data relevant to minority health also x^/ere developed for the
use of Task Force. Reports on these issues appear in Volume II.
Resources
More than 40 scientific papers were commissioned to provide recent
data and supplementary information to the Task Force and its subcommittees.
Much material from the commissioned papers was incorporated into the
subcommittee reports; others accompany the full text of the subcommittee
reports.
VI
An inventory of DHHS program efforts in minority health was compiled
by the Task Force. It includes descriptions of health care, prevention,
and research programs sponsored by DHHS that affect minority populations.
This is the first such compilation demonstrating the extensive efforts
oriented toward minority health within DHHS. An index listing agencies
and program titles appears in Volume I. Volume VIII contains more
detailed program descriptions as well as telephone numbers of the offices
responsible for the administration of these programs.
To supplement its knowledge of minority health issues , the Task
Force communicated with individuals and organizations outside the Federal
System. Experts in special problem areas such as data analysis, nutrition,
or intervention activities presented up-to-date information to the Task
Force or the subcommittees. An Hispanic consultant group provided inform-
ation on health issues affecting Hispanics. A summary of Hispanic health
concerns appears in Volume VIII along with an annotated bibliography of
selected Hispanic health issues. Papers developed by an Asian/Pacific
Islander consultant group accompany the report of the Subcommittee on
Data Development appearing in Volume II.
A nationwide survey of organizations and individuals concerned with
minority health issues was conducted. The survey requested opinions
about factors influencing health status of minorities, examples of success-
ful programs and suggestions for ways DHHS might better address minority
health needs. A summary of responses and a complete listing of the
organizations participating in the survey is included in Volume VIII.
Task Force Report
Volume I, the Executive Summary, includes recommendations for
department-wide activities to improve minority health status. The
recommendations emphasize activities through which DHHS might redirect
its resources toward narrowing the disparity between minorities and
nonminorities and suggest opportunities for cooperation with nonfederal
structures to bring about improvements in minority health. Volume I
also contains summaries of the information and data compiled by the Task
Force to account for the health status disparity.
Volumes II through VIII contain the complete text of the reports
prepared by subcommittees and working groups. They provide extensive
background information and data analyses that support the findings and
intervention strategies proposed by the subcommittees. The reports are
excellent reviews of research and should be regarded as state-of-the-art
knowledge on problem areas in minority health. Many of the papers commissioned
by the Task Force subcommittees accompany the subcommittee report. They
should be extremely useful to those who wish to become familiar in greater
depth with selected aspects of the issues that the Task Force analyzed.
vu
The full Task Force report consists of the following volumes:
Volume I: Executive Summary
Volume II:
Volume III:
Volume IV:
Volume V :
Volume VI:
Volume VII:
Crosscutting Issues in Minority Health:
Perspectives on National Health Data for Minorities
Minority Access to Health Care
Health Education and Information
Minority and other Health Professionals Serving Minority
Communities
Cancer
Cardiovascular and Cerebrovascular Diseases
Homicide, Suicide, and Unintentional Injuries
Infant Mortality and Low Birthweight
Chemical Dependency
Diabetes
Volume VIII: Hispanic Health Issues
Survey of the Non-Federal Community
Inventory of DHHS Program Efforts in Minority Health
viu
SUBCOMMITTEE ON CANCER
Jane Henney, M.D., Chairperson
Deputy Director
National Cancer Institute
Claudia Baquet, M.D. , M.P.H.
Program Director, Minority Field Program
Division of Cancer Prevention and Control
National Cancer Institute
Cheryl Damberg, M.P.H.
Research Fellow
Office of Disease Prevention and Health Promotion
Office of the Assistant Secretary for Health
Peter Greenwald, M.D.
Director, Division of Cancer Prevention and Control
National Cancer Institute
J. Michael McGinnis , M.D.
Assistant Surgeon General
Deputy Assistant Secretary for Health
Director, Office of Disease Prevention and Health Promotion
Office of the Assistant Secretary for Health
Earl Pollack, Sc.D.
Formerly, Chief, Biometry Branch
Division of Cancer Prevention and Control
National Cancer Institute
William Robinson, M.D. , M.P.H.
Deputy Director, Bureau of Health Professions
Health Resources and Services Administration
T. Franklin Williams, M.D.
Director
National Institute on Aging
Staff Liaison:
Lemuel Clark, M.D.
IX
Cancer In Minorities
Report of the Subcommittee on Cancer, Part I
y--v>i^^'-Vri-^' ;■! ■„ '.'■j^ninwimy
National Cancer Institute
Cancer Control Science Program
Cancer Control Applications Branch
Division of Cancer, Prevention and Control
ACKNOWLEDGEMENTS
This report was coordinated by Dr. Claudia Baquet , Cancer Control Appli-
cations Branch, Division of Cancer Prevention and Control, National Cancer
Institute. We gratefully acknowledge the following researchers for preparing
technical papers that contributed to this report.
Margaret Hargreaves, Ph.D.
Department of Internal Medicine and Clinical Nutrition
Meharry Medical College
Nashville, Tennessee
Irving Kessler, M.D.
Department of Preventive Medicine and Epidemiology
University of Maryland Medical School
Baltimore, Maryland
V/alter Stewart, Ph.D.
Department of Epidemiology
Johns Hopkins University
School of Hygiene and Public Health
Baltimore, Maryland
National Cancer Institute:
Claudia Baquet, M.D., M.P.H.
Thomas Glynn, Ph.D.
Thomas Kean, M.P.H.
Earl Pollack, Sc.D.
Knut Ringen, Dr.P.H.
Jerome Wilson, Ph.D.
John Young, Jr., Dr.P.H.
Xll
INTRODUCTION
Cancer is a disease with major public health impact. It is the second
leading cause of death in the United States, surpassed only by cardiovascular
disease. Although the group of illnesses termed "cancer" is of importance to
the general population, cancer has a particularly severe impact on specific
minority population groups, especially Blacks.
This report focuses on cancer mortality in minorities with emphasis on
areas of excess mortality. However, analysis of the cancer problem today
and projections about the future cannot be made on the basis of mortality
data alone. Information on incidence and survival rates is also required, as
mortality, incidence, and survival rates for cancer are interrelated. Changes
in incidence and/or survival for a particular cancer over time can result in
changes in the mortality rate for that cancer. In addition, a change in
exposure to factors which predispose individuals to greater risk for a cancer
will affect incidence and later mortality for that cancer.
Lung cancer mortality rates illustrate the interrelation of these factors.
Tobacco is a known causative factor for lung cancer. An increase in cigarette
smoking in the first half of the century resulted in a sharp rise in the inci-
dence and mortality rates for lung cancer. Changes in cigarette smoking
practices, particularly following the Surgeon General's report on smoking in
1964, have resulted in recent decreased Incidence of lung cancer among some
groups (notably white males) and an early indication that this trend of lov/er
Incidence will extend to other groups where the smoking prevalence rates are
falling. Since lung cancer has a low survival rate, incidence trends are
predictors of future mortality rates with an increase or decrease in incidence
being followed, within a very short time, by a corresponding increase or
decrease in the mortality rate. For groups where smoking prevalence is still
Increasing (notably women), we can expect rising incidence and mortality rates
for lung cancer in the future. This holds true for other cancers — stomach,
pancreatic, and esophogeal — for which survival rates are presently low. Another
way to illustrate the interrelation of these factors is where an improvement
in survival rates over time, particularly when incidence rates hold steady,
will result in decreases in the mortality rate. One example is testicular
cancer, where mortality rates fell sharplj' following a rise in survival
rates In the nid-1970's.
The following report describes the cancer experience of U.S. Blacks and
other ethnic minorities based on current, available data. Blacks are the
major focus of this report for two reasons: (1) historically they have been
the largest U.S. ethnic minority, and (2) more cancer-related data are avail-
able for Blacks than for other minority groups. Based on these data. Blacks
have experienced dramatic increases in age-adjusted cancer incidence and
mortality since the mid-1950's. Blacks develop and die of certain cancers
at greater rates than non-minorities, even when matched for stage.
There Is a need for continuing development of similar information on other
ethnic minority groups, particularly among the rapidly increasing Hispanic and
Asian populations. Preliminary data suggest an increased risk for certain cancers
common to members of these groups, e.g., primary liver cell and nasopharyngeal
cancers among Asians. As the numbers of persons at risk for these cancers
increase, observance of these types of cancer in the U.S. may also increase.
These large groups contain subpopulatlons for which cancer experience differs.
For Hispanics the subgroups include those of Mexican, Puerto Rican, Cuban,
and other Latino descendants; for Asian/Pacific Islanders, subgroups are of
Japanese, Chinese, Filipino, Hawaiian, and other descendants. Accurate
registration of these subpopulatlons in the census and in cancer case registra-
tion is necessary, since existing data and analysis of those data are not
adequate to clearly understand the current cancer experience of these groups.
Part I of this report presents highlights of available descriptive
epidemiology for incidence, mortality, and survival experience for Blacks and,
where possible, other minorities as well as comparisons to non-minorities when
differences in cancer rates exist. Information on cancer-related risk factors
and behaviors is presented which may explain in part the differences in cancer
rates between the two groups. The General Overview section discusses epidemi-
ological data, but focuses primarily on more detailed information relating
to risk factors such as tobacco, occupation, and health behaviors including
Pap smears and breast self-examinations.
Risk factors are discussed because they are critical to the understanding
of exposures that may predispose a person to cancer development. Major risk
factors — tobacco, alcohol, nutritional and dietary factors, and occupation —
account for approximately 70 percent of cancer mortality and 69 percent of
incidence. Environmental factors that increase risk for cancer may be endog-
enous, as in dietary and nutritional status, or exogenous, such as exposures
in the workplace. It should be noted that an individual is exposed to a
variety of environmental risk factors and a combination of risk factors
accumulated throughout life. Effects of exposures and risk factors may not
be immediately apparent because long latency periods or lag time exist between
exposure and cancer development.
The concept of competing risks and co-morbidity are also Important v/hen
considering cancer incidence and mortality. Tobacco use, a major risk factor
for several cancers, is also a contributing factor in heart and pulmonary
disease. Alcohol, a risk factor for cancer, may contribute to the high rate
of accidents in American Indians, where mortality due to accidents is higher
than from cancer. Cancer incidence and mortality data for groups where
competing risks are prominent may be influenced by early death rates from
other diseases, thus masking actual cancer rates. Additionally, the presence
of multiple chronic diseases, e.g., hypertension and renal disease, may affect
cancer survival negatively.
Socioeconomic status (SES) is an important factor in considering cancer
incidence and survival and, therefore, mortality. Socioeconomic status has an
impact on such factors as educational attainment; access, availability, quality
and utilization of health care including state-of-the-art cancer care; occupation;
and nutrition, Immune status, and response to cancer treatment. Blacks, in
particular, are overrepresented in lower socioeconomic groups, have lower
educational attainment, and are subject to discriminatory practices in employ-
ment, including the greater likelihood of work assignments to worksites where
they are exposed to hazardous materials. These adverse problems affect other
minority population segments as well.
The data included in this report were derived from numerous sources and
individual studies. The data cover a variety of denominators, time periods
and groupings, including cancer rates by sex, both sexes combined, all sites
combined, etc. Although data will be consistent within studies, they may not
be consistent across studies and, therefore, exact comparability may not be
possible between all racial/ethnic groups.
This report is divided in two parts. Part I is a narrative discussion
of risk factors and cancer epidemiology in major racial/ethnic minority groups.
The narrative is followed by a bibliography of available literature on sub-
jects of relevance to this report to which readers are directed for further
Information. Part II is a compendium of cancer statistics: Blacks, non-
minorities, and other group comparisons. It contains charts, tables and
graphic presentations, and provides further information on cancer incidence,
mortality, and survival in minorities and non-minorities.
A report prepared by the National Cancer Institute, "Demographic and
Health Services Patterns" discusses (1) the demographic characteristics of
the major minority groups: Blacks, Hispanics, American Indians, and Asian/
Pacific Islanders, and (2) health service patterns in minority populations.
This report can be obtained from the National Cancer Institute, Division of
Cancer Prevention and Control, Blair Building, Room 4A01, Bethesda, Maryland
20892-4200.
GENERAL OVERVIEW
Patterns of cancer distribution among U.S. population groups vary accord-
ing to racial and ethnic background. These patterns challenge Investigators
and health providers to provide explanations for the large differences in
cancer incidence, mortality, and survival among minority and non-minority
Americans. In examining these differences, this report looks at the available
epidemiological and statistical information regarding Incidence, mortality, and
survival; information relating to prominent factors that affect risk for cancer
development; and available observations on knowledge, attitudes, and practices
regarding cancer. In short, differences in cancer experience and possible
contributing factors to these differences between minorities and non-minorities
are discussed.
Most of the statistical Information relating to cancer incidence and
survival rates is derived from the Surveillance, Epidemiology, and End Results
(SEER) program of the National Cancer Institute. Mortality data are derived
from the National Center for Health Statistics.
The SEER program obtains cancer patient incidence and survival information
from 11 population-based cancer reglsterles that cover more than 12 percent
of the U.S. population. Within the racial and ethnic groups In the United
States, SEER data cover 12 percent of non-minorities, 12 percent of Blacks,
27 percent of American Indians, 32 percent of Chinese, 47 percent of Japanese,
38 percent of Filipinos, and 12 percent of Hispanics. The 11 areas covered
by SEER are six states (Connecticut, New Jersey, Iowa, New Mexico, Utah, and
Hawaii), four metropolitan areas (Atlanta, Detroit, San Francisco, and Seattle),
and the Commonwealth of Puerto Rico.
Because numbers for minority populations are small, particularly when
examining cancer experience by site and stage at diagnosis, SEER data must be
utilized and Interpreted with caution, particularly for comparisons between
groups. Where statistically significant comparisons can be made, they have
been. VJhere data or comparisons should be viewed with caution, this has been
noted.
Blacks are the largest U.S. minority and the one for which most data are
available. For this reason, this report focuses mainly on Blacks. However,
where relevant, reliable information is available for other minority groups
(Hispanics, Asian/Pacific Islanders, and American Indians). These are presented.
EPIDEMIOLOGY
Blacks have the highest overall age-adjusted rates of cancer Incidence
and cancer mortality of any U.S. population group. The overall 5-year
"relative survival for cancer for Blacks was 12 percentage points below that
of non-minorities (1973-81). Of the 25 primary cancer sites for which survival
data were available. Blacks had lower survival rates for all but three cancer
sites — ovary, brain, and multiple myeloma, all cancers with relatively low
Incidence and low survival in all population groups. In general, survival
rates for other racial/ethnic minority groups are lower than for non-minorities
also. It can be hypothesized, supported by much of the scientific literature,
that the differences in cancer survival among Blacks and non-minorities involve
social and/or environmental factors. As discussed in the section on Black
Americans, preliminary data indicate that differences in survival status between
Blacks and non-minorities seem to be substantially based on socioeconomic
status and the overrepresentation of a race/ethnic group in the lower categories
of socioeconomic status. Socioeconomic status affects access to health services,
nutritional status, immune status and function, educational level and employment
status, and cancer prevention attitudes, awareness, and practices. In turn,
all of these affect survival and ultimately mortality.
RISK FACTORS
Lower socioeconomic status, then, may be correlated with poorer survival
for cancer. It also is seen to be a factor in increased incidence of certain
types of cancer. These include lung, esophagus, stomach, and cervix. Other
major risk factors for cancer have been identified and will be discussed here.
These include tobacco, nutritional/dietary factors, occupational exposures,
and combined tobacco-alcohol consumption.
Scientific evidence accumulated over the last two decades indicates that
factors in the social and natural environments either cause the majority of
cancers or promote their development. This does not mean that host factors,
genetic or otherwise, are unimportant to the biology of neoplastic diseases
because most people who are similarly exposed to external risk factors do not
develop cancer. Host factors, such as nutritional and immune status, clearly
influence the biological response. It is estimated that the genesis of that
biological response may be triggered by environmental factors in approximately
80 percent of the cases. These factors, because they are environmental,
in principle are preventable.
The risk factors of greatest concern at this stage of scientific knowledge
are listed below:
• Tobacco. Smoking today causes more cancer than any other risk factor.
When combined with excess alcohol consumption, the risk from tobacco
is significantly enhanced. Smokeless tobacco use has also been associ-
ated V7ith causation of certain cancers.
• Nutrition. The relationship of diet to cancer is gaining rapidly in
importance. Nutritional and dietary factors may promote certain types
as well as protect against certain types of cancer.
• Occupational exposures. Exposures in the workplace carry significant
cancer risks. However, these risks are thought to be concentrated in
the "blue collar" population segments and, therefore, are potentially
of greater significance to minorities because of historic patterns In
employment practices.
Although these risk factors are, for the most part, discussed separately
in this section and the following sections relating to specific minority groups,
this separation is not an accurate representation of reality. Indeed, more
often than not, these risk factors occur in combination, and with detrimental
results, such as the following:
• Tobacco use is higher in blue collar workers. When it is combined
with agents in the workplace (such as asbestos) that interact with
tobacco, it creates additive or synergistic risks for lung and other
cancers.
• Alcohol Is a powerful solvent and may enhance body absorption of
carcinogens such as polycyclic aromatic hydrocarbons.
• Alcohol abuse may result in nutritional deficiencies that aggravate
cancer incidence and deter survival following treatment.
The interaction of many risk factors for cancer has two major implications:
(1) By initiating actions to prevent one factor, a number of other factors will
also be affected (the multiplier effect); but (2) it is difficult to address
each factor in isolation if the aim is to create effective cancer prevention.
TOBACCO
Cigarette smoking is responsible for 30 percent of all cancer deaths.
Nearly 90 percent of all lung cancers are caused by cigarette smoking.
Cigarette smoking also is a contributing factor in laryngeal, oral, esophageal,
bladder, pancreatic, kidney, and cervical cancers. Blacks have higher incidence
rates for the tobacco-related cancers of the lung, esophagus, pancreas, and
stomach. Survival for these particular cancers is poor, regardless of racial
or ethnic groups.
Smoking-related cancers seem to be particularly high among Blacks. Blacks
have higher prevalence rates for smoking than non-minorities and develop a
proportionately greater number of smoking-related cancers. Research shows
that, although more likely to be smokers, a smaller percentage of Blacks than
non-minorities are heavy smokers, and evidence pointing to the fact that
cigarette smoking is more easily modified among light smokers offers hope that
prevention efforts among Blacks might reduce this high prevalence rate. In
addition, although Blacks are less likely than non-minorities to be former
smokers, more Blacks than non-minorities indicate an interest in stopping
smoking. This finding of greater desire to stop smoking among Blacks is based
on a small sample. If accurate, however, it suggests that smoking cessation
efforts aimed at Blacks might have good potential to be effective.
Although Hispanics have lower rates of lung cancer and are generally
believed to have lower rates of smoking than Blacks or non-minorities, one
review of recent surveys suggests that smoking prevalence among Hispanic males
is at least as high as that of non-minority males. (Hispanic female smoking
rates are considerably lower than those of white females.) These findings
suggest that Hispanic rates for tobacco-related cancers may increase in the
future and that special attention to cessation and prevention efforts aimed
at this group is needed.
It is now established that smokeless tobacco use causes cancer. There is
evidence that use of smokeless tobacco products is growing, particularly
among young Americans. According to one regional study, American Indians may
be the highest users of smokeless tobacco. Although other minority groups
appear to be somewhat lower users of smokeless tobacco than non-minorities,
vigilance is required to ensure that they do not adopt higher levels of use
in the face of increased commerical enticements.*
ALCOHOL
Alcohol is estimated to be responsible for 3 percent of all cancer deaths.
Alcohol has been demonstrated in epidemiological studies to be an etiological
factor In cancers of the mouth, larynx, tongue, and esophagus.
Alcohol abuse appears to be correlated more with SES than with race. When
social class was controlled in one study, the quantity and frequency of alcohol
consumption among Blacks and non-minorities were found to be comparable. One
survey, however, observed a general difference between Black and non-minority
women, with Black women more likely than non-minorities to be either abstainers
or heavy drinkers. Similarly, Hispanics appear to be concentrated at the
extremes of the drinking scale distribution (i.e., more heavy drinkers and
abstainers than frequent light drinkers).
The exact way in which alcohol promotes cancer is unknown, but possible
mechanisms have been proposed by a number of investigators. These include:
• Local effects of alcohol on the upper gastrointestinal tract due to
direct contact with the agent.
• Direct effect of carcinogens present in alcoholic beverages.
• Induction of enzyme activities by alcohol in microsomes of the liver,
intestine, and lungs.
• Alcohol-induced liver injuries.
• Nutritional disturbances involving vitamins A, B, Bj, Bg, E, and C,
folic acid, iron, or minerals associated with chronic alcohol abuse.
ALCOHOL AND TOBACCO
Alcohol combined with tobacco use presents a risk for cancer. Epidemio-
logic data indicate that the combination of chronic alcohol consumption and
tobacco use substantially increases the risks of cancers of the oral cavity,
esophagus, and pharynx, though probably not of the lung. The cancer sites
for which tobacco and alcohol jointly are major determinants occur with
greater frequency in Blacks than non-minorities.
*Readers are referred to the following recent literature:
• Health Implications of Smokeless Tobacco Use. National Institutes of
Health, Concensus Development Conference Statement, Bethesda, MD. Jan 1986,
• lARC Monograph on the Evaluation Of The Carcinogenic Biology Of Chemicals
To Humans: Tobacco Habits Other Than Smoking, Betel-quid And Areca-nut
Chewings And Some Related Nitrosamines. Vol. 37, Lyon, Sept 1985.
• Winn, D: Tobacco Chewing and Snuff Dipping: An Association With Human
Cancer. In: N-nitroso Compounds: Occurrence, Biological Effects and
Relevance to Human Cancer. (O'Neill, I.K. et al , eds.) lARC Scientific
Publications No. 57. International Agency for Research on Cancer, Lyon,
1984.
Evidence points to an association between cigarette smoking and alcohol
consumption in general. It appears that the level of consumption of either
substance increases with the increased use of the other. Although several
theories exist, there is uncertainty regarding alcohol's role, the modifying
effects of tobacco, and the dose-response relationships among the two agents
in cancer causation,
NUTRITION
Dietary factors are thought to account for 35 percent of all cancer deaths.
The most important factors associated with cancer causation are total dietary
fat, alcohol, and N-nitroso compounds. Dietary factors which appear to have a
protective effect against cancer include fiber, vitamins such as A and C, and
minerals such as selenium and zinc.
Several mechanisms relating to cancer have been proposed, but the exact
nature of causation is not known. Studies have associated specific foods and
nutritional factors with risk to specific cancers, with some variance in the
strength of supporting data. The list below summarizes, by cancer site,
dietary and other risk factors found in nutritional studies related to specific
cancers.
• Esophageal: high alcohol intake, hot beverages, poor nutritional
status, smoking.
• Stomach: N-nitroso compounds; pickled, spiced, and smoked foods; low
socioeconomic status; smoking.
• Breast: total and saturated fat, cholesterol, fried foods, obesity.
• Endometrium: obesity, high fat consumption, hypertension, diabetes
mellitus.
• Prostate: "Western" diet, e.g., high fat consumption.
Found to be generally protective for cancers are fresh fruits and vegetables,
fiber, vitamin A, and vitamin C.
Research in the area of nutrition, diet, and cancer is important, but it is
difficult to conduct studies that yield conclusive results because of many
methodologic problems. Rigorous studies in the population groups that are the
subject of this report are lacking or nonexistent.
OCCUPATION
Occupational exposures are believed to account for 4 percent of overall
U.S. cancer deaths. Most epidemiological studies of occupational factors
associated with cancer risk have been studies of non-minority males. Limited
information is available on occupational factors associated with cancer in Blacks,
and because of major differences historically in social and employment patterns,
it would be improper to extrapolate from risks identified in non-minority workers
to those expected among Black workers.
Blacks entered the industrial workforce in large numbers in response to
improved employment opportunities during and following World War II. This
trend accompanied a migration of Blacks from the South to the industrial, urban
Northeast and mid-West, and later the western part of the nation. Studies of
these migratory populations to Ohio suggest that rising cancer rates, especially
for lung cancer, were associated with the migration and, hence, industrial
employment. At the same time, it was thought that the adverse conditions of
early life predisposed these workers to the effects of the carcinogenic exposures
experienced in the industrial workplaces.
Minorities are more likely to be excluded from selected Industries and
jobs, are more likely to start work at a lower entry level job (usually
unskilled), and are less likely to be promoted to jobs demanding more skills.
At least for Black workers these employment practices have resulted in quite
different exposure profiles, both in terms of a complete work history and
exposures incurred within a single industry. As a result, even if risks for
the same occupational or exposure group are assessed, a comparison between
non-minority and Black workers is likely to be confounded by different ex-
posure experiences that precede and follow the specific industry or occupation
of interest.
Findings of cohort mortality studies reporting risks by race and occupation
or exposure within race subgroups indicate that differences in risk are apparent
between non-minorities and minorities for selected occupations. One study of
steel industry workers suggests that the higher lung cancer risk among Blacks
has resulted from a higher concentration of Blacks in high-risk jobs. Other
occupations where studies have found higher cancer rates among minorities in-
clude dye manufacturing and the rubber industry.
KNOWLEDGE, ATTITUDES, AND PRACTICES
The available scientific literature about cancer-related knowledge, attitudes,
and practices (KAP) among minorities is scant. Sample sizes in the two existing
national studies on Blacks and non-minorities are too small to provide meaningful
comparisons, and studies of Blacks and non-minorities in specific locales may
identify differences that are peculiar to a specific geographic area. These
potential problems should be considered in interpreting the points discussed
below.
In general, Blacks and Hispanics tend to know less about cancer than non-
minorities, although the differences vary depending on specific cancers,
screening, tests, etc. One national survey (EVAXX, Inc.) reported that Blacks
tend to underestimate the prevalence of cancer and that their knowledge of
warning signs is lower than that of non-minorities. The National Breast Cancer
Survey indicated that Blacks are closer to non-minorities in their knowledge of
breast self-examination (BSE) than they are to Hispanics, almost 25 percent of
whom had never heard of BSE. A telephone survey of Illinois residents found
Blacks to be less aware than non-minorities of specific cancer tests, including
the Pap smear, BSE, proctoscopy, and prostate palpation.
The EVAXX survey found that Blacks also tend to be more pessimistic than
non-minorities about their chances for survival should they develop cancer.
Blacks tend to be more fatalistic and less likely to believe that early detection
makes a difference and that existing treatments are effective. A substantial
proportion of Blacks (25 to 50 percent in some cases) accept many of the
common myths (e.g., bruises cause cancer) as fact.
Hlspanics in the National Breast Cancer Survey's purposive sample per-
ceived themselves as more likely to contract cancer some day than did non-
minorities. Hlspanics also tended to believe that breast cancer would affect
sexual and social relationships much more than non-minorities or Blacks. On
the other hand, more Blacks in the national sample believed that breast cancer
would affect their ability to do strenuous housework than non-minorities did.
The Illinois telephone survey found that, despite virtually equal access
to general physical examinations. Blacks were likely to obtain fewer screening
tests, which suggests potential differences in quality of care even when
access is equal.
Generally, findings from these surveys suggest that differentials in KAPs
seem to exist between minorities and the general population, but that these
differentials are not uniform across minority groups or across specific cancer
topics.
The exact relationship of differences in KAPs between minorities and the
general population and their subsequent effect on cancer incidence, morbidity,
and mortality rates is suggestive but speculative. For example, the marked
difference in cancer survival between Blacks and non-minorities is well
established. Available data on KAPs suggest similar differences. However, it
is not known if participation in regular gynecologic screening by Blacks at the
same rate as non-minorities would eliminate the current survival differences.
Further, it is not specifically known which of the differences in KAP measures
have any real impact on cancer rates. For example, does the belief among some
Blacks that breast cancer affects their ability to do strenuous housework also
affect their utilization of breast self-examination and mammography and, in
turn, does this result in poorer survival from breast cancer? These interactions
across KAP measures are likely to be highly variable, and their full complexity
is not well explored.
Current levels of KAP are related to demographic differences, both between
minorities and the general population and within each minority group itself.
A study of participation in Pap smear screening by Blacks in Buffalo, New York,
found an Inverse relationship between age and participation in Pap testing, a
finding consistent with many earlier studies. Education was clearly related to
Pap testing behavior, but two common measures of socioeconomic status, source
of Income and occupation, were not related to either number or recency of Pap
testing.
There is a strong connection between social status and KAPs. For example,
to the extent that minorities are overrepresented in low SES groups, they will
evidence KAP consistent with that condition. It has been shown that low SES
individuals are generally less knowledgeable about disease and health status,
are often hard to recruit to screening and other health service programs, and
often delay seeking medical care in the presence of symptoms. On the other hand,
cultural Influences also have been shown to influence the beliefs and acceptance
of preventive services. Basic Issues about health KAP of various minorities
are beginning to emerge and call into question some of the stereotyping that
10
may have occurred in the past. For example, are low-income Blacks more like
low-income non-minorities in their health and cancer-related KAP than they
are like middle- or upper-income Blacks?
DEMOGRAPHY
This section discusses the demographic characteristics of Blacks, Hispanics,
Asian/Pacific Islanders, and American Indians. Demographic profiles include
population characteristics such as regional distribution, median age, family
size, median family income, and education.
Although Blacks represent the largest U.S. ethnic minority group, the most
dramatic increases in population are for Asian/Pacific Islanders.
Similarities in regional distribution between Blacks, Hispanics, and
Asian/Pacific Islanders, with the majority residing in central cities, are in
contrast to the American Indian/Alaska Native population, who reside primarily
in 11 of the 28 reservation states.
For American Indians, the birth rate is almost twice that of all U.S.
racial/ethnic groups, except Hispanics, and life expectancy is 6 years less.
Birth rates for Blacks are also increasing. In contrast to American Indians,
however. Blacks are living longer, narrowing the gap between life expectancy
for non-minorities and Blacks.
Among American Indians, the median age of 22.4 is lower than the median
age of all U.S. racial/ethnic groups, except Puerto Ricans and Mexican Americans,
and the average number of persons per family for American Indians is 4.6 compared
4o 3.8 for all groups. A higher proportion of Black families have a significantly
lower median income which falls below the poverty level.
Asian/Pacific Islanders show the most substantial increase in educational
attainment compared to non-minorities but represent higher percentages in
service occupations compared to non-minorities. Unemployment rates are lower
for Asians (4.7 percent) in comparison to the U.S. unemployment rate of 6.5
percent in 1980 and higher for Blacks (approximately 14% in 1980), revealing
double the unemplojmient rate for non-minorities.
HEALTH SERVICES PATTERNS
The crucial question in examining health services patterns is whether
improvements in the health care system would have a major impact in reducing
morbidity and mortality in special populations. It is unclear whether the
differences in health outcomes and access to health information and health
services are due to factors other than race or ethnic backgrounds. The key
issue concerns the role that the health services system may play in elimi-
nating differences in mortality and morbidity rates among non-minorities and
Blacks, Hispanics, and other minority populations.
Blacks experience higher rates of morbidity and mortality than non-
minorities from major illnesses such as cancer. Because Blacks and other
minorities have higher rates of unemployment, they tend to have less continu-
ous and/or more limited health insurance coverage. This inhibits health
11
services utilization. Also, lower Income individuals are less likely to have
a private physician as a usual source of medical care and are less likely to
receive preventive health care screening.
12
BLACKS
In 1980, the Black population in the United States was 26.5 million, an
increase of 17.3 percent over 1970. Blacks comprised about 12 percent of the
total U.S. population in 1980. Blacks have the highest overall age-adjusted
cancer rates for both incidence and mortality of any U.S. population.
For cancer incidence, the SEER (Surveillance, Epidemiology, and End Results)
data, 1973-81, show a 10 percent excess incidence of cancer among Black Americans
compared to non-minority Americans. Excess incidence is particularly pronounced
among Black males. The incidence rate is 25 percent higher among Black males
compared to non-minority males. Cancer rates among Black females are 4 percent
lower than those for non-minority females. The overall trend in incidence
for all cancers combined suggests an increase for the total population. The
rate of increase for Blacks, however, is much higher. Between 1973-77 and
1978-81, non-minorities showed a 2 percent increase while the Increase for Blacks
was 7 percent. The greatest increase was among Black males, with a 10 percent
Increase; while non-minority males had a 4.3 percent increase, non-minority
females experienced a slight (0.4 percent) decrease and Black females had a
3.3 percent increase.
Blacks also experience excess cancer mortality. The overall cancer mortality
rate among Black and non-minority females is about the same, but Black males had
an 11 percent excess compared to non-minority males according to the SEER data
through 1981. Black males had the largest increase (8 percent) in cancer mortality
between 1973-77 and 1978-81. Non-minority women have the lowest increase (2 per-
cent). Until the early 1950's, reported U.S. cancer mortality rates for Blacks
were lower than those for non-minorities among both males and females. However,
over the past three decades, cancer deaths among Black males have risen even
faster than those for non-minority males; rates for Black females have remained
steady; and rates for non-minority females have declined slightly. From 1955
to the present, the highest U.S. mortality rates have occurred among Black males,
followed by non-minority males. Black females, and non-minority females.
Although the rise in cancer mortality rates for U.S. males from 1915 to
1975 may be partially a result of improved reporting for causes of death, many
experts feel that it also represents a true increase in the number of cancer
deaths. During this period, there also has been a continuing decrease in
mortality for all races by other causes such as heart disease and infectious
diseases. Exposures to carcinogenic agents including smoking and tobacco use
has also increased.
Another factor contributing to the increase in cancer mortality among both
non-minority and Black males may be due in part to a shift to occupations that
entail greater exposures to carcinogenic agents. This has been clearly demon-
strated for Black workers in certain occupational categories including those
assigned to coke ovens in the U.S. steel industry. Also during the 1940's, a
large rural to urban migration began among Blacks brought about increased
individual exposures to environmental factors now known to be associated with
cancer.
13
EXCESS MORTALITY AND INCIDENCE
Sites of excess mortality in the Black population include lung, esophagus,
stomach, pancreas, prostate, cervix, and corpus uteri. Mortality and incidence
data for these sites are discussed below by site.
Lung
Black males experienced a 45 percent excess death rate compared to non-
minority males. The death rate among Black and non-minority females is about
the same. A large increase in the lung cancer death rate occurred among all
females between 1973-77 and 1978-81. High lung cancer mortality rates for
Blacks are matched by excess incidence, which is expected to rise even more in
the future. It is estimated that there will be a 31.8 percent increase in lung
cancer incidence among Black males compared to a 20.7 percent increase in non-
minority males from 1980 to 1990. Among women, it is estimated there will be
a 98.6 percent increase in lung cancer incidence among Black females compared
to an 86 percent increase among non-minority females between 1980 and 1990.
Similar increases in mortality rates for lung cancer can be anticipated.
Cigarette smoking is a major cause of lung cancer, with fully 90 percent
of lung cancer deaths being related to cigarette smoking. Survey data indicate
that the prevalence of smoking is greater among Blacks than non-minorities.
Most of this difference is due to the high smoking rates of Black males rather
than Black females. Other factors predisposing an individual at increased risk
for lung cancer include lower socioeconomic status and residing in an urban
rather than a rural setting. Occupational exposure to a variety of elements
including asbestos, polycyclic hydrocarbons, and chromium is an additional
risk. One dietary factor associated with lung cancer incidence is a low
level of vitamin A intake.
Esophagus
For cancer of the esophagus, excess mortality is pronounced among Blacks,
particularly among Black males. For this group, mortality is 3 times higher
than for non-minority males. Mortality rates among Black women are 2.5 times
higher than for non-minority women. Age-adjusted incidence rates for esophageal
cancer are correspondingly high: 3.5 times higher for Black men compared to
non-minority men, and almost 3 times higher in Black women than non-minority
women. Urban Blacks appear to be more likely to develop esophageal cancer than
rural Blacks.
Major risk factors for cancer of the esophagus include alcohol intake and
tobacco use (both smoking and chewing). One study of Washington, D.C. Blacks
identified the major factor responsible for excess deaths from esophageal cancer
to be alcoholic beverage consumption and nutritional deficiencies. While it is
not possible to generalize the findings of this small, localized study based on
death certificates, it does support the general concept of alcohol consumption
as a major factor in increasing the risk for esophageal cancer.
Both cigarette smoking and alcohol consumption have been shown to be
etiologic factors in cancer of the esophagus. In combination the two represent
an additional risk. The exact role of these factors and the dose-response
relationship betvreen the two are not known. Regardless of this lack of infor-jj
14
mation on the specific nature of the interaction, epidemiologic data indicate
that the combination of chronic alcohol and tobacco consumption substantially
increases the risk of cancer of the esophagus.
Other factors associated with increased risk for cancer of the esophagus
include exposure to radiation and to asbestos. A possible dietary factor is
consumption of hot food and drink or thermal irritation.
Prostate
Prostate cancer is the most common cancer among U.S. males. Mortality and
incidence rates for prostate cancer are higher among Blacks than non-minorities.
Death from prostate cancer is two times higher among Black males than among
non-minority males. The death rates increased by 11.8 percent among Blacks and
only 4.2 percent among non-minorities between 1973-77 and 1978-81. Incidence
data show that Black males have a 60 percent excess incidence of prostate cancer
compared to non-minority males in the United States. The reported incidence
and mortality from prostatic cancer among Black males has risen sharply over
the past 3 decades. Between 1973-77 and 1978-81, there has been a 10 percent
increase in these incidence rates for both Black and non-minority males. Age-
specific incidence and mortality rates for prostate cancer are higher in all
age groups for Blacks than non-minorities.
The causes of prostate cancer are unknown, but incidence varies according
to familial aggregation and whether an individual has ever married. High con-
sumption of fat may play a role in the risk of developing this cancer. Some
studies have suggested that the hormone testosterone may also play a role in
the development of prostatic cancer. At least one occuoatlonal hazard, cadmium,
has been suggested as a risk factor. Because the causes of prostate cancer
are unclear, the reasons for this excess among Black males are equally unclear.
Stomach
Mortality from stomach cancer is more than 1.5 times greater among Blacks
than non-minorities. Mortality rates for both groups have decreased during the
time period 1973-77 and 1978-81, with non-minorities experiencing an 11 percent
decrease in death from stomach cancer, while the decrease for Blacks was lower,
only 6 percent. Stomach cancer incidence is almost twice as high among Blacks
compared to non-minorities. Moreover, between 1973-77 and 1978-81, the in-
cidence decreased by 6, 7, and 4.5 percent among non-minority males, non-
minority females, and Black females, respectively. Incidence, however, did
not decrease during this time period for Black males, who instead showed a
3.4 percent increase in the incidence of stomach cancer.
Lower socioeconomic status has been correlated strongly with increased
rates of stomach cancer. As in many other cancers, tobacco and alcohol use
have been implicated in stomach cancer, as has dietary intake of salty foods.
N-nitroso compounds, as found in foods, the environment, and the workplace
(asbestos) have been Implicated. Foods rich in ascorbic acid seem to be pro-
tective against stomach cancer.
15
Cervix
Both mortality and incidence rates for cervical cancer are 2.5 tines
higher among Black females than non-minority females. Between 1973-77 and
1978-81, cervical cancer incidence rates for both groups increased about 20
percent. Mortality rates in this period went down for non-minorities but not
for Blacks. Non-minority females showed a 20 percent decrease in cervical
cancer deaths between 1973-77 and 1978-81, while Black females experienced a
27 percent increase during this same period.
Cervical cancer is one of the most extensively studied cancers and yet
no clear causes have been found. A number of risk factors have been suggested,
including recent data linking papilloma virus as a possible cause of this
disease. The major risk factors suggested for all women are multiple sex
partners and early age at first intercourse.
Corpus Uteri
Black females experienced a 33 percent excess death rate from cancers of
the corpus uteri compared to non-minority females. Over the period 1973-81,
non-minority females showed a 10.5 percent increase in death from cancer of
the corpus uteri and Black females showed a 3.4 percent increase. Blacks have
lower incidence than non-minorities.
Cancer incidence for corpus uteri has been associated with higher socio-
economic status and nulliparity along with early menarche and older age at
menopause. Additional risk factors include diabetes mellitus, obesity, and
hypertension.
EXCESS INCIDENCE
Increased incidence among Blacks has been noted for the following cancers:
multiple myeloma, pancreatic cancer, and laryngeal cancer, as well as where
noted in discussions of cancer for which excess mortality rates are known to
exist.
Multiple Myeloma
The incidence of multiple myeloma is more than twice as high for Blacks
than for non-minorities. The incidence for Black males is 9.6 per 100,000 and
for Black women it is 6.7. The rate for non-minority males is 4.3 and for non-
minority females it is 3.0.
Several preliminary studies have linked occupational exposures, ionizing
radiation, immune competence, and genetic susceptibility with increased risk
for the development of multiple myeloma. At the present time, none of the
studies offer any conclusive evidence for the causes of multiple myeloma. Risk
factors associated with race and gender have yet to be identified.
16
Pancreas
The Incidence of pancreatic cancer among Blacks is 1.5 times higher than
for non-minorities. During 1973-77 and 1978-81, Black males showed an increase
in the incidence of pancreatic cancer. This type of cancer is more common
among males than females, among older persons, and among those who are not
married. Excess risk has been found among cigarette smokers and some studies
have linked diabetes mellitus with the risk of developing pancreatic cancer.
Larynx
The incidence rate is 1.5 times higher for cancer of the larynx among
Black males and 1.3 times higher among Black females compared to non-minority
males and females, respectively. The greatest increase in incidence between
1973-81 was found for non-minority females (23 percent) followed by Black
females (11.1 percent) and Black males (8.7 percent). Only a slight increase
occurred among non-minority males (1.2 percent). Risk factors include combined
tobacco and alcohol use.
SURVIVAL EXPERIENCE
Survival Experience for Blacks
According to data derived from the Surveillance, Epidemiology, and End
Results (SEER) program of the National Cancer Institute, the 5-year overall
relative survival rate for 1976-81 was 50 percent for non-minorities and 38
percent for Blacks — a difference of 12 percentage points. There are striking
differences in Black/non-minority survival for cancers of certain sites from
1976-81, as shown below.
5-Year Relative Survival
Cancer Site Black Non-minority Difference Black/Non-minority
Breast 63% 75% 12%
71 10
86 31
74 20
49 12
Of the 25 primary cancer sites for which survival data were available.
Blacks had higher 5-year relative survival rates for three sites (1973-81) —
ovary, brain, and multiple myeloma — all relatively low incident cancers with
only small percentage point advantages in Blacks.
When comparing survival rates for 18 selected cancer sites between 1973-75
and 1976-81, 5-year relative survival improved in Blacks for all sites but three;
survival for cancer of the pancreas and cancer of the breast remained the same;
and survival for corpus uteri cancer decreased by 4 percentage points.
17
Prostate
61
Corpus Uteri
55
Bladder
54
Rectum
37
Survival by Stage
Black/non-minority survival within primary cancer stage for selected cancer
sites is of interest, although the sample of Blacks for many sites is too small
in certain stage categories to present reliable information from which to draw
conclusions. For all stages combined, Black patients had significantly lower
survival than non-minorities for several cancer sites. However, these differ-
ences tend to decrease within individual stage categories for a number of cancer
sites. This is due to the greater distribution of lower stages (less advanced
cancers) in non-minority patients. Highlights of Black survival by stage are
reviewed below.
• Survival for uterine corpus cancer showed the greatest difference in
stage-specific survival between the Blacks and non-minorities. The
stage I disease difference (92 percent non-minorities versus 75 percent
Blacks) was statistically significant. The distribution of Black
patients in other stage categories was too small to make reliable con-
clusions.
• Black patients had better survival rates than non-minorities for ovarian
cancer for all stages combined and also within each stage category.
• The breast cancer survival difference (Blacks, 63 percent; non-minorities,
75 percent) was statistically significant. This was related to the large
number of Blacks who had lymph node involvement or direct extension of
tumor to adjacent tissue at the time of diagnosis (stage III B).
• The difference in 5-year relative survival for Blacks and non-minorities,
for all stages combined (Blacks, 37 percent; non-minorities, 49 percent)
for rectal cancer was statistically significant. The same is true for
the Black and non-minority survival difference for all stages combined
for colon cancer (Black, 47 percent; non-minority, 53 percent) and
bladder cancer (Black, 54 percent; non-mlnorlty , 74 percent).
FACTORS CONTRIBUTING TO POORER SURVIVAL IN BLACKS
Among the primary factors in survival to be considered are: socioeconomic
status, stage at diagnosis (late), delay in detection and treatment, treatment
differences, and biologic/constitutional factors.
Much of the scientific literature to date supports a hypothesis that the
differences in cancer survival between non-mlnorltles and Blacks are attrib-
utable to social or environmental factors rather than inherent genetic or bio-
logic deficits. Emerging theory suggests that distribution of resources (for
example, health services behavior) can affect cancer outcome, e.g., survival.
The Black/non-minority difference does not seem to be based on race/ethnic
origin but rather on socioeconomic status and the overrepresentation of a
race/ethnic group in the lower categories of socioeconomic status.
Socioeconomic status has major ramifications, including accessibility,
availability, utilization, distribution, and delivery of health services. These
health services Include state-of-the-art cancer screening, detection, treatment,
and rehabilitation services; nutritional status and dietary patterns; immune
status and function; education level/attitude and awareness of cancer preventive
concepts/behaviors; and acceptance of cancer as a real and potential threat.
Cancer patient survival studies Indicate that when adjustments are made
for stage at diagnosis, survival differences decrease for certain cancers
between Blacks and non-minorities, but when adjustments for socioeconomic status
are made, the gap between the two groups is further reduced. Further support
for the hypothesis that socioeconomic status affects cancer survival is shown in
studies where non-minority patients' survival was examined according to socio-
economic status. These studies found the survival experience of indigent
patients to be worse than that of non-indigent patients when type of cancer
care was held constant.
A study of Black and non-minority cancer patients from a VA hospital
showed that there was no difference (except for bladder cancer) in survival
betv/een the two groups because they received the same type of cancer care.
For cancers of the bladder and corpus uteri, blacks experience signifi-
cantly lower survival rates than whites and have higher distributions of more
aggressive histologic types of cancer.
KNOWLEDGE, ATTITUDES, AND PRACTICES
The body of knowledge about Blacks' cancer-related knowledge, attitudes,
and practices (KAP) is scant. Those studies that have been conducted generally
involve such small samples that they should be viewed with caution, but may
still provide an indication of potential cancer-related KAP among Blacks and
the relation of these to those of non-minorities.
In general, Blacks tend to know less about cancer than non-minorities
although differences vary depending on specific cancers, tests, etc. One study
reports that Blacks tend to underestimate the prevalence of cancer and that
their knowledge of warning signs is lower than non-minorities. In addition.
Blacks were reported to be more pessimistic than non-minorities about their
chances for survival should they get cancer. They also tend to be more fatal-
istic and are less likely to believe that early detection makes a difference
and that existing treatments are effective. A substantial proportion of Blacks
(25 to 50 percent in some cases) were reported to accept many of the common
myths (e.g., bruises cause cancer) as fact. This study also found that Blacks
are less likely to report seeing a physician in response to symptoms than are
non-minorities.
Information for one specific cancer-related behavior, cigarette smoking,
is of special interest. The prevalence of cigarette smoking is greater among
Blacks than among non-minorities. This difference is due largely to the high
smoking rates of Black males rather than Black females. Although they are more
likely to be smokers. Blacks are less likely than non-minorities to be heavy
smokers (25 or more cigarettes per day). While non-minorities are more likely
than Blacks to be former smokers, one 1980 survey found that more Blacks than
non-minorities were Interested in stopping smoking.
19
CONCLUSION
Blacks experience greater incidence rates than non-minorities for cancers
of the esophagus, pancreas, stomach, cervix, prostate, and larynx. Excess
mortality exists for cancers of the following sites: esophagus, stomach, lung,
cervix, corpus uteri, bladder, and prostate. Poorer survival occurs for many
cancers and is marked for cancer of the breast, corpus uteri, bladder, prostate,
and rectum. Excess incidence and mortality is particularly pronounced among
Black males.
Where there is excess mortality or Incidence in Blacks, many cancers are
related to similar risk factors including tobacco, tobacco and alcohol combined,
occupation, and dietary patterns and nutritional status. These risk factors are
also significant for other illnesses including cardiovascular, cerebrovascular,
pulmonary, and other diseases.
Certain exposures in the workplace Impact significant cancer risk. However,
these risks are thought to be concentrated In the "blue collar" population
segments and are, therefore, potentially more significant to Blacks because of
historic patterns in emplojonent practices. Due to past employment practices
and socioeconomic factors in general. Black workers are disproportionately
represented in unskilled positions that may have the greatest exposure potential
to carcinogens.
A number of the cancers that occur at greater rates in Blacks are uniformly
fatal regardless of ethnic group. However, Blacks generally present at later
stages for cancer diagnosis than non-minorities. Once diagnosed. Blacks delay
as much as 3 to 12 months before seeking definitive treatment.
SEER data Indicate that the overall 5-year relative survival rate for
1976-81 was 50 percent for non-minorities and 38 percent for Blacks, a 12
percentage point difference. Of the 25 primary cancer sites for which survival
data are available. Blacks had better (only by a few percentage points) 5-year
relative survival for three sites (1973-81) — ovary, brain, and multiple myeloma
— all relatively low incident cancers.
Factors to be considered as contributing to poor cancer survival in Blacks
include socioeconomic status, later stage at diagnosis, delay in detection and
treatment, treatment differences, and biologic/ constitutional factors.
In general, Blacks tend to know less about cancer than non-minorities
although differences vary depending on specific cancers, screening test, etc.
One study reports that Blacks tend to underestimate the prevalence of cancer
and that their knowledge of warning signs is lower. Blacks were also reported
to be more pessimistic than whites about their chances for survival should
they develop cancer. Many Blacks were reported to accept common myths about
cancer as fact.
20
HISPANICS
In 1980, the 14.6 million U.S. Hispanics (an increase of 61 percent over
1970) represented 6.4 percent of the total population. When discussing the cancer
experience in Hispanics, it is important to remember that the Hispanic population
within the United States is diverse. Sixty percent of the 1980 Hispanic category
were of Mexican descent (9 million). The remainder of the Hispanic population
was represented by 2 million of Puerto Rican origin, fewer than 1 million of
Cuban origin, and 3 million originating in other Hispanic areas of the Caribbean
or Central or South America. Although these groups are frequently aggregated in
statistical analyses, specific differences exist among the groups in terms of
socioeconomic status, cancer experience, and cultural heritage. Further analysis
of existing data is necessary to accurately present the cancer experience of
subgroups. If population growth among Hispanics continues as expected, cancer
among members of this population will become of even greater importance in health
planning efforts.
Cancer-related statistics are available from SEER data for three Hispanic
subpopulations — Hispanics in Puerto Rico, San Francisco, and New Mexico. Thus,
the Hispanic cancer rates in this report are not representative of the various
U.S. Hispanic populations nor their geographic distribution. This should be kept
in mind when interpreting comparisons with U.S. groups. Overall age-adjusted
incidence rates for Hispanics from New Mexico and Puerto Rico are lower than for
Blacks or non-minorities. SEER age-adjusted incidence data for 1978-81 indicate
that Hispanics have an overall age-adjusted cancer incidence rate of 246.2 per
100,000 compared to 335 for non-minorities and 372.5 for Blacks. Overall incidence
rates for New Mexico and Puerto Rico are considerably lower than those for non-
minorities. However, an overall upward trend in incidence appears for New Mexico
males and Puerto Rico males and females.
EXCESS INCIDENCE (Mortality data on Hispanics are not available.)
Specific sites of excess incidence among Hispanics are the stomach, esophagus,
pancreas, and cervix. Stomach cancer incidence in Hispanics is twice that of
non-minorities. While stomach cancer is higher for most minority groups, a
downward trend exists for all U.S. groups except New Mexico Hispanic females and
American Indian males. Stomach cancer incidence has been correlated with diets
high in smoked, pickled, and spiced foods, especially those high in N-nitroso
compounds. Tobacco use also has been implicated in stomach cancer development.
While the incidence of prostate cancer is slightly higher among New Mexico
Hispanic males than among non-minorities (2 percent) in the U.S. population, it
is lower than New Mexico Anglos. Although the excess incidence is not great, it
represents a 40 percent increase over earlier figures, four times the increase
among non-minorities during the same period. Puerto Rican males, with lower rates
than non-minorities, showed an upward trend that was slightly higher than that
of non-minority males. Although the causes of prostate cancer are unknown,
suggested risk factors include environmental influences such as diets high in fat
and low in green or yellow vegetables, the hormone testosterone, and occupational
exposures in the rubber industry.
21
Incidence of esophageal cancer Is 20 percent higher among New Mexico
Hispanic females. Studies suggest a link between the development of esophageal
cancer and smoking and alcohol consumption with these two having a synergistic
effect. Other suggested risk factors include poor nutritional status and
drinking hot beverages.
New Mexico Hispanics have rates of cancer of the pancreas that are higher
than those of non-minorities. Excess risk for this cancer has been found
among cigarette smokers.
Cervical cancer is twice as high among Hispanics in New Mexico and Puerto
Rico as non-minorities. The incidence among Hispanics is, however, lower than
that for Blacks, American Indians, and Chinese-Americans. Recent studies have
suggested the papilloma virus as a possible cause of cervical cancer. Major
risk factors are multiple sex partners and early age of first intercourse.
SURVIVAL
Survival data on Hispanics are derived mostly from New Mexico and San
Francisco Hispanics. The overall 5-year relative survival rate in Hispanic
males is almost identical to that of non-minorities. Hispanic females have
somewhat lower survival rates than non-minority females. Survival data are
similar for Hispanics and non-minorities for all but three sites. These are
bladder cancer and Hodgkin's disease, where survival is poorer among Hispanics,
and ovarian cancer, where survival is poorer among non-minorities.
Data were not available from Puerto Rico when this report was prepared.
A preliminary study of Puerto Rico's survival data suggests that survival
experience for this population is smiliar to that of U.S. Blacks, which is
12 percentage points below non-minorities, but further analysis of these data
are required.
KNOWLEDGE, ATTITUDES, AND PRACTICES
Information on cancer-related knowledge, attitudes, and practices among
Hispanics is limited. Smoking rates among Hispanics are considered to be lower
than for Blacks or non-minorities, but a review of recent surveys suggests that
prevalence among Hispanic males is as high as that of non-minority males. Also,
recent marketing efforts in the Southwest aimed at encouraging tobacco use may
result in increased smoking among Hispanics.
In general, Hispanics tend to know less about cancer than do non-minorities.
One small purposive sample (417) of Hispanic women within a larger survey on
breast cancer found the Hispanic women to be less informed than non-minorities
about breast cancer. Hispanic females were much less aware than non-minorities
of family history as a risk factor for breast cancer. Only 25 percent of
Hispanic females had heard of breast self-examination. Hispanics in this pur-
posive sample perceived themselves as being more likely to believe that breast
cancer would affect sexual and social relationships. Information from this
small sample cannot be generalized to the Hispanic population.
22
CONCLUSIONS
The Hispanic population in the United States is diverse and includes
individuals of Puerto Rican, Mexican, and Cuban descent as well as individuals
from the Caribbean or South America. The cancer experience among these groups
varies widely.
SEER data are available for Hispanics in Puerto Rico and New Mexico.
Overall age-adjusted incidence rates for Hispanics are lower than those for
Blacks or non-minorities. However, an overall upward trend in incidence appears
for New Mexico males and Puerto Rico males and females. Specific sites of excess
incidence among Hispanics are the stomach, prostate, esophagus, pancreas, and
cervix.
Mortality data are not available for Hispanics. Hispanics have particularly
high incidence of stomach cancer. The rate for stomach cancer is higher for
Hispanics than for Blacks and almost double that for non-minorities. Cervical
cancer is twice as high among Hispanics as non-minorities. The incidence among
Hispanics is, however, lower than that for Blacks, American Indians, and Chinese-
Americans.
The overall 5-year relative survival rate of Hispanic males is almost
identical to that of non-minorities. Hispanic females have somewhat lower sur-
vival rates than non-minority females. Survival data are similar for Hispanics
and non-minorities for all sites except bladder cancer and Hodgkin's disease,
where survival is poorer for Hispanics, and ovarian cancer, where it is poorer
for non-minorities.
23
ASIAN/PACIFIC ISLANDERS
According to the 1980 census, the Asian/Pacific Islander population was
3.5 million in size, more than double that of the 1970 census. If the present
upward trend continues, an even greater increase in this population is expected
by 1990. This population growth may have implications for future U.S rates of
certain types of cancer known to be prevalent among Asians, including refugees,
thus impacting the health care system and requirements for future health surveil-
lance and planning.
The U.S. Asian/Pacific Islander population is diverse, with several sub-
groups existing within this larger population. These groups may have different
cultures, languages, and different cancer experiences. Subpopulations are
identified primarily by country of origin, but length of residence in the U.S.
and whether native or foreign born are also important factors in the diversity
of the Asian/Pacific Islander populations. In terms of country of origin,
Chinese-Americans are the largest subpopulation among Asians, followed by
Filipinos and Japanese. Overall, three-fifths of the Asian/Pacific Islander
population are foreign born. The proportion of foreign born is relatively
small among Japanese and higher for Chinese and Filipinos.
This section will focus primarily on four subpopulations with the larger
group of Asian/Pacific Islander for which certain data on cancer experience are
available. These are Americans of Chinese, Japanese, Filipino, and Hawaiian
descent. Although rates for Hawaiians are provided here, these should be inter-
preted with caution because the small population base from which they are drawn
may artifically inflate rates.
Cancer incidence varies widely among the four Asian/Pacific Islander sub-
populations for which statistics are available. Hawaiians have an overall age-
adjusted cancer incidence rate of 357.9 per 100,000 (second highest of any
American population), lower than Blacks at 372.5 per 100,000 and higher than
non-minorities at 335 per 100,000. Three Asian American groups have incidence
rates at least 100 points below those of Hawaiians. The rate for Chinese is
252.9, for Japanese it is 247.8, and for Filipinos it is 222.4. These three
groups also have lower incidence than that of non-minorities. Among Chinese and
Japanese, rates for males are higher than those for females, with Chinese rates
being 293.8 for males and 230.3 for females while those for Japanese are 225.5
for males and 210.1 for females. There is, however, an upward trend in incidence
rates for both sexes of the Chinese population with a 3.2 percent increase for
males and a 0.4 percent increase for females, and for Japanese males where the
increase is 2.2 percent for the period 1973-81.
EXCESS MORTALITY AND INCIDENCE
• Among Asian/Pacific Islanders, excess mortality is found among Japanese-
Americans for stomach cancer and Chinese-Americans for cancer of the cervix and
for nasopharyngeal cancer. Hawaiians have excess mortality for cancers of the
breast and lung.
24
The mortality rate for stomach cancer among Japanese-Americans is higher
than for any other Asian group. The standard rate ratio for stomach cancer in
Japanese-Americans is the highest of any other Asian group for this type of
cancer.
Stomach cancer mortality for Japanese-Americans is higher for both sexes
than the rates for non-minorities. These mirror the excess incidence rates
found among Japanese of both sexes, where incidence is 2.5 times higher for
Japanese males and 3.8 times higher for females than for non-minority males
and females. A general downward trend in incidence for most minority groups,
including the Japanese, has been noted. Stomach cancer has been correlated with
smoking tobacco and with consumption of smoked, pickled, and spiced foods,
especially those high in nitrate.
Migratory studies of Japanese point to environmental influences, in this
case primarily dietary practices, in three major cancer sites: stomach, breast,
and colon. Stomach cancer incidence and mortality rates in Japan are quite high.
Incidence rates for Japanese living in Hawaii are lower than for those in Japan,
and lower still for Japanese living on the U.S. mainland. For breast and colon
cancers, Incidence is higher among Japanese living on the U.S. mainland than for
those in Hawaii or Japan. Again, incidence among Japanese in Hawaii is between
that of those on the mainland or in Japan, in this case higher than in Japan
and lower than on the mainland. Dietary practices are believed to influence
the differences among the three groups, with incidence falling for stomach
cancer and rising for breast and colon cancers as migrating Japanese adopt a
"western" diet.
Chinese-Americans have excess mortality rates for cervical cancer. The
mortality rate for this group is three times that of non-minorities. In terms
of age-adjusted incidence, Chinese Americans have a cervical cancer rate of 11.2
compared to 8.8 for non-minorities. Japanese females are the only U.S. minority
group that does not have cervical cancer incidence rates above that of non-
minorities. However, both Chinese and Japanese females exhibit a trend toward
higher rates. The cause of cervical cancer is still unknown, but major risk
factors include multiple sex partners and early age at first intercouse. Recent-
ly, the papilloma virus has been suggested as a possible cause.
Chinese-Americans have unusually high incidence and mortality rates for
nasopharyngeal cancer, which is an extremely rare cancer. One literature review
of all countries for which cancer registries exist found an average incidence
rate of less than 1 per 100,000. Nasopharyngeal cancer age-adjusted incidence
rates greater than 5 per 100,000 were reported only for these areas or popula-
tions: San Francisco Bay Area Chinese (19.1 for males, 7.1 for females),
Singapore Chinese (18.7 for males, 7.1 for females), and Hawaii Chinese (10.3
for males, 5.1 for females). Although data for China and Taiwan were not
available for review, rates of nasopharyngeal cancer are known to be high in
those countries as well.
Research into the high rate of nasopharyngeal cancer points to both genetic
and environmental factors. Chinese have been known to have a genetic suscepti-
bility to this kind of cancer. In addition, they have a high rate of exposure
25
to chemical agents formed from Ingestants that are popularly consumed in the
folk diet. The Epstein-Barr virus may also be linked with nasopharyngeal
cancer.
Hawaiians indicate a high overall cancer mortality rate (200.5). Since
this is based on a small number and may be artifically inflated, these figures
should be viewed with caution. They are provided here to indicate possible
areas of excess mortality and incidence among Hawaiians. As in cancer incidence,
the mortality rate is second only to the 208.5 mortality rate of Blacks, and
above the 163.6 rate of non-minorities. Sites of excess incidence and mortality
are breast cancer and lung cancer (both male and female). The high cancer rates
of Hawaiians are closer to those of Blacks and non-minorities than to those of
Chinese, Japanese, or Filipinos.
Lung cancer is associated with cigarette smoking, while breast cancer has
been correlated with family history of breast cancer, age at first birth, pre-
vious breast benign disease, and age at menarche. A high fat diet also has
been linked with breast cancer.
INCIDENCE AMONG JAPANESE AND CHINESE
As stated earlier, the three Asian populations have lower incidence for
cancers of all sites than non-minorities. This section will discuss incidence
of various major cancers among Japanese and Chinese, groups for which this
information is most available.
For prostate cancer, Japanese and Chinese have incidence rates that are
about 70 percent lower than the rate in non-minorities. There is, however, an
upward trend in incidence among Japanese.
Chinese-Americans have an increased incidence of about 17 percent over
non-minorities in multiple myeloma. Although there is no conclusive evidence
for the cause of multiple myeloma, preliminary studies have linked occupational
exposure, ionizing radiation, immune competence, and genetic susceptibility
with increasing risk for this cancer.
Incidence of esophageal cancer is higher for Japanese males and Chinese
males and females than for non-minorities. The rate for Japanese males is 2.5
times higher, for Chinese males it is 1.8 times higher, and for Chinese females
it is 1.6 times higher. Most studies into the causes of esophageal cancer
suggest that the major risk factors are smoking and alcohol consumption, with
the use of both having a synergistic effect. Consumption of hot beverages has
been associated with esophageal cancer. In Japan, a strong direct relationship
was found between esophageal cancer and high intake of tea-cooked rice gruel.
Pancreatic cancer incidence is about 20 percent higher among Chinese females
than among non-minorities , and an upward trend in incidence exists for Chinese
of both sexes. Japanese, particularly Japanese females, show considerably lower
incidence than non-minorities. Excess risk for pancreatic cancer has been found
among cigarette smokers and some studies have suggested a link with diabetes
mellitus.
26
Blacks and non-minorities have the highest incidence rates for cancer of
the larynx. However, there is a trend toward higher rates for all minorities
except Chinese males. Within this rising trend, the most dramatic increases
are in Asians, with Chinese females showing an increase of 250 percent and
Japanese males showing an increase of 157 percent.
Other sites of increased incidence rates for Asians, discussed along with
mortality rates above, are stomach cancer for Japanese males and females and
cervical and nasopharyngeal cancer in Chinese.
SURVIVAL
Survival data, presented here by major Asian/Pacific Islander subpopulations,
varies — according to sample size — in its ability to express differences between
the population noted and the U.S. non-minority population. Overall survival rates
for each group are presented here, as are site-specific survival rates when
statistically reliable data (standard error <10 percent) exists.
The total number of Chinese-American cancer cases in the SEER registry is
small (3,048 during 1973-79), and site-specific survival rates are therefore
often unreliable and will not be examined here. Five-year relative survival
for all sites was 35 percent in males and 50 percent in females compared to
40 percent and 55 percent in non-minorities during the 1973-79 time period.
Japanese-American cancer cases totaled 5,030 in 1973-79. Survival experi-
ence of this group was generally higher than for other groups. Overall 5-year
relative survival was 40 percent for males and 59 percent for females. The
5-year survival rates for both sexes was the highest of 8 ethnic groups in the
period 1973-79 for cancers of the stomach, colon, and breast (27, 59, and 84
percent respectively). Survival among Japanese was also higher than for non-
minorities for cancers of the lung and bronchus (14 percent), prostate (74 per-
cent), cervix (70 percent), and ovary (39 percent). Japanese males also had
greater survival for bladder cancer with a 5-year relative survival of 79 percent
compared to 73 percent for non-minority males.
Filipino-American cancer cases totalled 2,355 during 1973-79. The site-
specific relative survival rates vary widely with some rates being the lowest
of 8 ethnic groups and others being much higher. Overall 5-year relative
survival was 34 percent for males and 56 percent for females. For stomach cancer,
5-year relative survival was identical to that in Blacks and non-minorities, and
survival from prostate cancer was higher in Filipinos with 70 percent compared
to 56 percent for Blacks and 66 percent for non-minorities. Survival for cervix
and corpus uteri cancers were 70 percent and 85 percent respectively. Filipinos
had the lowest survival of all ethnic groups for colon cancer (35 percent) and
the highest for ovarian cancer (55 percent).
Survival rates for Hawaiians vary widely and are, again, to be viewed with
caution as they are based on a small number of cases. Overall survival was 30
percent for males and 52 percent for females. Hawaiians experienced compara-
tively high survival rates for lung, breast, prostate, and cervix cancer and
comparatively lower survival rates for ovarian (38 percent) and corpus cancers
(76 percent . )
27
KNOWLEDGE, ATTITUDES, AND PRACTICES
Documented information on Asian/Pacific Islander knowledge, attitudes, and
practices relating to cancer in general or to the particular cancers where excess
rates exist could not be located during the preparation of this report.
CONCLUSION
Cancer incidence varies widely among Americans of Chinese, Japanese,
Filipino, and Hawaiian descent. Hawaiians have an overall age-adjusted cancer
Incidence rate that is second highest of any American population, below Blacks
and above non-minorities. The rates for Chinese, Japanese, and Filipinos are
below non-minorities. There is, however, an upward trend in incidence rates
for both sexes of the Chinese population and for Japanese males.
Excess mortality among Asian/Pacific Islanders is found among Japanese-
Americans for stomach cancer. Chinese -Americans have excess rates for cancer of
the cervix and for nasopharyngeal cancer. Hawaiians have excess mortality for
cancers of the breast and lung. The high cancer rates of Hawaiians are closer
to those of Blacks and non-minorities than to those of Chinese, Japanese, or
Filipinos.
Survival data vary, according to sample size, in their ability to express
differences between the population noted and the U.S. non-minority population.
SEER registry data (1973-79) indicate that for Chinese-Americans the 5-year
relative survival for all sites was 35 percent in males and 50 percent in
females compared to 40 percent and 55 percent in non-minorities.
Among Japanese-Americans the overall 5-year relative survival was 40 per-
cent for males and 59 percent for females. The 5-year relative survival rates
for both sexes were the highest of 8 ethnic groups for cancers of the stomach,
colon, and breast. Survival rates among Japanese were also higher than non-
minorities for cancers of the lung and bronchus, prostate, cervix, and ovary.
Japanese males had greater survival than non-minority males for bladder cancer.
Filipino-American site-specific relative survival rates vary widely with
some rates being the lowest of 8 ethnic groups and others being much higher.
Filipinos had the lowest survival of all ethnic groups for colon cancer and the
highest for ovarian cancer. (It should be noted that standard errors for
5-year relative survival for colon and ovarian cancers was 10-20% of the rate.)
Survival rates for Hawaiians also show large variations. Hawaiians have
comparatively high survival rates for lung, breast, prostate, and cervix cancers
and comparatively low rates for ovarian and corpus cancers.
28
AMERICAN INDIANS
Existing data on the cancer experience of the U.S. American Indian/
Alaska Native population are presented here. These data are limited, however,
in that they are drawn from the small sample of American Indians in the SEER
program or from a sample of American Indians residing in reservation states.
The data should be used with caution in interpreting the cancer experience of
American Indians and in comparing this with the experience of other groups.
American Indians and Alaska Natives have the lowest rates of overall cancer
incidence and mortality of all U.S. populations (including non-minorities).
SEER data indicate that the cancer incidence rates for American Indians in
New Mexico, both males and females, are about half that of the non-minority
majority. Cause of death data indicate that cancer, the second leading cause
of death for the U.S. population as a whole, is the third most common cause
of death (preceded by accidents and heart disease) among American Indians
and Alaska Natives. In 1975, the age-adjusted mortality for cancers was 39
percent lower for Indians than for the general U.S. population.
American Indians generally experience low survival rates according to
1973-79 SEER data. Overall 5-year relative survival for males was 26 percent
compared with 40 percent for non-minority males, and 39 percent for females
compared with 55 percent for non-minority females.
RATE COMPARISONS: AMERICAN INDIANS RESIDING IN RESERVATION STATES
One researcher, whose findings are the basis for the following discussion,
points out that in reservation states relative frequency of various types of
cancer differs widely in American Indians. They have rates below non-minorities
for the most common cancers — lung, colon, breast, and prostate cancer — and
much higher rates for cancers of the cervix, gallbladder, and kidney.
The Standard Mortality Ratio (SMR) for all American Indians in the 28
reservation states shows the level of excess mortality in cancer sites to be:
cervix — 229, gallbladder — 435, and kidney — 154. SMR deficits are: lung — 43,
colon — 49, breast — 53, and prostate — 81.*
Rates vary among American Indians. Those populations having substantially
non-Indian ancestry and living off reservations (here principally tribes in
Oklahoma) have mortality for most sites that is between the national average
and the rates of tribes in the Southwestern states living on the reservation and
of mostly Indian heritage.
Differences in overall cancer mortality for American Indians and non-
minorities is believed to be due more to environmental and cultural factors
than to genetic factors. Examples of cancer sites for which American Indians
have rates differing from the non-minority population illustrate this.
*Standard Mortality Ratios (SMR's) show proportionate relationship of observed
to expected deaths based on the standardized national rates in non-minorities;
over 100 indicates an excess mortality, while less than 100 indicates a deficit.
29
For example, the lung cancer SMR is 43 for all Indians in reservation
states. However, Oklahoma Indians have an SMR of 89, while Southwestern tribes
have a much lower SMR of 9. The mean lung cancer mortality among Oklahoma
tribes is 9 times greater than that of Southwestern tribes. Environmental and
cultural factors, in this case heavy smoking among Oklahoma Indians but not
among Southwestern tribes, undoubtedly play a role in this discrepancy.
Indians of the Southwest, who seldom smoke extensively, have low rates of
squamous cell bronchogenic carcinoma, a common type of lung cancer and the one
most commonly associated with heavy smoking. Their rates of less common lung
cancers (not associated with smoking) are in keeping with national averages.
Among Oklahoma Indians, where lung cancer SMR is higher, both cigarette smoking
and lung cancer mortality more closely mirror the national average.
One particular type of bronchogenic carcinoma (small cell, undifferentiated)
is higher among one group of Indians — Navajo uranium miners — pointing to the
possible contribution of occupational exposure to cancer incidence and mortality.
For colon cancer, the overall SMR for American Indians is 49. Again, the SMR
is higher for Oklahoma tribes (71) than for those in the Southwest (17). Here,
dietary factors are likely to play a role in cancer incidence, since most South-
western tribes consume large amounts of beans and, therefore, fiber when compared
with Oklahoma Indians.
In breast cancer, where mortality is lower for Indians than non-minorities,
factors associated with decreased incidence such as pregnancy, multiparity, and
lower socioeconomic status are more common among Indians than among non-minorities.
In cancer of the gallbladder, where American Indians show excess mortality,
it is Indians of the Southwest who have the greater SMR (636) when compared with
Oklahoma Indians (227). The excess incidence of cancer of the gallbladder is
generally attributed to the Indians' high rate of cholelithiasis. This high rate
probably has a genetic basis.
American Indians also have excess mortality from cancer of the cervix.
Factors associated with high rates of cervical cancer (including lower socio-
economic status and multiple pregnancies) are found as a risk factor in most
Indian populations. The papilloma virus has been implicated as a risk factor in
cervical cancer.
ALASKA NATIVES
Alaska Natives are reported to have increased incidence of cancer of the
gallbladder and excess mortality from primary liver cell cancer.
KNOWLEDGE, ATTITUDES, AND PRACTICES
I
Research on cancer-related knowledge, attitudes, and practices among American
Indians was not available for inclusion in this report.
30
CONCLUSIONS
Linlted data are available to describe the cancer experience among American
Indians. Interpretation of the data and comparisons with other groups should be
made with caution. American Indians, as a group, are younger in age than the
majority population. American Indians have a shorter life expectancy and as a
result many times do not reach the age to develop cancer. Cause of death data
Indicate that cancer, the second leading cause of death for the U.S. population
as a whole, is the third most common cause of death, preceded by accidents and
heart disease among American Indians and Alaska Natives.
American Indians are considered to be a low-risk population for cancer
when compared with the general population. However, according to 1973-79 SEER
data, American Indians have low survival rates. Overall 5-year relative sur-
vival for males was 26 percent compared with 40 percent for non-minority males,
and 39 percent for females compared with 55 percent for non-minority females.
According to one study, the relative frequency of various types of cancer
differs widely in American Indians. They have cancer rates below non-minorities
for lung, colon, breast, and prostate and much higher rates for cancers of the
cervix, gallbladder, and kidney.
It is believed that differences in overall cancer mortality for American
Indians and non-minorities is due more to environmental and cultural factors
than to genetic factors. American Indians have a high rate of obsesity and
have high rates of diseases associated with alcohol and tobacco use. These
risk factors could lead to higher cancer rates in the future.
31
Table A
Numbers and Standarized Mortality Ratios (SMR's) for the 10 Leading Cancer
Sites among the Amerind of the 26 Reservation States, 1974-1976
Male
Female
Total
Site
SMR
SMR
Observed (No.
,) Expected (No.)
SMR
Lung
39
66
153
352,
.1
43
Colon
51
47
89
181,
.8
49
Breast
—
53
78
148,
.0
53
Stomach
89
113
76
78,
.1
97
Pancreas
71
98
74
90.
.9
81
Cervix
—
229
66
28,
.8
229
Gallbladder
—
432
54
12.
.4
435
Prostate
57
—
53
93,
.5
57
Kidney and
renal
pelvis
145
171
52
33,
.8
154
Liver
101
138
29
25,
.3
115
All cancer
deaths
55
89
1,202
1;
,736.
.9
69
Items listed in order of frequency. Data from Indian Health Service (supplied
by Mr. Mozart I. Spector, Director, Office of Program Statistics.)
SMR=( observed/expected) x 100
32
Table B
Numbers and Standardized Mortality Ratios (SMR's) for Cancer of the Lung,
Colon, and Gallbladder, 1974-1976, Compared by Sex,
for the Tribes of the Southwest and of Oklahoma
^H
Southwest
Oklahoma
Site Obse;
rved (No.)
Expected
(No.)
SMR
Observed
(No.
, ) Expected
(No.)
SMR
Lung
Male
5
105.8
5
47
55.1
85
Female
6
21.2
29
12
11.0
109
TOTAL
11
127.0
9
59
66.1
89
Colon
Male
7
34.0
21
15
17.7
85
Female
4
11
31.4
65.4
13
17
9
24
16.3
34.0
55
71
Gallbladder
Male
8
1.2
667
2
0.6
333
20
28
3.2
4.4
625
636
3
5
1.6
2.2
188
227
From Indian Health Service (IHS) data supplied by Mr. Mozart I. Spector, Director,
Office of Program Statistics. The 1975 IHS Indian population base for the South-
west (Arizona, California, Colorado, Nevada, New Mexico, and Utah) = 223,437; for
Oklahoma = 116.394 (U.S. Department of HEW, 1978a).
33
TABLES
• Smoking and Cancer
• Alcohol and Tobacco
• Nutrition
• Occupation
34
Smoking and Cancer
Table 1
Age-Adjusted (1970 U.S. Standard) Death Rates per 100,000
Population for Lung Cancer in the United States, 1969-1981
Year of
Death
White Males
Black Males
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
AAPC*
S5.55
57.39
59.11
60.86
61.58
63.16
64.16
65.69
66.82
68.18
68.76
70.03
69.86
1.91
63.68
65.54
66.70
73.35
74.76
78.10
79.29
81.56
87.34
88.31
89.22
92.70
94.93
3.36
*AAPC=average annual percent change from 1969 to 1981
Source: National Cancer Institute.
35
Smoking and Cancer
Table 2
Age-Adjusted (1970 U.S. Standard) Death Rates per 100,000
Population for Lung Cancer in the United States, 1969-1981
Year of
Death White Females Black Females
1969 10.30 10.56
1970 11.01 11. S4
1971 11.94 12. SO
1972 12.76 12.44
1973 13.28 13.53
1974 14.34 14.17
1975 15.27 14.80
1976 16.51 15.78
1977 17.37 17.25
1978 18.72 17.78
1979 19.46 19.11
1980 20.96 21.41
1981 21.69 21.74
AAPC* 6.19 5.92
*AAPC=average annual percent change from 1969 to 1981.
Source: National Cancer institute.
36
Smoking and Cancer
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Smoking and Cancer
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38
Smoking and Cancer
Table 5
Current Cigarette Smokers Among Males 20 Years of Age and Over,
by Race: United States, 1965, 1976, 1980
Race Current Smoker
1965 1976 1980
All Males 52. 1 41.6 37.9
White Males 51.3 41.0 37.1
Black Males 59.6 50.1 44.9
Source: National Health Interview Survey.
39
Smoking and Cancer
Table 6
Current Cigarette Smokers Among Females 20 Years of Age and Over,
by Race; United States, 1965, 1976, 1980
Race Current Smoker
1965 1976 1980
All Females 34.2 32.5 29.8
White Females 34.5 32.4 30.0
Black Females 32.7 34.7 30.6
Source: National Health Interview Survey.
40
Smoking and Cancer
Table 7
Cigarettes Smoked p^r Day by Male Current Smokers 20 Years of Age
and Over, by Race: United States, 1965, 1976, 1980
Race
Cigarettes Smoked per Day
Less than 24
Source: National Health Interview Survey.
25 or more
1965
1976
1980
1965
1976
1980
All Males
75.8
69.3
65.9
24.1
30.7
34.2
White Males
74.0
66.7
62.7
26.0
33.3
37.3
Black Males
91.4
89.3
86.3
8.6
10.8
13.8
41
Smoking and Cancer
Table 8
Cigarettes Smoked per Day by Female Current Smokers 20 Years of Age
and Over, by Race; United States, 1965, 1976, 1980
Race
Cigarettes Smoked per Day
Less than 24
Source: National Health Interview Survey.
More than 2S
1965
1976
1980
1965
1976
1980
All Females
87.0
81.0
76.7
13.0
19.0
23.2
White Females
86.1
79.2
74.8
13.9
20.9
25.2
Black Females
95.3
94.5
91.5
4.6
5.6
8.6
42
Smoking and Cancer
Table 9
Former Cigarette Smokers Among Males 20 Years of Age and Over,
by Race; United States, 1965, 1976, 1980
Race Former Smoker
1965 1976 1980
AM Males 20.3 29.6 30.5
White Males 21.2 30.7 31.9
Black Males 12.6 20.2 20.6
Source: National Health Interview Survey.
43
Smoking and Cancer
Table 10
Former Cigarette Smokers Among Females 20 Years of Age and Over,
by Race; United States, 196S. 1976, 1980
Race
Former Smoker
All Females
White Females
Black Females
1965
S.2
8.5
5.9
1976
13.9
14.6
10.2
1980
15.7
16.3
11.8
Source: National Health Interview Survey.
44
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Alcohol and Tobacco
Table 12. Relationship of Average Daily Smoking and Drinking Habits
Before the Diagnosis of the Index Primary Cancer
Men
Women
Risk
Factors*
Single
Primary
Multiple
Primaries
Single
Primary
Multiple
Primaries
Tobacco
Alcohol
No. %t
No. %t
No. %t
No. %t
Low
Low
45 9
^^ ^>~*
63 37
3 21
Low
High
28 6
1 3
12 7
2 14
High
Low
110 22
5 13
30 18
2 14
High
High
273 54
28 72
51 30
7 50
Unknown
53 10
5 13
15 9
—
Total
509 100
39 100
171 100
14 100
♦Tobacco: Low = 0-19 equivalents/day; high = 20 or more equivalents/day.
Alcohol: Low = 0-2 equivalents/day; high = 3 or more equivalents/day.
Data on smoking were translated into cigarette equivalents as follows: 1
cigar = 5 cigarettes; 1 pipe = 2.5 cigarettes. Alcohol consumption was
translated into units of absolute alcohol as follows: 1 unit (approxi-
mately 12 cc absolute alcohol) = 1 ounce liquor or spirits = 4 ounces wine
= 8 ounces beer.
tPercentage distribution does not total 100 because of rounding.
Source: Schottenfeld, et al. (1974)
46
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48
Nutrition
Table 15
Percentage distribution of persons aged 1-74 years
by race, poverty level, and frequency of different food groups
Frequency
of intake
per day
Black
White
Below
Above
Below
Above
(# of times)
Poverty
Poverty
Poverty
Poverty
MILK
Whole
Less than
52
48
42
38
1-2
34
39
38
39
3 or more
13
14
20
22
Skim
Less than
97
96
91
95
1 - 2
3
3
7
5
3 or more
0
0
2
1
MEAT & FISH
Meat &
Less than
16
18
14
26
Poultry
1-2
80
78
84
72
3 or more
4
4
2
1
Fish &
Less than
99
99
99
99
Shellfish
1-2
1
1
1
1
3 or more
0
0
0
0
MEAT ALTERNATES
Eggs
Less than
78
76
86
77
1-2
21
25
14
23
3 or more
0
0
0
0
Cheese
Less than
94
95
87
91
1-2
5
5
13
9
3 or more
0
0
0
0
Legumes
Less than
90
86
91
81
Seeds &
1-2
9
14
8
19
Nuts
3 or more
0
0
0
0
FRUITS & VEGETABLES
All
Less than
16
22
7
17
1-2
65
65
69
66
3 or more
18
13
24
17
Vit. A
Less than
90
94
95
97
Rich
1-2
11
6
4
3
3 or more
0
0
0
0
Vit. C
Less than
64
66
61
71
Rich
1-2
35
32
38
29
3 or more
1
1
1
0
49
Nutrition
Table 15 (continued)
Frequency
of intake
per day
Bla
ck
White
Below
Above
Below
Above
(# of times)
Pover
ty
Poverty
Poverty
Poverty
BREADS & CEREALS
Breads
Less than
14
13
12
14
1-2
56
55
67
59
3 or more
31
33
20
28
FATS & OILS
Fats
Less than
44
48
28
36
1-2
51
46
61
53
3 or more
5
7
12
10
SWEETS
Desserts
Less than
62
62
58
64
1-2
36
37
40
34
3 or more
2
1
2
1
Candy
Less than
76
69
84
79
1-2
22
29
16
21
3 or more
2
3
1
1
Beverages ,
Less than
51
53
66
67
Sweetened
1-2
40
40
30
28
3 or more
8
7
5
5
OTHER BEVERAGES
Beverages,
Less than
97
98
95
97
Sweetened
1 - 2
3
2
4
3
Artif ically
3 or more
0
0
0
0
Coffee & Tea
Less than
57
64
37
44
1-2
35
30
34
36
3 or more
8
7
29
20
SNACK FOODS
Salty Snacks
Less than
85
78
89
91
1-2
15
20
11
9
3 or more
1
0
0
0
Source: DHEW Publication No. (PHS) 79-1658
50
Nutrition
Table 16
Mean percent of standard and percent of population below standard
for nutrient intake and
biochemical measures of nutritional status, by race
Mean percent
of standard (S.E)
Black
l^ite
Percent of population
below standard (S.E)
Black
White
Protein intake 150(2.1) 166(1.9) 26.8(1.5) 19.0(0.7)
Total serum protein 114(0.4) 110(0.3) 2.8(0.4) 6.9(0.6)
Serum albumin 125(0.3) 128(0.3) 0.6(0.1) 0.4(0.1)
Vitamin A intake
Serum vitamin A
109(3.3)
248(3.5)
111(2.7)
274(2.5)
68.7(1.2)
0.4(0.1)
65.2(0.9)
0.2(0.1)
Thiamine Intake
Urinary thiamine/
creatinine ratio
100(2.1)
457(96.8)
106(1.0)
895(32.5)
60.6(1.6)
28.5(1.6)
54.8(0.8)
13.7(0.6)
Riboflavin intake
Urinary riboflavin/
creatinine ratio
112(1.9)
499(58.8)
137(1.2)
768(28.7)
50.8(1.2)
7.6(0.9)
33.7(0.7)
2.5(0.3)
Source: Kerr, G.R. et al. Amer J. Clin. Nutr. 35: 294-307, 1982
51
Nutrition
Table 17
Mean caloric and nutrient intakes of persons aged 1-74 years
as a percent of standard according to income level
and race (black and white only)
Black
White
Calories
Protein
Calcium
Iron
Vitamin C
Thiamine
Riboflavin
Below
Above
Below
Above
Poverty
Poverty
Poverty
Poverty
83.6
86.4
102.0
93.2
142.4
147.3
161.6
161.6
135.3
142.2
184.5
193.0
82.8
85.8
82.2
96.2
155.7
170.8
143.7
183.3
169.0
169.0
161.5
162.6
169.3
167.4
161.5
188.4
Source: DREW Publication No. (PHS) 79-1657; Series 11, No. 209
52
Nutrition
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Table 19
Nutrition
Mean caloric and nutrient Intakes and percent adequacy
for persons aged 10-16 and 60 and over
by income level and race (black, white and Hispanic)
Blacks
# Below
Above
Hispanic
Below
Above
Whites
Below
Above
Calories
10-16 yrs MI
PA
1863.30 2426.40
71.60 90,10
2219.50 2383.20
94.60 89.70
2232.40 2498.90
86.50 94.00
60 yrs MI 1299.70 1483.80
& over PA 59.80 66.10
1710.40 1562.90
81.90 77.20
1670.20 1794.90
81.50 84.00
Protein
10-16 yrs MI 69.48 93.00 81.74 88.95 80.79 97.37
PA 129.70 169.40 173.30 164.50 154.60 184,80
60 yrs
& over
MI
PA
54.40
77.80
63.70
87.80
73.10
108.90
64.80
98.60
67.07
101.80
75.03
108.90
Calcium
10-16 yrs MI 709.95 941.40
PA 98.00 144.20
655.19 1034.00
100.30 143.00
995.30 1190.90
152.60 182.80
60 yrs
& over
MI
PA
508.04
126.90
511.80
127.20
528.89
131.70
681.77
167.30
737.18
183.60
691.19
172.00
Iron
10-16 yrs MI 10.72 13.26 14.35 13.30 12.14 13.40
PA 66.90 82.30 97.10 92.10 77.40 89.50
60 yrs
& over
MI
PA
8.89
88.50
9.57
95.30
12.29
122.50
9.88
97.10
10.72
106.40
12.39
123.60
Vitamin A
10-16 yrs MI
PA
4935.00 895.20 2760.86 3764.50
167.70 189.80 95.40 129.00
3847.00 4658.80
133.90 176.80
60 yrs MI 5551.19 5343.10
& over PA 158.00 152.40
3400.77 2781.00
96.60 78.80
4411.90 5457.17
125.50 176.30
Thiamine
10-16 yrs MI 1.12 1.37 1.49 1.68 1.25 1.32
PA 108.30 123.80 159.40 159.90 120.80 123.90
60 yrs
& over
MI
PA
0.84
94.80
0.93
100.70
1.12
128.90
1.22
143.30
1.05
124.70
1.00
113.30
Riboflavin
10-16 yrs MI 1.81 1.99 1.80 2.24 2.04 2.32
PA 128.00 134.90 139.00 153.60 128.90 158.90
60 yrs
& over
MI
PA
1.49
123.90
1.22
101.10
1.52
133.20
1.60
142.60
1.60
140.30
1.58
137.40
Preformed Niacin
10-16 yrs MI
PA
60 yrs
& over
MI
PA
13.45
13.23
17.41
12.95
15.42
21.46
15.67
11.36
14.42
14.12
18.35
19.23
Vitamin C
10-16 yrs
MI
PA
57.36
190.10
65.63
218.30
74.70
248.30
74.80
248.70
62.63
208.10
76.54
254.62
60 yrs
i over
MI
PA
59.45
197.60
58.01
193.00
64.15
213.20
47.92
159.10
62.10
206.60
67.54
224.60
Source: DHEW Publication No. (HSM) 72-8133. (TSNS - V)
(MI - mean Intake; PA » percentage adequacy; # - poverty level)
54
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Nutrition
Table 22
Percentage of days intake per individual
of energy and energy nutrient, vitamins and minerals,
total respondents for 1979-80 and 1977-78 (USDA)
Milk &
Meat,
Eggs,
Grain
Fruits,
Fats,
Milk
Poultry,
Legumes
Products
Vegetables
Sweets,
Products
Fish
Beverages
Sources of Energy and
Energy Nutrients
Food Energy
1979-80
1977-78
15
15
26
26
7
6
27
30
13
12
12
11
Protein
1979-80
1977-78
19
18
43
44
10
8
19
22
8
7
1
1
Fats
1979-80
1977-78
19
19
39
40
9
8
15
17
8
8
10
8
Carbohydrate
1979-80
1977-78
11
11
6
5
4
3
42
45
21
19
16
17
Vitamins
Vitamin A
Value
1979-80
1977-78
20
20
10
11
8
8
17
18
37
37
8
6
Thiamine
1979-80
1977-78
12
11
22
21
5
5
42
45
18
17
1
1
Riboflavin
1979-80
1977-78
30
29
23
22
7
7
28
31
10
9
2
2
Preformed
Niacin
1979-80
1977-78
3
3
39
41
4
3
34
35
14
13
6
5
Vitamin B6
1979-80
1977-78
13
13
36
38
9
7
19
21
21
20
2
1
Vitamin C
1979-80
1977-78
10
10
6
5
2
1
10
10
66
64
6
10
57
Nutrition
Table 22 (continued)
Milk &
Meat,
Eggs,
Grain
Fruits,
Fats,
Milk
Poultry,
Legumes
Products
Vegetables
Sweets,
Products
Fish
Beverages
Minerals
Calcium
1979-80
47
8
7
23
11
4
1977-78
46
7
6
26
11
4
Iron
1979-80
4
31
11
35
14
5
1977-78
4
31
9
37
14
5
Magnesium
1979-80
20
16
10
21
21
12
1977-78
20
17
8
24
19
12
Phosphorus
1979-80
30
26
10
20
10
4
1977-78
28
26
9
23
10
4
Source: USDA Human Nutrition Service, Preliminary Reports, No. 11 and 13
58
Nutrition
Table 23
Amount of Food disappeared per capita by civilians
in 1960 and 1980 (USDA)
MEAT
Beef
Veal
Lamb & mutton
Pork
Total
1980
values as
Amount of
Food
Percent of
1960
1980
1960
values
85.0 (a)
103.4
121
6.1
1.8
30
4.8
1.5
31
77.7
73.4
95
173.7
180.0
104
Edible offals
10.2
9.6
94
FISH
Fresh & frozen
Canned
Cured
Total
POULTRY
Chicken
Turkey
Total
MEAT ALTERNATES
Eggs
Cheese
Peanuts (kernel)
Tree nuts
Dry edible beans
Dry field peas
Total
MILK
Milk fat
Milk solid
Cheese
Condensed & evap.
Dry whole
Dry nonfat
Frozen dairy
All dairy milk
equivalent
5.7
7.9
139
4.0
4.5
113
0.6
0.3
50
10.3
12.7
123
27.8
50.0
180
6.2
10.5
169
34.0
60.5
178
334.4 (b)
272.4
81
8.4
17.6
210
4.9
6.1
124
4.5
1.7
38
7.3
3.6
49
0.6
0.4
67
360.1
301.8
84
24.5
19.9
81
43.4
36.6
84
8.4
17.6
210
13.7
3.8
28
0.3
0.3
100
6.2
3.2
52
18.3
17.3
95
653.4
541.7
83
FATS & OILS
Butter
Lard
Margarine
Shortening
Other edible
Total
7.5
4.5
60
7.5
2.4
32
9.3
11.3
122
12.6
18.3
145
11.5
22.4 (c)
198
45.3
57.2 (c)
126
59
Table 23 (continued)
Amount of Food
1960 1980
FRUITS & VEGETABLES
Fresh
Canned (rice, potatoes)
Frozen
Frozen potato products
Potatoes
Sweet Potatoes
Corn (inch grain)
Total
105.7
44.7
7.0
2.7
101.3
7.1
47.5
316.0
108.3
52.0
10.4
16.9
79.9
4.4
109.0
380.9
Nutrition
1980 values as
Percent of
1960 values
FRUIT
Citrus
33.7
28.7
85
Apples
18.3
16.7
91
Other
41.9
42.0
100
Total
Fresh (d)
93.9
87.4
93
Canned fruit
22.6
17.4
77
Canned juices
12.9
16.9
131
Frozen juices
5.9
9.9
168
Frozen noncitrus
(fruits & juices)
3.5
3.0
86
Dried
3.1
2.9
94
Melons
25.8
18.6
72
Total
261.6
233.5
89
VEGETABLES
102
116
149
626
79
62
229
121
BREADS & CEREALS
Wheat (grain)
Wheat flour
Rye
Rice
Oats
Barley
Total
164.7
118.0
1.4
6.1
7.5
1.6
199.3
159.3
117.0
0.9
9.3
6.5
1.7
194.7
97
99
64
152
87
106
98
SWEETS
Total cane & beet sugar
97.6
83.6
86
BEVERAGES
Coffee
Tea
Cocoa
Total
15.8
10.4
66
0.6
0.7
117
3.6
3.2
89
20.0
14.3
92
CONDIMENTS
Spices & flavouring
(a) refers to pounds unless footnoted
(b) refers to number of eggs
(c) 1979 figure, 1980 not available
(d) variable frequently
(e) 1000 pounds
1.0 (e)
1.6
160
60
Nutrition
Table 24
Amount of Food Groups disappeared per capita by civilians
in 1960 and 1980 (USDA)
Milk
Cheese
Meat & Poultry
Meats
Edible offals
Poultry
Total
Fish
Meat Alternates
Fruits and Vegetables
Fruits Fresh
Citrus Fresh
Citrus Frozen
Total Fresh
Vegetables Fresh
Sweet Potatoes
Total
Breads & Cereals
Fats & Oils
Sweets
Beverages: Coffee, Tea, & Cocoa
Condiments
1980
values as
Amount
of Food
Percent of
1960
1980
1960
value
653.4
541.7
83
8.4
17.6
210
173.7
180.0
104
10.2
9.6
94
34.0
60.5
178
217.9
259.1
119
10.3
12.7
123
360.1
301.8
84
93.9
87.4
93
33.7
28.7
85
2.4
6.9
288
130.0
123.0
95
105.7
108.3
102
7.1
4.4
62
112.8
112.7
100
199.3
194.7
98
45.3
57.2
126
97.6
83.6
86
20.0
14.3
92
1.0
1.6
160
61
Nu trie Ion
Table 25
Percent of persons who reported using specific foods for which
there is a significant difference by race (USDA)
Food Groups
Fruits
Noncritus fruits
Potatoes
Dried beans and peas
Dark green vegetables
Whole grain bread
Qulckbreads
Breakfast cereals
Cooked cereals
Rice
Milk, yoghurt, cheese
Milk
Lowfat milk
Cheese
Natural cheese
Processed cheese
Red meats
Beef
Poultry
Eggs
Nuts
Desserts
Soups
Snack foods
Potato chips
Condiments
Candy
Sugar-based beverages
Carbonated beverages
Fats
Table spreads
Salad dressings
Cream and substitutes
Bacon and salt pork
Coffee and tea
White
R a c e
Black
Other
74
64
70 (a)
61
37
54
80
64
84
22
29
62
14
27
13
24
8
16
34
46
49
54
64
66 (a)
15
34
26
15
47
51
93
80
93
85
76
88 (a)
20
4
2
50
23
36
24
10
15
25
13
20
82
83
98 (a)
70
62
88
41
64
60
53
66
69
28
11
13
73
52
57
32
22
49
31
17
18
20
13
12 (a)
36
28
23 (a)
16
7
5
60
76
74
55
69
64
87
78
84 (a)
70
50
62
47
32
38
18
4
5
24
39
18
68
48
52
(a) - significant at the 1 percent level (p<0.01)
All other differences significant at the 0.1 percent level (p<0.
001)
Source: Cronin, F J et al. JADA 81: 661-673, 1982
62
Nutrition
Table 26
Percent of persons who reported using specific foods for which
there is a significant difference by income (USDA)
Income level
under $20,000
Noncltrus fruit
Dried beans and peas
Other vegetables #
Whole grain bread
Rice
Grain mixtures
Milk, yoghurt, cheese
Lowfat milk
Cheese
Natural cheese
Meat, fish, poultry
Beef
Eggs
Nuts
Desserts
Grain-based desserts
Dairy desserts
Candy
Snack foods
Potato chips
$5,000
or more
53
66
27
20
82
92
21
30
27
16 (a)
27
42 (a)
86
95 (a)
8
25
34
53
14
29
98
100 (a)
60
77
63
52
20
31 (a)
58
79
50
72
25
38 (a)
9
20
17
38
10
25
Condiments
22
41
Fats
Salad dressings
74
33
87
50
(a) - significant at the 1 percent level (p<O.Ol)
All other differences significant at the 0.1 percent level
(p<0.001)
Source: Cronin, F J et. al. JADA 81: 661-673, 1982
63
Nutrition
55
48 (a)
1
4
61
51
23
18 (a)
Table 27
Percent of persons who reported using specific foods for which
there Is a significant difference by sex (USDA)
S e X
Male Female
Fruits 70 75 (a)
Whole milk
Yoghurt
Luncheon meats
Meat, fish, poultry
sandwiches
Eggs 59 52 (a)
Desserts
Grain-based desserts
Sugar and sweet spreads
Coffee and tea
Low calorie carbonated
beverages
(a) - significant at the 1 percent level (p<0.01)
All other differences significant at the 0.1 percent level
(p<0.001)
Source: Cronin, F J et al. JADA 81: 661-673, 1982
74
67 (a)
64
58 (a)
68
59
61
67 (a)
6
11
64
Nutrition
Table 28
Mean number of times per day that users reported foods,
by food groups, for which there is a significant difference by race
Food Groups
Fruits and vegetables
Fruits
Vegetables
Breads and cereals
Yeast breads
Ready to eat cereals
Milk, yoghurt and cheese
Milk
Skim milk
Meat, fish, poultry, eggs
Desserts
Grain-based desserts
Fats
Coffee and tea
— R a c e-
White
Black
Other
2.9
2.3
3.2
1.2
1.0
1.4
2.0
1.7
2.2
2.4
2.5
2.8
1.4
1.3
1.4 (a)
0.7
0.6
0.6
2.0
1.4
2.0
1.8
1.3
1.9
1.2
0.6
2.7 (a)
1.8
2.0
2.0
1.0
0.8
0.8
0.8
0.6
0.7
1.3
1.1
1.0
1.9
1.1
1.6
(a) - significant at the 1 percent level (p<0.01)
All other differences significant at the 0.1 percent level (p<0.001)
Source: Cronin, F J et al. JADA 81: 661-673, 1982
65
Nutrition
Table 29
Mean number of times per day that users reported foods,
by food groups, for which there is a significant difference by Income
Income level
under $20,000
$5,000 or more
Fruits and vegetables
2.6
3.1
Fruits
1.2
1.4
(a)
Vegetables
1.8
2.1
Vegetables
1.2
1.5
(exclude potatoes.
dried beans and peas)
Other vegetables #
1.0
1.2
(a)
Meat, fish, poultry
1.4
1.6
(a)
Desserts
0.8
1.1
Grain-based desserts
0.7
0.9
Fats: table spreads
1.0
0.9 (a)
(a) - significant at the 1 percent level (p<0.01)
All other differences significant at the 0.1 percent
level (p<0.001)
Source: Cronin, F J et al. JADA 81: 661-673, 1982
66
Nutrition
Table 30
Mean number of times per day that users reported foods,
by food groups, for which there is a significant difference by sex
Breads and cereals
Yeast breads
White breads
Milk, yoghurt, cheese
Milk
Meat, fish, poultry, eggs
Meat, fish, poultry
Red meats
Desserts
Grain-based desserts
Sugar and sweet spreads
S e X
Male
Female
2.6
2.3
1.5
1.3
1.4
1.2
2.0
1.8 (a)
1.8
1.6 (a)
2.0
1.7
1.7
1.5
0.8
0.7
1.0
0.9 (a)
0.9
0.8 (a)
1.1
1.0 (a)
(a) - significant at the 1 percent level (p<0.01)
All other differences significant at the 0.1 percent
level (p<0.001)
Source: Cronin, F J et al. JADA 81: 661-673, 1982
67
Occupation
Table 31
Industrial Processes and Chemicals with Known Human Carcinogenicity
Industrtcal Processes and Occupations:
Auramlne manufacture
Boot and shoe manufacture and repair
(certain occupations)
Furniture manufacture
Isopropyl alcohol manufacture
(strong -acid process)
Nickel refining
Rubber industry (certain occupations
Underground haematite mining
(with exposure to radon)
Chemicals and groups of chemicals;
4 -Ami nob 1 phenyl
Analgesic mixtures containing phenacetin
Arsenic and arsenic compounds
Asbestos
Azathioprine
Benzene
Benzidine
N,N-Bis(2<hloroethyl ) -2-naphthylamine (Chlornaphazine)
Bis(chloromethyl )ether and technical -grade chloromethyl methyl ether
1,4-Butanediol dimethanesulphonate (Myleran)
Certain combined chemotherapy for lymphomas (including MOPP)
Chlorambucil
Chromium and certain chromium compounds*
Conjugated oestrogens
Cyclophosphamide
Oiethylstiboestrol
Melphalan
Methoxsamen with ultra-violet A therapy (PUVA)
Mustard gas
2-Naphthylamine
Soots, tars and oils
Treosulphan
Vinyl chloride
Source: International Agency for Research on Cancer.
I ARC Monographs Supplement 4. Lyons, 1982
68
OccL'parion
Table 32
Minority Representation by Occupational Category
Percent
Occuaptional Category Non-white
All Occupations
Processional Technical
Managers and Administrators (non-farm)
Sales
Clerical
Crafts
Operatives (non-transportation)
Transportation Operatives
Laborers (non-farm)
Farm Laborers
Service
Private Household Workers
1972
1981
10.6
11.6
7.2
9.9
4.0
5.8
3.6
5.4
8.7
11.6
6.9
8.5
13.2
16.2
14.8
15.5
20.2
16.5
15.1
12.3
18.5
18.4
40.6
32.4
Source: U.S. Oept of Commerce, Bureau of Che Census. Statistical
Abstract of the United States 1982-83, table 651, pp. 388-390. U.S.
Government Printing Office, Washington, D.C. , 1983.
69
Occupation
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72
BIBLIOGRAPHY
• Demography
• Epidemiology
• Tobacco Use
• Nutrition and Cancer
• Occupation
• Knowledge, Attitudes, and Practices
• Health Services Patterns
• Interventions
73
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99
HEALTH SERVICES PATTERNS (continued)
Kamaroff A, Duffell P. An evaluation of selected Federal categorical health
programs for the poor. Am J Public Health 1976; 66(3) :255-261
Kasper JA, Barrish G. National Health Care Expenditures Study, data preview
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Li F, Schlief N, Chang C, et al. Health care for the Chinese community in
Boston. Am J Public Health 1972; 62(4) :536-539
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Health Care Financing Administration, April 1982; HCFA publication no. 03128
National Cancer Institute. Surveillance, epidemiology, and end results:
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(NIH publication no. 81-2330)
National Center for Health Statistics. Annual summary of births, deaths,
marriages, and divorces: United States, 1983. Hyattsville, Maryland:
National Center for Health Statistics, 1984; DHHS publication no. (PHS)84-1220.
(Monthly vital statistics report: vol 32; no 13)
National Center for Health Statistics. Health, United States, 1983. Public
Health Service. Washington, DC: US Government Printing Office, December
1983; DHHS publication no. (PHS)84-1232
National Center for Health Statistics. Characteristics of nursing home
residents, health status, and care received. National Nursing Home Survey,
United States, May-December 1977. Hyattsville, Maryland: National Center
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National Center for Health Statistics. Health, United States, 1979.
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100
HEALTH SERVICES PATTERNS (continued)
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101
HEALTH SERVICES PATTERNS (continued)
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102
INTERVENTION
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103
Cancer Statistics Review:
Black, White, and Other
Group Comparisons
Report of the Subcommittee on Cancer, Part n
Acknowledgements
This review of cancer statistics presents selected highlights of the
cancer experience - survival, incidence, and mortality - of whites, blacks,
and other minority groups for specified time periods.
The following sections within the National Cancer Institute's Divison of
Cancer Prevention and Control are gratefully acknowledged for their
contributions to the preparation of this document:
• Cancer Control Application Branch
• Demographic Analysis Section
• Biometry Branch
106
TABLE OF CONTENTS: PART 2
Introduction to the Cancer Statistics Review
Contents, Section I 109
Introduction .110
Figures > . . . 113
Tables 114
II. Incidence and Mortality for Blacks, Whites,
and other Groups
Contents, Section II 115
Introduction 117
Figures 119
Tables 151
III. Five-year Relative Survival for Blacks, Whites,
and Other Groups
Contents, Section III . 155
Introduction 156
Figures 158
Tables 174
IV. Survival Trends: Five-year Relative Survival
by Year of Diagnosis for Blacks and Whites
Contents, Section IV > . . 175
Introduction >..,............. 176
Figures .................. 177
V. Survival Trends: Relative Survival by Numbers
of Years after Diagnosis for Blacks and Whites
Contents, Section V 183
Introduction ................. 185
Figures ..........>....... 186
VI. Trends: Comparison of Incidence, Mortality,
and Survival for Blacks and Whites
Contents, Section VI ....... 216
Introduction ,..,,,.. .... 218
Figures 220
107
VII. Distributions of Histologic Types of Cancer
for Blacks and Whites
Contents, Section VII ...... 250
Introduction ................. 251
Figures ......... 252
VIII. Five-year Relative Survival by Cancer Stage
at Diagnosis for Blacks and Whites
Contents, Section VIII 257
Introduction 258
Figures 259
108
Section I
Introduction
Discussion 110
Figures :
Surveillance, Epidemiology, and End Results (SEER) Program,
National Cancer Institute ........ 113
Tables :
Percent distribution of geographic area of all cancer cases
used in survival analysis for each ethnic group:
SEER Program, 1973-1979 114
109
Section I; Introduction
The purpose of this report is to present selected examples of cancer
statistics in order to show comparisons between blacks, whites, and other
racial and ethnic groups. This presentation displays in greater detail
than in the past comparisons of the cancer experience of these groups.
Differences between blacks and whites indicate where efforts must be directed
to address the cancer needs of blacks in order to achieve improvement in
survival and mortality.
The data presented in this report are derived from two sources.
Mortality data are obtained from the National Center for Health Statistics
(NCHS). Data tapes on all deaths in the United States are obtained annually
from the NCHS and form the basis for all of the mortality statistics.
Incidence and survival data are derived from the Surveillance, Epidemiology,
and End Results (SEER) Program of the National Cancer Institute. Cancer
incidence and patient survival data are derived from the eleven population-
based cancer registries of the SEER Program (Figure I.B-1). The patients
in SEER cover over 12 percent of the U.S. population. From 1973 to 1979,
462,613 cancer cases were diagnosed in the SEER areas; of these, 402,752
cancer cases were used for data analysis. These cases had the following
racial/ethnic distribution:
Anglo (non-Hispanic white) 87.0
Black 7.5
Hispanic 2.1
American Indian 0.3
Chinese 0.8
Japanese 1.2
Filipino 0.6
Hawaiian 0.5
100.0%
Table I. shows how these eight racial/ethnic groups of cancer cases were
distributed within the SEER geographic areas.
The SEER program began in 1973 and presently includes six entire states
(Connecticut, Hawaii, Iowa, New Mexico, New Jersey, and Utah), four large
metropolitan areas (Atlanta, Detroit, San Francisco, and Seattle) and Puerto
Rico. New Jersey joined the SEER program in late 1983 but its data are not
yet available. It is now possible to analyze changes within the time period
covered by SEER since it has been in operation for over 10 years. The
majority of the SEER data on blacks is obtained from Atlanta, Detroit, and
San Francisco.
110
Content of Report
This report is presented in 8 sections as follows:
Section I Introduction
Section II Incidence and Mortality for Blacks, Whites, and
Other Groups
Section III Five-Year Relative Survival for Blacks, Whites,
and Other Groups
Section IV Survival Trends: Five-Year Relative Survival by
Year of Diagnosis for Blacks and Whites
Section V Survival Trends: Relative Survival by Number of Years
After Diagnosis for Blacks and Whites
Section VI Trends: Comparison of Incidence, Mortality, and
Survival for Blacks and Whites
Section VII Distributions of Histologic Types of Cancer for
Blacks and Whites
Section VIII Five-Year Relative Survival by Cancer Stage at
Diagnosis for Blacks and Whites
Definitions
Rate; An expression of the frequency of an event in an entire population.
It is characterized by "counts of an event" during a specified time period.
The total number of events, the numerator is divided by the population
at risk (or mid-year population), the denominator. For example, the crude
death rate is calculated by dividing the total number of deaths registered
during the calendar year (January 1 to December 31) by the total population
at the middle of the year (July 1). This is then multiplied by 1000.
Mortality Rate: The cancer mortality rate is the number of deaths from
cancer occurring during the year in a specified population. It is expressed
as a number per 100,000 population and includes those deaths where
cancer is the reported underlying cause of death. This can be calculated
for each specific type of cancer as well as for all cancer sites combined.
Observed Survival Rate; The proportion of newly diagnosed cancer patients
surviving for a specified period of time after diagnosis.
Relative Survival Rate: The ratio of the observed survival rate for the
patient group to the expected survival rate for persons in the general
population similar to the patient group with respect to age, sex, race and
calendar year of observation. Since almost half the cancers occur in
persons 65 years of age or older, many of these individuals die of other
causes with no evidence of recurrence of the cancer. Thus, because it is
obtained by adjusting observed survival for the normal life expectancy of
the general population of the same age, the relative survival rate is an
estimate of the chance of surviving the effects of cancer. The Five-Year
Relative Survival Rate, then, can be considered the proportion potentially
curable.
Ill
Definitions (Continued)
Age-Adjusted Rate; A weighted average of the age-specific cancer mortality
(or incidence) rates, where the weights are the numbers of persons in the
corresponding age groups of a standard population. This has the effect of
eliminating differences in age distributions of two populations as a factor
in comparing their mortality (or incidence) rates for all ages combined.
For this report, the 1970 United States population is used as a standard.
Standard Error; The standard error of a survival rate indicates the amount
of sampling variability in the rate. Throughout this report, those rates
for which the standard error is greater than 10% are indicated by "**" and
those with a standard error between 5 and 10% by "*". All other survival
rates have standard errors less than 5%.
Statistical Significance; A difference in survival rates is considered
statistically significant if the probability that the difference is due to
chance is less than 5%. These are indicated by "t" throughout this report.
112
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Incidence and Mortality for Blacks, Whites and Other Groups
Discussion 117
Figures:
Age-specific Incidence and Mortality Rates,
Black and White, 1978-1981. All sites 119
Incidence Rates, Age-adjusted, Black, X^ite,
and Other Groups 1978-1981. All sites 120
Incidence Rates, Age-adjusted, Black, White,
and Other Groups 1978-1981. Selected sites:
Bladder 121
Brain and CNS 122
Breast, female 123
Buccal cavity 124
Cervix uteri 125
Colon 126
Corpus uteri 127
Kidney 128
Larnyx 129
Lung 130
Melanoma 131
Ovary 132
Pancreas 133
Prostate 134
Rectum 135
Stomach 136
Incidence Rates, Age-adjusted, for Hematopoietic
and Lymphoid cancers; Black, White, and Other groups.
1978-1981:
Hodgkin's Disease 137
Leukemia 138
Non-Hodgkin's Disease 139
115
Figures (continued)
Mortality Rates, Age-specific, Black and White; 1978-1981.
Selected Sites:
Cervix uteri 140
Colon and Rectum
Male 141
Female 142
Corpus uteri 143
Esophagus
Male 144
Female 145
Lung
Male 146
Female 147
Multiple Myeloma
Male 148
Female 149
Prostate 150
Tables:
Cancer Incidence Rates, Age-adjusted, Black, White
and Other Groups; 1978-1981; by Primary Site 151
Cancer Mortality Rates, Age-adjusted, Black, White
and Other Groups; 1978-1981; by Primary Site 152
Ratio of Black and White Incidence and Mortality Rates,
Age-Adjusted, by Primary Site 153
116
Section II; Incidence and Mortality for Blacks, Whites, and Other Groups
A. Discussion
The information about cancer incidence contained in this section is
based on SEER data collected between 1978 and 1981. Cancer incidence
rates measure the rate of occurance of new cases of cancer during a year
per hundred thousand persons in that population. The cancer incidence
rates presented here are an average of four annual cancer incidence rates:
1978, 1979, 1980, and 1981.
The cancer mortality information used in this section is taken from
national mortality data collected by the National Center for Health Statistics,
Organization of Figures and Tables
The first figure contains two line graphs presenting age-specific
incidence and mortality rates for blacks and whites for all cancer sites
combined. This is followed by a set of bar graphs showing age-adjusted
cancer incidence rates for blacks, whites, and other racial/ethnic groups.
A set of line graphs follow which compare age-specific mortality rates
for selected cancer sites for blacks and whites. The next two tables
present average annual age-adjusted cancer incidences and mortality rates
for all and selected cancer sites for blacks, whites, and other racial/ethnic
groups. The last table shows black/white ratios of age-adjusted cancer
incidence and mortality rates.
Highlights
• After ages 35-39 blacks had higher age-specific incidence rates
for all cancer sites combined than whites. This difference
increases to ages 55-59 and then decreases until ages 70-74 where
it begins to increase again.
• Blacks experienced higher age-specific mortality rates for all
cancer sites combined than whites after ages 30-34.
• Among the major racial/ethnic groups, blacks had the highest
overall incidence rate for cancer followed by Hawaiians and then
whites. American Indians had the lowest cancer incidence rate.
• Among the racial/ethnic groups for which cancer data is available:
- Blacks had the highest incidence rate for cancers of the
colon, larynx, lung, pancreas and prostate.
- Whites had the highest incidence rate for cancers of the
bladder, brain and CNS, melanoma, and pancreas. They also
had the highest incidence rates for the three heraatopietic and
lymphoid cancers: Hodgkin's disease, leukemia, and non-Hodgkin's
disease.
117
- American Indians had the highest incidence rate for cancers
of the female cervix, and kidney. They had the lowest incidence
rate for cancers of the bladder, colon, rectum, larynx, male
and female lungs, female breast, corpus, ovary, brain and CNS,
buccal cavity and the three hematopietic and lymphoid cancers:
Hodgkin's disease, non-Hodgkin's disease and leukemia.
- Hawaiians had the highest incidence rate for cancers of the
female breast, ovary, corpus, stomach and female lung.
- Puerto Ricans had the highest incidence rate for cancers of
the buccal cavity.
- Japanese Americans had the highest incidence rate for cancer
of the rectum. They had the lowest incidence rate for cancers
of the cervix and multiple myeloma.
- Hispanics had the lowest incidence rate for cancer of the
esophagus.
- Chinese Americans had the lowest incidence rate for cancer
of the prostate gland.
- Filipinos had the lowest incidence rate for cancers of
the kidney and stomach,
• Blacks were nearly four times as likely as whites to have cancer
of the esophagus and more than twice as likely to have multiple
myelomas.
• Black females were more than twice as likely as white females
to have cancer of the cervix uteri.
• Blacks had a mortality rate that was over three times the rate of
whites for cancer of esophogus and more than twice the mortality
rate of whites for cancers of the cervix uteri, prostate gland,
and multiple myeloma.
118
WHITES RND ELRCK5, 1978-81
RLL SITES
nGE SPECIFIC INCIDENCE RATES
2100-1
22D0-
2000-
leoo-
o
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1600-
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1200-
1000-
600-
600-
100-
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0-
Legend
^ BLACK
X WHITE
T 1 1 1 1 1 r
4 10-M 20-24 30-34 40-44 50-54 60-54 70-74 80-64 85*
AGE
1500 n
1400-
1200-
RGE SPECIFIC MORTRLITY RRTE5
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119
1978-81 INCIDENCE^ ALL SITES
RATE PER lee.eee
e 200 400
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anex^ican Indians
Hispanics CN.M.>
Puerto Rico
120
1978-81 INCIDENCE. BLADDER
RATE PER lee^eee
e 10 20
Uhites
Blacks
Chinese
Japanese
Fil ipinos
Hawaii ans
Anerican Indians
H i span i cs ( N . M . >
Puerto Rico
121
1978-81 INCIDENCE, BRAIN & CNS
RATE PER lee^oee
e 5 10
Uhi tes
Blacks
Chinese
Japanese
Fi lipinos
Hawai ians
Awe vi can Indians
H i span i cs < N . M . >
Puerto Rico
122
1978-81 INCIDENCE,
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hafttfai ians
Anerican Indians
Hispanics CN.M.>
Pueic^to Rico
BREAST, FEMALES
RATE PER 180,000
O 60 120
123
1978-81 INCIDENCE, BUCCAL CAUITV
RATE PER lee^eee
e 10
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anex^ican Indians
Hispanics CN.M.>
Puex^to Rico
20
124
1978-81 INCIDENCE,
Uhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anex^ican Indians
Hispanics <N.M.>
Puerto Rico
CERUIX, FEMALES
RATE PER 100,000
O 15 30
125
1978-81 INCIDENCE, COLON
RATE PER lee^eee
e 20 40
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Aneie^ican Indians
Hispanics (N.M.>
Puex^to Rico
126
1978-81 INCIDENCE,
Uhi tes
Blacks
Chinese
Japanese
Fi lipinos
Hawaii ans
Anerican Indians
Hispanics <N.M.>
Puerto Rico
CORPUS. FEMALES
RATE PER 100, eee
e 15 30
127
1978-81 INCIDENCE, KIDNEV
RATE PER 100,800
O 5
Uhites
Blacks
Chinese
Japanese
Filipinos
HaMai ians
Aner^ican Indians
Hispanics <N.M.>
Puerto Rico
10
128
1978-81 INCIDENCE, LARVNX
RATE PER 108,000
O 5 10
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Aneif^ican Indians
Hispanics CN.M.>
Puerto Rico
129
1978-81 INCIDENCE, LUNG
RATE PER lee^eee
e 40
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anepican Indians
Hispanics CN.M.>
Puerto Rico
88
130
1978-81 INCIDENCE, MELANOMA
RATE PER 108, eee
e 5
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anepican Indians
Hispanics <N.M.>
Puerto Rico
10
131
1978-81 INCIDENCE, OUARV. FEMALES
RATE PER lee^eee
Q le
20
Uhiti
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Aneic^ican Indians
Hispanics <N.N.>
Pue]c*to Rico
132
1978-81 INCIDENCE, PANCREAS
RATE PER lee^eee
0 10
Whites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Aneir^ican Indians
Hispanics (N.M.>
Pueic^to Rico
20
133
1978-81 INCIDENCE^
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anex^ican Indians
Hispanics <N.M.>
Puex«to Rico
PROSTATE, MALES
RATE PER 100,008
O 70 140
134
1978-81 INCIDENCEj, RECTUM
RATE PER 100. eee
e le
i4hites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anepican Indians
H i span i cs < N . M . >
Puerto Rico
20
135
1978-81 INCIDENCE, STOMACH
RAtE PER 100,800
0 20 40
Mhi tes
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anerican Indians
Hispanics <N.M.>
Puerto Rico
136
1978-81 INCIDENCE, HODGKIN'S DISEASE
RATE PER lee^eeo
e 2
Mhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hai#ai ians
Aneic^ican Indians
H i span i cs < N . M . >
Puerto Rico
137
1978-81 INCIDENCE. LEUKEMIA
RATE PER lee^eee
o 5 le
Uhiti
Blacks
Chinese
Japanese
Filipinos
Hawaii ans
Anerican Indians
Hispanics <N.M.>
Puerto Rico
138
1978-81 INCIDENCE, NON-HODGKIN' S
RATE PER lee^eee
e 8
Uhites
Blacks
Chinese
Japanese
Fi 1 ipinos
Hawai ians
Anepican Indians
H i span i cs ( N . M . >
Puerto Rico
16
139
AGE-SPECIFIC CFINCER HORTflLITY RFlTES PER 100,000
UNITED STRTES, 1978-81
50"
FEnflLES, CERVIX UTERI
40--
-■ BLACKS
30"
o
o
o
o
o
2
tL
20"
10"
WHITES
0- 4 lO-l-t 20-24'30-34-^0-J-* 50-5-4 eO-e-tZO-Z-* 80-84 85+
RGE
140
RGE-SPECIFIC CANCER HORTRLITY RRTES PER 100,000
UNITED STRTES, 1978-81
500
MflLES, COLON ♦ RECTflL CflNCER
400- -
-■ BLflCKS
300 --
o
o
o
»
o
o
§ 200
S
100 -■
WHITES
0 ' J J.,!. J-J-J-J-Tr
0- 4 10-H 20-24 30-34 40-44 50-54 60-64 70-74 80-84 85*
W
141
AGE-SPECIFIC CANCER HORTfiLITY RATES PER 100,000
UNITED STATES, 1978-81
500 -r
FEMfiLES, COLCW * RECTfiL CflNCER
400"
-■ BLACKS
300 --
o
o
o
o
o
s
a.
200"
100"
UHITES
0- ^' 10-14 '20-24 '30-3'^'*0-M'50-5'f60-64'70-71 '80-84 '85 +
142
AGE-SPECIFIC CANCER MORTALITY RATES PER 100,000
UNITED STATES, 1978-81
50--
FQIflLES, CORPUS UTERI
-10--
BLflCKS
30--
o
o
o
o
o
2
UJ
1-
20--
10--
WHITES
0- 4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 '85^
AGE
143
AGE-SPECIFIC CANCER rtORTALITY RATES PER 100,000
UNITED STATES, 1978-81
100 --
WILES, ESCFHflGEflL CflNCER
SO-
SO--
-• BLACKS
70--
60--
o
o
o
50
o
r-t
§
^o
LU
s
30
20--
10--
WHITES
/N
/ ^
0- 4'lO-14'20-24'30-3'*40-54'50-54 60-64'70-74 80-84 iB5*
144
AGE-SPECIFIC CANCER rtORTflLITY RATES PER 100,000
UNITED STATES, 1978-81
50"
FEMflLES, ESOPHflGEflL CflNCER
40--
-• BLACKS
30-.
o
o
o
*
o
o
i
20"
10
WHITES
I..I. .1
0- 4 lO-l-f 20-24 30-34 40-44 50-54 60-64 70-74 80-84 85*
'S^
145
RGE-SPECIFIC CflNCER MORTRLITY RATES PER 100,000
UNITED STATES, 1978-81
500"
flflLES, LUNG CflNCER
400"
" BLACKS
300"
o
o
o
o
o
a.
200"
100"
WHITES
0- 4'l0-14'20-24'30-34'ipi:54 50-54'60-64'70-74 80-84'85*
146
AGE-SPECIFIC CflNCER nORTFILITY RRTES PER 100,000
UNITED STATES, 1978-81
100"
FEMflLES, LUNG CPINCER
80"
" BLflCKS
60"
o
o
o
o
o
40"
20"
WHITES
0- ^'iO-m'eO-E^'SO-S'^'K)^^ 50-54 60-64 70-74 80-84 185+
147
RGE-SPECIFIC CaNCER nORTflLITY RATES PER 100,000
UNITED STRTES, 1978-81
100 -r
rtflLES, nULTIPLE nVELOnfl
90"
80--
" BLflCKS
70--
60
o
o
o
o
50
o
■n
0.
-^0
UJ
<L
OC
30
20--
10--
WHITES
/ N
-I 1 |--f-
0- 4 10-1-^ 20-2-^ 30-3-^ ^O-f-^ 50-5-^ 60-64 70-74 80-84 85 +
AGE
148
AGE-SPECIFIC CANCER nORTRLITY RATES PER 100,000
UNITED STATES, 1978-81
50 J
FEflFILES, MULTIPLE MYELOnfl
40"
BLFICKS
30"
o
o
o
o
o
2
hi
I-
20"
10"
WHITES
/v
0- 4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 85+
AGE
149
AGE-SPECIFIC CANCER nORTALITY RATES PER 100,000
UNITED STATES, 1978-81
1000 --
MALES, PROSTATIC CfiNCER
900"
800- -
-■ BLACKS
700 -■
600"
o
o
o
o
o
: 500"
§ 400"
i
2 300 +
EOO
100"
WHITES
rt-efi
0- 4 10-14 20-24 30-34 40-d4 50-54 60-64 70-74 80-84 85*
AGE
150
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Ratio of black to white age-adjusted (1970 U.S. standard)
cancer incidence and mortality rates by primary site,
Surveillance, Epidemiology, and End Results Program
1978-81
Primary site
All sites
Esophagus
Colorectal
Colon
Rectum
Pancreas
Larynx
Lung - male
- female
Breast
Cervix uteri
Prostate gland
Multiple myeloma
Incidence
Mortality
rates
rates
1.11
1.27
3.89
3.47
1.00
1.03
1.10
1.04
.78
1.00
1.53
1.31
1.43
1.92
1.47
1.32
1.08
1.00
.84
.99
2.30
2.75
1.60
2.09
2.30
2.08
153
154
Section III
Five-Year Relative Survival for Blacks, Whites, and Other Groups
Discussion 156
Figures:
Five-year Relative Survival Rates, All Sites,
Males and Females; Black, White, and
Other Groups. 1973-1981 158
Five-year Relative Survival Rates, Selected Sites
Black, White, and Other Groups. 1973-1981:
Bladder 159
Breast, female 160
Cervix uteri 161
Colon 162
Colon and rectum 163
Esophagus 164
Larynx 165
Lung and bronchus 166
Lung and bronchus, male . 167
Lung and bronchus, female 168
Multiple myeloma 169
Pancreas 170
Prostate 171
Rectum 172
Stomach 173
Tables ;
Five-year Relative Survival Rates by Site,
Black, White, and Other Groups, 1973-1981 174
155
Section III: Five-Year Relative Survival Fot Blacks, Whites, and Other
Groups
A. Discussion
This section presents information about the relative five-year cancer
survival patterns of blacks, whites, and other racial/ethnic groups. The
survival rates shown represent the percent of persons with cancer who are
alive five years after diagnosis. This information comes from the reports
of patients first diagnosed within SEER geographic areas 197 3-81. The
term Anglo as shown in the bar graphs and tables in this section is
synonymous with white.
Organization of Figures and Tables
The first figure is a bar graph that compares the five-year relative
survival rates for cancer, all sites combined, for blacks, whites, and
other groups. This is followed by a set of bar graphs showing five-year
relative survival rates for selected cancer sites for the same groups. The
information presented in these bar graphs is combined into one table at the
end of this section.
Highlights
• The five-year relative survival rate for Japanese Americans was
51%, the highest rate among the eight racial/ethnic groups presented,
Whites, or Anglos, had the next highest rate, (50%) and Native
Americans had the lowest overall five-year relative survival rate
(34%).
• Among the major racial/ethnic groups presented:
- Chinese Americans had the highest five-year relative survival
rate for cancers of the esophagus, lung and bronchus for men, and
bladder (along with whites).
- Japanese Americans had the highest five-year relative
survival rate for cancers of the female breast, colon and
rectum, multiple myeloma, and stomach.
- Hawaiians had the highest five-year relative survival rate
for cancers of the cervix uteri, larynx, lung and
bronchus for women, and prostate.
Blacks had the lowest five-year relative survival rate for
cancers of the cervix uteri and esophagus.
- Filipinos had the lowest five-year relative survival rate for
cancers of the colon, larynx, and lung and bronchus for women.
156
Highlights (Continued)
- Hispanics had the lowest five-year relative survival rate for
multiple myeloma.
- Native Americans had the lowest five-year relative survival
rate for cancers of the bladder, female breast, colon and rectum,
lung and bronchus for men and women combined, lung and bronchus
for men, prostate, rectum, and stomach.
The lowest five-year relative survival rates among all racial/
ethnic groups were for cancers of the pancreas. Only 2 to 3 percent
of persons diagnosed with pancreatic cancer within each group were
alive after five years.
157
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174
Section IV
Survival Trends: Five-year Relative Survival by Year of Diagnosis,
Blacks and Whites. 1973-1975 and 1976-1981
Discussion 176
Figures :
Five-year Relative Survival Rates by Year of Diagnosis,
Blacks and Whites, 1973-1975 and 1976-1981.
All sites combined 177
Five-year Relative Survival Rates by Year of Diagnosis,
Blacks and Whites, 1973-1975 and 1976-1981.
Selected sites:
Bladder 178
Breast, female 179
Colon 180
Prostate 181
Rectum 182
175
Section IV - Survivlal Trends: Five-year Relative Survival by Year of
Diagnosis, 1973-75 and 1976-81, for Blacks and Whites
A. Discussion
The survival information presented in this section is based on SEER
data collected from 197 3-81. Cancer survival trends are shown by presenting
a series of bar graphs comparing black and white five-year relative survival
rates for two time periods, 197 3-75 and 1976-81.
Organization of Figures and Tables
The first graph compares black and white five-year relative survival
rates for cancer, all sites combined. The graphs that follow compare these
rates for five selected cancer sites.
Highlights ,
• Overall survival rates for cancer increased slightly for both blacks
and whites over the two time periods, 1973-75 and 1976-81.
• Blacks had substantial increases in survival rates for cancers
of the bladder, prostate, and rectum.
• The gap in cancer survival rates between blacks and whites, where
blacks had significantly lower survival rates than whites, narrowed
from 1973-75 to 1976-81 for cancers of the bladder and rectum. The
gap increased slightly for cancers of the female breast, colon, and
prostate.
176
tr
(7.) 3iuy lyAiAdns
177
m
17.) 3iyy lyAiAyns
178
O X J
0^ X (D
or
(X) 3iud nyAiAyns
179
o -
or
(7. J 3iyy lUAiAyns
180
a:
['/.] 3iyy ibiAiAyns
181
^11
['/.] 3iuy nuAiAyns
182
Section V
Survival Trends: Relative Survival by Year of Diagnosis and
Number of Years After Diagnosis, Blacks and Whites, 1973-1975 and
1976-1981.
Discussion 185
Figures :
Relative Survival Rates by Year of Diagnosis and
Number of Years After Diagnosis; 1973-1975 and 1976-1981.
All sites:
Black 186
White 187
Relative Survival Rates by Year of Diagnosis and
Number of Years After Diagnosis and 1973-1975 and 1976-1981.
Selected sites:
Bladder
Black 188
White 189
Breast, female
Black 190
White 191
Cervix uteri
Black 192
White 193
Colon
Black 194
White 195
Colon and Rectum
Black 196
White 197
Esophagus
Black 198
White 199
Larynx
Black 200
White 201
183
Figures (continued)
Lung and Bronchus , male
Black 202
White 203
Lung and Bronchus , female
Black 204
White 205
Multiple Myeloma
Black 206
White 207
Pancreas
Black 208
l^ite 209
Prostate
Black 210
White 211
Rectum
Black 212
White 213
Stomach
Black 214
White 215
184
Section V: Survival Trends:
Relative Survival by Year of Diagnosis and Number of Years
after Diagnosis, 1973-1975 and 1976-1981, for Blacks and
Whites
A. Discussion
In this section relative cancer survival rates for blacks and whites
are presented by the number of years after a diagnosis of cancer is made.
These rates are compared for two time periods 1973-75 and 1976-81. The
data come from SEER reports.
Organization of Figures
This section contains a set of line graphs that compare survival
patterns for primary cancer sites for two time periods. Black and white
survival patterns are shown on seperate graphs. The first two graphs
present overall cancer survival patterns for blacks and whites. These are
followed by a series of graphs showing black and white survival patterns
for primary cancer sites.
Highlights
• The overall cancer survival pattern for blacks was virtually
unchanged from 1973-75 to 1976-81. Blacks experienced similar
survival rates each year after diagnosis for the two time periods.
Whites, however, had slightly higher survival rates in 1976-81 than
1973-75 for each year after diagnosis.
• Blacks had substantial increases in survival from 1973-75 to 1976-81
three, four, and five years after diagnosis for cancer for the
esophagus.
185
ALL SITES
SEER RELATIVE SURVIVAL RATES BY YEAR OF DL^GNOSIS
2 3 4
YERRS RFTER DIRCNOSIS
NOTE: BLRCK MRLCS I TEMRLES
186
100
ao
?<
]^ .0
(Z
W3
20
10
ALL SITES
SEER RELATIVE SURVIVAL RATES BY YEAR OF DL^GNOSIS
1973-75
1976-8 I
-1100
- 80
40
20
10
0 12 3 4
YEARS AFTER DIAGNOSIS
NOTC: WHITE MALES L FEMALES
187
BLADDER
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
bJ
*- 40
>
oc
=> 20
10
100
•0
40
20
1973-75
1976-BI
10
2 3 4
YERRS RFTER DIRDNOSIS
NOTE: BLRCK MflLCS I PEMflLES
188
BLADDER
SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
80
UJ
(X
at
40 ■
(A
20
10
I
YEARS AFTER DIAGNOSIS
NOTE: WHITE MRLES i. FEMflLES
1973-75
l97S-ai
100
-I 80
40
20
- to
189
BREAST
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
t- 40'
>
3 so-
lo
10 -
100
•0
40
30
1973-75
1976-81
10
2 3 4
YERRS RFTER DIRDNOSIS
NOTE: BLfiCK rCHRLCS
190
BREAST
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
UJ
s
40-
>
=> JO-
V3
10
1973-75
1976-8 J
100
•0
- 40
20
10
2 3 4
TERRS RFTER DIAGNOSIS
NOTE: WHITE TEflFILE:
191
CERVIX UTERI
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
^J
UJ
»- 40-
(E
a:
0£
3 20-
10-
100
•0
- 40
- 20
1973-75
1976-81
10
2 3 4
YEARS AFTER DIADNOSIS
NOTE: BLACK PCMRLCS
192
UJ
H. 40
oc
10 -
CERVIX UTERI
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
NOTE: WHITE FEMRLES
2 3 4
YEARS AFTER DIAGNOSIS
1 973-75
lS76-ai
- 100
- 80
- 40
20
. .<
193
COLON
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
»- 40 -
c
U3
20 -
10 -
100
•0
40
30
I973--75
1976-81
10
YERRS RFTER DIflDNOSIS
NOTE: BLfiCK MALES I TEMflLES
194
COLON
SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS
n:
H- 40
cr
W3
20 -
to -
1973-75
l976-ei
-1100
- 80
- 40
20
10
0 12 3 4
YEARS AFTER DIAGNOSIS
NOTE: WHITE MALES k FEnflLES
195
COLON/T^ECrUM
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
»-> 40
cr
a.
>
>
10
100
•0
40
20
1 SIS-IS
isie-ai
10
2 3 4
YERRS RFTER DIRDNOSIS
NOTE: BLACK MflLEB L rCMRLES
196
COLON/RECTUM
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
»-> 40
>
>
20 -
10
t973-7S
>87S-«t
1 I I
2 S 4
YEARS AFTER DIflGNOSIS
NOTE: WHITE MRLES i TEnflLES
100
BO
40
20
10
197
ESOPHAGUS
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
a
>
>
2 3 4
YERRS RFTER OIRDNOSIS
NDTE: BLRCK MRLES I TEMRlES
198
ESOPHAGUS
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YEARS AFTER DIflONOSIS
NOTE: WHITE MALES L TEMflLES
199
LARYNX
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
N!
UJ
H- 40-
S
>
>
3 so-
lo
10-
100
10
40
20
1973-75
lS7B-ei
10
2 3 4
YERRS RFTER DIRGNOSIS
NOTE: BLRCK MALES I TEMRlES
200
LARYNX
SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
100
x
t- 40 ^
c
oe.
a.
3 20
U3
10 -
-t 100
ao
- 40
- 20
J 973-75
1976-Sl
10
2 3 4
YEARS AFTER DIflCNOSIS
NOTE: WHITE MALES I TEMRLES
201
LUNG Sc BRONCHUS
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YEARS RFTER DIRGNOSIS
NOTE: BLRCK MFILCS
202
LUNG &c BRONCHUS
SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
YEARS AFTER OIAONOSIS
NOTE: WHITE MALES
203
LUNG AND BRONCHUS
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3
YERRS RFTER DIRDNOSIS
NOTE: BLRCK rCnflLCS
204
LUNG &: BRONCHUS
SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YEARS AFTER DIAGNOSIS
NOTE: WHITE FEMALES
205
MULTIPLE MYELOMA
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YERRS RFTER DIRGNOSIS
NOTE: BLACK MflLES I TEMRLES
206
MULTIPLE MYELOMA
SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS
■H 100
. 80
- 40
- 20
10
2 3 4
YEARS RFTER DIflONOSIS
NOTE: WHITE MALES i FEMALES
207
PANCREAS
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
cc
K
a
>
>
D£
2 3
YEARS RFTER DIRGNOSIS
NOTE: BLACK MALES L TEMflLES
208
V.B-24
PANCREAS
SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YEARS AFTER DIfiCNOSIS
NOTE: WHITE MALES I TEMRLES
209
V.B-25
PROSTATE
SEER RELATIVE SURVIVAL RATES BY YEAR OF DUGNOSIS
M
Ui
»- 40
(E
V3
so-
lo H
100
•0
- 40
20
J973-7S
IS^E-Bl
2 3 4
YEARS RFTER DinGNOSIS
10
NOTE: BLACK MALES
210
UJ
(O
20 •
10
V.B-26
PROSTATE
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
NOTE: WHITE MALES
2 3 4
YEARS AFTER DIAGNOSIS
100
J ao
• 40
1973-75
1976-81
• 20
10
211
RECTUM
4
SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS
2 3 4
YERRS RFTER DlflDNOSIS
NOTE: PLfiCK MALES L TEnflLES
212
cc
>
DC
V>
40
20
10
RECTUM
SEER RELATIVE SURVIVAL RATES BY YEAR OF DUGNOSIS
-tioo
- 80
- 40
- 20
1976-ai
2 3 4
YEARS AFTER DIAGNOSIS
NOTE: WHITE MALES L FEMflLES
10
213
STOMACH
SEER RELATIVE SURVIVAL RATES BY YEAR OF DL^GNOSIS
2 3
YERRS RFTER DIRGNOSIS
NOTE: BLRCK nflLES i rCMRLES
214
STOMACH
SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS
2 9 4
YERRS RFTER OIRCNOSIS
note:: white nflLES i rEMflLES
215
Section VI: Trends
Comparisons of Incidence, Mortality, and Survival for Blacks and Whites
Discussion 218
Figures:
Annual Five-year Relative Survival Rates and
Annual Age-adjusted Incidence and Mortality Rates
by Year of Diagnosis.
All sites:
Black 220
White 221
Annual Five-year Relative Survival Rates and
Annual Age-adjusted Incidence and Mortality Rates
by Year of Diagnosis.
Selected sites:
Bladder
Black 222
White 223
Breast , female
White 224
Black 225
Cervix uteri
Black 226
White 227
Colon
Black 228
White 229
Colon/Rectum
Black 230
White 231
Esophagus
Black 232
White 233
Larynx
Black 234
White 235
216
Figures (continued)
Lung and Bronchus, male
Black 236
White 237
Lung and Bronchus , female
Black 238
White 239
Multiple Myeloma
Black 240
White 241
Pancreas
Black 242
White 243
Prostate
Black 244
White 245
Rectum
Black 246
White 247
Stomach
Black 248
White 249
217
•
Section VI; Trends; Comparison of Incidence, Mortality, and Survival for
Blacks and Whites
A. Discussion
The purpose of this section is to illustrate the complex set of
interrelationships among cancer incidence, survival, and mortality for blacks
and whites. As indicated earlier, cancer incidence rates measure the rate
of occurrence of new cases of cancer during a year per hundred thousand
persons in the population; cancer patient survival rates measure the
proportion of cases, first diagnosed during a particular period of time,
surviving for specific lengths of time following diagnosis, usually adjusted
for the effect of deaths from other causes; and cancer mortality rates, the
rate of deaths during the year with cancer given as the underlying cause of
death per hundred thousand population. The survival rate for a particular
cancer can be affected by changes in the incidence of that cancer. Changes
in incidence and/or survival for a particular cancer over time can result
in changes in the mortality rate for that cancer. The following are examples
that will illustrate some of the relationships among these measures.
1) The incidence rate for a specific cancer can change over time due to
changes in the prevalence of risk factors for that cancer. For
example, increases in the prevalence of cigarette smoking among white
males during the first half of this century has resulted in sharp
increases in the incidence of lung cancer. Changes in the smoking
practices in this group, particularly following the Surgeon General's
report on smoking in 1964, has resulted in a decrease in the incidence
of lung cancer among white males under 45 years of age in the past
few years and there is an indication that this trend is beginning to
extend to older age groups.
2) For a cancer with a low survival rate, such as lung cancer, an increase
in the incidence rate is accompanied, with a very short time lag, by a
corresponding increase in the mortality rate.
3) If an increasing number of less severe cases of a particular cancer
are identified, this will have the effect of increasing the 5-year
relative survival rate for that cancer. This may be the explanation
for example, for the rapid increase in incidence of melanomas among whites
over the past few years, accompanied by an increase in 5-year relative
survival rates.
4) An improvement in survival rates over time, particularly in the absence
of any changes in the incidence rate, will result in decreases in the
mortality rate. A dramatic example of this was a sharp reduction in
mortality from testicular cancer due to a huge increase in the survival
rate for that cancer in the mid 1970's.
Data Sources
The data presented in this section pertain entirely to the period
covered by the SEER Program. For each cancer, the 5-year relative survival
218
Data Sources (Continued)
rate is presented for black and white patients first diagnosed during each
year 197 3-77. The corresponding SEER incidence rates and U.S. mortality
rates are presented for each year from 1973-81. (Mortality rates for all
SEER areas combined for each cancer, follow very closely those for the
United States). By examining these three measures on a single page, for a
given cancer, the reader can obtain a better understanding of the trends
for that cancer than would be possible by examining each of these measures
in isolation. The reader should be cautioned, however, that the observed
measures for a particular time period are also influenced by events occurring
during that time period. Because of long latent periods for the effect of
some risk factors to appear as cancers, the incidence rate for a particular
cancer may increase or decrease due to changes in the risk factors a number
of years earlier. The number of persons dying of a particular cancer during
a given year include not only those who were first diagnosed during that
year but also a number who had been diagnosed in earlier years. Care should
be used when comparing the graphs between blacks and whites because the
vertical axes are not always identical. These factors must be kept in mind
when reviewing the data on the following pages.
Organization of Figures
In this section a set of figures are presented that contain incidence,
mortality, and five-year survival information by year of diagnosis. Black
and white data are shown seperately. The first two figures present this
data for all sites of cancer, combined, for blacks and whites; these are
followed by Similar figures for selected cancer sites.
219
ALL SITES
«n
FIVE YEAR RELATIVE SURVIVAL RATES
r
77
T
78
75 76
YEAR OF DIAGNOSIS
T
79
-r
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
tooo-
800-
o
o soo-
o
o
o
— 400 H
a.
bJ
IHCIOENCE
200'
100'
nORTRLiTT
73
75
NOTE: BLACK MALES 1 TEMRLES
^■»— — —i^MI ..-
77 79
YEAR OF DIAGNOSIS
220
1000
soo
800
400
VLf
200 %a
Z 100
81
ALL SITES
FIVE YEAR RELATIVE SURVIVAL RATES
az
CO
60-1
55-
50-
45-
40-
35-
/5 76
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
o
•
o
o
UJ
0-
UJ
►—
<r
OS
1000-
800-
600-
400-
200-
100-
INCIOENCE
wwww^fmuiH-^^—m—JSSS
^1000
- 800
- 600
nORTRLJTT
73
— r"
76
— 1-
77
400
REF
200
nr
' 100
79
81
NOTE: WHITE MALES i FEMALES
YEAR OF OlflONOSIS
221
BLADDER
FIVE YEAR RELATIVE SURVIVAL RATES
60-1
76 77 78
YEAR OF DIAGNOSIS
r
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
100 -
BO -
40 -
20 -
10
• -i
2 -
I -
iNCIOENCE
nonrntlTT
73 7S
NOTE: BLfiCK nflLES 4 rcnflLES
77
YEAR OF DIflCNOSIS
222
— r-
79
-IIOO
80
40
:« «
20 -
to
8
KEf
4 «Ef
- 1
81
BLADDER
FIVE YEAR RELATIVE SURVIVAL RATES
80-1
75 76 77 78 79
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
o
a
o
100 -
BO -
40 .
20
a. 8 -
UJ
2 -
I -
INCIDENCE
nORTRLJTT
73
— T-
75
-{100
- SO
40
77
79
YEAR OF DIflONOSIS
20
KEF
10
8
«£f
81
NOTE: WHITE MALES i FEMflLES
223
BREAST
FIVE YEAR RELATIVE SURVIVAL RATES
75 76 77
YEAR OF DIAGNOSIS
61
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
]00-
■0-
g "1
o
o
o
« 40-
• 5
JO-
10
INClDENCe
nORTBLITT
73
WOTE: BLACK rCnfltCS
75
77 73
TERR OF OlflGNOSIS
224
100
•0
10 '
>Ef
-40
Rcr
20
10
81
BREAST
80 n
riVE YERR RELATIVE SURVIVRL RRTE5
75 76 71 78 79
YEAR or DIRGNOSIS
80
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
73
76
NOTC: WHITE rCnfl^CS
100-
•0.
10-
_,^^- — .
^,
,
-
o
o
o
•
INCIDENCE
-
o
o
40-
.
Ul
0.
so-
nORTBLlTT
-
10-
_^
77
79
YEAR OF DIRGNOSIS
BO "ET
- 10
- 40
RCf
- 20
81
225
CERVIX UTERI
FIVE YEAR RELATIVE SURVIVAL RATES
75 n
75 76 77 78
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES
too -
80 -
40 -I
o
o
o
O 20
o
K to .
^ ■ -
4 -
2 -
INCIDENCE
nORTflUJTT
73
75
77
— r-
79
100
80
40
REF
20
ȣf
10
8
81
NOTE: BLACK TEnflLES
YEAR OF DIAGNOSIS
226
CERVIX UTERI
FIVE YEAR RELATIVE SURVIVAL RATES
75-1
76 77 78 79
YEAR OF DIAGNOSIS
r
80
T
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
100 -
80 -
o
o
a 20
o
a.
UJ
10
s
4 -
2 -
I -
INCIDENCE
-1100
. 80
• 40
- 20
REF
10
8
REF
YEAR OF DIAGNOSIS
NOTE: WHITE TEMflLES
227
COLON
FIVE YEAR RELATIVE SURVIVAL RATES
55 n
><:
a:
>
73
75 76 77 78 79
YEAR OF DIAGNOSIS
80
T-
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
o
(0'
JO-
to-
T-
73
nOHTflUITT
I
7S
NOTE: BLACK HflLCS 4 TEMRLES
— r-
77
79
YEAR OF DIAGNOSIS
228
100
- ao
so
- «0
20
nr
RCF
d 10
81
COLON
FIVE YERR RELATIVE SURVIVRL RATES
55 H
73 74
75 76 71 78 79
YEAR OP DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCffiENCE AND MORTADTY RATES
o
o
o
100
80
60
o
o
M 40
K
0-
« 20
10
73
INCIOENCE
nORTRLJTT
75
77 79
YEAR OF DIAGNOSIS
-| too
- 80
60
40
.JL i
HEF
20
REF
- 10
81
nc:l: wh]:[, «^LC^. i T^iRLf.?.
229
COLON/RECTUM
FIVE YEAR RELATIVE SUKVIVflL RATES
SSn
75 76 77 78 79
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
o
as
UJ
UJ
(X
100-
80-
«0-
10-
T-
73
INCIDENCE
nORTBLITT
— r-
7S
NOTE: BLACK MALES I TEMflLES
77 79
YEAR OF OlflGNOSIS
230
- 100
- 80
- SO
- . BET
- «0
:o
RET
10
SI
COLON/RECTUM
FIVE YERR RELATIVE SURVIVAL RATES
55-1
75 76 77 78 79
YEAR OF DIAGNOSIS
80
T
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALnT RATES
o
o
100-
80-
60-
o
^ 40
K
(U
a.
UJ
H-
(Z
20-
10-
73
INCIDENCE
nORTPUITY
I
75
77 79
YEAR OF DIflONOSIS
HI 00
80
H 60
Rcr
40
t%f
20
- 10
81
note:: white MflLCS I PEMflLES
231
ESOPHAGUS
20-1
- 15-
LJ
q:
10-
>
3
FIVE YEAR RELATIVE SURVIVAL RATES
^
^
P^^
73 74 75 7fi i7 78 79
YEAR OF DIAGNOSIS
80
I
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
10
B
I -
O
0.
I—
2 -
I -
73
7S
NOTE: BLACK HflLCS t TEnRLES
77
YEPR OF OlflGNOSIS
232
73
-
-
INCtOENCE
-
nORTBLiTT
1
T
-
10
a
nir
81
20-1
:. 15-
az
>
«n
10-
ESOPHAGUS
FIVE YERR RELATIVE SURVIVAL RATES
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
o
o
o
OS.
UJ
0.
LU
10 -
8 -
6 -
4 -
2 -
1 -i
INCIDENCE
. ■ ■ ^ . . . .
fc»»i
nORTBLITY
73
— T-
75
77 79
YEAR OF DIAGNOSIS
-llO
- 8
- 6
- 1
81
NOTE: WHITE MALES i TEMflLES
233
LARYNX
FIVE YEAR RELATIVE SURVIVAL RATES
UJ
i—
cc
>
>
80-1
75-
70-
55-
60-
55-
50-
45-
40-
35-
30 d
0=C
i^^^^^^ t^^y^^A y^^^^^ zy^y^^.^ Y-y'y^y^^yi
I
78
73 7\ 75 75 77 78 79
YEAR OF DIAGNOSIS
"T-
80
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES
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nORTflLiTT
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NOTE: BLACK MFILES i TEnfiLES
— T-
77
79
YEAR OF DIAGNOSIS
234
81
-110
■
%tf
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- I
LARYNX
FIVE YEAR RELATIVE SURVIVAL RATES
6—
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75 76
YEAR or DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES
10 H
8 -
O
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73
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NOTE: WHITE MALES I FEMflLES
-|tO
- B
- 6
REF
- 4
REF
77
79
81
YERR OF DIAGNOSIS
235
LUNG &: BRONCHUS
FIVE YEAR RELATIVE SURVIVAL RATES
15-1
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100 «Cf
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NOTE: BLACK nflLES
236
LUNG &c BRONCHUS
FIVE YEAR RELATIVE SURVIVAL RATES
(T.
en
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YEAR OF DIAGNOSIS
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
77 79
YEAR OF OlflGNOSIS
NOTE: WHITE nflLES
237
LUNG AND BRONCHUS
20-1
FIVE YEAR RELATIVE SURVIVAL RATES
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YEAR or DIAGNOSIS
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60
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TERR OF DIAGNOSIS
NOTE: BtRCK rCnflLES
238
LUNG &c BRONCHUS
FIVE YEAR RELATIVE SURVIVAL RATES
20-1
75 76 77 78
YEAR OP DIAGNOSIS
r
79
80
1
81
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40
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REF
ur
I I I r
d 10
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NOTE: WHITE PEMflLES
239
MULTIPLE MYELOMA
FIVE YEAR RELATIVE SURVIVAL RATES
40 n
75 76 71 78 79
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
%tf
KU
NOTE: BLRCK MflLCS i rCMHLES
YERR OF DlflONOSIS
240
MULTPLE MYELOMA
FIVE YEAR RELATIVE SURVIVAL RATES
30-1
a:
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NOTE: HH]TE MALES i TEMRLES
241
PANCREAS
25 ^
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FIVE YEAR RELATIVE SURVIVAL RATES
74
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80
I
81
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NOTE: BLACK HPILCS I TEMflLES
YEAR OF DIAGNOSIS
242
PANCREAS
25-1
20-
t^ IS
cc
10-
5-
^
^
FIVE YEAR RELATIVE SURVIVAL RATES
^
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YEAR OF DIAGNOSIS
— r-
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NOTE: WHITE MALES i FEnflLES
=»===2=»=
77 79
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243
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PROSTATE
FIVE YEAR RELATIVE SURVIVAL RATES
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YEAR or DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES
1000 -
800 •
NOTE: BLACK MflLES
YEAR OF DIflGNOSIS
244
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80 n
75-
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75 76 77 78 79
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80 81
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JOO -
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INCIDENCE
■*■■ "■■■
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NOTE: BLACK MALES 1 TEMPLES
saa*>
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YFRR OF DIflCNOSIS
246
>^^a
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•4 10
40
20
— r
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to
■
RET
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RECTUM
FIVE YEAR RELATIVE SURVIVAL RATES
55-1
76 77 78 79
YEAR OF DIAGNOSIS
80
T
81
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES
o
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— T"
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I
79
YEAR OF DIAGNOSIS
-jlOO
. 80
40
20
REF
10
s
REF
- I
81
NOTE: WHITE MALES I TEMflLES
247
STOMACH
FIVE YEAR RELATIVE SURVIVAL RATES
— 15-
CE
Q::
>
>
a:
3
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
NOTE: BLRCK MflLES 1 TCnflLES
YEAR OF DinONOSIS
248
STOMACH
FIVE YEAR RELATIVE SURVIVAL RATES
20-,
75 76 77 78
YEAR OF DIAGNOSIS
AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES
o
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81
NOTE: WHITE MALES i PEMflLES
249
Section VII
Distribution of Histologic Types of Cancer for Blacks and Whites
Discussion 251
Tables:
Percent Distribution of Cancer Cases by Histologic Types ,
Blacks and Whites, 1978-1981.
Selected sites:
Bladder 252
Breast, female 253
Corpus uteri 254
Prostate 255
Rectum 256
250
Section VII: Distribution of Histologic Types of Cancer for Blacks and
Whites
A. Discussion
Information on the histologic distributions of cancer for selected
cancer sites is presented in this section. Certain histologic types of
cancer have been associated with good or poor survival prognosis. For
example, more histologically aggressive or less differentiated cancers such
as sarcomas have poorer survival than well-differentiated adenocarcinomas.
Differences in the survival rates observed between blacks and whites for
various cancer sites may be explained in part by differences in the
distributions of histologic types. Therefore, histologic distributions may
be used as a proxy measure of biologic differences in cancer between blacks
and whites.
Organization of Tables
A set of five tables are presented showing the percent distributions of
histologic types of cancers for selected sites for blacks and whites.
251
BLADDER CANCER
Percent distribution of cases by histologic type,
Surveillance, Epidemiology, and End Results Program
1978-81
Total number of cases
12.018
520
Percent microscipically
confirmed
98.4%
97.7%
Histologic type
Carcinoma, NOS
1.8%
3.9%
Papillary adenocarcinoma
3.6
1.6
Squamous cell carcinoma
2.1
9.1
Transitional cell
36.0
41.3
Papillary transitional cell
54.5
36.2
All others
2.0
7.9
NOS = Not otherwise specified
252
FEMALE BREAST CANCER
Percent distribution of cases by histologic type,
Surveillance, Epidemiology, and End Results Program
1978-81
WHITE BLACK
Total number of cases 35,220 2,648
Percent microscipically
confirmed 97.6% 97.1%
Histologic type
Carcinoma, NOS 3.5% 3.9%
Adenocarcinoma, NOS
Mucinous adenocarcinoma
Duct adenocarcinoma
Medullary carcinomanal cell
Lobular carcinoma
Paget 's disease
All others
NOS = Not otherwise specified
10.3
11.5
2.2
2.3
69.5
65.2
3-.0
6.8
8.3
5.7
1.2
1.3
2.0
3.3
253
CANCER OF THE CORPUS UTERI
Percent distribution of cases by histologic type,
Surveillance, Epidemiology, and End Results Program
1978-81
Total number of cases 10,323 475
Percent microscipically
confirmed 99.4% 98.9%
Histologic type
Carcinoma, NOS
Papillary adenocarcinoma
Adenocarcinoma, NOS
Adenosquamous carcinoma
Mullerian mixec tumor
Leiomyosarcoma
All others
2.1%
1.9%
6.5
14.0
73.4
52.8
10.8
8.7
1.9
7.0
1.2
6.0
4.0
9.6
NOS = Not otherwise specified
254
CANCER OF THE PROSTATE GLAND
Percent distribution of cases by histologic type.
Surveillance, Epidemiology, and End Results Program
1978-81
WHITE BLACK
Total number of cases
Percent microscipically
confirmed
Histologic type
Carcinoma, NOS
Adenocarcinoma, NOS
All others
NOS = Not otherwise specified
23,740
2,864
95.1%
94.6%
4.0%
3.9%
94.3
94.5
1.7
1.6
255
RECTAL CANCER
Percent distribution of cases by histologic type,
Surveillance, Epidemiology, and End Results Program
1978-81
WHITE BLACK
Total number of cases
11,620
707
Percent microscipically
confirmed
96.8%
96.9%
Histologic type
Carcinoma, NOS
1.4%
1.6%
Papillary adenocarcinoma
10.1
10.7
Adenocarcinoma, NOS
80.9
75.2
Mucinous adenocarcinoma
5.9
7.9
All others
r.7
4.6
NOS = Not otherwise specified
256
Section VIII
Five-year Relative Survival Rates by Stage of Cancer at Diagnosis for
Blacks and Whites
Discussion 258
Figures :
Five-year Relative Survival Rates by Cancer Stage at
Diagnosis for Blacks and Whites, 1977-1981.
Selected sites:
Bladder 259
Breast, female > . . . . 260
Cervix uteri ... ........ 261
Colon 262
Colon/Rectum 263
Corpus uteri .......... 264
Esophagus (whites only) « . . 265
Lung 266
Melanoma (whites only) 267
Ovary 268
Prostate 269
Rectum 270
Stomach ........ 271
Testis (whites only) .............. 272
257
Section VIII; Five-year Relative Survival Rates by Stage of Cancer at
Diagnosis for Blacks and Whites
A. Discussion
The detailed classification of patients by stage of disease at diagnosis
has been available in a consistent, comparable manner through SEER only
since 1977. The classification of stage used in SEER is compatible with
that developed by the American Joint Committee on Cancer. Since earlier
stage of disease data (before 1977) are not comparable, it is not possible
to assess changes in stage distributions over time. Thus, the data presented
in this section are derived entirely from SEER.
The data presented here compare five-year relative survival rates
between white and black, patients within stage of disease categories for ech
primary site. For many sites the numbers of black patients are too small
in specific stage categories to draw meaningful conclusions. For several
sites, however, even though the survival rates for white patients are
significantly higher than those for black patients for all stages combined,
the differences tend to disappear within individual stage categories. This
is due to generally more favorable stages of disease detection for white patients.
Organization of Figures
The figures in this section are a set of bar graphs that compare black
and white five-year relative survival rates for various stages of disease
for primary cancer site. For cancers of the esophagus, melanoma, and testis
survival data by stage of disease were available for whites only.
Highlights
• The difference in survival for breast cancers between white and
black patients was large and statistically significant (75% vs.
63%) , but this was accounted for primarily by those who came to
diagnosis with lymph node involvement or direct extension of the
tumor to adjacent tissue (stage III.B) (VIII. B-2).
• For cancer of the uterine corpus, the site with the greatest
difference in survival between black and white patients, even for
stage I disease there was a large, statistically significant
difference (92% vs. 75%) (VIII. B-6). The numbers of black patients
were too small to draw meaningful conclusions for the other stages.
• Black patients had higher survival rates for cancer of the ovary
than did white patients. This was true not only for all stages
combined but also within each stage (VIII. B-10).
258
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