, 7^ <5?j&c ] Volume III: Cancer -03 I"/ S S" Report of the Secretary's Task Force on Black & Minority Health U.S. Department of Health and Human Services NLM Q017bb52 1 NATIONAL TIBRARYUH MEDICU PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE Volume III 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 William T. Friedewald, M.D. Robert Graham, M.D. M. Gene Handelsraan 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. US2r V-3 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. Reuter Clay Simpson, Jr., Ph.D. Ronald J. Wylie n 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 in 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. v • 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 were 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. vn The full Task Force report consists of the following volumes: Volume T: Executive Summary Volume II: 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 Volume III: Cancer Volume IV: Cardiovascular and Cerebrovascular Diseases Volume V: Homicide, Suicide, and Unintentional Injuries Volume VI: Infant Mortality and Low Birthweight Volume VII: Chemical Dependency Diabetes Volume VIII: Hispanic Health Issues Survey of the Non-Federal Community Inventory of DHHS Program Efforts in Minority Health vin 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 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 Walter 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 lower 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 sharply following a rise in survival rates in the mid-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 1 increase, observance of these types of cancer in the U.S. may also increase. These large groups contain subpopulations 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 ot Japanese, Chinese, Filipino, Hawaiian, and other descendants. Accurate registration of these subpopulations 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 when 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. 2 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. 3 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 registeries 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. Where 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 auS°' J1^ h™othesized> supported by much of the scientific literature that the differences in cancer survival among Blacks and non-minorities involve 4 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 with 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: 5 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 mav be the highest users of smokeless tobacco. Although other minority groups appear to be somewhat lower users of smokeless tobacco than non-minorities 6 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, B5, 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, • IARC 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.) IARC Scientific Publications No. 57. International Agency for Research on Cancer, Lyon, 1984. 7 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. 8 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 9 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. Hispanics in the National Breast Cancer Survey's purposive sample per- ceived themselves as more likely to contract cancer some day than did non minorities. Hispanics 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 unemployment 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. LunS 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 between the two are not known. Regardless of this lack of infor- 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 occupational 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 times 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- -minori ty Difference Bl ack/N Breast 63% 75% 12% Prostate 61 71 10 Corpus Uteri 55 86 31 Bladder 54 74 20 Rectum 37 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 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-minority, 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-minorities 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 18 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 between 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 employment 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. J 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. f* inclden"™?e_ 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 Ind 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 Research on cancer-related knowledge, attitudes, and practices among American Indians was not available for inclusion in this report. 30 CONCLUSIONS Limited 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 AmerLnd 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 Southwest Oklahoma Site Observed (No.) Expected (No.) SMR Observed (No. ,) Expected (No.) SMR Lung Male 5 105.8 5 47 55.1 85 Female TOTAL 6 11 21.2 127.0 29 9 12 59 11.0 66.1 109 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 3.2 625 3 1.6 188 28 4.4 636 5 2.2 227 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 ptr 100,000 Population for Lung Cancer in the United States, 1969-1981 Year of Death White Males Black Males 1969 S5.S5 63.68 1970 S7.39 65.54 1971 59.11 66.70 1972 60.86 73.35 1973 61.58 74.76 1974 63.16 78.10 1975 64.16 79.29 1976 65.69 81.56 1977 66.82 87.34 1978 68.18 88.31 1979 68.76 89.22 1980 70.03 92.70 1981 69.86 94.93 AAPC* 1.91 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 10.30 10.56 11.01 11.54 11.94 12.50 12.76 12.44 13.28 13.53 14.34 14.17 15.27 14.80 16.51 15.78 17.37 17.25 18.72 17.78 19.46 19.11 20.96 21.41 21.69 21.74 6.19 5.92 •AAPC=average annual percent change from 1969 to 1981. ■Source: National Cancer Institute. 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 AAPC* 36 Table 3 ESTIMATES OF LUNG CANCER INCIDENCE PER 100,000 PERSONS (BASED ON SEER DATA) -J 31.8% 1 * »»»» 20.7% ' M.7 J\ 81.8 i 1 999 9W 174.8 : 88.0% •8.6% Whites Blacks MALES ] 1980 Whites Blacks FEMALES mm™ C/J a o 7? ►-• P 00 ft> P CL o n n Table A TRENDS IN SURVIVAL BY SITE OF CANCER, BY RACE Cases Diagnosed in 1960-63, in 1970-73 and in 1973-80 WHITE BLACK 1960-63' 1970-73' 1973 80' 1960-63' 1970-73' 1973-80J Relative 5-year Relative 5-year Relative 5-year Relative 5-year Relative 5-year Relative 5- year Sue Survival (%) Survival (%) Survival (%) Survive (%) Survival (%) Survival (%) Prostate 50 63 68 35 55 58 Kidney 37 -46 50 38 44 52 Uterine Corpus 73 81 88 31 44 58 Bladder S3 61 73 24 36 48 Colon/Rectum 41 48 50 31 35 42 Uterine Cervix 58 64 68 47 61 62 Breast 63 68 74 46 51 62 Ovary 32 36 37 32 32 39 Brain and Central Nervous 18 20 21 19 19 23 Lung and Bronchus 8 10 12 5 7 10 Stomach 11 13 14 8 13 14 Esophagus 4 4 5 4 3 Hodgkin's Disease 40 67 70 70 Lymphocytic Leukemia-Acute 4 28 43 Leukemia 14 22 32 27 Non-Hodgkin's Lymphoma 31 41 46 46 Larynx 53 62 67 57 Melanoma ol Skin 60 68 79 " Testis 63 72 82 67 Thyroid 83 86 92 I 89 Source: Biometry Branch. National Cancer Institute 'Rates are based on data Irom a series of hospital registries and one populcUton-based registry 'Rates are Irom the SEER Program and include patients diagnosed through 1980 and loNow-up on all patients through 1981 They are based on data Irom population-based registries in Connecticut. New Mexico. Utah. Iowa. Hawaii, Atlanta. Detroit. Seattle-Puget Sound, and San Francisco-Oakland. 'Rates coukJ not be calculated because of insufficient number of cases. Smoking an Table 5 Current Cigarette Smokers Among Males 20 Years of Age and Over, by Race; United States, 1965, 1976, 1980 Race Current Smoker All Males White Males Black Males 1965 52.1 51.3 59.6 1976 41.6 41.0 50.1 1980 37.9 37.1 44.9 Source: National Health Interview Survey. 39 Table 6 Smoking and Cancer Current Cigarette Smokers Among Females 20 Years of Age and Over, by Race; United States, 1965, 1976, 1980 Race Current Smoker 1965 1976 1980 Alt 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 per 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 Cance 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 More than 25 1965 1976 1980 All Females 87.0 81.0 76.7 White Females 86.1 79.2 74.8 Black Females 95.3 94.5 91.5 1965 13.0 13.9 4.6 1976 1980 19.0 23.2 20.9 25.2 5.6 8.6 Source: National Health Interview Survey. 42 Smoking and Table 9 Former Cigarette Smokers Among Mates 20 Years of Age and Over, by Race; United States, 1965, 1976, 1980 Race Former Smoker 1965 1976 1980 All Males 20.3 29.6 30.5 White Mates 21.2 30.7 31.9 Black Males 12.6 20.2 20.6 Source: National Health Interview Survey. 43 Smoking an Table 10 Former Cigarette Smokers Among Females 20 Years of Age and Over, by Race; United States, 1965, 1976, 1980 Race Former Smoker 1965 1976 1980 All Females 8.2 13.9 15.7 White Females 8.5 14.6 16.3 Black Females 5.9 10.2 11.8 Source: National Health Interview Survey. 44 Table 11. Cancer Death and Proportion Attributable to Alcohol Consumption by Site and Sex, 1974 Total Proportion Number Total Proportion Number ICDA code for attributable attributable for attributable attributable and site__________males_____to alcohol______to alcohol_____females to alcohol_______to alcohol' 140 149 5,686 0.50 Buccal cavity and pharynx 150 4,917 0.75 Esophagus 155 1,600 0.30 Liver 0.50 1,413 436 0.40 174 0.04 8,424 166,338 0.02 2,648 2,843 2,282 3,688 1,735 480 865 0.40 913 0.75 1,301 0.30 260 161 2,826 Larynx Total 199,194 (all sites) Source: Rothman (1980) 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 Primarie Tobacco Alcohol no. zt No. Zt No. Zt 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 Table 13 Results of Selected Prospective Studies on the Relationship Between Alcohol Consumption and Cancer' lfW*4tff*IOI and Oafol Pubfccalio-n Foi>ul»uon and Veattol Ot>sousa and Alcoholism undar Contract No HSM 42-73-116. 1977 -Eacataiva alcohol cancai raiatad morlalily alto lound In madiaslinum and Inyo-* c «■*.«,( and laukamia wara aacaativa in whitfcay drmfcars •Stgntlicani al lha 0 05 lava! -Stgmlicar-J al lha 0 01 laval •Sientlicanl al lha 0 001 laval •Ihraa digit calagoriaa In lha Eighth Ravtalon. Initnational Ciasuhcaiion .~f {■itarnam. Adaptad 1965 (ICOA) LIVfN 155* 6 31 66* 44 3 2 0 77 CHI AS 156 5 3 I 4 221 105 137 3 lb 39 6 16 042 19 14.1 39 11 145 240 5 061 6 26 19 60 12 21 1 042 16 14 6 47 66 40 526 0 76 7 112 4 57 4 42 3 5 1 608 800 3 16 79 109 2 066 «7 121 i 27 34 16 199 ft 63 816 1.1366 09 22 30 7 54 62 9 099 Alcohol and Tobacco Table 14. Age-adjusted annual incidence rates for selected cancer sites in various population groups in the United States Place Population Tongue Mouth Oropharynx Hypopharynx Esophagus Liver Larynx sites' ■t>. 00 California Alameda White 3.0 Black 2.2 Bay Area White 3.2 Black 2.1 Connecticut 2.8 Iowa 1.4 Detroit White 2.7 Black 3.3 New Mexico Spanish 0.4 Other 2.2 white New York State 2.2 Puerto Rico 7.5 Utah 2.1 3.7 4.1 4.2 4.8 4.3 2.6 3.3 3.3 0.7 2.8 3.2 7.8 2.5 2.2 2.2 2.6 3.3 2.1 1.1 2.0 2.1 0.4 1.4 1.3 4.3 0.9 1.1 1.5 1.5 1.5 1.5 1.2 1.2 1.1 0.2 0.3 0.8 4.4 0.4 3, .6 13, .2 4, .0 15, .2 5 .7 3 .0 4 .0 14 .1 2 .2 3 .0 4 .5 14 .8 1 .8 Total ProportIon for all of all cancer cancers iver Larynx sites • (%) 2.2 7.9 23.70 8.5 4.3 12.9 40.40 12.3 2.8 7.5 25.80 8.6 4.2 11.8 42.90 12.5 2.0 7.8 26.20 9.2 1.6 5.8 16.70 6.7 2.6 7.5 23.30 8.7 4.5 7.7 36.10 11.3 3.0 2.7 9.60 6.1 3.1 5.8 18.60 6.7 1.9 5.9 19.80 8.0 3.3 6.4 48.50 27.9 0.9 4.4 13.00 6.1 Source: Thuyns (1979) 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 (# of times) Black Below Above Poverty Poverty White Below Above Poverty Poverty MILK Whole Skim MEAT & FISH Meat & Poultry Fish & Shellfish MEAT ALTERNATES Eggs Cheese Legumes Seeds & Nuts FRUITS & VEGETABLES All Vit. A Rich Vit. C Rich Less than 1 1-2 3 or more Less than 1 1 - 2 3 or more Less than 1 1-2 3 or more Less than 1 1-2 3 or more Less than 1 1 - 2 3 or more Less than 1 1-2 3 or more Less than 1 1-2 3 or more Less than 1 1-2 3 or more Less than 1 1-2 3 or more Less than 1 1-2 3 or more 52 34 13 97 3 0 16 80 4 99 1 0 78 21 0 94 5 0 90 9 0 16 65 18 90 11 0 64 35 1 48 39 14 96 3 0 18 78 4 99 1 0 76 25 0 95 5 0 86 14 0 22 65 13 94 6 0 66 32 1 42 38 38 39 20 22 91 95 7 5 2 1 14 26 84 72 2 1 99 99 1 1 0 0 86 77 14 23 0 0 87 91 13 9 0 0 91 81 8 19 0 0 7 17 69 66 24 17 95 97 4 3 0 0 61 71 38 29 1 0 49 Nutrition Table 15 (continued) Frequency of intake per day Black White Below Above Below Above (# of times) Poverty Poverty Poverty Poverty BREADS & CEREALS Breads Less than 1 14 13 12 14 1-2 56 55 67 59 3 or more 31 33 20 28 FATS & OILS Fats Less than 1 44 48 28 36 1-2 51 46 61 53 3 or more 5 7 12 10 SWEETS Desserts Less than 1 62 62 58 64 1-2 36 37 40 34 3 or more 2 1 2 1 Candy Less than 1 76 69 84 79 1-2 22 29 16 21 3 or more 2 3 1 1 Beverages, Sweetened Less than 1 1-2 51 40 53 40 66 30 67 28 3 or more 8 7 5 5 OTHER BEVERAGES Beverages, Sweetened Less than 1 1-2 97 3 98 2 95 4 97 3 Artifically 3 or more 0 0 0 0 Coffee & Tea Less than 1 57 64 37 44 1-2 3 or more 35 8 30 7 34 29 36 20 SNACK FOODS Salty Snacks Less than 1 1-2 3 or more 85 15 1 78 20 0 89 11 0 91 9 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 White 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 112(1.9) 137(1.2) 50.8(1.2) 33.7(0.7) Urinary riboflavin/ 499(58.8) 768(28.7) 7.6(0.9) 2.5(0.3) creatinine ratio Source: Kerr, G.R. et al. Amer J. Clin. Nutr. 35: 294-307, 1982 51 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 Below Above Below Above Poverty Poverty Poverty Poverty Calories 83.6 86.4 102.0 93.2 Protein 142.4 147.3 161.6 161.6 Calcium 135.3 142.2 184.5 193.0 Iron 82.8 85.8 82.2 96.2 Vitamin C 155.7 170.8 143.7 183.3 Thiamine 169.0 169.0 161.5 162.6 Riboflavin 169.3 167.4 161.5 188.4 Source: DHEW Publication No. (PHS) 79-1657; Series 11, No. 209 52 Table 18 Mean values for biochemical measures of nutritional status for persons aged 3-74 years according to race and poverty level --------------Black------------ Below Poverty Above Poverty No Mean SE No Mean SE Hemoglobin (gm/dl) Hematocri (%) White blood cell ct. (x 109 /L) Serum iron (mg/dl) Serum TIBC (mg/dl) Transferin sat. (%) Serum zinc (mg/dl) Serum copper (mg/dl) Serum vit. C (mg/dl) Serum albumin (g/dl) Serum vit. A (mg/dl) Red blood cell ct. (x 1012 /L) 904 13.1 0.05 1262 13.11 0.06 904 39.4 0.12 1262 39.6 0.19 885 6.7 0.10 1234 6.5 0.09 841 91.1 1.61 691 380.9 3.24 691 24.1 0.38 652 82.7 0.83 627 140.3 1.76 720 0.9 0.03 734 4.6 0.02 184 31.0 0.61 890 4.6 0.02 Source: DHHS Publication No. (PHS) 83-1682 ---------------White--------------- Below Poverty Above Poverty No Mean SE No Mean SE 1885 14.0 0.02 12742 14.1 0.03 1885 41.1 0.05 12742 41.3 0.09 1881 7.6 0.05 12681 7.4 0.03 1191 94.3 1.49 1796 97.7 1.03 1045 374.9 2.20 1576 378.3 5.55 1042 25.7 0.37 1574 26.4 0.29 972 85.2 0.64 1584 85.1 0.52 966 134.2 1.27 1562 125.0 0.82 1067 1.0 0.02 1670 1.0 0.03 1079 4.7 0.01 1628 4.7 0.01 174 33.8 0.56 335 33.1 0.63 1236 4.6 0.02 1878 4.7 0.01 12209 101.1 0.40 11058 374.5 1.34 11037 27.4 0.16 10729 87.0 0.32 10665 121.4 0.46 11437 1.1 0.01 11127 4.8 0.01 1678 33.9 0.30 12658 4.7 0.01 r+ -5 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) Bla cks Hlsp anlc Whites # Below Above Below Above Below Above Calories 10-16 yrs MI PA 1863.30 71.60 2426.40 90.10 2219.50 94.60 2383.20 89.70 2232.40 86.50 2498.90 94.00 60 yrs & over MI PA 1299.70 59.80 1483.80 66.10 1710.40 81.90 1562.90 77.20 1670.20 81.50 1794.90 84.00 Protein 10-16 yrs MI PA 69.48 129.70 93.00 169.40 81.74 173.30 88.95 164.50 80.79 154.60 97.37 184.80 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 PA 709.95 98.00 941.40 144.20 655.19 100.30 1034.00 143.00 995.30 152.60 1190.90 182.80 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 PA 10.72 66.90 13.26 82.30 14.35 97.10 13.30 92.10 12.14 77.40 13.40 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 4935.00 167.70 895.20 189.80 2760.86 95.40 3764.50 129.00 3847.00 133.90 4658.80 176.80 60 yrs & over MI PA 5551.19 158.00 5343.10 152.40 3400.77 96.60 2781.00 78.80 4411.90 125.50 5457.17 176.30 Thiamine 10-16 yrs MI PA 1.12 108.30 1.37 123.80 1.49 159.40 1.68 159.90 1.25 120.80 1.32 123.90 60 yr6 & 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 PA 1.81 128.00 1.99 134.90 1.80 139.00 2.24 153.60 2.04 128.90 2.32 158.90 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 13.45 17.41 15.42 15.67 14.42 18.35 60 yrs & over MI PA 13.23 12.95 21.46 11.36 14.12 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 & 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 Table 20 Percent of persons having deficient or low values for biochemical measures of nutritional status by ethnic group and income Blacks Below Poverty Above Poverty No Def Low No Def Low Hispanics Below Poverty Above Poverty No Def Low No Def Low Whites Below Poverty Above Poverty No Def Low No Def Low Hemoglobin 8590 7.6 29.8 3446 3.5 23.4 1896 8.3 12.3 2910 2.3 15.4 3822 1.8 13.8 12127 1.0 8.3 Albumin 4126 2.0 11.1 2006 0.2 2.8 1553 2.3 10.6 2060 0.0 1.0 2561 0.5 3.5 8730 0.2 2.3 # # Protein 4298 3.5 6.0 2158 0.2 0.7 # # 1580 5.4 5.8 2106 0.2 0.5 2621 3.0 5.3 8999 0.4 1.9 # # Vitamin A 6225 0.8 8.2 1970 0.6 5.5 1712 4.0 29.1 2051 0.2 2.1 2952 0.6 5.1 7224 1.1 6.4 Vitamin C 5909 2.5 8.5 1849 0.3 2.6 1526 2.9 4.9 1831 0.3 1.6 3025 2.3 6.5 7815 0.5 2.5 Riboflavin 4026 5.2 21.9 2176 1.2 12.5 1736 3.0 16.6 2338 0.7 6.0 2439 2.0 8.5 8847 0.9 6.0 Thi ami ne 3791 1.7 9.5 1886 1.4 7.8 1719 0.7 5.4 1878 0.6 4.8 2358 1.4 5.8 6527 0.6 3.6 Iodine 3715 0.5 1.8 1775 0.4 2.1 1838 0.0 0.2 1035 0.1 1.6 2118 0.9 2.1 5831 0.3 1.1 # - Based on values for persons over sixteen years of age Def - deficient Source: DHEW Publication No. (HSM) 72-8132 Table 21 Percent of persons with a poverty income ratio less than one having deficient or low values for biochemical measures of nutritional status by ethnic group and income Blacks Below Poverty Above Poverty No Def Low No Def Low Hispanics Below Poverty Above Poverty No Def Low No Def Low W h i t e s Below Poverty Above Poverty No Def Low No Def Low Hemoglobin 5152 7.7 29.5 1012 4.4 25.7 1165 5.5 11.9 856 2.0 14.6 1325 2.3 14.6 1842 1.5 9.3 Albumin 2575 2.2 10.4 593 0.0 3.7 951 1.2 10.7 633 0.0 1.3 970 0.6 3.4 1346 0.3 3.3 Protein 2665 3.6 5.5 646 0.0 0.9 972 4.8 5.3 643 0.2 0.6 982 2.6 4.1 1395 0.4 1.9 # # // // Vitamin A 3562 0.9 9.5 578 1.4 5.5 1050 5.4 30.2 612 0.0 1.9 1015 1.0 5.7 1071 0.8 5.2 Vitamin C 3307 2.4 6.9 535 0.7 1.9 913 2.8 5.0 536 0.4 1.7 1080 3.0 6.7 1171 0.5 2.8 Riboflavin 2695 5.4 23.2 664 1.4 13.0 1078 3.0 18.4 700 0.9 6.7 922 2.9 8.7 1368 1.1 6.7 Thi ami ne 2517 1.7 9.6 563 1.1 7.6 1059 0.8 5.4 533 0.5 6.3 905 1.2 5.2 1006 0.8 3.2 Iodine 2555 0.6 2.1 524 0.0 1.9 1144 0.0 0.2 329 0.0 1.8 828 1.9 3.3 983 0.4 1.2 Source: DHEW Publication No. (HSM) 72-8132 (TSNS - IV) (Def - deficient) 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) Sources of Energy and Energy Nutrients Milk & Meat, Eggs, Grain Fruits, Fats, Milk Poultry, Legumes Products Vegetables Sweets, Products Fish Beverages Food Energy 1979-80 15 26 7 27 13 12 1977-78 15 26 6 30 12 11 Protein 1979-80 19 43 10 19 8 1 1977-78 18 44 8 22 7 1 Fats 1979-80 19 39 9 15 8 10 1977-78 19 40 8 17 8 8 Carbohydrate 1979-80 11 6 4 42 21 16 1977-78 11 5 3 45 19 17 Vitamins Vitamin A 1979-80 20 10 8 17 37 8 Value 1977-78 20 11 8 18 37 6 Thiamine 1979-80 12 22 5 42 18 1 1977-78 11 21 5 45 17 1 Riboflavin 1979-80 30 23 7 28 10 2 1977-78 29 22 7 31 9 2 Preformed 1979-80 3 39 4 34 14 6 Niacin 1977-78 3 41 3 35 13 5 Vitamin B6 1979-80 13 36 9 19 21 2 1977-78 13 38 7 21 20 1 Vitamin C 1979-80 10 6 2 10 66 6 1977-78 10 5 1 10 64 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 Pork & mutton 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) Nutrition FRUITS & VEGETABLES FRUIT Citrus Apples Other Total Fresh (d) Canned fruit Canned juices Frozen juices Frozen noncitrus (fruits & juices) Dried Melons Total 1980 values as Amount 1960 of Food 1980 Percent of 1960 values 33.7 18.3 41.9 28.7 16.7 42.0 85 91 100 93.9 22.6 12.9 5.9 3.5 3.1 25.8 261.6 87.4 17.4 16.9 9.9 3.0 2.9 18.6 233.5 93 77 131 168 86 94 72 89 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 4.4 109.0 380.9 102 116 149 626 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 Nutrition Table 25 Percent of persons who reported using specific foods for which there is a significant difference by race (USDA) Food Groups White Black Other Fruits Noncritus fruits 74 61 64 37 70 (a) 54 Potatoes Dried beans and peas Dark green vegetables 80 22 14 64 29 27 84 62 13 Whole grain bread Quickbreads Breakfast cereals Cooked cereals Rice 24 34 54 15 15 8 46 64 34 47 16 49 66 (a) 26 51 Milk, yoghurt, cheese Milk Lowfat milk 93 85 20 80 76 4 93 88 (a) 2 Cheese Natural cheese Processed cheese 50 24 25 23 10 13 36 15 20 Red meats Beef Poultry 82 70 41 83 62 64 98 (a) 88 60 Eggs Nuts 53 28 66 11 69 13 Desserts 73 52 57 Soups 32 22 49 Snack foods Potato chips 31 20 17 13 18 12 (a) Condiments 36 28 23 (a) Candy Sugar-based beverages Carbonated beverages 16 60 55 7 76 69 5 74 64 Fats Table spreads Salad dressings Cream and substitutes Bacon and salt pork 87 70 47 18 24 78 50 32 4 39 84 (a) 62 38 5 18 Coffee and tea 68 48 52 (a) - significant at the 1 percent level (p<0.0l) 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 $5,000 or more Noncitrus fruit 53 66 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 Condiments 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 22 41 Fats Salad dressings 74 33 87 50 (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 63 Nut 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 --------R ace 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 (a) - significant at the All other differences significant at the 0.1 percent level (p<0.001) Source: Cronin, F J et al. JADA 81: 661-673, 1982 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 0.7 0.6 0.6 2.0 1.4 2.0 1.8 1.3 1.9 1.2 0.6 2.7 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 1 percent level (p<0.01) 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 Fruits and vegetables Fruits Vegetables Vegetables (exclude potatoes, dried beans and peas) Other vegetables // Meat, fish, poultry Desserts Grain-based desserts ---Income level--- under $20,000 $5,000 or more 2.6 3.1 1.2 1.4 (a) 1.8 2.1 1.2 1.5 1.0 1.2 (a) 1.4 1.6 (a) 0.8 1.1 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 ----S e x----- Male Breads and cereals 2.6 Yeast breads 1.5 White breads 1.4 Milk, yoghurt, cheese 2.0 Milk 1.8 Meat, fish, poultry, eggs 2.0 Meat, fish, poultry 1.7 Red meats 0.8 Desserts 1.0 Grain-based desserts 0.9 Sugar and sweet spreads 1.1 (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 Female 2.3 1.3 1.2 1.8 (a) 1.6 (a) 1.7 1.5 0.7 0.9 (a) 0.8 (a) 1.0 (a) 67 Occupation Table 31 Industrial Processes and Chemicals with Known Human Carcinogenicity Industrical Processes and Occupations: Auramine manufacture Boot and shoe manufacture and repair (certain occupations) Furniture manufacture Isopropyl alcohol manufacture (strong-add process) Nickel refining Rubber industry (certain occupations Underground haematite mining (with exposure to radon) Chemicals and groups of chemicals: 4-Ami nob1 phenyl Analgesic mixtures containing phenacetln Arsenic and arsenic compounds Asbestos Azath1opr1ne Benzene Benzidine N,N-B1s(2 Study Lead Asbestos Soot Bagasse Petrol & oil Tar Lead Asbestos Soot Bagasse Lung 37 18 6 3 8 14 13 3 2 1 3.1 3.2 7.2 1.7 3.3 7.3 2.1 1.0 5.1 1.2 tumors among African males. Cases were relatively young, 79% of lung ca. cases were less than 60 years of age. No statistical adjust-ment for age. Cases & controls were ask-ed about specific jobs & industries with carcinogenic Keller, 1969, US VA Hospitals Population- based Case- control study. Cases identi- fied from VA hospitals Professionals Managerials Clericals Sales workers Craftsmen Operators Service workers Laborers Farmers (%) (%) Mouth 3 4.4 1.2 35 5.5 1.0 & 1 1.4 0.3 22 3.4 0.6 Pharynx 4 5.8 2.5 53 8.3 1.6 1 1.4 — 41 6.4 1.1 11 16.0 1.3 191 30.0 1.2 9 13.0 0.9 67 10.5 1.3 22 31.9 1.8 103 16.2 1.3 9 16.0 0.7 36 5.7 1.3 6 8.7 1.1 2 0.3 0.1 related exposures. Lung ca. cases had a lower SES ranking & higher amount smoked Occupation was taken from the medical record and classified into broad cat- egories based on the Dept. of La- bor classification scheme. The job taken probably represents the most recent. o o n c ■a O) C-+ _j. o 3 *For case-control studies n refers to the number of cases exposed and the % is the corresponding percent of cases exposed. Table 33 (continued) Author, Year, Study Country_________Design Industry Lloyd, 1971, Non- Steel U.S. concurrent prospective Risk Estimates Cancer Occupation Exposure Site Blacks i* % risk Whites i* % risk comments Coke Oven Coal Tar Lung 17 3.0 3 1.6 The coke oven group Non-oven 4 3.6 1 0.6 includes workers re- quired to spend some of their time at the topside or side of the ovens. The anal- ysis is limited to workers employed on or before 1953. 91% of all blacks & 42% of whites were em- ployed in the coke oven areas. -j Monson and Non- Nakamo, 1976, concurrent U.S. prospective Rubber Ross et al, 1979, U.S. Rates for 1972-75 Production workers Professionals Managers Salesman Clerical Craftman Operatives Transportation Laborers Service Workers Digestive 15 0.8 47 0.7 Lung 11 0.8 41 0.8 Bladder — --- 8 1.1 Brain — --- 4 0.8 Lymphatic & myeloma 3 1.3 12 1.2 Leukemi a — --- 8 0.9 Prostate Not 185 1.5 Presented 263 1.6 96 1.2 49 0.8 156 0.7 53 0.6 30 0.8 35 0.9 63 0.9 986 black & 5501 white males were em- ployed sometime be- tween 1933-71. Usual work area was used to define exposure, however, analysis by exposure status is not presented. Cases identified from the Los Angel- es County Cancer Surveillance Prgm. Only 11 black cases of testicular ca. were identified. However, 792 pro- state cases were found. *For case-control studies n refers to the number of cases exposed and the % is the corresponding percent of cases exposed. o o o c ■o Table 33 (continued) Author, Year, Country______ Pickle & fj Gottlieb, 1980, US Sheffet et al, 1982, US Study Design Risk Estimates Industry Goldsmith Nested Rubber et al, 1980 Case- & Control Tire Study Population- based Case- Control Study Non- Pigment concurrent Plant prospective Occupation Exposure Cancer Site Blacks i* % risk Whites t* % risk comments Batch prep. Batch service Reclaim Fabrication Janitoring Shipping & Receiving Salary Heavy metals, oxides, and organic accelerators Prostate 2.3 2.1 1.0 3.7 7 24 10 12 13 3.2 2.6 1.4 0.7 1.3 2.8 Cohort is comprised of active & retired hourly rubber work- ers. 88 cases & 258 controls were identified from DC. Risk estimates are for those employed at least 1 month in the defined occupa- tional group. White collar Pancreatic 0.3 0.9 19 parishes in Craftsmen Males 1.0 1.0 Louisiana were se- Operators 1.3 1.2 lected for a case- Laborers 1.1 0.9 control study be- Service worke rs 0.7 1.1 cause of high ca. Farmers 1.0 1.2 rates. White collar Females 0.6 1.4 Laborers 0.6 --- Service worke rs 0.8 0.9 Farmers 1.0 --- 3 Exposure Lead & Esophagus 0 --- 1 1.0 1,296 white & 650 groups de- Zinc Stomach 3 1.6 5 2.0 non-white males em- fined on the Chrornate Large in- ployed sometime basis of testine 0 --- 2 0.5 between 1940-69. level and Rectum 1 2.2 2 1.4 Results are pre- frequency of Pancreas 2 1.7 4 1.7 sented for all 3 exposure Lung 10 1.6 21 1.6 exposure groups o Prostate 1 0.6 3 1.2 combined. n Hodgkins 0 --- 2 2.9 Leukemia 2 3.7 1 0.5 CD Lymphatics ; 2 3.7 1 1.1 o" 3 *For case-control studies n refers to the number of cases exposed and the % is the corresponding percent of cases exposed. 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Washington, DC: US Government Printing Office, May 1983 Walton Report. Cervical cancer screening programs. Can Med Assoc J 1976; 114:11 Warnecke RB. Intervention in black populations. In: Mettlin C, Murphy GP, eds. Cancer among black populations. New York: Alan R Liss, Inc, 1981: 167-183 Warnecke RB, Graham S. Characteristics of blacks obtaining Papanicolaou smears. Cancer 1976; 37:2015-2025 Warnecke RB, Havlicek P, Manfredi C Awareness and use of screenings by older aged persons. Perspectives on prevention and treatment of cancer in the elderly. New York: R Yanick, 1983:275-287 Wilensky GR, Walden DC. Minorities, poverty, and the uninsured. Presented at the 109th annual meeting of the American Public Health Association, Los Angeles, November 1981 101 HEALTH SERVICES PATTERNS (continued) Wilson RW, Danchik KM. A comparison of "black" and "other than white" data from the National Health Interview Survey and mortality statistics. Classifi- cation issues in measuring the health status of minorities. Presented at the annual meeting of the American Statistical Association under the sponsorship of the Social Statistics Section, Houston, August 11-14, 1980 102 INTERVENTION American Society of Preventive Oncology. The role of primary and secondary prevention in reducing cancer mortality among U.S. blacks. Fifth annual meeting of the American Society of Preventive Oncology, Bethesda, Maryland, March 26-27, 1981 Burrell-Roberson N. Outreach programs. Community networking. Proceedings of the fourth national conference on cancer nursing of the American Cancer Society, 1983 Clark RA, Blackburn GL. The role of nutrition in disease prevention and health promotion. Compr Ther 1983; 9(4):12-22 Enterline JP, Gold EB. A method for estimating the potential effects of primary and secondary prevention activities in high-risk populations. Prog Clin Biol Res 1983; 130:249-259 Fruchter RG, Boyce J, Hunt M. Invasive cancer of the cervix: failures in prevention. I. Previous Pap smear tests and opportunities for screening. NY State J Med 1980; 80(5):740-745 Holleb Al. Progress in clinical cancer control. CA 1982; 32(6):363-365 Lundahl S, Weller E, Celentano D, Waalkes TP. Employee cancer education and detection demonstration program [Meeting Abstract]. Fifth annual meeting of the American Society of Preventive Oncology, Bethesda, Maryland, March 26-27, 1981 Peck S. Education and communications for a community-based cancer control program. Fam Community Health 1981; 4(3):61-65 103 Cancer Statistics Review: Black, White, and Other Group Comparisons Report of the Subcommittee on Cancer, Part H 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.................HO Figures.........•........H3 Tables ..................11A Incidence and Mortality for Blacks, Whites, and other Groups Contents, Section II.............. 115 Introduction........» ......117 Figures ............ ...... 119 Tables..................151 Five-year Relative Survival for Blacks, Whites, and Other Groups Contents, Section III............• "155 Introduction ........ ......... 15° Figures .......... ........ 158 Tables..................17A Survival Trends: Five-year Relative Survival by Year of Diagnosis for Blacks and Whites Contents, Section IV.............. 175 Introduction ,..-.....»........ 176 Figures ...».». ...... ..... 177 Survival Trends: Relative Survival by Numbers of Years after Diagnosis for Blacks and Whites Contents, Section V.............. 183 Introduction .... ...... ....... 185 Figures ........ ' > ....... 186 Trends: Comparison of Incidence, Mortality, and Survival for Blacks and Whites Contents, Section VI.......»......216 Introduction ,..»..•».......... 218 9 90 Figures..................-z-u 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 or 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 Surveillance Epidemiology and End Results Program National Cancer Institute USA .<* Hawaii Connecticut New Jersey ... 4?4> Puerto Rico TABLE I. Percent Distribution of Cancer Cases by Geographic Area and Ethnic Group SEER Program, 1978-81 Area No. of cases Percent residing in All areas San Francisco- Oakland _ Connecticut * Detroit Hawai i Iowa New Mexico Seattle Utah Atlanta Arizona Indians Total for all ethnic groups Anglo American Hispanic Black Indian Chinese Japanese Filipino Hawaiian 297,571 252,095 6,158 23,952 872 2,299 3,682 1,815 1,331 100.0 100.0 1U0.0 100.0 100.0 100.0 100.0 100.0 100.0 16.8 15.7 33.5 20.4 3.8 64.1 9.2 36.1 2.4 16.9 18.8 5.4 8.6 1.4 1.0 0.2 0.2 0.1 19.4 18.3 1.4 45.9 1.5 1.4 0.4 1.7 0.1 3.4 1.4 - 0.2 - 28.6 82.9 55.8 97.0 15.1 17.6 1.6 1.8 1.7 0.2 0.2 0.2 - 4.4 3.8 51.3 0.8 42.4 0.2 0.1 - - 12.7 13.7 1.6 3.2 12.6 3.8 5.6 6.6 0.4 4.3 4.8 4.8 0.2 3.2 0.2 1.3 0.2 - 3.1 5.6 0.6 16.6 0.4 0.3 0.1 0.1 0.1 0.1 - - - 32.7 - - - _ Section II 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, White, 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................1^3 Esophagus Male..................144 Female.................145 Lung Male..................146 Female.................I47 Multiple Myeloma Male..................1^8 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 hematopietic 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 AND ELRCKS, 1978-81 ALL SITES RGE SPECIFIC INCIDENCE RATES 2400-j 2200- 2000- 1800- a o o 1600- o o 1400- •*■■■■' ex LJ a. 1200-1000- LJ a: LC 800- 600- 400- 200- 0- Legend *BLACK xWHITE T I I I I I I I 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 85* AGE o o o o o cc LJ Q. 1600- 1400- 1200- 1000- 800- RGE SPECIFIC MORTALITY RATES LJ 600- l— C LC 400 H 200- \**r Leoend i BLRCK * WHITE D ■» ■ t u f " "T—:---1-----~~i-------1-------1----~""r~~ ' 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 85* RGE 119 1978-81 INCIDENCE. ALL SITES RATE PER 100,000 0 Mhi tes Blacks Chinese Japanese Fi1ipinos Hawai ians AMexican Indians Hispanics t #o iJ in 0) 6 a 3 J2 o O .0-LZ T5) c < a 2 CD * E < > 167 ON 00 LUNG & BRONCHUS SEER 1973-81 - FEMALES FIVE YEAR RELATIVE SURVIVAL RATES Os so InrvrwkCA - Fi^prio -j BackJ Hawaiian H Antfo -\ Chinese H Hfepcric n MULTIPLE MYELOMA SEER 1973-81 - MALES I FEMALES FIVE YGAR RELATIVE SURVIVAL RATES 21] •^ -J o Black jj Japanese -{5 Chinese Ancfo Hispanic Filipino RVNCREAS SEER 1973-81 - MALES A FEMALES FIVE YEAR RELATIVE SURVIVAL RATES PROSTATE SEER 1973-81 - MALES FIVE YEAR RELATIVE SURVIVAL RATES |76| 47 Native Amer. STOMACH SEER 1973-81 - MALES A FEMflLES FIVE YEAR RELATIVE SURVIVAL RATES lE p7| -J Japanese Ancjo Fllfcino Chinese Hispanic Hawaiian Black Naflve Amer. RECTUM SEER 1973-81 - MALES A FEMALES FIVE YEAR RELATIVE SURVIVAL RATES |44| 24 Primary Site Anglo All Sites 50 Esophagus 5 Stomach 14 Colon & Rectum Colon Rectum 51 52 49 Pancreas 3 Larynx 67 Lung & Bronchus Male Female 12 11 16 Breast - female 75 Cervix Uteri 68 Prostate 69 Urinary Bladder 74 Multiple Myeloma 24 SEER 1973-81 Five Year Relative Survival Rates Hispanic Black Native Amer. Chinese Japanese Filipino Hawaiian 47 38 34 44 51 45 44 - 3 - 11* - - - 16 15 9 16 28 16 14 46 48 44 44 46 37 37* 44* 24* 50 53 44 59 61 55 41 38 45 51* 59* 42* 2 3 - 3 3 2 - 60* 59 - 67** 75* 57** 79** 11 9 15 11 10 14 5 2 15 15 15 14 13 17 12 12 11 15 13 24 72 63 53* 78 85 72 76 69 63 67* 72* 72 72* 73* 71 59 47* 76* 76 73 85* 70 50 37** 74* 72 49* 48** 21* 27 - 24* 30* 29* 26* 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..................lgl Rectum ..................lg2 175 Section IV - Survivlal Tr-nd,.- Flve-ye^ Relative Survival by Year of "Diagnosis. 1973-7S and 1 -tf 1 , 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 Panting 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, 197 3-75 and 1976-81. • Blacks had substantial increases in survival rates for cancers of the bladder, prostate, and recturm. • 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 .X LJ H- > >> cn RRCE EZJ WHITE ■i BLRCK 1973-75 1976-81 YERR OF DIRBNOSIS 181 SURVIVAL RATE 17.) 8Sn £ X CD or SI (7.) 3iya nyAiAyns 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 2Q2 Rlack................' [ ] 203 White ............... Lung and Bronchus, female Black White 204 205 Multiple Myeloma -qa Black .................. White . Pancreas Black , White , Prostate Black , White Rectum Black White Stomach Black 207 208 209 210 211 212 213 214 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 197 3-75 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 DIAGNOSIS 100 UJ ►- 40- cr ac cr > a: 3 20 to io H 100 •o 40 20 1973-75 1976-81 10 YEARS RFTER DIAGNOSIS n:?E: BLp.CK MRLES & TEMPLES 186 ALL SITES SEER RELATIVE SURVIVAL RATES BY YE.AR OF DIAGNOSIS so - i YEARS AFTER DIAGNOSIS NOTE: WHITE MALES t FEMALES 1973-75 1976-81 187 BLADDER SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS n::e: black males i temples 188 100 UJ ►- 40 - cc > oc =3 to 20 - 10 - BLADDER SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 100 80 - 40 - 20 1973-75 1976-91 - 10 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE MALES i FEMALES 189 BREAST SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS n: r- 40 (Z oc > oc =) 20 to 10 - 100 60 40 20 1973-75 1976-81 10 2 3 4 YERRS AFTER DIAGNOSIS n::e. black temales 190 BREAST SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 100 > lO UJ i- 40 GC > 20- 10 -i 1973-75 1976-81 100 10 40 20 10 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE TEMALE: 191 CERVIX UTERI SEER RELATIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 100 ►- 40- cr on > > oc tn 20- 100 60 40 20 1973-75 1976-61 10- 10 YEARS AFTER DIAGNOSIS NC7E: blp:< rEH,P_CS 192 CERVIX UTERI SEER REUTIVE SURVIVAL RATES BY YE.AR OF DUGNOSIS M UJ i- 40 > QC to 20 10 - 1973-75 1976-91 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE FEMALES 193 COLON SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 2 3 YEARS AFTER DIAGNOSIS NC7E: BLACK MALES 1 TEMPLE5 194 COLON SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS tn 20 - 10 - YEARS AFTER DIAGNOSIS NOTE: WHITE MALES I FEMALES 1973-7S 1976-61 195 COLON/RECTUM SEER REUTIVE SURVIVAL RATES BY YEAR OF DIAGNOSIS 100 x r- 40 cr Q_ -J > oc 100 80 40 20 1973-75 1976-81 10 10 2 3 4 YEARS AFTER DIAGNOSIS N-TE: fi-FCK MALES l FEMALES 196 10 - COLON/RECTUM SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS YEARS AFTER DIAGNOSIS 1973-71 1976-61 NOTE: WHITE MALES I FEMALES 197 ESOPHAGUS SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS a. tX > > IO 2 3 4 YEARS AFTER DIAGNOSIS n:~l. ElA:k ma_es i females 198 ESOPHAGUS SEER REUTIVE SURVTV.AL RATES BY YEAR OF DUGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS 1973-75 1976-91 - 1 NOTE: WHITE MALES I FEMALES 199 LARYNX SEER REUTTVE SURVIVAL RATES BY YEAR OF DUGNOSIS too n: 100 80 r- 40- cr 40 > > oc (O 20- 10-1 1973-75 1976-61 20 10 YEARS AFTER DIAGNOSIS ncte: BlAck mawes i temples 200 LARYNX SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 40 - UJ > QC 3 20 to 10 - 1973-75 1976-61 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE MALES I FEMALES - 10 201 LUNG &c BRONCHUS SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS NCTE: B-ACK MA.ES 202 10 - LUNG &c BRONCHUS SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 1973-75 1976-81 H100 YEARS AFTER DIAGNOSIS NOTE: WHITE MALES 203 LUNG AND BRONCHUS SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS sCTE: ela:* temales 204 10 - LUNG & BRONCHUS SEER REUTIVE SURVIV.AL RATES BY YEAR OF DUGNOSIS 1973-75 1976-91 -1100 90 YEARS AFTER DIAGNOSIS NOTE: WHITE FEMALES 205 MULTIPLE MYELOMA SEER REUTTVE SURVIVAL RATES BY YEAR OF DUGNOSIS 100 UJ cr ac a. > >- QC 3 CO 100 90 40 20 10 - 2 3 4 YEARS AFTER DIAGNOSIS 10 n::e. Black ma.es & tema.es 206 MULTIPLE MYELOMA SEER REUTIVE SURVIVAL RATES BY YE.AR OF DUGNOSIS 40 - YEARS AFTER DIAGNOSIS NOTE: WHITE MALES I FEMALES 207 PANCREAS SEER REUTTVE SURVIVAL RATES BY YEAR OF DUGNOSIS UJ cr cr > > QC 3 tn 2 3 4 YEARS AFTER DIAGNOSIS n:te: ElAck males l females 208 V.B-24 PANCREAS SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE MALES I FEMALES 209 V.B-25 PROSTATE SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 100 40- cr K. cr > > QC =3 20 CO io A 1973-75 1976-81 2 3 4 YEARS AFTER DIAGNOSIS 100 60 40 20 10 NC7E: BLACK MALES 210 V.B-26 PROSTATE SEER REUTTVE SURVIVAL RATES BY YEAR OF DUGNOSIS -j 100 - 80 to 20 - 10 - 1973-75 1976-61 NOTE: WHITE MALES 40 20 10 2 3 4 YEARS AFTER DIAGNOSIS 211 RECTUM SEER REUTTVE SURVIVAL RATES BY YEAR OF DUGNOSIS 2 3 4 YEARS AFTER DIAGNOSIS NOTE: BLACK MALES i FEMALES 212 RECTUM SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 1 i ■ "■ ■ i • " i 2 3 4 YEARS AFTER DIAGNOSIS 1973-75 1976-81 NOTE: WHITE MALES k FEMALES 213 STOMACH SEER REUTIVE SURVIVAL RATES BY YEAR OF DUGNOSIS 3 4 YEARS AFTER DIAGNOSIS NC7E: BLACK mAlES I TEMALES 214 STOMACH SEER REUTTVE SURVIVAL RATES BY YE.AR OF DUGNOSIS 100 2 3 4 YEARS AFTER DIAGNOSIS NOTE: WHITE MALES k FEMALES 215 Section VI: Trends Comparisons of Incidence, Mortality, and Survival for Blacks and Whites Discussion Figures: 218 Annual Five-year Relative Survival Rates and Annual Age-adjusted Incidence and Mortality Rates by Year of Diagnosis. All sites: Black...................22° 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 ^ite.................! ! 233 Larynx Black............... 234 White.............. ^r 216 Figures (continued) Lung and Bronchus, male „i i . . . • • 236 Black.............. _ White...................ZJ Lung and Bronchus, female ..... 238 Black . White . Multiple Myeloma Black . White . Pancreas Black . White . . . Prostate Black . White . Rectum Black . . . White . . . Stomach Black . White . . . 239 240 241 242 243 244 245 246 247 248 249 217 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 FIVE YERR RELRTIVE SURVIVAL RRTES 73 74. 75 76 77 78 79 YERR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES 1000- 800- o O 600- O • o o — 400H QC UJ 0- 200' K .iUH-a- lOO-^ INC10CNCE 1000 600 600 400 n mata i i fctwwwwm&man nr 200 «F H0RTRLITT 73 75 —T" 77 _d too 79 81 YEAR OF DIAGNOSIS N07E: SL^CK MALES I FEMALES 220 ALL SITES FIVE YEAR RELATIVE SURVIVAL RATES LJ CT QC tiC CD 60 -i 55- 50- 45- 40- 35- 73 74 /5 76 77 78 79 YEAR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTALITY RATES o o o • o o QC UJ Ol. UJ ta»....ILa...a>..«.A.w *EF - 100 77 79 61 YERR OF OlflGNOSIS NOTE: WHITE MALES I FEMflLES 221 60-i 55- 50- LJ ■X QC 4.5 _J en > MM > QC 40 en 35- X BLADDER FIVE YERR RELRTIVE SURVIVRL RRTES E^a ^^ t^pi ^p^ s^—r 73 74 75 76 77 78 79 80 YEAR OF DIAGNOSIS -r 81 J AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES o a o • o o 100 - 60 - «0 - 20 - QC 2 - 73 1HC10ENCE mmM4 nORTflUTT 7S —T 77 T 79 YEAR OF DIAGNOSIS NOTE: BLBCK MALES I TEMALES 222 100 80 40 20 10 8 REF 4 «f - 2 - I 81 999999 80-i BLADDER FIVE YEAR RELATIVE SURVIVAL RATES YEAR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTALITY RATES o o o o o QC UJ a. UJ ►— cc QC 100 - 80 - 40 - 20 - 10 8 2 - I - INC20ENCE nORTRLJTY T" 73 —t 75 77 —T 79 100 80 40 20 REF 10 6 REF - 2 - 1 61 YEAR OF DIAGNOSIS NOTE: WHITE MALES L FEMALES 223 BREAST FIVE YERR RELRTIVE SURVIVRL RRTES 73 74 75 76 YERR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES 100- 80- O o 60- o o — 40H 20- INC10ENCE HORTRLITT 10- 73 -r 75 NCTE: BLACK TE^LES 77 79 YEAR OF 0IAGN0SIS 224 100 - 60 60 40 20 10 81 BREAST FIVE YEAR RELATIVE SURVIVAL RATES 8O-1 75- X 70- LJ E 65- QC 5 60- > 3 55- tn 50- ^ ^^ T r -T--J 73 74 75 76 77 78 79 YEAR OF DIAGNOSIS 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES NOTE: WHITE FEMALES YEAR OF OIAGNOSIS RET REF 225 CERVIX UTERI FIVE YERR RELRTIVE SURVIVRL RRTES 75-i 70- LJ £ 60-| QC > 5S" QC Z) 50 H CO 45- X i— —i— —r- —i----------1----------1----------1- 73 74 75 76 77 78 79 80 YERR OF DIAGNOSIS 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES NOTE: SLACK FEMALES YEAR OF OIAGNOSIS 226 REF CERVIX UTERI FIVE YEAR RELATIVE SURVIVAL RATES 73 74 75 76 77 78 YEAR OF DIAGNOSIS 79 T' 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES 100 - 80 - o 40- o o O 20 - o S i0 - a- 8 " UJ £ 4- 2 - INCIDENCE 1 "t, flORTBLlTY 73 75 77 79 NOTE: WHITE FEMALES YEAR OF OIRGNOSIS 227 100 80 40 20 10 6 REF REF - 2 - 1 81 03 COLON 55-i FIVE YERR RELRTIVE SURVIVRL RRTES 75 76 77 78 79 YEAR OF OIRGNOSIS 80 —r 81 AGE AD-JUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES o o o 100- 60- 60- o o — 40< QC UJ a. 1NC10ENCE 20- nORTPLITT 10 T- 73 —T- 75 77 79 YEAR OF DIAGNOSIS 81 NOTE: SLACK MALES 4 FEMALES 228 COLON FIVE YEAR RELATIVE SURVIVAL RATES 55-i 75 76 77 78 79 YEAR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES too 80 100 80 o o 60 - a o — 40 QC UJ a. 60 INCIDENCE - 40 __jc-r: REF •X 20 QC - 20 ■wRsaKr=ssn*H .JL______u REF H0RTRLIT7 .0 ^ 73 —r 75 —r 77 J 10 79 81 YEAR OF DIAGNOSIS 1 ! VT'L ' ( 229 COLON/RECTUM FIVE YERR RELATIVE SURVIVRL RATES 74 75 76 77 78 YEAR OF DIAGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES 73 NOTE: BLACK MALES I FEMALES 77 79 YEAR OF OIAGNOSIS 230 REF REF 81 COLON/RECTUM FIVE YEAR RELATIVE SURVIVAL RATES 75 76 77 78 79 YEAR OF DIAGNOSIS -7- 80 -r 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES o o 100- SO. 60-1 o o ~« 40 QC UJ a. 20- INCIDENCE H0RTRLIT7 10- 73 75 NOTE: WHITE MALES k FEMflLES 77 79 YEAR OF DIAGNOSIS 231 100 80 SO 40 REF REF - 20 - 10 81 ESOPHAGUS 20-i ~ 15- Ld QC > QC ZD CD 10- FIVE YEAR RELATIVE SURVIVAL RATES T 78 7fi 77 78 79 YEAR OF DIAGNOSIS 80 T 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES NOTE: BLACK MALES i TEMALES YEAR OF OIRGNOSIS 232 REF REF ESOPHAGUS FIVE YEAR RELATIVE SURVIVAL RATES 20-i LJ az QC ._] a: > > QC ZD 73 74 75 76 YEAR OF DIAGNOSIS r 79 T 80 81 o a a o QC UJ a- UJ 10 H 8 - S - 4 - 2 - AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTAUTY RATES INC10ENCE nORTRLJTY 1 -I 73 —r 75 —r 77 79 81 YEAR OF DIAGNOSIS NOTE: WHITE MALES k FEMflLES 233 LARYNX FIVE YEAR RELATIVE SURVIVAL RATES 8O-1 75- 70- E 6S" U 60- \W 55- d 50- > 45- 40- 35- 30 J. 0 = QC 07 WfSi CSS^A ryy^SSy* ISWfXA K-V^l "T" 81 t-------r- 73 74 75 76 77 78 79 YEAR OF DIAGNOSIS 80 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES o o 10 8 6 - O o mm 4 QC UJ a. 7 - I - T 73 INCI0ENCE nORfflLITT 7S NOTE: BLACK rALES k FEMALES —r 77 79 YEAR OF OIRGNOSIS 234 10 6 REF REF 81 LARYNX FIVE YEAR RELATIVE SURVIVAL RATES lj > QC tn 80-j 75- 70- 65- 60- 55- 50- 45- 40- 35- 30 J. cr=- f'f* y 73 74 vi K>^>wa X**Sf!A ******>A 78 75 76 77 YEAR OF DIAGNOSIS 79 —r~ 80 —r 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES QC UJ 0. UJ fr- CE QC 10 H 8 - O § « o o INCIDENCE 4 - 2 - flORTALlTY l -4 73 —p 75 77 79 YEAR OF DIAGNOSIS 61 I10 - 8 - 6 - 4 REF - 2 REF A i NOTE: WHITE MALES k FEMALES 235 LUNG k BRONCHUS FIVE YEAR RELRTIVE SURVIVRL RRTES 15-i LJ (E QC CE > QC tn 75 76 77 78 79 YERR OF OIRGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES o o o • o o QC UJ Q. UJ cr QC 1000 - ■00 - 400 - 200 - 40 - 20 - 10 1000 BOO 400 200 nORTRLlTT 100 REF 60 REF 40 V 73 75 20 - 10 77 79 YEAR OF DIAGNOSIS 61 NOTE: BLACK MALES 236 LUNG & BRONCHUS 15-. 10- Zi in 5- FIVE YEAR RELATIVE SURVIVAL RATES 73 —i-------r- 75 76 77 78 79 YEAR OF DIAGNOSIS 80 ~T 81 AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTALITY RATES NOTE: WHITE MALES YEAR OF DIAGNOSIS 237 9573 LUNG AND BRONCHUS FIVE YEAR RELATIVE SURVIVAL RATES 73 75 76 77 78 79 YERR OF OIRGNOSIS AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES 1000 H too 400 - o o o • 200 - o o 100 0. UJ cr QC 60 - 40 - INCIDENCE YEAR OF DIAGNOSIS 1000 BOO - 400 200 100 80 - 40 NOTE: BLACK FEMALES 238 20-i LUNG &c BRONCHUS FIVE YEAR RELATIVE SURVIVAL RATES - 15- LJ tr- (E QC > > QC 10- U7 5r IP ^ « ^H T-------1-------1- 73 74 75 76 77 78 79 80 YEAR OF DIAGNOSIS 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES too h 80 - a o o o o QC UJ ra- ce QC 60 40 - 100 80 60 40 INCIDENCE 20 - - 20 REF REF nosTALin 10 73 —T" 75 —T" 77 —T" 79 d 10 81 YEAR OF DIAGNOSIS NOTE: WHITE FEMALES 239 MULTIPLE MYELOMA 40-i FIVE YEAR RELATIVE SURVIVAL RATES r 75 76 77 78 YEAR OF DIAGNOSIS T 79 T 80 T 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES YEAR OF DIAGNOSIS 240 REF REF NOTE: BLACK MALES I FEMALES MULTIPLE MYELOMA FIVE YEAR RELATIVE SURVIVAL RATES LJ *■■-« CE QC _J CE QC zj CD 30-i 25-1 20- 15- 10- 74 75 76 77 78 79 YEAR OF DIAGNOSIS 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTAUTY RATES a o a • a o QC UJ a. UJ ►— -X QC 10 -j 8 - 6 - 4 - INCIDENCE 2 - 10 8 - 2 REF REF nORTRLITY 1 -. 73 75 77 79 YEAR OF DIAGNOSIS -* i 61 NOTE: WHITE MALES k FEMALES 241 PANCREAS 25-i 20- LJ £ 15-1 CE QC _J CE > 10- > QC Z3 U7 5-1 FIVE YEAR RELATIVE SURVIVAL RATES f?5f53 ^ ^ t— —i--------r- 75 76 77 78 79 YEAR OF DIAGNOSIS 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTAUTY RATES YEAR OF DIAGNOSIS NOTE: BLACK MALE5 k FEMALES 242 PANCREAS 25-. 20- £ 15 CE QC > QC ZD en 10- 5- FIVE YEAR RELATIVE SURVIVAL RATES •—i 55- > QC Z3 U7 50- 45- ol t^g^ &&V44 &&y*H VttffA V*X*i T 81 73 74 75 76 77 78 79 YERR OF OIRGNOSIS 80 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES 1000 - 800 - 400 - a a o • 200 H o o 100 - 25 so a. CE QC 40 - 20 - 10 - (NCI0ENCE ■ ■"" NOTE: BLACK MALES YEAR OF OIRGNOSIS 244 1000 800 400 200 i oo ntr 60 «o mr - 20 - 10 PROSTATE FIVE YEAR RELATIVE SURVIVAL RATES 80-i 75- ~ 70- l\2 65 - CE "= 60- CE 2; 55- > QC in son 45 X nl B^pi &Z223 V&&X V&fZi V&fX—|— 73 74 75 76 77 78 YEAR OF DIAGNOSIS 79 80 T 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTAUTY RATES 100 so o o o a o ~* 40 QC UJ a_ QC 20 -» io -I 73 INCI0ENCE flOKTALlTY 7S Ml 77 —T 79 91 YEAR OF DIAGNOSIS NOTE: WHITE MALES 245 RECTUM 55-1 50- ',1 £ 45 H CE QC CE > 40- > QC ZD CO 35 H FIVE YEAR RELATIVE SURVIVAL RATES tsssssa Q "~~ K"y~'^ tS^^Y^ T,+***A vn>*^y.l i^s 77 "T- 78 73 74 75 76 YEAR OF DIAGNOSIS 79 -T- 80 8! AGE ADJUSTED (1970 US STD) INCIDENCE AND MORTALITY RATES o o 100 - 80 - 40 - 20 - oe 10 - V •- QC 2 - I - T" 73 INCIDENCE R0RTRLITT —T 75 NOTE: BLACK MALES 1 FEM«t.E5 -f W-*w*a n 79 YFAR OF OIRGNOSIS 246 "—f T 81 100 60 40 20 10 I REF REF - 2 - I RECTUM FIVE YEAR RELATIVE SURVIVAL RATES 55-i 73 i 74 75 76 77 78 79 YEAR OF DIAGNOSIS 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTAUTY RATES o o o o o 100 - 80 - 40 - 20 - QC UJ 10 - 0- 8 - UJ QC 4 - 2 - t -L. 73 INCIDENCE nORTHLJTY 75 —r 77 —r 79 YEAR OF OIRGNOSIS 100 80 - 40 20 REF 10 B REF - 2 - 1 61 NOTE: WHITE MALES k FEMALES 247 STOMACH FIVE YEAR RELATIVE SURVIVAL RATES 73 74 r ■ ■ ■ ■ ■ i---------1---------1---------1---------r- 75 76 77 78 79 80 YEAR OF DIAGNOSIS 81 AGE ADJUSTED (1970 US STD) INCIDENCE AND MORT-AUTY RATES YEAR OF DIAGNOSIS NOTE: BLACK MALES I FEMALES 248 STOMACH 20-i 15- 10- 5- FIVE YEAR RELATIVE SURVIVAL RATES pi p 73 74 75 76 77 78 79 YEAR OF DIAGNOSIS 80 81 AGE ADJUSTED (1970 US STD) INCIDENCE .AND MORTALITY RATES INCIOENCE WHITE MALES k FEMflLES YEAR OF DIAGNOSIS 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 Percent microscipically confirmed Histologic type Carcinoma, NOS Papillary adenocarcinoma Squamous cell carcinoma Transitional cell Papillary transitional cell All others NOS = Not otherwise specified 12,018 520 98.4% 97.7% 1.8% 3.9% 3.6 1.6 2.1 9.1 36.0 41.3 54.5 36.2 2.0 7.9 252 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 2.1% 1.9% Papillary adenocarcinoma 6.6 14.0 Adenocarcinoma, NOS 73.4 52.8 Adenosquamous carcinoma 10.8 8.7 Mullen an mixec tumor 1.9 7.0 Leiomyosarcoma 1.2 6.0 All others 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 23,740 2,864 Percent microscipically confirmed 95.1% 94.6% Histologic type Carcinoma, NOS 4.0% 3.9% Adenocarcinoma, NOS 94.3 94.5 All others 1.7 1.6 NOS = Not otherwise specified 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 Papillary adenocarcinoma Adenocarcinoma, NOS Mucinous adenocarcinoma All others NOS = Not otherwise specified 1.4% 1.6% 10.1 10.7 80.9 75.2 5.9 7.9 1.7 4.6 256 Section VIII Five-year Relative Survival Rates by Stage of Cancer at Diagnosis for Blacks and Whites 9 S8 Discussion ............... • Figures: Five-year Relative Survival Rates by Cancer Stage at Diagnosis for Blacks and Whites, 1977-1981. Selected sites: Bladder..................^59 Breast, female ........... ..... Cervix uteri.................^J „ -, , .....262 Colon ......»•••••••••• Colon/Rectum ................. ~ , • • 264 Corpus uteri .....••••*•••• Esophagus (whites only) ............. 265 ..... 266 Lung.......•..... Melanoma (whites only) ............. ~ •••••• Zoo °vary • • '...... .......269 Prostate............. Rectum............... Stomach.......•....." „-,« Testis (whites only) ....•••••••••" 257 Section VIII: Five-year Relative Survival Rates by Sta^e of Cancer 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 URINARY BLADDER SEER 1977-81 FIVE TEftR RELftTIVE SURVIVAL Rf ITES Si^^^^^^^^^^ RLL STAGES -STAGE I \ LOCRLIZED NOS i |S4| ^97 |B5f to sj\ |66| &2i] SO STA6E 11 -STR6E III - K**^*^^ < STROE IV-UNKNOWN - 1I7J* RACE K3 NHITES |l0| ■H BLACKS * sampIo too BmoLt 1 ' 1 1 1 1 1 1 1 D 10 20 30 40 SO 80 70 SURVIVAL RATE U) I 00 90 100 FEMALE BREAST SEER 1975-81 FIVE YEftR RELftTIVE SURVIVAL RftTES ALL STRGES SURVIVAL RATE IXI CERVIX UTERI SEER 1977-81 FIVE YEftR RELftTIVE SURVIVAL RATES OS ALL STAGES STAGE I STAGE II RACE ESI NHITES OB BLACKS SURVIVAL RATE U) COLON Os to SEER 1977-81 FIVE YEftR RELftTIVE SURVIVftL RftTES ALL STAGES i ^^^^^^^Sl on STAGE I \ ^^^!^^S^^^» ^^f87] |85| STAGE 11 \ f70| STAGE III |42| STAGE IV -J [J] Ej RACE ES NHITES UNKNOWN ] S^^aB MM BLACKS iD t 1 "i'"........■■ 1 10 20 30 1111 10 50 60 70 SURVIVAL RATE IX) 1 1 1 00 90 100 COLON-RECTUM SEER 1977-81 FIVE YEAR RELftTIVE SURVIVAL RATES to Os ALL STAGES STAGE I STAGE II STAGE III STAGE IV UNKNOWN RACE ESI NHITES ■I BLACKS 90 100 SURVIVAL CORPUS UTERI to 2 ALL STAGES STAGE I STAGE II STAGE 111 - i STAGE IV UNKNOWN SEER 1977-81 FIVE YEftR RELftTIVE SURVIVftL RftTES KK&KK^ ^^^3 RACE ESI NHITES ■i BLACKS K sample too small SURVIVAL RATE IX) ESOPHAGUS - WHITES ONLY to Os LA ALL STAGES STAGE I STAGE II STAGE III N6 5TA6E IV ^ b 10 UNKNOWN SEER 1977-81 FIVE YEftR RELftTIVE SURVIVftL RftTES • i i i i i----------------1----------------1-----------------1-----------------1 10 30 30 40 SO BO 70 BO 90 100 SURVIVAL RATE IX) LUNG SEER 1977-81 FIVE YEAR RELftTIVE SURVIVftL RftTES ALL STAGES STAGE I to Os Os QTfiCr II- jlnbL 11 STAGE III- * UNKNONN \ ^TT|| RRCE KS NHITES ■H BLACKS * sample tOO 8ltQt t 0 10 T" 20 30 10 "T- 50 -T" 80 "T" 70 00 90 100 SURVIVAL RATE IX) MELANOMA - WHITES ONLY SEER 1977-81 FIVE YEAR RELATIVE SURVIVAL RATES RLL STAGES STB8E I to Os -J STAGE II STAGE III- 5TAGE IV- 21 UNKNOWN "^ 73 10 20 "1" 30 40 50 60 "T" 70 "T- 80 SURVIVAL RATE IX) -f- 90 100 OVARY ALL STAGES to ON 00 STAGE I STAGE II STAGES III-IV UNKNOWN SEER 1977-81 FIVE YEAR RELftTIVE SURVIVAL RftTES RRCE SS WHITES ■I BLACKS T~ 00 ~T~ 90 -1 100 SURVIVAL RATE PROSTATE GLAND SEER 1977-81 FIVE YEAR RELftTIVE SURVIVftL RftTES to Os sO ALL STAGES STAGES I & II STAGE HI STA6E IV UNKNOWN RRCE ES WHITES ■I BLACKS SURVIVAL RATE IX) RECTUM SEER 1977-81 FIVE YEAR RELATIVE SURVIVAL RATES to o ALL STRGES STRGE I STAGE II STAGE III STAGE IV UNKNOWN RRCE ESI NHITES ■1 BLACKS SURVIVAL RATE STOMACH SEER 1977-81 FIVE YEAR RELftTIVE SURVIVftL RftTES to -J ALL STAGES STAGE I STAGE II STAGE III STAGE IV UNKNOWN RACE ESI WHITES ■i BLACKS SURVIVAL RATE TESTIS - WHITES ONLY SEER 1977-81 FIVE YEAR RELATIVE SURVIVAL RATES to -J to ALL STAGES STAGE I STAGE II STAGE HI STAGE IV UNKNOWN £ 58 N 77 ~T" 10 -i---------1----------1---------1---------r- 20 30 40 SO 80 _l-------,-------,-------, 70 BO 90 100 5URVIVAL RATE IX) Sw NA-I0M41 , BRAK* Of MIOICINE NLM 0017bb52 T NLM001766529